The level of healthcare quality received by a service user directly influences clinical outcomes and patient experiences (Maybin and Thorlby, 2008). Lord Darzi’s comprehensive review of the NHS in England in 2007 identified a need for further improvement in quality and outcomes despite an increase in capacity (Darzi, 2008). The expectation of every user of NHS services is high-quality, safe, and effective healthcare. Regrettably, many patients often find that the care they receive falls short of these standards (Dixon-Woods et al., 2013). Despite concerted efforts, NHS England still struggles to consistently meet the expected benchmarks for delivering quality care (Hogan et al., 2012). Notably, several high-profile cases have exposed significant deficiencies in quality and safety. Nevertheless, progress has been made in the pursuit of uniform, high-quality care delivery (Benning et al., 2011a; Benning et al., 2011b). Key elements critical to the delivery of quality care have been identified, with organizational culture emerging as a prominent factor. This article explores how cultivating a positive organizational culture can enhance healthcare quality.
Quality in Healthcare
Defining quality in healthcare proves to be a complex endeavor. In his report, Lord Darzi (2008) characterized quality as encompassing patient safety, the patient experience, and the clinical effectiveness of care. Therefore, the NHS recognizes that delivering quality care necessitates achieving good clinical outcomes and safety, alongside providing a positive patient experience. Personal attributes, such as patient-provider relationships, shared decision-making, and comprehensive needs fulfillment, all contribute to the overall quality of care (Jun et al., 1998).
The Mid-Staffordshire NHS Foundation Trust case (Francis, 2010) is a glaring example of the NHS’s failure to provide quality care. The subsequent public inquiry (Francis, 2013) uncovered many deficiencies in patient safety and care quality. The existing oversight, accountability, and influence systems proved inadequate, with a widespread breakdown in control and leadership at all levels (Dixon-Woods et al., 2013). The underlying organizational culture fostered an environment conducive to substandard care delivery. Key elements shaping the organization’s culture, such as policies, rules, regulations, resources, and incentives, were found to be lacking. This resulted in a tolerance for low standards and a noticeable disconnect between managerial responsibilities and frontline staff (Francis, 2010).
Following the inquiry, a comprehensive survey of healthcare professionals in NHS England yielded encouraging findings, revealing that values centered on care and compassion were central to organizational and personal commitments across all levels (Dixon-Woods et al., 2013). In alignment with the Francis inquiry, the most significant influence on an organization’s commitment to quality was observed at the board level. Therefore, the tone set at the highest echelons permeates throughout the organization, profoundly impacting the care received by the patient. The board’s influence on the performance of all staff reflects the organizational culture, encapsulating the institution’s priorities and overarching vision.
An environment conducive to collaboration between providers and patients is indispensable for delivering quality care (Mosadeghrad, 2014a). Organizational culture delineates how an institution arranges itself, outlining its rules, procedures, and core beliefs (Handy, 1981). Culture constitutes the overarching framework that elucidates why and how employees conduct themselves. Different organizational cultures are recognized, and within healthcare organizations, multiple cultural styles often coexist. Variations in culture can impede cohesive collaboration due to conflicting priorities and communication challenges.
In the NHS, a Role Culture prevails, where individuals have distinct roles, and tasks are distributed throughout the organization to create specialist roles and eliminate redundancy. While these cultures are efficient and productive, they tend to be inflexible and resistant to adaptation (Handy, 1981). This intersects with the bureaucratic culture of the NHS, characterized by a focus on systems and procedures, risk aversion, hierarchical structures, and non-commercial objectives (Handy, 1981). Cultures emphasizing strong hierarchies, centralization, and bureaucratic control are barriers to delivering quality care. All levels of personnel need a sense of autonomy and empowerment to make decisions. This requires individuals to assume responsibility and be accountable for their actions, something unattainable in a blame-oriented culture (Khatri et al., 2009). Blame cultures have historically permeated healthcare organizations. Pinpointing and blaming an individual when mistakes occur fosters secrecy and the concealment of errors. Cultures that promote secrecy, protectionism, denial of failings, and a reluctance to accept responsibility for addressing them are incompatible with delivering quality care (Walshe and Shortell, 2004). In the Mid-Staffordshire case, the failure to acknowledge patients’ concerns, inadequate management systems, and fragmented knowledge sharing contributed to the problem (Francis, 2010). Quality and safety are compromised wQuality and safety are compromised when failings go unrecognized and unaddres (Leape, 1994).
A Culture to Deliver Quality Care
Enhancing care quality necessitates a shift from cultures of shame and blame to those where systems are designed with safety and quality in mind (Reason, 1997). Ironically, external mandates ensuring high-quality, safe care often led organizations to adopt defensive and reactive policies (Power, 2003). Many NHS organizations responded to these external pressures by implementing a bureaucratic management style to ensure compliance. This resulted in broad, prescriptive policies that generated frustration and negativity (Dixon-Woods et al., 2013). This task-focused approach inadvertently diminished quality and safety. Lord Darzi (2008) recognized the need for greater local control and fewer top-down, centrally dictated targets to improve quality. Empowering local services was pursued, with local quality indicators enabling clinicians to benchmark their performance (Dixon, 2008). Greater emphasis was placed on clinicians’ intrinsic motivation to enhance the quality of their services, coupled with a recognition of professionalism and personalization. While clinical leadership became the new focal point, Darzi acknowledged that managerial tasks were vital for improving service quality (Maybin and Thorlby, 2008). Holding healthcare professionals more accountable for their services and giving them greater responsibility for managing and enhancing the healthcare system brought about fundamental shifts in the NHS’s culture.
The cultures within healthcare organizations are influenced by numerous variables that introduce competing and conflicting demands. It becomes essential to consider the needs of patients, caregivers, families, regulators, providers, and partners, even though these needs often vary and are challenging to define precisely. Historically, the hierarchical culture in the NHS has frequently given rise to silos—individual units functioning in isolation, unaware of how their actions impact others. The emphasis on productivity, efficiency, and cost control has fostered a culture detrimental to delivering quality care (Gaba et al., 1994). Quality care necessitates collaboration between patients and providers within a supportive environment (Ovretveit, 2012). They are establishing a positive culture characterized by visionary leadership, forward-thinking planning, and a collaborative, team-based approach positions organizations to deliver quality care effectively.
This core belief shapes a culture prioritizing the delivery of quality care, and the shared commitment to this objective guides the discretionary behaviors exhibited by staff (Glickman et al., 2007). Such a culture must acknowledge that errors will occur and proactively seek to identify and address potential root causes (Westrum, 1992). Achieving harmonious cooperation among all levels of an organization’s staff is bolstered through shared, unifying goals and a convergence of beliefs. Plans facilitate the recognition of priorities for continuous improvement, motivating staff, and ensuring the allocation of necessary resources. Moreover, establishing clear goals across different levels is associated with high levels of patient satisfaction (Dixon-Woods et al., 2013). Nevertheless, disparities between the goals set at the board level and the practices of frontline staff underscore the challenges in fostering a culture centered around a shared vision (Dixon-Woods et al., 2013). Defining how these goals should be achieved, possessing the requisite leadership to realize them, and implementing effective quality management systems are pivotal (Mosadeghrad, 2014b).
The impact of management on an organization’s culture and the quality of care delivered cannot be underestimated. Standardized mortality ratios are inverse to positive and supportive organizational cultures (West and Dawson, 2012). Effective management and leadership are crucial for cultivating a caring, positive, and innovative culture (Khatri et al., 2009). Leaders establish the direction and ethos of the organization. They encourage and empower staff to tackle challenges and devise innovative solutions. Supporting team through education and training, enabling them to make decisions, and facilitating patient-centered care all contribute to enhancing quality (Mosadeghrad, 2014a). Clear correlations exist between the quality of care and staff satisfaction and contentment (Haas et al., 2000; DiMatteo et al., 1993). Employees must receive training and support and be acknowledged and rewarded for their commendable performance (Mosadeghrad, 2013). Individuals and teams demonstrating compassion, cooperation, and civility exemplify the delivery of quality care. They comprehend their roles and motivations and remain committed to learning, improving, and fostering innovation. Patients are treated with kindness, and their dignity is upheld. To facilitate these behaviors, the managerial approach, while demanding personal accountability from staff, must identify and resolve systemic constraints that impede staff from delivering quality care. When boards take proactive measures to pinpoint and rectify systemic issues, they promote cultural change, ultimately benefiting patients (Dixon-Woods et al., 2013).
Quality in healthcare encompasses providing safe, efficient care that aligns with patient expectations. The NHS faced challenges in maintaining quality while under pressure to boost productivity. Prominent instances of the NHS falling short in delivering quality care prompted a heightened focus on this matter, leading to the implementation of measures and incentives to encourage the provision of quality care. The impact of the NHS’s culture and that of its constituent organizations emerged as a pivotal factor influencing the quality of care dispensed. Cultivating a positive culture oriented towards quality, supported by policies, procedures, and behaviors rooted in quality principles, can enhance both patient and clinical outcomes.