On Culture

At TORTUS we work a 4.5 day working week, which means every second Friday the entire company is off. On another post perhaps I will reflect on why we decided to work this way (and the huge benefits), but this gives me time every fortnight to think about what’s gone well, where we screwed up, and what we are learning. I’ve decided to record these reflections for my own posterity, and you are welcome to read them too if you’d like as well. Try. Fail. Repeat.

These past few weeks we have been building the team and with it the culture. We went from a team of two to four a few months ago and we are now expanding the team to eight. So culture is becoming more and more important.

As a doctor, whenever I rotated into a new department I would always approach the new ‘thing’ in the same way;
Step 1: Read all the books about the thing
Step 2: Do the thing.

When I came to sit in the CEO chair again this time around, I took the same approach, reading as many books as I can get my hands on. There is so much to read about start-ups and I’ve read a lot in the past nine months. Many of these books give conflicting advice but one of the areas which is pretty consistent is the importance of creating and maintaining a strong culture.

So firstly, what do I think of as “culture”?

The best definition I’ve come across is ‘the set of normal behaviours that govern how people within the company interact with each other’. That covers everything from saying good morning when coming into the office to navigating a complex multi-team crisis project. Some of this is set at the company value level (see below) but a lot of this is far more granular.

From a neurobiological perspective, I’m starting to realise a better definition might be ‘the collective sum of every individual’s engrained habits pertaining to life at work’. I’ve written before about the Power of Habit at home, but never really thought about the same idea of habits at work. Instilling habits in a team is much harder than instilling them in oneself, but the principles are the same – the key principle being consistency.

So what makes a good ‘culture’? I was surprised to find myself having really strong feelings about company culture despite never having actively thought about it before as a ‘thing’. On reflection I realise it’s because I’ve been a part of, and even contributed to, some bad cultures in the past. So I thought these previous cultures might be worth revisiting and learning from.

Culture #1: The NHS:

  • I worked for nearly ten years in the NHS, and longer as a student before that, across many hospitals in the UK. Despite the name ‘National Health Service’, the NHS is anything but a homogenous national organisation.
    On a macro level every hospital and GP surgery functions as its own business and has their own company ethos and values. On a micro level within those organisations, departments have their own culture, and even within those departments individual teams/wards have their own fiefdoms and individual cultures as well. This means as a trainee doctor on rotation in the NHS you will traverse a pretty varied terrain of different ‘cultures’, some easier to navigate than others.
  • The biggest and most obvious issue with the bad cultures I experienced (toxic relationships, ignoring big problems, colleagues fighting over/avoiding responsibilities) was the lack of accountability. I couldn’t tell you WHO was ultimately accountable for the culture in any team or department I ever worked in across the NHS. I’m sure nominally there was someone, but I didn’t know who that was, and to me, felt like no one was. Therefore first and most importantly, as the CEO, I am accountable for the culture.
  • The second issue was the lack of visibility. I’m sure every hospital had a set of values or code of conduct somewhere, but this was never front and centre anywhere and I couldn’t tell you any value for any of 15+ NHS organisations I ever worked at.
  • Together, this meant there was never a set of visible and agreed values for all staff AND generally no one was holding anyone accountable to those values anyway. The net result wasn’t great. There were pockets of great culture I was lucky enough to be a part of in my career, but equally many terrible ones as well.
  • If it were possible to measure I would intuit there’s a direct correlation between the quality of the culture of any given NHS team/department and a) retention and staff absence rates and b) the actual patient mortality/morbidity outcomes as a consequence.*
  • The most obvious reason for this culture is the lack of resource. Staff are strapped for time and money across the board in the NHS – this only makes it that much harder to get staff engaged and to prioritise culture building. Like a garden, if you neglect the culture it grows wild and unpredictably. So last lesson from the NHS – you get the culture you pay for.

Culture No.2: The Healthcare Workers Foundation (formerly known as HEROES)

  • So my next culture I was a part of was the charity I co-founded and ran as CEO and Chair for a few years from 2020-2022. For some context, we founded, fundraised and scaled a team in a crazy time at the start of the pandemic to support healthcare workers rapidly with PPE needs – we went from 0 to a team of 20+ in about three weeks and we raised £3.2m in the first year, most of which came during the first wave of Covid (Mar – May 2020). Despite the insane pace and working remotely, the initial culture we had was amazing.
  • At the time the macro-environment created almost total alignment -> we were all in lockdown, we were only focussing on one very specific thing (helping NHS workers), and we were all part of a wider national effort. So without trying at all, the macro-environment and mission created an instant, really great culture.
  • Similarly as time drifted and the pandemic waned, the mission itself drifted, the culture changed as people shifted back to their full-time jobs, and it was harder and harder to maintain that same culture.
  • So a few lessons here:
    1) Great mission alignment bootstraps cultural alignment
    2) Remote organisations need really explicit effort to curate a good culture, especially over time.
    3) As I ran the charity part-time over the next few years I couldn’t keep up with the culture, therefore not only does the CEO need to create the culture, they need to maintain it. And that’s a full time job.

So what I am trying to do differently at TORTUS, and what have I learnt so far?

  1. Values are everything
    The most high value piece of advice we received as a company was to create some values early on and stick to them. So we did;

    – Put the Patient First – we always put the patient first – in function and in data privacy.
    – Be Kind – this covers a lot of what I hated about previous organisations – politicking, in-fighting, squabbling.**
    – Stay Curious – We are scientists, we infuse the scientific method into everything we do from ML modelling to marketing.
    – Kick Ass – We are trying to do something really hard, to create massive impact. This requires aiming for the moon in nearly everything we think about.

    Learning from previous, I make them highly visible. They are literally stuck on the walls in our office, we put them front and centre on the website and we hire against them as well (see below). What I’ve found surprising is just by being on the wall, how much these four values enter our thinking now – whenever’s there’s a decision to make usually at least one of these principles becomes the deciding factor.
  2. Values are verbs:
    Like in some of my previous jobs, values without visible action are meaningless. So don’t choose values you can’t keep yourself ie don’t choose values that are just words, you have to actually act on them. We deliberately chose values that were already pretty aligned to ourselves personally, and therefore this isn’t that hard, at least so far.
  3. Values aren’t everything
    I think my biggest mistake in this area was believing values alone are sufficient to define culture. Although values govern a lot of macro level interactions, and guide decisions on what to do, they don’t necessarily tell us how to do specific things like agreeing product timelines or feature sets for example. For that we need to include our processes.
    So now I’m thinking culture = values + processes. The processes are the daily routines and rituals that define the company culture. These processes are like drops of water on a stone, slowly shaping the stone with repetition and time.
    For example, we created a shared project management board for the whole company – each day that we review this board as a team reaffirms in a small way that the culture values the power of working together.
    Anything done daily has huge impact in the long-term. So pick your processes as carefully as you pick your values and consider how they shape the culture long-term as well.
  4. Screen for skill, match for culture
    At TORTUS we now have a culture interview as part of the last stages of the interview process. Chris and I don’t sit on the culture interviews***, and the team decide independently if someone embodies our values and our mission and they then let us know. We’ve already turned down a few candidates at this stage, and although it’s sometimes unfair it’s an essential high bar to maintain the culture. It’s also a great hack to get the team to own the values and the culture of the company as well, by representing it to the outside world.
  5. “If you are sick of saying it, they are only just hearing it”
    Another mistake of mine was to think of communication as symmetrical – the effort it takes to compose a sentence and speak is equal to the effort it takes to listen and take on board what is said.
    I realise now it isn’t. Listening is way harder than speaking – genuinely paying attention and modifying behaviour takes a lot more effort than it does to say a bunch of things. The best advice I’ve heard is as above – only when you are sick of repeating something, is the other person actually hearing it.
    So now I repeat our mission, strategy goals, and values at the start of every stand up meeting. It does make me sound insane. But I hope at least if you stopped anyone at TORTUS on the street and asked them what our values are and what is our mission, they would now be able to reel it off. I’m also starting to see this in the work itself. For example our mission is “to eliminate human error in medicine”, and I’ve observed the team amongst themselves making individual decisions based on this statement alone. That’s culture.

6. “Culture eats strategy for breakfast” Peter Drucker
Everything about founding is counter-intuitive. One of the most counter-intuitive parts I’m finding is where to apply effort for results. In a start-up it would make sense that you should apply maximum effort as a CEO into making the product and selling it. If you are a start-up of one, then that makes sense. But as Jim Collins points out you have to get the ‘right people on the bus, in the right seats’ before you go anywhere. The bus is the culture itself – the vehicle.
I think now the order of priority for execution should be:
1. People
2. Culture
3. Strategy

Culture is the ability of the bus to take corners, go over bumps and up hills, and still get where you are going. For example, with the people we have in the company right now (physicians, engineers and scientists) and the culture that we have, I would be quite happy to build pretty much anything in healthcare, to go pretty much anywhere. With a very bumpy AI and economic terrain ahead of us, I think culture is our most valuable asset going forward.

So that’s it, everything I’m thinking about culture right now.

Footnotes:

*I have no idea how to fix this by the way, it’s just my observation. Also another caveat; it’s the people that really keep the NHS going, and the pockets of the good – teams that really cared about each other, focussed on good work, had a team mentality and invested in each other’s abilities – keep the whole system going. For now at least.

**Empathy is also a business superpower, so directly curating it in the company seems like a good idea.

*** If the culture is the normal interactions between people in the company, we recognised that there isn’t much ‘normal’ about interacting with the CEO compared to colleagues. Therefore although I am responsible for the culture, I don’t actually experience it personally, so the true guardians of the culture in this respect at the actual people in the company.