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. Similarly, there may be micro-cultures among certain specialities or in particular locations (such as wards/units) within a hospital. 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’.     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, and between patient and staff satisfaction, 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. 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. Even within departments/specialities, correlations between individual tenets are either weak   or non-existent.
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
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