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Culture and behaviour in the English National Health Service : overview of lessons from a large multimethod study

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journal contribution
posted on 2014-03-26, 13:08 authored by Mary Dixon-Woods, Richard Baker, Kathryn Charles, Jeremy Dawson, Gabi Jerzembek, Graham Martin, Imelda McCarthy, Lorna McKee, Joel Minion, Piotr Ozieranski, Janet Willars, Patricia Wilkie, Michael West
Methods: Mixed-methods study involving collection and triangulation of data from multiple sources, including interviews, surveys, ethnographic case studies, board minutes and publicly available datasets. We narratively synthesised data across the studies to produce a holistic picture and in this paper present a highlevel summary. Results: We found an almost universal desire to provide the best quality of care. We identified many ‘bright spots’ of excellent caring and practice and high-quality innovation across the NHS, but also considerable inconsistency. Consistent achievement of high-quality care was challenged by unclear goals, overlapping priorities that distracted attention, and compliance-oriented bureaucratised management. The institutional and regulatory environment was populated by multiple external bodies serving different but overlapping functions. Some organisations found it difficult to obtain valid insights into the quality of the care they provided. Poor organisational and information systems sometimes left staff struggling to deliver care effectively and disempowered them from initiating improvement. Good staff support and management were also highly variable, though they were fundamental to culture and were directly related to patient experience, safety and quality of care. Conclusions: Our results highlight the importance of clear, challenging goals for high-quality care. Organisations need to put the patient at the centre of all they do, get smart intelligence, focus on improving organisational systems, and nurture caring cultures by ensuring that staff feel valued, respected, engaged and supported.


We thank the Department of Health Policy Research Programme (Reference No 0770017) for funding this research programme. Write up of this paper was supported by a Wellcome Trust Senior Investigator award (MDW) WT097899MA.



BMJ Quality and Safety, 2014, 23 (2), pp. 106-115

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/Organisation/COLLEGE OF MEDICINE, BIOLOGICAL SCIENCES AND PSYCHOLOGY/School of Medicine/Department of Health Sciences


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