Special article Organisational culture and quality of health care

Introduction 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 issues 2 and a recent report from the Institute of Medicine pointed to the considerable toll of medical errors. In the UK a series of scandals has propelled quality issues to centre stage 5 and made quality improvement a key policy area. 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”. 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”. 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 diYcult 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. Although often referred to, it is unclear whether talk of “cultural transformation” is merely a convenient metaphor or is, instead, shorthand for a more tangible raft of specific changes. If the latter, then it would seem essential to have some clear idea about the meaning of organisational culture, the extent to which this culture can be managed within health care, and the nature of the organisational cultures which underpin quality improvement activity in health care. This paper draws on a wide social science literature to open this debate. It explains some of the current conceptualisations of organisational culture and explores the implications of these for health systems (such as the NHS) or healthcare providers (such as hospitals and primary care networks) that are seeking organisational transformation.