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Organization culture is transmitted and embedded via a wide range of media, including established working procedures and practices e. It is unrealistic to expect culture change strategies to be effective on all these fronts simultaneously. Successful strategies require realistic time frames to implement the types of complex and multi-level changes required. External influence. The influence of outside interests may cut across and sometimes work against efforts towards internal reform.

Culture change strategies need to heed the constraints posed by external stakeholders in determining the values and behaviour of health professionals [ 37 ]. In the UK it is accepted that attempts to change the culture of the NHS may also need to target external bodies such as the Royal Medical Colleges, which exert control over training and influence the internalization of professional core values [ 38 ].

Similarly, research in Australian hospitals has shown that profession-based attitudes and beliefs have hampered the efforts of health authorities to promote more outcome-focused approaches to health care organization and management [ 37 ]. More widely, the Romanow Commission acknowledges the crucial importance for successful health care reform of working with, not against, core public values [ 39 ]. Lack of appropriate leadership. Leadership plays a central role in any cultural transformation.

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Inadequate or inappropriate leadership has been identified as a key factor when attempts to change culture fail [ 40 ]. Integrating these two styles is a necessary and challenging project. For example, it may be possible to manipulate employment to reward behaviour patterns appropriate to patient-centred care. But such a naive behaviourist transactional approach would be insufficient. In this way practitioners will not only be rewarded for appropriate behaviour, they will view their roles relative both to one another and to patients and their families in a different light.

This cognitive behavioural or transformational approach to leadership defines cultural as opposed to structural organizational change [ 41 ]. Cultural diversity. As we have noted, health care organizations are likely to comprise competing and overlapping professional subgroups. Thus, a key challenge to culture change programmes is to consider carefully the impact of change on specific groups e.

Building on the work of Tung [ 43 ], Child and Faulkner [ 42 ] have developed a useful typology to assess approaches to managing organizational change in the face of cultural diversity. Their analysis is structured according to two fundamental choices. The second relates to the decision either to integrate different subcultures in order to derive synergy between them or to segregate the various subcultures with the aim of avoiding conflict or efforts devoted to culture management.


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These strategic choices give rise to four possible bases for accommodating cultural diversity Figure 3. The first three offer some scope for establishing a cultural fit, whilst the fourth may give rise to serious dysfunctional consequences. The meeting of cultures: achieving a cultural fit. Derived and expanded from a classificatory scheme on strategic alliances developed by Child and Faulkner [ 42 ] and based on original work by Tung [ 43 ]. Figure reproduced with permission. Dysfunctional consequences. In addition to, or instead of, driving beneficial outcomes, culture change policies may induce a range of unintended and dysfunctional consequences [ 44 ].

This is seen, for example, in the range of adverse behaviours generated by the rise of a performance management culture in the UK NHS [ 45 ]. There are also fears that similar problems are emerging because of the culture of public reporting that has grown in the US [ 46 ]. Therefore, it is imperative that culture change policies are not monitored only in terms of the extent to which they foster constructive change, but also in terms of the perverse side effects that they inadvertently generate.

There is increasing international interest in managing organizational culture as a lever for health care improvement. Changing the organizational culture along with its structure has become a familiar prescription in health system reform. Yet planned culture change is a difficult, uncertain, and risky enterprise. In this article we have sought to sharpen thinking around the theory and feasibility of culture change in health care. We have: 1 argued that organizational culture is a complex and contested terrain; 2 emphasized the importance of distinguishing between different types of subcultures; 3 highlighted the crucial role of leadership; and 4 outlined common barriers to culture change and suggested a variety of approaches to surmounting these.

We end on a note of caution for those planning cultural reform: efforts targeted at culture change may not always generate the anticipated organizational outcomes. Indeed, experience in health care and other sectors suggests that such attempts have the potential to induce seriously dysfunctional as well as functional consequences.

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E-mail: rm15 york. The views expressed in the paper represent those of the authors and not necessarily those of the UK Department of Health. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Sign In. Advanced Search. Article Navigation. Close mobile search navigation Article Navigation. Volume Article Contents. Organizational culture. Managing culture change. Concluding remarks. Oxford Academic. Google Scholar. HUW T.

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Medical Quality Management: Theory and Practice

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Figure 2. Figure 3. Department of Health. Institute of Medicine. Smith P ed. Cameron K, Freeman S. Culture congruence, strength and type. Res Org Change Dev. Kotter J, Heskett J. Corporate Culture and Performance. Driscoll A, Morris J. Stepping out: rhetorical devices and culture change management in the UK civil service. Publ Admin. Health Serv Res. Assessing the impact of total quality management and organizational culture on multiple outcomes of care for coronary artery bypass graft surgery patients. Med Care. Ferlie E, Shortell S. Improving the quality of health care in the United Kingdom and the United States: a framework for change.

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Medical Quality Management: Theory and Practice

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Medical Quality Management: Theory and Practice

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