On a medical ward, a nurse needs a new pressure-relief mattress for a patient. She knows exactly which one. The request goes to her head nurse, then to purchasing, then back for a signature. Four days later, the mattress arrives. The patient has developed a pressure sore in the meantime.
No one in that chain did anything wrong. Each step followed the rules. That is what culture looks like in practice: not a value on a poster, but the way a decision travels.
Organizational culture in healthcare is the set of shared habits, beliefs and unwritten rules that shape how people work together, decide and care for patients. It shows in who is trusted to act, how mistakes are handled and how fast a concern reaches someone who can do something about it.
This article looks at why culture change in healthcare organizations has become a strategic question, what models such as Teal and Buurtzorg can teach us, where their limits are, and how to go about implementing culture change in healthcare in a way that lasts.
Healthcare organizations are under pressure from every side: ageing populations, staff shortages, rising costs, new technologies and higher expectations from patients and professionals alike. Most of them have answered with new strategies, new structures and new tools.
Many of those answers have not delivered what was hoped. Not because the plans were wrong, but because the culture underneath them stayed the same.
The link between culture and care is well documented. In a systematic review published in BMJ Open in 2017, Jeffrey Braithwaite and colleagues analysed 62 studies on organizational and workplace culture and patient outcomes. They found a consistently positive association across settings and countries: positive cultures went with lower mortality, fewer falls, fewer hospital-acquired infections and higher patient satisfaction. Most studies were cross-sectional, so they show association rather than proof of cause, but the direction was remarkably consistent.
How people work together shows up in the care patients receive.
Culture is therefore not a soft topic for healthcare leaders. It is part of quality, safety and performance.
In his book Reinventing Organizations (2014), Frederic Laloux describes how organizational models have evolved, and gives each stage a colour.
Amber organizations are built on stability, clear hierarchy and standard processes. Decisions flow from the top, roles are fixed and predictability is valued above all. Many hospitals still carry strong Amber features, often for good reasons: safety, regulation and the need for reliable procedures.
Orange organizations focus on performance, targets and innovation. They introduced management by objectives, dashboards and competition. Much of today's healthcare management, with its indicators and efficiency programmes, comes from this model.
Green organizations add a strong focus on values, culture and stakeholders. They invest in empowerment, consensus and a caring climate. Many healthcare organizations that talk about patient-centered care and employee experience are drawing on Green ideas, even when their structures remain Amber or Orange.
Teal organizations, as Laloux describes them, rest on three breakthroughs:
Teal is not a structure to copy. It is a different set of assumptions about trust, autonomy and why the organization exists. That is what makes it interesting for healthcare, and also what makes it difficult.
The best-known example of these ideas in healthcare is Buurtzorg, a Dutch home care organization founded by nurse Jos de Blok. It started in 2007 with a single team in Almelo, out of frustration with a home care system that had become fragmented, bureaucratic and driven by time slots.
Buurtzorg works with small, self-governing teams of about 10 to 12 nurses, each responsible for 50 to 60 patients in a neighbourhood. Teams decide how care is organized, who does what, how they plan their work and how they collaborate with general practitioners and families. A small back office and regional coaches support them, without acting as managers.
By 2014, according to a case study published by the Commonwealth Fund in 2015, Buurtzorg had grown to about 8,000 nurses in roughly 700 teams, caring for around 65,000 patients.
The results drew international attention:
The full picture is more nuanced than it is often presented. The same KPMG analysis found that total costs, including nursing home, hospital and physician care, were about average compared with other providers. The gains were real, but they were not the miracle sometimes described.
Buurtzorg's lesson is not that hierarchy should disappear. It is that professionals close to the patient can make many more decisions than traditional systems allow.
Buurtzorg also faced real challenges. Scaling the model while keeping teams autonomous, maintaining quality across regions and fitting a self-managing organization into a funding and regulatory system designed for hierarchies all required constant work.
Laloux also describes Heiligenfeld, a group of psychosomatic clinics based in Bad Kissingen, Germany. Its practices show what wholeness can look like in an inpatient setting.
One practice stands out: regular large-group reflection meetings, where staff from across the organization reflect together on a theme linked to their work and their relationships. These meetings build a shared language, reduce conflict and give people a place to raise what is usually left unsaid.
Heiligenfeld is a specialized setting, and its practices cannot simply be transferred to an acute hospital. But it shows that wholeness is not a vague idea. It can be built into concrete, repeated rituals.
It is tempting to see Teal as a ready-made answer for healthcare. It is not.
Acute hospitals deal with high-risk procedures, round-the-clock continuity, strict regulation and complex interdependencies between dozens of professions. Some decisions must remain clearly assigned. Some standards must remain non-negotiable. Full self-management, as Buurtzorg practises it in home care, does not translate directly to an emergency department or an operating theatre.
The evidence also needs care. Much of what is written about Teal organizations in healthcare is based on case descriptions rather than comparative studies, and many organizations described as "Teal" have adopted a few practices rather than the whole model.
What does transfer are the principles behind the label:
The question for most healthcare leaders is not "Should we become Teal?" It is "Which decisions could our teams take themselves, and what would they need to do it safely?"Why organizational culture in healthcare matters now
Healthcare enterprise transformation means changing how an organization works as a whole: its culture, structures, decision rights, processes and leadership practices, not just one department or one tool. Done well, it has effects on three levels.
Organizational performance. When decisions sit closer to the work, they are taken faster and with better information. Fewer escalations, less duplication and clearer accountability free time for care. Buurtzorg's lower overhead is one illustration of what simpler structures can achieve.
Patient outcomes. When teams trust each other, speak up early and coordinate across professions, care becomes safer and more continuous. The association between positive culture and outcomes such as mortality, falls and infections, found in Braithwaite's review, points in this direction.
Long-term system sustainability. Healthcare systems will not remain sustainable if they keep losing the professionals they train. Cultures that give people autonomy, recognition and meaning help retain staff, which protects both quality and costs over time.
The stakes are concrete in Switzerland. Analysing federal survey data from 2016 to 2018, the Swiss Health Observatory (Obsan) found that around 42% of people trained as nurses at tertiary level were no longer working in their profession. Training more professionals only helps if the culture gives them reasons to stay.
Transformation that ignores culture rarely lasts. Culture change that ignores structures and processes rarely holds either. The two must move together.
Culture is hard to see from the top. It becomes visible in small, repeated signals that leaders often treat as isolated incidents. Some of the most common ones in healthcare organizations are:
None of these signals proves anything on its own. Together, they show where the culture and the declared strategy have drifted apart.
Workarounds are data. When people consistently build informal systems, the formal system is failing somewhere.
No culture change in healthcare works if people are afraid to speak. Amy Edmondson, professor at Harvard Business School, calls the opposite condition team psychological safety: a shared belief that it is safe to take interpersonal risks, such as asking a question, admitting a mistake or challenging a decision.
In a study of 51 work teams in a manufacturing company, published in Administrative Science Quarterly in 1999, she found that psychological safety was associated with learning behavior, such as asking for help, discussing errors and seeking feedback, and that this learning behavior was linked to team performance.
Her earlier work in hospitals points in the same direction. In a 1996 study of eight inpatient units in one university hospital, the units with stronger nurse manager leadership and better relationships reported more medication errors, not fewer. Her interpretation: these teams were probably not making more mistakes. They were more willing to talk about them.
A culture where problems surface early is a culture that can change. That is why psychological safety comes before structures, methods or new models.
Head nurses, unit leaders and heads of department are where culture change succeeds or stalls. They translate strategy into daily work, decide how mistakes are handled and set the tone in their teams.
Yet they are often the most overloaded people in the organization, caught between management expectations and the reality of their teams. When a culture change programme adds new tasks without removing old ones, it is usually at their level that it quietly stops.
Supporting them is not an optional extra. It means giving them time to lead, a clear mandate on the decisions they own, and spaces to share difficulties with peers. If middle managers do not experience the new culture themselves, they cannot pass it on.
Healthcare organizations do not need to adopt a whole model to benefit from its ideas. Some practices can be tested within existing structures:
Each of these practices is small. Together, they shift where decisions are taken and how people relate to each other, which is what culture change is about.
Culture change cannot be ordered. It can be created through consistent decisions and repeated behaviors. These seven steps help structure the work.
Before deciding where to go, understand where you are. Listen to teams across professions and levels, observe how decisions actually travel, and look at what people work around rather than what the procedures say.
Useful questions include:
Culture change needs sponsors who go further than approving a project. Leaders must be ready to change their own behaviors, delegate decisions and accept that some control will move closer to the front line.
If the leadership team does not change how it works, the rest of the organization will notice quickly.
Values only matter when they guide daily decisions. Involve teams in defining what your purpose and values mean in concrete situations: a difficult discharge, a disagreement between professions, a mistake.
Translate each value into a few observable behaviors, so that everyone shares the same understanding of what is expected.
Identify the decisions that teams could take themselves within a clear frame: scheduling, small purchases, organization of care, collaboration with partners. Define the boundaries, the escalation rules and the support available.
Start with a pilot unit, learn from it, then extend.
Middle managers are the key to any culture change. They need to move from controlling and reporting to coaching, facilitating and removing obstacles.
That shift requires:
Share information openly, including what is not going well. Create regular spaces where teams can raise tensions without fear of blame. A Just Culture approach helps here, by distinguishing human error, at-risk behavior and reckless behavior, and responding fairly to each.
Culture change is not a project with an end date. Set up short feedback loops, review regularly what is changing and what is not, and adjust. Celebrate progress, and treat setbacks as information rather than failure.
Imagine a surgical ward where every change to the nursing schedule needs the approval of the head of nursing. Requests pile up, swaps are refused because no one has time to review them, and staff feel they have no control over their own lives.
The unit decides to test a different approach for three months. Within agreed rules on minimum staffing, skills mix and rest periods, the team organizes its own roster. The head nurse moves from approving every change to coaching the team when conflicts arise. A short weekly huddle reviews what works and what does not.
After three months, the team reviews the results together: how many swaps were handled, how many conflicts needed escalation, how staff felt about their schedules, and whether patient care was affected. Based on what they learn, they adjust the rules, and other units ask to try the same approach.
Nothing in this example requires a new organizational model. It requires trust, a clear frame and the willingness to learn.
That is how culture change in healthcare usually happens: not through a single announcement, but through small, visible experiments that show people a different way of working is possible.
What gets measured shapes what leaders pay attention to. To follow a culture change, combine a few indicators of different kinds:
Review them regularly with the teams concerned, and look for patterns rather than single numbers. The purpose is to learn, not to grade.
Every culture change meets resistance and obstacles. Anticipating them makes them easier to handle.
People may resist leaving familiar structures, out of fear of losing control, of taking on more responsibility or of yet another initiative that will not last.
How to respond: explain the reasons for the change honestly, involve teams in designing it, and start with pilots that let people experience the new way of working before it is extended.
Funding models, regulations, IT systems and HR policies are often designed for hierarchies. New practices can collide with them.
How to respond: start where the room for manoeuvre is greatest, adapt systems step by step, and involve the functions that own them, such as finance, HR and IT, from the start.
Leaders who built their careers in hierarchical systems may find it hard to let go of control, or may not know how.
How to respond: invest in leadership development grounded in real situations, with coaching, practice and peer exchange, rather than one-off training.
Some units change quickly, others not at all. Inconsistency can create frustration and a sense of unfairness.
How to respond: create a small network of people who support the change across units, share what works, and hold regular organization-wide moments to align.
Traditional indicators do not always capture what culture change produces.
How to respond: combine outcome, experience and process measures, such as patient outcomes, staff turnover and engagement, time to decision and the number of issues raised early. Involve teams in choosing the measures so they are meaningful to them.
To go further, Bee'z offers a free guide for healthcare, pharmaceutical and medical device organizations: "How to change and transform your organization to succeed in turbulent times (keeping your people on board)".
The evolution of organizational culture in healthcare is not about adopting a fashionable model. It is about recognizing that strategies, structures and tools only work when the culture underneath them supports them.
Models like Teal and examples like Buurtzorg are useful because they challenge assumptions about hierarchy, trust and autonomy. Their real value lies in the questions they raise for every healthcare organization:
Culture does not change because it is described better. It changes when people practise different behaviors, again and again, in the moments that matter.
At Bee'z Consulting, we help healthcare and life sciences organizations implement culture change that holds: from diagnosis to new leadership practices, with the people who do the work.
Our work draws on practical methods such as Values in Action, to translate values into observable behaviors; Just Culture conversations, to balance accountability and learning; the Emotional Culture Deck, to name the emotions teams want to experience at work; and the Team Dynamics Method, to build trust through behavior rather than words.
If you are preparing a cultural transformation, or are in the middle of one and feel it is losing momentum, let's talk: https://www.beez-consulting.com/contact
Organizational culture in healthcare is the set of shared habits, beliefs and unwritten rules that shape how professionals work together, make decisions and care for patients. It shows in who is trusted to act, how mistakes are handled and how quickly concerns reach someone who can act. It often matters more to daily care than formal structures or procedures.
Culture shapes how teams communicate, coordinate and speak up about risks. A 2017 systematic review in BMJ Open by Braithwaite and colleagues, covering 62 studies, found a consistently positive association between organizational and workplace culture and patient outcomes, including lower mortality, fewer falls, fewer hospital-acquired infections and higher patient satisfaction.
Start with an honest diagnosis of how decisions really travel and where people feel blocked. Secure leaders who are ready to change their own behaviors. Translate values into observable behaviors, move some decisions closer to patients, support middle managers, build psychological safety, and test changes in pilot units before extending them. Review progress regularly and adjust.
A Teal organization, as described by Frederic Laloux in Reinventing Organizations (2014), is built on three principles: self-management, wholeness and evolutionary purpose. Teams organize their own work, people bring their whole selves to work, and the organization is guided by its purpose rather than a fixed plan. It contrasts with hierarchical Amber and target-driven Orange models.
Buurtzorg is a Dutch home care organization founded by nurse Jos de Blok, which started in 2007. It relies on self-governing teams of about 10 to 12 nurses, each caring for 50 to 60 patients in a neighbourhood, supported by a small back office and coaches. It became an international reference for self-management in healthcare.
Rarely in full. Acute hospitals manage high-risk procedures, continuous care and strict regulation, so some decisions and standards must remain clearly assigned. But many Teal-inspired principles can be applied: moving decisions closer to patients, trusting teams within a clear frame, attending to the whole person and letting purpose guide daily choices. Pilots at unit level are a good starting point.
Amber culture relies on hierarchy, fixed roles, standard processes and top-down decisions, valuing stability and predictability. Teal culture relies on self-management, trust and purpose, with decisions taken by those closest to the work. Many healthcare organizations combine both: Amber features where safety requires them, and Teal-inspired practices where autonomy improves care.
Common barriers include resistance to leaving familiar structures, funding and regulatory systems designed for hierarchies, leaders unused to coaching styles, inconsistent progress across units and difficulty measuring results. Overloaded middle managers are often where change quietly stalls. Anticipating these barriers and addressing them openly makes cultural transformation far more likely to last.
There is no fixed timeline, but meaningful culture change usually takes several years rather than months. Early signals, such as faster decisions, more issues raised early or better team climate, can appear within a few months in pilot units. Lasting change depends on leaders modelling new behaviors consistently and on structures that reinforce them.
Combine several types of indicators: outcome measures such as safety incidents or readmissions, experience measures such as patient surveys and staff engagement, process measures such as time to decision or issues raised early, and people measures such as turnover and absenteeism. Review them with the teams concerned and look for patterns over time.
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