Health Systems

, Volume 6, Issue 2, pp 91–101 | Cite as

When the world calls for emergency services, who answers? A surgeon general’s perspective on running a high performance health services organization

  • Suzanne J. WoodEmail author
  • Matthew L. Nathan
Original Article


This article records an interview by the author with Vice Admiral (retired) Matthew L. Nathan, 37th surgeon general of the United States (U.S.) Navy and chief of the U.S. Navy’s Bureau of Medicine and Surgery. The interview provides insights into developing a globally dispersed yet highly integrated health system managed and operated by an agile, mission-focused team of devoted professionals whose credo is to deliver “World-Class Care…Anytime, Anywhere.” We examine characteristics of Navy Medicine that align with evidence-based factors of high performance organizations (HPOs) to determine whether the system itself should be classified as an HPO. In conclusion, we summarize key implications for practice.


Healthcare management Organization theory High performance organization Military medicine Interview Surgeon general 

Management researchers have examined myriad organizations in various industries in an attempt to uncover factors responsible for developing and sustaining significant levels of performance over time (Evans and Davis 2005; Gant et al. 2002; Gittell 2001, 2003). Such efforts have led to the discovery of high performance organizations (HPOs): those that significantly and consistently outperform competitors for a period of ten years or longer (Collins 2001; Collins and Porras 1994, 1996; Katzenbach and Smith 1993; Peters and Waterman 1982). Since the 1980s, organization scientists have also combined the concepts of high performance with high reliability, focusing on process consistency in extreme operational tempo environments (Gittell 2001, 2003; Roberts 1990; Schwartz 1987). Evidence suggests highly performing, high reliability organizations have the ability to deliver quality outcomes repeatedly (Bierly and Spender 1995; Roberts et al. 1994; Rochlin et al. 1998). Resulting frameworks imply that global and even industry-specific generalizations regarding factors that promote high performance and/or high reliability success remain awkward, particularly given the wide-ranging, contextually driven environments in which representative organizations have been studied (de Waal 2011). Yet, despite gains made in the scope and depth of our knowledge, translation of HPO research into the healthcare sector begs for further inquiry.

Research on high performance work systems often draws on human capital theory whose fundamental proposition is that intentional human resource practices can improve organizational performance by developing employee competence (Becker 1975; Gittell et al. 2010). For example, Gittell (2006) posits frequent, quality communication supported by employees’ shared goals and mutual respect, the theory of relational coordination, enables organizations to better achieve desired outcomes. Top managers, therefore, can facilitate achieving high performance when they adopt practices that encourage relational activities designed to leverage employee collaboration, including teamwork, in creating value (Collins and Clarke 2003; Katzenbach and Smith 1993; Vogus 2006a). Such findings have not been lost on health services researchers, as many have endeavoured to apply human capital frameworks to the healthcare delivery environment studying both employee performance as well as quality and efficiency concurrently (Gittell 2002, 2010; Pronovost et al. 2006; Scotti et al. 2007; Shih et al. 2008).

Aligned with and in support of previous research on HPOs, de Waal (2011, 2012) draws from broadly based empirical work in the areas of organizational psychology, human resource management, and strategic management to develop and test factors across many industries that can guide leaders to achieve the superior results associated with HPOs. Summative results of de Waal’s (2011, 2012) international studies conclude that a set of five major factors (with 35 descriptors) consistently and significantly contributes to higher levels of organizational achievement across many industries, sectors (including healthcare), and countries in the world. The ensuing HPO framework includes the following factors: (1) long-term orientation; (2) management quality; (3) workforce quality; (4) continuous improvement; and (5) openness and action orientation. De Waal asserts that each of the factors is complementary and highly correlated; as such, an organization should concentrate upon improving all HPO factors concurrently, with particular emphasis on long-term orientation, to realize maximum benefit.

Examination of de Waal’s (2011, 2012) assertion that the model can be applied generically to the healthcare sector is necessary. Since the 1980s, researchers have combined the concepts of high performance with high reliability in studies of U.S. federal aviation and/or U.S. Navy combatant commands (Bierly and Spender 1995; Gittell 2001, 2003; Roberts 1990; Roberts et al. 1994; Rochlin et al. 1998; Schwartz 1987). Consequently, it seems logical to extend such studies into the health system designed explicitly to support known HPOs, as with military combatant commands, under various circumstances and in multiple environments. One such system is U.S. Navy Medicine. The purpose of this study is to explore characteristics of Navy Medicine that contribute to its classification as an HPO using de Waal’s (2011, 2012) framework as a point of reference (see Appendix).

Preparing a globally dispersed organization to deliver healthcare anytime and anywhere

Since its inception over 241 years ago, U.S. Navy Medicine has been called upon to deliver emergency care and non-combat-related services in a variety of environments and locales. Few, if any, organizations in the world have the capacity or capability to repeatedly move personnel and assets to effectively address varied healthcare needs domestically or internationally, on land or at sea. The unique mission of Navy Medicine lends itself to the study of high performance management in the healthcare setting. Examining the organization through the lens of a seasoned healthcare leader’s personal experiences we explore areas of convergence with de Waal’s (2011, 2012) HPO model to determine Which factors best support the characterization of U.S. Navy Medicine as a high performance organization?

Vice Admiral (VADM, retired) Matthew Nathan is a former surgeon general and internal medicine specialist with 31 years experience in U.S. Navy Medicine. He is an advocate for what he calls “intrusive leadership” and sailor development at all levels of the organization. Nathan’s views on commanding a combat-capable, ready force derive from his years of varied experience in health services delivery and support organizations in domestic and overseas locations. He is known for outstanding leadership, overseeing U.S. Navy medical relief efforts following Hurricanes Ivan, Dennis, and Katrina, as well as shouldering the integration of the Walter Reed Army Hospital and the National Naval Medical Centre in Bethesda, Maryland, resulting in the largest military medical construction project in U.S. history (BUMED 2016). Against this backdrop, the author interviewed Nathan to capture his views on about which factors lend to Navy Medicine’s classification as a high performance healthcare organization and include his focus on developing agile, capable leaders within it. Presented here is a summary of key questions and responses, not a transcript. The interview is then followed by the authors’ exploration of interview components that contribute to Navy Medicine’s classification as an HPO as per de Waal’s (2011, 2012) framework. Fig. 1
Fig. 1

Biographical sketch

The interview with VADM (ret.) Matthew Nathan

SW: What do you think makes Navy medicine different from the civilian sector? What makes it more dynamic, particularly in the way that people deliver care for any number of disparate missions?

MN: Some people in military medicine forget this: We exist to support the operating forces. Our raison d’être is to be available to operational forces and war fighting as well as, when required, humanitarian assistance and disaster relief. That’s the main reason we do it. We operate a robust system of military hospitals and clinics; we operate a robust system of research, education, and training. The system is really geared toward being a mechanism of support to operating forces whether they have to go into harm’s way, into some kind of combat or warfare, or whether they have to respond to a humanitarian disaster. When people ask me what business I’m in, my answer is, “I’m in the readiness business.” My job is to be ready to answer the bell at any time, and that is a significant responsibility.

I use the following analogy: Imagine you are a world-class pristine healthcare facility and existing in Seattle, in the private sector, the academic sector, or in New York, California, or North Carolina. All of a sudden, somebody calls up the CEO and says, “You’ve got two days to empty out 400–600 of your personnel and be in a foreign country—or be on a ship—or be in an air terminal—or be en route to a war zone.” Most would say, “That’s not our job. This is not what we do. We don’t have the ability to do that and still care for our remaining patients!” So the task at hand for the Military Heath System is to be ready to deploy on a moment’s notice, to have their personnel ready to deploy because it’s not just a strategic requirement, it’s an individual requirement. The ability (or requirement) to leave your day job in a hurry and be somewhere else for a matter of days, weeks, months or sometimes years, falls on the same people that work in our healthcare facilities. The responsibility falls on moms and dads, sons and daughters, brothers and sisters.

So how do we create a cadre of such personnel—thousands and thousands of them? We instil in them the mindset that their main job is to be ready move and go, in a heartbeat. The challenge of leadership and military healthcare lies in operating a robust system of primary and tertiary care facilities that provide service comparable to any healthcare system in America. That’s our goal. Yet, we have to be ready to go. We, as leaders, should never say to any of our patients, “The care you going to get may or may not be good (as one would find in comparable facilities) because we’re so busy taking care of things overseas, in a war, or in response to a humanitarian crisis.” That would be unacceptable. I need to look every patient in the eye and say: “Don’t worry, even though we juggle a lot of things, we have never lost our centre of gravity, which is taking care of any patient—anywhere in the world—in any kind of environment.” That’s the biggest challenge for the military.

SW: Research and related applications of high performance, high reliability organizations have been conducted in a number of disciplines. How do these concepts apply to military medicine?

MN: Transforming military or civilian medicine into a high performance, high reliability organization is a challenge, particularly in terms of getting the same results time after time, yet it is essential. Researchers often draw examples from two things in the Navy: (1) the nuclear program (submarines, propulsion) and (2) aviation, particularly aboard aircraft carriers. Those two systems are often celebrated for having virtually no errors. Consider the complicated high risk within the tremendously dangerous environment on board a submarine, with a nuclear reactor at sea, or on the flight deck of an aircraft carrier (Bierly et al. 1995; Roberts 1990; Roberts et al. 1994; Rochlin et al. 1998). Weigh that against the fact that we’ve had no nuclear accidents and very few carrier-related mishaps. Everybody says, “We’ve got to be like those guys! We’ve got to figure how to integrate that kind of stability into our operations.”

In the book ‘Why Hospitals Should Fly’ (Nance 2008), the author compares the template of hospital care with that of the airline industry. The number of mishaps that occur compared to the number of times (they) fly suggests (they) have virtually no issues…. Walk into any hospital in America, the best ones and the ones that are not so well known, and ask, “Can you absolutely guarantee there’ll be no medical mistakes while I’m here?” The answer you’re going to get is, “We’re going to do our best. We hope there won’t be. We don’t think there will be, but I can’t guarantee it because medical mistakes still occur these days.” This happens for a variety of reasons: human elements, lack of standardization. That’s one of the challenges we have as a military. We need to drive out variation within our facilities and among the services: Army, Navy, and Air Force. I think the military can lead the way.

Each military service should preserve its culture and allegiance to its individual needs. We each have unique demands: (U.S.) Navy Medicine serves a mostly sea-going maritime organization; Army Medicine serves principally a land organization; and Air Force Medicine serves essentially an aviation community. We do so many things the same in certain areas, yet we still need to drive centralization. The (U.S.) Department of Defence is on a path to creating a more standardized approach to medical care, which I think is a good thing. We need individuals who can perform flawless surgery, support, recovery, and technical work. We also need them to do it at a hospital in Washington, Florida, Afghanistan, or Iraq within the same week. I’m in awe of our people. They can move back and forth between environments seamlessly.

SW: Leadership is an important element of high performing organizations. What is the role of leadership in supporting Navy Medicine’s mission?

MN: Something to be valued in Navy Medicine is the support system that’s created within the organization. We employ intrusive leadership; if we’re doing it right, it’s intrusive leadership (Yukl 1998). Intrusion, by definition, means interrupting, getting in someone else’s business, invading. That’s intrusion. We practice intrusive leadership in a different way: We want to know how you and your family are doing. We want to keep an eye on you to see whether you’re having emotional issues or stress, experiencing abuse, or are prone to hostile behaviour. We won’t sit idly by if we are doing this right. We won’t say, “Gee, I think Petty Officer Seafarer is drinking too much”, or “Golly, I think Commander Jones is a victim of spouse abuse. Maybe one of us should talk to them about it.” Rather, we engage. We involve ourselves. That intrusiveness extends to deployments, to moving people somewhere in a hurry. Our personnel reach out to families, monitor them, and see how they’re doing. The military has a formal system to engage and support individuals and families to make things as easy as possible and to address their concerns. What is it about our people that makes this so? The system isn’t perfect, but our ethos is such that we feel part of a team—and that team will take care of us. We have each other’s backs. That’s to be celebrated. That can never go away.

The military spends a tremendous amount of time and effort on formal programs to look for warning signs of depression, hostility, or suicidal tendencies. These problems occur in all organizations, many of which have programs for employees to call and ask for help. It’s not rare, however, for a military leader to establish a formal agenda item regarding deployed personnel and their families. A formal presentation would include prescribed intervals of: Who is in charge? Do we have contact with these people? When did you last speak with them? How are they? Not just, “Hey, has anybody heard from Ralph or Ralph’s family?” but a more formalized requirement for leaders to make sure people are covered.

SW: Success in complex organizations is often tied to individual leadership and how proficiency can be leveraged to enhance organizational capability. How do you develop the talent you need to cultivate a high performance organization?

MN: We want to ensure that the most junior person who comes into the service understands that they’re a leader. Somebody is watching them; someone is taking a cue from them: their kids, their friends, or their peers. There’s no rule that says a leader has to be high up in the organization. At some point, their job will be to take care of their people. It’s not a perfect system but in formal reviews, our personnel report on job performance as well as what they’re doing to support the professional development and personal growth of their subordinates. As they move up the chain of authority, they are asked specifically to address formal offerings: mentorship, training, or 360° programs to solicit feedback from peers. They’re expected to be facile in developing those coming up behind them.

As a rule, we work hard to celebrate people and their accomplishments. Paraphrasing Napoleon’s (1769–1821) expression, “My soldiers will fight for pay but they will die for medals.” That means people will show up and work for a day’s pay, but they will go above and beyond, perhaps pushing their boundaries or risking their lives, if they believe their talents and achievements will be recognized and celebrated. There’s nothing more demoralizing to go out of your way to do something great, perhaps even feeling personally rewarded for doing so, if that’s lost on the organization. Indifference quickly extinguishes exceptional behaviour. Celebrating personnel, formally or informally, is not only encouraged, but also mandated in our organization. That’s why these amazing young people do such heroic things. I can’t really affect their pay, that’s fixed, but I can impact their feelings of self-worth, particularly when they go above and beyond. It’s critical. It’s transformational.

SW: Based on your experience, is a particular type of person drawn to a high performance organization like the military? Could you list five qualities of such a person?

MN: We do a good job in Navy Medicine; people appreciate and understand that they have a tough job. We should be proud of the fact that we exist as an organization and work hard for it. There is great honour in working in any healthcare system in this country. It’s tough to be in healthcare these days, there’s a lot of pressure on people. I’m proud of anybody who does a good job in any healthcare system. Yet, in the (U.S.) Navy, not only do we have to work in the system, but we also have to be ready to leave in a moment’s notice to take care of victims of a hurricane, an earthquake, or in a combat situation. That makes our people special, it really does make them special—they give their all in California, Connecticut, or Florida one day and next week they’re going to have to bring their A-game to Iraq, Afghanistan, Haiti, or Japan; that makes them special. Doing this requires the best in our people: adaptability, focus, ownership, and teamwork. People in Navy Medicine embrace the mission, and they feel good about themselves for being a part of it. The individual that joins military medicine is somebody who appreciates service, somebody who realizes that the organization’s shortcomings are outweighed by the merits of making a difference. Just their willingness to stand up when called makes them special. Fig. 2
Fig. 2

Individual qualities that contribute to high performance

SW: High performing organizations depend on getting the most out of personnel; essentially, within such organizations exists a culture that supports elevated performance at all levels. How do you motivate personnel to achieve?

MN: Consider this: We rightly celebrate people who have gone to war or a major disaster and have sacrificed. Yet, others would approach to me later and say, “I feel as though I have not contributed because I didn’t go to war”, or, “I didn’t respond to an earthquake in Haiti or a tsunami in Indonesia… I don’t really feel like I measure up.” I would respond by asking, “Are you willing to go if I need you to go? Are you willing to stand up and step forward when called no matter how hard, or challenging, or demanding it is on you or your family?” Their answer was always, “Yes!” without hesitation. That makes them special.

Instilling a sense of purpose in our people is critical. Their job is to change lives—on the battlefield or in a stateside hospital in Connecticut or North Carolina. If we can get people to recognize their role, then they become stakeholders in the organization (Rosen et al. 2005). That’s done very well in many private sector organizations. It can be harder to do in military medicine because we have a transitory organization; people are coming and going constantly. We also have a highly bureaucratic organization. We have to adapt to younger generations’ needs. They’re different from my generation. Today, young people excel in volunteerism and altruism; they’re willing to work very hard when they understand what’s at stake.

SW: Proactively managing change is a key component of high performance organizations. When you took command, you instituted a focused strategic plan with the intent of cascading the strategy throughout the organization—a formalized change management initiative. What were the key drivers of the planning effort?

MN: When I took command, I wanted to have a simple answer to the question, “What’s the single most important thing in (U.S.) Navy Medicine?” My answer was: readiness. Readiness is the ability to be ready to deliver a healthy baby for the mother who seeks care in our stateside hospital. It’s the capability of that same provider to be ready to treat an injured Warrior on the battlefield—any wound, in any environment. Job one was readiness. I also wanted everyone under my command to be able to tell me that our most important goal was readiness. The understanding that readiness was key translated not only to how they performed on the job, but also in their personal lives. If they understood that readiness was key, they had to think about preparing themselves and their families for anything that might happen.

If readiness is job one, then number two is value. What is value in the organization? Value to me can be defined by an equation: it’s quality, times capability, divided by cost. The reason value became important was that I believed we had to look closely at what we did and what it cost us to do it. I didn’t want people to think that we were going to cut corners or cut costs at the expense of quality, but I wanted people to appreciate the cost of doing business. The military and the government in general, and somewhat fairly, have been chastised for not grasping cost. It was very important that we appreciated the value of the care we delivered. We had to figure out how to increase value while lowering the cost and keeping quality the same, or improving it.

We owe the tremendous successes of battlefield and casualty combat medicine to the joint operating capacities shared among the services. Hence, the third goal related to joint operations. Illustrating an example: We revolutionized casualty medicine—we changed the game. Over 100 years ago during the (U.S.) Civil War, we expected over 50 per cent of those with life-threatening wounds to die from them. In Vietnam, the combat survival rate increased to about 75 per cent. Now, over 95 per cent of life-threatening battlefield wounds are survivable because of the tremendous gains in battlefield care. The gains resulted from carefully orchestrated coordination of care among the (U.S.) Army, Navy, and the Air Force as well as advances in life-saving techniques. We need now to leverage that capability, the collaboration, and cooperation, applying it to peacetime healthcare delivery. So, I wanted our people to think about joint operations, specifically: What could we do with our sister services to make us stronger and to increase readiness and value? Essentially, I came into office with three tenets: readiness, value, and jointness. It didn’t mean that other things weren’t important; it just meant that if we did those three things well, we were going to succeed. Nobody had an excuse to not be able to recite what those things were.

SW: You alluded to standardization as a key element of high performance organizations. Tying standardization to strategy, how do you ensure the facilities across the organization are focused uniformly on strategic initiatives, and are measuring them in a similar manner?

MN: This is about organizational alignment. It does you no good as a CEO to craft an inspiring vision, as with putting a man on the moon or changing lives for the better (Collins and Porras 1996), and then have everyone measuring it in different ways. That’s courting disaster. Rather, leadership must create a strategic dashboard (Kaplan and Norton 1996) that applies across the organization and to which everyone is held accountable. There’s nothing more demoralizing to a local leader than to know what is important (readiness, value, and jointness), but nobody is telling him or her how to measure it. Establishing a dashboard solves the problem.

When you’re growing, you have to create a limited number of goals and identify common measures that apply across the board. One of the big mistakes leaders make is relying on an organizational matrix that they created over 20–30 years where everything is critical. They present this matrix to local leaders who are held responsible for reporting weekly on a dashboard containing 30 measures. Of course, it quickly gets watered down. My advice to leaders is to create less than ten goals at the strategic level, ideally five or six, and focus on measuring those. Bring each one up, work on it until the objectives are achieved, then bring another one up. You have to eat the elephant a bite at a time (quote attributed to General Creighton Abrams, Jr., 1914–1974). It’s a work in progress.

SW: One quality of creating an effective strategy is deemphasizing work on non-strategic concerns. How did you get the enterprise to focus on strategic priorities over day-to-day operations?

MN: Advocates for our efforts acknowledged we were creating strategic alignment and articulating matrix requirements that were manageable. Opponents accused us of trying to botanize the system. We really were creating a new system. In the past, we emphasized TQM (Total Quality Leadership) and TQL (Total Quality Management) (Swiss 1992), and everybody went off to TQM and TQL School to show that they could polish the apple and give it to the teacher. Unfortunately, we had 100 different TQM/TQL projects going all over the place, and everyone thought theirs was the best. Then, we came out with Lean Six Sigma (Jimmerson et al. 2005; Kaplan and Patterson 2007), and everybody went off became a green belts and black belts. Everyone started their own projects; there were green shoots everywhere. It was, at first, well-intentioned chaos, not coherent movement.

I’ll give you a great example: I went to one of our core hospitals to visit their operating room. They were very proud to show me how they had decreased turnover time and increased safety. Turnover was their daily bread; it affected the bottom line and the amount of surgery they could perform. If they could also make the process more fluid and less chaotic, patient safety was improved as well. To achieve gains, they had borrowed some best practices. I said, “That’s great! How is your sister hospital on the other coast doing it?” They replied, “I don’t know. I don’t think they’re doing it.”

That got my attention. We needed to create a strategic oversight group so that we did not have a runway train. In this case, a hospital was doing something that should have been adopted across the enterprise. Yet, what the incident told me was that any number of our departments or facilities could be growing green shoots that may or may not be worthwhile. Again, what we needed was standardization coupled with best practices…the definition of a learning organization. The number one challenge to achieving standardization was to create communication across the organization. People should have been able to try different things, not to have been reigned in necessarily. I just needed them to communicate with me and with each other as we brokered initiatives (Gittell 2006).

SW: There are differences between standardizing procedures in high performance industries and attempting to do so healthcare delivery. What causes this variation?

MN: Let’s borrow an example from the nuclear (U.S.) Navy. Say I took you on a submarine, into a reactor room, and had you work there. Then, I blindfolded and transported you across the globe and dropped you into another reactor room. When I took the blindfold off, you would know exactly where everything was because it looked exactly the same. You would know what the people to your right and left were responsible for and the job titles they had because they were identical (Bierly and Spender 1995). You would know what they did and didn’t do, what you did and didn’t do. If you were a 747 pilot, you would have precisely the same experience. What if I took a surgeon from an operating room in Utah, blindfolded them, and drove them to an operating room in Virginia? Chances are the instrument sets would be different for each procedure, the equipment may be dissimilar, and the subtle responsibilities would certainly be altered between the circulating nurse, scrub nurse, and surgical technicians, perhaps driven by provider preferences. You can’t have that. Some view standardization as stifling creativity or innovation. Yet, we could not have been highly reliable, and we could not have been high performing, unless we first created a learning organization based on standardization (Senge 2006).

If the research indicates we need to try a new project, we must do it with the awareness of the entire organization. If it works better, we must communicate our results back to everyone else. A learning organization is one that acquires knowledge and shares it with others. In the operating room case I provided earlier, one hospital learned, while the rest of the organization did not. Our challenge was that we were trying new things, but the enterprise was not benefitting from what individuals had learned locally. We needed strategic and a tactical communication across the enterprise to indicate what we were learning from specific efforts in real time.

SW: In closing, what do you believe is on the horizon in healthcare and in military medicine?

MN: Healthcare in general has to evolve into the next level… (in particular) virtual care. Aspects of medical care will be delivered much like banking or holiday shopping through digital communication between providers and patients. That’s what this generation is hungry for. On the horizon lies technology with the ability to use remote diagnostic tools. The challenge for (U.S.) Navy Medicine is that there’s no organization in the world that has the level of demand for isolated care that we do. We have many ships at sea and many sailors and marines deployed in remote places. The expectation is… that loved ones will get the same kind of care on a remote island, on a ship at sea, or in a faraway desert that they would receive in Maryland. We can’t do that without leveraging significant technology to provide care.

Young people today will expect digitalized care; they won’t drive in, circle a parking lot, wait in the line, sign in at a kiosk, or even be physically present. Through digitalization, we will diagnose and monitor problems, measure oxygen levels and heart rates, and obtain ECGs on our smart phones and with remote applications. Eventually, we should be able to offer patients 90 percent of their medical care virtually, bringing them in only when we cannot examine them with remote technology. It will take time, however, as most patients and providers are comfortable with current practices. However, there’s no need to spend an hour and a half getting into the office to spend 5 minutes in an exam room. Saving time and fostering access through technology will be key.

Application of the HPO model to practice

Drawing broadly from the human capital school of thought (organizational psychology, human resource management, and strategic management), which holds that to achieve HPO status de Waal (2011, 2012) asserts leaders must intentionally engage employees to develop and sustain high levels of performance over time. De Waal (2011, 2012) concludes that a set of five major factors (with 35 descriptors) consistently and significantly contributes to higher levels of organizational achievement: (1) long-term orientation; (2) management quality; (3) workforce quality; (4) continuous improvement; and (5) openness and action orientation (see Appendix). De Waal posits that each of the factors is complementary and highly correlated; some derive from the organizational level (e.g. policy, strategy, business processes, and organizational culture) and others speak directly to management (e.g. leadership traits, management style, and engagement). Organizational leaders craft and/or leverage both types of inputs, subsequently, to create conditions that support and encourage high performance among the workforce (Collins 2001; Collins and Porras 1994, 1996; de Waal 2011, 2012; Katzenbach and Smith 1993; Peters and Waterman 1982).

My interview with VADM (ret.) Nathan features his experience in successfully leading a unique health services organization, and provides insights into guiding an internationally dispersed health system whose mission lies in delivering world-class service in myriad, sometimes extreme, environments. Examining the organization in context, we uncover areas of convergence with de Waal’s (2011, 2012) HPO model to determine: Which factors best support the characterization of the U.S. Navy Medicine as a high performance organization? Based on insights from this interview, we summarize key themes.

1. Long-term orientation: fulfilling mission requires a contextual understanding.

According to de Waal (2011, 2012), factors that contribute to long-term orientation at the organization level include cultivating long-term relationships, providing the best possible service, and developing sustainable partnerships with all stakeholders. An HPO also boasts long-tenured managers, many of which have been promoted from within, thus reflecting a sense of job security among its workforce. Examining such factors as they align with VADM (ret.) Nathan’s interview supports the assertion that the U.S. Navy Medicine espouses the long-term orientation associated with de Waal’s (2011, 2012) HPO framework.

The U.S. Navy Medicine is a healthcare system that prides itself on an enduring tradition of service. Since its inception 241 years ago, Navy Medicine has existed to provide the U.S. military’s combatant commands globally responsive and high quality services in any environment (long-term relationships and service). Complementing this context of service is a shared culture steeped in seafaring tradition and whose adherence to a unified mission is job one (partnerships). Understanding mission in context and the unique challenges it poses are certainly germane to effective leadership (Pettigrew 1987); yet, HPO leaders must consider also the implications of mission fulfilment on business operations, particularly through the eyes of their workforce (Strebel 1996). Navy Medicine, therefore, deliberately and thoughtfully develops all of its managers internally over a long period of time seeking to mitigate operational weaknesses and recognizing individual strengths; hence, healthcare managers are promoted only over the long-term and solely from within. The process ensures that top managers serve in numerous environments and job classifications so as to challenge and expand individual competence and contribute to organizational stability and capability.

2. Management and 3. Workforce quality: cultivating individual leadership drives organizational alignment.

De Waal (2011, 2012) asserts factors that enhance HPO management and workforce quality occur at the individual trait level but also that such characteristics must be situated within a supportive and encouraging environment. Specifically, HPO management is trusted, has integrity, serves as a role model, and is decisive and quick to take action. HPO managers also achieve results through effective, confident leadership making tough decisions with regard to non-performers in support of mission accomplishment. Within this model, workforce quality takes its cues from management who holds individuals responsible and inspires employees to accomplish extraordinary results. To achieve such ends, managers must select or train employees to be resilient and flexible, yet also complementary.

VADM (ret.) Nathan and others argue that at all levels of the organization, developing a culture of individual leadership and accountability creates a more cohesive workforce and enhances resilience as well as adaptability (Chatman and Cha 2003; de Waal 2011, 2012). Further, he asserts employees should trust that leadership is interested in their success (Gómez and Rosen 2001; de Waal 2011, 2012); consequently, they must believe that workforce development is a priority, and that the expectation is for learning and growth over the long-term (Pfeffer et al. 1995; Tsui et al. 1997). In Navy Medicine, employees also believe hard work will be recognized, individually and as a team. They see evidence through engagement that the organization supports them as individuals and acknowledges the burdens of work–life balance on their families. They believe that the organization, in striving to fulfil a purposeful mission, will work to remove barriers and address concerns as expeditiously and effectively as possible. Workforce commitment to mission accomplishment as a whole is, therefore, greatly enriched (Rosen et al. 2005).

4. Continuous Improvement: The Process of Managing Change Should Be Focused.

Under the heading of Continuous Improvement, de Waal (2011, 2012) focuses on the uniqueness of organizational strategy (mission) and an approach to process improvement that is both constant and straightforward, the purpose of which is to align all parts of the organization. To bolster alignment, performance metrics as well as pertinent financial and non-financial data are shared openly with the workforce. Within this framework, the process of continuous improvement applies to individual competence as well as the organization’s products, processes, and services.

Navy Medicine’s unique mission to deliver, “World Class Care…Anytime, Anywhere” (BUMED 2016) sets it apart from both private and public sector health systems. As such, mission is a key driver in recruiting and retention. Because its mission requires mobilizing forces from myriad facilities and because the enterprise is spread globally, its strategy must be concise and focused. Nathan contends that if leaders create too many initiatives, the workforce will assume that either everything or nothing is important. The complexity and changing nature of many strategic planning efforts, therefore, overwhelms managers who are then burdened with innumerable initiatives and metrics (Strebel 1996). Priorities are often confused as a result. Leaders must distill a handful of their main concerns into a simple, intensive decree. The key is to taper a plan so as to streamline day-to-day operations, to reduce the burden on managers and personnel likely to chase everything, and enable movement on goals and objectives in a systematic, measurable way. In the end, individual employees will be able to translate strategic priorities into how they perform on the job, and in this case, also in their personal lives. They will know where to put their best efforts, expressing the organization’s plan succinctly and with confidence (Gant et al. 2002).

5. Openness and action orientation: a learning organization communicates effectively.

Management has a responsibility to engage its workforce in decision-making dialogue that results in an exchange of ideas that welcomes change, admits mistakes, and drives performance (de Waal 2011, 2012). If evidence suggests that the inclusion of a best practice is vital to effective operations (Pfeffer and Sutton 2006), the enterprise has the responsibility to ensure awareness across its facilities. If one facility or department has discovered a best practice, or perhaps uncovered a mishap, there must be a mechanism by which to communicate results to everyone else. According to Nathan, a learning organization is one that acquires knowledge locally and shares it with others in real time (March et al. 1991). The organization as a whole must benefit from efficacy in the form of evidence-based practices and by efficiency through communication that promotes organizational alignment. Communication, therefore, must be timely, meaningful, and well organized (Shortell et al. 1994).


Through the course of this interview, we highlight several aspects of the U.S. Navy Medicine that align with those of well-documented high performing organizations, as outlined in de Waal’s (2011, 2012) HPO model. VADM (ret.) Nathan’s observations, based on decades of leadership, support key findings from organizational theory and applied research. Lessons learned indicate a combination of epistemologies lies at the heart of informed theory development and evidence-based practice. We therefore present this paper in the spirit of collaborative learning. By examining the ways the U. S. Navy Medicine seeks to enhance capability in a multi-faceted environment, we suggest possible directions for understanding how evidence of high performing organizations may be extracted from their experience.


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Copyright information

© The OR Society 2017

Authors and Affiliations

  1. 1.University of WashingtonSeattleUSA
  2. 2.United States NavyWashington, D.C.USA

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