Developing a Winning Department Culture


Building a high-performer leads to success in performance, productivity and retention.

Dear Director,


I can’t get my ER to “click.”  I feel like we have a good plan but we haven’t been able to get the results that I’ve wanted.

“Culture eats strategy for breakfast” – Peter Drucker

I’m a huge advocate for building the right strategy to be successful with patient care, but many of us forget about the importance of our department culture.  As it turns out, it’s our department culture that actually determines how and why things get done.  And success in performance, productivity and retention are outcomes of high performing cultures.


EDs can be a tough place to work.  If you’ve never worked in a place with a toxic culture, you know someone who’s had that experience.  Perhaps it’s a result of a disastrous physician or nurse leader, or it could be related to interactions with the hospitalists or consultants, or maybe it’s due to a lack of staffing.  Fortunately, most of us don’t have those problems, but even an ED without an apparent culture issue should have its leaders working towards building a high performing culture.

I used to think I had the skill set to change culture where I worked.  I’d had some success, but have since figured out that luck may have had something to do with it in addition to my perceived skill set. In my best of summer reading column, I recommended The Culture Code: The Secrets of Highly Successful Groups by Daniel Coyle.  Today, we’ll dive into the book for lessons to help us build a better culture.

As background, Coyle spent four years researching his book. The research includes his observations on groups that perform at the 99th percentile for at least a decade, have changed up their personnel and have a culture that’s respected in and out of their industry.

Culture is approached through numerous examples, including an NBA team, the Navy SEALs, a group of jewel thieves and a restaurateur.  Additionally, Coyle weaves in academic research, such as why a group of five-year-olds outperform groups of grad students and other professionals on building a tower with string, tape, uncooked spaghetti and a marshmallow, and the communication lessons we can learn from them. Coyle believes that culture is created by a specific set of skills (see Box 1) that tap into the social aspects of our brain.


Box 1 Skills to Build Culture

Skill 1. Build Safety—explores how signals of connection generate bonds of belonging and identity.

Skill 2. Share vulnerability—explains how habits of mutual risk drive trusting cooperation.

Skill 3.  Establish Purpose—tells how narratives create shared goals and values.

What is our culture?

Company culture is the shared values, practices and beliefs of our company’s employees.1 Our culture is built by how we communicate with each other, hire, provide feedback, collaborate and resolve differences, and how we critically review an event.  Culture is how we work together to achieve a shared goal. While this may seem easy to analyze during a code, it’s harder to measure and change for our 24/7 practice.

Impacting our Culture

A medical director can have a significant impact on culture.  It starts with who we hire. In a review of Silicon Valley start ups in the 1990s, companies who hired on a commitment model where the focus was on the group sharing values and strong emotional bonds outperformed companies that hired on a star model (hiring the brightest) and the professional model (building the group around specific skills sets).

Think about the positive impact of commitment when it comes to a doc staying late to avoid signing out a complicated patient versus planning the last two hours of their shift so they leave the minute their time is up as well as the how people feel about the docs who are always willing to fill in on an emergency basis for a sick colleague versus those who never volunteer to pick up a shift.  I’ll take the commitment model for my team.

Another way to influence culture is how medical directors provide feedback.  For starters, I’m sure we don’t do it often enough. Sometimes we don’t even do it when we have grossly underperforming docs.  To build a high performing culture, we need to establish relationships with our team so they feel like they belong to the group.

In one study, a company added an hour to new hire orientation that focused on the employee with questions such as “What is unique about you that leads to your happiest and best performances at work?”  The employees who had this session had a much higher retention rate because they were believed to be more engaged than employees who didn’t receive this session.

Highly successful cultures aren’t just about happy employees, but rather getting everyone to a certain performance level.  This involves frequent feedback and coaching. In a study looking at teacher feedback to students, performance improved when teachers wrote one phrase: I’m giving you these comments because I have very high expectations and I know that you can reach them.

This type of approach sets the bar for the employee and also provides encouragement and shows that you have confidence in them achieving success.  This tells me that I need to be rounding more and meeting with my underperformers more regularly, but by building relationships and providing feedback, I may be able to improve performance from my “average” providers and shift the entire curve.


Group productivity rises when people work in close proximity to each other.  The magic distance is about eight meters and the increase in communication is referred to as the Allan Curve. Visual contact with our colleagues increases our communication and ultimately our productivity.  We generally had double coverage at the last ED I worked in.

The docs sat side by side at a table that was literally next to the “next to be seen” rack.  It was immediately clear when there was a new patient to be seen and each of us knew exactly who had seen the last patient, who had the complicated patient, or who was about to do the procedure, so it was clear the other doc would be the one to carry the load for a bit.

At another facility I worked in, a long counter or a bend in the department separated docs, typically sitting more than eight meters apart.  Docs worked independently, often unaware of what their colleagues were doing in the ED.  Without knowing who is busy or who has been picking up the last several patients, it’s easy to think you’re carrying your share of the workload when that may not be the case.

Another example comes from Tony Hsieh, the architect behind Zappos, who is working to rebuild the Las Vegas landscape around the Zappos headquarters. He believes it critical to have “collisions — personal encounters that drive creativity, community and cohesion.” These almost random encounters provide employees the opportunities to collaborate.

Stories abound as companies have enlarged and refreshed their cafeterias and break rooms or had universal break times so that people can meet and talk to others around the company. Both of these examples serve as a reminder that leaders need to get out of their offices to round on the docs working (decreasing proximity) and to spend time in the doctors lounge at key points of the day (increasing the opportunity for collisions).

The restaurant model

I’ve always felt we have a connection with the restaurant industry.  My summer bartending in a seafood restaurant actually didn’t teach me much about restaurants, but I do like to eat out and find a lot of similarities in how the wait staffs manage multiple tables and how we manage multiple patients.  I once worked with a nurse manager who liked to hire nurses who had previously waited tables.

Coyle spent time researching star restaurateur Danny Meyer, whose restaurants have won a top spot in Zagat’s best restaurants and dozens of James Beard awards.  He also created Shake Shack.  Coyle wanted to know how he is so consistently successful in a business where failure is commonplace.

Meyer learned as he went, initially modeling the behaviors he wanted, but realized that he needed to build a language to teach specific behaviors.  He and his staff ranked their priorities and then started to name the specific behaviors and interactions he wanted to create.  Many of us do the same—triage bypass, greet the patients, provide a comfort gesture, review the findings, etc. However, I suspect there are few EDs where employees know the priorities, speak the lexicon and are as consistent in their actions as the staff at one of Meyer’s restaurants.

After-Action Review

Many high performing cultures incorporate a formal review of the project at specific intervals.  Pixar calls it a Brain Trust meeting where the directors meet with studio executives regularly throughout the production to analyze the film and point out detailed issues.

The Navy SEALs perform an After-Action Review (AAR) that takes place immediately after each mission or training session. The team members list and analyze problems and are held accountable for their actions. Although they’re intense and can be difficult, the AAR is recognized as a critical component for making the team better for their next mission.  We have our own language for these events though we might not perform the reviews as often as we should.

The M and M conference is a great way to review a case. The purpose at my site is not to make the provider feel bad about their decisions, but to have the group discuss the options and hopefully educate so that each provider is on the same page and providing the same level of care when the situation presents again. There is likely an opportunity to review more in our workplace—cardiac arrests or other critical patients requiring tremendous numbers of staff to care for them, particularly good and bad flow days with the critical members of the team (triage and charge nurses, charge doc, etc…). As my nursing director and I have tried to improve our flow, we’ve spent a lot of time dissecting issues, but I see opportunities for improvement—include more people, have an organized approach, keep listing problems and let the group find the solutions.


Building a high performance culture is an intentional process that can lead to staff retention and improved productivity and metrics. Employees in high performing cultures often describe their teams as family and love working there. There is much we can learn from industries outside of medicine though we’ll find common ground in how we hire, communicate to staff, empower staff and educate.




EXECUTIVE EDITOR Dr. Silverman is Chairman of Emergency Medicine at the Virginia Hospital Center. He also serves as the Director of the Alteon-Mid Atlantic Leadership Academy. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman


  1. Fantastic comments and suggestions. One thing I would like to add is what the Google team developers call “Psychological Safety”. It is kind of immersed in few of the suggestions below, however, I think it deserves to be emphasized separately. This concept was discovered by “accident” when Google was analyzing high performance teams during the company’s early days. What they found was, that teams in which members felt comfortable opening up without fear of being criticized or blamed, they did much better than the teams with the highest IQ members. Unfortunately in medicine, there is a culture of blame and shame for making mistakes, instead, developing a more comfortable environment so team members can be opened and talk about when we all learn from their mistake is a more constructive approach that builds a better team.

    • Mike Silverman on

      That’s a great point. Thanks for bringing it up. We definitely have an opportunity to improve our environment.


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