JOINING FORCESJOINING FORCESJOINING FORCESJOINING FORCESJOINING FORCES A Crosswalk of the Human Services Value Curve with Organizational Culture and Climate By Anthony Hemmelgarn and Phil Basso JOINING FORCESJOINING FORCESJOINING FORCESJOINING FORCESJOINING FORCESJOINING FORCESJOINING FORCESJOINING FORCESJOINING FORCESJOINING FORCESJOINING FORCES Policy & Practice June 201624 A s we evolve in our working partnership with APHSA’s Organizational Effectiveness team and the University of Tennessee’s Center for Behavioral Health Research (CBHR), formerly the Children’s Mental Health Services Research Center, we have discovered great synergy in our respective efforts for supporting agency performance. These include APHSA’s efforts to help agencies progress through stages of the Health and Human Services Value Curve, and CBHR’s efforts to help agencies improve by addressing their organizations’ cultures and climates. The Value Curve is a lens—a way of looking at what we do from the point of view of our consumers—and its four levels represent ways of engaging consumers and their communities that result in greater impact as orga- nizations move up the Value Curve. At the first level, called the regula- tive level, the key word is “integrity.” Consumers receive a product or service that is timely, accurate, cost effective, and easy to understand. Next, at the collaborative level, the key word is “service.” Consumers have an easier time of it when they “walk through a single door” and have access to a more complete array of products and services because programs, and even jurisdictions, are collaborating to make it happen for them. At the integrative level, the key term is “root causes.” Products and services are designed using consumers’ input so that we address their true needs and even begin to reach “upstream” to address causal problems rather than “treating the symptoms.” At the gen- erative level, the key term is “bigger than the family.” Root- cause analysis is done at a “population-wide level,” resulting in prevention strategies and other forms of support broader than those an individual or family would receive directly.1 Organizational culture and climate is another potent lens that human service organizations can use to look at their performance and improve their outcomes. APHSA’s partners at CBHR have been building that case for more than 20 years, demonstrating the substantial impact of organizational culture and climate on the effective- ness of human services.2 Their work demonstrates that: (1) human service agencies vary widely in their organi- zational culture and climate profiles, (2) agencies with positive profiles have substantially better outcomes, and (3) agencies can improve their turnover, EBP/EBT implementation, client, and other outcomes through strategies that improve their cultures and climates. The CBHR uses its Organizational Social Context Measure .

1. JOINING FORCESJOINING FORCESJOINING
FORCESJOINING FORCESJOINING FORCES
A Crosswalk of the Human Services Value Curve
with Organizational Culture and Climate
By Anthony Hemmelgarn and Phil Basso
JOINING FORCESJOINING FORCESJOINING
FORCESJOINING FORCESJOINING FORCESJOINING
FORCESJOINING FORCESJOINING FORCESJOINING
FORCESJOINING FORCESJOINING FORCES
Policy & Practice June 201624
A
s we evolve in our working
partnership with APHSA’s
Organizational Effectiveness
team and the University of
Tennessee’s Center for Behavioral
Health Research (CBHR), formerly
the Children’s Mental Health Services
Research Center, we have discovered
great synergy in our respective efforts
for supporting agency performance.
These include APHSA’s efforts to help
agencies progress through stages of
the Health and Human Services Value
Curve, and CBHR’s efforts to help

2. agencies improve by addressing their
organizations’ cultures and climates.
The Value Curve is a lens—a way of
looking at what we do from the point
of view of our consumers—and its
four levels represent ways of engaging
consumers and their communities
that result in greater impact as orga-
nizations move up the Value Curve.
At the first level, called the regula-
tive level, the key word is “integrity.”
Consumers receive a product or service
that is timely, accurate, cost effective,
and easy to understand. Next, at the
collaborative level, the key word is
“service.” Consumers have an easier
time of it when they “walk through
a single door” and have access to a
more complete array of products and
services because programs, and even
jurisdictions, are collaborating to make
it happen for them.
At the integrative level, the key term
is “root causes.” Products and services
are designed using consumers’ input
so that we address their true needs
and even begin to reach “upstream” to
address causal problems rather than
“treating the symptoms.” At the gen-
erative level, the key term is “bigger
than the family.” Root- cause analysis
is done at a “population-wide level,”
resulting in prevention strategies and
other forms of support broader than

3. those an individual or family would
receive directly.1
Organizational culture and climate
is another potent lens that human
service organizations can use to look
at their performance and improve
their outcomes. APHSA’s partners at
CBHR have been building that case for
more than 20 years, demonstrating the
substantial impact of organizational
culture and climate on the effective-
ness of human services.2 Their work
demonstrates that: (1) human service
agencies vary widely in their organi-
zational culture and climate profiles,
(2) agencies with positive profiles have
substantially better outcomes, and (3)
agencies can improve their turnover,
EBP/EBT implementation, client, and
other outcomes through strategies that
improve their cultures and climates.
The CBHR uses its Organizational
Social Context Measure (OSC-M) to
profile agencies across dimensions of
culture and climate that have been
shown to be important to the suc-
cessful functioning of human service
organizations. Taken together, these
dimensions encapsulate key aspects
of an agency’s “personality” and offer
insights that can be used to improve
performance metrics.
As an example of the synergy

4. between our two models, the following
crosswalk describes proficiency, one
of the dimensions of culture, in the
context of the Value Curve. In profi-
cient cultures, staff shares expectations
that it will be responsive to the unique
needs of its clients and have up-to-
date knowledge and practice skills.3
Broadly, we expect proficiency levels to
rise as organizations advance to higher
levels on the Value Curve.
The Regulative Level
and Proficiency
The regulative level for organiza-
tions is about building a stable and
reliable infrastructure, and while
the value proposition is foundational
and compliance oriented, much of
the cultural focus is internal. This
includes laying out standards and pro-
cesses for how the organization will
operate, creating greater certainty, and
establishing a framework to achieve
efficiency. These are essential organi-
zational capabilities; without them,
there is chaos and failure.
Unfortunately, organizations at
this level can easily elevate order and
“covering the bases” to be ends rather
than means. When this happens, pro-
ficiency drops dramatically. Phil Basso
encounters this often in his fieldwork,

5. and coined the term “bad regulative”
for this approach (see his article in
April’s Policy and Practice, “Travels
with the Value Curve”).
A number of years ago Anthony
Hemmelgarn helped conduct 25
focus groups from one end of a state
to the other. More than 200 child
welfare managers participated. The
goal of each session was to answer a
single question: “What needs to be
measured to determine staff success?”
The answers, over and over, were
about process: how many clients were
contacted, how many seen, paper-
work completed on time. In and of
themselves, there is nothing wrong
with such responses. But not a single
manager suggested anything related to
clients getting better, and a laser focus
on this is essential for high proficiency.
This child welfare system was paying
little attention to addressing its clients’
needs. Proficiency, we can safely
assume, was extremely low.
Human service systems often rely
on standardized case management
practices, such as requirements to visit
families so many times per week, in
a sincere effort to improve quality of
care. But such tactics run counter to
proficiency. “One size fits all” policies
are, in fact, unresponsive to clients’
unique needs. Case managers’ time

6. and other valuable resources are rou-
tinely wasted. Morale suffers.
June 2016 Policy & Practice 25
It must also be noted that many
of the regulatory requirements that
agencies confront are externally
applied and beyond the control of
agency leaders and staff . They must
meet funder requirements. They must
trying new approaches, and effi cacy
in helping clients builds; attention to
eff ectiveness for clients increases along
with profi ciency. Front-line staff must
also be able to work closely together
within its own teams, and the teams
must have the skills and tools neces-
sary to eff ectively interact and problem
solve with other programs and depart-
ments, and with external organizations
and stakeholders.
Such work increases the probability
that programs and organizations will
reach out and work with others in the
community. As with individuals, a
sense of effi cacy increases confi dence
and openness to relating to others.
Eff ective teams with a clear sense of
purpose, organizational support, and
a sense of their competence to improve
their clients’ well-being provide plat-

7. forms for broadening the network of
relationships required to reach higher
levels of the Value Curve.
However, collaboration has its own
traps. Similar to the regulative level,
an overemphasis on process can undo
profi ciency. For example, spending
considerable time and eff ort negoti-
ating collaborations across programs
Ef� ciency in
Achieving Outcomes
Effectiveness
in Achieving
Outcomes
Regulative Business Model: The focus is
on serving constituents who are eligible for
particular services while complying with
categorical policy and program regulations.
Collaborative Business Model: The focus
is on supporting constituents in receiving all
services for which they’re eligible by working
across agency and programmatic borders.
Integrative Business Model: The focus
is on addressing the root causes of client
needs and problems by coordinating and
integrating services at an optimum level.
Generative Business Model: The focus
is on generating healthy communities by
co-creating solutions for multi-dimensional

8. family and socioeconomic challenges and
opportunities.
Generative
Business Model
Integrative
Business Model
Ou
tco
me
Fr
on
tie
rs
Collaborative
Business
Model
Regulative
Business
Model
© The Human Services Value Curve by Antonio M. Oftelie &
Leadership for a Networked World is licensed under a Creative
Commons Attribution-NonCommercial 4.0 International
License. Based on a work at lnwprogram.org/hsvc. Permissions
beyond
the scope of this license may be available at lnwprogram.org.

9. The Human Services Value Curve
comply with legal mandates. While
uniformly well intended, such external
pressures often result in barriers to
increasing profi ciency. This is particu-
larly true when compliance is enforced
negatively or in a punitive fashion.
The Collaborative Level
and Profi ciency
At this level, organizations are
concerned with connecting across
programs and agencies to improve
effi ciency and eff ectiveness. More pro-
fi cient organizations are likely to work
toward meaningful client outcomes
that cut across internal silos. They
are more likely to involve teams and
personnel at all levels in improvement-
driven activities such as Continuous
Quality Improvement. There is more
emphasis on the effi cacy of front-line
staff as well as support for the front-
line staff to learn from their errors,
mistakes, and problems.
At the most important end of human
service organizations—the front
line—staff must feel safe and confi -
dent in its ability to achieve outcomes
centered on client well-being. As skills
develop internally, safety increases for
Policy & Practice June 201626

10. Phil Basso is the
deputy director of
the American Public
Human Services
Association.
Anthony
Hemmelgarn is
an industrial and
organizational
psychologist, is a
research scientist
at the University of
Tennessee’s Center
for Behavioral Health
Research.
http://lnwprogram.org/hsvc
http://lnwprogram.org/
and organizations can consume
resources better directed toward
clients. Collaboration can also become
its own end rather than a means,
leading to excessive focus on collabo-
ration-driven sharing (e.g., paperwork)
and miss the boat on solving real
barriers to client care.
An additional concern is that the
research on collaboration as a way
to improve client outcomes is mixed.
Moreover, collaboration can be seen by
communities as a panacea to address a

11. lack of resources. Basically, let’s have
this poor program work with that
poor program, and we won’t need to
increase funding for this service. This
happens frequently in communities,
and is a harmful side of collaboration.
In Basso’s fieldwork he has, at
times, discovered that agency leaders
view themselves as operating at the
Integrative level, but then cannot
demonstrate related methods for
family-centered engagement, compre-
hensive risk assessment, root-cause
analysis tools and metrics, or related
caseworker skill-building, suggesting
the move to a collaborative mode was
targeted to streamlining business
processes only. Proficiency through
the Value Curve’s Collaborative stage
still requires sufficient resources to get
the desired value and set the stage for
further progress.
The Integrative Level
and Proficiency
The distinguishing characteristic
of this level is pulling clients into the
problem-solving process. In organiza-
tions that achieve this level, proficiency
is likely to be high. Integrating clients
into the process means letting go of
power and transferring it to the clients.
Teams and programs with the confi-
dence, skill, and support necessary to

12. do this will have high proficiency levels.
The integrative level also requires
rethinking casework practice and the
use of technology and data. The his-
torical failure rate for such endeavors
in child welfare is alarmingly high.
Why? Because these types of changes
are almost always applied from the top
down, assuming that it will be benefi-
cial for front-line case managers and
their clients. Little thought is given to
the perceived impact on the front line.
The OSC Measure and ARC (avail-
ability, responsiveness, and continuity)
change strategy are built on the socio-
technical model of change. This model
argues that technological change is as
much a social process as a technological
one. In sum, inattention to social issues
and concerns (organizational culture
and climate) dooms technological
change. This is a primary cause of the
numerous technological failures in child
welfare. Organizations at the integra-
tive level will necessarily have positive
cultures and climates, including profi-
ciency. This foundation is essential for
organizations to address the sweeping
challenges required to achieve this level.
APHSA’s Organizational
Effectiveness (OE) practice model and
toolkit focuses on guiding a process
whereby the organization’s own staff

13. generates solutions by first defining
a desired state, assessing current
strengths and gaps, determining the
root causes for gaps, and then setting
in motion solutions that are well-sup-
ported in implementation and ongoing
monitoring, forming a learning cycle.
This approach—similar to an integra-
tive casework approach—is designed
to build proficiency while establishing
a sound structure and process for
improvement and goal attainment.
The Generative Level
and Proficiency
This level moves to a broad, commu-
nity-based conceptualization of service
delivery and addressing risk factors at
a population level, through co-creating
new capacity in the community as a
whole, and through joint advocacy
efforts that affect general beliefs and
norms that may enable or impede
progress. To achieve this Value Curve
stage, multiple organizations will need
to come together. They will have to share
a great deal. They will have to trust each
other. They will have to share a common
vision. Funders, particularly federal and
state governments, will have to re-con-
ceptualize what they want to fund.
Frankly, it is hard to envision this in
most communities. At the same time,

14. when it comes to the culture of commu-
nity leaders, partners, and consumers
of health and human services, this stage
is most appealing as the desired state
of things. Head issues off at the pass by
working on them upstream. Pay me now
instead of paying me later. Build a com-
munity that evens the playing field for
people and helps them reach their full
potential. It is fair to say that high pro-
ficiency will be a prerequisite across all
participating organizations to reach the
generative level. And, both the expecta-
tion of proficiency and proficiency itself
will be prerequisite for funders and
other stakeholders.
What is certain in human services is
that the problems being addressed are
numerous, highly complex, and difficult
to solve. This article demonstrates that
our respective models add value to the
other, and we believe this can benefit
the organizations we work with. From
our perspective, combining these two
lenses leads to a better focus and clearer
solutions than either lens alone.
Reference Notes
1. See the Human Services Value Curve
at http://aphsa.org /content/dam/
aphsa/Toolkit/Human%20Services%20
Value%20Curve%209-5-14.pdf
2. Glisson, C., Hemmelgarn, A., Green, P.,

15. & Williams, N. (2013). “Randomized
Trial of the Availability, Responsiveness
and Continuity (ARC) Organizational
Intervention for Improving Youth
Outcomes in Community Mental Health
Programs.” Journal of the American
Academy of Child and Adolescent
Psychiatry, 52(5), 493–500.
3. Williams, N. J., & Glisson, C. (2013).
“Reducing turnover is not enough: The
need for proficient organizational cultures
to support positive youth outcomes
in child welfare.” Children and Youth
Services Review, 35:11, 1871–1877.
It is fair to say that
high proficiency will
be a prerequisite
across all participating
organizations to reach
the generative level. And,
both the expectation
of proficiency and
proficiency itself will be
prerequisite for funders
and other stakeholders.
June 2016 Policy & Practice 27
http://aphsa.org/content/dam/

16. Reproduced with permission of the copyright owner. Further
reproduction prohibited without
permission.
ESTABLISHING VALUES-BASED LEADERSHIP
AND VALUE SYSTEMS IN HEALTHCARE
ORGANIZATIONS
DAVID R. GRABER
ANNE OSBORNE KILPATRICK
Medical University of South Carolina
ABSTRACT
The importance of values in organizations is often discussed in
management literature. Possessing strong or inspiring values is
increasingly considered to be a key quality of successful
leaders.
Another common theme is that organizational values contribute
to the
culture and ultimate success of organizations. These
conceptions or
expectations are clearly applicable to healthcare organizations
in the
United States. However, healthcare organizations have unique
structures and are subject to societal expectations that must be
accommodated within an organizational values system.
This article describes theoretical literature on organizational
values. Cultural and religious influences on Americans and how

17. they
may influence expectations from healthcare providers are
discussed.
Organizational cultures and the training and socialization of the
numerous professional groups in healthcare also add to the
considerable
heterogeneity of value systems within healthcare organizations.
These
contribute to another challenge confronting healthcare managers
-
competing or conflicting values within a unit or the entire
organization.
Organizations often fail to reward members who uphold or
enact the organization’s values, which can lead to lack of
motivation
and commitment to the organization. Four key elements of
values-
based leadership are presented for healthcare managers who
seek to
develop as values-based leaders. 1) Recognize your personal
and
professional values, 2) Determine what you expect from the
larger
organization and what you can implement within your sphere of
influence, 3) Understand and incorporate the values of internal
stakeholders, and 4) Commit to values-based leadership.
180 JHHSA FALL 2008
In recent years, leadership writers and theorists have
increasingly described values as a key component of
effective leadership and as an essential trait for leaders to
possess. A common theme is that leaders should possess a

18. strong foundation of personal values, principles, or ethics.
Another recurring thought is that the values of the leader
should reflect the organization’s values, which are
transmitted to or at least accepted by the organization’s
members.
What is a value? It is defined in Webster’s
Dictionary as “something (as a principle or quality)
intrinsically valuable or desirable” (Merriam-Webster
Online Dictionary, 2005). Rokeach offered a frequently
cited definition of a human value as being an "enduring
belief that a specific mode of conduct or end-state of
existence is personally or socially preferable to an opposite
or converse mode of conduct or end-state of existence"
(Rokeach, 1973, p.5). Rokeach argued that one’s major
values combine to form a value system, which is "an
enduring organization of beliefs concerning preferable
modes of conduct or end-states of existence along a
continuum of importance" (1973, p.5). Thus, an individual
will possess a plethora of values and these values will be
given varying importance, albeit not necessarily
consciously.
Healthcare organizations often list principles in
their mission statements that are courses of action or
behavior, such as “Our hospital is committed to serving our
patients and their family members by providing the highest
level of patient care quality.” The underlying value for this
principle might simply be “quality care.”
The American public has deep-rooted values about
the provision of healthcare. These values, which include
compassion and service to others, may be at odds with
healthcare organizations that have an organizational culture
and organizational priorities that are largely independent of

19. JHHSA FALL 2008 181
these values. For a healthcare organization to fit into the
community and achieve some degree of community
goodwill, the organization should reflect and embody some
measure of the community’s values. A few exemplary
organizations may even be recognized for their professed
and enacted values. Values are therefore conceived by the
authors as critical contributors to the image and the success
of an organization and its leaders.
This article reviews recent literature on values and
principles as key characteristics of effective leadership.
Literature addressing the importance of values within the
healthcare field and for healthcare managers is also
described. The article discusses challenges facing
healthcare managers who have strong personal values and
wish to adhere to these values as much as possible. In
conclusion, suggestions are given regarding how personal
values systems may be successfully integrated into
healthcare management.
American Values and Healthcare
The heritage and history of the United States and
western culture is inextricably intertwined with American
values as they relate to the provision of health care.
Americans have always valued selfless service and
compassionate health care. The majority of Americans
raised in the Christian tradition were exposed from an early
age to such stories as those of Christ healing lepers, the
crippled, and the blind man, and the story of the Good

20. Samaritan. Throughout history many individuals who
served the sick and dying have been highly respected and
widely recognized. In the twentieth century, the work of
Albert Schweitzer and Mother Theresa’s Sisters of Charity
received world-wide acclaim. The early American
traditions of hospitals with religious affiliations and
almshouses founded by benevolent societies or religious
groups also may have contributed to values held by many
182 JHHSA FALL 2008
Americans that there should be access to care for all, and
the provision of healthcare should be something greater
than a purely financial or economic enterprise. On the
other hand, Americans tend to value individualism higher
than people in virtually all other countries, and tend to rate
a collectivist or community identification lower than people
in many other countries (Hofstede, 1980). Individualistic
values could be supportive of a healthcare system that does
not serve everyone in the community, but serves those
people who work hard, are successful, and are deemed to
be deserving.
Professional Values
Little has been written the relation of one’s personal
values to professional values, and the other levels of values
(e.g., religious values, national values). For example, an
individual will complete basic schooling, with an
established value system: one that is based in his or her
family, religious, cultural, and national background. After
this, professional socialization often takes place.
Professional socialization has been considered as
potentially homogenizing value differences (among
members of the same profession) and reducing individual

21. differences on at least some values (Hofstede, 1980).
Using a values scale, undergraduate management
students were noted to score higher on authority,
advancement, economic, and risk values and lower on an
altruism value, than undergraduate nursing students
(Thorpe & Loo, 2003). This study suggests that values are
related to choice of educational programs and to career
choices. What is less known is the extent to which these
values change during the course of education and
professional socialization. One study, using the Balanced
Emotional Empathy Scale, revealed a statistically
significant decline in empathy among male medical
students from the third to the fourth year of school (Newton
JHHSA FALL 2008 183
et al., 2000). Another study used the Jefferson Scale of
Physician Empathy, and noted a statistically significant
decline in empathy from the first year of medical school to
the third year among 125 medical students (Hojat et al.,
2004). For those who expect some degree of empathic
concern from their personal physician, these findings are
troubling. If these findings can be generalized, they
suggest that many medical students may enter medical
school with compassionate and humanistic values, but these
values are eradicated or suppressed during the course of
education
As the above-described study of Thorpe and Loo
(2003) suggests, there appear to be differences in the value
systems of individuals entering different disciplines: nurses
are likely to value caring and compassion than management
students, who may be more interested in authority and

22. advancement. However, the medical school education
studies cited above provide evidence that individual value
systems, whatever they may be at the inception of
professional education, are influenced and modified in the
course of professional education. Although values are
normally considered to be “enduring beliefs”, the apparent
malleability of the empathy value in the course of medical
education begs the question, “To what extent are values
truly enduring?” Are individual value systems modified
during the course of professional education, or are
professional values created, which do not supplant, but
coexist, perhaps at times uncomfortably, with one’s
underlying value system? Such questions have been
largely unexplored in research studies.
Values in Organizations
The most comprehensive review of leadership
literature in the early to mid-twentieth century may well
have been that of Ralph Stogdill, who examined 287
studies conducted from 1904 through 1970 (Bass, 1981).
184 JHHSA FALL 2008
He noted hundreds of leadership traits that had been
described in these studies - adherence to values or
principles was not identified as one of the top ten traits.
Stogdill’s work provides some evidence that a focus on
values (and associated qualities such as integrity or
character) was not, at least during most of the 20th century,
considered among the most critical traits of leadership. In
the latter part of the 20th century, a discussion of values in
management became more common. Selznick (1957)
wrote that organizations become mature and

23. “institutionalized” only when leaders infuse them with
values. A new way of perceiving and evaluating experience
is transmitted to employees, and the organization acquires a
unique identity and competence. For Selznick, institutional
change occurs in organizations through processes that are
developed and implemented by organizational leaders, such
as the transmission of values.
James Burns articulated the widely-known
paradigm of transformational leadership in the 1970s. The
interrelation of employee and managers values is a key
facet of transformational leadership. Burns stated, “The
essence of leadership in any polity is the recognition of real
need, the uncovering and exploiting of contradictions
among values and between values and practice, the
realigning of values…The leader’s fundamental act is to
induce people to be aware or conscious of what they feel --
to feel their true needs so strongly, to define their values so
meaningfully, that they can be moved to purposeful action”
(Burns, 1978, p. 43). For Burns, leadership clearly
involves influencing and clarifying human values and
aligning them with the needs of the organization.
In more recent years, management theorists have,
to varying degrees, acknowledged values, and related
factors, such as ethics and principles, as key ingredients in
a successful leadership formula. The most widely-read of
these theorists, Stephen Covey, in Principle-Centered
JHHSA FALL 2008 185
Leadership, asserted that our values should be aligned with

24. certain correct principles, which show us the way to
effective leadership. Covey also states that involving
employees in developing a shared vision and principles for
an organization will help unite people in the organization
(Covey, 1991, p.185). In recent years, there has been a
shift away from the concept of the leader as the primary or
sole creator of an organization’s values, and as stated by
Covey, a strong emphasis by many writers on organizations
developing shared principles, values, and missions using a
participative process.
Other writers appear to differ from Covey and do
not appear to consider values to be subjective, but consider
values to be objective and fundamental. For example,
Lebow and Simon (1997) list eight basic people values for
organizations: truth, trust, mentoring, openness, giving
credit, honesty, and caring.
In contrast to Covey’s emphasis on principles, many
organizational writers in recent years consider a focus on
values to be the critical challenge facing organizational
leaders. Blanchard and O’Connor (1997) consider solid
and enduring shared values to be the foundation of a
successful organization, and one that also leads to
profitability. They stress involving all stakeholders in the
process of formulating and institutionalizing the company’s
values. Conger (1998) also describes shared values as
critical, especially when seeking major change or making
an appeal to members of the organization.
Badaracco (1998) argued that values come to the
forefront in challenging or difficult situations that confront
organizations, which he termed defining moments. Then a
true leader will reflect on one or more of the following
questions, “Who am I?” “Who are we?” “Who is the
company?” This process of self-enquiry enables the leader

25. to deeply discern his or her true values and live up to them.
186 JHHSA FALL 2008
Thus, challenges and crises are in a sense necessary to not
only test, but to evoke, the leader’s values.
The writers described above represent only a few of
the numerous proponents of what is often termed, “values-
based leadership”. However, in healthcare organizations
values-based leadership is not always easily implemented,
due to their unique cultures, and their structural and
operational characteristics.
Challenges to Implementing Shared Value Systems in
Healthcare Organizations
The literature on values in management and in
healthcare organizations stresses the importance of
identifying values and adhering to values. Circumstances
and organizational structures that can ameliorate or even
negate a values-based approach to management are rarely
discussed. Healthcare is a unique field and particularly in
large healthcare organizations, implementing value systems
is almost always much more difficult than professing them.
Diverse values among organizational groups.
One of the main challenges to management-based
values in hospitals is that managers have limited authority
over professional, licensed personnel. This is particularly
salient in regard to physicians with whom management has

26. traditionally shared authority. Since physicians are often
not employees of a hospital (or of many other healthcare
organizations), management’s capacity to influence
physicians is limited.
Alexander and Morlock (1994) describe some of the
key cultural differences between physicians and healthcare
executives on several key dimensions. They state that the
executive’s focus is (or should be) on positioning the
organization for the future, so their time frame of action is
middle to long term. Physicians have a more short term
time frame, arising from the necessity of meeting the
JHHSA FALL 2008 187
immediate needs of patients. Executives are described as
viewing resources as limited and being highly aware of the
need to allocate scarce resources effectively. Conversely,
physicians are said to consider resources as critical for
serving their own patients and maximizing the quality of
care. Executives consider service to patients within the
organization and also providing services and programs to
the greater community as being highly important.
Physicians’ patient focus is considered to be much
narrower – on their individual patients. Clearly,
physicians and executives have different world views and
professional identities, and their professional identities are
based in different professional values. To minimize
problems and conflicts it would seem essential for
management to extensively elicit physician input in
formulating and implementing organizational values
systems. In doing this, both groups should learn to

27. understand what is important and worthwhile in each
other’s value systems.
Although physicians are undoubtedly key actors in
healthcare organizations, they are not the only element in
the considerable heterogeneity of these organizations. For
example, as mentioned previously, nurses may possess
stronger values of altruism and compassion than healthcare
administrators (Thorpe and Loo, 2003). Healthcare
organizations often have high proportions of members of
specific racial or ethnic groups who may be dissimilar to
management on some important values. Due to this
heterogeneity, which is very common in many regions of
the country, the formulation of organizational values should
involve a multitude of internal groups and stakeholders. In
such ethnically diverse situations, organizational members
should try to identify overarching values. Smolicz (1985,
p.11) notes that this process should allow ethnic groups to
retain certain core values relating to their traditions,
language, and religions, and also contribute to a dynamic
188 JHHSA FALL 2008
equilibrium, “between the overarching and shared
values…and the ethnic or core values.”
Similar to finding overarching values, is obtaining
normative consensus, that is, consensus or agreement on
the important norms for an organization. A norm is “a
principle of right action… serving to guide, control, or
regulate proper and acceptable behavior” (Merriam-
Webster Online Dictionary, 2005). Values are considered
internal and do not necessarily imply actions; however,
norms do involve actions and behavior. Nevertheless,

28. norms are grounded in personal values. Organizations may
wish to first establish overarching values, and then use this
as a foundation for identifying the key norms in different
department or units, using a participative approach to reach
a normative consensus.
Competing, conflicting, and shifting values
There are not only diverse and sometimes
competing values across professional groups, but values
may clash within any group in the organization. Worthley
(1999) describes common clashes in organizations between
serving the individual or the community; achieving quality
versus reducing costs; upholding patient rights or
organizational control; and allowing freedom versus
maintaining order and control. These are not uncommon
clashes. Indeed, issues around the relative importance of
one value to another take place continually in organizations
at all levels.
Who is right or wrong when values clash? This
decision can only be made when one set of values is
deemed to be higher or more worthy than another set of
values. Since values have worth, as many executives are
aware, sometimes a problem or a difficult decision is a
conflict between right and right (Badaracco, 1998). For
example, a healthcare organization’s managers may
strongly desire to raise nursing salaries, but also wish to
JHHSA FALL 2008 189

29. improve patient parking, and only have enough revenue to
accomplish one goal. A solution that is often suggested is
for managers or management to reflect on the
organization’s core values to guide them when making such
difficult decisions. This is a worthy suggestion; however,
values are generally not the only relevant consideration in
many difficult organizational situations.
There appears to be considerable overlap, but no
real consensus, on what should be included in a list of
values. There also is considerable heterogeneity among
values, and some appear to be more achievable by human
effort than others. For example, two of Rokeach’s
instrumental values are logical and intellectual (Rokeach,
1973). How capable is an emotion/feeling-centered person
of becoming highly logical or intellectual? Other values
propounded by Rokeach may be more attainable, such as
being helpful or polite. Writers on organizational values
have failed to note that it may be much easier to infuse
some values into an organization than others.
A dimension closely related to and overlapping with
values are human needs and dimensions of personality.
Various models or schema of human needs have been
posited and widely used in research, consulting, hiring, etc.
One model, the FIRO-B developed by William Schutz,
describes the primary human needs as being inclusion,
control, and affection (Schutz, 1966). Control and
affection are not identical to but overlap closely with
Rokeach’s values of self-control and being loving
(Rokeach, 1973).
On the group level, Schutz (1966) posited that the
predominant need would change at various stages of the
group’s development (e.g., early stage – inclusion; later
stage – affection). Organizational group assignments may

30. be more successful if the essential values or need profiles
of potential members are considered. To state the obvious,
a hospital task force to promote caring and compassion
190 JHHSA FALL 2008
should clearly seek to include at least a few members that
value affection or being loving. Managers also may seek to
stress specific organizational values to group members at
the beginning and at various stages of groups’ activity.
Leaders in organizations should consider
advocating a parsimonious set of values and also determine
if these key values are within the scope of the typical
organizational member to achieve or internalize. Such
reflection will make it far more likely that the final set of
organizational values are embraced and actualized
Inconsistency in rewards and organizational
support.
Although differing organizational and personal
values may be tacitly accepted by organizational members,
they will often have strong and negative reactions when the
expressed values of the organization are consistently
different from its actual values. This lack of consistency
was noted by Kerr (1995) in a reprint of his classic article,
“On the Folly of Rewarding A, While Hoping for B.” The
article notes the results of a survey (of executives) and
describes common conflicts between expressed
organizational values and the reward system (e.g., We hope
for innovative thinking and risk-taking, but we reward
proven methods and not making mistakes. We hope for

31. employee involvement and empowerment, but we reward
tight control over operations and resources). Thus,
conflicting or ambiguous values will be reflected in the
reward system, which will contribute to uncertainty about
what the organization really wants from employees, and
lead to a lack of motivation.
Failure to reward organizational members for
enacting desired values may at times be the result of the
failure of leaders to overcome a crystallized bureaucracy,
which continues to reward nonoptimal behaviors and at
times to suppress creativity. For example, a staff member
JHHSA FALL 2008 191
may have to work through several layers of bureaucracy to
implement a novel program or idea. Members of a
successful team may not be rewarded as the reward systems
that are supported by the bureaucracy do not recognize
team achievements.
It is clearly not enough to profess important values
only at the top of the organization. Those at the top must
establish mechanisms that reward those who enact these
values. As Kanter (1983, p. 299) noted, “The actions
implied by the changes cannot reside on the level of ideas,
as abstractions, but must be concretized in actual
procedures or structures or communication channels or
appraisal methods or work methods or rewards.” When
this is accomplished, a vibrant, dynamic working
environment is created. An analysis of numerous studies
on burnout noted that organizational cultures with little

32. burnout among employees had higher job involvement,
higher participation in decision-making, greater sharing of
information, greater autonomy, and higher supervisor
supportiveness than observed in organizations with high
levels of burnout (Golembiewski et al., 1996). These
observed high levels of participation and involvement in
low burnout organizations provide strong evidence of an
environment of normative consensus. These organizations
also appear to have clearly enacted and concretized their
underlying organizational values, which resulted in a
positive working environment where employees were
unlikely to experience burnout.
RECOMMENDATIONS FOR HEALTHCARE
MANAGERS
In our view there are four key steps or tasks for
health care managers who wish to practice values-based
leadership. Following these steps should contribute to the
development of a truly values-based organization, to less
192 JHHSA FALL 2008
conflict arising from diverse value systems, and the greater
integration of the disparate values within an organization.
Recognize Your Personal and Professional Values
One of the first steps for healthcare managers who
wish to uphold and communicate values, is to better
understand their own value systems at work. Senge (1990)

33. differentiates between our expressed or communicated
values (espoused theories) and the values we really act
upon (theories-in-use). A healthcare manager may be
highly directive and controlling over major projects, yet
may really believe she values input and participation. In
such cases, Senge believes a manager should do some soul-
searching about what he really values in order to learn and
grow as an individual and as a manager. Sometimes, Senge
asserts, managers need outside input to “see themselves,”
because it is often difficult for them to ascertain their own
theories-in-use.
Determine What You Expect From the Larger Organization
and What You Can Implement Within Your Sphere Of
Influence
Managers need to decide how much they will
expect from their healthcare organization, in terms of the
regard the organization will exhibit toward its espoused
values and how closely the organization will adhere to
these values. A few organizations have taken the stance
that they will stick to their core values even if it hurts the
bottom line or hampers organizational effectiveness.
However, most healthcare managers don’t work for such
organizations or expect so much from them. Nash (1993)
states that a more realistic attitude for managers is to
develop organizations that have the normal range of human
values and ethical instincts, and for them to work to see that
these are not compromised in the workplace.
JHHSA FALL 2008 193

34. A healthcare manager may work in an organization
that she feels doesn’t possess an acceptable value system:
or that the leaders espouse certain values, but aren’t really
faithful to these values. For the higher level manager or
executive, several options exist. An extreme, but sometimes
necessary, one is to leave the organization. Another is to
work with other like-minded leaders and healthcare
professionals to change the organizational culture to be one
with strong values that organizational members can
embrace and adhere to. However, even when working in
an organization without clear and positive values, for
lower-level managers there often is considerable scope to
enact strong value systems within their own department or
bailiwick. As Rosabeth Moss Kanter (1983) stated,
organizational changes often work best at the periphery in
“zones of indifference,” where no one else cares enough to
prevent a little deviance by a lower-level manager.
Understand and Incorporate the Values of Internal
Stakeholders
When healthcare managers are keenly aware of
their own professional values, they should also strive to
understand and appreciate the value systems of other key
stakeholders within the organization. Managers can and
should appreciate the value systems of healthcare
professionals such as physicians and nurses, who are the
most closely involved in helping, serving, and satisfying
the organization’s patients. When management and other
internal stakeholders work respectfully, openly, and
collaboratively to formulate the organization’s values, these
values are much more likely to be embraced by all
organizational members.
Commit to Values-Based Leadership

35. Many healthcare executives fail to realize the
foundation that values provide for effective organizations.
194 JHHSA FALL 2008
Mayer (2005) noted that “there is a pervasive attitude in the
business community that ethics and values are all about
restraint and denial, not about active and productive
investments.” However, creative healthcare managers who
are enthusiastic and committed to an established
organizational values system should be able to develop new
programs and services that are both financially viable and
reflective of the organization’s values.
Edgar Schein (1992) asserted that the only thing of
real importance that leaders do is to create and manage
culture. Organizational values are perhaps the main
element in the culture of all dynamic organizations.
Effective and influential leaders should not seek to be the
sole sources of organizational values, but should include a
multitude of internal groups in identifying key values.
Once this is accomplished, they should continually
communicate the organization’s values and work to assure
that these values are not neglected, but are enacted within
the organization. This includes structuring reward systems
that recognize employees who enact the organization’s
values. Leaders also need to stress that the organization’s
values not only create a unique and dynamic culture, but
also contribute to the competitiveness and success of the
organization.
Considering the frenetic, demanding world of
healthcare management, attention to organizational values

36. may seem to some to be a marginal or non-critical issue.
For others, attention to values may serve as a moral anchor
that helps them to be true to themselves and do their best
work in the fast-paced world of healthcare. In the view of
the authors, values are clearly the foundation and impetus
for a manager who seeks to serve the community and the
underserved, to carry out her responsibilities
conscientiously, and to communicate honestly and fully
with her employees. In our view, those managers with
strong personal, professional, and organizational values
JHHSA FALL 2008 195
will be the ones most likely not only to succeed, but also to
find fulfillment in their professional life.
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