Challenging the Idea of Hospital Culture

Welcome to this first News Blog of 2015, and happy birthday to sibling CLAHRCs. We are exactly one year old!

One of the things our CLAHRC likes to do is challenge the perceived wisdom. Today we challenge the idea that hospitals have a pervading culture that has a profound influence on the performance of front-line staff across the board – in particular, we question the idea that safe care turns on this latent variable of culture. Of course, we do not doubt the concept of culture itself. National cultures certainly exist, as eloquently demonstrated in a study of propensity among UN headquarters staff of different nationalities to misuse diplomatic immunity in violation of New York’s parking restrictions.[1] Similarly, there may be micro-cultures among certain specialities or in particular locations (such as wards/units) within a hospital.[2] But we think that culture is a weak force at the hospital level. Our argument is part theoretical, part empirical.

Theoretically, staff have cultural ties outside their hospital, particularly to their trade organisations, which operate over longer time frames than employment contracts. Within hospitals, interaction across departments is limited and episodic. There are thus reasons, a priori, to be sceptical about the hospital as the cultural locus for clinical staff.

A number of studies have looked for correlations between culture and various measures of hospital ‘performance’.[3] [4] [5] [6] [7] The results are mixed at best and the authors tend to seek reasons for unimpressive results, rather than question the importance of ‘culture’ itself. Correlations, albeit weak ones, have been found between mortality and staff satisfaction,[8] and between patient and staff satisfaction,[9] but many other potential explanations, such as better staff/patient ratios in higher performing institutions, could explain these findings. When looking for a direct correlation between culture and clinical performance none is found.[10] If culture were important then there should be a correlation between adherence to the tenets of good clinical practice between hospital departments/specialities within hospitals, but none is found.[11] Even within departments/specialities, correlations between individual tenets are either weak [12] [13] or non-existent.[14]

Why has the notion of hospital culture received such widespread support in the face of such paltry evidence? We speculate that the notion has been imported, along the supply line for management ideas, from the private sector. We suspect that commercial organisations have cultures that are stronger than those in hospitals. It is easy to be persuaded that ENRON, for example, had such a corporate culture – malign in that case. Whatever the explanation, it is clear to us that this notion of hospital culture feeds into a ‘meta-narrative’ – a story that is amplified through social networks to become an accepted part of folklore. Such stories become self-referential and hard to oppose – for example, we have anecdotal evidence of strong publication bias in studies on culture and plan to investigate this formally. We seek views and potential collaborators in future study of this topic from our readership. Happy New Year!

— Richard Lilford, CLAHRC WM Director
— Yen-Fu Chen, Senior Research Fellow


  1. Fisman R, Miguel E. Cultures of Corruption: Evidence from Diplomatic Parking Tickets. NBER Working Paper No. 12312. 2006.
  2. Brewer BB. Relationships among teams, culture, safety, and cost outcomes. West J Nurs Res. 2006; 28(6): 641-53.
  3. Wagner C, Mannion R, Hammer A, Groene O, Arah OA, Dersarkissian M, Sunol R. The associations between organizational culture, organizational structure and quality management in European hospitals. Int J Qual Health Care. 2014. 26(s1): 74-80.
  4. Willis C, Saul J, Bevan H, et al. Sustaining organizational culture change in health systems? J Health Organ Manag. [In Press].
  5. Mannion R, Davies TW, Freeman T, Millar R, Jacobs R, Kasteridis P. Overseeing oversight: governance of quality and safety by hospital boards in the English NHS. J Health Serv Res Policy. 2015; 20(s1): 9-16.
  6. Davies HT, Mannion R, Jacobs R, Powell AE, Marshall MN. Exploring the relationship between senior management team culture and hospital performance. Med Care Res Rev. 2007 64(1): 46-65.
  7. Millar R, Mannion R, Freeman T, Davies HT. Hospital Board Oversight of Quality and Patient Safety: A Narrative Review and Synthesis of Recent Empirical Research. Milbank Q. 2013; 91 (4): 738–70.
  8. Pinder RJ, Greaves FE, Aylin PP, Jarman B, Bottle A. Staff perceptions of quality of care: an observational study of the NHS Staff Survey in hospitals in England. BMJ Qual Saf. 2013; 22(7): 563-70.
  9. Dawson J. Staff experience and patient outcomes: what do we know? A report commissioned by NHS Employers on behalf of NHS England. London: NHS Confederation. 2014. [Online].
  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. 2003; 8: 105-17.
  11. Jha AK, Li Z, Orav EJ, Epstein AM. Care in U.S. hospitals – the Hospital Quality Alliance Program. New Engl J Med. 2005; 353: 265-74.
  12. Peterson ED, Roe MT, Mulgund J , et al. Association between hospital process performance and outcomes among patients with acute coronary syndromes. 2006; 295: 1912-20.
  13. Bradley EH, Herrin J, Elbel B, et al. Hospital quality for acute myocardial infarction: correlation among process measures and relationship with short-term mortality. JAMA. 2006; 296: 72-8.
  14. 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: 175-81.

6 thoughts on “Challenging the Idea of Hospital Culture”

  1. Evidence and experience would lead me to agree with the urge for caution about seeing a hospital as having a single culture. I am much more persuaded by the importance of a culture at the level of what Paul Batalden first described as the “clinical microsystem”. However one seemingly important attribute of a hospital, or of a healthcare system, which can be measured, is the extent of “medical engagement”. Peter Spurgeon (from Warwick) and colleagues designed, validated and have deployed a “Medical Engagement Scale”; results correlate fairly strongly with a range of measures of good, or bad, organisational performance. It is described here: Spurgeon P, Mazelan PM, Barwell F, Health Serv Manage Res August 2011 vol. 24 no. 3 114-120.

    There are echoes in this work of the views of Beverley Alimo-Metcalfe, and of Michael West, both of whom have written of the importance of creating a climate of engagement.

  2. Great piece and of course one of the most powerful pieces of empirical evidence is Mid Staffs where the poor culture in some wards coexisted with excellent patient experience reports in other parts of the hospital. Despite this a myth has been allowed to develop that the overall culture of the trust was poor.

  3. Really thought-provoking, evidence-based piece! Just echoing comments above – given size and complexity of hospitals, not surprising that strong common culture more likely to be seen at the functional team/clinical microsystem level. Work by Jill Maben and others for example indicate the strength of ward environment/culture and impact of role modelling/leadership influence at ward sister level.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s