NPC Archive Item: An improved organisational culture can support performance in healthcare

NOTE – This is an archive post from the NPC and has not been updated since first publication. Therefore, some hyperlinks may no longer be working.
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5 July 2011

Organisational culture matters when introducing change and in achieving high performance in healthcare. Some of the reasons why organisations may struggle to deliver change are:

  • Conflicting priorities
  • Acceptance of the status quo
  • Divergent thinking on what the key issues are
  • Challenged environments
  • A belief that making improvements will be impossible or ‘we have always done it this way’
  • Change is not perceived to be beneficial1

A recently published qualitative study in March 2011, ‘What distinguishes top-performing hospitals in Acute Myocardial Infarction (AMI) mortality rates‘,2 supports the notion that an improved organisational culture can improve performance in healthcare. A total of 158 staff from 11 U.S. hospitals took part in the study, which aimed to identify factors related to better performance in AMI care as measured by risk standardised mortality rates.

Hospitals in the high-performing and low-performing groups differed substantially in the domains of organisational values and goals, senior management involvement, broad staff presence and expertise in AMI care, communication and coordination among groups, and problem solving and learning. Participants described diverse protocols or processes for AMI care (such as rapid response teams, clinical guidelines, use of hospitalists, and medication reconciliation). However, these did not systematically differentiate high-performing from low-performing hospitals.

The study is necessarily limited by its qualitative design. However, it provides a useful reminder that there is more to implementation than evidence and policies. The key themes identified from the study as being present in high-performing hospitals included:

  • Shared values to provide exceptional, high quality care and alignment of quality and financial goals of the organisation.
  • Provision of adequate financial and non-financial resources, use of quality data in management decisions, and holding staff accountable for quality.
  • Sustained physician champions, empowered nurses, involved pharmacists, and high qualification standards for staff.
  • Diverse skills and roles, recognising interdependencies, and smooth information flow among groups.
  • Recognising adverse events as opportunities to learn, use of data for non-punitive learning, innovation and creativity in trial and error, and learning from outside sources.

The findings of the study suggest that achieving high performance may require long-term investment and concerted efforts to create an organisational culture that support full engagement in quality, strong communication and coordination among groups, and the capacity for problem solving and learning across the organisation.

What does this mean to medicines management?
In its 2008 publication ‘Moving towards personalising medicines management: Improving outcomes for people through the safe and effective use of medicines’,3 the NPC identified a range of factors that can contribute to successful improvements in services by NHS organisations. These factors were identified as not being specific to a particular care setting, but could be applied by any organisation seeking to make improvements. Several of them link to the six domains identified by the authors of the ‘What distinguishes top-performing hospitals in Acute Myocardial Infarction (AMI) mortality rates‘2 study.

The factors were:

  1. Involving and listening to patients and carers
  2. Clear leadership
  3. Multidisciplinary teams
  4. Medicines management objectives aligned to organisational priorities
  5. Local medicines management leader
  6. Effective communication
  7. Medicines management ‘champions’
  8. Measuring outcomes, not activity
  9. Protected time
  10. Shared learning and networking

The challenge is to make medicines management an integral part of service redesign in a way that focuses on patient needs and outcomes.3 The principles of good medicines management should apply in all settings where patients access and use medicines, and it should travel along patient pathways across all care interfaces, for example; from community pharmacy, to GP practice, to acute hospital admission, to intermediate care and back into the community.3

How does this relate to other publications or evidence?
How to create an organisational culture which provides the optimal environment for implementing evidence-based practice is therefore a key challenge. The guide ‘Managing Change in the NHS – Organisational Change: A review for all health care managers, professionals and researchers’4 was published in 2001 but is as relevant now to managing change in the NHS as it was then. The guide helps to provide a selective review of key change models and associated evidence to support organisational change in the NHS. It aims to support health professionals engender a culture of continuous change in the NHS in which change is ‘ongoing, evolving, and cumulative’, and in which ideas travel by translation rather than by passive dissemination.

The NICE clinical guideline 48 – Myocardial Infarction: secondary prevention – secondary prevention in primary and secondary care for patients following a myocardial infarction (2007)5 is useful guidance for health professionals involved in the care of AMI patients. The guidance offers best practice advice on secondary prevention in primary and secondary care for patients after a myocardial infarction (MI) including a list of key priority recommendations for implementation.


  1. Department of Health (2011). Available (online) (Accessed 4th July 2011).
  2. Curry, L. A., Spatz, E., Cherlin, E., Thompson, J. W., Berg, D., Ting, H. H., Decker, C. Krumholz, H. M., and Bradley, E. H. What Distinguishes Top-Performing Hospitals in Acute Myocardial Infarction Rates? A qualitative study. Annals of Internal medicine; March 2011, 154; (6); pp384 – 390.
  3. National Prescribing Centre (2008). Moving towards personalising medicines management: Improving outcomes for people through the safe and effective use of medicines.
  4. Iles, V., and Sutherland, S. (2001). Managing Change in the NHS – Organisational Change: A review for all health care managers, professionals and researchers.
  5. National Institute for Health and Clinical Excellence (2007). MI: Secondary prevention – Secondary prevention in primary and secondary care for patients following a myocardial infarction.

More information relating to the rapid review can be found on the cardiovascular disease – Post MI; and Personal Organisational Development – supporting healthcare individuals sections on NPC

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