Culture doesn’t live in the values poster. It lives in what happens when things go wrong.
What Culture Actually Affects
Culture gets assigned to human resources or to leadership communication, which means it gets treated as something separate from operations. That’s a mistake. Culture is one of the most direct determinants of operational performance, and treating it as a soft variable is a good way to be surprised by your results.
What culture means in an operational context: the assumptions people bring to their work about what matters, what’s allowed, and what happens when something goes wrong. Those assumptions shape behavior more reliably than any policy, because they’re active all the time, even when nobody’s watching.
Eric Cecava ran a system with three distinct entities: a hospital, a skilled nursing facility, and a medical group. Each had a culture that had developed independently over years before he arrived. Those cultures affected everything: how teams communicated during patient transfers, how quickly problems got escalated, how staff responded to process changes. You could not understand the operational performance of any of those units without understanding the culture driving the behavior.
The Operational Signals You’re Looking For
Culture shows up in operational data before it shows up anywhere else. The signals are things like: how quickly are near-misses reported? What’s the lag between a problem being identified and a problem being escalated? How much variation exists in how different teams follow the same process?
High reporting rates for near-misses are a sign of psychological safety, which is a cultural condition. Low reporting rates usually mean people don’t believe anything will change, or they’re worried about being blamed. Both of those are cultural conditions that directly affect quality and safety outcomes.
Process variation is another signal. When different teams execute the same process differently, it often means the process wasn’t designed with their input, or they don’t understand why the steps matter. That’s a culture and communication problem presenting as an operational problem.
How You Change It (And How You Don’t)
Culture doesn’t change through announcements. Eric Cecava has seen a lot of leadership teams try to change culture by articulating new values, running all-staff meetings, and updating the website. None of that is wrong, but none of it is sufficient. Culture changes through repeated behavior that signals different expectations.
The most direct tool a leader has is what they respond to and how. If a team surfaces a problem and the response is to find someone to blame, people stop surfacing problems. If the response is to understand the system failure that allowed the problem to occur, people keep surfacing problems. That pattern, repeated across hundreds of interactions, is what actually changes the culture.
The harder version is changing a culture that is actively resistant to change. That usually requires personnel decisions, not just communication. Cultures where bad behavior is tolerated because the person producing it is high-performing don’t change through values workshops. They change when the behavior has consequences.
The Connection to Results
Eric Cecava has not run an organization where culture and operational results were disconnected. In every case, the units with strong cultures — clear expectations, psychological safety, accountability without blame — outperformed the units with weak ones. The gap showed up in quality metrics, patient satisfaction, staff retention, and financial performance.
This is why the idea that culture is a soft variable deserves a pushback. It’s the variable that shapes all the other variables. Treating it as separate from operations is like treating the wiring as separate from the electrical system. It’s not separate. It’s what makes everything else work or not work.