Creating a culture of innovation takes a lot of work. Even when successful, it is typically unevenly distributed and good ideas tend to just pierce the waterline, like an iceberg, leaving most unseen.

One challenge is to not only say that "innovation is everyone's business", but, more importantly, going from said to done by giving everyone in the organization chart from the corner office to the cubicle the knowledge, skills , attitudes and competencies they need to do something with an idea.

Suppose, for example, a clerk or patient representative or nursing assistant comes up with an idea to improve something in your clinic. Would they know the why, what and how of what to do next? I doubt it.

Gallup’s 2017 State of the American Workplace report found that only three in 10 U.S. employees strongly agree that their opinions seem to count.

“No matter how open you are as a manager, our research shows, many of your people are more likely to keep mum than to question initiatives or suggest new ideas at work,” business school professors James R. Detert and Ethan R. Burris reported in a 2016 Harvard Business Review article. Indeed, a 2018 MIT study (pdf) looked at the level of power employees have regarding various issues; when companies are implementing new workplace technology, for example, about half of workers report that they have no or little say.

Driving innovation in an industry like sick care requires both horizontal and vertical strategies and tactics. The horizontal piece creates interprofessional links across disciplines, like medicine, nursing and pharmacy, but these usually occur at higher levels of training and credentials. That's why you need a vertical part as well, which spans every level of the organizational chart and every employee, not just the higher ups. That way you can see what's below the water line.

Here are some ways to do it:

1. Be sure your onboarding training and professional development offerings include innovation and intrapreneurship.
2. Have the requisite structure, policies and procedures in place particularly for entry and lower level employees.
3. Measure the output, not just the structure and process.
4. Offer a menu of education, resources, networks, mentors, access to experience, peer to peer support and career development guidance.
5. Include innovation and intrapreneurship activities as part of performance evaluations.
6. Be sure to explain the why before you move on the what and the how.
7. Make sure their are enough incentives.
8. Celebrate the successful champions and teams not matter how small the success.
9. Do a post-mortem on failed ideas to learn.
10. Encourage and measure employment term learning. 

The goal is to make innovation and intrapreneurship a habit from side to side and top to bottom. But doing so requires changing behavior. Now you know why so few do it right.

Arlen Meyers, MD, MBA is the President and CEO of the Society of Physician Entrepreneurs on Twitter@ArlenMD and Co-editor of Digital Health Entrepreneurship.