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CSU: Cultural capital

CSU: Cultural capital
4 September 2013

The culture of a health organisation will affect the experience patients receive. As clinicians take up leadership roles, how can they ensure they get it right and produce the best and safest outcomes?

The culture of a health organisation will affect the experience patients receive. As clinicians take up leadership roles, how can they ensure they get it right and produce the best and safest outcomes?
Organisational culture broadly captures what it feels like to work in a particular organisation and captures the unique values and norms of behaviour that characterise a place of work. Organisational culture therefore guides organisational members’ expectations about how they should act and behave at work, as well as what they should prioritise and attend to. Quality and safety is a key priority for the NHS and this needs to be reflected in the organisational culture of Trusts and CCGs alike. 
In this article, we draw upon theories and principles from organisational behaviour, as well as our own research with NHS staff and organisations, to examine how such a culture can be fostered and strengthened, and the impact it is likely to have on organisational outcomes. Our recommendations are based around four key areas; organisational vision, leadership, people management, and teamwork, each of which we outline in this article. 
Organisational vision 
Staff in the NHS are constantly required to juggle conflicting priorities, limited resources, targets, cost cutting, and efficiency as well as meeting the needs of various regulators. These are all an important and necessary part of their work, but above all of these, safe high quality care must take priority. The challenge faced by the NHS is to ensure that at all levels, including ministers, NHS England’s executive team, clinical commissioning groups (CCGs), Monitor, Care Quality Commission, trust boards, directorates, departments, managers and team leaders alike, high quality, safe, and compassionate care is the key purpose and priority. When any of these stakeholders take a different perspective they begin to produce a corrosion of purpose in the NHS. If productivity and efficiency are prioritised over high quality care in the culture of an organisation, the risk of another failure like Mid Staffordshire becomes that much greater. 
Quality and safety must therefore be in the DNA of NHS organisations, guiding the attitudes, behaviours and expectations of staff and ensuring high quality, compassionate and safe care for patients. However, there is often a gap between values espoused by an organisation, and what is experienced by those working at the sharp end. Values that prioritise safety and quality should therefore not only be reflected in writing, through organisational policy, vision and mission statements for example, but also enacted in everyday work. Organisational culture starts with the visions of the kind of health care system we want for our society. But in practice, it is about what staff at all levels value, what they actually do, and what they come to take for granted as the right way to behave. 
Leadership is pivotal in shaping organisational culture. The relationship that a staff member has with their immediate leader or manager is the lens through which they view the entire organisation. Therefore, if managers treat staff brusquely, uncaringly and disrespectfully they breed an organisational culture where patients are also treated brusquely, uncaringly and disrespectfully. 
Organisational vision is largely enacted through the messages that leaders send out about the priorities they are committed to, as well as the actions they take. Organisational culture is therefore influenced by what leaders most attend to, measure, monitor and reward, as these are what shape and reinforce the day-to-day behaviour and efforts of staff. If leaders prioritise efficiency, productivity and meeting targets over the experience of patients, this focus permeates the entire organisation and shapes the culture accordingly. Similarly, leaders who fail to deal with systems problems (for example, blockages in care pathways, inter-departmental conflicts, or unnecessary bureaucracy), dismiss staff concerns, ignore staff well-being, and/or avoid discussing workload pressures, directly undermine the espoused message of high quality and safe care. 
Leaders must instead show that they are listening to staff, supporting them and taking their comments seriously. Our research shows that where staff report high levels of supportiveness from their immediate manager, patients report receiving better care. Leaders must also ensure that staff have performance objectives which are directly underpinned by the organisational vision, mission and strategy. These objectives should be challenging and have a specific focus on improving patient experience, providing safe compassionate care, and developing innovative ways of improving the delivery of such care. Providing feedback on progress towards these objectives is also critical. This leads to the next topic for consideration, people management. 
People management 
Our research using NHS National Staff Survey data collected since 2004 demonstrates clear links between staff experience and patient outcomes (see here for a full report). This evidence suggests that human resource management (HRM) practices must encourage high quality care and compassion, right from the point of staff recruitment, through to induction, training and appraisal. More specifically, the data show that a well-structured appraisal leads to better health and well-being of staff, as well as higher levels of staff engagement, while poorly structured appraisals have no effect. Although the percentage of staff receiving appraisals in the NHS has increased by around 15% over the last decade (to 76%), the percentage of staff reporting that their appraisal was useful has barely changed from 35%. This suggests that too many appraisals are futile, box ticking exercises that do not involve effective objective settings, and instead leave staff feeling under-valued and unable to do their jobs better. This, in turn, has an impact on patient care. Indeed, patient satisfaction is highest in organisations where staff report clear objectives at every level. In such organisations, patients say they feel more involved in care decisions and experience good communication with staff. Conversely, when staff report poor health and well-being, trusts have higher injury rates, the patients are less satisfied. 
The associations between good people management, patient satisfaction and health care outcomes are consistent across all the types of health care, from acute and mental health, through to primary care and ambulance services. Were staff are working in an organisation in which they feel supported, valued and invested in, the delivery of health services is of a higher quality. This simple equation needs to be understood and enacted throughout the NHS if organisations are to embed a culture of quality and safety.
Effective teamwork
Effective teamwork is a crucial part of ensuring the delivery of safe high quality healthcare. Our research has examined the association between specific HRM practices and patient mortality and found a significant negative relationship between team working and mortality. Our findings concluded that in hospitals where over 60% of staff reported working in well-structured teams, mortality was around 5% below what would be expected. These findings held even after taking account of factors that might otherwise impact mortality, such as previous mortality rates in a hospital, number of doctors per 100 beds, and variations in local health profiles, hospitals and income. Our more recent findings with a large sample of community mental health teams also revealed that the most effective teams were those that reported a culture of learning, inclusiveness, and respect between different professional groups (West et al., 2012). On the other hand, teams which have a deep-rooted hierarchical structure, in which there is poor communication and conflict over decision making between different professional groups, find it difficult to establish a culture of safety in the team. 
As well as applying the insights discussed earlier in this article, namely ensuring effective leadership, clear objectives, and constructive appraisals for staff, healthcare teams must also ensure that another key team process is supported. This involves taking time to reflect on the performance and objectives of the team and adjusting them accordingly – a process referred to as team reflexivity. Team reflexivity allows teams to monitor their progress, discuss errors and address sub-standard performance, thus ensuring that safety and quality remain at the heart of what a team does. Managers must therefore allow teams to take time out to engage in team reflexivity, and ensure that every team member can speak openly and honestly in a safe and constructive environment. Team reflexivity is particularly important for fostering innovation and creativity, enabling teams to celebrate their strengths, address their weaknesses, and develop new and improved ways to deliver healthcare to patients. 
A culture of quality and safety is key for ensuring that NHS staff feel positive about their work. The more positive staff are about their work, the more positive patients will be about their care. Thus, if leaders and managers create positive, supportive environments for staff, then staff, in turn, will create caring, supportive environments for patients. 
West M, Alimo-Metcalfe B, Dawson J, El Ansari W, Glasby J, Hardy G, et al. Effectiveness of Multi-Professional Team Working (MPTW) in Mental Health Care. Final report. NIHR Service Delivery and Organisation Programme; 2012. 

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