Associations between Organisational Culture and Patient Outcomes: A Systematic Review

Table of Contents

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Glossary…………………………………………………….

List of Abbreviations…………………………………………..

Abstract…………………………………………………….

1. Introduction………………………………………………

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1.1. Background of Organisational Culture………………………….

1.1.1. Interpreting organisational culture……………………………

1.1.2. Cultural and organisational variables………………………….

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1.1.3. Subcultures and Diversity………………………………….

1.1.4. Culture and performance………………………………….

1.2. Culture formation and transformation…………………………..

1.2.1. Managing culture……………………………………….

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1.2.2. Managing competing cultures……………………………….

1.3. Measuring organisational culture………………………………

1.4. Rationale and Aims……………………………………….

2. Methodology………………………………………………

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2.1. Overview of systematic review………………………………..

2.2. Minimising the risk of bias at the review level……………………..

2.3. Search Strategy………………………………………….

2.4. Scoping and search terms……………………………………

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2.5. Searching Electronic bibliographical databases…………………….

2.6. Grey literature searches…………………………………….

2.7. Hand searched…………………………………………..

2.8. Data management………………………………………..

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2.9. Research questions and inclusion criteria…………………………

2.9.1. Research questions………………………………………

2.9.2. Inclusion Criteria……………………………………….

2.9.2.1. Population…………………………………………..

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2.9.2.2. Intervention………………………………………….

2.9.2.3. Comparators…………………………………………

2.9.2.4. Outcomes……………………………………………

2.10. Assessing the risk of bias…………………………………..

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2.11. Methodological quality assessment using the Mixed Methods Appraisal Tool.

2.12. Data extraction………………………………………….

3. Results…………………………………………………..

3.1. Identification of records and study selection………………………

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3.2. Study characteristics………………………………………

3.3. Patient outcome characteristics……………………………….

3.4. Organisational culture tool characteristics………………………..

3.5. Risk of bias within studies…………………………………..

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3.6. Risk of bias across studies: language bias…………………………

4. Discussion………………………………………………..

5. Conclusion……………………………………………….

1.     Introduction

Priority on delivering high quality, safe healthcare has been a key policy objective for governments in much of the developed world for nearly two decades (Davies, Nutley & Mannion 2000; Dixon-Woods, McNicol & Martin, 2012). Many individuals and agencies connected with healthcare quality and performance, have accentuated the need for cultural change to be operated alongside structural, financial and procedural reforms (Mannion, Davies, & Marshall, 2005). Despite encouraging evidence of improving quality and safety, delivery of the aforementioned policies has been meek (Benning et al, 2011; Wachter, 2010). Patients across the developed world continue to suffer avoidable harm and substandard care (Wachter, 2010), England’s National Health Service (NHS) not being immune from these issues; the Bristol Heart Scandal, high rates of paediatric mortality after cardiac surgery at the Bristol Royal Infirmary, during 1984-1995 (Smith, 1998); and the Mid Staffs scandal, poor care and high mortality rates at the Mid Staffordshire NHS Foundation Trust (FT), between 2005-2009 (Healthcare Commission, 2009). The Kennedy inquiry report that examined the failings at Bristol Royal Infirmary concluded “the culture of healthcare which so critically affects all other aspects of the service which patients receive, must develop and change” (Kennedy, 2001, p. 277). Kennedy described the prevailing culture during the 1984-1995 as a ‘club culture’ that emphasised excessive power and influence around a core group of senior managers (Mannion et al, 2008). Similarly, the Francis inquiry report that examined failings at Mid Staffordshire NHS FT, identifying causes of organisational degradation as systemic, he saw the underlying errors as institutional and cultural in character (Dixon-Woods et al, 2013). Francis (2013) blamed an “insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities” (p. 3).

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Francis’s findings are disappointingly recognisable, examples of failures with other healthcare systems around the world: Canada, Netherlands and New Zealand have experienced similar crises in healthcare (Walshe & Shortell, 2004). Poor management systems, failure to respond to patient concerns and cultures of denial of uncomfortable information were some of the features that Walshe and Shortell identified. Walshe and Shortell (2004) recognised similarities with the characteristics of failures “The causes and characteristics of major failures in countries with different ways of organizing health care are remarkably similar” (p. 107). Nevertheless, managing organisational cultures within the NHS has been included as part of previous policy reforms dating back to 1984 (Mannion et al, 2008). The Griffiths’ report led to a number of resource management programmes and the development of general management in hospitals (Department of Health and Social Security [DHSS], 1983). These initiatives propelled internal market reforms that increased managerial control and accountability within the NHS fostering a competitive business culture throughout (Davies et al, 2000). A question to consider here is concerning the extent of failures and similarities seen at Mid Staffordshire and Bristol Royal Infirmary, whether their features are symptoms of a more widespread culture, particularly as other organisations within the NHS are open to the same institutional and regulatory nature. Especially as the role of organisational culture in improving quality management and performance is not limited to healthcare; in fact it is a focus within other industries (Lapina, Kairisa & Aramina, 2015). Lapina et al (2015) studied organisational culture of a university, they found that organisational culture is directly linked with effectiveness and performance – the stronger the organisational culture the more effective the organisation. Despite the importance of organisational culture and its role it has on quality and performance, there appears to be a paucity of research within healthcare.

This systematic review attempts to pull together what is known about organisational culture within healthcare and its associations with quality and patient outcomes. Systematic reviews aim to identify evaluate and summarise the findings of all relevant individual studies, whilst offering available evidence to become more accessible to decision-makers (Centre for Reviews and Dissemination [CRD], 2009). More so, where appropriate, combining the results of several studies provides a greater reliability and specific estimate of an intervention’s effectiveness than one study alone (CRD, 2009). This is authenticated due to the strict scientific design guidelines, with pre-specified, reproducible methods used, limiting the flaws seen in narrative reviews (Impellizzeri & Bizzini, 2012). Not only can systematic reviews layout what we know about a particular intervention, it also establishes where knowledge is lacking and can guide future research (Brown et al, 2006; Greens & Higgins, 2011; Petticrew, 2003). This introduction will continue with exploration of the origins and conceptions of organisational culture, the significance of this in healthcare, the formation and transformation of culture (OC), and the instruments and tools used for measuring organisational culture within a healthcare setting.

1.1. Background of Organisational Culture

Anthropological literature going back many decades has deeply embedded conceptions of ‘culture’ to indigenous people (Malinowski, 1922). Although the function of these conceptions to organisations originated in the United States, directly after the Second World War period, however came to favourable attention in the 1980s (Blau, 1955; Mannion et al, 2008). This period saw an emergence of best selling management books, which rooted the concept of organisational culture as paramount in the management of organisational performance (Deal & Kennedy, 1999; Peters & Waterman, 1982). Organisational culture has continued to be one of the key themes in organisational research as few contending ideas can compete its status; existing literature is plagued with special issues on content, impact and dynamics of culture, which has placed huge emphasis on managers to consider the implications for their organisations of its culture (Ogbonna & Harris, 2002).

Many of the ideas and themes on organisational culture during the 1980s and onwards however were not original; in fact, more moderately, it has been argued these concepts can be seen as a continuum of a trend that started early 20^th century (Mannion et al, 2008). Mannion argues the focus of study on organisational culture is recognised as a movement away from the ‘mechanistic perceptions’ of organisations, connected with concepts of scientific management. The perceptions of scientific management or ‘Taylorism’ as it became known, based on the contribution of Frederick Taylor; advocated that an in-depth understanding of the technical means of production, coupled with time study and financial incentives could lead to a significant improvement of an organisation’s efficiency (Dean, 1997). Some authorities view Taylor’s work as an exclusive interest solely based on the pursuit of an organisation’s efficiency with no regard for the human element involved (Sheldrake, 1996). This distortion however is contested by some who argue about the concept of Taylor’s work focused on a main concern being ‘cultural issues’, which encompassed pre-empted strands of human relations theory, as well as organisational literature (Parker & Bradley, 2000; Taska, 1992). Taska (1992) suggests that prevalent writings on organisational culture have been formed from Taylor’s theories and driving forces of scientific management.

Further influences throughout the 20^th century on organisational culture include the human relations theory, most noticeably the works of Elton Mayo in the 1930s (Mayo, 1924; see also Witzel & Warner, 2015). Mayo’s work highlighted the importance of using informal social constructions, when studying human behaviour within organisations (Parker & Bradley, 2000). More so, Wright (1994) suggests that Mayo used anthropological research methods and expertise, which opened the door to anthropology within organisational studies. The exploration of culture within organisations continued during the 1950s and 60s with cited works including, the study of banana time (Roy, 1959) and the changing culture of a factory (Jacques, 1951). Although between these times and up until 1980s studies in the area of organisational culture were meek (Parker & Bradley, 2000). There is broad acknowledgment that Pettigrew (1979) coined the term ‘organisational culture’, however Jordan (1994) argues, wider interest in the concept of organisational culture was due to three best selling books; Ouchi’s (1981) Theory Z, sometimes referred as ‘Japanese Management’ style; Peters and Watermans’ (1982) In Search of Excellence; and, Deal and Kennedy’s (2000) Corporate Cultures (Mannion et al, 2008). These books all provided the same message that in order for organisations to be successful, ‘cultures’ had to be the main focus (Jordan, 1994). Jordan (1994) highlights during these times American businesses were concerned by their Japanese competitors, as ‘organisational culture’ was seen as the success for Japanese organisations.

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1.1.1.     Interpreting organisational culture

Despite the universal agreement that organisational culture exists and plays a fundamental role in shaping behaviour in organisations, there is little consensus on the definition and interpretation on organisational culture (Watkins, 2013). Van der Post, De Coning & Smit (1997) identified over 100 dimensions connected to organisational culture (see Table 1). Similarly, a critical review undertaken by Kroeber and Kluckhohn in 1963 identified 164 definitions of the term ‘culture’. This level of complexity exemplifies why there is no consensus, however without reasonable agreement it becomes difficult to understand the connections and other important elements that make up an organisation. This also prevents the ability to develop approaches to analyse and transform cultures (Watkins, 2013).

Table 1. 

Dimensions of Organisational Culture