Health system reforms have until recently tended to focus primarily on structural change. The introduction of managed care in the United States (Miller and Luft 1997), the establishment of standard-setting bodies such as the National Institute for Clinical Excellence (Department of Health 1998) in the United Kingdom, the development of medical error reporting systems in Australia (Wilson et al. 1995), and the restructuring of primary care in the United Kingdom and Canada (Hutchison, Abelson, and Lavis 2001) are examples of this approach. However, recent studies show that structural changes alone do not deliver anticipated improvements in quality and performance in health care (Le Grand, May, and Mulligan 1998; Shortell, Bennett, and Byck 1998). As a result, we hear calls for “cultural transformation” to be wrought alongside structural change in order to deliver improvements in quality and performance. This call has been prominent in the United States (Institute of Medicine 2001) and also as a central component of the recent reforms of the National Health Service (NHS) in the United Kingdom (Department of Health 2000, 2002).
A theory of organizational culture emerges from a combination of organizational psychology, social psychology, and social anthropology. The development of organizational culture as a subject of study can be seen as an elaboration of the human relations (Roethlisberger and Dickson 1939) and social systems approaches (Parsons 1977); which in turn developed as correctives to the scientific management techniques of Frederick Winslow (“Speedy”) Taylor, and his successor Frank B. Gilbreth. The study of organizations has been conducted from within various different theories or paradigms (Burrell and Morgan 1979). The term “organizational culture” first appeared in the academic literature in an article in Administrative Science Quarterly by Pettigrew (Pettigrew 1979; Hofstede et al. 1990)—though Jacques refers to the culture of a factory as early 1952 (Jacques 1952). Its constituent themes can be traced to earlier literature on organizational analysis. Pettigrew's own empirical study of a private British boarding school appears strongly influenced by Burton Clarke (Clarke 1970). Both trace the influence of the strong, idiosyncratic individuals who founded the organizations. This concern with the role of leaders and leadership in turn underlines the influence of Selznick's Leadership in Administration (Selznick 1957). Selznick distinguishes between two ideal types of enterprise: on the one hand, a rational instrumental organization and, on the other hand, the value-infused institution. According to Selznick, the term “organisation” suggests a technical instrument to harness human energies and direct them towards set aims, while the term “institution” suggests an organic social entity, or culture.
Organizational culture has been variously defined (Ott 1989; Schein 1990; Davies, Nutley, and Mannion 2000). It denotes a wide range of social phenomena, including an organization's customary dress, language, behavior, beliefs, values, assumptions, symbols of status and authority, myths, ceremonies and rituals, and modes of deference and subversion; all of which help to define an organization's character and norms. Unsurprisingly in view of this diverse array of phenomena, little agreement exists over a precise definition of organizational culture, how it should be observed or measured, or how different methodologies can be used to inform routine administration or organizational change. While some commentators see the task in terms of specific and measurable variables, traits or processes, others see it as a global challenge to capture culture as an intrinsic property of the social milieu that forms whenever people are brought together in common enterprise. A third approach sees organizational culture as an anthropological metaphor or a paradigm (Burrell and Morgan 1979; Burrell 1996) to analyze organizations as microsocieties (Morgan, Frost, and Pondy 1983; Smircich 1983; Morgan 1986).
According to Edgar Schein,
Organizational culture is the pattern of shared basic assumptions—invented, discovered, or developed by a given group as it learns to cope with its problems of external adaptation and internal integration—that has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those problems (Schein 1985a).
This definition captures one of the basic challenges faced by any culture to reconcile the often divergent aims and actions of its members. It also points to the difficulty of addressing that challenge. Its emphasis on the role of shared basic assumptions influencing beliefs and behavior suggests that organizational culture denotes much more than just “the way things are done around here” (Davies, Nutley, and Mannion 2000). Changing the way things are done appears, on the functional level of systems redesign, relatively easy. Attempting to understand why things are done in their distinctive ways, the factors underlying resistance to change attempts, and the extent to which new practices are sustained is far more challenging. To successfully engender change in organizational behavior we need to understand the collective thought processes informing that behavior at both conscious and unconscious levels. This is where a deeper analysis and understanding of organizational culture may be productive.
Advocates of strategic cultural change typically make a number of implicit assumptions. First, health organizations possess discernible cultures, which affect quality and performance. Second, although cultures may be resistant to change, they are to some extent malleable and manageable. Third, it is possible to identify particular cultural attributes that facilitate or inhibit good performance and it should therefore be feasible for managers to design strategies for cultural change. Finally, it is assumed that any benefits accruing from the change will outweigh any dysfunctional consequences. Although there is as yet little empirical evidence to support these assumptions, some academics and many policymakers are showing renewed interest in the quantitative measurement of organizational culture in order to determine its relationship with performance and quality of care (Davies, Nutley, and Mannion 2000; Shortell et al. 2000; Shortell et al. 2001). A range of tools designed to measure organizational culture have been developed and applied in industrial, educational, and health care settings over the last two decades. In this paper we describe the results of an extensive review of these instruments and examine their usefulness for health service researchers. The review forms part of a larger study into the relationship between organizational culture and the performance of health organizations (Scott et al. 2001, In press).