Presentation delivered by Mitch Wasden, Chief Executive Officer and Chief Operating Officer, University of Missouri Health Care, at the marcus evans National Healthcare CXO Summit Fall 2016 in California.

1. Mitch Wasden
Chief Executive Officer
1
Solving for Why
The Science of Transforming Culture through Identity

2. If culture is that powerful, why do
we have strategy retreats and
strategic plans, but NO culture
retreats and culture plans?
2
“Culture eats strategy for breakfast”
-Peter Drucker

3. RESULTS FROM LEADING WITH
CULTURE
3

4. Results at Ochsner Medical Center-Baton Rouge
How identity drove results from 2007-2012
• Hospital: From 15th percentile patient
satisfaction to 90th (3 years running)
• Clinic: From 50th to 95th (3 years running)
• Employee engagement from worst in the 8
hospital system to #1 in the 8 hospital system
• RAMI/RACI from worst in system and city to
tied for 1st
• From unprofitable to profitable

5. Results at MU Health Care
How identity drove results from 2012-present
• Hospital: From 15th percentile patient satisfaction to 89th
• Exceeded budget 4 straight years, margins from 4% in
2012 to 8.75% in 2016
• Employee engagement increases for four consecutive
years from 14th to 60th percentile
• UHC/Vizient Ranked MUHC #9 in the nation in 2014,
tracking in top quartile.
• Market share growth from 19.6% to 26.7% in four years
• 1,200 PDSA/QI projects done per year by 5,500 employees

6. Benefits of Engagement
How identity drove results from 2012-present
• Create 22% higher productivity (Gallup survey of 1.4M
employees)
• Doubles the rate of success of an organization
• Lower absenteeism
• 25% lower turnover
• Higher quality
– 41% fewer patient safety incidents
– 41% fewer quality incidents (defects)

7. Focusing on the correct order of Why, What,
How…
Definition Typical Order Necessary Order
What: What we do What Why
How: What we know How What
Why: Who we are Why How

8. 2) HOW
(Visible and
Invisible evidence
of knowledge)
3) WHAT
(Results/Outcomes)
What we often do:
Try to change #3 (results)
by going directly after How
and assume Why will fix
itself on it’s own.
What we must do instead:
Change results by changing
#1 (identity) 1) WHY
(Identity)
8
“Why” is invisible so we often miss it and focus
on the visible like What and How…

9. “Why” as the Engine, not the Caboose
When why powers organizations speed increases & friction decreases
howwhy
what
WHYHOW WHAT
(What Ordinary Organizations Do)
(What Extraordinary Organizations Do)

10. What is your organizational identity or “why?”
MISSION?
VISION?
VALUES?
10
Can you or your employees recite your:
Do you have BYOW Culture (Bring your own Why)?

11. 11
KNOWING THE
“WHY”
BEHIND WHAT WE DO
IS KEY TO CREATE
MEANINGFUL WORK!

12. KNOWING + DOING = SKILL
USELESS USEFUL
12
KNOWING
DOING
KNOWING
DOING
SKILL!

13. BKD Model: Work is MEANINGFUL when we
see our identity in it.
MEANINGFUL
WORK
13
USELESS
KNOWING
DOING
KNOWING
DOING
USEFUL
SKILL
KNOWINGDOING
BEING
MEANINGFUL
WORK

14. 10/5 Rule Say Do Ratio 1:1
Everything you need,
but nothing more
No Public Venting
1) Warm Welcome
2) Anticipate Needs
3) Fond Farewell
Big Impact and
Small Wake
Innovation finds
a way
“Is there anything I
can do for you?
I have the time.
VALUESBEHAVIORS
Thedifferencebetween
“Pros”andAmateurs
14
The Culture of Yes
Together we: Care, Deliver, Innovate and Serve

15. WE LIVE IN
COMPLEX TIMES
15

16. Exponential Intellectual Property
16
1900 1940 19701910 20001920 1930 19501950 1960 1980 1990
0
500
1000
1500
2000
2500
3000
3500
4000
Doubling every 2 yearsApplications
US Patent
Applications
EU Patent
Applications
Source: USPTO and EU PCT and EPC

17. Explosive Risk - Bankruptcy
17
1900 1940 19701910 20001920 1930 19501950 1960 1980 1990
0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
Doubling every 10 years
Personal
Bankruptcy/1000 persons
Source: Administrative Office of the US Courts and Census Bureau

18. Booming Population Growth
18
WorldPopulation(Billions)
100 900 1500300 2100500 700 1100 1300 1700 1900
0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
Source: World Population Growth: Historical Trends & Future
Prospects, Charles Hirschman

19. Our Mental Dilemma
What is noise and what is signal?
19
25 YEARS AGO:
5
15 YEARS AGO: TODAY:
20 100+
MEMOS/WEEK
VOICEMAILS/
DAY
EMAILS OR
TEXTS/DAY

20. “The healthcare industry is the most
complex form of organization we have
attempted to manage in human history.”
Peter Drucker
Question:
How can we expect leaders to have “System Thinking”
without an education in System Theory.
Complexity in the Healthcare Industry

21. Complex Adaptive Systems
21
Organizations that thrive in chaos are
called Complex Adaptive Systems.
They exhibit the traits of:
1. Self-similar but heterogeneous
(diversity of function)
2. Strong interdependence of its
members (you need each other)
3. Loose coupling between agents and
system (not too much bureaucratic
central control)
4. Self-organizing (solve issues w/out
much top down direction)
5. Adapt best when on the verge of
Chaos (called “Emergence”)

22. ANTS AS A COMPLEX ADAPTIVE SYSTEM
22

23. Chaos Theory
Example of computer generated Chaos Theory with
“Strange Attractors” (or Order)
23

24. Mandelbrot Set
Try to remember this image over the next several slides
24

25. Mandelbrot Set
25

26. Mandelbrot Set
26

27. Mandelbrot Set
27

28. Mandelbrot Set
28

29. Mandelbrot Set
29

30. Mandelbrot Set
Fractal = Identity
30

31. Mandelbrot Set
Organizational Chart: Complex Adaptive System
Centralized
Functions
Front lines
Chaos
31

32. Human Bias for Linear Thinking
CEO
CFO
Controller VP Rev Cycle
COO
VP
Outpatient
Nurse Exec
VP Planning
& Marketing
PR
CIO
Software
Director
Organization as it is… Organization as the brain
can conceive of it…
32

33. QUESTION:
How can I run a complex
non-linear organization using a
linear mind?
ANSWER:
CULTURE
33

34. 34
INSIGHT #1
YOU CAN ONLY MANAGE
COMPLEXITY WITH SIMPLICITY

35. 35
Group Behavior: Complex Flocking Behaviors

36. 3 individual instructions creates group order:
1. ALIGNMENT: Steer toward the average
heading of the flock (see the vision)
2. COHESION: Steer toward the average
position of local flock mates (stay close to
your team)
3. SEPARATION: Avoid crowding other birds
(but not too close…need for autonomy)
36
What complex flocking birds can teach us

37. 37
3 Rules make Order from Chaos

38. 38
INSIGHT #2
YOU MUST CREATE IDENTITY
WITH THE BRAIN IN MIND

39. IDENTITY - drives - ACTION - drives - RESULTS
39
Identity is behind every action
Identity is the butterfly effect, that small thing that
creates large scale change
VS.

40. Mother Doctor Stressed Victim
Every situation recruits new
identities which want to be
validated or enhanced. Only
occasionally do we drop
identities that don’t serve us.
The Identities cloud reality
and keep us from seeing
things clearly.
The Situation
You are running behind
schedule and have three more
patients before you can leave.
One of your partners told the
receptionist to send any walk-
in patients to you so they can
leave early for a social
function. You then walk into
the room to see the patient…
Recruited Identities Activated by the Situation
Possible Identities
Fear based identities keep us from
seeing clearly given they are more
clouded than power-based identities
(due to a limbic hangover)
40
When we perceive a situation through identity
filters, reality is obscured

41. 1) EMOTION
• How we feel about the identity
• Emotion is encoded on each
mental map
• The stronger the emotion, the
more quickly it can recruit the
mental identity map (for good
and bad)
2) INSTRUCTIONS
• The brain creates a list of
instructions regarding behavior
associated with that identity
IDENTITY MAP: I am a Mizzou Fan
1) Emotion Pride/Joy
2) Instructions Shout: MIZ…ZOU!
Yell at the other team
Wear Black and Gold
In a new context, identity maps
generally recruit .05 to 8 seconds
before we are consciously aware
of them affecting our behavior
41
Ingredients for a Mental Identity Map

42. PROPOSITION:
The root cause of failure in most
organizations is not a lack of KNOWLEDGE.
It is a lack of BEING.
BKD Model: Being, Knowing, & Doing
42

43. 43
INSIGHT #3
WE ALL THINK IN IDENTITY
NARRATIVES 95% OF THE TIME

44. When you see a group photo that you were in, who is the
first person you look for?
44
The Narcissist Test

45. Why can you listen to an hour
lecture and only recite back 7%
of it’s content but remember
almost 100% of the stories that
were told?
45

46. CHANNEL 1: NARRATIVE
• Plays our favorite program called “Me and My Story”
• We are always the main character
• We broadcast on this channel 95% of our
waking hours
• High ego needs
CHANNEL 2: DIRECT EXPERIENCE
• We broadcast on this channel 5% of the time
• We are not the main character but rather feel at one
with the story line and those in it.
• No ego needs
46
Science has proven the brain broadcasts on 2 channels

47. 47
INSIGHT #4
MAKING THE SCIENCE OF
IDENTITY PRACTICAL

48. CREATING A USEFUL IDENTITY AT WORK:
1) Aspirational
2) Something every employee can see themselves in
3) Something that mimics the way the brain creates
mental identity maps
4) Only 3-5 concepts so that the brain can remember
it. It’s ok to “chunk-down” concepts.
5) Use focus as a valuable resource
48
Creating a culture/identity in a way the brain can remember

49. 10/5 Rule Say Do Ratio 1:1
Everything you need,
but nothing more
No Public Venting
1) Warm Welcome
2) Anticipate Needs
3) Fond Farewell
Big Impact and
Small Wake
Innovation finds
a way
“Is there anything I
can do for you?
I have the time.
VALUESBEHAVIORS
Thedifferencebetween
“Pros”andAmateurs
49
The Culture of Yes
Together we: Care, Deliver, Innovate and Serve

50. PROGRAMS THAT ENFORCE IDENTITY
• Rounding on every employee every month
• Culture of Yes Awards
• Linking Culture of Yes to behaviors in evaluations
• Reciting the identity at the start of staff meetings
• Culture of Yes at the end of e-mails signatures, memos, etc…
• 99% of employees can recite COY based on rounding data,
and this year 90% can recite the 10 behaviors.
• Short phrases provide convenient short-hand for the culture
• Leadership using the language (ie. “it’s a wake issue,”)
50
The Practice: Culture Building through
“Attention Density”

51. RULES OF THE GAME:
• 3 of a kind = $10 gift card
• 2 pair = $15 gift card
• A full house = $20 gift card
Given to employees by their
manager, senior leadership, or by
nomination from a co-worker
51
Rewards & Recognition: Award cards

52. Attention Density of Key Messages Every Day….

53. 53
Culture of Yes Campaign for MU Health
https://www.youtube.com/watch?v=Ua
uS68WcS5o

54. 54
INSIGHT #5
OTHER ORGANIZATION WHO HAVE
DELIBERATELY FOCUSED ON
CULTURE AND BEHAVIORS

55. 55

56. • Launched in 1995 in Kevin Plank’s garage
• $4 Billion in sales in 2015
• Leapfrogged Adidas to become #2 behind
Nike ($30 Billion)
• By 2017 estimates are for Under Armour
to reach $7.5 Billion
• Now has the largest digital health-and-fitness
community with 150 Million users at a time when Nike
shut down their “Fuel band” product.
56
Under Armour Results

57. WHAT IS
UNDER AMOUR'S SECRET?
57

58. MISSION: Make all athlete’s better
• Plank-ism Behaviors
– Think like an entrepreneur
– Create like an innovator
– Perform like a teammate
58
“Culture is formed on habits”
Kevin Plank - CEO Under Armour

59. 59
CEO: Kevin Plank

60. 60
Culture as a trade secret

61. 61
INSIGHT #6
EMPLOYEES FOCUS ON WHAT
THE LEADER FOCUSES ON.
SO FOCUS ON THE DESIRED
ORGANIZATIONAL IDENTITY.

62. Cheerleading
Amusement
Boredom: “this
isn’t as fun as
it used to be”
Tough
Sledding
So you mean
this isn’t going
away? Ever?
Hard Wired
CultureStrength
Time
62
Anatomy of Culture Improvement Efforts

63. 63
Leader as a museum curator

64. 64

65. 65

66. 66

67. 67
Museum Curators
make choices
about what they
want people to
focus on...
Leaders make
choices about
what they
want people
to focus on...

68. 68

69. 69

70. 70
OUR ORG WHY
(BEING/VALUES/MISSION)
EMPLOYEES

71. 10/5 Rule Say Do Ratio 1:1
Everything you need,
but nothing more
No Public Venting
1) Warm Welcome
2) Anticipate Needs
3) Fond Farewell
Big Impact and
Small Wake
Innovation finds
a way
“Is there anything I
can do for you?
I have the time.
VALUESBEHAVIORS
Thedifferencebetween
“Pros”andAmateurs
71
What are your Masterpieces?
The Culture of Yes: Together we: Care, Deliver, Innovate and Serve

72. Employees focus on what the leader
(curator) is focused on...
If you don’t want employees to focus on
something (drama, victim mentality, etc…)
get it out of the gallery.
72
What employees focus on

73. 73
INSIGHT #7
THE SAME EMPLOYEES CAN
INCREASE THEIR RESULTS BANDWIDTH
WITH A STRONGER COLLECTIVE AND
INDIVIDUAL IDENTITY

74. • Amateurs can make some baskets, but pros can do it over, and
over, and over again.
• People don’t pay to watch amateurs
• Professionals take pride in their performance every day.
AMATEURS PROFESSIONALS
74
Pros vs. Amateurs: Individual Identity

75. • Diversities main value is accentuating differences
that make the whole better.
• Too often the focus is doctor vs. nurse, finance vs.
marketing, or differences in sex, gender, or race.
This kind of focus puts people in competing tribes
rather than putting them on one team
• There is far more value to be gained by focusing on
differences in proven strengths of each employee
and using that to coach each employee throughout
the year.
75
Individual Strengths as an Identity

76. TEAM FIRST POSITION SECOND
76
Hierarchy of Identity

77. 77
Reinforcing and Evaluating for the right
Individual Identity – Performance Evaluations
70 Percent of Performance Evaluations
either make performance worse or
show no improvement*
*A. Kluger and A. Denisi meta-analysis of 607 studies

78. Mar Apr May Jun Jul Aug Sep Oct Nov DecJan Feb
5
3-4
2
Impact on Engagement
©2015 Eli Lilly and Company | September 8, 2015 Illustrative
Deliver Rating, Pay Adjustment,
Bonus
85%
15%

79. BWHAT WOULD HAPPEN IF…
A focus on weaknesses prevents failure.
A focus on strengths leads to excellence.
1
First Second
Time Time
90 150
First Second
Time Time
350
Average reader
Above-average reader
2,900
Copyright © 2012 Gallup, Inc. All rights reserved.
WordsPerMinute

80. WHAT TO MEASURE
©2015 NeuroLeadership Institute | 52
Replace
rating
Worst
20%
20% 20% 20% Best
20%
With progress toward mastery
learning and progress
New to
X
skill
Very
high
level of
X
mastery
progress to
date
This is who you
are

81. ENGAGEMENT INCREASES WHEN MANAGERS FOCUS ON EMPLOYEES’
STRENGTHS
FOCUSING ON STRENGTHS IMPACT
63Copyright © 2016 Gallup, Inc. All rights reserved.

82. 82

83. 83
Quarterly GROW
Conversations
G: Goals
R: Results
O: On-track/Off-track
W: Way forward

84. 84
MOUNTAIN TRIBE VALLEY TRIBE
Strong Identities Drive Higher Performance

85. 85
“You were not
his mother…”

86. People will work hard for money, they will
work harder for other people,
but they will work hardest for a cause.
Our identity is the greatest cause we know,
we spend 95% of our waking hours thinking
in that language.
86

87. Questions?
87