ABSTRACT
Leadership is the most influential factor in shaping organisational culture. Using evidence to inform decisions about clinical care is the norm, but its use in determining the optimal leadership culture, climate and systems is less apparent. In the wake of well publicised clinical and service failings, and in the face of a substantial financial challenge, it would seem sensible for the NHS to put evidence into practice if the lives of staff and standards of care are to be improved as we would wish. The Faculty of Medical Leadership and Management, the King's Fund and the Center for Creative Leadership conducted a comprehensive review of literature published in the last ten years, of the evidence relating healthcare leadership to clinical outcome. The review demonstrated that the quality of healthcare experienced by patients is inextricably linked to the climate, culture and support experienced by staff.
Introduction
Effective leadership is the key ingredient in creating a climate and shaping the organisational cultures in which all healthcare staff can consistently deliver safe, cost-effective and quality patient care. At a time when the health and social care system faces significant challenges to service delivery and in balancing the books, creating the optimal environment within which staff operate is crucial and more likely to achieve desired results than imposing changes to structures and processes.
The Faculty of Medical Leadership and Management (FMLM), the King's Fund and the Center for Creative Leadership1 reviewed the world literature concerned with linking effective healthcare leadership and clinical outcome.2 The findings point clearly to the importance of leadership and management behaviours and practices; they also provide insights into which specific skills and approaches are likely to promote positive cultures and climates, which in turn motivate and support staff to deliver high-quality care.
What is the evidence for culture?
Organisational culture is defined as ‘the values and beliefs that characterise organisations as transmitted by the socialisation experiences newcomers have, the decisions made by management, and the stories and myths people tell and re-tell about their organisations’.3
Research concerning organisational culture in healthcare looks at a range of relevant cultural dimensions and the impact of these on staff, patient care and performance. There is clearly no panacea and elements of each have merit. However, a consistent finding in all key studies was that a hierarchical approach, typified by a preoccupation with target setting, rules, regulation and status, has a negative impact on staff, patients and performance. Indeed, a dominant hierarchical culture is negatively associated with inpatient satisfaction and organisations employing this as their dominant culture have long waiting times and poor data quality.4,5 Further, others suggest that a dominant hierarchical culture can inhibit a positive climate for safety due to fear of negative outcomes and blame for reporting safety-related concerns.6 Many cite this as the dominant culture in the NHS over the past decade, although any role the adoption of this approach may have had on public failings in the system is only conjecture at this time.
Targets and regulation clearly have an important role in assuring the public, benchmarking performance and ensuring efficient, quality and safe delivery of patient care. However, the problem arises when an over-reliance on priorities set by governments, inspectors and regulators results in front-line staff reporting they no longer know what is important.7
Studies have also revealed that a culture that emphasises cohesiveness, participation, loyalty, tradition and high morale appears to have a positive impact on healthcare and is more often associated with high inpatient satisfaction,4 fewer complaints, and a tendency to rate patient dignity and respect highly.5
A second major finding is that leaders and managers, and their behaviours and collective priorities, influence the dominant culture of the organisation. When those at senior levels encourage teamworking and an entrepreneurial culture, this has a positive impact on quality improvement efforts, group learning, and innovative approaches to problem solving and stakeholder satisfaction.5,8,9 Several large-scale studies have shown that organisations which promote effective teamworking, where staff are empowered and involved in decision-making, and have distributed leadership, perform better.10,11
Organisational cultures of this nature take time and consistent effort to develop. To achieve such cultures, leaders at all levels have a crucial role to play in demonstrating their high expectations of the organisation, through a focus on values and attitudes designed to establish a positive organisational climate (defined as ‘the shared meaning employees attach to the policies, practices and procedures they experience and the behaviours they observe getting rewarded, supported and expected’3).
What is the evidence for climate?
Research into the influence of organisational climate in the healthcare environment indicates that staff satisfaction is directly related to patient approval and clinical outcomes, up to and including mortality. The importance of staff satisfaction is also apparent in other customer-focused providers. A Harvard Business School analysis of the successful turnaround of Sears, the North American department store in the 1990s, observed that growth, profitability and improved quality are the natural products of good leadership.12 Indeed, the inference is that sustained value (cost plus quality) for ‘customers’ is impossible without effective leadership and good people management. Crucially, the intermediate step to customer satisfaction, quality and performance was staff satisfaction. This example, when shared with healthcare leaders, certainly seems to resonate.
In healthcare research, various elements leading to staff, and therefore patient satisfaction and outcomes, are identified. First, the importance of the support received from first-line supervisors and immediate managers is hugely important to patient satisfaction.13–15 Second, the implementation of HR policies and practices relating to training, participation and involvement and teamworking is linked with patient mortality.16 Teamwork in particular is shown to be associated with lower death rates.17 A large study in the NHS found that when staff had valuable appraisals and received relevant training with opportunities for development, there was a low and decreasing level of patient mortality.15 Moreover, in an NHS-based study, one standard deviation improvement in the extensiveness and sophistication of appraisal systems was associated with a reduction of 12.3% of the number of deaths after hip fracture.17 Clear, challenging objectives further help individuals do their job better and makes them feel valued, respected and engaged.15
While the research evidence tends not to have focused on particular staff groups in healthcare, a positive association is apparent between those organisations with high levels of medical engagement and lower mortality rates, fewer serious incidents, higher maintenance of service provision and patient care, sound financial status, achievement of targets and adherence to core standards.18
Research outside healthcare also emphasises the significance of engagement and demonstrates how important this is to happiness and positivity; people feel more positive and creative when they are happy and produce higher quality work.19
Conclusion
The sustainability of the NHS and the success of ambitious initiatives such as the Future Hospital Programme require effective leadership. Leadership operates through positive cultures and climates which take time to develop and which call for more stable, collaborative and value-based leadership than the NHS has enjoyed for some time. Pendleton and Furnham20 define this goal as the need to demonstrate leadership styles and teamworking necessary to establish a climate and culture in which staff have a great place to work and are treated well. The tri-organisational literature review proposes five key cultural elements that leaders need to focus on to sustain cultures of high quality, compassionate care for patients:
inspiring visions operationalised at every level
clear, aligned objectives for all teams, departments and individual staff
supporting and enabling people management and high levels of staff engagement
learning, innovation and quality improvement embedded in the practice of all staff
effective teamworking.1
There is nowhere for anyone to hide in this quest – governments, national bodies, provider organisations, commissioners and individual healthcare workers all have a part to play in the development of cultures and climates conducive to the delivery of safe, effective and compassionate care for patients. Further reading can be accessed at the following links.21,22
- © Royal College of Physicians 2015. All rights reserved.
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