Improving NHS culture

The first characteristics key to shaping an organisation’s culture are vision and values.

Leaders at every level should communicate an inspiring, forward-looking and ambitious vision focused on offering high-quality, compassionate care to the communities they serve.

There should be clear values that set expectations for how staff conduct themselves and interact with colleagues and patients. Values are set out in the NHS constitution, and patient-centredness and responsiveness are core.

Good leaders reiterate at every level the message that high-quality, compassionate care is the core purpose of all staff, so that everyone understands and acts on this commitment. This takes time, sustained energy and dedication.

The second cultural characteristic fundamental to the delivery of continually improving, high-quality care is to have clear goals and performance feedback.

Goals must be set at every level from the board to frontline staff. Board goals should be shaped by patient input. Performance feedback should be based on patient feedback and patient outcomes.

Staff in health services report that they are often overwhelmed by their workload and are unclear about the goals they are working towards. This produces stress, inefficiency and poor quality care.

Such situations can arise when senior managers insist on too many priorities. A clear vision and mission statement about high-quality, compassionate care provides a directional path for staff. But this must be translated into clear, aligned, agreed and challenging goals at all levels of the organisation. It must be matched by timely, helpful and formative feedback for those delivering care if they are to continually improve quality.

Supportive and compassionate behaviours form the third cultural characteristic fundamental to the delivery of continually improving, high-quality care.

If we want staff to treat patients with respect, care and compassion, all leaders and staff must treat their colleagues with respect, care and compassion.

Directive, aggressive or brusque leaders dilute the ability of staff to make good decisions, deplete their emotional resources and hinder their ability to relate effectively to patients, especially those who are most distressed or challenging. There are clear links between staff experience and patient outcomes. Staff views of their leaders are strongly related to patients' perceptions of the quality of care. The higher the levels of satisfaction and commitment that staff report, the higher the levels of satisfaction that patients report. If leaders and managers create positive, supportive environments for staff, they in turn create caring, supportive environments and deliver high-quality care for patients. Such leadership cultures encourage staff engagement.

The fourth cultural characteristic fundamental to the delivery of continually improving, high-quality care is encouraging learning and innovation.

Sustaining cultures of high-quality care involves all staff focusing on continual learning and improvement of patient care. Learning and quality improvement are dependent on continual patient input – innovation is most likely where patients’ views and feedback play a strong role.

A focus on improvement should ensure that:

• teams at all levels collectively take time to review and improve their performance
• quality and patient safety practices are an ongoing priority for all
• there are high levels of dialogue, debate and discussion across the organisation to achieve shared understanding about quality problems and solutions.

All staff should encourage, welcome and explore feedback and treat complaints and errors as opportunities for learning across the system rather than as a prompt for blame. This encourages collective openness to and learning from errors, near misses and incidents.

Effective teamwork and collaboration form the fifth cultural characteristic fundamental to the delivery of continually improving, high-quality care.

Where multi-professional teams work together, patient satisfaction is higher, health care delivery is more effective, there are higher levels of innovation in ways of caring for patients, lower levels of stress, absenteeism and turnover, and more consistent communication with patients.

Leadership that ensures effective team and inter-teamwork (both within and across organisational boundaries) is essential if NHS organisations are to meet the challenges ahead. Shared leadership in teams is a strong predictor of team performance.

Collective leadership is the sixth characteristic that will enable the development of cultures of high-quality, compassionate and continually improving care.

Our view is that leadership in the NHS should be collective and distributed rather than located in a few individuals at the top of organisations. Collective leadership means everyone taking responsibility for the success of the organisation as a whole – not just for their own jobs. It requires organisations to distribute leadership power to wherever expertise, capability and motivation sit within organisations. This includes patients taking on leadership roles, both in determining their own care and in shaping their health care organisations (via patient representatives and patient groups). 

Collective leadership should also be collaborative with leaders working together to prioritise quality of patient/service user care overall, not simply in their own areas of operation. And with a common style of supportive, enabling and empowering leadership. It is through collective leadership that cultures of high-quality, compassionate and continually improving care will develop and thrive. Every interaction by every leader at every level shapes the emerging culture of an organisation.