The quality of social and health services rendered to the public has become a major issue in most developed countries. The system mandated to provide these services have undoubtedly been put under increased strain given changing demographics, population growth, and adverse economic environment. However, experts in other management fields have raised concerns over the lack of a culture of excellence in regards to the quality of services rendered, particularly in healthcare (PAC, 1998; Chassin and Galvin, 1998 p.1000–5.); and have pointed out the change of organizational culture as key to improving the quality of services offered by the respective departments (Moss et al, 1998).
The appeal for a change in organizational culture has increased and forms a wide range of critics; this however raises the question of the tangibility of organizational culture. The answer to the question would differentiate between championing a cliché of “cultural transformation” and carrying out specific and targeted interventions aimed at solving problems in the system which are contributing to poor quality services. Indeed, if transforming an organization’s culture would have a domino effect of improving all aspects of service delivery, then the considerable effort should be placed on effecting such a transformation in the department of social and health services.
Organizational culture has been identified by management literature as playing a huge role in the way any organization effectively carries out its mandate. The interest in organizational culture has since spread to many fields and eventually found its place in the health and social services sector (Gerowitz, 1998 p.6). However, the final definition of the concept is still in dispute with many schools of thought emerging to challenge widely accepted notions every day. Indeed, some authors describe as many as 15 different definitions of organizational culture (Brown, 1995; p68). Two major schools of thought however dominate the subject (Langfield-Smith, 1995).
On one hand, culture can be defined as what an organization is, rather than being a separate concept found within the organization. In this view, transforming a culture would inevitably involve the overhaul of the organization or its abolishment altogether in favor of forming a new body. The other school of thought is of the view that culture and the organization are separable; and that the former can be manipulated without the destruction of the latter.
Additionally, such a concept could be created, nurtured, or managed to attain some specific management goal. The second opinion is more widely accepted, and many management strategies carried out in different settings assume that organizational culture is open to manipulation. Depending on the setting, any of the two views may be applicable at any one time; however, as mentioned before, there are many schools of thought which lay between these two extremes. One constant in any of the definitions can be explained either from the goals of the organization or the functionality of its structures.
The most common answer for the description of organizational culture would be “This is how things are done around here”. Shared beliefs, behaviors, practices, and attitudes of people working together eventually amalgam into a common way of functioning or thinking which permeates throughout the organization; this affects the judgment of all the players in the group and any new member is bound to be deeply influenced by such an environment. Indeed, even an individual who may be averse to some practice which he or she finds in a new work station will eventually find him or herself eventually engaging in it after a while.
Out of this set of thinking or structure, two levels of culture can be seen. On one level is an unwritten or unacknowledged set of ‘rules’ and beliefs that every member learns and follows after joining the organization. The next level is that which has developed into a concrete and tangible form; for example, in form of ceremonies, awards, and ranks which have developed over a significant period within and peculiar to an organization.
These two levels are very important in determining whether successful organizational transformation can take place, and particularly in the sector of health and social services delivery. As such, tangible practice can be easily manipulated; for example, dress code, hierarchy, and ranking; information transfer, storage, and analysis; awards and ceremonies. With enough resources and will, any of these and others can be changed within a relatively short period.
It is the deep-seated beliefs and values which offer a more daunting challenge; a failure to address these beliefs in a comprehensive and long-term based manner commonly only results in superficial changes which are eroded within a relatively shorter time. Of uttermost importance is to identify a problem and on which level of culture it falls. Issues such as budgetary allocations, procurement procedures, and worker compensations are easy to change; however, it is, for example, impossible to overcome a problem of communication precipitated by steep hierarchical structures or rigid ranking systems within an organization.
Aspects of organizational structure
There are some aspects in organizational structure that more often than not offer big challenges to attempts of transforming it; and which form the core of the ‘unwritten’ beliefs of the organization (Robbins, 1996, p164; Newman, 1996, p93). One of the most important is the attitude towards risk-taking and innovations; this determines whether the organization encourages the staff to follow the traditional and proven ways of operation or nurtures new thinking and experimentation. Depending on the route which the approach takes, the organization may find itself being increasingly rendered irrelevant by new challenges or competitors; and the quality of the services rendered losing their quality.
The degree of central direction is also a very important organizational culture aspect; this is the extent to which the goals, objectives, and mission of an organization are set from a centralized structure at the expense of devolution. Centralization versus devolution has their benefits and disincentives, and have to be applied in a manner that best suits the goals of an organization. However, in a field that offers so many different scenarios such as the health and social services sector, excess centralization can only result in increased red tape which more often than not results in less efficient service delivery.
The patterns of communication are also important in an organization; as such while one organization may require its members to stick to strict formal hierarchies, some may encourage a more informal setting of communication. Indeed, either of these ways may fit an organization depending on its nature. Another important aspect of culture is the focus of the organization; ideally, an organization should focus externally towards the target group to which it delivers its services. However, many find themselves focused internally on their structures and processes; and at the expense of the target population.
Other aspects of an organizations culture include whether it encourages conformity or diversity of opinions; how it values the individual as a human resource; whether it prefers teamwork or individual effort; the attitude towards aggressiveness, competition, cooperation, and coexistence; and finally its ability to accept change (whether many will opt to remain with a redundant system for the sake of retaining stability in the organization).
It is important to mention that even in a single organization, the culture therein is not homogenous; and the presence of several different subcultures may exist even in competition or opposition. For example, in a healthcare delivery setup, two different cultures, that of medical professionals and that of management staff may exist separately; joined only by a few aspects since they have to operate in synergy for the hospital to remain functional. However, they may differ greatly in issues such as cost reduction and medical ethics (Sutherland and Dawson, 1998).
The extent to which subcultures within an organization relate can be graded from integrated, where the culture is more or less homogenous (and not very common in our setting); to differentiated; to fragmented, which is the other extreme, seen as complete disagreement and conflict between the respective subcultures within the organization. The presence of subcultures within an organization can therefore be of no effect; be beneficial; or harmful.
It is also important to note that organizational structure cannot exist in a vacuum; as such, it receives influences from within and without it; such as the latest trends in the respective industry.
Culture and Performance
While the debate on the definition and different forms of organizational culture may be popular, little work has been done to measure its impact on the performance of organizations. A simple relationship between a culture of excellence and its occurrence of it is yet to be demonstrated; however, many organizations have sought to improve their organizational fitness to improve their performance (Deal & Kennedy, 1999). Many of the policies of improving the culture, especially in the healthcare sector, seem to be based on the theory that the parameters of culture are open to manipulation for a specific predetermined purpose; and have sought to exploit this malleability.
Public service organizations are usually vulnerable and targets of criticism and vilification for poor quality service or inadequate coverage. As such, efforts to transform such organizations are very common and widespread. Unfortunately, most of these efforts result in superficial changes which are eroded within a short period plunging the respective departments back into their old problems. At the Department of Health & Human Services where I work, various consultative meetings have identified and acknowledged poor services and coverage as being the two aspects that have shown the department in a bad light in the recent past.
Indeed, a good portion of these problems are caused by an inadequate allocation of financial and human resources to the department; thus inhibiting its ability to offer services of optimum quality and to adequately cover the target population.
However, a significant proportion of the problem can be attributed to some aspects of the department’s culture. While culture is dynamic and shifts in response to the prevailing situation, some aspects of it may endure even in times which they cripple the performance of the department. There also are huge gaps between overt statements (for example the mission statement) and what is happening on the ground. Most alarmingly, rather than bringing in new ideas to the department, new members tend to be recruited into the prevailing culture either explicitly or implicitly.
Among the aspects affecting the department include poor resource allocation and utilization; prejudicial attitude based on socioeconomic, racial, religious, political sexual orientation, cultural and ethnic extraction; poor attitudes towards the mission of the department; and disorganized and informal policy on communication.
It is not humanly possible to transform the culture of a department in a wholesale and simultaneous manner. For any transformation strategy to work it has to be selective; identifying issues that are urgent and those which may influence the whole picture if and when manipulated.
Additionally, a simple exhortation of the desired cultural values within the organization is not sufficient enough to effect change; an Account has to be taken of factors that kept the culture alive in the first place such as fear, anxiety, and uncertainty. Much more work has to be done within the organization which will involve all the parties to adopt new cultural values such as honesty, objectivity, accountability, cultural sensitivity, innovation etcetera.
Finally, care has however to be taken not to change or abolish cultural values which are beneficial to the organization; this danger is always lurking especially in cases where such transformation is being driven by a force outside an organization such as a professional or advocacy body. During the tumultuous time of change, the organization may lose its identity altogether; and may precipitate a complete dismantling of its structures.
Brown A. (1995). Organizational culture. London: Pitman.
Chassin M.R, and Galvin R.W. (1998). The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA; 280:1000–5.
Deal T.E, and Kennedy A.A. (1999). The new corporate cultures. Perseus.
Gerowitz M.B. (1998). Do TQM interventions change management culture? Findings and implications. Quality Management in Health Care; 6:1–11.
Langfield-Smith K. (1995). Organisational culture and control. In: Berry A, Broadbent J, Otley D, eds. Management control: theories, issues and practices. Macmillan: London.
Moss F, Garside P, and Dawson S. (1998). Organisational change: the key to quality improvement. Quality in Health Care; 7(Suppl):S1–2.
Newman J. (1996). Shaping organizational cultures in local government. London: Pitman.
Robbins SP. (1996). Organizational behavior: concepts, controversies, and applications. 7th ed. Englewood Cliffs, NJ: Prentice Hall.
Sutherland K, and Dawson S. (1998). Power and quality improvement in the new NHS: the roles of doctors and managers. Quality in Health Care; 7(Suppl):S16–23.
The President’s Advisory Commission (PAC) on Consumer Protection and Quality in the Health Care Industry. Quality first: better health care for all Americans. Washington: US Government Printing Office, 1998.