By Brant Couch, CIC

An organization’s ability to deliver great care requires great collaboration between gritty individuals, gritty teams of clinicians and non-clinicians, and gritty leaders who relentlessly push for improvement. Together they create and sustain gritty organizations.

For the past two years I’ve given presentations and moderated panels of hospital CEO’s under various titles that all included the word “grit”. This was intentional after reading the work of professor Angela Duckworth on the topic. I started found the topic has occupied the thoughts of many leaders in many disciplines who have written and spoken about what grit means and why it matters. From the Navy SEALs to Teddy Roosevelt, they all had a perspective on what makes people and teams successful and grit consistently was at the top of the list.

That’s why a recent article in the Harvard Business Review written by Angela Duckworth and Thomas H. Lee, Chief Medical Officer of Press Gainey caught my attention. It was right up my alley because it was specifically written from a health care industry point of view. The name of the article is Organizational Grit: Turning passion and perseverance into performance: the view from the health care industry.

If you lead a team of any kind in the health care industry you must read this article, but if you’re a busy healthcare leader you probably don’t have time to read the entire thing. Well, you’re in luck as I’ve summarized it and added my own thoughts. I hope you enjoy!

Stamina, Commitment, Sacrifice

Duckworth and Lee begin the article saying, “High achievers have extraordinary stamina. Even if they are at the top of their game, they always strive to improve. Even if their work requires sacrifice, they remain in love with what they do. Even when easier paths beckon, their commitment is steadfast. We call this remarkable combination of strengths ‘grit’.

Grit predicts who will accomplish challenging goals. Research done at West Point, for example, shows that it’s a better indicator of which cadets will make it through training than test scores and athletic ability.”

The authors go on to say grit, “propels people to the highest ranks of leadership in many demanding fields.” My experience working with successful leaders in healthcare has proven this time and time again.

One reason the article resonated so powerfully with me is this sentence, “Today great care requires great collaboration—gritty teams of clinicians who all relentlessly push for improvement.” Collaboration is one of the most powerful strategies behind successful healthcare leaders and the delivery of quality healthcare, and it forms the foundation for much of the work my team and I have been doing across the country.

Dr. Lee and Duckworth contend that, “the new model of grit in healthcare requires passion for patient well-being and perseverance in the pursuit of that goal become social norms at the individual, team and institutional levels. Health care, because it attracts so many elite performers and is so dependent on teamwork, is an exceptionally good place to find examples of organizational grit.”

In other words, while healthcare is blessed with some of the grittiest individuals, their individual grit won’t matter unless there is a culture of collaboration and their teams and organization are aligned.

Developing Gritty Individuals

The grittiest of gritty leaders will not succeed unless they can foster a collaborative culture among gritty individuals. Which Lee and Duckworth logically conclude, “begins with selecting and developing gritty individuals.”

Which means that organizations must look for leaders and team members who possess the “two critical components of grit”, passion and perseverance. “Passion comes from intrinsic interest in your craft and from a sense of purpose—the conviction that your work is meaningful and helps others. Perseverance takes the form of resilience in the face of adversity as well as unwavering devotion to continuous improvement.”

My experience again aligns with Lee and Duckworth’s research when it comes to the need for leaders to assess a person’s ability to prioritize goals in a hierarchy where small tasks build up to their overarching goals? “Less gritty people, in contrast, have less coherent goal hierarchies—and often, numerous conflicts among goals at every level.”

“How can you hire for grit? …look for multiyear commitments and objective evidence of advancement and achievement, as opposed to frequent lateral moves, such as shifts from one specialty to another. When checking references, listen for evidence that candidates have bounced back from failure in the past, demonstrated flexibility in dealing with unexpected obstacles, and sustained a habit of continuous self-improvement. Most of all, look for signs that people are driven by a purpose bigger than themselves, one that resonates with the mission of your organization.”

You can improve your environment to foster grit in your people. Even though your organization is demanding with high expectations make sure your people know they are supported in taking risks, making mistakes and continuously learning and growing. Lee and Duckworth point to the Cleveland Clinic which does an excellent job of this through their annual professional reviews (APRs) with their doctors. Each physician reflects on their progress the past year, completes an assessment and then meets with their supervisor to set goals for the new year. The clinic then offers relevant support and training to help them achieve those goals.

Building Teams

Lee and Duckworth studied and compared Navy SEAL training and UCLA’s highly successful kidney transplant IPU which lead to the conclusion that, “Gritty teams have the same traits as gritty individuals: a desire to work hard, learn, and improve; resilience in the face of setbacks; and a strong sense of priorities and purpose.

In health care, teams are often defined by the patients they serve (say, patients with breast cancer). Gritty team members may have their own professional goal hierarchies, but each will embrace the teams high-level goal – typically, a team specific goal, such as “improve our breast cancer patients’ outcomes, that in turn supports the organization’s overarching goal.”

Collaboration, again, is in the forefront. “Many people in health care associate commitment to a team with the loss of autonomy—a negative—but gritty people view it as an opportunity to provide better care for their patients. They see the whole as greater than the sum of its parts, recognizing that they can achieve more as a team than as individuals. Members meet frequently to review cases, set targets for improvement, and track progress. In many instances, the entire team discusses each new patient. These meetings reinforce the sense of shared purpose and commitment and help members get to know one another and build trust—another characteristic of effective teams.”

The authors cite the book “Team of Teams” by General Stanley McChrystal in which he says the purpose of the Navy SEAL training program is “not to produce super soldiers. It is to build super teams. Few tasks are tackled alone… the formation of SEAL teams is less about preparing people to follow precise orders than it is about developing trust and the ability to adapt within a small group.”

I think the pressures of saving lives whether in battle or in the hospital, creates an environment where teamwork is not only required, it is desired by team members who have personal grit. My takeaway is simple: a commitment to a shared purpose, a focus on improvement and mutual trust are the hallmarks of gritty teams.

Gritty Organizations

Lee and Duckworth say that if gritty individuals and gritty teams are to thrive, healthcare organizations need to develop cultures that make them a reflection of their best teams and people. In other words: gritty organizations.

The authors contend this is done through aligning organizational objectives. Sounds simple, right? The problem is all too often leaders promote high level objectives that people won’t embrace or they promote multiple missions at once creating room for poor decisions. Dr. Lee suggests every gritty healthcare organization has a primary goal of putting patients first. This doesn’t mean there aren’t other initiatives or focus for an organization, but their research shows the grittiest organizations put the patient first.

Aligning Organizational Objectives

Gritty health care organizations have clear goal hierarchies. Lower level goals support those at the next tier, in service of a single, overarching top-level goal or mission. If leaders don’t use this top-level goal to make decisions, it will undermine their credibility. The authors say Press Ganey data indicates “that when clinicians and other employees embrace their organization’s commitment to quality and safety, and when those goals reflect their own, it leads not only to better care but better results.”

So how do leaders translate this into practical use? Again, turning to the Cleveland Clinic, Lee and Duckworth identify four core strategies:

  • Engage teams in sharing stories or examples of incidence in which the care a patient received made them proud. Cleveland Clinic did this. It was timely and expensive, but Toby Cosgrove, CEO says it was one of the most powerful ways he helped the organization align around its mission.
  • Establish social norms that support the top-level goal. At Mayo Clinic the social norm is for clinicians to respond to a page immediately. No excuses. If on the road they pull over and respond. In survey’s teams were asked “what if you don’t answer your page right away”. Some said “you won’t do well here” while others joked “the earth will swallow you up”. While there is more to the Mayo Way, this is part of the culture.
  • Foster restlessness with the status quo and an unrelenting drive to improve.
  • Promote from within and establish a “growth mindset” while learning from mistakes. This, of course, requires leadership to accept, and even publicly communicate, complications and errors—something that doesn’t always come easily in health care.

The Gritty Leader

Lee and Duckworth look back as they look forward in defining the gritty leader:

“Ralph Waldo Emerson observed that organizations are the lengthened shadows of their leaders. To attract employees, build teams, and develop an organizational culture that all have grit, leaders should personify passion and perseverance—providing a visible, authoritative role model for every other person in the organization. And in their personal interactions, they too must be both demanding—keeping standards high—and supportive.”

They then profiled the career of Toby Cosgrove, CEO of Cleveland Clinic. Cosgrove was diagnosed with dyslexia in his mid-30s which explained his lackluster grades as a student and why 12 of the 13 medical schools he applied to rejected him. He was drafted into Vietnam and upon returning was dead set on becoming a heart surgeon even though many discouraged it. He went on to perform over 22,000 cardiac surgeries, pioneer new technologies and earn several patents. Cosgrove’s development has a world class surgeon is a case study in grit on its own, but his persistence as the CEO of Cleveland Clinic for over 13 years is inspirational for those leaders who strive to be gritty.

On the article, he is quoted as saying, “I decided I had to become a student of leadership… I had stacks of books on leadership, and every night when I came home, I would go up to my little office and read. And then I called up Harvard Business School professor Michael Porter.”

With the help of others – in particular, Harvard Business School professor Michael Porter who is widely considered to be the father of the modern field of strategy – Cosgrove learned “he needed to be more than a renowned surgeon and an enthusiastic leader.” Porter helped him understand that, “he needed to evolve the organization’s strategy, focusing on how to create value for patients and achieve competitive differentiation in the process.”

The institutional changes Cosgrove and his team have accomplished are too numerous to catalog, but here are a few:

  • Swapping parking spaces so that patients, not doctors, are closest to the clinic’s entrances.
  • Moving medical records from hard copy to electronic storage.
  • Developing standard care paths to ensure consistency and optimize the quality of care.
  • Refusing to hire smokers
  • And, in response to the national opioid crisis, doing random drug testing of all Cleveland Clinic staff, including physicians and executives.

Lee and Duckworth say it’s hard to argue with the results achieved during his 13-year tenure as CEO, and I agree. In addition to the improvements in patient experience, revenue grew from $3.7 billion in 2004 to $8.5 billion in 2016, and total annual visits increased from 2.8 million to 7.1 million. Quality on virtually every available metric has risen to the top tier of U.S. health care.

“Cosgrove showed grit. And led an organization that has become his reflection.”

The Future of Rural Healthcare
Building organizational grit is no easy task, but this article breaks down the components and uses real examples from healthcare leaders we’re all familiar with, in a way that is not only inspirational, but serves as a blueprint for the future success of rural healthcare.

The timing of this article couldn’t have been better because it reinforces my work with National Rural Health Association and our ongoing “True Grit” webinar series. With the sponsorship of NRHA, our collaborative program called Rural Hospital Insurance of America (RHIA) is making it possible for community hospital CEO’s and other healthcare leaders to embrace and foster grit, while collaborating to leverage their combined buying power and shared wisdom.

If you would like to learn more about our true grit work, RHIA or any of the concepts in this review, please contact me 888-665-1539.