Background: There is growing international interest in managing organisational culture as a lever for healthcare improvement. This has prompted a practical need to understand what instruments and tools exist for assessing cultures in healthcare contexts. The present study was undertaken to determine the culture assessment tools being used in the English NHS and assess their fitness for purpose.
Methods: Postal questionnaire survey of clinical governance leads in 275 English NHS organisations, with a response rate of 77%.
Results: A third of the organisations were currently using a culture assessment instrument to support their clinical governance activity. Although we found a high degree of satisfaction with existing instruments, in terms of ease of use and relevance, there is an immediate practical need to develop new and better bespoke culture assessment tools to bridge the gap between the cultural domains covered by extant instruments and the broader range of concerns of clinical governance managers.
Conclusion: There is growing interest in understanding and shaping local cultures in healthcare, which is not yet matched by widespread use of available instruments. Even though extant tools cover many of the most important cultural attributes identified by clinical governance managers, the over-riding focus of tools in use is on safety rather than a holistic assessment of the dimensions of healthcare quality and performance.
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Underpinning and binding many of the recent reforms in the UK NHS is the notion that a major cultural transformation of the organisation must be secured alongside structural and procedural change if the desired improvements in quality and safety are to be achieved.1–8 Only a transformation of professional and organisational cultures, it is believed, will enable the instillation of new values, beliefs and assumptions to guide and underpin new ways of working in healthcare organisations. Such interest is not confined to the UK: there is increasing international interest in managing organisational culture as a lever for health improvement. In the United States, health policy is embracing culture change as a key element of health system redesign;9 and many other countries are also focusing on cultural renewal as a potential lever for performance improvement.1011
The difficulties of managing culture change are legion.12 Indeed, the precise nature of culture change in healthcare policy often remains underspecified, and the desirability and feasibility of such strategies have been called into question.1314 Nonetheless the language of culture change that is central to discussions of healthcare improvement has prompted a practical need to understand what instruments and tools exist for assessing cultures in healthcare contexts.5
In view of the widespread policy, managerial and clinical interest in this area, we wanted to know what tools are used currently in the NHS to assess organisational cultures and how well these tools meet the practical requirements and domains of interest of those interested in assessing and changing cultures within their organisation and across local healthcare communities. Our evidence is derived from a national survey of clinical governance managers in acute and primary care trusts throughout England.
MEASURING AND ASSESSING ORGANISATIONAL CULTURE IN HEALTHCARE
Organisational culture is an anthropological metaphor, one of many used to inform research and consultancy in organisations, and one frequently invoked by those seeking to explain organisational environments.4 The key methodological principle in studies of organisational culture is to investigate organisations as mini-societies.15 Here organisations are seen as organic social entities infused with values and emerging from natural social processes. The metaphor of organisational culture focuses on that which is shared between people within organisations: the values, beliefs and assumptions; and their shared narratives and sense making.16 This shared way of thinking, and the behaviour that arises from them, defines what is legitimate and acceptable within any given organisation. They are the social and normative glue that bind people into a collective enterprise: they are “the way things are done around here.”17
Previous literature review and empirical work exploring linkages between organisational culture and healthcare performance has concluded that more research was required into the practical aspects of measuring and assessing healthcare cultures.18 As part of this earlier work we reviewed the (mainly quantitative) instruments available to health service researchers wishing to measure culture and culture change.6 Our search identified 84 articles that appeared to report the development or use of culture assessment instruments, at least two dozen of which were assessed as having potential relevance to healthcare organisations. We identified a number of general themes across these instruments. First, such tools either adopt a typological approach in which the assessment results in one or more “types” of organisational culture, such as the Competing values Framework,19 or a dimensional approach, which describes a culture by its position on a number of continuous variables, such as the Organisation Culture Inventory.20 Second, some of the instruments have a strong theoretical and conceptual provenance, while others have been developed in a more pragmatic way. Third, the instruments vary in scope, some focusing on the assessment in one or more specific domains of organisational culture, others assessing a more comprehensive range of issues. Fourth, they differ in terms of the levels of culture they tap into, with none convincingly addressing the deeper underlying assumptions that guide attitudes and behaviour and inform the stable substrate of culture. Finally, the instruments vary in the extent of their use in empirical studies, and the degree to which their scientific properties have been evaluated.
Thus, review work to date reveals a diversity of potential approaches to culture measurement and assessment, but little evaluation of the use and practical application of those tools or how well they connect with ongoing policy, managerial or service preoccupations. In this regard the concept of “fitness for purpose” has gained increasing importance within the health measurement literature2122 and requires the evaluation of the quality of a given assessment instrument to be conducted in the context of its application, audience and intended use. When considering the practical application of cultural assessment methods, these may be delineated broadly as serving formative, summative or diagnostic purposes.
Formative assessment provides organisations with feedback on the cultural elements of performance and change and can be used to facilitate feedback on progress and aid organisational learning.
Summative assessment provides a measure of achievement (or failure) in respect of intended changes in organisational culture and performance.
Diagnostic assessment ascertains prior to any managerial intervention the organisation’s strengths and weaknesses and its aptitude and preparedness for change.
Our study was designed to explore the availability and use of culture assessment tools with regard to these issues of practical relevance. It took place within the context of clinical governance activity in acute and primary care organisations in the English NHS.
Box 1 Three major culture assessment instruments used in the NHS
The Manchester Safety Framework, developed at the University of Manchester, is a facilitative educational tool. It aims at providing insight into an organisation’s safety culture and how it can be improved among teams. It uses nine dimensions of patient safety and describes what an organisation would look like at different levels of patient safety.2324
The Safety Attitude Questionnaire (SAQ) is the main safety climate questionnaire package developed in the US by Bryan Sexton and colleagues at the Centre of Excellence for Patient Safety Research & Practice, University of Texas.25 The instrument is available at The University of Texas Centre of Excellence for Patient Safety Research and Practice site.25 The SAQ is a refinement of the Intensive Care Unit Management Attitudes Questionnaire which was derived from the Flight management Attitudes Questionnaire widely used in the aviation industry.26 The various versions of the SAQ, together, comprise 60 survey items, designed in the form of five-point Likert scales to help organisations assess their safety culture and track changes over time.26 The instrument is used to measure provider attitude about six patient safety-related domains: safety climate, team work climate, stress recognition, perceptions of management, working conditions and job satisfaction.26 Individual scores are aggregated to give an indication of the strength of the organisation’s extant safety culture.
The Safety Climate Survey (SCS) is a version of the SAQ.25 The application of the SCS, in particular, has been promoted by the Institute for Healthcare Improvement (IHI) and is being piloted among a small number of hospitals in the UK National Health Service as part of the Health Foundation’s Safer Patients Initiative.27
Data collection and analysis comprised a national postal survey undertaken between November 2006 and February 2007 of Clinical Governance Leads in Acute and Primary Care Trusts in England (n = 325). (275 (or 87%) of the total number of English NHS organisations (n = 325) gave R&D approval for the survey and these were targeted in the postal survey.) The questionnaire (available from the authors) gathered information on the current use of culture assessment tools (or similar) in each organisation; clinical governance managers’ views on the relevance and ease of culture tools used; and views on the extent to which extant tools meet their needs when managing change and ensuring appropriate clinical cultures for quality/safety improvement. Postal reminders and telephone follow-up were carried out to ensure a high response rate. The precoded quantitative responses were analysed using the computerised statistical package SPSS; and open-ended responses were grouped under broad themes.
We found that about half of NHS organisations had used Manchester Patient Safety Framework (MAPSAF) at each of the team, departmental or organisation level (52–54%); for the other tools, combined use was more likely with the whole organisational (47%) and at the department level (40%) than at the team level (27%).
Culture instruments can also be used for different purposes. More respondents believed that culture assessments should serve formative ends (86%) than summative purposes (65%), and almost a third in both acute and primary care settings “tended to disagree” that culture assessment should be used for summative purposes at all (table 3).
We obtained completed questionnaires from 212 respondents (77% of the NHS organisations contacted in the national postal survey). The vast majority of respondents (97%) reported that an understanding of local organisational culture is a central task for clinical governance. We found that a third of the organisations contacted (33%) were currently using at least one culture measurement instrument as part of their clinical governance activity. By far the most frequently used culture instrument was the MAPSAF, recorded by 59 (table 1), or 28 percent of the respondents (84 percent of the organisations which reported using a tool); this was followed by the Safety Attitude questionnaire, and the Safety Climate Survey, both recorded by eight (4%) and 7 (3%) respondents respectively (box 1). A wide variety of other tools were used by very small numbers of organisations.
Over 80% of those using MAPSAF found it relevant or very relevant to their needs, as compared with about 70% aggregated across all of the other tools (the rather limited use of all other tools apart from MAPSAF precludes a more detailed analysis by tool table 2). In terms of ease of use, the vast majority perceived the instrument as easy to use, 80% for MAPSAF and 93% for the others.
Respondents in the national postal survey were also asked how important they thought a range of organisational culture attributes were in supporting their clinical governance and quality-improvement activities. As shown in table 4, over 90% of respondents thought that senior management commitment, clear governance and accountability arrangements and safety awareness were very important organisational attributes to support them in their role. Responses in the open part of the questionnaire supported this view and revealed that there is a latent demand for measures of these cultural attributes within organisations. In contrast, only just over a quarter of respondents believed that the prioritisation of choice was a very important cultural attribute.
Culture assessment instruments are relatively new tools in the quality and patient safety arena and are used increasingly to inform and assess quality and safety improvement activity in healthcare organisations.28 As in other health systems, there is widespread interest in the NHS in managing organisational cultures in order to improve quality and safety. Despite a plethora of culture assessment tools being described in the literature, relatively few of these have seen much use in the NHS. On the basis of our survey, a third of NHS organisations in England are currently using a culture assessment instrument to support their clinical governance activity, and almost all the tools and instruments used focus heavily on the assessment of safety cultures rather than broadly on perspectives of quality and performance.
Nevertheless, we found a high degree of satisfaction with existing tools and instruments, in terms of ease of use and relevance. Although extant tools such as the MAPSAF and the Safety Attitude Questionnaire cover many of the most important cultural attributes of high-quality care as identified by clinical governance managers, including senior management team commitment to quality and safety improvement, teamwork and collaborative working, our survey highlighted other cultural attributes which link to the interests and aspirations of local clinical governance leads, including the development of a blame-free environment and support for innovation that are not well served by extant instruments.
We are grateful to all the clinical governance managers who completed the postal questionnaire and J Wright and R Thomson for useful feedback on an early draft of the questionnaire.
Competing interests: None.
Funding: The study was funded by the NHS Service Delivery and Organisation R&D Programme.
Ethics approval: Ethics approval was obtained from Newcastle (MREC) Research Ethics Committee.
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