We speak to him about how to nurture the sort of leadership that enables positive changes in culture.
What is culture and why is getting the right culture in health care organisations so important to improving care?
Culture is ‘the way we do things around here’ or more formally, it is the set of shared, taken-for-granted implicit assumptions that members of an organisation hold, and that determines how they perceive, think about and react to things (Schein 1992). It can be observed in most aspects of organisational life such as how staff talk to or about patients and how they talk to each other. Every interaction in an organisation reveals and shapes its culture.
An organisation’s culture reflects what it values: quality, safety, productivity, survival, power, secrecy, justice, humanity, etc. If there are strong values of compassion and safety, new staff will learn the importance of caring and practising safely. If they observe senior staff aggressively or brusquely to others, they learn that ‘this is the way we do things around here’. Culture represents the most potent set of influences on behaviour in organisations, so if we want to improve care, we must focus on nurturing appropriate cultures.
Why is leadership so critical to shaping the culture of an organisation?
Leaders may have the power to reward and punish; they may control information and resources; they may make choices about structure; and they can shape the work lives of others for better or worse. They may therefore command much of our attention.
We may be far more influenced by a leader’s positive or negative mood than by those of our other work colleagues because we pay closer attention to them. We are vigilant in relation to what they value (their values) – what they pay attention to, monitor, reward and reinforce. That tells us the values we must adopt to ensure we will win approval. We may mimic their behaviours too, for good or ill. The followers of positive, supportive leaders behave more cooperatively and empathically. Leaders are powerful sculptors of culture and their every interaction is a stroke with the chisel.
You have spoken about five key components of culture, what are these?
First is an enacted (not simply espoused) vision focused on high-quality, compassionate, patient-centred care that influences behaviour from the board to the front line. Second is ensuring this vision translates into clear, challenging, measureable objectives or priorities (no more than five or six) for every directorate, division, team and individual within the organisation. Third is enlightened people management producing high staff engagement through positive, supportive, devolved leadership and enlightened HR practices that reinforce the culture. Fourth is a focus on continually improving quality of care at every level, with every individual within the organisation using data intelligently to set goals and gather feedback on performance. And fifth is effective team-working (with clear goals, roles and communication), inter-team co-operation and integration across professional and organisational boundaries in the interests of patient care.
Why do you feel that it’s so important for organisations to have a defined leadership strategy?
We cannot leave the development of healthy cultures to chance or piecemeal interventions. Healthy cultures need to be designed and supported to deliver improved and improving care. We have to plan for leadership that will shape culture. We need to know what leadership is needed now and in the foreseeable future and where it is needed within an organisation; which characteristics are needed (diversity, professions, experience, etc.); what values and behaviours are essential and how these will be sustained and developed; and how an organisation can develop leadership that prioritises the success of the organisation overall, rather than only people’s own areas and functions.
This means that boards need to ensure there is dialogue and planning across the organisation for a collective leadership strategy. And the purpose is to consciously develop, implement and sustain a leadership strategy that nurtures appropriate cultures focused on high-quality and continually improving patient-centred care.
The paper speaks about collective leadership. What is this and why is it important?
To create a learning organisation that innovates in order to deliver continually improving care requires the collective leadership of all in the organisation. To develop such a culture we need managers, clinicians, patients, and boards to work together to reinforce the values that should underpin the NHS – high-quality care, transparency, supportiveness, learning, listening, co-operation and compassion.
Where collective leadership is established, leaders (both formal and informal) ensure the success of their work function but also support other leaders within and across organisations to ensure integrated, high-quality care. This means extending our concept of leadership to recognise that all those who have expertise in the organisation must feel empowered to lead, be proactive and innovate to deliver improved patient care. A well-developed collective leadership strategy will deliver the transformation in cultures needed to meet the health care needs of our communities.
The King’s Fund, in partnership with the Center for Creative Leadership, is looking to work with NHS organisations to design and deliver a collective leadership strategy that will support the organisation in achieving a healthy culture. For more information contact Nicola Hartley.
This article was taken from the summer 2014 edition of Insight: The latest health care insights from The King's Fund.