Russell Mannion

Organisational culture and quality of health care

“ A student of management and organisation theory could only be stunned by how little the efforts to improve quality [in health care] have learnt from current thinking in management and from the experience of other industries .” Christian Koeck BMJ 1998; 317: 1267–8. Health policy in much of the developed world is concerned with assessing and improving the quality of health care. The USA, in particular, has identified specific concerns over quality issues12 and a recent report from the Institute of Medicine pointed to the considerable toll of medical errors.3 In the UK a series of scandals has propelled quality issues to centre stage45 and made quality improvement a key policy area.6 But how are quality improvements to be wrought in such a complex system as health care? A recent issue of Quality in Health Care was devoted to considerations of organisational change in health care, calling it “the key to quality improvement”.7 In discussing how such change can be managed, the authors of one of the articles asserted that cultural change needs to be wrought alongside structural reorganisation and systems reform to bring about “a culture in which excellence can flourish”.8 A review of policy changes in the UK over the past two decades shows that these appeals for cultural change are not new but have appeared in various guises (box 1). However, talk of “culture” and “culture change” beg some difficult questions about the nature of the underlying substrate to which change programmes are applied. What is “organisational culture” anyway? It is to this issue that this paper is addressed.Many previous policy reforms in the National Health Service (NHS) have invoked the notion of cultural change. In the early 1980s the reforms inspired by Sir Roy Griffiths led …

Nip, tuck and click : medical tourism and the emergence of web-based health information.

An emerging trend is what has become commonly known as ‘Medical Tourism’ where patients travel to overseas destinations for specialised surgical treatments and other forms of medical care. With the rise of more affordable cross-border travel and rapid technological developments these movements are becoming more commonplace. A key driver is the platform provided by the internet for gaining access to healthcare information and advertising. There has been relatively little attention given to the role and impact of web-based information to inform Medical Tourism decisions. This article provides a brief overview of the most recent development in Medical Tourism and examines how this is linked to the emergence of specialized internet web sites. It produces a summary of the functionality of medical tourist sites, and situates Medical Tourism informatics within the broader literatures relating to information search, information quality and decision-making. This paper is both a call to strengthen the empirical evidence in this area, and also to advocate integrating Medical Tourism research within a broader conceptual framework.

Payment for performance in health care

Debates about performance related pay seem to have moved on from whether it is desirable to how to make it work. But Russell Mannion and Huw Davies cautionthat we still don’t know enough about the potential problems

Exploring the relationship between senior management team culture and hospital performance

The purpose of this study was to explore relationships between senior management team culture and organizational performance in English hospital organizations (NHS trusts [National Health Service]). We used an established culture-rating instrument, the Competing Values Framework, to assess senior management team culture. Organizational performance was assessed using a wide variety of routinely collected measures. Data were gathered from all English NHS acute hospital trusts, a total of 197 organizations. Multivariate econometric analyses were used to explore the associations between measures of culture and measures of performance using regressions, ANOVA, multinomial logit, and ordered probit. Organizational culture varied across hospital organizations, and at least some of this variation was associated in consistent and predictable ways with a variety of organizational characteristics and measures of performance. The findings provide particular support for a contingent relationship between culture and performance.

Impact of star performance ratings in English acute hospital trusts

Objective To explore some of the impacts of star performance ratings in acute hospital trusts in England. Methods A multiple case study design was used which incorporated purposeful sampling of ‘low’ and ‘high’ performing trusts using the star rating system. In each case study site, data collection comprised semi-structured interviews and documentary analysis. Between eight and 12 senior managers and senior clinicians were interviewed in each organisation. Results There was a general view that the star ratings as presently constituted did not represent a rounded or balanced scorecard of their own organisations performance and a widespread belief that the information used to calculate the ratings was often incomplete and inaccurate. The star ratings were viewed by some managers as useful, in that they gave added weight to their trusts modernisation agenda. In addition to driving beneficial change, the ratings were also sometimes reported to have inadvertently induced a range of unintended and dysfunctional consequences, including tunnel vision and a distortion of clinical priorities, bullying and intimidation, erosion of public trust and reduced staff morale, and ghettoisation. Conclusions Set in the context of an international body of research, this study highlights some important gaps in knowledge and failings in current policy and practice. In particular, the many dysfunctional consequences of publishing star ratings indicate a need for a re-examination of performance management policies.

An open letter to The BMJ editors on qualitative research

Seventy six senior academics from 11 countries invite The BMJ ’s editors to reconsider their policy of rejecting qualitative research on the grounds of low priority. They challenge the journal to develop a proactive, scholarly, and pluralist approach to research that aligns with its stated mission

Unintended consequences of performance measurement in healthcare: 20 salutary lessons from the English National Health Service.

The objective of the study is to review the evidence on the consequences associated with the introduction of national performance measurement systems in the National Health Service (NHS), with the aim of informing the development of similar national performance measurement programmes proposed for Australia. Narrative review of the published evidence on the unintended and adverse consequences of performance measurement systems in the NHS is the data source. We identified 20 different dysfunctional consequences of national performance measurement systems in the NHS in four headings. These are poor measurement (measurement fixation, tunnel vision, myopia, ossification, anachronism and quantification privileging), misplaced incentives and sanctions (complacency, silo‐creation, overcompensation, undercompensation, insensitivity and increased inequality), breach of trust (misrepresentation, gaming, misinterpretation, bullying, erosion of trust and reduced staff morale), and politicisation of performance systems (political grandstanding and creating a diversion). Performance measurement programmes can contribute to systems improvement, delivering benefits to health services and patients, as evidenced by the dramatic reduction in waiting times in the NHS following the incorporation of targets and indicators for waiting times. Nevertheless, experience from the NHS shows that in addition to generating desired improvements, performance measures can induce a range of unintended and dysfunctional consequences. We recommend Australia to heed the lessons of the NHS, and strive to balance effective performance measurement and management against the potential drawbacks and adverse consequences. Any national performance measures need to be piloted and carefully evaluated to assess potential benefits and pitfalls.

The relationship between organizational culture and performance in acute hospitals.

This paper examines the relationship between senior management team culture and organizational performance in English acute hospitals (NHS Trusts) over three time periods between 2001/2002 and 2007/2008. We use a validated culture rating instrument, the Competing Values Framework, to measure senior management team culture. Organizational performance is assessed using a wide range of routinely collected indicators. We examine the associations between organizational culture and performance using ordered probit and multinomial logit models. We find that organizational culture varies across hospitals and over time, and this variation is at least in part associated in consistent and predictable ways with a variety of organizational characteristics and routine measures of performance. Moreover, hospitals are moving towards more competitive culture archetypes which mirror the current policy context, though with a stronger blend of cultures. The study provides evidence for a relationship between culture and performance in hospital settings.

Assessing organisational culture for quality and safety improvement: a national survey of tools and tool use

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.

Managing change in the culture of general practice: qualitative case studies in primary care trusts

Abstract Objectives To explore the potential tension between the need for managers to produce measurable change and the skills required to produce cultural change, and to investigate how managers of primary care trusts are attempting to deal with this tension. Design Qualitative case studies using data derived from semistructured interviews and a review of published documents. An established cultural framework was to used to help interpret the findings. Setting Six primary care trusts in England purposefully sampled to represent a range of cultural, structural, geographical, and demographic characteristics. Participants 42 interviews with 39 different senior and middle primary care trust managers conducted over an 18 month period. Results We found two distinct and polarised styles of management. One group of managers adopts a directive style and challenges the prevailing norms and values of clinicians, an approach characteristically seen in organisations with hierarchical cultures. This group is made up mostly of senior managers who are driven principally by the imperative to deliver a political agenda. Managers in the second group are more inclined to work with the prevailing cultures found in general practice, attempting to facilitate change from within rather than forcing change from outside. This management style is characteristically seen in organisations with a clan-type culture. The approach was manifest mostly by middle managers, who seem to act as buffers between the demands of senior managers and their own perception of the ability and willingness of health professionals to cope with change. The different management approaches can lead to tension and dysfunction between tiers of management. Conclusions The development of primary care depends on high quality managers who are able to draw on a range of different management skills and styles. Managers are most likely to be effective if they appreciate the merits and drawbacks of their different styles and are willing to work in partnership.