A Culture of Quality: Join the Debate

There are two theories about hospital level culture:

  1. The general view that is probably overstated. This says that a person can walk into a hospital and within ten minutes they will accurately discern whether or not it is a safe place to be treated. Yet evidence for this latent variable called culture is weak at the hospital level. Certainly I know of no evidence that a person can just walk in and ‘smell’ the culture. My peer CLAHRC Director, Prof Derek Bell of Northwest London, has recently reviewed the literature on the association between patient experience on the one hand and certain outcomes and clinical processes on the other.[1] These two sets of variables were statistically correlated in many cases, but the paper does not say how large the associations were. (These would have been hard to summarise from a diverse literature.) However, Jha and colleagues, in a massive survey of US hospitals,[2] found that the difference in adherence to quality standards between the highest and lowest quartiles for satisfaction varied by less than three percentage points – a result that was statistically, but not practically, significant. Likewise, an extensive review of the relationship between clinical processes (technical safety and quality) and standardised mortality rates showed a correlation, but again it was very weak, such that one could not be a useful diagnostic test for the other. Jaipaul and Rosenthal [3] studied the link between various measures of patient satisfaction and the tractable domain of standardised hospital mortality. While they too show associations, the correlations are weak (all are lower than 0.4). Perhaps most telling of all, there is there is little or no correlation between adherence to the quality of clinical care standards themselves.[4] [5] It is of more than passing interest that the now notorious Stafford Hospital did not show up as an outlier on the patient survey. So pervasive is the belief in the cultural explanation that it is more difficult to get an article accepted if it is null than if it is positive, as I have found at an anecdotal level.
  2. The Director’s view. This holds that the idea of a zeitgeist that can be manipulated to simultaneously improve performance across a hospital is a seductive, but over-used concept. The Good Samaritan experiment [6] is a good example of the ‘situated’ nature of human behaviour, meaning that local environment has a persuasive impact on what we do.[7] Albert Bandura is a ground-breaking researcher on how behaviour is strongly influenced by what other people are doing in the immediate vicinity, rather than a set of fixed values driving behaviour across a social group.[8] A recent systematic review of intervention studies did “not identify any effective strategies to change organisational culture”,[9] while another association study concluded “current policy prescriptions which seek service improvement through cultural transformation are in need of a more secure evidential base”.[10] The poor or non-existent correlations cited above support the conclusion that if you want to improve hospital care, make the right thing to do the easy thing to do and do not obsess over this notion of a magic, cultural bullet that will make everything all right.

Please post your views on evidence on the above important issue.

–Richard Lilford, CLAHRC WM Director


  1. Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013; 3: e001570
  2. Jha AK, Orav EJ, Zheng J, Epstein AM. Patients’ Perception of Hospital Care in the United States. NEJM. 2008; 359: 1921-31.
  3. Jaipaul CK, Rosenthal GE. Do hospitals with lower mortality have higher patient satisfaction? A regional analysis of patients with medical diagnoses. Am J Med Qual. 2003; 18(2): 59-65.
  4. Jha AK, Li Z, Orav EJ, Epstein AM. Care in US hospitals – the Hospital Quality Alliance program. NEJM. 2005; 353(3): 265-74.
  5. Wilson B, Thornton JG, Hewison J, Lilford RJ, Watt I, Braunholtz D, Robinson M. The Leeds University Maternity Audit Project. Int J Qual Health Care. 2002; 14(3): 175-81.
  6. Darley JM, Batson D. “From Jerusalem to Jericho”: A Study of Situational and Dispositional Variables in Helping Behavior. J Pers Soc Psychol. 1973; 27(1): 100-8.
  7. Bandura A, Ross D, Ross SA. Transmission of aggression through imitation of aggressive models. J Abnorm Soc Psychol. 1961; 63: 575-82.
  8. Bandura A. Social Learning Theory. Englewood Cliffs, NJ: Prentice Hall, 1977.
  9. Parmelli E, Flodgren G, Beyer F, Baillie N, Schaafsma ME, Eccles MP. The effectiveness of strategies to change organisational culture to improve healthcare performance: a systematic review. Implement Sci. 2011; 6: 33.
  10. Scott T, Mannion R, Marshall M, Davies H. Does organisational culture influence health care performance? A review of the evidence. J Health Serv Res Policy. 2003; 8(2): 105-17.

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