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Measuring and Assessing Organisational Culture in the NHS

Measuring and Assessing Organisational Culture in the NHS (OC1) Research Report Produced for the National Co-ordinating Centre for the National Institute for Health Research Service Delivery and Organisation Programme (NCCSDO) June 2008 prepared by: Russell Mannion The Centre for Health and Public Services Management, University of York Huw Davies (University of Dundee & St Andrews), Frederick Konteh (University of York), Tobias Jung (University of Edinburgh), Tim Scott (University of St Andrews), Peter Bower (University of Manchester), Dianne Whalley (University of Manchester), Rosalind McNally (University of Manchester), Robert McMurray (University of York). Address for correspondence: Dr Russell Mannion Director The Centre for Health and Public Services Management The York Management School University of York Sally Baldwin Building Block A Heslington YORK, Y010 5DD E-mail: Contents 5 1 6 2 MAKING SENSE OF Organisational Culture IN HEALTH 9 Policy context and Culture change in the The Emergence of Organisational Culture as a field of 13 Conceptualising Organisational 16 Organisational Culture and 24 Approaching Organisational 25 Concluding 29 3 REVIEW OF INSTRUMENTS, TOOLS AND APPROACHES FOR Measuring AND Assessing Organisational 31 31 Data 36 Psychometric quality 38 Findings and 41 Origin and Context of 43 Key 50 Psychometri

Measuring and Assessing Organisational Culture in the NHS (OC1) Research Report Produced for the National Co-ordinating Centre for the National Institute for Health Research Service

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Transcription of Measuring and Assessing Organisational Culture in the NHS

1 Measuring and Assessing Organisational Culture in the NHS (OC1) Research Report Produced for the National Co-ordinating Centre for the National Institute for Health Research Service Delivery and Organisation Programme (NCCSDO) June 2008 prepared by: Russell Mannion The Centre for Health and Public Services Management, University of York Huw Davies (University of Dundee & St Andrews), Frederick Konteh (University of York), Tobias Jung (University of Edinburgh), Tim Scott (University of St Andrews), Peter Bower (University of Manchester), Dianne Whalley (University of Manchester), Rosalind McNally (University of Manchester), Robert McMurray (University of York). Address for correspondence: Dr Russell Mannion Director The Centre for Health and Public Services Management The York Management School University of York Sally Baldwin Building Block A Heslington YORK, Y010 5DD E-mail: Contents 5 1 6 2 MAKING SENSE OF Organisational Culture IN HEALTH 9 Policy context and Culture change in the The Emergence of Organisational Culture as a field of 13 Conceptualising Organisational 16 Organisational Culture and 24 Approaching Organisational 25 Concluding 29 3 REVIEW OF INSTRUMENTS, TOOLS AND APPROACHES FOR Measuring AND Assessing Organisational 31 31 Data 36 Psychometric quality 38 Findings and 41 Origin and Context of 43 Key 50 Psychometric 62 Concluding 63 4 STAKEHOLDER 65 Overall methodological 65 Stakeholders One: Clinical Governance 66 Stakeholders Two.

2 Representative, developmental and regulatory 84 Stakeholders Three: Patients, carers and service 95 5 EMPIRICAL EXPLORATION OF THE APPLICATION AND USE OF Culture ASSESSMENT INSTRUMENTS IN TWO NHS CASE 106 106 107 TRUST A Case Study 109 TRUST B Case Study 113 Drawing 122 6 SUMMARY, POLICY, MANAGEMENT AND RESEARCH 126 126 A reminder of the ambitions of this 126 Summary Of Key Findings And Implications For Policy And Management In The 127 Challenges In Project 136 Research 137 Concluding 139 141 Appendix 1 List of Cultural Dimensions Explored by Various 169 Appendix 2 Psychometric Assessment 182 Appendix 3 Practical Administration Issues of Scales187 Appendix 4 Detailed Measure 207 Appendix 5 Clinical Governance 265 Appendix 6 Patient 278 Appendix 7 Glossary .. 284 List of Boxes/Tables Box Various Dimensions of Organisational Culture Box Schein s Levels of Organisational Culture and their Interaction Box Hawkins Five levels of Organisational Culture Box Culturals Levels Box Perspectives on Organisational Culture .

3 Rationalism, Functionalism and Symbolism Box Culture as a variable or a Root Metaphor I Box Culture as a Variable or a Root Metaphor II Box Defining Characteristics of the Integration, Differentiation and Fragmentation Perspectives Box List and Description of Databases searched Box Example search protocol Medline Box Assessment Framework Box Psychometric Quality Assessment Criteria Box Instruments and Approaches for Exploring Organisational Culture Box Instruments and Approaches subjected to Psychometric Assessment in this review Box Timeline of Development Dates Box Instruments Country of Origin Box Psychometric Instruments that have seen previous Application in Healthcare Box Other instruments that have seen Previous Application in Healthcare Box The Nature of Cultural Differences: the national occupational, and Organisational levels Box Typological approaches Box Assumed Methodological Differences between the Qualitative and Quantitive Approach Box Prominent Qualitative Approaches to Cultural Exploration Box Prominent Commercial Packages Measuring and Assessing Organisational Culture in the NHS (OC1) This report presents independent research commissioned by the National Institute for Health Research Service Delivery and Organisation Programme.

4 The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. NCCSDO 2007 4 Table Respondents job title Respondents professional background The use, understanding and influencing of local Culture in clinical governance Measuring and Assessing Organisational Culture in the NHS (OC1) Acknowledgements Our thanks and acknowledgements for advice and support go to: Annette Barber, Liz Brodie, Sarah Christie, Caroline Greep, Barbara Lessels, Professor Martin Marshall, and Mia Senn We would particularly like to thank all those from the NHS and associated organisations who gave so freely of their time and insights during every phase of this project Queen s Printer and Controller of HMSO 2007 5 Measuring and Assessing Organisational Culture in the NHS (OC1) The Report 1 Introduction Many individuals and agencies concerned with health care quality and performance have emphasised the need for cultural change to be wrought alongside structural, financial and procedural reforms (Mannion et al 2005).

5 This interest in understanding and shaping the basic values, beliefs and assumptions that underpin patterns of behaviour among health professionals calls for better understanding about the nature of Organisational Culture , how it can be assessed and measured, and how such assessments can be integrated into beneficial programmes of change. In view of the widespread policy, managerial and clinical interest in this area, it is important to know what tools are used currently in the NHS to assess Organisational cultures and how well these tools meet the practical requirements and domains of interest of those interested in Assessing and changing cultures within their organisation and across local health care communities. This report details the findings of a two year National Institute of Health Research Service Delivery and Organisation programme funded project into the measurement and assessment of organisation Culture in the NHS undertaken by an inter-disciplinary consortium of researchers based at the Universities of York, St Andrews, Edinburgh and Manchester.

6 Aims and objectives of the study The overall aim of the project was to investigate, through literature work and empirical study, the range of extant tools, instruments and approaches that have been developed for the assessment of Organisational Culture and to assess the extent to which these may have some utility in the NHS. Specifically we sought to: identify the range of existing tools, instruments and qualitative approaches available for Measuring , Assessing and understanding Organisational cultures in health care, as well as Assessing their scientific properties, practicability and the levels and dimensions of Culture they tap into; review the extent to which these Culture assessments tools and qualitative approaches have been tested and used in the NHS and other health care contexts; Queen s Printer and Controller of HMSO 2007 6 Measuring and Assessing Organisational Culture in the NHS (OC1) explore with key NHS stakeholders their needs and interests with regards to understanding, Assessing and shaping Organisational cultures, and explore how various stakeholders might use Culture assessment methods to address these issues.

7 Gauge the degree of fit between existing approaches to measurement and assessment, and the needs and interests of NHS stakeholders; obtain information on the views and interests of users, patients and carers regarding the value domains they would wish to see expressed in Organisational ( Culture ) change programmes and assessments; undertake in-depth case study work to assess the development, use and impact of Culture assessment methods within current policies and programmes in the NHS; make recommendations for instrument use, future tool development and a new research agenda in the context of informing ( Culture ) change programmes in the NHS. Previous work by the authors The study builds on the accumulated experience of members of the research team gained from a previous Department of Health Policy Research Programme funded project which documented a range of Culture assessment tools.

8 Our previous study concluded that more research was required into the theoretical and practical aspects of Measuring and Assessing cultures, to inform the work of a range of agencies interested in understanding, Assessing and changing cultures in the NHS (Mannion et al 2003). As part of our earlier study we reviewed the (mainly quantitative) instruments available to health service researchers wishing to measure Culture and Culture change (Scott et al 2001, 2003a). Our literature search identified 84 articles that appeared to report the development or use of Culture assessment instruments, and over two dozen tools were assessed as having potential relevance to health care organisations. We identified a number of general themes across these instruments. First, such tools either adopt a typological approach in which the assessment results in one or more types of Organisational Culture , such as the Competing values Framework (Cameron and Freeman 1991) or a dimensional approach, which describe a Culture by its position on a number of continuous variables, such as the Organisation Culture Inventory (Cooke and Rousseau, 1988).

9 Second, some of the instruments have a strong theoretical and conceptual provenance, while others have been developed in a more pragmatic way. Third, the instruments vary in scope, some focusing on the assessment of one or more specific dimensions of Organisational Culture , others Assessing a more comprehensive range of issues. Fourth, they differ in terms of the levels of Culture they tap into, with none convincingly addressing the deeper underlying assumptions and that guide attitudes and behaviour and inform the stable substrate of Culture . Finally, the instruments vary in the extent of their use in empirical studies, and the degree to which their scientific properties have been Queen s Printer and Controller of HMSO 2007 7 Measuring and Assessing Organisational Culture in the NHS (OC1) evaluated. Thus previous review work reveals a diversity of potential approaches to Culture measurement and assessment, but little practical application of those tools, and only limited connection with ongoing policy, managerial or service preoccupations.

10 Research design and project overview The study of Organisational cultures and how these may be measured and assessed are the focus of many disciplines, including health services research, industrial sociology, anthropology and organisation studies. Thus the project was avowedly multi-disciplinary and multi-method from its inception. In essence the study consisted of three distinct but interlocking strands: 1. A literature review based on systematic principles that sought to uncover developed tools and approaches (quantitative, qualitative and multi-method), and both document and assess these against an explicit framework that prioritises fitness for purpose . 2. A stakeholder mapping exercise that sought to understand the interests and needs of NHS stakeholders around the assessment and shaping of health care Organisational Culture . Core stakeholders identified include: regulatory agencies ( CHAI, MONITOR); organisations with representative or developmental roles, health service delivery organisations; and patients, users and carers.


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