How can promoting a positive NHS culture promote anincreased quality of patient care?
Introduction
The quality of healthcare a service user receives reflects the clinical outcome, the patient
outcomes and experiences (Maybin and Thorlby, 2008). Lord Darzi’s review of the NHS
in England back in 2007 revealed that, whilst capacity had increased, quality andoutcomes required further improvement (Darzi, 2008). High quality, safe and effective
healthcare is the expectation of every user of NHS services. Yet, the care that many
patients receive often fails to meet these requirements (Dixon-Woods et al., 2013).
Despite much effort, the delivery of quality care by NHS England still falls short of the
expected standards (Hogan et al., 2012). Several high-profile cases have demonstrated
significant failings in quality and safety. Yet, despite such scandals, progress has been
made towards ensuring the uniform delivery of high quality care (Benning et al., 2011a;
Benning et al., 2011b). Factors key to the delivery of quality care have been identified.
One such factor is culture. In this article, how a positive organisational culture canincrease the quality of healthcare is discussed.

Quality in Healthcare
The concept of quality in healthcare is difficult to define. In his report, Lord Darzi (2008)
described quality in terms of patient safety, the patient experience and the clinicaleffectiveness of the care. Thus, the NHS recognises that good clinical outcomes andsafety are necessary to deliver quality care, whilst simultaneously providing a goodpatient experience. Personal attributes such as patient-provider relations, shareddecision-making and the comprehensive meeting of needs all contribute to the qualityof care (Jun et al., 1998).
The case of the Mid-Staffordshire NHS Foundation Trust (Francis, 2010) is an example
where the NHS failed to deliver quality care. The public inquiry (Francis, 2013) identified
a catalogue of failings concerning patient safety and care quality. The systems that werein place to ensure oversight, accountability and influence were inadequate with largescale failure of control and leadership at all levels (Dixon-Woods et al., 2013). The
underlying organisational culture had created an environment ripe for the delivery ofsub-standard care. Factors forming the basis of the organisation’s culture such aspolicies, rules, regulations, resources and incentives, were all found wanting. This led toa tolerance of poor standards and a demonstrable dissociation between managerial
responsibilities and front-line staff (Francis, 2010).

Following the inquiry, an extensive survey of NHS England healthcare professionals wasperformed. Encouragingly, it revealed that the values of care and compassion are at theheart of both organisational and personal commitments at all levels (Dixon-Woods etal., 2013). Consistent with the Francis inquiry, the greatest influence on an organisation’scommitment to quality was found at board level. Thus, the tone set at the top filters
down throughout the organisation to affect the care that the patient receives. The
influence of the board on the performance of all staff reflects the culture of theorganisation, representing the priorities and vision of the institution as a whole.

Organisational Culture
An environment that supports cooperation between provider and patient is essential todeliver quality care (Mosadeghrad, 2014a). An organisation’s culture determines theenvironment, describing how an institution organises itself, its rules, procedures andbeliefs (Handy, 1981). Culture is the overarching theme that describes how and why
employees do what they do. Different types of organisational culture are recognised andin healthcare organisations, more than one cultural style is usually found: The different
professional disciplines, departments or wards may have different cultures. Such
differences can impede cohesive working due to conflicting priorities andcommunication difficulties.
In the NHS, a Role Culture prevails where individuals all have a specific role. Tasks arespread throughout the organisation leading to specialist roles and removingduplication. These cultures are efficient and productive, but are inflexible and difficult toadapt (Handy, 1981). This overlaps with the bureaucratic culture of the NHS.
Bureaucratic cultures are system and procedure-led. They are risk averse and lessadaptable with hierarchical structures and non-commercial aims (Handy, 1981). Cultures
focused on strong hierarchical structures, centralisation and bureaucratic control act as abarrier to delivering quality care. People at all levels need a sense of autonomy and tofeel empowered to make decisions. This requires people to take responsibility and be
accountable for their actions, something that is impossible in a blame-orientated culture(Khatri et al., 2009). Blame cultures have historically pervaded healthcare organisations.
The process of identifying and blaming an individual when something goes wrong leads
to secrecy and the hiding of errors. Cultures that foster secrecy and protectionism,
denial of failings and an avoidance of accepting responsibility for addressing themcannot deliver quality care (Walshe and Shortell, 2004). In the case of Mid-Staffordshire,
the failure to respond to patients’ concerns, poor management systems and thefragmentation of knowledge regarding issues, all contributed to the problem (Francis,2010). Where failings are not recognised and addressed, quality and safety arecompromised (Leape, 1994).

A Culture to Deliver Quality Care
Improvements in care quality require a shift from shame and blame cultures to ones
where systems are designed with safety and quality in mind (Reason, 1997). Ironically,external requirements that sought to ensure high-quality, safe care often resulted inorganisations displaying defensive and reactive policies (Power, 2003). Many NHS
organisations responded to these external pressures by imposing a bureaucratic
management style to ensure compliance. This resulted in broad, prescriptive policies
that led to frustration and negativity (Dixon-Woods et al., 2013). This task-focused
approach actually reduced quality and safety. Lord Darzi (2008) recognised the need for
greater local control and fewer top-down, centrally determined targets to improve
quality. The empowerment of local services was pursued with local quality indicators
allowing clinicians to benchmark their own performance (Dixon, 2008). Greater emphasis
is placed on the clinician’s own innate desire to improve the quality of their services withrecognition of professionalism and personalisation. Whilst clinical leadership became
the new focus, Darzi was aware that managerial tasks were important to improve service
quality (Maybin and Thorlby, 2008). Making healthcare professionals more accountable
for the services they deliver, and giving them more responsibility for managing andimproving the healthcare system, imparted fundamental changes to the culture of theNHS.
The cultures of healthcare organisations are affected by many variables that produce
competing and conflicting demands. The needs of patients, carers, families, regulators,providers and partners must all be considered, but are often inconsistent and difficult todefine. Historically, the hierarchical culture of the NHS often produced silos: individual
units that operate in isolation, ignorant of how their actions affect others. The focus onproductivity, efficiency and controlling costs, created a culture detrimental to thedelivery of quality care (Gaba et al., 1994). Quality requires the cooperation of patientand provider within a supportive environment (Ovretveit, 2012). Creation of a positive
culture where organisations have supportive visionary leadership, forward planning anda collaborative, team-based approach will be best able to deliver quality care.
A culture that prioritises the delivery of quality care will be shaped by this belief and thesharing of this goal will guide the discretionary behaviours exhibited by staff (Glickmanet al., 2007). Such a culture must accept that errors will occur and so proactively seek to
identify and address potential causes (Westrum, 1992). The harmonious working of alllevels of an organisation’s staff is enhanced through shared, unifying goals and analignment of beliefs. Goals allow the recognition of priorities for continual improvement:
motivating staff and ensuring the necessary resources are found. Furthermore, thesetting of clear goals throughout the different levels is associated with high levels ofpatient satisfaction (Dixon-Woods et al., 2013). However, disparities observed between
the goals set at board level and the practices of front-line staff highlight the difficulties
in creating a culture based around a unifying vision (Dixon-Woods et al., 2013). Defining
how such goals should be achieved, having the necessary leadership to achieve them,and the necessary quality management systems in place, is crucial (Mosadeghrad,2014b).
The effect of management on an organisation’s culture and the quality of care deliveredcannot be underestimated. Standardised mortality ratios are inversely related withpositive and supportive organisations (West and Dawson, 2012). Good management andleadership are essential to create a caring, positive and innovative culture (Khatri et al.,2009). Leaders set the direction and tone of the organisation. They encourage andempower staff to address the challenges that they encounter and to provide innovativesolutions. Supporting staff through education and training, empowering them to makedecisions and facilitating the delivery of patient-centred care all enhance quality(Mosadeghrad, 2014a). There are clear relationships between the quality of care andstaff satisfaction and contentment (Haas et al., 2000; DiMatteo et al., 1993). Employees
need to be trained and supported, recognised and rewarded, to ensure their good
performance (Mosadeghrad, 2013). Individuals and teams who show compassion,cooperation, and civility demonstrate the delivery of quality care. They know what they
are doing and why, they are committed to learning, making improvements andinnovating. Patients are treated with kindness and their dignity respected. To facilitate
these behaviours, the managerial approach, whilst demanding personal accountability
from staff, must identify and resolve systemic constraints that prevent staff fromdelivering quality care. Where boards take steps to identify and fix system issues, they
support cultural change, which ultimately benefits patients (Dixon-Woods et al., 2013).

Conclusion
Quality in healthcare is described as the delivery of safe, effective care that meetspatient’s expectations. Following pressures to increase in productivity throughout theNHS, quality was felt to have suffered. High profile failings of the NHS to deliver quality
care led to increased emphasis on this issue with measures and incentives introduced to
reward the delivery of quality care. The culture of the NHS and its organisations wasrecognised as influential in the quality of the care provided. Instilling a positive, qualitydriven culture with policies, procedures and behaviours linked to quality improves
patient and clinical outcomes.

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