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T Scott, R Mannion, H Davies, M Marshall. Abingdon, Oxon: Radcliffe Medical Press, 2003, pp 131. ISBN 1 85775 914 1
In the last five years quality and performance improvement have been articulated as central policy objectives for the NHS. Securing meaningful change in organisational culture, together with concomitant structural reforms, is seen to be critically important in achieving those objectives: “meaningful and sustainable quality improvements in the NHS require a fundamental shift in culture, to focus effort where it is needed and to enable and empower those who work in the NHS to improve quality locally” (A First Class Service – Quality in the New NHS, Department of Health, 1998, page 71).
Healthcare Performance and Organisational Culture offers a timely examination of the concept of organisational culture within a healthcare context. It reviews a huge amount of literature and is presented in three sections: the theoretical foundations of organisational culture; tools for measuring organisational culture; and an overview of empirical evidence on the links between culture and performance, both in health and non-health settings. Counter to the implication of the title, the book is weighted towards theories, conceptualisations, and methodologies relevant to studies of organisational culture, rather than towards the role of culture in healthcare performance.
It is a formidable book and the authors have taken on the Herculean challenge of succinctly and coherently summarising the intellectual antecedents and theoretical constructs of organisational culture. The book is replete with nuanced concepts but, in seeking comprehensiveness, inevitable compromises have had to be made in terms of depth and development of what are often very sophisticated arguments.
The book discusses the difficulties of trying to manage culture and highlights how, on the one hand, culture is seen by some as an overwhelming force, impossible to influence or act in opposition to, while, on the other hand, it is often conceptualised as a simple means to achieve predictable organisational control. Neither view is particularly helpful to those seeking to secure meaningful change and the contents of the book provide a more balanced account of organisational culture, showing it to be much more complex—abstract, socially constructed, contested, multifaceted, often intangible, and sometimes responsive (although unpredictably so).
Perhaps the book’s greatest contribution is the way in which it highlights how little we know about the link between organisational culture and performance, both within and outside a healthcare context. Despite the current emphasis placed on—and effort invested in—securing culture change, the authors found that the evidence base attesting to the contribution of culture to performance is extremely weak. Many published studies were found to be marred by methodological flaws, often focusing on superficial levels of analysis and using narrow definitions of performance.
The book is difficult to pigeon hole. In seeking to cover such a vast intellectual territory, it is unable to explain fully many of the concepts it introduces and therefore may be frustratingly cursory both for newcomers to the field and for those interested in engaging in academic discourse. It does provide a useful roadmap to the enormous subject of organisational culture and raises important and urgent questions about the role and evaluation of culture within healthcare organisations; for this it is to be commended.