(1)
Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
Abstract
This chapter presents the abstract philosophical principles behind the methods presented in prior chapters. The unique culture and philosophy of Branch Banking & Trust (BB&T) Corporation is studied and presented with applications to clinical medicine. The knowledge of the organization is increasingly recognized as the wealth of corporations and wealth of nations. With increasing complexity of products, knowledge and innovation are increasingly a collaborative effort. Organizations that are unable to collaborate and create fail to synergize their talents into creating great products or services. This chapter looks at the genesis of knowledge in organizations. Vision, mission, and values give birth to knowledge. Knowledge gives birth to processes. Knowledge development leads to development of an organization’s identity and development of core competencies. This leads to a culture of excellence. Teamwork synergizes individual talents into a great product or service which is beyond the capability of any one individual alone. These principles are presented for forming a basis for successful outcomes in medicine. Case examples of poor outcomes from lack of teamwork and of immense success from successful teamwork are presented. Teamwork should not be seen as intellectual or professional altruism, but as a force and knowledge multiplication method. Features which guide successful teamwork are presented. The career of a physician goes through many seasons of evolution and development for which ongoing training, leadership, and development of strong institutional culture and loyalties are essential. Management concepts of mentorship, ownership, and collaborative responsibility are presented.
Keywords
Values driven organizationKnowledge-driven organizationProcess-driven organizationContinuous learningTeamworkCore competencyCultureManaging complexityPhilosophic perspectivesDo not walk in front of me, I may not follow. Do not walk behind me, I may not lead. Walk beside me and I will be your friend
Albert Camus
Introduction
The prior chapters introduced methods and tools which improved dependability in diagnosis and treatment. This chapter is an exploration of the philosophical principles that evolved those methods and form the heart of enduring and iconic companies. These principles form the heart of the organization; they provide the abstract principles and basis for growth and evolution of the organization. In this chapter, we study the principles which helped BB&T Corporation, one of the leading banks in the United States successfully weather the recent financial crisis.
BB&T, headquartered in Winston Salem, North Carolina, with $176 billion in assets is the 12th largest bank in the United States [1]. BB&T has a footprint of over 1,800 centers in 12 states and Washington DC. BB&T provides consumer and commercial banking, securities brokerage, capital markets, asset management, mortgage and insurance products and services. A study of BB&T’s resilience holds valuable lessons for how dependability, in the face of uncertainty and systemic risk, can be achieved. BB&T’s strength lies in its core values—The BB&T Philosophy which is blended with a process-driven approach for managing day-to-day banking and developing employee potential. The origins of the BB&T philosophy lie in its history and development as a small North Carolina bank which grew because of a keen sense of dedication to its small business customers. BB&T’s origins as a small state bank lending to farmers shaped its operating philosophy during its growth into a large regional bank. BB&T views its philosophy as a lighthouse guiding the bank in the changing tides of finance. The operating philosophy, whether at the abstract corporate level or at a local branch, is shaped by its moral sense of delivering a great fiduciary responsibility towards its customer. BB&T’s methods have valuable lessons for synergizing and developing knowledge workers who form the core of many services-related fields such as medicine.
BB&T Philosophy
The heart and soul of BB&T is its philosophy, also termed its core values. This is ingrained in all employees at all levels of the organization. BB&T’s refers to employees as “associates” in its management terminology. BB&T’s values form the basis for all actions performed by all employees during the course of their duties. BB&T’s guiding vision is to create the best financial institution possible, “to be the best of the best”. This quest for excellence is perhaps the primordial factor maximizing human performance and lays the seeds for long-term growth and evolution. BB&T’s approach to dependable finance is very human; by maximizing human potential, the bank’s potential is maximized thus delivering shareholder and client value and dependability. These values are of course long term. The hierarchy and interaction of the core values are as shown in Fig. 10.1.
Fig. 10.1
BB&T values. Source: Annual General Report. 2013. Used by permission
BB&T’s philosophy develops the associate and governs their actions to the highest moral, fiduciary, and intellectual standards. The customer is the focus of all bank activity, therefore he or she is the direct beneficiary of investments made in the associate. It follows therefore that to deliver the best of the best to the customer, the associate has to perform at peak capacity. Associate development by necessity is a long-term process and to travel this long journey, an employee needs two things, a core philosophy or set of values which acts as a moral and ethical compass and a method or process that delivers these values into tangible transactions. Therefore, an associate must be viewed as a long-term asset in whose growth and development lies the means to be the best of the best.
But firstly, what are values? They are hard to define since they vary so diversely with culture. The Oxford English Dictionary defines values as “beliefs about what is right and wrong and what is important in life” [2]. Values therefore establish standards for behavior and judgment. They provide guidance and clarity in uncertain times. They provide consistency in our actions. Actions guided by values therefore are least likely to stray from high ethical, moral, and legal standards. Therefore, once values are well established, conscientious actions follow. By consistent application, values proceed from our conscious to our sub-conscious behavior and actions. BB&T’s core philosophy is composed of ten values which every associate is encouraged to internalize and apply consistently [3]. The stress on values comes from BB&T’s belief that “ideas matter and an individual’s character is of critical significance” [3]. In the following section, BB&T’s ten values are listed followed by a brief discussion in the context of delivering dependability.
1.
Reality
The actions of all associates should be grounded in objective facts (reality-based) as opposed to being driven by subjective beliefs or perceptions. Decisions which are reality-based are less likely to go wrong and have negative consequences. Decisions should not be based on what associates “wish was so” or on ephemeral theories disconnected from reality [3]. It is important to realize that reality-based decision making does not constrain innovation. This leads to a deeper question of which objective facts are trustworthy and reliable. The barrage of conflicting economic data and volatility during the recent economic crisis makes reality-based decision making more challenging than it may appear on the surface. Associates are therefore encouraged to not merely accept and incorporate data into decision making, but also to examine its veracity closely. Reality-based decision making blends closely with critical analysis and error correction.
2.
Reason (Objectivity)
Clear thinking forms the basis for rational decision making based on objective facts. A mind that is grounded in reality should be capable of thinking clearly. Clear thinking requires rigorous intellectual discipline and is based on sound premises and logical thinking. Associates should be able to perform both inductive (from specific examples to general conclusions) or deductive (from general principles to specific problems) reasoning. The thought process should be guided by what is essential and have a clear mission and purpose [3]. An equally important virtue is to be able to continue to refine and clarify the reasoning process.
3.
Independent Thinking
Each associate is encouraged to think independently. Every person is therefore responsible for what they do and ownership of their ideas. Creativity is strongly encouraged and results only from independent thought. Each associate should assume responsibility for their actions and individual success or failure. Independent thinking is not contradictory to teamwork. It emphasizes that clear thinking is an essential part of teamwork. Creativity and new ideas which result from independent thinking are essential for making things better [3]. New ideas are judged by their impact on the whole organization and how they contribute to the accomplishment of the mission. Independent thinking is an essential component of an employee’s growth in the organization.
4.
Productivity
Wealth creation is at the heart of BB&T’s business. Greater return on investment and improved productivity can happen only with rational allocation of capital through the lending and investment process in an efficient manner. Profitability is a measure of efficiency of an organization, which results from productivity. It follows therefore that to be the best of the best in the financial realm, all employees need to be the most productive. This is important for creating shareholder value and for contributions to society as a whole [3]. Striving for greater productivity inspires employees and organizations to innovate, whether by way of greater profits or lower costs. Lower costs lead to reduced waste in business processes. The idea behind this value is to inspire employees to turn their ideas into actions to improve economic well-being [3].
5.
Honesty
The highest standards of honesty and integrity are expected from all employees. This ideal is viewed as being consistent with reality [3]. This is important because conflict with reality is self-defeating. Being disconnected from reality leads to behavior and decision making which ignores objective facts leading to failure. Honesty blends with transparency which leads to institutional safety. It allows objective analysis of all outcomes, whether good or bad, and promotes understanding of failures which can be prevented in future. Honest failures from unforeseen circumstances should never be punished. It promotes free discussion of ideas. It encourages employees to assume responsibility for their thoughts and actions.
6.
Integrity
All employees are encouraged to behave consistent with principles. Being inconsistent with principles leads to long-term detriment. Principles must never be sacrificed under any circumstances. Violating principles, which may bring tempting returns in the short term, always leads to failure in the long term. The bank views itself as an organization with the highest integrity [3].
7.
Justice (Fairness)
The evaluations and rewards offered to individual employees should be objective and be based on their contributions towards accomplishing the goals of the institution and adhering to the institution’s values. Such a system being reality-based and backed by objective facts is therefore inherently just. It therefore follows that those who contribute the most should also receive the most. A just, fair, reality-based approach is applied by managers towards their employees and vice versa. The idea is to prevent employee unhappiness which follows when employees perceive managers rewarding underperforming team members and underrewarding strong performers. High achieving, motivated employees would leave the institution if they perceive unfairness in their evaluation and career advancement. This serves not just to deplete the institution of talent but also strengthens competitors. Rewards for superior performance encourages average performers to strive towards excellence, thus improving overall standards in the institution and fostering innovation. BB&T has an institutional culture of discriminating solely based on competency, performance, and character. Individual employees are judged solely based on their values, performance, and merits. BB&T’s operational culture simultaneously rejects egalitarianism and collectivism [3].
8.
Pride
Pride is the happiness that is earned from living cherished values. Pride is a natural consequence of living a “strenuous life”, one which is just, honest, independent in thought leading to great achievements (productivity). This form of pride must be distinguished from arrogance which is purely negative and undermines institutional excellence. Aristotle believed that “earned” pride (not arrogance) was the highest of virtues because it inspired all the others [3]. Striving for earned pride is therefore only a call to values-driven thought and action. Employees are encouraged to earn pride in their ideas and actions. Earned pride leads to strong loyalties to the institution, something which employees and customers would love to be associated with. Earned pride leads to high self-esteem.
9.
Self–Esteem (Self–Motivation)
Self-esteem stems from pride and accomplishment. It is the result of a job done well. It encourages employees to challenge themselves towards greater goals and develop ideas to achieve those goals. Self-esteem is closely allied with self-motivation. Self-motivation provides the energy for the quest for excellence. Guided by a strong work ethic, it leads to achievement. BB&T believes that what an employee receives from their work is proportionate to how much they contribute [3].
10.
Teamwork/Mutual Supportiveness
The day-to-day operation of a large bank with multiple services and lines of business is achieved by the collaborative, concerted efforts of its employees. Each employee contributes his independent thoughts and skills to the group of individuals that he is associated with to achieve these goals. Each employee must consistently act to achieve the agreed-upon objectives of the team. The need for team work stems from the evolution of the financial services industry into a complex system which requires diverse skills ranging from human resources management to risk management to financial modeling to be successful. As emphasized earlier, teamwork does not contradict independent thinking, it merely reinforces it in a more challenging context. Outstanding individuals can contribute more when they channel their talents and energies as members of a team and synergize each other’ strengths [3].
The core values lie at the heart of all matters big and small at BB&T; they influence all aspects of operations. These values provide the framework for an employee’s thoughts and actions during their growth at BB&T. The internalization of these values tempers emotions which transform from reflexive feelings to a deeper understanding of thought and happiness. Emotions evolve in a manner where they reinforce best decisions and behavior towards long-term success and happiness. Beliefs inspire behaviors which lead to results [3].
While mission values are not unique to BB&T, translating them from abstract principles to day-to-day actions across thousands of employees is an important process. This is all the more important when a company grows by mergers and acquisitions, assimilating thousands of new employees in short periods of time who come from different organizations. A core philosophy therefore needs a process to spread these principles across the organization. BB&T achieves that through very innovative employee education programs which will be studied in subsequent sections.
The basis of BB&T’s success is to understand the customer and to act only in the best interests of the customer. BB&T encourages all associates to understand the customer’s needs, credit requirements, business processes, and best interests as the basis for all transactions [4].
BB&T University
BB&T University is the primary learning and development arm of BB&T. The main campus is located in Winston Salem with training centers across the bank’s footprint. The main functions of the university are:
Develop and administer the University Certification Program (UCP).
Responsibility for learning administration through the learning management system (LMS).
Operate the Leadership Development Program (LDP).
Provide all merger training to newly acquired bank associates.
Operate the BB&T Banking School at Wake Forest University.
The university operates on a “Demand-Pull” business model. Demand-Pull itself is discussed in detail in Chap. 8. Applied to banking operations, this refers to the fact that a business knowledge need is first identified (“demand”) in the organization followed by course development to meet that need (“pull”). BB&T University is geared towards providing banking and financial industry knowledge for new employees who will serve as officers in the bank. The BB&T Banking School at Wake Forest University is geared towards existing bank employees who have shown exceptional performance but have a non-banking or finance background. This program helps such individuals gain domain knowledge in banking to lay the foundation for further career advancement at BB&T.
LDP is designed for training and mentoring new hires who are college graduates. Graduates of the LDP progress to solid careers at BB&T. They have served long, successful careers in the organization and form the vast majority of officers on the executive team of the bank. Class sizes vary depending on economic conditions and hiring requirements, ranging from 120–150 individuals in economic boom years to 50–60 in more recent times. A great emphasis is placed on company culture and values throughout the program. The company core values are emphasized during all phases of the program. The course structure involves lectures from senior management, including the chairman. This allows new associates to come face to face with senior management, division heads, and understand company policies and management direction. There are two major training areas—business and corporate. The idea is to create knowledgeable employees who would fit into leadership roles within the organization in the years to come. Coursework includes finance, accounting, regulation, economics, and business administration. Training is divided into three phases.
Phase I introduces new associates to the company culture and philosophy. The aim is to internalize within them that BB&T is a values-driven organization. There is constant teaching and exposure of “vision/mission/values”. Associates are able to determine during this phase if they fit in or not. This is also a great “self-awareness” phase. Associates learn to relate to one another and learn banking. They understand BB&T’s positioning in the industry and their potential role in the organization. They learn different banking models. During this phase they learn the business and processes of a small community bank (BB&T’s birth and roots). Progressively they learn the more complex range of products and services of a large bank. They learn to compare and contrast BB&T’s operations with competitors. The topics during this phase are variable and include a talk and interactive session with the chairman. This phase typically lasts the first few months. Towards the end of this phase, associates are expected to be driven by the core values of the bank and get a sense of direction of where they fit in the organization. Phase I introduces associates to the basics of financial products and banking processes. Associates learn fundamental banking concepts such as credit analysis, financial analysis, and introduction to commercial underwriting. They learn to appraise loans and the underwriting process. This phase focuses on developing domain knowledge, understanding credit models, and building familiarity with different software used in banking. Associates learn to work in teams and tackle problems collaboratively. By the end of this phase, associates blend independent thinking and critical analysis with collaborative teamwork skills.
Phase II training becomes more specialized depending on the career interests of the associates. It is broadly classified into business and corporate. This phase usually lasts 3 months. Business associates go on to careers in commercial banking. This phase is very intensive since it expands considerably on skills acquired in phase I. By the end of phase II, business associates would have learnt all aspects of working in a community bank. The corporate trainees develop skills for roles in BB&T’s core management and operations. Associates from this track go onto careers in human systems, regulations, audit, etc.
In Phase III, all associates come back together for a final review and undergo a series of formal end of program evaluations. All associates undergo a 90 day, 6 month, and end of program review. They are required to turn in papers and undergo formal testing in a bank simulator. The simulator exposes them to different credit problems under different economic conditions and evaluates their responses. They are evaluated by a panel of senior managers from BB&T where they discuss and defend their actions in the simulations process. Upon successful completion, associates graduate and then undergo placement for their first job.
At the completion of their training, graduates are paired with their respective mentors. Every graduate is assigned a mentor for at least 2 years. Graduates with prestigious MBA degrees receive an additional 2 years of mentoring, for a total of 4 years. Mentoring is considered an extremely important aspect of career development at BB&T. Retention programs to prevent attrition of trained associates starts almost immediately following graduation. Past experience suggests that the greatest risk of attrition is during the 18–36 months period. There are many factors which account for this, two of the more important reasons are:
Career disenchantment: During this period, stressors such as increased work responsibility or lack of fulfillment may play a role in seeking new career opportunities.
Competing offers: BB&T’s educational emphasis is well recognized in the banking industry. During the 18–36 month period, successful associates have built sufficient reputation to be approached for competing jobs in the financial services industry.
Mentoring plays a great role in mitigating attrition. Associates can communicate freely with a person outside their reporting lines and discuss perceived negatives (for example unsupportive boss, “work is not interesting” etc.) without fear of retribution. They can learn coping strategies from their mentors. Skill deficiencies can be addressed and goals for performance improvement can be formulated. In cases of major mismatches of an associate’s aptitude and job responsibilities, mentors can help with transitions within the organization which can bring greater work satisfaction. Beyond the 5-year period, associate retention and satisfaction is much greater.
UCP refers to BB&T University’s job-specific training process. Associates hired or promoted into a specific position are assigned the corresponding training curriculum (e.g., teller, retail lender, commercial lender, mortgage lender, etc.) to develop the skills necessary for discharging their job responsibilities. They are allotted 30 months to complete the program. The statistics confirm the benefits of investing in associate training and development. UCP graduates show consistently superior performance compared to their peers:
Certified vs. non-certified Banking Service Officers
○ 40 % higher loan production
○ 68 % higher fee-based revenue
Certified vs. non-certified Financial Center Leaders
○ 77 % higher loan production
○ 28 % higher net new transaction accounts
Most importantly, a statistical analysis comparing the UCP to associate retention has shown a strong positive correlation of +0.507 between the two. Therefore, investments in associate education and career development have a positive impact on performance and retention. Therefore, through BB&T University (including the LDP) and Banking school programs, the human systems division integrates recruitment, training, leadership development, and retention [5].
Section “From Values to Knowledge to Processes” will explore medical implementations of ideas borrowed from BB&T for patient care and physician training.
From Values to Knowledge to Processes
At the heart of successful organizations lie core values. Core values inspire an organizational mission and vision. This inspires the development of knowledge to deliver the mission objectives. The successful day-to-day translation of these objectives and delivery in the form of products and services requires the development of efficient processes. As the organization succeeds, it inspires new thought, development of new knowledge and newer processes on a bedrock of unchanging values (Fig. 10.2).
Fig. 10.2
The intertwined relationship between core values, organizational vision, mission, knowledge, and business processes of the organization
Knowledge Development in Medicine
Explicit and Implicit Knowledge
The knowledge of the organization takes many diverse forms. In their work The Knowledge Creating Company: How Japanese Companies Create the Dynamics of Innovation, Ikujiro Nonaka, and Hirotaka Takeuchi study the two types of knowledge that form the core of management decision making—implicit and explicit. Explicit knowledge is what is emphasized in western management; it is knowledge through rigor, deductive reasoning, formal education in the form of management degrees; found in articles, manuals, and databases and applied based on rules and guidelines. A vast majority of evidence-based medicine, professional guidelines come under this classification. Implicit knowledge is intuitive, based on individual insight and imagination which is not gained through formal education [6, 7]. Implicit knowledge forms the basis for new ideas and innovation. Successful companies create a background of core values, mission objectives, and a culture of learning that forms the milieu for development of explicit and implicit knowledge. This approach finds great application in medicine as well.
Core Competence
Core competence is an idea that dominated the business world in the 1990s based on an influential paper by management gurus C.K. Prahalad and Gary Hamel [6, 8]. During the last two decades, most western firms have shrunk their businesses into a few areas—defined by the concept of core competence. This has grown from exiting product manufacturing to technology development as well. For example, in the automobile industry, not only are vendors expected to supply parts conforming to a certain design, they are tasked with developing the technology as well. In its day-to-day application, core competence has come to mean defining a narrow range of products and services seen as the “core business” of a corporation and exiting anything that is seen as “non-core”. During the same timeframe it was closely coupled with “outsourcing” whereby corporations, usually advised by management consultants, identified processes and services as core vs. non-core and divested the latter. This led many companies to exit entire business areas and shrink their portfolio of products and services.
The concept advocated by C.K. Prahalad and Gary Hamel, however, was core competencies. The two authors defined this as “the collective learning in the organization, especially how to co-ordinate diverse production skills and integrate multiple streams of knowledge”. They envisioned the core competencies of an organization as the roots of a tree [6, 8]. These roots form an organization’s core products which yield “end products”, which are the goods or services delivered to the customer. Viewed this way, an automobile company should view its core competency as engineering and product development. Perhaps finance, marketing are not its core competencies and can be safely outsourced to an outside vendor whose competencies lies in accounting, finance, and marketing, respectively. However, the design of engines, transmissions, brakes, and ongoing technology development in these areas are part of the firm’s core competency of engineering. The end product is not the core competence of a corporation; it is merely a manifestation of its core competency. Core competency is abstract; core competence is a narrow physical manifestation of core competency.
Immunosuppression as a Core Competency
The conventional trend has been increasing knowledge fragmentation in the form of sub-specialization in medicine. The author’s own sub-specialization in neurology lies in the field of EMG and neuromuscular medicine. The practice of neuromuscular medicine involves a host of autoimmune neurological disorders like myasthenia gravis, Guillain-Barré Syndrome (GBS), CIDP, and inflammatory myositis. While these conditions are neuromuscular, the treatment of these conditions over time led to increasing familiarity with immunosuppression. Over time, the author developed an interest (as a dilettante!) in “autoimmune clinical neurology” and Parkinson spectrum disorders as a core competency. Conversely, the author does not identify muscular dystrophy clinics or autonomic disorders which are within the realm of neuromuscular medicine as a core competency. The following examples illustrate successful application of this core competency to the organization’s mission despite the applications being in an entirely different sub-specialty area. Case examples 1 and 2 are examples of core competency. Case example 3 is an example of implicit knowledge gained during the course of clinical work with valuable application in a completely different context a few years later.
Case Example 1
NG is a 35-year-old woman who initially presented with new right hemisphere onset seizures with secondary generalization. Patient was discharged on phenytoin and levetiracetam. She required readmission to the hospital 48 h later with multiple recurrent generalized tonic–clonic seizures. Additionally, the recurrent seizures were associated with progressive confusion, amnesia, encephalopathy, and decreasing level of consciousness. This was also associated with personality changes of hyper-religiosity, hyper-sexuality, and auditory hallucinations.