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How do strategies to change organizational culture affect healthcare performance?

‘Organizational culture’ refers to characteristics shared by people who work within the same organization. These characteristics may include beliefs, values, norms of behaviour, routines, and traditions. The management of organizational culture is viewed increasingly as a necessary part of health system reform. It is therefore important for policymakers to be aware how strategies to improve organizational culture affect healthcare performance.

Key messages

Strategies to improve organisational culture include:

-Leadership commitment and action through the clear communication of values and concerns related to the decisions taken, the reinforcement of desired behaviours during crisis periods, the use of role models, the allocation of rewards, and clear criteria for the selection and dismissal of employees.

-Programmes to improve job satisfaction, organisational commitment, teamwork and morale.

It is uncertain whether any of these strategies to improve organisational culture are effective in changing healthcare performance, as no studies met the review’s inclusion criteria.

The implementation of strategies to improve organisational culture should include well-designed evaluations.

Who is this summary for?

People deciding how to improve organizational culture in order to influence healthcare performance.

This summary includes:

Key findings from research based on a systematic review
Considerations about the relevance of this research for low income countries

Not included:

Recommendations
Additional evidence not included in the systematic review
Detailed descriptions of interventions or their implementation

This summary is based on the following systematic review:

Parmelli E, FlodgrenG, SchaafsmaME, et al. The effectiveness of strategies to change organizational culture to improve healthcare performance. Cochrane Database of Systematic Reviews 2011, Issue 1. Art. No.: CD008315.

What is a systematic review?

A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.

SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.

Glossary of terms used in this report

Background references on this topic

Background

Increasing emphasis has been placed on how changes to organizational culture and organizational structure impact upon healthcare performance. Organizational change is difficult to manage and its precise impacts on healthcare and healthcare policy are often poorly understood or unclear. The desirability and feasibility of adopted strategies to improve organizational change have therefore been called into question.

How this summary was prepared

After searching widely for systematic reviews that can help inform decisions about health systems, we have selected ones that provide information that is relevant to low-income countries. The methods used to assess the reliability of the review and to make judgements about its relevance are described here

Knowing what’s not known is important

A reliable review might not find any studies from low-income countries or might not find any well-designed studies. Although that is disappointing, it is important to know what is not known as well as what is known.

A lack of evidence does not mean a lack of effects. It means the effects are uncertain. When there is a lack of evidence, consideration should be given to monitoring and evaluating the effects of intervention, if it is used.

About the systematic review underlying this summary

Type of	What the review authors searched for	What the review authors found
Review objectives: To determine the effectiveness of strategies to change organizational culture in order to improve healthcare performance and considering – when possible – different patterns of organizational culture.
Study designs & interventions	Any strategy intended to change organizational culture in order to improve healthcare performance. The comparator could be normal care or any other active in-tervention. The following study designs were consid-ered: randomized trials, non-randomized trials, controlled before-after studies and in-terrupted time series studies.	No eligible studies were found for in-clusion in this review.
Participants	Healthcare organizations in which strategies to change organizational culture were applied.	No eligible studies were found for in-clusion in this review.
Settings	Any type of healthcare organization in any country.	No eligible studies were found for inclusion in this review.
Outcomes	Professional performance such as prescrip-tion rates, evidence-based practice, quality of care, and efficiency. Patient outcomes such as mortality, condition-specific measures of outcomes, quality of life, func-tional health status, and patient satisfaction. Organizational performance indicators such as wait times, inpatient hospital stay times, and staff turnover rates.	No eligible studies were found for inclusion in this review.
Date of most recent search: October 2009.
Limitations: This is a well-conducted systematic review with only minor limitations. However, no studies that met the inclusion criteria were identified.

About the certainty of the  evidence (GRADE)

High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.

Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.

Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.

Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.

* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.

† Substantially different = a large enough difference that it might affect a decision.

See last page for more information.

Summary of findings

It is not possible to draw any conclusions about the effectiveness of strategies to change organizational culture since no studies met the inclusion criteria for this review. An example of an excluded evaluation is a controlled before-after study that assessed the impact of an intervention to change organizational culture on the frequency of staff handwashing to decrease nosocomial infection rate. It was excluded because there was only one intervention and one control site and therefore any intervention effect is confounded with the effect of other differences between the two sites. Another example is a study that assessed the effectiveness of a program to improve spirit at work and staff wellness at a long term care site. This study did measure a change in culture.

These studies illustrate examples of strategies to change organizational culture, but do not provide reliable evidence of the effects of these strategies. The first study aimed to improve handwashing compliance through active support from hospital managers and medical and nursing leaders. Efforts to effect changes in organizational culture through leadership action focused on five key mechanisms:

-The communication of values and concerns underlying their choices.

- Reinforcement of the desired behaviours during times of crisis.

- Role modeling.

- The allocation of rewards.

- Clear criteria for the selection and dismissal of employees.

In the second study, a ‘spirit at work program’ was implemented to improve job satisfaction, organizational commitment, teamwork and morale. This intervention would be difficult, if not impossible to replicate, since details about the intervention were not provided.

The effects of strategies to improve organizational culture on changing organizational culture and healthcare performance are uncertain. No reliable studies that measured these effects were found.

1 Schein E. Organizational culture and leadership. San Francisco: Jossey Bass; 1985.

2 Kinjerski V, Skrypnek BJ. The promise of spirit at work: increasing job satisfaction and organizational commitment and reducing turnover and absenteeism in long-term care. J Gerontol Nurs. 2008 Oct;34(10):17-25; quiz 26-7.

Relevance of the review for low-income countries

Findings	Interpretation*
APPLICABILITY
No studies were included.	There may be a shortage of personnel with the skills needed to design and develop strategies to change organizational culture in low-income countries. The implementation of organizational culture strategies may be negatively impacted by institutional corruption within governments and healthcare organizations.
EQUITY
No studies were included.	The organizational cultures of healthcare providers that serve disadvantaged populations may vary. Interventions to implement change may need to consider these differences if they are to be effective. More resources may be needed to reach healthcare organizations in underserved areas in appropiate ways.
ECONOMIC CONSIDERATIONS
No studies were included.	Intervention costs will vary and these must be determined for the specific settings in which organizational change interventions will be used. The value of using resources for interventions to change organizational culture needs to be weighed against the uncertain effects that these interventions have.
MONITORING & EVALUATION
No reliable evidence of the effects of strategies to improve organisational culture is available.	Strategies to improve organizational culture should be evaluated using robust study designs, such as randomized trials or interrupted time series studies. Levels of resource use, and impacts on organizational performance, professional practice or patient outcomes should be measured.
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods

Additional information

Related literature

Elena Parmelli, Gerd Flodgren, Fiona Beyer, et al. The effectiveness of strategies to change organizational culture to improve healthcare performance: a systematic review. Implementation Science 2011, 6:33.

Tim Scott, Rusell Manion, Huw Davies and Martin Marshall. Healthcare performance and organizational culture. Radcliffe Publishing, 2003.

Scott T, Mannion R, Davies H, and Marshall M. The quantitative measurement of organizational culture in health care: A review of the available instruments. Health Serv Res. 2003 June; 38(3): 923–945.

Davis H. Understanding organizational culture in reforming the National Health Service. J R Soc Med. 2002 March; 95(3): 140–142.

Boan D and Funderburk F. Healthcare Quality Improvement and Organizational Culture. Insights, Delmarva Foun-dation. November, 2003.

This summary was prepared by

Cristian Herrera, Unit for Health Policy and Systems Research, School of Medicine, Pontificia Universidad Católica de Chile, Chile.

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

Acknowledgements

This summary has been peer reviewed by: Martin Eccles, Robert Basaza, Ekwaro A Obuku, and Hanna Bergman

This review should be cited as

Parmelli E, FlodgrenG, SchaafsmaME, et al. The effectiveness of strategies to change organizational culture to improve healthcare performance. Cochrane Da-tabase of Systematic Reviews 2011, Issue 1. Art. No.: CD008315.

The summary should be cited as

Herrera C. How do strategies to change organizational culture affect healthcare performance? A SUPPORT Summary of a systematic review. August 2016. www.supportsummaries.org

Keywords

evidence-informed health policy, evidence-based, systematic review, health sys-tems research, health care, low and middle-income countries, developing coun-tries, primary health care, organizational culture

About certainty of evidence (GRADE)

The “certainty of the evidence” is an assessment of how good an indication the research provides of the likely effect, i.e. the likelihood that the effect will be substantially different from what the research found. By “substantially different” we mean a large enough difference that it might affect a decision. These judgements are made using the GRADE system, and are provided for each outcome. The judgements are based on the study design (randomised trials versus observational studies), factors that reduce the certainty (risk of bias, inconsistency, indirectness, imprecision, and publication bias) and factors that increase the certainty (a large effect, a dose response relationship, and plausible confounding). For each outcome, the certainty of the evidence is rated as high, moderate, low or very low using the definitions on page 3.

For more information about GRADE

SUPPORT collaborators:

The Cochrane Effective Practice and Organisation of Care Group (EPOC) is part of the Cochrane Collaboration. The Norwegian EPOC satellite supports the production of Cochrane reviews relevant to health systems in low- and middle-income countries . www.epocoslo.cochrane.org

The Evidence-Informed Policy Network (EVIPNet) is an initiative to promote the use of health research in policymaking in low- and middle-income countries. www.evipnet.org

The Alliance for Health Policy and Systems Research (HPSR) is an international collaboration that promotes the generation and use of health policy and systems research in low- and middle-income countries. www.who.int/alliance-hpsr

Norad, the Norwegian Agency for Development Cooperation, supports the Norwegian EPOC satellite and the production of SUPPORT Summaries. www.norad.no

The Effective Health Care Research Consortium is an international partnership that prepares Cochrane reviews relevant to low-income countries. www.evidence4health.org

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