The expectation that healthcare quality will improve, if proper incentives exist to do so, is debated at each intersection of policy and payment. However, providers often react to these discussions with tacit acknowledgement of the issue while they get on with the business of caring for patients. In the heat of the battle, clinicians don’t stop to think about academic discussions of best practice; but without haste, they attend to the needs of the patient. And before the day is over, they must figure out how to manage the tasks of care compromised by time and resource constraints. When do clinicians think about quality? Hardly ever; rather, it’s ingrained into every decision made throughout their care delivery day and guided by the clinical culture where they practice.
In the healthcare environment, organizational culture has been associated with elements of organizational performance that impact quality such as safety, nursing care, job satisfaction and patient outcomes. The organizational culture of the practice environment is the most powerful influence of quality and must be considered first when initiating improvements of quality and performance. However, changing culture to improve quality is the most difficult challenge in affecting quality change. According to Author 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.” (E. Schein, Organizational Culture and Leadership, San Francisco: Jossey-Bass; 1985)
There is substantial evidence that organizational culture can account for a significant portion of the variability in quality improvement efforts. The concepts of learning organization, leadership development, high-reliability, high-performance teams, readiness for change and organizational climate all describe aspects of an organization’s culture. There is evidence associated with all of these concepts showing that they contribute to the development of skills and organizational behaviors that impact patient safety and quality improvement.
Quality is a perception based on expectation. The perceptions and expectations of a care delivery organization’s culture define the performance levels delivered. As clinicians within an organization, our professional incentives to provide quality care contribute to this organizational culture. Our professional expectations must emphasize learning, teamwork and patient focus as prerequisites to patient care quality and guide leadership to embrace the role of advancing a quality culture through mission and vision. Failing to expect these prerequisites for quality care limits the effectiveness and professional accountability for which we were prepared.