Culture Is the Most Valuable Clinical Variable

A note before we start. This one builds on a note I wrote for HealthView’s own site on why culture is the most important clinical variable in care, and on The Buildings, the first note in From Scrubs to Strategy by Monica D. Cutia, BSN, RN, PHN, COS-C. Every number is sourced on the page. Most of the research shows strong links, not proof, and I’ll say where it stops.

01

Nobody from the office is in that room

Banksy left the original at Southampton General Hospital in England in May 2020, in the first wave of the pandemic, with a note for the staff: “Thanks for all you’re doing. I hope this brightens the place up a bit, even if it’s only black and white.” It sold the next year at Christie’s for 16.8 million pounds, about 23 million dollars, and the money went to health charities.

Here’s what a home health visit actually looks like. Our nurse parks out front and walks in with a bag, and for that visit she is the whole hospital. No charge nurse down the hall. No doctor on the floor. She decides what to check, what to teach the family, and what has to go to the doctor today. The aide who comes the next morning decides how much time the bath gets.

Every one of those calls gets made by a person carrying whatever we gave them that week. A caseload she can handle or one she can’t. A manager who picked up the phone or one who let it ring.

That’s what I mean by culture. It’s how we treat the people who make those calls: their caseload, their pay, their manager, and whether they trust us to back them when they call a doctor at six at night about something small. All of it walks into the house with them. In the manifesto I called culture a clinical variable, in the same conversation as staffing ratios and readmissions. This note is the evidence, and what we did about it.

02

The best argument against me

The strongest pushback is that culture is a soft word for hard things. Staffing, training and pay are the real variables, and culture is the feeling they leave behind.

Part of that is right. A nurse with too many patients can’t give any of them a good visit, and a thank-you lunch won’t change that. Where the research pushes back is on which comes first. A team at Penn’s nursing school studied 665 hospitals in four states. Giving each nurse fewer patients lowered deaths mostly in hospitals where nurses rated their work environment well. In hospitals with poor work environments, cutting the patient load brought no benefit at all.

Same investment, more nurses. It paid off in one kind of workplace and not the other. The environment decided whether the staffing worked. That’s why culture goes first for me. It’s the variable that decides whether the others pay off.

Nurses figured this out a long time ago. In 1983, the same year Medicare started paying for hospice, the American Academy of Nursing went looking for hospitals that could attract nurses and keep them. Of the 163 it studied, 41 stood out. They became known as magnet hospitals. Thirty years later, Penn researchers compared more than 600,000 surgery patients in Magnet and non-Magnet hospitals. Death rates were 20 percent lower in the Magnet hospitals.

The places nurses wanted to stay turned out to be the places patients were more likely to survive.

03

The nurse who stays

Retention is where culture turns into outcomes you can count.

In England, researchers matched the national staff survey to hospital results. Trusts where staff were more engaged, including more willing to recommend their own hospital as a place to work or be treated, had lower patient mortality. For every step up in engagement, about 2.4 percent lower.

Home care points the same way. Researchers from Penn and Rutgers matched nurse surveys from 118 home health agencies with Medicare’s data on their patients. Agencies with good work environments had fewer patients end up back in the hospital. Researchers at NYU followed 23,886 people with dementia getting home health care. Patients whose visits were spread across more nurses had about 30 percent higher odds of going back to the hospital than patients who mostly saw the same nurse.

Now put that next to how often people leave. In the latest national survey, about one in four hospice registered nurses left their hospice within the year. At home care agencies, about one in three aides did. In The Invoice I added up what it costs a hospital when a bedside nurse quits, about sixty thousand dollars. The family pays too, every time somebody new walks in and they explain Mom all over again.

Who left their job within the year

Hospice registered nurseslatest national hospice surveyabout 1 in 4Home care aideshome care salary and benefits reportabout 1 in 3

And when a dementia patient’s home health visits were spread across more nurses, the odds of going back to the hospital were about 30 percent higher.

And the people who stay can burn out. A 2024 review pooled 85 studies from 32 countries. Nurse burnout was linked to worse patient safety, including more infections, falls and medication errors, and to lower patient satisfaction.

Line those up and you can see the machine. How we treat our people decides whether they stay and whether they burn out. A nurse who stays knows your mom. One who isn’t burned out catches the small change before it turns into an ambulance ride.

04

Who answers at three in the morning

I listen to people talk about death every day at work. When I walk outside those walls, almost nobody talks about it, like it’s never going to happen. I want people talking about death, and about how theirs is going to go. Not talking about it doesn’t make it go away.

I might be the guy who always talks about death. But death is a great teacher. It tells you how we delivered care up to that point, and how a person lived. That’s why I work backwards from it. It shows us how to make the years before it healthier, and how to get there with no regrets.

So here’s something most families don’t learn until they need it. Medicare’s rules require a hospice to have nursing available 24 hours a day, seven days a week. That’s the phone call at three in the morning, when the breathing changes and nobody in the house knows what it means. The person who answers is a nurse, and she’s often the one who drives over.

About half of the Medicare beneficiaries who died in 2023 used hospice. But the median stay was 18 days, and a quarter of them got five days or less. Most families come to hospice late, so a lot of what a hospice nurse does in those few days is teach. What the medicine is for. What the next few days will look like. When it’s over, Medicare asks the family whether the hospice taught them how to care for the person they love.

Most families come to hospice late

Half of patientsthe median stay18 days or lessA quarter of patientsthe 25th percentile5 days or less

Scale: a 30-day month. 51.7 percent of Medicare beneficiaries who died in 2023 used hospice.

Whether that nurse has the time, the backup and the patience for that conversation at three in the morning is a culture question. It gets answered long before the phone rings.

05

Who sets the culture

The survey researchers use to measure a nurse’s work environment has 31 questions, built at Penn. It asks whether nurses have a say in how the place runs, whether their manager backs them up, whether there are enough people, and whether nurses and doctors work well together. Every one of those gets decided in a meeting. So look at who’s in the meeting.

Gallup has asked Americans to rate the honesty and ethics of professions for decades. Nurses have ranked first every year since they were added in 1999, except 2001, when firefighters took it after September 11. In the latest poll, 75 percent of Americans rated nurses high or very high.

Then look at the boards. Nurses hold about four or five percent of the voting seats on hospital and health system boards. In the American Hospital Association’s last national survey, 63 percent of hospitals and systems didn’t have a single nurse with a vote. A 2023 study of 15 top-ranked hospitals found fewer than one percent of their board members were nurses, and more than half came from finance and business. A 2015 study of academic medical centers found 44 percent of the high performers had a nurse on the board, against 11 percent of the low performers. That’s one study, and it’s a link, not proof.

Most trusted, least seated

Americans who trust nurseshonesty and ethics rated high or very high75%Hospitals with no nurse who voteson the board, AHA national survey63%Board seats held by nurseshospitals and health systemsabout 5%Board members who are nursesat 15 top-ranked hospitals0.9%

At those 15 hospitals, more than half the board members came from finance and business.

A nurse on the board

High-performing centersacademic medical centers44%Low-performing centersacademic medical centers11%

One study, and a link, not proof.

No other industry would think this was normal. Nobody designs an airplane and leaves the engineers out of the room. Boeing came close. After it took over McDonnell Douglas in 1997, it moved its headquarters out of Seattle, where the planes were built, to Chicago. Two 737 MAX crashes later killed 346 people, and the congressional investigation found production pressures and a culture of concealment, where what the technical people knew didn’t reach the people who needed it. Healthcare does a version of this every day. We design the work of a nurse who is alone with a dying patient in a family’s living room, in a room with no nurse in it.

Nurses have been trying to get into that room for a long time. Florence Nightingale counted how British soldiers were dying in army hospitals during the Crimean War, drew it as charts, and put them in front of Queen Victoria and the prime minister. She got a Royal Commission in 1857, and the next year she became the first woman elected a Fellow of the Royal Statistical Society. Monica opened From Scrubs to Strategy the same way. “I’m a nurse,” she wrote. “I brought documentation.”

About nine in ten registered nurses in this country are women, so this is also a story about women in leadership. Women are 65 percent of the healthcare workforce, about 30 percent of the C-suite and 13 percent of the CEOs, and they’ve held 28 percent of hospital board seats since 2011.

Healthcare runs on women. The top doesn’t show it.

Registered nursesNCSBN, 2024about 90%Healthcare workforceOliver Wyman, 201965%C-suiteOliver Wyman, 2019about 30%Hospital board seatsAHA, since 201128%CEOsOliver Wyman, 201913%

06

So I built it

Culture gets set by the people leading the place. If the people leading it have stood at the bedside, they know what a caseload feels like at seven at night, and they make different calls. I didn’t see that happening, so I built it.

We’re the culture company. And every one of us is going to be a customer of bad health, good health, and eventually death. The next real change in how people die in America will be led by nurses, using the business systems and the technology that actually change somebody’s last months, not the ones that look good in a pitch deck. Nightingale wrote the question for it in 1859, in Notes on Nursing. Whoever is in charge, she said, should keep asking not how she can do the right thing herself, but “how can I provide for this right thing to be always done?” That’s a culture question. It came from a nurse.

I’m not a nurse. I came up on the operations side, and I’ve been in healthcare since 2006. We were told culture and taking care of people were too expensive, and I get why. Medicare pays home health by the 30-day period and hospice by the day, so every hour a nurse spends on anything but a visit looks like cost on a spreadsheet. We spend it anyway.

We put nurses in charge of the work. Monica runs clinical operations, and she sits on the executive team with me, next to Carol Mislang-Tondares, also a registered nurse, who runs compliance and education. Our two executive directors, Shermane Constantino in hospice and Cindy Diaz in home health, are both licensed vocational nurses. So are the care continuum managers who keep a patient’s care connected across doctors, families and our own teams. The people deciding caseloads have carried one.

We wrote down how our best managers already worked and made it the way every team runs. A few goals for each team every quarter. A brief before every one-on-one. Every promise a manager makes to someone on their team tracked until it’s kept. It runs on CultureAI, which we built inside HealthView, and Monica was its clinical founder.

Two of our licensed vocational nurses, Victor Rodriguez in home health and Nicole Ryder in hospice, were named to the Frontline Honors class of 2024. Neither of them applied. Their colleagues nominated them. When Hospice News talked to Nicole, she said she wished leaders understood the pressures on the front lines. Leaders understand it a lot faster when somebody who lived it is sitting at the table.

And we measure it, the way a nurse measures blood pressure. In 2026, 98 percent of our people told Great Place To Work that HealthView is a great place to work. At a typical U.S. company it’s 57 percent. Every person surveyed said management is approachable. Fortune ranked us No. 16 on its Best Small Workplaces list for 2026, up from No. 23, and in 2025 it ranked us No. 12 among the Best Small and Medium Workplaces in Health Care. It hasn’t cost us growth. HealthView is No. 97 on the 2026 Inc. 5000.

07

Where I could be wrong

Most of these studies show links, not proof. A place that treats its people well might also have more money or healthier patients, and researchers can only adjust for what they can measure. Most of the evidence comes from hospitals. Nobody has run a controlled trial of nurses on boards, and not every great nurse wants the room. Our own survey measures how our people feel about working here, which is the input, not how your mom’s care went. And I run a company that does better when you believe this, which is why every number here links to where it came from.

What would change my mind is research showing an agency can burn through its people and still give families the same care at the end. I haven’t seen it.

08

Count the room

If you run a healthcare company, look at the next meeting where caseloads, staffing or the budget get decided. Count the people in it who have carried a caseload. Then check how many of your nurses left last year, and ask what that cost the families they were seeing.

And whoever you are, have the other conversation too. Ask somebody you love how they want the end to go, and tell them how you want yours to go.

Most of the people I named in this note are women. Next week’s note is about the two I’m raising.