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Analysis Quality Improvement

Understanding organisational culture for healthcare quality improvement

BMJ 2018; 363 doi: (Published 28 November 2018) Cite this as: BMJ 2018;363:k4907

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  1. Russell Mannion, professor1,
  2. Huw Davies, professor2
  1. 1Health Services Management Centre, University of Birmingham, Birmingham, UK
  2. 2School of Management, University of St Andrews, St Andrews, UK
  1. Correspondence to: R Mannion r.mannion{at}

Russell Mannion and Huw Davies explore how notions of culture relate to service performance, quality, safety, and improvement

Key messages

  • Organisational culture represents the shared ways of thinking, feeling, and behaving in healthcare organisations.

  • Healthcare organisations are best viewed as comprising multiple subcultures, which may be driving forces for change or may undermine quality improvement initiatives

  • A growing body of evidence links cultures and quality, but we need a more nuanced and sophisticated understandings of cultural dynamics

  • Although culture is often identified as the primary culprit in healthcare scandals, with cultural reform required to remedy failings, such simplistic diagnoses and prescriptions lack depth and specificity

If we believe the headlines, health services are suffering epidemics of cultural shortcomings. Extensive enquiries into failures and scandals in the NHS over several decades have indicated aspects of hospital culture as leading to those failings.(box 1).12 The recent report into over 450 premature deaths at Gosport War Memorial Hospital mentions culture 21 times.3 After such reports, widespread and fundamental cultural change is typically prescribed as the remedy (box 1).45

Box 1

Centrality of culture to healthcare scandals: from Kennedy to Francis

From Ian Kennedy’s review of the failings in paediatric cardiac surgery in Bristol during the 1980s and 90s2 to Robert Francis’s inquiry into the systemic failings at Mid Staffordshire Hospital Trust over a decade later,1 culture has been implicated.

Culture as culprit

“There was an insular ‘club’ culture [at Bristol], in which it was difficult for anyone to stand out, to press for change, or to raise questions and concerns” (p302)2

“Aspects of a negative culture have emerged at all levels of the NHS system. These include: a lack of consideration of risks to patients, defensiveness, looking inwards not outwards, secrecy, misplaced assumptions of trust, acceptance of poor standards, and, above all, a failure to put the patient …

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