RT Journal Article SR Electronic T1 Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study JF BMJ Quality & Safety JO BMJ Qual Saf FD BMJ Publishing Group Ltd SP bmjqs-2013-001947 DO 10.1136/bmjqs-2013-001947 A1 Mary Dixon-Woods A1 Richard Baker A1 Kathryn Charles A1 Jeremy Dawson A1 Gabi Jerzembek A1 Graham Martin A1 Imelda McCarthy A1 Lorna McKee A1 Joel Minion A1 Piotr Ozieranski A1 Janet Willars A1 Patricia Wilkie A1 Michael West YR 2013 UL http://qualitysafety.bmj.com/content/early/2013/08/28/bmjqs-2013-001947.abstract AB Background Problems of quality and safety persist in health systems worldwide. We conducted a large research programme to examine culture and behaviour in the English National Health Service (NHS). Methods Mixed-methods study involving collection and triangulation of data from multiple sources, including interviews, surveys, ethnographic case studies, board minutes and publicly available datasets. We narratively synthesised data across the studies to produce a holistic picture and in this paper present a high-level summary. Results We found an almost universal desire to provide the best quality of care. We identified many ‘bright spots’ of excellent caring and practice and high-quality innovation across the NHS, but also considerable inconsistency. Consistent achievement of high-quality care was challenged by unclear goals, overlapping priorities that distracted attention, and compliance-oriented bureaucratised management. The institutional and regulatory environment was populated by multiple external bodies serving different but overlapping functions. Some organisations found it difficult to obtain valid insights into the quality of the care they provided. Poor organisational and information systems sometimes left staff struggling to deliver care effectively and disempowered them from initiating improvement. Good staff support and management were also highly variable, though they were fundamental to culture and were directly related to patient experience, safety and quality of care. Conclusions Our results highlight the importance of clear, challenging goals for high-quality care. Organisations need to put the patient at the centre of all they do, get smart intelligence, focus on improving organisational systems, and nurture caring cultures by ensuring that staff feel valued, respected, engaged and supported.