Journal of Evaluation in Clinical Practice ISSN 1356-1294
Understanding culture and culture management in the English NHS: a comparison of professional and patient perspectives jep_1376
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Frederick H. Konteh BA(Hons) PhD, Russell Mannion BA(Hons) PhD2 and Huw T. O. Davies BA(Hons) MA PhD3 1
Research Fellow, Centre for Health and Public Services Management, The York Management School, The University of York, York, UK Professor of Health Systems, Health Services Management Centre, University of Birmingham, Birmingham, UK 3 Professor of Healthcare Policy and Management, Social Dimensions of Health Institute, University of Dundee, Dundee, UK and University of St Andrews, St Andrews, UK 2
Keywords clinical governance, organizational culture, patient, perspectives, quality, safety Correspondence Professor Russell Mannion Health Services Management Centre University of Birmingham Park House 40 Edgbaston Park Road Birmingham 15 2RT UK E-mail:
[email protected] Accepted for publication: 3 September 2009 doi:10.1111/j.1365-2753.2010.01376.x
Abstract Rationale and objectives The growing interest in patient-focused health care in the National Health System (NHS), especially in the wake of high-profile failures in clinical practice, has underlined the need to involve patients in the design and evaluation of organizational change management programmes at the local level. This includes an evaluation of the relevance of culture and how culture might be assessed and managed in the delivery of high-quality and safe care. The purpose of this study is to compare and contrast the perspectives of health care professionals and patient representatives on purposeful attempts to manage culture change in the English NHS. Methods We used the mixed approach, but with more quantitative than qualitative data. A postal questionnaire survey of clinical governance leads and patient representatives from 276 NHS trusts was followed up with a focus group discussion of eight of the survey participants and semi-structured interviews with 18, including health care professionals and patient representatives from various organizations. We used spss to analyse the survey data and Atlas.ti to analyse the qualitative data. Results and conclusions Both clinical governance leads and patient representatives considered culture management and change to be integral to quality and safety improvement efforts. However, clinical governance leads were more positive than patient representatives about anticipated results from ongoing efforts to manage culture change at the local level. Further, in spite of general agreement on various attributes for culture assessment efforts, there was a striking difference in the level of importance respondents attached to blame free (more important to clinical governance managers) and customization (more important to patient representatives).
Introduction In 2001, the highly influential report published by the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary concluded that the culture of health care in the NHS1 ‘which so critically affects all other aspects of the service which patients receive, must develop and change’ [1]. Kennedy recognized that while some problems were peculiar to Bristol, in many ways the Bristol experience exemplified what were and are national issues in the NHS. In making his recommendations Kennedy highlighted a number of cultural shifts seen as necessary to transform the NHS 1
NHS stands for the National Health System.
into a high-quality, safety-focused institution, one that was sensitive and responsive to the needs of patients. Since the Kennedy report there has been increasing interest among policy makers, managers and health professionals in managing organizational cultures as a lever for improving quality of care; and strategies for culture change initiatives, as well as the underlying challenges in implementing them, have been well documented [1–8]. Of particular note is the emphasis over recent years on promoting a range of beliefs, values and norms of behaviour in professional practice that support the delivery of high-quality care designed and centred around the needs, especially that of safety, of patients and carers [6–13]. Patient involvement is also high on the policy agenda [10–12], including the need for patients to be involved in all aspects of
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health service redesign and evaluation, service planning, data gathering/research and decision making [13,14]. However, there has been a paucity of research into how professionals and patients may differ in their perceptions of purposeful attempts to manage organizational cultures to beneficial effect [14]. Recent approaches to understanding organizational culture recognize that the traditional view of an organization’s culture as a closed system does not adequately take into account the increasing influence of customers and service users [7]. Patients influence not just through their use of services, but also through their active involvement as they help health care organizations to focus on designing and evaluating services from a user perspective [15]. If patients are involved in co-creating health care cultures, certain implications follow. One is that the essence of organizational culture is not limited to the behaviour, values and assumptions of staff, as patients too are brought into the equation. Another implication is that intervention on one side or the other, patients or practitioners, may be worth considering in changing the culture shared between them. Inspired by these insights and the thrust of recent policy in the NHS, we were interested in collecting relevant information, comparing and contrasting the perspectives of both health care professionals and patient representatives on the nature of local health care cultures; how these evolve and transform within health care settings; and how (if at all) they can be shaped at the local level to support quality, safety and performance improvement. We start with an overview of the key theoretical debates around the study of culture change in health care organizations.
What is organizational culture? Despite its widespread use and appeal among policy makers, the meaning and definition of organizational culture remains essentially contested. There is no clear-cut agreement on the definition of ‘culture’; for example, a critical review of dimensions associated with the term ‘culture’ by Kroeber and Kluckhohn identified 164 unique definitions of the term [16]. In spite of the diverse notions in the literature [16–18] there are two distinct schools of thought: the first considers culture as a metaphor, ‘something that an organization is’ while the second approach treats culture as an attribute or a set of variables (something that an organization has) [3]. The distinction between conceiving organizational cultures as either an attribute or a metaphor holds important implications for policy and the nature and feasibility of planned cultural change. The view of culture as an attribute directs attention at ‘reengineering’ an organization’s value system towards instrumental ends. If by contrast organizations are approached as cultural systems (culture as metaphor) the whole emphasis shifts from what organizations accomplish to an ethnographic understanding of how organizations are socially accomplished and reproduced, thus offering fewer levers for change agents to effect change. The most frequently cited articulation of the nature of culture is Schein’s distinction of artefacts, values and basic assumptions [19]. Artefacts are the most visible and tangible manifestations of an organization’s culture and include the physical environment, products, technology used or not used, as well as patterns of behaviour, and the use of language and other symbolic forms. The second level is made up of values that underlie and influence behaviour. Unlike artefacts that can be perceived as ‘what is’, values represent ‘what ought to be’; they incorporate moral and 112
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ethical codes, ideologies and philosophies. The final level forms the basis for real cultural understanding; it comprises basic underlying assumptions: enshrined fundamental beliefs and perceptions that impact on individuals’ thinking, behaviour and feelings. This level differs from values, which are espoused, in that assumptions are those beliefs that have become so internalized as to be unconscious reflexes [19]. Complex health care organizations are likely to comprise a number of coexisting subcultures. While these may share some common orientations and similar espoused values, they may also diverge and clash or maintain uneasy and shifting tensions. Traditionally in the NHS, organizations such as hospitals have been clearly differentiated along distinctly occupational lines and these may give rise to a wide range of non-mutually exclusive subcultures in terms of clinical specialism, department, ward or clinical network affiliation [10–22]. Previous research has shown that some professional, or service user, subgroups may be more or less resistant to managerial attempts to engineer change in norms of behaviour and established working practices.
Research questions and aim The rationale underpinning this paper is that, by tapping into perceptions of health professionals and service users about the domains of culture in NHS organizations valued and experienced by each, we could inform efforts to understand and manage cultures. In the main, we wanted to find out, from the perspective of each category of respondents: • How important ‘culture’ is in their organization’s everyday language? • How might culture be assessed, changed or managed to beneficial ends? • What determining factors and dimensions of culture do they consider important for improved service delivery? Therefore, the research aim was to compare the views and perceptions of clinical governance leads2 and patient representatives3, with reference to the organization they are involved with, on the dynamics and implications of organizational culture for improved service delivery in the NHS.
Methods The research was based mainly on the quantitative approach involving a postal questionnaire survey of clinical governance leads and patient representative. However, we saw the need for some qualitative data to provide contextual perspectives to the survey results. Between March and September 2006 we approached all English NHS trusts (acute and primary care, a total of 325 organizations) for R&D approval and targeted the clinical governance leads and 2
A clinical governance lead is generally head of governance with primary responsibility for managing change for high-quality service delivery in an NHS organization, whether structural, procedural or cultural, lies with clinical governance leads. 3 A patient representative is a member of the local community (who would normally have used the health care services before) who volunteers to represent the interest of service users at meetings, committees and fora with health care professionals.
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patient representatives from 276 (or 85%), those granting approval. The postal survey was conducted between October 2006 and February 2007, and produced a response rate of 77% for clinical governance leads and 37% for patient representatives of the NHS organizations contacted4. Specifically the survey questionnaire covered the following issues: use of culture as part of the language of the local organization; respondents’ understanding of the meaning of organizational culture; the place and significance of culture in the operational domain of clinical governance and in promoting or impeding quality and safety improvement; and views on specific cultural attributes that may be considered important for virtuous programmes of change within their organization. We captured and analysed the data using the statistical package for the social sciences (spss). To add depth and richness to the data from the postal questionnaire we organized a focus group discussion (FGD) with eight clinical governance managers and semi-structured interviews with 18 individuals (including health care professionals and patient representatives). Twenty of the people who completed the questionnaire had indicated their willingness to take part in a follow-up FGD and stated their contact address. We managed to get eight of these to meet with us and discuss the same questions they had responded to in the questionnaire in open and unstructured manner. We also conducted semi-structured interviews over the phone with eight more clinical governance leads and 10 with patient representatives. These were randomly drawn from organizations that had taken part in the survey but were not represented at the FGD. The data were transcribed and analysed with the aid of the qualitative software package – Atlas.ti.
Results The usage of ‘culture’ in English NHS trusts The way(s) in which culture is conceived and conceptualized, as well as the extent to which it is part of the organization’s vocabulary, can be a measure of how far this notion is assuming practical relevance and may reflect the level of importance of culture and culture domains in respect of actual goals, aspirations and activities the local organizational level within the NHS. For these reasons, both clinical governance leads and patient representatives in the national postal survey were asked whether the term culture is used in their organization and how far their understanding of ‘culture’ agrees with a ‘working’ definition of the concept. Most of the respondents, almost 90%, stated that ‘culture’ is used in their organization ‘to describe the ways things are done around here’ (Table 1). The results were very similar for both clinical governance leads and patient representatives. In the qualitative interviews it became apparent that culture change was an integral element of local quality improvement activity even when the term itself was not always used explicitly by managers and patient representatives to describe what they do. We don’t talk about culture specifically, but we do sort of try and see where we have come from and where we want to go and how are we actually going to get there . . . (FGD participant no. 2) 4
Questionnaire is available from the authors on request.
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Table 1 Use of ‘culture’ to describe the ways things happen in the organization
‘Yes, often’ ‘Yes, some times’ ‘Not really’ ‘No, rarely’
Clinical governance leads % (n = 212)
Patient representatives % (n = 102)
56 34 9 1
53 35 9 3
We, we haven’t actually ever talked about . . . you know, the, the, the culture, the ethos. I mean I suppose although I can’t recall what it is, but there must be some hospital mission statement or position statement, you know, what it stands for . . . those are only to tell you if people actually . . . have that ethos in their hearts and minds that they work in the way in which the mission statement affects people. (Patient representative no. 1) In the postal questionnaire the researchers proposed a definition of culture as ‘the shared beliefs, values attitudes and norms of behaviour in the work place, including the local routines, tradition, ceremonies, and ways of making sense of the local work environment’ and asked respondents, how far this definition accorded with their own understanding of the term. All the clinical governance representatives (100%) and nearly all the patient representatives (97%) surveyed stated that the definition was consistent with their understanding of organizational culture. Despite such agreement, from the interviews it emerged that respondents, both clinical governance and patient representatives, tend to understand or define culture from their individual perspectives: they emphasize the specific aspects of their organization’s culture that hold the greatest relevance to them. For example, patient representatives focused on patient safety and the involvement of patients or their representatives in health care decision making in their responses, whereas clinical governance managers focused on those aspects of culture that are associated with staff satisfaction, organizational performance and standards of service delivery: I would say it’s the culture within the overall organisation that affects its approach to how it administers its services, how it treats the individuals within the organisation, what it sees its purpose is and how it drives the overall changes within the organisation and its place in relation to similar organisations in the locality. (Clinical governance respondent no. 1) . . . it’s the culture that where safety is, is sort of paramount and, and you’ve got to look at the ways, different ways that, you know, these, these, levels can, can be maintained and possibly improved on. I mean we’re the third safest hospital in England, you know what I mean, but I don’t see any reason why we couldn’t be the first safest . . . so there is work to be done . . . as well. (Patient representative no. 1)
Local culture, clinical governance and high-quality services If culture is the vehicle through which improved performance and high-quality health care can be attained then an important research 113
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question was whether ‘understanding the local culture is a central task for clinical governance’. Nearly all the clinical governance leads (97%) confirmed that ‘understanding the local culture is a central task for clinical governance’ within their organization. The majority of patient representatives (88%) recorded the same response. Data from the semi-structured interviews with clinical governance leads reinforce the above results. On the other hand, open-ended responses from patient representatives underscore the responsibility of the leadership of NHS organizations, especially the role of the executive, as critical to culture change management and high-quality service delivery, rather than a narrow focus on clinical governance. One perception was that it is only when the top hierarchy of the organization is committed to reform measures that the rest of the organization’s membership can be involved in culture change initiatives in any practical sense. Conversely, some NHS officials interviewed feared that it was a common practice to strategize and take key decisions at the top and pass them down in the form of orders to be followed; in some instances this was believed to be counterproductive to efforts at promoting change for high-quality service delivery: Yes, clinical governance sees itself as a quality tool . . . em one that is ensuring that the practice is at a certain level and that the people who work within the organisation maintain certain types of quality and so it important that we influence the culture within the organisation. Clinical governance would want the culture of the organisation to be a quality one, so it values certain aspects of practice and outcome. (Clinical governance respondent no. 5) The reality has been that the direction of organisations has all come from the centre, so in the past it was Chief Executive of the NHS, the Chief Executive of Strategic Health Authorities, the Chief Executives of NHS organisations, so what has passed for leadership in the NHS has been the willingness to follow orders no matter how perverse or stupid those orders may be. (Clinical governance respondent no. 4) I think it’ll probably come from the top, from the chief executive. . . . it’s got to, it has to cascade down and it’s the senior managers that have to because they are, a lot of them have put in a way of working. that doesn’t cascade down to the general work force. (Patient representative no. 6) Both sets of respondents were asked whether they agreed that established local cultures can sometimes serve as significant obstacles to health care improvements. A very high proportion (nearly nine-tenths) overall thought that this was the case with only one-tenth tending to disagree. However, more clinical governance managers (53%) ‘strongly agreed’ with the statement than patient representatives (36%).
An alternative way of looking at aspects of the organization’s local culture was how amenable or subversive they were to efforts at improving health care performance and service delivery. Even though the majority of each category of respondents indicated that there were certain aspects of their organization’s local culture, which were ‘very helpful’, patient representatives were not as positive in their response as clinical governance managers, with 22% and 33% recording ‘strongly agree’, respectively (Table 2). Similarly, 87% of clinical governance managers as compared with 76% of patient representatives agreed that certain aspects of their local culture were ‘unhelpful’ to high-quality health care delivery. In both the postal survey and the interviews, respondents pointed out examples of aspects of their organization’s local culture that they considered inimical to high-quality service delivery. These included self-centredness and individualistic tendencies among certain professionals that sometimes undermine cooperation and collaborative working; undue focus on finance at the expense of quality service; the existence of subcultures often in the form of cliques and tribes, which are sometimes at variance with the organization’s corporate cultures; and resistance to change and to nationally prescribed policies. One example of cultural difficulties has been seen within a department that have historically seen themselves as unique. They have not integrated with the rest of the organisation, but a series of unfortunate incidents have led to a focused review of their service. They are still reluctant to report incidents, and persuading them of the need to change for the good of the patients, the team and the organisation has not been easy. (Clinical governance respondent – open response from postal survey) I think, like many other NHS organisations, I think there are sub-cultures within different specialties, different groupings within the organisation; people tend to see themselves as belonging to their own little group first and foremost and maybe to the organisation secondary and so they have a culture within their own sub-group. Now and again that sub-group can work in tandem with the dominant culture, but some times it can be subversive and I’m sure that we have areas within our organisation where subculture dominates and is not always helpful to the dominant culture. (Clinical governance respondent no. 1) The interviews also identified those aspects of respondents’ local organizational culture that were believed to foster high-quality and safe care. Several clinical governance managers highlighted such aspects of the trusts’ culture as ‘openness in dealing with incident reporting’ and ‘being quality and patient focused’ as helpful to the promotion of quality health care performance. Several patient representatives referred to efforts to engage patients and their
Table 2 Aspects of local culture being ‘helpful’ and ‘unhelpful’ Very helpful
Strongly agree Tend to agree Tend to disagree
114
Very unhelpful
Clinical governance leads % (n = 112)
Patient representatives % (n = 102)
Clinical governance leads % (n = 112)
Patient representatives % (n = 102)
33 58 9
22 57 21
24 63 13
20 56 24
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Table 3 Local organizational culture, ‘a long way to go in supporting performance’
‘Strongly agree’ ‘Tend to agree’ ‘Tend to disagree’ ‘Strongly disagree’
Clinical governance leads % (n = 212)
Patient representatives % (n = 102)
9 19 56 16
12 43 38 7
representatives as a positive aspect of their local organization’s culture in aspiring to improved service delivery. Yes. . . . The first of, of those is . . . the importance that the Trust attaches through its directorate of nursing to quality of care throughout the hospital and they have an initiative called Caring at its Best that. is a very good instance of how a principle is being applied throughout the organisation and that principle is that quality of care is crucial at the very point of delivery to the patient . . . and I think that’s, that’s probably the best example of the lot. (Patient representative no. 7) It’s about openness, honesty, and being supportive. We are this kind of organisation, we want you to feel you are part of it, we want to hear your views and we want you to be involved. (FGD participant C) In terms of changes . . . yes . . . and there is I think an example where they are trying to make it much much more sensitive to patients’ . . . needs . . . So that if somebody does have a question or possible complaint, there is a route through . . . to get an answer to their question fairly quickly.(Patents representative no. 4) We also sought to gauge the perception of clinical governance leads and patient representatives on how long it would take for their organization to realize a culture change, which supports clinical performance in terms of quality and safety. The results are dissimilar for the two categories of respondents with clinical governance leads expressing greater optimism than patient representatives (Table 3). Among the clinical governance and patient representatives interviewed, some reflected this pessimism about the prospects for the changes required for higher-quality services in the NHS. Keys among the arguments underlining less optimism for culture change initiatives at the local NHS organizational level include: • being inward-looking and not doing enough to engage/listen to service users; • top management’s failure to engage the rest of the organization’s membership or to encourage and appreciate the full involvement of everyone in critical decision-making process; • not doing enough to keep the rank and file of the membership happy, and • undue emphasis on financial performance at the expense of quality service. Well I think the Health Service’s organisational culture is . . . it’s, it’s another world from the outside, it’s always taken on the . . . of the people within the NHS know better than what the patients do. They don’t listen, they use a different language and they seem totally divorced from what’s happening on the front line. (Patient representative no. 6)
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Right. The willingness to listen and learn . . . organisations will only change . . . if they are willing to listen to their users, listen to what is happening elsewhere in similar organisations and learn from what they hear. (Patient representative no. 7) I am at an organisation now that the culture is about not engaging and involving people, it’s almost a culture of alienating people; the rate at which people are leaving you never know. There are so many unhappy people- people feel as though they’ve got no power no influence, their opinions don’t count any more. And that to me was always the great thing that drove the NHS . . . . (Clinical governance respondent no. 2)
Culture domains for high-quality health care delivery Culture assessment instruments are normally based on certain cultural parameters, those that are considered key to the organization’s desire to ensure high-quality service delivery. Respondents were asked how much they thought a list of culture attributes were important for inclusion into culture assessment tools (Table 4). The results show a similar pattern for both clinical governance leads and patient representatives in terms of the degree importance each attached to certain cultural attributes. Although the percentage of respondents for each response was consistently greater for clinical governance leads than for patient representatives, the overwhelming majority of either category (between 80% and 95%) considered the following attributes to be ‘very important’: • patient centredness; • quality focus; • senior management commitment; • safety awareness, and • team working. It is obvious that from the perspectives of both health care professionals and patient representatives, quality care, safety and performance represent the raison d’être, as well as the basis and embodiment of those cultural attributes, which are considered to be very important for consideration into any assessment efforts. However it became apparent that health professionals and patient representatives do not always agree on the importance of every cultural attribute. Nearly three-fourths of clinical governance leads considered a ‘blame free’ environment to be very important for cultural assessment, as against less than half of patient representatives; the reverse is the case for ‘customized care’, which was accorded rather greater weight by patient representatives than by clinical governance leads. These particular results suggest that the level of importance that either a health professional or a patient (or their representative) attaches to the assessment of a particular cultural attribute may be a function of how directly they are affected by the attribute in question.
Discussion As in other health systems, notably the USA, efforts at improving quality and safety in health service delivery in the English NHS have increasingly seen the need for culture change alongside structural and procedural change. Both the quantitative and qualitative results from this study have shown a high degree of convergence in the views and perceptions of clinical governance leads and patient representatives, two of the most important stakeholders in the 115
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Table 4 Importance of culture attributes for high-quality health care Very important (%)
Somewhat important (%)
n = 212
Clinical governance leads % (n = 212)
Patient representatives % (n = 102)
Clinical governance leads % (n = 212)
Patient representatives % (n = 102)
Senior management commitment Quality focus Clear governance/accountability Patient centredness Safety awareness Team working Collaborative working Blame free environment Support for innovation Customized care Standardization of care Focus on cost-effectiveness Public service ethos Prioritization of choice
96 94 93 93 93 92 84 74 58 45 39 40 38 28
84 92 82 95 83 89 80 46 63 72 43 30 57 31
4 6 7 7 7 8 16 24 39 54 59 56 53 64
14 8 17 5 17 13 20 43 30 26 51 54 35 61
health sector, on the importance of culture and culture change to quality and safety in the NHS. The survey has shown that culture is a common concept in the everyday language of NHS organizations. It is significant that both clinical governance managers and patient representatives overwhelmingly recognize culture as a critical ingredient of efforts at improving quality and safety at the local level. Both senior health professionals in charge of clinical governance and patient representatives would therefore seem to welcome culture change initiatives geared towards improved health care delivery. Also, the role of clinical governance in shaping the local culture towards the desirable goal of improved safety, quality and performance in health care delivery was acknowledged by the overwhelming majority of both clinical governance leads and patient representatives. Although there is a great deal of optimism for the future in terms of shaping and managing the local organizational culture in the direction of improved and safe health care delivery for many NHS organizations, and for a sizeable proportion of clinical governance and a highly significant percentage of patient representatives, their organizations still have a long way to go before any meaningful cultural change could be realized. Among other things the reasons suggested for this include: the inability to listen to or consult with all key players including patients and front line staff members; and an excessive focus on financial performance and cost saving at the expense of higher-quality service delivery. As with every study interpretation of the findings should be tempered with a degree of caution because of methodological considerations. Perhaps the most serious limitation of this piece of research is that we used a postal questionnaire to assess views on culture and culture change. Given that culture is an extremely complex issue many of the responses may have been in part an artefact of the questions used in the survey. Nevertheless our qualitative interviews were able to provide additional depth and richness to the postal survey responses.
Concluding thoughts The views and perceptions of clinical governance and patient representatives regarding the nature of culture change are remark116
ably similar and appear to support the current policy of viewing organizational culture as a lever for health service improvement. The cultural attributes that are considered as very important by the majority of both sets of respondents are related to high-quality care, safety and performance. Patient centredness, quality focus, senior management commitment and safety awareness are among the dimensions expected to receive immediate and maximum attention in measuring or assessing local culture towards desirable outcomes. However, the striking disparities in the results for blame free culture and customized care, in particular, are an indication that health care professionals and patient representatives can sometimes differ on the importance they attach to certain cultural domains perhaps depending on how directly they can be affected by the domain. While clinical governance leads and patient representatives appear to recognize the need to manage culture at the local level in the NHS institutions, and see this as part of the responsibility of clinical governance, many are consciousness of the many challenges that this entails and are alert to subversive aspects of local cultures that can thwart attempts to engineer change from above. Our data suggest that patients and their representatives could be useful allies as new cultural directions are articulated and cultural change initiatives are implemented.
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