If your hospital undertakes a building or remodeling project, it will hire a team of architects and designers to create a detailed set of blueprints specifying the location of every electrical outlet and the color of every carpet square. Considering that the "invisible architecture" of core values, corporate culture and the emotional climate of the workplace is far more influential on both the patient experience and the satisfaction of employees, it's surprising that in most organizations it is allowed to evolve haphazardly, without a plan or blueprint.

It's been said with good reason that culture eats strategy for lunch, but it's a rare organization that puts as much thought into the cultural blueprint as it does into blueprints for bricks and mortar. Here, we'll look at how one hospital rethought its invisible architecture.

In June 2007, Tucson (Ariz.) Medical Center was in trouble. Not only did it face a budget shortfall of $11 million, it was suffering from plummeting morale among employees and medical staff. It had experienced significant turnover in senior management, including the CEO position, and the management team lacked strategic focus. Meanwhile, the board was engaged in due diligence in preparation for a potential change of ownership.

At that point, the board brought back TMC's former chief nursing and chief operating officer to serve as CEO. During her first 18 months, she focused on structure, process and accountability for achieving measurable goals. The entire organization had to come to terms with high costs and a lack of focus on the patient. Tough decisions were embraced as the staff rallied around excellence and productivity. The organization began to quickly achieve results as expenses were cut, turnover declined, employee and physician engagement grew, and patient satisfaction scores improved. Based on these results, the board elected to maintain the hospital's independence.

At this point, the CEO knew that longer-term success would have to be built on a more solid foundation of values and culture. She engaged a consultant to assist the entire organization in rethinking the existing statement of values, which had minimal buy-in or resonance with the staff. Employees were engaged in the process of rethinking TMC's values through interactive town hall meetings. When the new statement of values was presented to the board, one trustee captured the spirit of the work by saying, "This really is who we are and who we want to be."

The next stage in developing the invisible architecture is currently under way: fostering a corporate culture and an emotional climate that honors those core values. To begin that process, TMC started with its emergency department, which is the second busiest in Arizona. In summer 2009, TMC's ED had some of the hospital's lowest employee, patient and physician satisfaction scores. TMC began its work by considering eight essential characteristics of a culture of ownership. This framework created a common understanding of the ideal culture in which ED staff wanted to work.

The characteristics are:

Commitment: To values, vision and mission

Engagement: Being fully present, physically and emotionally

Passion: Loving your work and letting it show

Initiative: Seeing what needs to be done and taking action to get it done

Stewardship: Effectively shepherding limited resources

Belonging: Being included, feeling included and including others

Fellowship: Being a friend and having friends at work

Pride: In your profession, your hospital, your work and yourself

The consultant also conducted a series of focus groups for ED staff and submitted a fairly critical report to the department director. The director in turn shared that report, unedited, with the entire staff and committed to a much higher level of visibility within the department to address staff members' concerns. She and her team began to aggressively address problem areas and enlisted the support of ancillary departments when needed.

Since then, there has been a palpable transformation in the culture and emotional climate of the ED. The most negative staff members have either improved their attitudes or left the organization, management visibility and communications have been greatly enhanced, and the department is receiving a much higher level of support from ancillary departments and from the ED medical staff. As of the most recent surveys, employee satisfaction is up by 18 percent, and patient satisfaction is up by 12 percent. The ED director has shared her success stories with other managers, and because the ED is so central to hospital operations overall, their wins are being repeated around the hospital.

The TMC leadership team knows that in a competitive health care market, every action—from the board's decision regarding hospital ownership status to a staff member's treatment of a patient in the ED—must be grounded in the medical center's core values.

They also know that if staff members don't live up to the behavioral expectations created by those values, TMC board members are likely to hear about it by being accosted by an unhappy patient or family member at the grocery store.

Over the next several years, hospitals will be challenged to accelerate commitments to patient-centered care and clinical integration. They will be faced with what is projected to be the most serious staffing shortage in history while simultaneously trying to meet the demands created by increased health care needs and expectations of an aging baby boom generation—all under constraints imposed by health care reform. The most successful hospitals will be those that have built a culture of ownership. Trustees should take a vital interest in designing that blueprint.

Joe Tye (joe@joetye.com) is CEO of Values Coach Inc., Solon, Iowa, and a member of Health Forum's Forum Faculty Speaker Service. Judith F. Rich (judy.rich@tmcaz.com) is president and CEO of Tucson (Ariz.) Medical Center.

Tucson Medical Center Statement of Values