1

CHAPTER 2
Literature Review

Sr. No. Contents Pg. No.

Part – I: Hospitals in India
2.1 Introduction 49
2.2 Hospital Resources: an overview 52

2.3 Hospital as a Service Organization 54

2.4 Hospitals and Competitive Market 56

Status of Health and Healthcare System in India:
2.5 59
an overview
Challenges Confronting Public Hospitals in India:
2.6 61
an overview
2.7 Maharashtra State: an overview of the state 66
2.8 Public Health Status of Maharashtra 70
2.9 Summary 77
Part – II: Organization Culture in Hospitals

2.10 Culture: an overview 78

2.11 Layers of Culture 83

2.12 Development of Culture 88

2.13 Culture and Organizations 91

2.14 Position of Culture in an Organization 94

2.15 Cultures and Subcultures 96

2.16 Organizational Culture 99

2.17 Organizational Culture in Hospitals 104

2.18 Organizational Culture in Indian Hospitals 107

 2

2.19 Organizational Culture and Safety 121

2.20 Patient Safety Culture 128

2.21 Summary 129

Part – III: Patient Safety Culture in Hospitals

2.22 Introduction 131

2.23 Safety Culture 133

2.24 Patient Safety 137

2.25 Patient Safety Culture (PSC) 148

2.26 Patient Safety Culture in Hospitals 151

2.27 Patient Safety Culture in Indian Hospitals 153

2.28 Patient Safety Studies in India 161

2.29 Dimensions of Patient Safety Culture 165

2.30 Consolidated Literature Review on PSC 167

2.31 Summary 171

Part – IV: Theoretical Framework

2.32 Theories of Organizational Culture 172

2.33 Theories of Patient Safety 190

2.34 Summary of Theoretical Understanding 200

2.35 Conceptual Framework for the Study 204

2.36 Summary 206

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CHAPTER 2
Literature Review

‘A Hospital is no place to be sick’

-Samuel Goldwyn

Part – I: Hospital in India

The previous chapter introduced the background and context of the study. In Part I of
this Chapter the discussion is focused on Hospitals and its approach to human
resources in India; Hospital as a Service organization and role of Hospital in the
healthcare market. This chapter identifies the current healthcare scenario of public
hospitals in Maharashtra.

2.1 Introduction

Healthcare is one of the most complex activities in which human beings are engaged.
Hospitals are mainly service organizations. It is found that the professional area of an
organization is predisposed to its user’s satisfaction. Healthcare services frame a
significant portion of national expenses, and therefore it is essential that the nature
and quality of services be explored. When considering healthcare services the patient
satisfaction is one of the primary outcome variables.

As a major social organization, the hospital gives to both the patient and the society
considerable advantages. Some health troubles or problems which require personal
care and intensive medical treatment cannot be offered or made available at the
patient’s house or home or in the doctor’s clinic, this can be made available only
in a hospital where a large number of professionally and technologically or
 4

technically skilled people with the help of modern medical and sophisticated
equipment apply their knowledge and skill. The primary and the principal function of
a hospital are to give without any social, economic or racial discrimination a proper
care to the sick and injured.

In the earlier time, the hospitals were established as aid organization or charity
institutions, particularly for poor, vulnerable and weaker sections of the society. The
sole function of those hospitals or institutions was to take care of the poor and
suffering mankind. Recently, the hospitals are set up with an aim to serve all sections
of the society. Some of them, in addition, is also engaged in organizing and promoting
medical education, training, and research in the society. The growth of healthcare
facilities is influenced not only by the opening of healthcare centers or hospitals but
further so by their proper administration and management. If the healthcare centers
and hospitals are managed properly, there would be a chance of expansion in the
medical care facilities, even with the smallest amount of investment.

Advances in sciences have brought radical changes in human society as the industrial
revolution, having a great impact, in addition to industry, on agriculture, business, and
services. The services comprise also the Hospital sector of Healthcare industry. Until
now, human resources have been treated and described as tools in the expanded
business and industrial machines. The production and profit of the industry used to be
the priority for the employer in practice, while far less attention was given to
employees’ human rights and demands. Consequently, there was a considerable rise
in production, but only at the expense of emergence of economic, social, political and
human problems. It was, later on, realized critically, that human factor had a unique
valve in spite of office computerization and availability of factories automaton. In all
business enterprises, be those small, local, national or international, human being
obtains the key place.

Hospitals are distinct from other industry, have a different entity. The function of this
department and its head has a task cut out and exclusive. In hospital industry, the
advent of modern technology, computerization, new diagnostics and intervention
techniques, has not reduced the necessity of the human labor, unlike any other
industry. On the converse, there is a desired growth in the need to appoint dedicated
 5

manpower at various levels of patient care, which has derived from the thought
procedure of those professionals and promoters, who are progressive with the need to
persuade quality control in patient care.

The researchers Rondeau and Wagner have assessed the impact of HRM practices and
the contingency theory on 283 Canadian nursing homes. The measurement indicators
were client and staff satisfaction, operating efficiency and revenue. Their observation
has stated that the ‘best performing’ nursing homes were found to be more likely to
have put into practice the ‘High Performance’ or ‘Progressive’ HRM practices and
also maintained a workplace climate that sturdily values employee participation.

The health sector, resource availability and employee competence are found to be
essential but are not sufficient to guarantee desired employee performance. Even
though employee motivation is an important element of health systems performance,
it is mostly understudied. The most valuable resource for any organization is its
human resource because of its allied potentials. The potential can be worn only by
creating a climate that can incessantly identify, bring outside, nature and use the
capabilities of people. The health organizations will also have to satisfy their
physicians, nurses and all other employees on quality, cost and patient satisfaction to
acquire the performance (Franco et al. 2002).
 6

2.2 Hospital Resources: an overview

Hospitals have developed into complex organizations as they utilize the vast amount
of resources in providing a wide range of healthcare services. The increased cost of
medical care, aging population and the potentially declining levels of service threaten
the quality of service delivered. A new dimension was added to the delivery and
pricing of healthcare services after the liberalization of the medical insurance sector.
Poor quality of services not only waste resources but is positively dangerous to the
health and welfare of the patients and the community at large.
The resources of any hospital are as given in below Table 2.1

Table 2.1 Hospital Resources

Organizational Resources Hospital Resources

Medical, Para-medical and Administrative staff; regular

Human Resources
Financial Resources
Material Resources
Equipment and devices
and contract service.
Income from patient care, Donations, Grants, and so
on.
Medical, Surgical, Laboratory items, Office
stationeries, House-keeping items, and so on.
Medical equipments, devices and instruments.

Source: Hospital Management: Text and Cases, Dr. K. V. Ramani (2013)

Hospital services can be broadly classified into:

 Outpatient services
 Inpatient services

Clinical departments such as the department of medicine, general surgery, and cardiac
care and so, on are responsible for providing outpatient and inpatient services. In
providing clinical services, these departments are ably assisted by the investigation
departments, namely, the clinical laboratory and the radiology /imaging departments.
 7

Paramedical services are offered by the nursing department, physiotherapy, and so on.
Administrative support for service delivery is provided by general administration
departments such as finance, HR, house-keeping medical stores, medical records and
bio-medical wastes.
 8

2.3 Hospital as a Service Organization

A hospital is an extremely multifaceted organization and this is manifested by the fact

that it provides all necessary services which must be accessible 24 hours a day. Life
and death are the problems that every hospital has to deal with it daily. Healthcare
organization comes under the domain of Services. For example, one cannot benefit
oneself of the services of staying in a hospital with no use of other services like
catering services, paramedical services, clinical services, etc. The services presented
by healthcare organization do not exist, they are generated as and when required
(Goel and Kumar 2004).

The hospital provides a broad variety of services like providing complete nursing care
to the patients, diagnostic equipment for all sorts of illnesses, beds, and linen,
arranging transportation (ambulances), prepared food or catering services, etc. Most
services are provided for essential and needy people. It is purely based on the labor
force.

The services cannot be put in storage. It is also factual with services provided by
hospitals that their skill cannot be stored. They are unpreserved or fragile. If one is not
engaging them, they are worthless for the day. They are produced or created as and
when required. Only the material part of those help providing services exists. For
example, in an emergency, if a patient needs to be moved or transfer from his house to
the hospital, he receives the service from the hospital authorities in the form of an
ambulance and followed by a proper accommodation there. (Stewart et al. 2000).

The hospitals are now taking the saying ‘being hospitable’ to a new height. With the
changing time, the conventional concept of the hospital is being changed. The
hospitals are now an amalgamation of healthcare and hospitality. There has been
remarkable progress in the area of medicine in the last few years. Newer drug
discovery and Advances in medical technology have played the most significant role
in curing the patients. The last decade gave a new meaning to the healthcare industry.
The impact of ‘feels good’ factor appears to have stronghold everywhere. With the
improved socio-economic status and easier access to medical care, along with the
 9

escalating literacy information made available at the fingertip, print media

(newspapers and magazines) and electronic media have changed the way of thinking
of Indian patient and their attendees.
 10

2.4 Hospitals and Competitive Market

Today the competitive market permits no space for error. The healthcare market
slowly but surely is changing from being mainly a seller’s market to a buyer’s market.
The ‘patient focus care’ is a mantra at present in Hospital Industry. Patient and
employee satisfaction surveys are often considered as the most accurate barometers to
predict the achievement of any organization because they straightforwardly ask about
the critical success factors of the available services. It is observed that customer
satisfaction surveys can provide powerful incisive information and impart ways to
gain a competitive edge.

Hospitals are difficult to manage where the top caliber and best knowledge
management is required. Though management style may be different, of all
developed, developing and developed countries but they all are faced with similar
problems with respect to claims of patients. In a developing country like India, the
healthcare operating expense is generally out of pocket expenditures, were the
healthcare consumer pays each and every penny for the services they are provided
with (Valarie et al 2008).The patients look for the best available services and are
ready to pay the affordable cost. This makes stronger the competition within the
healthcare providers to perform best at the lowest possible cost, devoid of
compromising the quality of services provided.

Healthcare scenario is rapidly changing all over the world. In the present day, Indian
healthcare industry is business oriented and one can see access of all sorts of service
providers to be part of this huge multi-core business, increasing up at the rate of
13percent annually. The functioning of the healthcare system has also been changed
due to globalization and privatization. The private health network is spreading rapidly
throughout the country. The healthcare and the delivery of the healthcare services are
mainly influenced by economic, political, social, environmental and cultural factors.

Research of this study will be conducted in the Six District (public) Hospitals of
Maharashtra. Thus, a brief overview of the Hospitals in India is been presented before
starting the research objectives of the study. Health and Socio-economic
 11

developments in our country are so closely intertwined that it is impossible to

accomplish one without the other. Despite the fact that the economic development in
India has gained momentum over the last decade, our healthcare system is at
crossroads at present. Hospitals are trying to achieve not only the societal goals but
also their own financial goals.

However the biggest challenge is not just the additional requirement of financial
resources, but to utilize those financial resources effectively and proficiently in
delivering healthcare services. Optimal utilization of human resources for service
delivery is the managerial challenge facing the Indian healthcare sector, particularly
the hospital sector. The predictable requirement for the number of hospital beds
demands a large number of hospitals to turn up in the near future. Development in the
field of medical sciences and information technology together with increased hope
from the public for better healthcare services call for improvement in the management
of our hospitals.

Hospitals have become complex organizations as they consume a vast amount of

resources in delivering a wide range of healthcare services. The increased cost of
medical care, aging population, and the potentially declining levels of service threaten
the quality of service delivered. Liberalization of the medical insurance sector has
added a new dimension to the delivery and pricing of healthcare services. Poor quality
of services not only wastes resources but is positively dangerous to the health and
welfare of the patients and the community at large. Hospital managers, current, and
future aspirants, therefore need a certain amount of professional management inputs
so as to manage the hospitals effectively and efficiently. Hospital managers require
"problem-solving skills"(HPWPs) besides developing a conceptual understanding of
hospital management challenges, in order to be effective and efficient in service
delivery.

Under such circumstances, it is imperative for Indian Hospitals to focus on human

resource capital through adaptation of the appropriate high-performance work
practices system to gain a competitive edge. Only those Hospitals would be in the
advantage that will focus on capacity building through the adoption of high-
performance work practices system. Therefore, current industrial dynamics open the
 12

door to explore the relationship between high-performance work practices and

performance. The current study is in the same context. Now Hospitals are to look
inside for competitive advantage. Human resources are one of the key options for
Hospitals to gain a competitive edge over their competitors. Only those Hospitals are
to make difference in the market that have adopted high-performance work practices
which leads to competitive advantage. This situation creates a lot of room for current
study.

Other reasons also support the decision to study the Indian Hospitals. The Hospitals
are expected to remain a strong contributor to the sustained recovery and growth of
the Indian economy. Further, the Hospital sector remains the largest source of creating
employment opportunities, through seeking new Hospital Executive or
Administrators, Health IT Professionals, Medical Receptionist, and Allied Healthcare
Professionals like cardiovascular technologists (CVT), ultrasound techs, and surgical
tech.

Finally, giving the importance of Hospital employees to the economic growth and a
lack of systematic study in HRM practices in Hospital sector recommends immediate
action to examine the relationship between HRM practices and organizational
performance of Hospitals.
 13

2.5 Status of Health and Healthcare System in India: an overview

Any appraisal of the health status of a nation must be done against the backdrop of its
population. Presently, we are 1 billion and our population is growing at a rate of about
18 million every year. With only 2.4 percent of the world land area, India has to
support 16 percent of its population. As per the 1901 census, India's population was
238 million (the then India included India, Pakistan and Bangladesh of today). During
these hundred years, the population of India alone has become more than four times.
All our economic progress is becoming far outstripped by the increase in our
numbers. And this galloping growth in population is the most important determinant
of all aspects of our national wellbeing including health. Though the crude death rate
has been constantly declining, yet the crude birth rate has not come down to the extent
it was desired. Despite a slight decline in the growth rate, the population continues to
grow at an alarmingly high rate.

Among the major achievements of the country, the notable are (i) the declining trend
in vaccine-preventable disorders due to improvement in immunization coverage and
(ii) sincere efforts being made for the eradication of poliomyelitis through country-
wide Pulse Polio Immunization Programme. In fact, the rate of decline of morbidity
has not been up to the desired level, though mortality has come down considerably in
these years.

When one considers the health and related policies in India, we find that we have
well-formulated policy guidelines in terms of National Policies for Health, Nutrition,
Education, Children, etc. These policies provide an overall framework for health and
development and reflect political commitment. The Constitution of the country, the
directive principles and the national policies provide the broad guidelines for
mobilization and distribution of resources in such a way as to meet the health needs of
the masses. The constitutional amendments from time to time and their ratification by
the State assemblies also provide the guidelines to planners and administrators to
direct the resources to the priority areas.

Over the years the country has expanded the healthcare delivery system and has by
and large, adequate availability of health manpower, except for a few categories, and
training institutes. We have a vast infrastructure spread across the length and breadth
 14

of the country (1.3 lakh sub-centres, 22600 primary health centers and 2600
community health centers).

A nationwide comprehensive study (2002-2004) ‘Assessment of Injection Practices in

India’–by the India CLEN Program Evaluation Network (IPEN) for Department of
Family Welfare, Ministry of Health & Family Welfare indicates that a very large
number (3 to 6 billion) of injections are administered in India every year. Nearly two-
thirds of these injections are unsafe (62.9percent).

Govt. of India had signed a pledge in July 2006 to work to reduce healthcare-
associated infections in collaboration with world alliance for patient safety. India
leads the world in terms of maternal deaths, 57000 maternal deaths in 2010, MMR
212 as against 109 of MDG in 2015. The dearth of qualified medical professionals in
rural areas is observed. Health insurance covers only about a fifth of the population.
The unorganized private sector accounts for almost 80 percent of outpatient
healthcare.

Having reviewed the health scenario in India, it becomes evident that concerted
efforts have to be made by the government and the community for improving the
quality of life of people. Moreover, human resource planning, human resource
development, performance appraisal system, work culture, rational transfer-policies,
incentives and career development opportunities for health manpower would ensure a
motivated workforce. Therefore, this aspect would need adequate attention.

Strengthening of health promotion and protection by development of an integrated

education and health promotion programme, with locally relevant content and media
for dispersion of the messages, implementation of preventive and promotive health
activities in an integrated and comprehensive manner with involvement of all health
and related sectors, and making health as an integral part of the development
programme along with strict and effective enforcement of legislation related to health
and environment are some of the other primary level strategies for the future.
 15

2.6 Challenges Confronting Public Hospitals in India: an overview

The fact is that public hospitals have become increasingly detached from the larger
context in which medicine operates. If the public hospitals are to be made responsive
to the health needs of the people, then problems facing these institutions ought to be
located in the broader conditions (we may call these structural problems) that
influence their functioning, rather than locating these in their inner working alone.
This also implies that the solutions to these problems ought to be socially oriented
rather than being guided by narrow managerial or technocentric approaches.

Public sector healthcare shall continue having its relevance for a long time in order to
reach out healthcare to vast sections of underserved populations in developing
countries like India. In the context that the 12th Five-Year Plan Document has rolled
out an ambitious scheme to achieve “Universal Healthcare” in the country, this
overview sets out the following objectives before itself:

(i) Elucidate the more important challenges facing public hospitals in India and
document their enormity;
(ii) Understand the social, economic, and political sources/factors leading to the
emergence of these challenges;
(iii) (iii) In accordance with the aforementioned analysis, propose solutions that are
feasible within the present political and economic system.

2.6.1 Main Challenges Confronting a Public Hospital

The main challenges confronting the public hospitals today are as follows:
(1) Deficient infrastructure
(2) Deficient manpower
(3) Unmanageable patient load
(4) Equivocal quality of services
(5) High out of pocket expenditure.
 16

1. Deficient Infrastructure: The format of the public health structure in the country
draws directly from the recommendations of the Bhore Committee Report, 1946.
However, the public health infrastructure has evolved lags far behind in matching
the content and the spirit of the committee’s report. The committee proposed the
implementation of its recommendations in two distinct phases—“three-million
plan” and the “ten-year plan.” The “three-million plan” laid down the required
health infrastructure to provide for the health needs of an average district in India
having a population of three million. This was to be implemented over a period of
three to four decades. Anticipating resource constraints, both in terms of
manpower and money to make such an infrastructure available in a short time, the
committee recommended a shorter “ten-year plan” to be implemented first.
Table 2.2 Deficient Infrastructure

(Source: RHS Bulletin, 2012, MOHFW)

Non-availability of facilities like water and electricity can only be expected to

deeply undermine the functioning of existing facilities. It is very much possible
that if the facility has one resource, it may not have other resources to optimally
utilize the available resources; for example, if a health worker is available at the
facility, it may not have water/electricity, thus undermining the ability of the
health worker to perform his/her functions optimally.
2. Deficient Manpower: Deficiency of human resources in health adds further insult
to injury caused by a deficiency of health infrastructure. Deficiency of human
resources in health occurs at several levels—between regions, between rural and
urban areas, and between the public and private sectors. On the one hand, there is
unwillingness of doctors and other health personnel to serve in rural areas; on the
 17

other hand, even in the urban areas, there is a preponderance of the health
manpower in the dominant for-profit private health sector in the country, thereby
putting their services beyond the reach of the majority of poor in the country.
Despite deficiencies in their training as managerial physicians, doctors have
generally come to be perceived as responsible members of healthcare team
comprising paramedical and other support staff. They are expected to lead the way
in problem-solving and supervising the work of other team members. As such,
deficiency of doctors, besides impacting the delivery of curative services, may
also reflect adversely in the overall functioning of the health team. Shortage of
manpower is only made worse by the absence of a comprehensive and integrated
health manpower policy dealing with health manpower requirement projection,
manpower production, training, recruitment, career development, supportive
supervision, skill enhancement, postings in underserved areas, retention and
transfers, and so forth.
3. Unmanageable Patient Load: Secondary or tertiary level public hospital in bigger
cities is today bursting at seams due to a heavy rush of patients. The huge
unplanned increase of Indian cities has resulted in the urbanization of rural
poverty causing expansion of slums and marginal populations starved of health
and other basic amenities. Deficiency of urban health infrastructure, overcrowding
in hospitals, lack of outreach, and functional referral system, standards, and norms
for urban healthcare delivery system, social exclusion, unavailability or ignorance
of information for accessing modern healthcare facilities, and lack of purchasing
power are some of the issues that have been identified as challenges to urban
health care in the country. These factors are further complicated by poorly
functioning sub-centers, PHCs, and CHCs resulting in people from rural areas
having to increasingly depend on hospitals in the bigger cities and towns for their
curative needs thereby stretching the infrastructure at these hospitals to limits.
4. Equivocal Quality of Services: Patient load much in excess of what the
infrastructure is capable of handling is bound to undermine the quality of care.
“Chacha Nehru Bal Chikitsalaya,” a Delhi government-run childcare hospital in
east Delhi had much to celebrate when it became the first public hospital in the
capital to be accredited by the National Accreditation Board for Hospitals
(NABH). However, with the patient load bursting at its seams, the hospital soon
found itself struggling to survive. Till date, it has been difficult to arrange
 18

sufficient resources for the much-required expansion of infrastructure to cope with

the rush of patients.
Apart from general deficiencies in the development of public health infrastructure
in the country, there has been a particularly marked deterioration in services of
public hospitals in more than two decades of pursuit of neoliberal policies in
general and in health sectors as well which have been oriented towards the
strengthening of private healthcare. The growing dominance of private healthcare
has resulted in the molding of public hospitals also in the image of the private
hospitals. Some of the steps in this direction have been outsourcing of many
services in public hospitals such as security, laundry, cleaning, kitchen services,
and, in later stages, even the diagnostic and curative facilities on public-private
partnership mode. Progressive imposition of user charges is another of such
features.
5. High Out of Pocket Expenditure: The last “National Health Accounts” for India
published in 2004-05 unambiguously stated: “Among all the sources, households
contributed a significant portion at 71.13percent of total health expenditure for
availing healthcare services from different healthcare institutions. This covers
expenditure on inpatient, outpatient care, family planning, and immunization, and
so forth”. The only saving grace for India is that, among its neighbors, Pakistan
and Myanmar spend lesser public resources on health than India. India’s public
health expenditure fails to match even that of the least developed countries and
sub-Saharan Africa. It is well acknowledged that catastrophic health expenditure
is a significant cause for people being pushed below the poverty line in India. As
noted form records, that 2.13 percent more people have pushed below the poverty
line on account of the out of pocket (OOP) expenditure on health between 1993-
94 and 2004-05. The decade between 1993-94 and 2004-05 was the period when
neoliberal economic reforms were at their zenith. During this period, there was an
increase in OOP expenditure as a proportion of the total household (HH)
consumption expenditure across expenditure quintiles. Maximum increase was
seen in the “richest” quintile.
With the position of public healthcare becoming, even more, dwarfed, the private
sector has increasingly come to set the standards both for the care and its cost at
terms congenial to its profits. Increasing commercialization of the services of
public hospitals through measures like imposition of user charges at all levels
 19

under the impact of the dominant private sector has heightened the challenges
facing a public hospital in meeting the people’s curative needs.

2.6.2 Solutions

With respect to the challenges facing public hospitals in India, it need be remembered
that the sorry state of affairs of public healthcare in the country is not for want of
policies or managerial skills or for want of latest technologies. The situation is what it
is because it suits the interests of the dominant classes in the society. To undo this
conundrum ought to be much more than a bureaucratic or technocratic putsch. This is
a situation which demands popular based mobilization of the widest possible sections
of the society, especially the working masses to support policy initiatives directed at
demolishing the elite capture of healthcare and the medical profession in the country.
From a healthcare researcher and hospital administrator’s point of view, our account
would indeed be very disappointing as there are no readymade shortcuts on the offer
to improve the outcomes.
Nonetheless, it is important to realize that health is a social phenomenon and a public
hospital is a social institution which cannot be studied in isolation from the societal
conditions in which it operates. The analysis presented here is in conformity with this
reality. However, we are sure that there still are public hospitals that offer much to
learn in terms of internal workings of these hospitals for improving the services of a
public hospital. Taken overall, the public healthcare system in the country stands at
crossroads where there is little in the present system that is worth emulating.
However, even as the adversities seem insurmountable, the solution lies in
propagating and creating space for an alternative paradigm both in the realm of theory
and practice. In order that theory gains in virility, it must develop the language to
articulate people’s struggles for an alternative development paradigm.
 20

2.7 Maharashtra State: an overview

Maharashtra occupies the western & central part of the country and has a long
coastline stretching nearly 720 km along the Arabian Sea. The Sahyadri mountain
ranges provide a natural backbone to the State on the west, while the Satpuda hills
along the north and Bhamragad-Chiroli Gaikhuri ranges on the east serve as its
natural borders. The State is surrounded by Gujarat to the North West, Madhya
Pradesh to the north and Chhattisgarh to the east, Telangana to the south-east, and
Karnataka to the south and Goa to the south-west. The State enjoys tropical monsoon
climate. The hot scorching summer from March onwards is followed by the monsoon
in early June. The rich green cover of the monsoon season persists during the mild
winter that follows through an unpleasant October transition.

Maharashtra is the second largest state in India in terms of population and has a
geographical area of about 3.08 lakh sq. km. As per Population Census-2011, the
population of the State is 11.24 crore which is 9.3 percent of the total population of
India and is highly urbanized with 45.2 percent people residing in urban areas.
Mumbai, the capital of Maharashtra and the financial capital of India, houses the
headquarters of most of the major corporate & financial institutions. India's main
stock exchanges & capital market and commodity exchanges are located in Mumbai.
The State has 36 districts, which are divided into six revenue divisions viz. Konkan,
Pune, Nashik, Aurangabad, Amravati, and Nagpur. Well developed infrastructure,
abundant natural resources, connectivity to all major areas, skilled manpower and
quality education make Maharashtra an ideal destination for setting up of new
industries.

The State has focused on the development of infrastructure & smart cities. Agriculture
is a major occupation of the people in Maharashtra. Both food and cash crops are
grown in the State. Maharashtra is not just a geographical expression but an entity
built on collective efforts of its people. Natural as well as cultural diversities have
helped in the development of a unique Marathi culture. It has its own spiritual
dimension and traditionally known as Land of Saints. Varied customs and traditions
co-exist peacefully in Maharashtra. The State is well known throughout the country
for its rich music and dances. Lavnis, Bharuds, Povadas, and Gondhals are the major
forms of folk music in the State and represent the best that the Maharashtrian society
 21

has contributed in the field of music. Maharashtra also has a very good theatre
tradition. Maharashtra celebrates all major religious festivals from around the world in
a peaceful and harmonious manner.

As such the State has played a significant role in the social and political sphere of the
nation. Monuments such as Ajanta, Ellora and Elephanta caves, Gateway of India and
architectural structures like Viharas and Chaityas attract tourists from all over the
world. The State also has a traditional high reputation for religious tourism and
popular for eco-tourism. It has produced many important personalities covering
almost every aspect of human development. The State has a sizable contribution to
sports, arts, literature and social services. The world famous film industry, popularly
known as ‘Bollywood’ is located in the State. All of the above factors make
Maharashtra a dynamic and extravagant place to live in.

As per Population Census 2011, the population of the State is 11.24 crore. The State
constitutes about 9.3 percent population of the country and ranks second after Uttar
Pradesh. Of the total population, the female population is 48.2 percent. The
percentage of urban population is 45.2. The decadal growth of the population is 16.0
percent, less by 6.7 percentage points than that of the previous decade. 1.38 Sex ratio
in the State is 929, which is 894 for age group 0-6 years as compared to 943 and 919
respectively at All-India level. The literacy rate in the State is 82.3 percent. The
literacy rate of Scheduled Castes is 79.7 percent and that of Scheduled Tribes is 65.7
percent.

As per the fifth ‘Employment & Unemployment Survey’ conducted during 2015-16,
for persons aged 15 years & above labor force participation rate was 52.7 percent,
worker population ratio was 51.6 percent and the unemployment rate was 2.1 percent
in the State according to usual principal status approach. Birth Rate, Infant Mortality
Rate, and Death Rate were 16.3, 21 and 5.8 respectively in 2015. Maternal Mortality
Ratio during 2011-2013 was 68.

The Indian State of Maharashtra came into existence on 1 May 1960. It is also known
as Maharashtra Day, initially with 26 districts. 10 new districts have been created
since then, and currently, the number of districts in the state is 36. These districts are
grouped into six administrative divisions shown below.
 22

2.7.1 Regions and Divisions

Regions 7 : Geographically, historically, and according to political sentiments,

Maharashtra has five main regions:

1. Konkan - (Konkan Division)

2. Paschim Maharashtra Region - (Pune Division)

3. Khandesh and Northern Maharashtra Region - (Nashik Division)

4. Marathwada - (Aurangabad Division)

5. Vidarbha - (Nagpur and Amravati divisions) - (Central Provinces and Berar)

Figure 2.1 Six Divisions of Maharashtra with Region and Districts

Source: Census of India 2011

7
List of districts and divisions(http://www.maharashtra.gov.in/english/mahInfo/)
 23

Figure 2.2 Districts by Administrative Divisions

Source: Maharashtra Tourism 20178

Note: Districts and Divisions of Maharashtra (without Palghar district)

8
www.maharashtratourism.gov.in
https://www.maharashtratourism.gov.in/maharashtra/regions-in-maharashtra
 24

2.8 Public Health Status of Maharashtra9

The State has been at the forefront of healthcare development in India. Healthcare
facilities are being provided by the public, private and voluntary sectors with basic to
advanced healthcare services. Public health services aimed at providing reliable,
accountable, adequate, qualitative, preventive and curative healthcare to the
population with a focus on improving maternal and child health. In addition, public
health facilities are also provided considering local and cultural diversities,
particularly for tribal and rural communities.

The GoM (Government of Maharashtra) has created three-tier health infrastructure to

provide comprehensive health services to the people. The primary tier comprises Sub

9
1. Indian Standard Basic Requirement for Hospital Planning; Part 2 Upto 100 Beded Hospital, Bureau
of Indian Standards, New Delhi, January, 2001.

2. Rationalisation of Service Norms for Secondary Care Hospitals, Health & Family Welfare
Department, Govt. of Tamil Nadu. (Unpublished)

3. District Health Facilities, Guidelines for Development and Operations; WHO; 1998.

4. Indian Public Health Standards (IPHS) for Community Health Centres; Directorate General of
Health Services, Ministry of Health & Family Welfare, Govt. of India.

5. Population Census of India, 2001; Office of the Registrar General, India.

6. KPMG, “Post-Budget sectoral point of view”, KPMG Healthcare, February 29, 2016, accessed
September 28, 2016,

https://www.kpmg.com/IN/en/services/Tax/unionbudget2016/Documents/Healthcare.pdf.

7. KPMG, “Healthcare in India: Current State and Key Imperatives”,

https://assets.kpmg.com/content/dam/kpmg/in/pdf/2016/09/AHPI-Healthcare-India.pdf.

8. Overview on 2017 - Economic Survey of India, February 2017,

www.oecd.org/eco/surveys/economic-survey-india.html

9. ANNUAL REPORT (1998-99): Ministry of Health and Family Welfare, Government of India.

10. BULLETIN ON RURAL HEALTH STATISTICS IN INDIA (1999): Rural Health Division,
Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India,
New Delhi.
11. DRAFT REPORT OF THE SUB-GROUP ON HEALTH EDUCATION AND IEC FOR NINTH
FIVE YEAR PLAN (1996): Planning Commission, Government of India, New Delhi.
12. ECONOMIC SURVEY (1996-97): Ministry of Finance, Government of India, New Delhi.
13. HEALTH INFORMATION OF INDIA (1994): Central Bureau of Health Intelligence, DGHS,
Ministry of Health and Family Welfare, New Delhi.
14. MID-TERM APPRAISAL OF THE EIGHTH FIVE YEAR PLAN 1992-93, Planning Commission
(1996): Government of India, New Delhi.
15. NATIONAL FAMILY HEALTH SURVEY (1995): International Institute for Population Sciences,
Mumbai, India.
 25

Centres, Primary Health Centres (PHC) and Community Health Centres (CHC). The
sub-district hospitals
spread across rural & semi-urban areas and district-based
hospitals constitute secondary tier. Whereas, well equipped medical colleges and
super-specialty hospitals located in major cities are at tertiary level. The circlewise
health infrastructure maintained by the public, local bodies and trust hospitals in the
State is given in Table 2.3 (10.11) whereas, the detailed series of medical facilities
available (public, local bodies and trust hospitals) are given in Appendix D1 (Annex
10.6). The series of selected health indicators are given in Annexure D2 (Annex 10.7).

Table 2.3 (10.11) Circle wise Healthcare Infrastructure of Maharashtra

Source: GOI Economic Survey of Maharashtra 2016-17

The State health infrastructure includes 342 trust hospitals, 44 trauma care units, four
general hospitals, two super specialty hospitals, one women hospital, four hospitals
exclusively treating TB and four hospitals exclusively treating leprosy run by
Directorate of Health
Services, GoM. In addition to this, 25 medical hospitals
affiliated with sixteen government medical colleges with about 14,000-bed strength
and 14 Employees’ State Insurance Scheme hospitals with 2,380-bed strength provide
health services in the State. The number of Sub Centres, PHC and CHC functioning in
selected states are given in Table 2.4 (10.12).
 26

Table 2.4 (10.12) Number of Sub Centers, PHC and CHC functioning in the
Selected States

Source: GOI Economic Survey of Maharashtra 2016-17

Based on the data of Registered Medical Practitioners for allopathy estimated doctor
population ratio is 1:1418 in the State. For producing skilled human resources, a
number of medical and paramedical institutions including Ayurveda, Yoga &
Naturopathy, Unani, Siddha and Homeopathy (AYUSH) institutions have been set up.

2.8.1 District Hospitals in India

District Hospital is an integral part of the District Health System (DHS), which is, the
point of origin for implementing various health policies and delivery of healthcare. It
fulfills the need for the secondary level of health care acting as a center for curative,
preventive, and promotive health care services as well as interface with institutions
controlled by non-government and private voluntary health organizations. The current
functioning of most of the District Hospitals is below the level of expectations due to
non-uniformity in staff/bed strength, equipment and service availability and
population coverage.

The National Rural Health Mission (NRHM) launched by the Hon’ble Prime Minister
of India on 12th April, 2005 aims to restructure the delivery mechanism for health
towards providing universal access to equitable, affordable and quality healthcare that
is accountable and responsive to the people’s needs, reducing child and maternal
deaths as well as stabilizing population and ensuring gender and democratic balance.
 27

As envisaged under NRHM, Subdistricts/Sub-divisional Hospitals would be upgraded

from its present level to a level of a set of Standards called ‘Indian Public Health
Standards (IPHS)’.

The Indian Public Health Standards (IPHS) for District Hospitals has been worked out
by constituting an Expert Group comprising of various stakeholders under the
Chairmanship of Director General Health Services, Ministry of Health & Family
Welfare, and Government of India. These Standards have been prepared bed strength-
wise for 101-200 beds, 201-300 beds, and 301-500 beds. The Indian Public Health
Standards (IPHS) for District Hospital has been prepared, keeping in view the
minimum resources available and mention the functional level of the Hospitals in
terms of space, manpower, instruments, drugs and other basic healthcare services.
Constitution of Rogi Kalyan Samittee /Management Committee with the involvement
of PRIs, Citizen Charter is expected to make improvement in the functioning and
accountability of these Hospitals.

2.8.2 District Health System

India’s Public Health System has been developed over the years as a 3-tier system,
namely primary, secondary and tertiary level of healthcare. District Health System is
the fundamental basis for implementing various health policies and delivery of
healthcare, management of health services for define geographic areas. District
hospitals is an essential component of the district health system and functions as a
secondary level of healthcare which provides curative, preventive and promotive
healthcare services to the people in the district.

Every district is expected to have a district hospital linked with the public
hospitals/health centers down below the district such as Sub-district/ Sub-divisional
hospitals, Community Health Centres, Primary Health Centers and Sub-centres. As
per the information available, 609 districts in the country at present are having about
615 district hospitals. However, some of the medical college hospitals or a sub-
divisional hospital are found to serve as a district hospital where a district hospital as
such (particularly the newly created district) has not been established. Few districts
have also more than one district hospital.
 28

The Government of India is strongly committed to strengthening the health sector for
improving the health status of the population. A number of steps have been taken to
that effect in the post-independence era. One such step is strengthening of referral
services and provision of specialty services at district and sub-district hospitals.
Various specialists like a surgeon, physicians, obstetricians and gynecologists,
pediatrics, orthopedic surgeon, ophthalmologists, anesthetists, ENT specialists, and
dentists have been placed in the district headquarter hospitals.

The District Hospitals caters to the people living in urban (district headquarters town
and adjoining areas) and the rural people in the district. District hospital system is
required to work not only as a curative center but at the same time should be able to
build an interface with the institutions external to it including those controlled by non-
government and private voluntary health organization. In the first changing scenario,
the objectives of a district hospital need to unify scientific thought with practical
operations which aim to integrate management techniques, interpersonal behavior and
decision making models to serve the system and improve its efficiency and
effectiveness.

The current functioning of the most of the District Hospitals in the public sector is not
up to the expectation especially in relation to availability, accessibility, and quality.
The staff strength, beds strength, equipment supply and service availability and
population coverage are not uniform among all the district hospitals.

As per Census 2001, the population of a district varies from as low as 32,000 (Yanam
in Pondicherry, Lahul & Spiti in Himachal Pradesh) to as high as 30 lakhs (Ludhiana,
Amritsar districts) the bed strength also varies from 75 to 500 beds depending on the
size, terrain, and population of the district. As per the second phase of the facility
survey undertaken by the Ministry of Health & Family Welfare, Government of India,
covering 370 district hospitals from 26 states has revealed that 59percent of the
surveyed district hospitals have tap water facility. The electricity facility is available
in 97percent of the districts with a standby generator facility in 92percent of the cases.
Almost all the DHs in India have one operation theatre and 48percent of them have an
OT specifically for the gynecological purpose. About 73percent of the surveyed
district hospitals have laboratories. A separate aseptic labor room is found in the only
45percent of the surveyed district hospitals. Only half of the total numbers of district
 29

hospitals have OPD facility for RTI/STI. As regards, manpower 10percent of the
district hospitals do not have O&G specialists and pediatricians. 80percent of the DHs
have at least one pathologist and 83percent of the total DHs have at least one
anesthetist. The position of general duty officers, staff nurses, female health workers
and laboratory technicians are available in almost all district hospitals. Only 68percent
of the district hospitals have linkage with the district blood banks.

2.8.3 Grading of District Hospitals

The size of a district hospital is a function of the hospital bed requirement, which in
turn is a function of the size of the population it serves. In India, the population size of
a district varies from 35,000 to 30,00,000 (Census 2001). Based on the assumptions of
the annual rate of admission as 1 per 50 populations and the average length of stay in
a hospital as 5 days, the number of beds required for a district having a population of
10 lakhs will be around 300 beds. However, as the population of the district varies a
lot, it would be prudent to prescribe norms by grading the size of the hospitals as per
the number of beds.

Grade I: District hospitals norms for 500 beds

Grade II: District hospitals norms for 300 beds

Grade III: District hospitals norms for 200 beds

Grade IV: District hospital norms for 100 beds.

The disease prevalence in a district varies widely in type and complexities. It is not
possible to treat all of them at district hospitals. Some may require the intervention of
highly specialized services and use of sophisticated expensive medical equipment.
Patients with such diseases can be transferred to tertiary and other specialized
hospitals. A district hospital should, however, be able to serve 85-95percent of the
medical needs in the districts. It is expected that the hospital bed occupancy rate
should be at least 80percent.
 30

2.8.4 Functions of District Hospitals

A district hospital has the following functions:

1. It provides effective, affordable healthcare services (curative including specialist

services, preventive and promotive) for a defined population, with their full
participation and in co-operation with agencies in the district that have a similar
concern. It covers both urban population (district headquarter town) and the rural
population in the district.

2. Function as a secondary level referral center for the public health institutions below
the district level such as Sub-divisional Hospitals, Community Health Centres,
Primary Health Centres and Sub-centres.

3. To provide wide-ranging technical and administrative support and education and

training for primary health care.

2.8.5 Essential Services provided at District Hospitals

a. Services include OPD, indoor, emergency services.

General Medicine including Nephrology, Cardiology, and Pulmonary Medicine
General Surgery including Urology and Plastic Surgery Obs & Gyne, Paediatrics
including Neonatology, Emergency (Accident & other emergency) (Casualty),
Critical care (ICU), Anaesthesia, Ophthalmology, ENT, Dermatology & Venerology
including RTI/STI, Orthopaedics, Radiology, Dental care, Public Health
Management.

b. Para-clinical services
Laboratory services, X-ray facility, CT Scan services, Sonography (Ultrasound),
ECG, EEG, Echocardiogram, Pathology, Blood Bank, Physiotherapy, Dental
Technology (Dental Hygiene), Drugs and Pharmacy.

c. Support Services
Medico-legal/postmortem*, Ambulance services, Dietary services, Laundry services,
Security services, Counseling services for domestic violence, gender violence,
adolescents, etc., Gender and socially sensitive service delivery be assured. Waste
management, Warehousing/central store Maintenance and repair Electric Supply
(power generation and stabilization), Water supply (plumbing), Heating, ventilation
 31

and air-conditioning, Transport, Communication, Medical Social Work, Nursing

Services, Sterilization and Disinfection, Horticulture (Landscaping), Lift and vertical
transport, Refrigeration.
* Subject to the location at District Headquarter.
d. Administrative services
i. Medical records (Provision should be made for computerized medical records
with antivirus facilities whereas alternate records should also be
maintained)
ii. Procurement
iii. Personnel
iv. Housekeeping and Sanitation
v. Education and training
vi. Inventory Management
e. Services under various National Health and Family Welfare Programmes
f. Epidemic Control and Disaster Preparedness

2.9 Summary

In this Part I of the chapter, the researcher presented information on Hospitals and its
approach to human resources in India; Hospital as a Service organization and role of
Hospital in the healthcare market. This chapter focused on current status of health and
healthcare system in India. It also justified the role and challenges confronting public
hospital in India. The rationale for selecting public hospitals (district) of Maharashtra
for research are discussed and justified here, through an overview of Maharashtra
state and also by giving the public health status of Maharashtra. The next Part II of
this chapter provides details of other studies in the same area related to organizational
culture in hospitals.
 32

Part – II: Organizational Culture in Hospitals

‘We cannot change the human condition, but we can change the conditions under
which humans work’

– Reason, 2000, p. 769.

This Part II of this chapter reviews the literature which relates to organizational
culture in hospitals and identifies the different concepts and definitions related to it. It
also describes the layers of culture and development of culture. It focuses on culture
and organization, and position of culture in an organization. The characteristics of a
culture and subculture and give an overview of the importance of assessing patient
safety culture in hospitals. Furthermore, it elaborates on the main aspects or
dimensions that have been used in previous studies to assess the patient safety culture
in context to organizational culture in hospitals. Moreover, it includes the current
organizational culture in hospitals and its relation to safety. It considers whether a gap
exists in the literature and provides the justification for conducting a study on this
topic in India.

2.10 Culture: an overview

The scientific study of culture reveals the great variety and various disputes and
scholars often differ on what culture actually ‘is’ (Keesing 1981). Unlike animals,
humans develop a culture. Whereas the meaning of an animal’s behavior at one end of
the world will be comparable to the meaning of a similar animal’s behavior at the
other end, the ideational systems and convictions of humans from both these ends are
often quite dissimilar. According to Geertz, there is no culture without humans but
also, ‘more significantly, without culture no men’ (Geertz 1973: 49).

An early notion, still echoing imperialistic times, placed cultures on a single

continuum ranging from savage (low) to civilized (high), with high cultures
obviously enjoyed by the colonialists and low cultures held by the conquered
 33

natives (Avruch 1998). This view could be labeled ‘colonialist’, being both
ethnocentric and evaluative and putting much emphasis on refinement and
(evolutionary) development. This notion of social evolution was later dismissed
by many in favor of a descriptive stance, emphasizing the uniqueness and
variety of cultures, none of them superior over or more developed than the
others (ibid.).

An important function of culture is related to the reduction of uncertainty

(Van Hoewijk 1988) or even anxiety (Schein 2004) which, consequently, leads to
more continuity, because less time is spent on various mutual adjustments within
a group. The fact that people know what to expect in a variety of situations – e.g.
with regard to particular rituals (like celebrations, meetings, appointments and so
on), the expression of emotions, dress codes, behaviors, et cetera – makes life
more predictable and hence more fluent. Culture has also been linked to adaptation
(Schein 1992) and habituation. Habituation is well-developed in all organisms that
have a nervous system – the working of this mechanism has been described in as
primitive a life form as the marine snail (Kandel and Schwartz 1985: 817 ff.). 10
Adaptation is important for learning, for continuity and therefore for survival.

Forces from outside the organism that demands its adaptation will initiate change;11
in this view, cultures are considered both functional and well adapted to their
environment. However, while adaptation and learning are both necessary aspects
of culture, they define neither its essence nor its working mechanisms.
As early as 1952 Kroeber and Kluckhohn had already compiled a list of
164 definitions of culture (Kroeber and Kluckhohn 1952) so it does not appear
useful to embark on a personal definitional cruise. Hofstede defines culture briefly
as ‘the collective programming of the mind, which distinguishes the members
of one group or category of people from another’ (Hofstede 2001: 9) and
considers culture ‘mental software’.12 He distinguishes three levels of such mental
programming (Hofstede 1991: 6, 2001: 3):

1. Human nature: universal

10
For instance, Castellucci et al. (1978) have shown that repeated stimulation of a single nerve cell
results in this cell not responding to that stimulus anymore.
11
Please note that Schein (Schein 1992: 298 ff.) follows a similar reasoning about culture change.
12
Following Geertz, who refers to ‘plans, recipes, rules, instructions, […] programs’ (1973: 44).
 34

2. Culture: collective
3. Personality: individual.
Human nature corresponds to the programs all humans around the world are
instilled with, but this ‘software’ can be influenced by both culture and personality.
For instance, the way an individual expresses his or her anger will be determined
both by this person’s personality and by their culture (and by situational
conditions, but these are kept out of the discussion for the time being). Applying
the psychoanalytical idiom to this three-way split, human nature would represent
the Id, personality would be considered the Ego and culture, also encompassing
various assumptions about ethics and behavior would represent the Superego.
Considered in this way the attention given to (organizational) culture from a
managerial point of view is certainly not surprising.

Hence, culture is distinguished from human nature and personality in that it

is shared by a defined group of people, whereas human nature and personality
13
are not. Culture is often considered the ‘collective memory’ of a group and is
therefore thoroughly intertwined with the history of that group. Moreover, the
term ‘memory’ implies that culture is learned, not inherited. Importantly, one
a person can belong to many groups and can, therefore, share several cultures with
different people. This particular characteristic makes the study of culture extremely
difficult, because of what particular culture should any observed or otherwise
assessed regularities of groups are attributed? This issue will be taken up more
extensively later on in the chapter.

(National) cultures should not be compared normatively. However, within

it bounds a culture provides norms for thoughts and action, perceptions and
behavior. Therefore, within a (national) culture actions and justifications for
these actions can be compared to the norms that have developed within that
culture (Hofstede 2001: 15). Indeed, such norms can become part of the culture
and define its core, alongside its values. Consequently, culture provides one of
the anchors for behavior. This behavioral aspect is actually not captured in
the definition supplied by Hofstede. Anthropologists Spradley and McCurdy
(1975: 4) define culture as ‘the acquired knowledge people use to interpret

13
Human nature is shared by everybody and a personality is held by only one person. Additionally,
Hofstede considers culture the ‘personality’ of a group (2001: 10).
 35

experience and generate behavior’. Combining this definition with Hofstede’s

produces the following:

Culture is the acquired and collective knowledge groups or categories of people

use to interpret experience and generate behavior, which distinguishes them
from other groups or categories of people.

In this definition the learned and shared aspects of culture as well as its sense
making and action components are captured. As satisfying a definition as it might
seem, it still misses the fuzziness of the concept, which is captured in Spencer-
Oatey’s (2000) definition:

Culture is a fuzzy set of attitudes, beliefs, behavioral conventions, and basic

assumptions and values that are shared by a group of people, and that influence
each member’s behavior and each member’s interpretations of the ‘meaning’
of other people’s behavior.

Attempting to reveal the essence of a culture raises an important question;

i.e. to what extent are cultures comparable and to what extent are they unique
(Hofstede 2001: 24 ff.)? This distinction is discussed in various (social) sciences,
e.g. sociology, anthropology, cross-cultural psychology, and brings along its own
vocabulary (ibid.). Basically, it pertains to the issue of generality and specificity;
Gestalt (unique holistic configurations) versus Gesetze (general laws);
idiography versus nomothetic; and emic (as in phonemic, i.e. unique) versus etic
(as in phonetic, i.e. general). Evidently, this discussion also throws some light
on the issue of safety culture and it will be taken up further below. An argument
of the generalists could be that each group (collective, category, society) has
to face similar problems during its lifetime. However – as the specifics would
retort – each group will develop solutions based on its unique personal situation.
It would be too much of a simplification to narrow this discussion down to a
‘basic problems focus’ versus ‘unique solutions focus’ dichotomy although
the aspect of survival is quite important in this discussion. Survival of the
the organization is also the primary incentive for change in Schein’s conception of
 36

organizational culture, resulting in (external) adaptation and (internal) integration

(1992: 51 ff.).

An outcome of a generalist approach is that cultures can be described with

a limited number of aspects, e.g. dimensions, facets or factors. A unique culture
the approach does not have this common underlying framework and its descriptions
are limited to single cultures. However, either approach can ultimately lead to
a third approach that is a typology of cultures. All three approaches are well
represented in the organizational culture literature and can be discerned also in
the literature on safety culture. Again, this topic will be discussed more extensively
below.
Summarising, humans develop a culture when they interact and try to achieve
something. This culture is primarily locally defined. Having acquired this culture
not only means that an influence is exerted on behavior, but also that other
people’s behavior is interpreted in this culture’s way.
 37

2.11 Layers of Culture

Next to the levels of mental programming present in humans – i.e. universal,

collective and individual – and the various levels of aggregation at which
culture can be studied – e.g. societal, regional, occupational, organizational –
most scholars consider culture as something consisting of a core surrounded
by one or more layers, not unlike the anatomy of an onion. Whereas the core
is something (deeply) hidden, the culture projects itself gradually through and
onto the outer layers. The more remotely a layer is located at the core, the
more easily it can be observed but also the more indirect, or interpretive, its
relation with the core becomes. This simply implies that it is not straightforward
to understand a culture from its outer layer(s).

With regard to changing a culture a similar rule is sometimes put forward: the more
deeply a layer is located, the more difficult it becomes actually to change it (Meijer
1999; Sanders and Neuijen 1987). Hofstede, citing Bem, argues that a particular
culture can be more effectively changed by starting with the practices of the outer
layers, not the values of the core (Bem 1970; Hofstede 2001: 12). The latter change
only gradually, with different time estimates for different levels of culture.
For instance, a substantial change in national culture might take no less than
a millennium (Hofstede 2001), whereas an organizational culture might take
around 25 years (Schein 1992). Various conceptions of the layers of culture are
presented in Table 2.5.
 38

Table 2.5 The Layers of Culture according to various authors

Author(s) Central Core Layer 1 Layer 2 Layer 3

Deal and Kennedy Values Heroes Rites and rituals Communication

(1982) network
Van Hoewijk Fixed Norms and Myths, heroes, Codes of
(1988) convictions values symbols, stories conduct, rituals,
procedures
Hofstede (2001) Values Rituals Heroes Symbols

Meijer (1999) Fundamentals Practices --- ---

Rousseau (1990) Fundamental Values Behavioral Patterns of

assumptions Norms behavior; and
artifacts (=4th
layer)
Sanders and Nuijen Values and Rituals Heroes Symbols
(1987) principles
Schein (2004) Basic Espoused Artifacts ---
underlying values
assumptions
Spencer-Oatey Basic Beliefs, Systems and Artifacts and
(2000) assumptions attitudes and institutions products;
and values conventions rituals
and behavior
Trompenaars and Basic Norms and Explicit culture ---
Hampden-Turner assumptions values (e.g. behavior,
(1997) clothes, food,
language,
housing)
Source: Compilation from various studies by researcher

All authors have something quite deep and profound positioned at the
core – values, convictions, principles, fundamental or basic assumptions –
but beyond that, there are differences, not so much concerning the nature of
the layers, but regarding their position in the onion. Importantly, of the authors
mentioned in Table 2.5 the scholars Hofstede, Spencer-Oatey, and Trompenaars
and Hampden-Turner focus mostly on national culture, whereas the others have
primarily organizational culture in mind. Regarding organizational culture,
Hofstede argues that the core – i.e. the values – is less relevant to the study
 39

of organizations, although it offers a reflection of the organization’s national

values, i.e. the values of the country where the organization is situated. Hofstede
therefore maintains that the notion of (national) culture does not apply so much
to differences between organizations within a country. They only differ in what
he calls ‘practices’, i.e. the outer three layers of his onion: rituals, heroes and
symbols (Hofstede 1991: 182–3).

Schein does not differentiate between the more visible aspects of culture,
i.e. between rituals, heroes, and symbols, all of which he sweeps up under the heading
of ‘artifacts’, along with all visible behavior. 14 However, he divides the core into
‘espoused values’ and ‘basic assumptions’, thereby indicating that he does not take
for granted the values that members of an organization express when asked about
these. Schein also makes a point of calling his core ‘basic assumptions’ and not
‘values’. To him, values are still negotiable whereas basic assumptions are not
(Schein 1992: 16). As can be seen in Table 2.5, more authors use this distinction
between (basic) assumptions on the one hand and values on the other; this way values
(and attitudes and beliefs) are modeled to change still more radically, whereas the
(basic) assumptions will not. Spencer-Oatey introduces the notion of institutions, a
topic that will be discussed later when the process of cultural development is
discussed. Institutions either teach or otherwise develop and disseminate some of the
values of a culture. As is clear from the table, at this stage these values are not yet
internalized, to the extent that they are cultural values.

This rather extensive discussion should make another point clear, namely that
the labels given to the layers are typically assigned from an analyst’s point of view.
For a member of a particular culture, these aspects are thoroughly intertwined and
their meaning is obvious. It is, therefore, the researcher who labels these activities
as such and in many cases their differences are not clear-cut.

Regarding research on the culture, it is possible to distinguish two contrasting

approaches; one approach considers culture a socio-cultural (i.e. behavioral)
system, whereas the other, considers it an ideational system, i.e. a system

14
Pedersen and Sorensen, taking Schein’s research model as a starting point, bring some diversity to
his rather amorphous artefacts, distinguishing (1) physical symbols, (2) language, (3) traditions and (4)
stories amongst them, all of which they consider important for a cultural analysis (Pederson and
Sorensen 1989: 29).
 40

comprising ideas, concepts, rules and meanings (Keesing 1981: 68). Whether
it is sufficient to observe the practices and not understand they're underlying
the rationale seems much more a matter of preference for a particular paradigm
then something that can be resolved through scientific inquiry. On the one hand,
researchers observing only practices might sometimes be bothered by their
inconsistency, their irrationality or their incongruence and might end up relying on
in basic, behavioral psychology (cf. Avruch 1998: 19). On the other hand,
researchers focussing on the core have a hard time untangling it.

It is, however, important to look a little deeper into what is at the core.
Several authors refer to the core as ‘deep’ (Schein 1990: 109). This immediately
triggers the question as to what deep exactly is, or entails. Deep appears to refer to
something fundamental and pre-conscious. People become emotional when their
fundamentals are questioned or under attack (Avruch 1998; Hofstede 1991), often
without being aware of why this is so important to them. Moreover, ‘[t]he more
deeply internalized and effectively loaded the more certain images or schemas are
able to motivate action’ (Avruch 1998: 19).

It is quite illuminating to bring up the reason why Schein considered

organizational culture as something that goes beyond the notion of ‘practices’.
After the Korean War, Schein and his colleagues worked closely with prisoners
15
of war (POWs) who had been brainwashed by the Chinese. Whereas some
of them simply distanced themselves from the ideas being forced upon them,
others had adopted a communist worldview and had even confessed to ‘crimes’
they did not commit, that is, not from a Western point of view. Rather later,
Schein began to see parallels between the beliefs of these POWs and the beliefs
schools, both private and public organizations try to establish in their pupils
and personnel, albeit through a much milder process (ibid.). According to
Schein, it is possible to provide people with such strong tacit beliefs, which are
indeed much deeper than the more superficial ‘practices’ Hofstede has in mind
regarding his distinction between organizations. This is not to say that Schein’s
basic assumptions and Hofstede’s values coincide. Hofstede’s values are indeed
acquired at a much earlier stage – Hofstede claims before the age of 10 – and

15
Afterwards, the process through which these POWs had been converted by the Chinese was named
‘coercive persuasion’ (Schein 1992: 327–9, 1999).
 41

are therefore quite static and rather fixed. Schein’s basic assumptions are more
dynamic and subject to change, but changing these requires much effort and
unleashes ‘large quantities of basic anxiety’ (Schein 1992: 22) because of members
of the organization lose many of their certainties for a period of time. It is
therefore not surprising that this organizational change process has been likened
in the process of mourning (Kets de Vries 1999).

Yet culture is not only deep because it is so fundamental and covert, it is also
immensely patterned and therefore related to everything we think, perceive and
do. When attempting to change one belief, we have to change many related ones
and much that has been built upon these. The ‘large quantities of basic anxiety’
and the process of mourning mentioned here are quite understandable when such
basic belief networks are taken apart.

Trying to formulate such deeply seated assumptions, these ‘webs of

significance’ as Geertz calls them (1973: 5), will be particularly difficult because
they are so taken for granted (Schein 1992) that, within the boundaries of a
culture, they are never challenged and, consequently, never have to be verbalized.
Because of its fundamental nature, culture can be blinded by itself to itself.
Schein’s distinction between basic assumptions and their verbal counterpart,
i.e. espoused values, seems therefore quite valid and sensible. Comparable
reasoning can be found with Bloch (1998) who proposes that much (conceptual)
knowledge – and hence also cultural ‘knowledge’ – is essentially nonlinguistic and
acquired primarily through experience, not through explanation, i.e. communication.
When such knowledge is ‘rendered into language’, its character is also changed.
Hence, what is considered ‘deep’ can also be considered non-linguistic and implicit.
Making this deep knowledge explicit also changes its overall character.

Summarising, the whole idea behind the onion model seems to depict the
the essence of culture as something hidden rather deeply under a layered set of more
or less visible manifestations upon which it exerts its influence. These layers can
function as a key to the nature of the underlying culture.16

16
In using the culture concept this way, one should beware of the reification of culture
with a thing that can act, almost on its own (Avruch 1998: 14). Such notions often lead to
quite simplistic linear models of influence and modification.
 42

2.12 Development of Culture

A straightforward account of the development of culture comes from Hardin

(2009); simply stated – (behavioral) experience leads to knowledge leads to
culture. This is not to say that all experience leads to knowledge and that all
knowledge leads to culture. First of all, because culture is shared, this knowledge
should be shared too. Moreover, for experience to become shared knowledge
it should be shared between (some of) the members of a group and an agreement
should be reached on what the experience is about and what the knowledge
should entail.

Halfway through the 1960s, Berger and Luckmann published The Social
Construction of Reality, in which they put forward a process model along
which societies develop their version of reality (Berger and Luckmann 1966).
Organizations too can be regarded as social communities that also share
a particular version of reality, on which they act and respond. Berger and
Luckmann’s model has been taken as a starting point for the model outlined
below. This model describes the process of organizational culture formation and
it's internalization over time.
 43

Figure No 2.3 Development of organizational culture based on a model

by Berger and Luckmann (1966) - 1

Experiencing, Adjusting, Standardising, Collective

explaining agreeing norming, experiencing,
institutionalising collective agreeing

Internalising

Source: Berger and Luckmann (1966)

In Figure 2.3, a model of cultural development is put forward, which describes

the formation of cultures in groups, like organizations. The first box of the model
pictures the situation a member of the group finds himself in; the individual is
trying to make sense of the experiences he encounters. With regard to safety
and risk these are particular perceptions of both constructs that will partly
determine this individual’s behavior, e.g. what is safe and risky behavior. The
the result of this process is an individual understands reality. This particular
understanding is brought into the second box, the process of interaction with
group members. This interaction is often based on communication, i.e. dialogue,
discussion, correction, and results in mutual adjustments, agreements and various
expectations of each other’s behaviors. The outcome of this box is shared
understandings, e.g. standards of behavior, roles, and norms. In the third box the
formal processing of standards and norms is pictured, i.e. the establishment of
norms and the institutionalization of behavior and expectations. The fourth box
pictures the situation in which norms, standards, and expectations are accepted
to the extent that they are considered the ‘best’ or, perhaps, the ‘only’ way of
doing things. Members of the group share a comparable understanding of reality,
at least with regard to the part of reality the group acts on. This understanding is
 44

internalized by the members of the group and forms the ‘basic assumptions’ with
which individuals within the group understand reality.

This model makes a few things clear with regard to culture. Firstly, this process
takes some time to complete. Secondly, it is not easy to predict the outcome of
this process, as it is dependent on, for instance, the composition of the group,
the communication the group members have, the distribution of power within the
group and the particular context the group operates in. Thirdly, the outcome is
more arbitrary than intentional, although some members will deliberately try to
influence the process. However, the result may be that particular standards are
established which are not the result of consensus and are therefore not internalized
as ‘basic assumptions’ but rather as ‘obligations’, i.e. ‘the way we have to do
things around here’ instead of ‘the way we do things around here’.

Obviously, when individuals enter a group, this process has been going on for
some time and therefore many assumptions are already widely established. The
the individual is then either trained or otherwise socialized into the group. It may be
that the individual does not agree with the various assumptions of the group and him
can either pretend that he does or leave the group. Going against the assumptions
is yet another option but, depending on the age of the group and various other
conditions, this is often a futile quest.

Importantly, this is not the only way a culture develops itself. For instance,
Schein describes a process of culture formation based on the reduction of anxiety
all members have when facing a new group that has to work together from some
time. Initially, the group has to resolve the issue of power and has to develop routines
that work for it. After that, the group can start working within the boundaries it has
developed for itself (Schein 2004: 63 ff.). Nevertheless, a process of adjustment and
the agreement is also at work here, leading to a shared understanding of what is going
on.
 45

2.13 Culture and Organizations

According to Schein, an organizational culture develops in organizations that have

existed for some time and that have experienced significant external or internal
difficulties or changes. Alongside the influence of founder(s) of a company or of
significant leaders (heroes), the solution for problems that are effectively resolved
or overcome might become part of the leading but tacit assumptions about a company
entertains (Schein 1992). Such internal difficulties could very well be a major safety
problems, like fatal accidents, explosions or releases of dangerous chemicals, but
they also include reorganizations or retrenchments. External problems are often
of an economic nature, like pending closure or loss of customers, but could also
arise because of new legislation or drastic technological changes (Hofstede 2001:
Exhibit 1.5). Organizational culture could be considered the by-product of the
an adaptation that follows these difficulties; viewed this way, organizational
culture is a product of social ecology.

When considering organizations, three major components can be distinguished

that ‘work’ together to generate the desired output. These aspects are structure,
culture, and processes and they are dynamically interrelated (e.g. see Hofstede
2001; Van Hoewijk 1988), which means that they all influence and are influenced
with each other. Together they also provide the context in which behavior, and
hence also safety-related behavior, takes place.17

Organizational structure can be defined as ‘the division of authority, responsibility,

and duties among members of an organization’ (Whittington and Pany 2004). The
structure primarily outlines the formal organization – i.e. how the work should be
done and by whom. From the point of view of management an efficient structure
facilitates both effective coordination and communication. With regard to the
structure of organizations several scholars have proposed taxonomies of which
Mintzberg’s is perhaps the most well-known (Mintzberg 1979; 1980; 1983). These
taxonomies offer solutions for structuring organizations in relation to their mission,
main output(s) and environment. Apart from the ‘organizational’ structure all

17
Hofstede makes a distinction between strategy, structure, control and culture (Hofstede
2001: 408 ff.). It is not difficult to translate his ‘controls’ into the ‘processes’ of the present
model. Moreover, I see his ‘strategy’ as the outcome of processes at the highest (strategic)
level of the organization, therefore this element in his model could be considered redundant.
 46

‘physical’ structure can also be subsumed under this heading, e.g. the buildings, the
hardware and the technology the organization uses, as well as the various systems
the organization uses to carry out its processes in a uniform way and to control these.

Figure No 2.4 Development of Organizational Culture based on a model

by Berger and Luckmann (1966) - 2

Structure Culture

Processes =
Interaction

Source: Berger and Luckmann (1966)

The culture is the basic assumptions, the underlying tacit convictions,

described as a group’s shared understanding above. For instance, ‘We need a lot of
supervisors because our people need to be watched constantly’. Such a conviction
will be found reflected in the structure of the organization and therefore also on
the work floor.

The processes are the actual processes and interactions going on in the entire
organization. These processes are often formally described in the structure. Task
execution at all levels might be according to what has been laid down in the
structure, but this does not have to be the case. For instance, some supervisors
do not watch constantly, or do not correct workers, although they see them make
mistakes or violations. The reason for this might be structural – the wrong man in
 47

the right place – or cultural – the convictions of a group of people do not match
up to the structure.

The tri-partition can be projected onto the various steps of the development
the process of culture described above, where ‘processes’ match with the first two
steps of sensemaking an agreement, ‘structure’ with the step of formalization and
institutionalizing and ‘culture’ with the remaining steps of the collective agreement
and internalizing.

An important implication of Figure 2.4 is that an organization’s culture

cannot be isolated from its structure or its processes. Harrison and Stokes (1992)
actually take structural characteristics (high vs. low formalization and high vs. low
centralization) to construct quadrants that define four culture types (‘archetypes’)
– i.e. the role, achievement, support and power culture. Comparable taxonomies
can be found in Handy (1995) (Zeus, Apollo, Athena and Dionysus culture) and
Cameron and Quinn (1999) (Hierarchy, Market, Clan and Adhocracy culture).
This makes a strong case for a holistic exploration of organizational culture,
i.e. research that also includes structure information and data from various
organizational processes. Figure 2.4 brings yet another issue to the fore, namely
that of how to position culture within an organization. This subject will be taken
up in the next paragraph.
 48

2.14 Position of Culture in an Organization

Looking at Figure 2.4, one could conclude that an organizational culture can
be isolated quite easily from organizational structure and processes. Regarding
the position of culture in an organization four approaches can be distinguished
(Frissen 1986):

1. Culture as a contingency factor

2. Culture as a subsystem of the organization
3. Culture as an aspect system of the organization
4. The organization as a cultural phenomenon
A somewhat similar classification can be found with Smircich (1983), who states
that an organizational culture can be viewed either as an independent or external
variable; as an internal variable within an organization; or as a root metaphor
representing a collective view of life and experience.

Hofstede can be considered a proponent of the first approach, in that he

considers an organizational culture to be primarily a product of national culture.
Organizations within a country only differ in their ‘practices’, i.e. the outer layers
of the culture onion, not so much in their values. When culture is considered
a subsystem it is seen as functioning relatively independently next to other
subsystems and can, therefore, be singled out easily for any further analysis. When
culture is regarded as an aspect system, culture cannot be separated so easily because
it is ingrained in many subsystems of the organization. Finally, when
immersing oneself deeply in an organization, one will probably get the impression
that the organization not so much has a culture but basically is a culture, i.e. is a
cultural phenomenon. In this view, culture is considered a ‘root metaphor’ (ibid.),
‘a way of looking at life within a collectivity’ (Martin 2002: 42), and culture stops
being a research variable. In so doing, we have arrived at the fourth approach.

Frissen (1986) presents his approaches not as mutually exclusive but rather
as successive stages of research into an organization’s culture. When starting
a project, culture is often considered as something influencing an organization
(culture as a contingency factor). One then tries to isolate culture and study it in more
detail (culture as a subsystem) and in its manifestations (culture as an
 49

aspect system). When the investigation is both deep and broad, the culture will be
encountered not so much as a part or aspect but as something the organization
invariably is – culture as a root metaphor. Once again, however, one should be
wary of reification, which is sometimes hard to resist (Avruch 1998). In the
next paragraph the concept of organizational culture will be examined further,
looking at the issue of diversification of culture, i.e. culture and subcultures.
 50

2.15 Cultures and Subcultures

Organizational cultures can be defined as having one unifying culture. Several

scholars, like Schein, held this position for some time and this notion might
have been inspired by research done on national or indigenous cultures.
Organizational culture research conducted with standardized questionnaires
often implies a common set of dimensions or scales on which such cultures
primarily differ and hence also contains the notion of a single culture, although
with local nuances. Moreover, the word ‘organizational’ already seems to imply
a large, monolithic entity and certainly not something that is disintegrated or
even fragmented.

However, organizations are quite open systems with leaders changing places
rather often. Furthermore, many organizations are spread over more than one
building or location. So most members of the organization do not have a chance
to interact and develop much together as a collective. Additionally, members
bring along their own cultures – for instance, their national culture, their regional
culture, their professional or occupational culture, their religious culture and
their (socioeconomic) class culture. It is therefore quite possible that no specific
organizational culture develops, especially when organizational setbacks are
comfortably absent (Guldenmund et al. 2006), assuming that such upheaval
initiates the (re-)formation of a culture. However, local subcultures might also
develop, for instance, based on the professional background of members or some
challenging events a certain group had to face in the past. When members have
a similar educational background, they do not even have to interact to share
common cultural features. This seems to be the case in Schein’s interpretation of
subcultures (Schein 1996) and might also underlie Jones and James’ findings in
the US Navy (Jones and James 1979).

Nowadays, the notion of a unitary organizational culture has lost popularity

in favor of a view promoting differentiation (Martin 2002; Richter and Koch
2004). In this view, (an organizational) culture is not considered unitary but
consists of multiple subcultures. A quite radical view is based on social
constructivism and proposes that culture is predominantly dynamic and much
more defined situation-ally, i.e. a fragmentation view (Martin 2002). The heart of
 51

the matter lies perhaps between these latter two views, in that culture in the form
of basic assumptions will be the ultimate result of continual interaction between
group members, partly shown situation-ally and partly shown universally.

Additionally, whatever the point of view – i.e. integration, differentiation or

fragmentation – within a group or population, culture can very well be ‘socially
distributed’ (Avruch 1998: 18 ff.). That is, individuals belonging to a particular
culture does not share their cultural content perfectly; this phenomenon has already
been hinted at in the discussion of Figure 2.4 above. Additionally, culture can be
‘psychologically distributed’ within a group, meaning that cultural content can be
deeply ingrained in one individual whereas in another it is only superficial (ibid.).18

One could question whether the characteristics of culture that have been
discussed earlier apply in equal force to the concept of organizational culture.
As already commented above, the word ‘organizational’ seems to suggest a large
entity. The word ‘culture’ elicits the work and paradigms of anthropologists
and sociologists and invites their ontology and epistemologies into the realm
of organization research. Indeed, initially the concept of culture as applied to
organizations seemed rather attractive and provided explanations for certain
phenomena that went unexplained previously. But organizational research also
supplies managers with new ideas and ideologies and organizational culture
also became something they wanted to manage, to control. Consequently,
organizational culture became another instrument with which managers tried to
pull things their way. When that happened some scholars of organizational culture
pulled out, because they did not feel like contributing to yet another management
tool (Salzer-Morling 2003).

A similar process can be recognized in the development of the safety culture

concept. The first anthropologist has already stood up and summoned the research
community with more sensitivity and (safety) managers to more modesty regarding
the assessment and control of (safety) culture (Haukelid 2008). The current
the discussion will now be narrowed down to the safety culture concept, which will
be held up against the theoretical light of (organizational) culture that has been

18
See also Schein’s experiences with POWs, discussed above.
 52

kindled in the previous discussion. In the next few paragraphs the assessment of
safety culture will be reviewed and analyzed.

Table 2.6
Diverse definitions of culture

Topical Culture It consists of everything on a list of topics, or categories, such

as Social organization, religion, and economy.

Historical It is a social heritage or tradition, that is passed on to future

Culture generations.
Behavioral It is shared, learned human behavior; a way of life.
Culture
Normative It is ideals, values, or rules for living.
Culture
Mental Culture It is a complex of ideas, or learned habits, that inhibit impulses
and distinguish people from animals.

Functional It is the way humans solve problems of adapting to the

Culture environment or living together.
Structural It consists of patterned and interrelated ideas, symbols, or
Culture behaviors.
Symbolic It is based on arbitrarily assigned meanings that are shared by
Culture a society.
Source: Bodley, 1994.
 53

2.16 Organizational Culture

The existence and emergence of organizations is not a new phenomenon. But the
study of the organization is relatively of recent origin. Any study on the organization
and its manifestation should necessarily start with Fall, Taylor, and Bernard.
Organizations are made of members who bring in their emotions, egos and complex
personalities. Organizational culture is the sum of all these personalities, which
creates a common ideology or identity for the organization. Some aspects of
organizational culture get created along the way, while most aspects are evolved by
the founders and leaders of the organization stated in simple terms organizational
culture is the culture that exists in an organization.

In the modern days, it is highly necessary to understand organizational culture, for

various reasons – some of which are purely academic and others for the benefit of
organizations themselves. Culture influences people in good and bad ways. Culture
creates the identity of the organization itself. Vendors, customers, employees and
other external agencies factor in the organizational culture of these organizations
when they make their business decisions. Organizational culture also helps the
company to relate to these external entities. It helps the company to gear up for ever-
increasing competition. Potential business partners study the organizational culture
before making any strategic moves. Even valuation of the business is influenced by
the organizational culture, as can be seen in mergers, acquisitions, and takeovers.

Organizational culture is the confluence of various ideologies (brought by all its

participants), beliefs, languages, customs and these collectively form guidelines for
conformed behavior. All implicit and explicit behaviors form the foundation for
organizational culture.

To observe the culture of an organization, one has to study the visible signals and
symbols along with invisible values, attitudes etc. For instance, do most people of the
organization belong to a particular section of the society? What are the merits and
awards instituted by the company? What is the value system that is strongly carried
out by members of the organization? What are the guiding principles for the
organization and answers to such questions generally describe the culture of the
organization?
 54

Apart from the visible signs and symbols, organizational culture can also be seen in
the value system instilled by the founder members as well as its leaders of the
organization. Senior management is responsible for creating a viable organizational
culture that suits the needs of the business and sends a meaningful message to all who
matter to the organization both internal and external. Hence, certain values are
enforced by seniors by setting examples and by propagating with the help of symbolic
behaviors. This has a percolating effect in the organization and gets carried out to the
lowest rung of the organization.

It is worthwhile to note few definitions of organizational culture and its relation to its
constituent elements. “It is the collective programming of the mind” (Hofstede,1980);
“It is the way things are done around here” (Pascale R.T et al,1981); “It is the
philosophy that guides an organization’s policy towards employee and customers”
(Terrnse E Deal et al,1982); “It is the dominant value espoused by an organization
(John H Sheridon,1988).

Organizational culture has attracted the attention of academicians as well as

researchers, in recent times. It has a definite bearing on the employee satisfaction and
performance. The attention to the study of organizational culture in the recent past has
increased as many of the domestic organizations started working in other parts of the
world. Corporations and organizations either becoming or trying to become MNCs, is
the order of the day. An organization may become a multinational company on its
own or through acquisitions and mergers. The ways in which an organization is
managed as well the organization functions are mainly due to organizational culture
itself. Knowledge of national culture is also necessary for an organization which sees
it operating in other parts of the world in these days of globalization.

Organizational culture is a complex concept is to be studied using universally

accepted common characteristics. George G Gordon et al (1979) have identified
Individual initiatives, Risk tolerance, Direction, Integration, Management, Control,
Identity, Reward system, Conflict tolerance and Communication pattern as key
characteristics. Fred Luthans (2005) has identified Observed behavioral regularities,
Norms, Dominant values, Philosophy, Rules and Organizational climate as other key
components.
 55

Thus above elements can be considered as the constituents of organizational culture,

which of course, gets manifested with different facets, depending upon the nature of
the business, it is carrying out and the environment in which it is operating.

Sometimes Organizational culture shapes itself with the entry of new employees.
Values and beliefs get redefined and a new form of organizational culture emerges.
Many times, a controlling mechanism is to be in place so that desired outputs are
cultivated and undesirable outputs are weeded out. Then how can be organizational
culture controlled? The organizational culture needs to change if there is an influx of
inappropriate organization behavior or when there is an erosion of organization
values. There cannot be a culture change without the support of top management.
Every department has to make a conscious effort to manage the change process.
Specific steps must be incorporated in the change plan with intermediate feedback
mechanisms. Cultural change takes a long period of time and its effects are seen over
much longer periods. Hence it must be ensured that the cultural change process is
attended to, keeping future in mind.

Just as an individual is known for his / her personality, organizational culture is the
personality of the organization. Culture is comprised of the assumptions, values,
norms and tangible signs (artifacts) of organization members and their behaviors.
Members of an organization soon come to sense the particular culture of an
organization, Culture is one of those terms that is difficult to express in clear terms,
but everyone knows it when they sense it. That is, only a few facets of an organization
can be explained, but many facets still remain undescribed and unexplained. While
discussing the elements of organizational culture the HR issues such as employee
engagement, ability, task identity, work-life balance are to be considered.
Accordingly, these become the parameters associated with major variables. While
discussing the leadership issues in the context of organizational culture, the concepts
of transactional and transformational leadership, trust, empathy are taken care of. At
the macro level learning orientation, absorptive capacity and virtual corporate ship are
also involved.

A corporate culture which is synonymously same as an organizational culture which

can be looked at as a system with input, output, and throughput with a feedback
arrangement. The process is based on one’s assumptions, values, and norms, e.g.
 56

values of money, time, facilities etc. Outputs or effects of one’s culture e.g.,
organizational behaviors, technologies, strategies, products, services etc. is seen at the
end part of the organization. The concept of culture is particularly important when
attempting to manage organization-wide change. Practitioners are coming to realize
that, despite the best-possible plans, organizational change must include not only
changing structures and processes but also changing the corporate culture as well.

There are numerous ways of defining organizational culture. One commonly accepted
definition is as follows; It is a pattern of shared employee beliefs, values, behaviors
and ways of doing and thinking about the organization. Such beliefs, values etc. are
learned, shared and transmitted by and through organization employees.

A more comprehensive definition of “Organizational culture refers to a system of

shared meaning”.

In every organization, there are patterns of beliefs, symbols, rituals, myths and
practices that have evolved over time. These, in turn, create a common understanding
among members as to what the organization is and how its members should behave.
Hence following are generally considered on the constituents of organizational culture
are Individual initiative, b. Risk tolerance, c. Direction, d. Integration, e. Management
Support, f. Control, g. Identity, h. Reward System, i. Conflict tolerance, j.
Communication patterns.

Organizational Culture and Organizational change

The first source of organizational culture is its founding fathers. An organization's

current culture, customs, traditions are largely due to what has been done before and
also its success in doing so. i.e. successful traditions, practices continue for more time.
Founding fathers have a vision/mission when they establish an organization.
Typically all organizations start as small organizations. (an example is that of Infosys
which started as group i.e. an organization of husband/wife and few friends and now
is an organization of more than 1 lakh employees) .Hence it is relatively easy for
founding fathers to disseminate their values and beliefs. Original founders have not
only the idea of its creation but also the means of fulfilling these. Thus the resultant
culture is one of the founders' ideas/beliefs and the first employees' reaction to
founders' ideas/beliefs. Once it is created, the question of its management arises.
 57

Following guidelines are useful in managing (i.e. planning, creating, sustaining)

organizational culture.

1. Formulate a clear strategic vision

2. Display Top management commitment

3. Model, culture change at the highest level

4. Modify the organization to support organizational change (i.e. modifications in

structure, HR resources, information, and control system

5. Select and socialize new-comers and terminate deviants (When a cultural change
has to be brought in, it is necessary to remove such people who cannot match with
new values, beliefs; and it is also necessary to bring in such people who subscribe
to organization's values and beliefs.)

6. Develop ethical and legal sensitivity: It is obvious that no culture shall exceed the
limits set by ethics that they cherish and laws which they have to abide by.
 58

2.17 Organizational Culture in Hospitals

Health is the fundamental quality of life. All human beings have an equal right to
good healthcare. A healthcare system may belong to public or/private. Health or
healthcare is the treatment and prevention of illness. Healthcare is delivered by
professionals in medicine, dentistry, nursing, pharmacy and allied health. The
healthcare industry incorporates several sectors that are dedicated to providing
healthcare services and products. According to industry and market classifications,
such as the Global Industry Classification Standard and the Industry Classification
Benchmark, the healthcare industry includes health care equipment and services as
well as pharmaceuticals, biotechnology, and life sciences. The particular sectors
associated with these groups are biotechnology, diagnostic substances, drug delivery,
drug manufacturers, hospitals, medical equipment and instruments, diagnostic
laboratories, nursing homes, providers of healthcare plans and home health care.
According to government-industry classifications, which are mostly based on the
United Nations system, the International Standard Industrial Classification,
healthcare generally consists of hospital activities, medical and dental practice
activities, and other human health activities.

The last class consists of all activities for human health not performed by hospitals,
physicians or dentists. This involves activities of, or under the supervision of, nurses,
midwives, physiotherapists, scientific or diagnostic laboratories, pathology clinics,
home, or other Para-medical practitioners in the field of optometry, hydrotherapy,
medical massage, yoga therapy, music therapy, occupational therapy, speech therapy,
chiropody, homeopathy, chiropractic, acupuncture, etc. Health and healthcare need to
be distinguished from each other for no better reason than that the former is often
incorrectly seen as a direct function of the latter. Heath is clearly not the mere absence
of disease. Good Health confers on a person or groups freedom from illness – and the
ability to realize one's potential. Health is, therefore, best understood as the
indispensable basis for defining a person's sense of well being. The health of
populations is a distinct key issue in public policy discourse in every mature society
often determining the deployment of huge society.

Healthcare covers not merely medical care but also all aspects pro preventive care too.
 59

Nor can it be limited to care rendered by or financed out of public expenditure- within
the government sector alone but must include incentives and disincentives for self-
care and care paid for by private citizens to get over ill health. Where, as in India,
private out-of-pocket expenditure dominates the cost financing healthcare, the effects
are bound t be regressive. Heath care at its essential core is widely recognized to be a
public good. Its demand and supply cannot, therefore, be left to be regulated solely by
the invisible hand on the market. Nor can it be established on considerations of utility
maximizing conduct alone.

Four criteria could be suggested- First universal access, and access to an adequate
level, and access without excessive burden. Second fair distribution of financial costs
for access and fair distribution of burden in rationing care and capacity and a constant
search for improvement to a more just system. Third training providers for
competence empathy and accountability, the pursuit of quality care and cost-effective
use of the results of relevant research. Last special attention to vulnerable groups such
children, women, disabled and the aged.

The Indian healthcare dates back to the Vedic system of healthcare (Ayurveda) in 5000
BC. Ayurveda proliferated the most during the Vedic period. The Ayurvedic principles
of positive health and therapeutic measures related to the physical, mental, social and
spiritual welfare of human beings. During the early Vedic period, Ayurveda was
perhaps the only system of overall healthcare and medicine. It enjoyed the unquestioned
patronage and support of the people and their rulers. Thereafter, the long medieval
history was marked by uncertain political conditions and several invasions. This was
when Ayurveda faced utter neglect and its growth was stunted. The Unani medicine
entered India during this time and gained momentum with the extensive support of
Mughal emperors. Later with the British invasion, Allopathy made an entry into
India. It was widely accepted because of its swift results.

In the past five decades, India has made a significant improvement in healthcare but it
still lags behind other developing countries on key health indicators. Being one of the
largest sectors in India, the revenues from the healthcare sector account for 5.2 percent
of the GDP making it the third largest growth sector in India. Public health expenditure
in India as a percentage of GDP is only 1percent leading to increasing private
 60

expenditure on healthcare. It has grown from USD 4.8 bn to USD 35 bn in 2007 and is
expected to touch USD 78.6 bn in 2012 and expected to cross USD 150 bn in 2016.

1. Employs over 4 million people Growth of 15percent per year expected over next
45 years Private segment constitutes the bulk and expected to reach USD 38 bn
by 2012.

2. India constitutes 17percent of the world's population but contributes to 20percent

of the disease burden. It has not been able to achieve the national goal set for the
year 2000 for a reduction in MMR, Polio, BCG cases by the National Health
Policy 1983.
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2.18 Organizational Culture in Indian Hospitals

Culture is an integral part of human lives and manifests in different forms such as
national culture, regional culture, organizational culture, department culture and so
on. Emile Durkheim often described as the classical social theorist of culture, defined
culture as an emergent web of representations which embodied the values, beliefs and
symbolic systems of a natural collectively. According to Durkheim, culture is a
manifestation of social bindings and human beings’ collective efforts to deal with the
complexities and uncertainties of life. It can be further described as a system of shared
values, beliefs and behaviors considered valid by the members of the organization and
taught to the newer members in the organization as the correct way to think, feel and
behave.

Edgar Schein divides organizational culture into three levels: Artefacts, Espoused
Values and Basic Underlying Assumptions. In other words, Culture is manifested in
the form of artifacts, mindset, and behavior. The various artifacts through which an
organizational culture can be observed are mission and vision statements of the
organization, logo, dress code, arrangement of furniture, language used, work-hour
flexibility, reward structure, performance evaluation processes and so on. Sometimes,
stories about the history of the organization are passed on through generations of
employees and are a source of great pride for the organization. Norms followed in an
organization give an idea about its culture too. Specific rituals and ceremonies
distinguish cultures of different organizations.

Hofstede’s analysis of national cultures can be applied to organizational culture as

well. Accordingly, there are four dimensions of culture: power-distance, uncertainty
avoidance, individualism versus collectivism and masculinity versus femininity.
Power distance refers to the degree of equality in the organization as perceived by an
employee lower in the hierarchy. Higher power distance indicates that inequalities
exist between different classes of employees. Uncertainty avoidance describes the
level of acceptance of uncertainty and ambiguity within the organization. The
dimension of individualism/collectivism denotes the degree to which the organization
emphasizes on individual/collective achievement. Masculinity versus femininity
denotes which are the predominant values of the system. While masculine
organizational cultures are denoted by competitive and assertive value systems,
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feminine organizational cultures have focused on relationships and quality of life. The
Hofstede’s model of cultural dimensions will be used in the subsequent sections to
understand the organizational culture of healthcare organizations in India and abroad.

The role of culture is important in assessing an organization’s performance. Culture

generates a commitment to something larger than the individual self-interest.
Employee performance attributes like productivity, job satisfaction and motivation
have been found to be positively correlated with organizational culture.
Organizational culture has an impact on various aspects of the Organization
including strategy, management practices, employee behavior, organizational
structure, policies, processes, and procedures. Organizational culture has been
classified into two types: strong and weak culture. Although, a strong culture shows
tremendous unity in the workplace, and commitment to the principles of the
organization, strong cultures have been shown to be associated with high inertia to
change. Strong culture may lead to failure of the organization if the employees stick
to their existing beliefs and methodologies in the face of change. But organizations
with strong culture also see high levels of commitment from employees and low
employee turnover.

Understanding the organizational culture and evaluating its impact on the organization
is crucial for the management to improve the performance outcomes of the
organization, along with helping them to decide strategies for the future.

Healthcare Sector is one of the fastest growing sectors in India. Privatization of the
sector has resulted in private sector owning 80percent of the healthcare market in
India. With many super-specialty hospitals in operation, affordable costs of treatment
and a vast base of experienced and skilled doctors, Indian Healthcare sector has
developed a lot in the last few years. Medical Tourism in India is at present a million
dollar business. Overseas patients come to India because of the low costs of treatment
(treatment costs in India are approximately 30-70percent lower than that of US) and
availability of skilled doctors. While the private hospitals are mostly a part of urban
India, Government provides healthcare services throughout the country extending
from the national level to the village level. The effort has been made in this thesis to
understand and capture the Organizational cultures of both private sector and
Government hospitals and analyze how it impacts their performance.
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a. Constituents and Structure of Organizational Culture in Healthcare

Organizations in India

Organizational Culture of Healthcare Organizations can be best understood by

looking at their vision and mission statements, organizational structure, their
leadership and management styles, and performance management and reward
systems. Hofstede’s cultural dimensions can prove useful for analyzing the
Organizational Culture of Healthcare institutions. The Organizational Culture also
depends on the psychological aspects of the work of hospital employees, like
emotional and physical stress, type of patients, social support system etc. The culture
is different for the private sector and Government organizations due to different
organizational structures, different goals, and different management styles.
Organizational Culture components and structure for both the private sector and
Government healthcare organizations are described below. The discussion on the
organizational culture of Government and private sector healthcare organizations are
based on study through visits to these hospitals and observing the day-to-day
functioning.

b. Government Healthcare Organizations

The healthcare services provided by the Government extend from national level to
village level. At the central level, there is the Union Ministry of Health and Family
Welfare, followed by various state level, regional level, and district level and
community level healthcare centers.

The Government Healthcare Organizations are run by a non-profit motive. These

organizations are characterized by a hierarchical structure. The employees have job
security, along with benefits like accommodation facilities. Moreover, the
Government healthcare organizations generally have pay-for-experience
compensation systems. The performance measurement systems use traditional
methods, mostly assessment by the immediate supervisor.

Using Hofstede’s cultural dimensions the culture of Government Healthcare

Organizations can be easily described. Government healthcare employees perceive the
existence of the large power gaps between the superiors and subordinates. Thus, the
culture is more segmented than unified in terms of power. Government healthcare
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employees are more set in their ways, with low levels of change-acceptance and
change-management. Thus, this culture scores low on the uncertainty avoidance
dimension. Government healthcare organizations have more feminine characteristics
with low-importance on competitiveness and high-importance on personal attributes.
The absence of pay-for-performance reward structures promotes a collectivist work
culture in these organizations.

c. Private Healthcare Organizations

Private Healthcare Organizations run with a profit motive. These organizations are
characterized by higher efficiency systems and processes, use of modern technology
and systems for operations, and competitiveness. The Organizational Structure
commonly found in the private healthcare organizations is hierarchical. Employees
are performance driven. Most of these organizations have high treatment costs as
compared to Government healthcare organizations. Accordingly, they aim to provide
better services through state-of-the-art infrastructure, better food facilities, more
personal care through the higher value of nurse-patient ratio etc.

The organizational culture varies with different private organizations. However, some
common characteristics do exist, which can be explained through Hofstede’s cultural
dimensions.There is the existence of power-gaps in the organization, with the
management and leadership essentially in control of decision making and change
management processes. Physicians are more empowered than the nurses to suggest
any changes in the management processes. These healthcare organizations are highly
competitive as they are run with profit-motives. Hence, a higher emphasis is given to
masculine cultural dimensions like competitiveness and assertiveness. Pay-for-
performance reward structures encourage individualistic culture rather than
collectivist culture. The management’s focus is on sustaining in the competitive
healthcare industry, and hence, they frequently change strategies. The employees,
thus, are more open to changes and are adaptable. Thus, there exists a culture of lower
uncertainty avoidance.

d. Cultural Characteristics of Healthcare Organizations

Healthcare Organizations, in general, have a demanding work environment. The

nurses and physicians, in particular, have a hectic job-life, with a weak social-support
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system in the hospitals. Many times, high emotional turmoil is faced by nurses and
physicians involved with patients nearing their ends. Physicians and nurses working
in surgical departments and ICUs also deal with stress. Nurses, especially, face the
stress of balancing work-home life. This stressful work environment requires a social
support system, which however is not well-developed in Indian Healthcare
Organizations.

Physicians and nurses have been found to favor a culture of internal focus, stability,
and control. Physicians and nurses also indicated that they had a low level of personal
involvement in their organizations, with both of these groups perceiving the
organizational structure to be hierarchical. However, they have a high preference for
clan culture and least performance for hierarchical culture. Moreover, nurses perceive
the existence of high power-distance in the organization and believe they have less
possibility to propose changes in management activities.

Lack of flexibility at the job place is another challenge for the healthcare
organizations. Maintaining a work-life balance is tough for the hospital staff with shift
duties assigned to them. Female hospital staffs, including nurses and receptionists,
have to manage night-time shifts, along with taking care of their family. This gives
rise to the need for support in the workplace and from the family. Many times, the
family of the female staffs are not supportive of their working night shifts. Turmoil at
home with lack of a social support system at the workplace does not provide a healthy
work climate for the female employees of the hospital.

Jobs related to intensive-patient care have high attrition rates, especially in the private
sector healthcare organizations. This problem is not limited to India only. Continence
care in nursing homes is one such area which sees high attrition rates across the
world.

An example to show how the organizational culture of an organization can be

identified by looking at the artifacts, and mindset and behavior of the employees of
the organization is given below:

Apollo hospitals are one of the largest healthcare organizations operating in India and
Asia, with their businesses ranging from hospitals to pharmacies and consultancies.
This organization has total employee strength of 30,640. The Company’s vision
 66

statement is “to touch a billion lives” and its mission statement is “to bring healthcare
standards within the reach of every individual…committed to the achievement and
maintenance of excellence in education, research and healthcare for the benefit of
humanity”. This vision and mission statement shows that the organizational culture of
this organization is more leaned towards innovation and competition. The inclusion of
education and research in its mission statement shows that Apollo hospital is
promoting an innovative and knowledge-oriented work culture. The vision to touch a
billion lives basically indicates the management is emphasizing on being competitive.
On analyzing the artifacts and business processes of Apollo Hospitals, it is found that
most of the processes are computerized, again leading towards technology innovation-
and competition-oriented organizational culture. The doctors and nurses are provided
with customized training programs. This provides a sense of involvement to the
doctors and nurses and encourages them to develop themselves, helping the
organization build a culture focusing on education and innovation.

e. Impact of Organizational Culture on Performance of Healthcare

Organizations in India

The notion that organizational culture has an impact on the performance of healthcare
organizations is based on certain assumptions: a) healthcare organizations have
identifiable cultures b) culture is related to performance c) culture can be modified to
have an impact on performance and d) this alteration will provide a worthwhile return
on investment. It has been established in the previous section that healthcare
organizations, be it Government or private sector, and have cultures specific to their
organizations. There is also evidence for the second assumption. Research in
management areas has established that there exist links between culture and
performance. A wide range of studies in the area of culture and change have shown
that organization culture is susceptible to change and changes in organizational
culture may generate minor, major or dysfunctional effects on the organizational
performance. These researchers are mainly concentrated on the non-healthcare
organizations. Russell Mannion and his companions have done an extensive literature
review to link these research results to healthcare organizations as well. Thereby, it
can be concluded that healthcare organizations have cultures, which can be impacted
by procedural or structural changes, and thus affect the performance of the
organizations.
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Organizational Culture of a healthcare organization has been shown to influence the

performance of the organizations in many aspects: human resource management,
service to patients, and economic performance. Various success stories of
achievement of organizational excellence by transforming organizational culture exist
in the literature. One such story is that of Baptist Hospital in Florida. It started with
the CEO of the hospital constructing a vision for the hospital to make it the best
healthcare organization in America. Priority was changed to relationships between
employees and patients. These changes enabled the hospital to become number one
inpatient service quality which has been acknowledged in different surveys and by the
prestigious Baldrige Group.

Organizational Culture has been shown to impact job-satisfaction and motivation of

employees. A healthy organizational culture can work wonders on job-satisfaction of
employees. This can be illustrated by the example of Griffin Hospital in Connecticut.
This organization approached the problem of high attrition rate and lower employee
motivation by bringing about a change in the organizational culture. The leadership
changed the hierarchical organizational structure to convert it into a caring culture.
Nursing turnover decreased significantly and patient satisfaction increased.

Culture and Human Resource Management are interrelated. While human resource
practices like recruitment styles, compensation and reward structures, performance
management systems, and socialization events help in creation and maintenance of the
culture of an organization, organizational culture also has impact on human resource
practices like ensuring motivation and job-satisfaction among employees for better
productivity, employee retention, creation of positive employment image for
prospective employees and effective team-work systems.

Research pertaining to the impact of organizational culture on the performance of

healthcare organizations in India is not well developed. However, there are
similarities between the healthcare organizations’ cultures, and the basic assumptions
remain the same. Hence, inferences from the research done on foreign healthcare
organizations can be applied to the Indian Healthcare Organizations as well.

One such success story in the Indian healthcare scenario is that of Sri SatyaSai
Hospital in Puttaparthi, Andhra Pradesh. This healthcare organization is different
from other healthcare organizations in many ways. Its unique culture arises from a
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caring culture, driven by the belief of ‘Seva’. World-renowned doctors come to serve
in the hospital free of cost, just to get happiness from doing service to mankind. The
quality of service of this organization is considered one of the best in the world, with
free treatments given in super-specialty areas. The success of this organization in
service quality and high involvement of doctors and nurses is an example of how
organizational culture impact organizational performance.

Hierarchical organizational culture has been negatively associated with satisfaction

with managerial decisions. Research shows that organizational culture not only
impacts work attitudes but also has an impact on organizational climate.
Organizational Climate depicts a global representation of one’s organization and
influences employee’s behavior and attitude in the workplace. It includes perceptions
of the employee regarding work environment and tasks. Constructive culture is
required for the positive organizational climate which will improve the work attitudes
of employees for better performance of healthcare organizations. Some of the
essential cultural characteristics that will have a positive impact on the performance of
the healthcare organizations are people orientation, team orientation, and an open
attitude towards change and innovation. However, transforming culture is not an easy
task. Cultural change strategies may be targeted at first order or second order change.
Strategies covering structural, process and contextual dimensions are required for
successful cultural transformation.

f. Role of Leadership in Managing Organizational Culture in Healthcare

Organizations

An effective leader is one who leads the way towards the vision of the organization by
ensuring employee involvement and satisfaction in the process. Healthcare
environment calls for a supportive leader who is empathetic and responsive to the
employees and preserves the power status within the hospital system. Leadership can
influence the organization climate, thereby influencing the workplace attitudes of the
employees. Leadership behavior has been shown to be positively correlated with job
satisfaction.

Leaders need to be dynamic and far-sighted. In today’s dynamic and unpredictable

world, leaders need to set direction, create motivation and commitment among
employees, partners, and stakeholders, while continuing to provide high-quality
 69

patient care. Healthcare Organizations of the present day world face as much
challenges in their operations as do the banking organizations. Healthcare
Organizations’ success depends on their ability to attract and retain highly-qualified
and experienced doctors and nurses. Healthcare Organizations are affected by
changing Government policies regarding safety and environment, rapid technological
obsolescence of existing facilities and medical equipment, and competition from
existing and new players in the market. This requires an effective leadership and
management team in place to ensure the smooth-running of the organization. The
various challenges faced by the employees of the healthcare organizations have to be
handled by the leadership. Leaders in the healthcare industry need to be empathetic to
the hospital staff. At the same time, the leadership needs to be aware of the changing
rules of the game of the industry. An efficient leader for a healthcare organization is
one who can motivate the employees of the organization, provide them with a positive
work environment, and lead the organization towards its vision.

Research shows that healthcare organizations are yet to develop themselves in the
leadership arena. The key findings of a CCL study in the area of leadership in
healthcare organizations are: a) top-priority for leadership development in the
healthcare sector is to enhance skills for leading teams b) provide current and future
leaders with cross-organizational experiences and c) emphasize on qualities like
adapting to change.

As said by Peter Drucker, “Management is about doing things right; whereas

Leadership is doing the right things”. A poll held in 2003 showed that 90 of 180
healthcare executives believed that healthcare as a profession drives away potential
leaders from the industry. Moreover, it is being predicted that there will be a 15
percent drop in the leadership pool of the healthcare industry over the next few years.
Thus, there is a need to develop leadership qualities among the executives of the
healthcare industry, as well as attract leaders from outside the industry.

Leadership talent can be developed in healthcare organizations through five key steps:

a)Identification of key competencies for leadership b)effective job design c) giving

priority to leadership recruitment, development and retention d) leadership training
and development programs and e) continuous leadership assessment and performance
management.
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Some of the characteristics of highest performing leaders are a strong character,

strong technical knowledge, deep understanding of the industry, initiative-taking and
driving for results, and strong at interpersonal skills. The character of a person is
generally by birth. Leadership development programs should hence focus on building
up the developable competencies like communication skills.

The leadership qualities can be developed through continuous leadership training and
development programs. The success of these programs should also be assessed at
regular intervals. Some of the expected direct results for the healthcare organization
through the creation of effective leadership are excellent service, retention of
employees, lower attrition and absenteeism, an increase in market share and revenues.
Some other indirect measures of successful leadership are employee motivation and
job satisfaction in the workplace. These success measures should be assessed
continuously for measuring the effectiveness of the leadership development programs.

g. Hospital Work Culture

People in most countries see healthcare as an important priority and it is likely to

become even more important as populations age. In response to this need, national
and local governments devote significant amounts of their budgets to funding their
healthcare systems. With all the changes taking place in healthcare, now is a good
time to look at your hospital's culture.

No matter the healthcare industry, company culture is a vital component in the

productivity and performance of the workforce. A hospital’s internal culture can
impact nurse relations, patient care and even the amount of overtime certain workers
accumulate. In an article for Nursing Times, Steve Mee, senior lecturer at the
University of Cumbria, wrote nurses’ substandard performance can often be attributed
to their hospital’s workplace culture. In fact, professionals in many industries believe
their current company cultures don’t foster teamwork well enough as it should. A
recent study by consulting firm Booz & Company found 96 percent of more than
2,200 surveyed executives, managers and employees believe their companies need a
drastic culture change.

With hospital culture being an essential aspect to nurse performance and engagement
as well as their ability to deliver high-quality patient care, examining culture’s role in
 71

the workplace might be a great way for Chief Executive Officers and Nursing
Superintendents to understand the changes that are needed. From recruiting top talent
to tracking nurse performance, reviewing the hospital cultures is important to enable
the health system to transition to pay-for-performance and determine safe staffing
levels. Using talent management solutions within the Healthcare Workforce
Information Exchange (HwIE) can help hospitals optimize their workforce and
improve employee productivity even more.

h. Assessing and Improving Hospital Culture

According to an interview with The Wall Street Journal’s The Experts blog, Robert
Plant, an associate professor at the University of Miami, said research has shown a
company with an effective workplace culture can have 20 to 30 percent higher
employee performance than a competitor with a mediocre culture. A hospital’s culture
is normally embedded deep within the organization, yet Plant said workplace culture
can evolve to cultivate strong performance and productivity. According to human
resource site TLNT, company culture can be difficult to effectively manage if leaders
haven’t established a strong foundation. In healthcare, this base can be delivering
great care to patients, and executives can utilize a three-step process from Stephen
Covey, a professor at Utah State University, to determine their organization’s type of
culture:

1. Assess the current culture and employee performance

2. Define the final vision of workplace culture and top performance priorities

3. Clarify expected results, behaviors, and values

Hospital executives can begin evaluating their organization’s workplace culture

through Covey’s first step, which might show improvements, such as nurse
manager training, are needed for nurses and other members of staff to boost their
performance. CEOs and other organization decision-makers might see opposition,
however. According to Mee, some hospital employees might try to explain their
negative behavior or subpar performance as being external to them. Essentially, Mee
wrote often nurses with unsatisfactory performance may say in their own way that, “It
was not me, it was the culture.” However, Mee wrote fostering a culture where nurse
training is provided, high quality of care is expected and performance transparency is
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a focus can help hospitals determine which nurses are the best and prevent subpar
work from being blamed on the organization. Altering a negative hospital culture
might even improve the hospital’s retention of the best nurses, effectively reducing
hiring costs as well.

Younger doctors, nurses, and staff who enter the system bring with them new values,
beliefs, and work styles. And yet every hospital operates with exactly the same
culture--values, beliefs, and behaviors--as it had done for many years.

The approach grounded in the research and methods developed by Kim Cameron and
Robert E. Quinn at the University of Michigan. For more than a decade, they
researched the many different types of cultural styles at play in companies and
organizations. They then grouped these styles into four quadrants, differing by the
degree to which companies were internally or externally focused, and flexible or
controlling.

Based on the Competing Values Framework developed by Robert E. Quinn, they

developed a short but very powerful questionnaire to help companies assess their
culture as they experience it today and as they prefer it in the future. This tool is
called the Organizational Culture Assessment Instrument (OCAI).

OCAI creates a graph for each person, expands it to each department and then the
entire organization. There are always deep tensions at the heart of a culture change
process. People may not like "the way it's always been done" yet they hold on tight to
what they know. Habits are hard to break and the brain hates to change. Therefore, the
process to undertake culture change must be highly collaborative and very much like
a theatrical performance. Even if people don't want to perform the play anymore,
everyone knows their roles. Culture change is very much like learning a new role in a
new performance.

Once the journey begins and a new script is learned, it is harder to go back to the old
(which wasn't getting you to the future anyway). So what will make "a new way of
doing things" stick? Strong leadership, lots of small wins and constant
encouragement.
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i. Best Practices to foster a great Hospital Culture

Becker’s Hospital Review suggested hospital administrators and managers recruit

nurses with positive attitudes and who would help cultivate a culture of teamwork,
collaboration and high quality of care expectations. These new nurses can help Chief
Executive Officers (CEOs) and hospital executives begin to evolve the company
culture toward value-based care and encourage other nurses to follow suit. This might
be a great way for hospitals to use Covey’s second step – defining the organization’s
vision – because it can help health systems establish their core values and motivate
employees to keep these qualities in mind.

Other best practices can include these three priorities: monitoring nurse performance
to only promote and reward the workers who foster a positive culture and great
performance; encouraging top workers to refer candidates; and making sure culture
expectations are put forward in the hiring process.

The challenges of the healthcare industry today require hospitals and health systems
to apply all available resources to a strategy for reducing cost and improving quality.
One of healthcare organizations' greatest resources — and often the key to the success
of new initiatives — is their employees. Attracting and retaining skilled employees
necessitates a nurturing environment that encourages and rewards innovation through
both material and nonmaterial benefits.

While tangible benefits, such as health insurance and compensation, are important to
employee satisfaction, what may be more important are intangible benefits, such as
respect and recognition. "It's not about the money," says Paul Spiegelman, founder
and CEO of BerylHealth, a company focused on the patient experience. "People want
to feel valued." In fact, most of the following pillars of success involve abstract
concepts that while difficult to define, may ultimately separate a "good" workplace
from a "great" one.

Hospitals and health systems identified by employees as great places to work have
developed a culture that reflects the values of the workers and organization. "An
overarching cultural tenet of the health system is transparency, inclusiveness, and
stewardship toward our employees. It's the overarching cultural component that drives
 74

everything else," says Stephen L. Mansfield, Ph.D., president, and CEO of Dallas-
based Methodist Health System.

Similarly West Orange, N.J.-based Barnabas Health focuses on creating a friendly

environment to make employees feel welcome and happy. To create this environment,
the recently retired Barnabas Health president and CEO Ronald J. Del Mauro
encouraged people to always say hello to each other, according to current health
system president and CEO Barry H. Ostrowsky.

Just as something simple like saying hello can improve an environment, building a
healthy workplace culture generally depends on many small factors rather than one
expensive program, according to Mr. Spiegelman. "[It's about] very small things that
simply show people that you care about them and not about doing expensive events,"
he says. Sending a note of recognition, for instance, can affect a patient as much as or
more than a large, costly party. Dr. Mansfield attributes Methodist Health System's
eight consecutive Dallas Business Journal Best Places to Work awards to a myriad of
elements that "become embedded in the culture."

Creating a culture focused on the organization's employees is important not only for
employee satisfaction but also for patient engagement. Mr. Spiegelman says
healthcare organizations are beginning to realize that "the only way to be patient-
focused is to be employee-focused and to start first with developing an environment
in which employees enjoy what they do every day." The organization's leadership is
essential for developing an enduring employee-focused culture
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2.19 Organizational Culture and Safety

Ever since INSAG coined the term ‘safety culture’ to denote the far from
optimal conditions and decision processes at the Chernobyl nuclear power plant
(International Nuclear Safety Advisory Group 1986), it has become part of
the standard explanatory safety vocabulary. Safety culture became a term with
which people all around the globe explained everything they could not explain or
understand otherwise. Whether the concept itself remained fuzzy, did not seem
to matter much. However, this fuzziness is both its strength and its weakness.
Indeed, (groups of) people sometimes seem to perform in dark mysterious ways
(Kets de Vries 1999) and, when groping for an explanation, a concept such as safety
culture is highly attractive. A similar (initial) attraction can be identified
in the development of the organizational culture concept (Salzer-Morling 2003);
a discussion of the weakness of such a concept will be taken up below.

As with culture and organizational culture, safety culture has been defined by
different authors differently, although many seem to refer to the same notion of
shared basic assumptions, a shared understanding of reality (Antonsen 2009). How
safety culture is studied will be discussed next, organized according to the three
major approaches, the academic, the analytical and the pragmatic approach. For
each of these approaches the dominant paradigm, the primary research methods
and some example studies will be given.

a. Academic or Anthropological Approach

The primary research methodology of cultural anthropology is field research

(ethnography), which is qualitative in nature. Its purpose is to describe and
understand a culture rather than evaluate it and, hence, it is non-normative
or value-free. Moreover, the subject is never fitted onto some researcher’s
pre-existing notions. Because of these characteristics, it is not well-suited for
comparative research. Applied to organizations, culture is considered as something
an organization is, rather than has. This approach is labeled ‘academic’ as it
is employed almost exclusively by academics and it is hardly used outside the
scientific realm (Hofstede 1991: 180), although the International Atomic Energy
Agency (IAEA) is currently advocating a safety culture self-assessment (SCSA)
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for its member states, involving just such an approach. Schein has adopted this
the approach in what he calls ‘clinical research’ (Schein 1987). The term clinical
already betrays the fact that some evaluation is taking place, but this is more in
terms of a discrepancy between a given organization’s ambitions or intentions and
what it actually accomplishes. In terms of safety, this can become pertinent when
a company claims to put safety as its number one priority, but nevertheless has
many accidents.

The research method can be narrative research, a phenomenological study, a

study using grounded theory, an ethnography or a case study (Creswell 2007), or
various combinations thereof. Ideally, the research starts with a problem definition
or an issue turned into a problem to focus the investigation; for instance, the
the discrepancy between safety priority and performance mentioned above. Research
techniques include interviews, observations, document studies and whatever else
the company brings forth that may hold clues to its underlying assumptions
(see Guldenmund 2010 for an overview). What is important, however, is that
information is collected with sufficient context so that it can be interpreted
accurately.

Whatever research method is chosen (case study, grounded theory, etc.) the
results are (almost) never quantified because it is meaning and interpretation
and not some numerical abstractions and calculations that drive the research.
Moreover, numbers are never taken as data abstracted from an objective world, which
would be in conflict with the research paradigm. The result is a ‘thick
description’ (Geertz 1973), or a ‘theory’ of the culture of an organization
(cf. Glaser and Strauss 1967). When the description or theory turns out to be
incomplete or ‘wrong’, the theory is adjusted to accommodate the contrasting
empirical findings. Falsification can occur when another researcher with the
same data comes with a different description or theory. In this approach safety
culture is considered to be a nominal variable.

Current safety culture literature is still not well endowed with qualitative
studies. This might be due to both publication policies, i.e. encouragement of
quantitative rather than qualitative studies, and limitations regarding length of
papers. Books describing such studies are equally absent. Moreover, methods are
 77

limited to either studies building on grounded theory (e.g. Berends 1995; Stave
and Törner 2007; Walker 2008) or case studies (e.g. Brooks 2008; FarringtonDarby et
al. 2005; Guldenmund 2008; Meijer 1999).

b. Analytical or Psychological Approach

This approach is the study of safety culture through (self-administered)

questionnaires, which is the primary research instrument of (social and
organizational) psychologists. This approach could be considered ‘analytical’ in
that it considers safety culture an attribute of an organization, i.e. something an
the organization has, rather than is (cf. Hofstede 1991, but see also the discussion
above) and isolates parts of it that are considered important or indicative to assess.

The field of safety culture is very much dominated by questionnaire studies;

possibly because surveys are deceptively simple to use; probably also, because
questionnaires are so popular with organizational psychologists. In various
papers this approach has been disqualified as culture research and has been
placed under the heading of safety climate (Collins and Gadd 2002; Glendon and
Litherland 2001; Guldenmund 2000). Safety climate is considered to be a transient
psychological variable, much less stable than safety culture.

Questionnaire studies generally follow this routine. First, potential concepts or

facets of interest are identified that together make up the construct; this could be
the result of a qualitative study. Based on these a questionnaire is composed using
questions that cover the pertinent concepts best. This is at first an assumption
which is tested in a subsequent survey where the questionnaires are put to an
appropriate population. Subsequent data analyses should reveal whether the
assumed concepts are actually present in the responses. The concepts are often
conceived as dimensions spanning a multidimensional space; (sub-) cultures than
become positions in that space. Additional analysis methods can model various
relationships between the concepts that make up the cultural construct and other
numerical variables from outside the questionnaire. This way culture is caught in
a web of concepts.

Paradigmatically, this appears to be a positivistic, (semi-)quantitative approach,

because the questionnaire results are numerical as the questions are often answered on
 78

19
a numbered response scale (e.g. a Likert-scale or a semantic differential).
However, the analytical approach also has qualitative – that is, interpretive –
elements to it. For instance, although the questionnaire should have a solid theoretical
underpinning (as reflected in the chosen concepts), a subsequent analysis could go
beyond these concepts and aim for new and (or) improved ones. Nevertheless, the
the final goal is to develop a robust set of general concepts (factors, dimensions,
scales,
facets) on which organizations can be assessed and, if necessary, compared. These
latter characteristics make the analytical approach, in contrast to the previous
the academic approach, well-suited for comparative research. Such comparisons are,
in principle, non-normative; that is, the mean scores do not have an evaluative
sign to them, although the underlying individual responses might be based on such
evaluations, preferences or perceptions (cf. Hofstede 2001: 15 ff.).

There are several important aspects of this approach, however, that are
sometimes overlooked. For one thing, the numbers obtained from the rating
scales are basically at the ordinal level of measurement. When such numbers are
treated as though they are at a higher measurement level, there should at least be
checks to see whether this assumption is justified. For another, although safety
the climate is not culture, it is still an emergent property of a group and therefore
the within-group agreement, i.e. the coherence, should be tested (e.g. Zohar
and Luria 2005). There are several indices available for this purpose, see Bliese
(2006) for an overview.

The analytical approach can be considered a research methodology, which

can be employed in either a case study or a (comparative) survey encompassing
several organizations. Its research technique is a standardized questionnaire
that is typically self-administered. It can be administered either group-wise, for
the instance at the start of a company training session, or sent to the worker’s home
addresses.

To summarise, viewed from the analytical perspective culture is a

multidimensional construct and different cultures can be positioned at diverse

19
There is a way of putting the questionnaire to qualitative use. The analysis then is not aimed at
spanning a multidimensional space and projecting cases into it. The responses are used to generate
themes, which are used in subsequent (qualitative) research (for example, see Guldenmund 2008).
 79

positions in that space. These dimensions are either given beforehand or

determined by analysis. An organization’s position in the culture space is
calculated using questionnaire responses, often by using the mean as a descriptor
of a dimension. There is abundant literature about research applying the analytic
the approach, aimed at the development of a questionnaire (e.g. Berends 1995;
DeDobbeleer and Béland 1991; Díaz-Cabrera et al. 2007; Human Engineering
Ltd. 2005; Kines et al. 2011), a case study (e.g. Guldenmund 2008; Havold
2005; Reiman and Oedewald 2004), a comparative study (e.g. Nielsen et al.
2008; Reiman et al. 2005; Zohar and Luria 2005), or modeling relationships
(e.g. Cheyne et al. 1998; Johnson 2007; Neal and Griffin 2006).

c. Pragmatic or Experience-based Approach

There is yet another approach that can be distinguished in safety culture research.
While the previous approaches could be considered descriptive, the pragmatic
the approach is normative. From an academic, interpretative point of view a
culture can be neither ‘good’ nor ‘bad’; such evaluations having been replaced
by a relativist position. From the ‘academic’ perspective cultures are largely
functional and have to mean in relation to their context and history. However,
an organizational culture might be considered dysfunctional in relation to its
future, for instance in relation to particular ambitions or goals. Such ambitions
can be about many things, and therefore also about safety. For example, an
organization’s ambition might be to have ‘zero’ accidents but serious accidents
might still occur occasionally.

This normative approach has been labeled pragmatic because of its content
is not so much the result of empirical research on cultures but is rather based
on experience and expert judgment. In practice, the pragmatic approach
concentrates on both the structure and processes or interactions of an organization,
which, because of their dynamic interplay, will influence the culture in the long
run (see Figure 2.2). Applied approaches concentrating on processes often focus
on desired behavior and the correction of deviations (e.g. DuPont’s STOPTM or
ProAct Safety’s Lean Behavior-Based SafetySM). It is thought that a change in
behavior will result in subsequent cultural adjustments. According to cognitive
dissonance theory (Eagly and Chaiken 1993: 469 ff.), attitudes and thoughts
 80

about particular behaviors will change in the long run when the two are
incongruent and the desired behavior is rewarded.

Typically, what an organization should do to obtain an advanced or mature status

is prescribed in detail; that is, what processes should be implemented, supported
by an accompanying structure. Geller’s Total Safety Culture (Geller 1994) is a
a prime example of this approach, and the IAEA requirements and characteristics for
nuclear power plants are of a similar nature (International Nuclear Safety Advisory
Group 1991). Descriptive approaches towards culture such as the ones already
discussed are of less relevance here, because it is not the organization’s current
status but deviations from a predefined norm that is assessed and considered.
However, knowledge of the current status might result in dissatisfaction with
management which can be helpful in providing the organization with a sense of
the urgency for change. Moreover, such knowledge also provides information on what
structure and processes are suitable given the current status.

Lately, stages or levels of organizational maturity with regard to safety

management has become fashionable (e.g. Energy Institute undated; Lardner
2004; Parker et al. 2006; Westrum 2004). Each level describes common local
attitudes and behaviors in relation to safety, especially in relation to incident and
accident prevention, reporting, investigation and solutions. An initial diagnosis of
the current organizational status in relation to these attitudes and behaviors might
be prepared. However, the main objective is to ascend the safety maturity hierarchy.

This might be accomplished by following the behavioral approach above, i.e. an

emphasis on processes and behaviors in these, or with more structural adaptations.
It is again assumed that culture will follow in the wake of these interventions. This
the approach assumes, rather implicitly, that safety culture is something an
organization
has, or does not have; that is, mature ‘generative’ or ‘cooperating’ organizations
have ‘it’, whereas immature ‘pathological’ or ‘emerging’ (Energy Institute undated;
Lardner 2004; Westrum 2004) organizations do not.

The level of development of an organization is assessed through behaviorally

anchored rating scales, with either overt or covert ordinal scales. These
assessments are always done in groups for two important reasons. Firstly, it is a
 81

group’s shared opinions one is after, not the mean score of a group of employees.
Secondly, it is not so much the rating but the ensuing discussion that follows
because of this rating process that is considered the most important outcome.
Nevertheless, scores are calculated and reported back to the organization.

From the point of view of the interpretative academic approach the inferences
that are made about an underlying culture solely based on descriptions of behavior
are committing a mortal sin. According to this approach, it is impossible to infer
such meanings based on observed behavior. Geertz, quoting the philosopher Ryle,
illustrates this nicely by comparing a wink with a twitch and with a parody of a wink:
all three look much the same but have quite different meanings (Geertz 1973: 6 ff.).

To summarise, regarding the matter of safety culture and its assessment, there
are several aspects that require particular attention:

1. From an academic viewpoint, culture is a value-free concept (a nominal

variable) whereas safety is not. The required purpose of safety culture
assessments are not descriptions but evaluations, preferably with
recommendations on how the underlying culture can be improved to
support safety (more).
2. Safety is about behavior, whereas culture is about the meaning of
behavior. The relationship of culture with behavior is partly dependent on
the strength with which the core assumptions are held. Hence, knowledge
about the direction of assumptions is not sufficient; also their intensity is
important for behavior.
3. The assessment of culture is therefore complicated and certainly not
straightforward. Behavior has become the major focus of allusions
to an underlying culture. In the end, the actual meaning of the observed
behavior becomes much less important than the behavior itself.
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2.20 The concept of Patient Safety Culture

Patient safety culture is a reasonably new development of the organizational safety

culture construct. As with other types of culture, the addition ‘patient safety’
serves as a qualifier for the general concept of organizational culture. By using this
qualifier the proposition is made that an organizational culture can be conducive,
or unfavorable, to patient safety.

Within hospitals, several distinct groups operate, with different functions,

tasks, and experiences and with different educational backgrounds. Through
the interaction between them and with patients, common systems of meaning
will develop in teams, wards, departments and even hospitals. Because of these
interactions will be intense and often emotion-laden, several of these meanings
around patient safety will be profound. Moreover, public attention to patient
safety will also have shaped these meanings. Overall, the notion of patient safety
culture appears to have face validity.

The exploration of patient safety culture through the exclusive use of

questionnaires are contrary to the concept of safety culture. This approach has
been labeled ‘analytical’ above. While questionnaires certainly have merit in
the study of culture, the insight they provide is shallow compared to the results
of the qualitative ‘academic’ approach. Moreover, what might be an important
(cultural) meaning in one hospital might be different or absent in another.
Questionnaires do not adapt themselves to such local differences or nuances,
whereas an ethnographic field study does. Furthermore, surveys collect thoughts,
attitudes, and perceptions rather than the basic assumptions, which are thought
to underlie these and actual practice. It should be clear that the study of patient
safety culture should comprise both approaches, so the validity of the concepts
used in the questionnaire, can be tested across hospitals within and between
countries.
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2.21 Summary

Culture is a prerequisite for human beings to be able to live, to understand their

surroundings, to work together. There are many definitions around and these
often differ in their wording, but not so much in their essence (e.g. Antonsen
2009). Culture is the result of a process based on sense-making and interaction and
adjustment within a group, yet it is never an intended result but rather a modus
vivendi developed by the group while operating together. Culture transcends the
individuals that share the culture, as it is passed on and, relatively, enduring.

Conceptually, culture can be thought of as a group’s shared understanding of

the reality, as a way of looking at and experiencing that reality and all the things that
happen in it. Culture research is aimed at describing the lens through which a
particular group experiences its reality. Culture can be studied at different levels,
with the level of the nation considered to be the highest one. The construct can
be modeled as something consisting of an invisible and relatively intangible
the core that is projected onto one or more outer layers, which are taken as the
manifestations of the core. The core represents the basic assumptions of the group
that help its members understand reality. Built onto these are various norms,
rituals, institutions, symbols, and behaviors which are particular expressions of
the core.

Three ways of approaching culture are available, the academic, the analytical
and the pragmatic approach. The academic approach makes use of qualitative
techniques and results in a thick description of a culture which is value-free.
The analytical approach is based on self-administered questionnaires and makes
comparisons between (sub-) cultures possible. Finally, the pragmatic approach
uses developmental hierarchies to describe cultures. Organizations are supposed
to aim for the highest steps on these hierarchies.

The culture development process might be used to formulate general

intervention strategies that could influence the different steps of this process. In
general, using several interventions at the same time might be more effective than
carrying them out in succession or doing a few.
 84

Finally, the concept of patient safety culture appears to have face validity.
However, its study should not limit itself to the use of climate questionnaires but
should rather encompass qualitative studies that could provide the questionnaire
with a more solid conceptual backing.
 85

Part – III: Patient Safety in Hospitals

‘Primum non nocere’

--First, do no harm (Latin Phrase)

The previous Part II of this chapter introduced the organizational culture in hospitals.
This Part III of this chapter follows by defining the topic’s terminology and providing
the historical development of patient safety. It presents a review of the relevant
literature on different aspects of patient safety, including strategies used to improve
patient safety internationally and in India. This study reviewed and evaluated previous
research critically to determine important foundations in safety science in general and,
more specifically, in patient safety.

2.22 Introduction

In November 1999, the Institute of Medicine (IOM) in the United States of

America estimated that from 44,000 to 98,000 people died each year as a result of
medical errors. At the same time, the financial damage that resulted from medical
errors were estimated at US$17 billion to US$29 billion (Kohn, Corrigan &
Donaldson, 2000). Like nuclear generator plants, as well as the aviation industry
and chemical industry, medical institutions are considered high-risk industries.
However, when compared to the large volume of media attention and reports
sparked off by aviation accidents, it is generally believed that mistakes committed
by medical institutions are underreported. This is large because cases are sporadic
and the attribution of mistakes is unclear, hence attracting less attention (Gaba,
2000). Although less attention is paid to the problem, it continues to exist and
patients accepting medical care will forever bear uncertain risks as long as the
problem remains.

According to the literature, organizational characteristic factors such as organizational

culture, leadership style and the degree of leader involvement, communication
 86

systems, participation of patients and families, and human resource management

methods (Firth-Cozens, 2001; Wakefield et al., 2001; Nieva & Sorra, 2003; Pronovst,
Weast & Holzmueller, 2003; Singer et al., 2003; Flin & Yule, 2004; Hoff, Jameson,
Hannan & Flink, 2004; Rockville, Sorra & Nieva, 2004; Wong & Belglaryan, 2004;
Singer & Tucker, 2006) could all affect the successful implementation of patient
safety. Among them, organizational culture is the most important factor. This is
because the spread of culture by word-of-mouth, role models, and other
considerations, can communicate the behavior and attitudes that the organization
prefers or expects (Schein, 1992). Therefore, through organizational culture,
organizations can create the most desirable behavior (Davies, 2000), which includes
the requirement for a safe patient environment. Patient safety is defined as the
avoidance, prevention, and amelioration of undesirable events or harm that can occur
in the treatment process. These undesirable events are made up of terms such as
errors, risk, hazard, healthcare-associated injuries, near mistakes, adverse events,
negligence, deviation and accident (Gaba, 2000; Battle & Lilford, 2003).

The importance of organizational culture lies in its omnipresence. It could be

the glue that binds the organization together (Deal & Kennedy, 1982) or it could set
the boundaries of the values and behavior of its members (Rousseau, 1990). It
could even play the role of societal control in clarifying or understanding if the
conduct and attitude displayed by organizational members is appropriate (O’Reilly
& Chatman, 1996). Therefore, the role of culture in an organization is very
important, particularly when it comes to implementing new policies that require
culture to drive and shape them (Scally & Donaldson, 1998; Kohn et al., 2000).
 87

2.23 Safety Culture

‘Few phrases occur more frequently in discussions about hazardous technologies

than safety culture. Few things are so sought after and yet so little understood’
--Reason (1997)

Safety culture of an organization is the product of individual and group values,

attitudes, perceptions, competencies, and patterns of behavior that determine the
commitment to, and the style and proficiency of an organization’s healthcare and
safety management.

One of the most important elements which draw on the systems approach is
the concept of safety culture. The Chernobyl accident investigation report by
the International Atomic Energy Agency (IAEA) for example, described the
accident as partly arising through a ‘poor safety culture’ at the plant and within
the wider Soviet society (INSAG 1986; Antonsen 2009). Since that time there
has been an enormous amount of research on the topic and a wide variety of
measurement tools and frameworks exist across a range of application domains
(e.g. rail – RSSB 2011; aviation – Isaac et al. 2002; the nuclear industry – Lee
1998 and Lee and Harrison 2000; offshore installations – Mearns et al. 2003; and
construction – Fang and Wu 2013).

Almost from the outset, the concept of safety culture has tended to be
something which has elicited strong opinions. The word ‘culture’ is enough
in itself to generate widely differing opinions. The literary theorist Raymond
Williams (1983) listed several hundred definitions in his book Keywords. The
quotation from James Reason at the beginning of this chapter and the title of a
a paper by Cox and Flin (1998), ‘Safety culture: philosopher’s stone or man of
straw?’ reflect the character of some of the debates which have taken place over
the years.
 88

Defining what we mean by safety culture has taken up many of the pages
of scientific articles and books in the last few decades. A recent roundtable
involving experts, organized by the Healthcare Foundation in March 2013,
touched upon one of the thornier issues which were raised by a number of these
articles, namely the ‘culture’ vs ‘climate’ debate (e.g. Schein 1984; Mearns and
Flin 1999). The definitions provided by the roundtable (Healthcare Foundation
2013: 3) attempted to distinguish between the two, whilst noting that definitions
vary within the research literature:

Climate emerges through a social process, where staff attaches

meaning to the policy and practice they experience and the behaviors
they observe.

Culture concerns the values, beliefs, and assumptions that staff infers
through story, myth, and socialization and the behaviors they observe
that promote success.

In other words, culture is more interpretative. For the purposes of simplicity, and
partly because it seems to be the most widely used term in industries including
healthcare industry, we use the term ‘culture’ in this chapter of Literature review.

Characteristics and Components of a ‘Safe Culture’

In contrast to the debates which surround the differences between ‘culture’ and
climate, the characteristics, and components of what constitutes safety culture
tend to have elicited more agreement amongst researchers and practitioners.
The UK Health and Safety Executive (HSE) for example list the following
‘markers’ of what constitutes a ‘good’ company safety culture (HSE 2002):

 Managers regularly visit the workplace and discuss safety matters with
the workforce.
 The company gives regular, clear information on safety matters.
 We can raise a safety concern, knowing the company take it seriously and
they will tell us what they are doing about it.
 Safety is always the company’s top priority; we can stop a job if we don’t
feel safe.
 89

 The company investigates all accidents and near misses, does something
about it and gives Feedback.
 The company keeps up to date with new ideas on safety.
 We can get safety equipment and training if needed – the budget for this
seems about right.
 Everyone is included in decisions affecting safety and is regularly asked
for input.
 It’s rare for anyone here to take shortcuts or unnecessary risks.
 We can be open and honest about safety: the company doesn’t simply find
someone to blame.
 Morale is generally high.

Typically, these types of components are further broken down and decomposed
into sets of factors and survey items which are used quantitatively to assess and
measure safety culture in organizations. Examples of these factors include: levels
of staffing and workload; supervisor support; trust in management decision making;
levels of organizational commitment and employee communication.
In other cases, the use of qualitative methods such as interviews, observational
and ethnographic studies and participatory workshops are common in assessing
safety culture. These include the use of a combination of both quantitative and
qualitative measures, in parallel with maturity frameworks, which can be used
to assess the extent to which an organization is progressing with its efforts to improve
its safety culture.

One of the most well-known of these is the ‘Hearts and Minds’ safety programme
which has been used extensively by a number of petrochemical companies including
Shell (2006) to measure and benchmark progress from what is termed a ‘pathological’
attitude to safety (characterised by a ‘who cares as long as we are not caught’ attitude)
to a generative approach (characterised as ‘health and safety is how we do our
business around here’). These types of approaches have also been influential in
healthcare and include the Manchester Patient Safety Framework (MaPSaF) which
was adopted widely within the UK by the National Patient Safety Agency (NPSA).
 90

Figure 2.5 Types of medical errors in healthcare organizations

Source: Ehteshami, et al.: IT and patient safety improvement

 91

2.24 Patient Safety

What is a Patient safety?

The simplest definition of patient safety is the “prevention of errors and adverse
effects to patients associated with healthcare”. While healthcare has become more
effective it has also become more complex, with greater use of new technologies,
medicines, and treatments. Health services treat older and sicker patients who often
present with significant co-morbidities requiring more and more difficult decisions as
to health care priorities. Increasing economic pressure on health systems often leads
to overloaded healthcare environments.

Unexpected and unwanted events can take place in any setting where healthcare is
delivered (primary, secondary and tertiary care, community care, social and private
care, acute and chronic care). Every 10th patient in Europe experiences preventable
harm or adverse events in hospital, causing suffering and loss for the patient, their
families, and healthcare providers, and taking a high financial toll on healthcare
systems. Safety is part of the quality agenda and therefore a dimension of the quality
culture, requiring broad commitment from both the organization and the community.
WHO/Europe is committed to enhancing the quality of healthcare, and patient safety
is a crucial element of that quality. This encompasses:

 developing active networks of patients and providers;

 sharing experiences;

 learning from failure and pro-active risk assessment;

 facilitating effective evidence-based care;

 monitoring improvement;

 Empowering and educating patients and the public, as partners in the process
of care.

a. World Health Organization’s (WHO) 10 Facts on Patient Safety

Patient safety is a fundamental principle of healthcare. Every point in the process of

care-giving contains a certain degree of inherent unsafety. Adverse events may result
 92

from problems in practice, products, procedures or systems. Patient safety

improvements demand a complex system-wide effort, involving a wide range of
actions in performance improvement, environmental safety and risk management,
including infection control, safe use of medicines, equipment safety, safe clinical
practice and safe environment of care.

1. Patient safety is a serious global public health issue

There is now growing recognition that patient safety and quality is a critical
dimension of universal health coverage. Since the launch of the WHO Patient Safety
Programme in 2004, over 140 countries have worked to address the challenges of
unsafe care.
2. One in 10 patients may be harmed while in hospital
Estimates show that in developed countries as many as 1 in 10 patients is harmed
while receiving hospital care. The harm can be caused by a range of errors or adverse
events.
3. Hospital infections affect 14 out of every 100 patients admitted
Of every 100 hospitalized patients at any given time, 7 in developed and 10 in
developing countries will acquire healthcare-associated infections (HAIs). Hundreds
of millions of patients are affected worldwide each year. Simple and low-cost
infection prevention and control measures, such as appropriate hand hygiene, can
reduce the frequency of HAIs by more than 50percent.
4. Most people lack access to appropriate medical devices
There are an estimated 1.5 million different medical devices and over 10 000 types of
devices available worldwide. The majority of the world's population is denied
adequate access to safe and appropriate medical devices within their health systems.
More than half of low- and lower-middle-income countries do not have a national
health technology policy which could ensure the effective use of resources through
proper planning, assessment, acquisition and management of medical devices.
5. Unsafe injections decreased by 88 percent from 2000 to 2010
Key injection safety indicators measured in 2010 show that important progress has
been made in the reuse rate of injection devices (5.5 percent in 2010), while modest
gains were made through the reduction of the number of injections per person per year
(2.88 in 2010).
6. Delivery of safe surgery requires a teamwork approach
 93

An estimated 234 million surgical operations are performed globally every year.
Surgical care is associated with a considerable risk of complications. Surgical care
errors contribute to a significant burden of disease despite the fact that 50percent of
complications associated with surgical care are avoidable.
7. About 20percent–40percent of all health spending is wasted due to poor-
quality care
Safety studies show that additional hospitalization, litigation costs, infections acquired
in hospitals, disability, lost productivity and medical expenses cost some countries as
much as US$ 19 billion annually. The economic benefits of improving patient safety
are therefore compelling.
8. A poor safety record for healthcare
Industries with a perceived higher risk such as the aviation and nuclear industries
have a much better safety record than healthcare. There is a 1 in 1 000 000 chance of a
traveler being harmed while in an aircraft. In comparison, there is a 1 in 300 chance of
a patient being harmed during healthcare.
9. Patient and community engagement and empowerment are key
People’s experience and perspectives are valuable resources for identifying needs,
measuring progress and evaluating outcomes.
10. Hospital partnerships can play a critical role
Hospital-to-hospital partnerships to improving patient safety and quality of care have
been used for technical exchange between health workers for a number of decades.
These partnerships provide a channel for bi-directional patient safety learning and the
co-development of solutions in rapidly evolving global health systems.

b. Patient Safety when things go wrong

When things go wrong, news spreads fast, and the search to find who is at fault is on.
This is like a witch hunt, with the blame game shifting culpability from one person to
another. The setting for this may vary from a departmental investigation, a peer
review meeting, or a morbidity and mortality conference. Whichever one it is, it
represents a retroactive response to an untoward incident. By reviewing and dissecting
out the full sequence of events that led to the incident, one uses a process of Root
Cause Analysis to identify how the error occurred and who or what could be
responsible. The process is very effective, but it leaves casualties in its wake. Due to
 94

fear, people intentionally do not report errors or adverse events in the future. This
results in larger errors which are because of a bad system and not bad people.

“Examine the systems” should be the motto as is the practice in industry and in the
aviation sector. Be proactive and try to define the weak points in the system and take
appropriate steps. It was not realized at the time that it required a dedicated person to
clean the laparoscope of all organic matter before it could be sent for sterilization. The
system was at fault. There was no question of negligence on the part of theatre staff,
but patients suffered from institution’s lack of foresight.

c. Causes of Healthcare Errors

Healthcare error can be simply defined as a preventable adverse effect of care. A

conservative average of both the IOM and Health Grades reports indicates that there
have been between, 400000 to 1.2 million error-induced deaths during 1996 to 2006
in the United States. These casualties have been attributed to the following.

1. Human factors: Variations in healthcare providers’ training and experience,

fatigue, depression, and burnout; diverse patients, unfamiliar settings, and time
pressures; moreover, failure to acknowledge the prevalence and seriousness of
medical errors.
2. Poor communication: Unclear lines of authority of physicians, nurses, and
other
care providers.
3. Similar drugs names: Look-alike and sound-alike drugs. An inadequate system
to share information about errors hampers analysis of contributory causes and
improvement strategies.

d. Patient Safety and Risk Management

Medication error should not be considered as a total despair and if substantial

measures are taken, the medication errors are decreased or finished. Following are the
measures which have a potential to do this.

1. Ensuring patient identity: At times of blood collection, blood transfusion,

laboratory investigation, and surgery, correct identity is crucial. Use of
 95

wristband worn by the patient having relevant information is an old procedure.

New advancement should be added to this procedure like the use of bar codes
and chips instead of using written strips. This will help to prevent the loss of
patient information and so decreases medication errors. Mistakes are not
common but can be devastating when they occur.
2. Use evidence-based medicine to save lives: Five years after the 1999 report of
the IOM, the save 100 000cLives Campaign was initiated to add momentum to
the quality and safety campaign in healthcare. Common clinical situations were
identified where simple clinical interventions including drug therapy were
known to be effective. Among these were a) acute myocardial infarction b)
central line infections c) surgical site infections d) ventilator-associated
pneumonia. The challenge here was not intellectual, but one of determination to
implement what was already known for the benefit of each and every patient.
3. Better communication between healthcare workers: Since a single stay in
the hospital may involve interaction with ten or more caregivers, errors may
occur during changes in nursing shifts and when daytime junior doctors transfer
care to emergency doctors at night. Proper documentation of unstable patients’
status of case files including DNR orders can avoid distress and futile
resuscitation efforts in the event of a cardiac arrest. Nurses should also follow a
protocol for receiving verbal laboratory reports and other information over the
telephone to avoid error.
4. Hand hygiene to prevent nosocomial infection: These infections cost lives
and increase morbidity and healthcare costs. There are pluralities of morbidity
cases due to lack of hygiene in the hospitals. It is in a nature of doctors, nurses,
and paramedical staff to do multiple works at a time. What makes the matter
worse is distraction caused due to some devices like mobile phones, pagers,
casualty calls, and emergencies superimposed upon patient work and meetings.
Proper delivery of checklists and bundles in the Intensive Care Unit should be
done to ensure that no component of care has been missed.
5. Safer delivery of healthcare: Multitasking is inbred into the daily life of
doctors and nurses with the distraction of pagers, casualty calls, and
emergencies superimposed upon patient work and meetings. Checklists and
bundles should be followed for common clinical conditions for delivering daily
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care to patients especially in ICUs to ensure no component of care has been

missed.

Table 2.7 International Patient Safety Goals

Sr. No International Patient Safety Goals

1. Identify patients correctly

2. Improve effective communication among providers

3. Improve the safety of high alert medications

4. Eliminate wrong site, wrong patient, wrong procedure surgery

5. Timeout to verify checklist before starting a procedure

6. Mark the precise site for surgery

Reduce the risk of healthcare – acquired infections with hand

7.
hygiene

8. Reduce the risk of patient harm from falls

(Source: from Joint Commission International 2008)

Due to recent advances in technology, medicines are increasingly technology driven.

The development of new technology gives birth to new errors and constant vigilance
is required to track this. One powerful tool that can be used is anonymous incident
reporting by doctors, nurses, and technicians working in high-risk areas. Lapses of
discipline, errors or incidents are noted and dropped into a ‘ballot box’. The head of
the department opens the box at intervals and uses the reports to generate a discussion
on how practices can be improved. Free dialogue is encouraged and no one need feel
threatened. Moreover, improving the working conditions of the nurses may also help
in improving the patient safety.

Other strategic procedures like the involvement of the media and nongovernment
organizations for the prevention of patient rights will be beneficial. A more people-
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centered approach to care which addresses the needs of consumers, healthcare

workers, health institutions, and the healthcare system at large is required. Patient
education, creating awareness, and healthcare provider’s propensity toward the
awareness programs of patient safety should be increased. When things go wrong,
there should be a proper management which is done only by creating the partnerships
between the providers and consumers to improve the quality of healthcare. In
response, there is a need for improving how work is organized and services are
delivered; including patient safety in medical and nursing curricula; strengthening the
numbers, distribution, and skills of the workforce; and moving patient safety beyond
the hospital to community-level care.

The nine solutions are now being made available in an accessible form for use and
adaptation by the WHO Member States to redesign patient care processes and make
them safer. They are as follows: Look-alike, sound-alike medication names; patient
identification; communication during patient handovers; performance of correct
procedure at correct body site; control of concentrated electrolyte solutions; assuring
medication accuracy at transitions in care; avoiding catheter and tubing
misconnections; single use of injection devices; and improved hand hygiene to
prevent healthcare-associated infection. Moreover, in order to prevent some common
errors, some hospitals do a counting of sponges and instruments before and after the
operation is done.

A medical error has been described and studied for the best part of a century.
However, the extent and seriousness of the problem was either not recognized
or not acknowledged within the medical profession (Vincent 2010). Part of
the reason for this ‘denial’ was that the patterns of socialization and training
within the medical profession ill-equipped them to deal with situations which
acknowledged fallibility or error. As Charles Bosk showed in his detailed
ethnography of the work of surgeons in the USA, Forgive and Remember
(1979, 2003), the ability to stand back and take an objective view of error was
not normal practice for members of the medical profession. Likewise, the full
extent and high rates of error within medicine were not as well documented or
understood, as compared to today.
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In 1994 the Harvard-based surgeon Lucian Leape published a paper which

summarised evidence showing that error rates in medicine were very high
(Leape 1994). The publication of two reports in 1999 and 2000 on either side
of the Atlantic (the UK Department of Health, 2000, An Organization with a
Memory and the US Institute of Medicine (IOM) To Err is Human – Kohn et
al. 1999) provided further backing for Leape’s arguments and almost overnight
resulted in the issue of medical harm and patient safety grabbing the newspaper
headlines and reaching the attention of the politicians and the general public.
A second outcome was the start of a programme of research which has
developed and expanded dramatically over the last few decades. Both reports
focused on statistics which showed that medical error was often the cause of
unnecessary deaths amongst patients undergoing treatment in a variety of
healthcare settings (e.g. hospitals). Perhaps the most striking of these statistics
is from the IOM report which showed that between 44,000 and 98,000 people
die in US hospitals each year as a result of medical errors (Leape 2000). Within
the UK the investigations into the causes of high numbers of pediatric deaths
following cardiac surgery at the Bristol Royal Infirmary during the 1980s
(Department of Health 2001; Walshe and Offen 2001) raised the specter of
widespread systemic failings amongst hospital staff and greatly added to the
the debate surrounding ways of preventing error in healthcare.

e. Human Factors and Patient Safety

Hale and Hovden (1998) described management and culture as the third age
of safety. The first age was about technical measures, the second about human
factors and individual behavior (Hale and Glendon 1987) and these merged
with the technological approaches. Catchpole et al. (2011) in their summary
of the development of patient safety research in healthcare, characterized
early human factors work in patient safety as focusing on attempts to
locate the source of error within medicine. Other exploratory work, took
a number of forms, including a review of patient’s case notes (Vincent et al.
2001), observational studies (e.g. de Leval et al. 2000) and the implementation
of quality improvement programmes such as incident reporting systems
(Webster and Anderson 2002). Much of this work was conducted by retrospective
review of documentation or using direct observation of medical practice and
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without the involvement of clinical practitioners. What was missing at the time
was a vocabulary or framework for understanding error. At about this time
some of the human error models which had been used in other safety domains
(e.g., the aviation, nuclear and rail industries) started to be used within
healthcare. James Reason’s work on active and latent failure modes in
organizations and his well-known ‘Swiss Cheese’ model of accident causation
(Reason 1990) influenced the development of generic models of errors and
accidents in healthcare (e.g., the London Protocol – Vincent et al. 1998; Rogers
2002), but was also applied to specific areas of healthcare (e.g. surgery –
Catchpole et al. 2005).

More recently, models drawing on establishing work within human factors

and ergonomics, as well as sociotechnical systems theory (Trist and Bamforth
1951; Waterson 2013) have begun to appear. It might be argued that human
factors and ergonomics, alongside socio-technical systems, represent one of
the unifying strands in the emerging field of research on patient safety (Norris
2012; Flin et al. 2013). One of the most well-known examples of systems of
sociotechnical models are the Systems Engineering Initiative for Patient Safety
(SEIPS) model (Carayon et al. 2006 – Figure 4.1).
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Figure 2.6 The SEIPS Model

Source: Carayon et al. 2006.

The Systems Engineering Initiative for Patient Safety (SEIPS) model

contends that patient
safety hazards can emerge from a variety of work system
factors, including the
technology and tools being used by medical professionals,
the particular way in
which work is organized and allocated (e.g. team working
arrangements, leadership), situational and individual factors (e.g. individual
competences, the extent of training and skills), as well as the degree to which work
tasks match or mismatch with other elements. A critical factor determining
patient safety outcomes and the quality of care processes is the degree to which
environmental factors support work tasks. These environmental factors might
take the form of traditional human factors and ergonomics variables (e.g. noise,
temperature, lighting), but more critically, they might also involve aspects of the
the culture within the work systems (e.g. surgical unit) and the wider organization
(e.g. hospital).
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f. The First Patient Safety Culture Measurement Tools

Around 2004 the first safety culture tools designed for healthcare began to appear.
Many of these tools are in the form of survey instruments or questionnaires,
the two most well-known being the Hospital Survey on Patient Safety Culture
(HSPSC) developed by the US Agency for Healthcare Research and Quality
(AHRQ) and the Safety Attitudes Questionnaire (SAQ – Sexton et al. 2006). A
number of other tools exist, some of which aim to target specific aspects of safety
culture (e.g., leadership behaviors, communication during surgical handover – World
Health Organization 2013). These tools have been applied to a wide arrange of
healthcare contexts and healthcare systems around the world. Despite their
popularity, it is fair to say these tools are still very much under development and
assessments and improvements to their content and psychometric properties continue
at a pace. Taken as a whole, these are exciting times with respect to the development
of patient safety culture tools and instruments. Much is likely to change in the future
and patient safety culture is still a relatively new area in which there remains much to
be done.
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2.25 Patient Safety Culture

Patient safety has become a major priority for policymakers, healthcare providers, and
managers. Instigating a strong patient safety culture is pivotal for promoting this
concept among healthcare professionals and sustaining this concept in healthcare
organizations. Making patient safety culture a top priority is dependent on having a
strong and positive patient safety culture. Some components of a strong patient safety
culture include open communication, teamwork, and acknowledged mutual
dependency. Assessing a healthcare organization’s patient safety culture is the first
step in developing a strong and solid safety culture. Reflecting that, many
international accreditation organizations now require patient safety culture
assessments to evaluate the perception of healthcare staff on issues such as teamwork,
actions taken by management and leadership to support and promote patient safety,
staffing issues, frequency of incident reporting, and other patient safety culture issues.
Such assessments allow healthcare organizations to obtain a clear view of areas
requiring attention to strengthen their patient safety culture and identify specific
challenges relating to patient safety within hospital units. Most importantly,
healthcare organizations conducting such assessments can benchmark their results
against similar surveys conducted within their country or on an international level.

Patient safety culture is the overarching theme involving organization’s individual and
group values. It incorporates beliefs, behaviors, perceptions, and attitudes that
determine the organization's commitment to safety (Agency for Healthcare Research
and Quality [AHRQ], 2011). There is growing evidence that an effective patient
safety culture is related to decreased incidence and increased reporting of adverse
events. Successful safety culture improves bidirectional communication between
leadership and staff, focusing efforts on staff recognizing safety as a necessity (Singer
et al., 2009). “Safety… depends on achieving a culture of trust, reporting,
transparency, and discipline” (Leape et al., 2009, p. 429). Organizations with an
effectively integrated safety culture are characterized by communication founded on
mutual trust. Mutually shared perceptions of the importance of safety build
confidence in preventative measures and improve their efficacy (AHRQ).

Flawed systems foster an environment in which people are prone to make mistakes or
fail to prevent them – causing adverse events (Singla, Kitch, Weissman, & Campbell,
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2006). Colla, Bracken, Kinney, and Weeks (2005) described healthcare as a “high
hazard industry” because of the inherent risk of morbidity and mortality. This
understanding has led to expanded interest beyond technical failures and into
organizational processes, managerial, and human factors, which are the primary
causes of adverse events (Colla et al.). This has encouraged organizations to
concentrate on predictive safety measures, including the use of surveys measuring
safety culture (Colla et al.).

Classen et al. (2011) reported findings stating adverse events occurred in one-third of
hospital admissions. Communication and awareness are key elements in the culture of
patient safety, with documented benefits. However, creating an organizational
environment where staff supports a culture of safety remains a challenge (Groszek,
2010). Challenges with promoting a culture of safety are numerous. Discrepancies
have been documented in medical records reviews, inconsistencies are noted on
walking rounds, and incident and injury reports raise additional concerns.

Medical care’s potential to cause harm has been discussed throughout history. The
Hippocratic Oath written in late 5th century BC includes abstinence from doing harm
(Smith, 2005). The term premium on nocere translated to “first, do no harm” was
introduced to English medical culture by W. Hooker in 1847 along with the principle
of non-malfeasance (Ilan & Fowler, 2005; Smith, 2005). In 1863 Florence
Nightingale stated, “It may seem a strange principle to enunciate as the very first
requirement in a hospital that it should do the sick no harm” (as cited in Smith, C.,
2005, p. 373).

The catalyst for the patient safety movement in healthcare was the report by the IOM
- To Err is Human (Groszek, 2010). Although it is not the first publication to
systematically address patient safety in healthcare, it stirred immense public attention.
Healthcare is a high pace environment. The Institute of Medicine (2001) has
examined this type of environment and the importance of improving the delivery of
healthcare services by identifying the gaps between ideal care and actual care. The
report was significant in bringing a systems perspective to the healthcare
environment, recognizing that humans are fallible and errors will occur. That beyond
the individual involved, a situation and/or current process has contributed and created
the framework causing the individual to fail (Groszek).
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The findings by the IOM had a significant impact on health policy debates, medical
malpractice policy debates, and the decision that patient safety needed to be improved
in America. Along with summarizing the causes of the problem, the report provided
recommendations to address interventions on several levels (Ilan & Fowler, 2005).
Congress advised the creation of a Center for Patient Safety, which would set goals,
track progress, develop knowledge, and facilitate legislation. Congress allocated $50
million in 2001, to the Agency for Healthcare Research and Quality (AHRQ), an
agency within the Department of Health and Human Services, to develop patient
safety and improvement programs (Groszek, 2010).

As Congress passed The Patient Safety and Quality Improvement Act of 2005,
healthcare organizations worked on improving the quality of care and reducing errors
and patient harm. Some of the main advantages of this statute are privilege and
confidentiality protections associated with information collected, shared, and analyzed
by covered entities. A standardized reporting system was created nationally to
organize and analyze events that may compromise patient safety. Federal regulations
authorized the development of patient safety organizations to encourage error
reporting, data analysis, and facilitate learning (Groszek, 2010). Recommendations
for healthcare organizations and professionals were to established performance
standards focused on patient safety and the establishment of patient safety programs
(Ilan & Fowler, 2005). Final guidelines were released in 2008. Healthcare entities
continue to develop strategies for implementation (Groszek).
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2.26 Patient Safety Culture in Hospitals

Hospitals provide care in a complex, dynamic environment with its focus on

delivering patient care in a resource-constrained competitive market. Modern medical
care involves quick decision making by healthcare professionals with the risk of
errors being committed in such circumstances and sometimes, a possibility of
unintentional harm to a patient. Medical errors are being detected with increasing
frequency, such errors causing 44,000-98,000 deaths annually in hospitals of USA e
more than that caused by car accidents, breast cancers or AIDS.

Safety is a fundamental principle of patient care, involving a broad range of actions in

performance improvement, environmental safety and risk management including
infection control, safe use of medicines, equipment safety, safe clinical practice and
safe environment of care. Several International organizations like the Institute of
Medicine, USA, and The Joint Commission are urging healthcare organizations to
address patient safety through safety culture surveys and appropriate quality
interventions following such surveys.

The current focus on measuring and improving patient safety in hospitals has brought
to the fore the concept of safety culture that includes shared beliefs, values, norms and
behavioral characteristics of the hospital staff. Relative difficulty in measuring several
non-tangible components of safety culture has led to a shift towards evaluating patient
safety climate, patient safety climate being the measurable component of safety
culture.

Recent advancement in the technology has created an immensely complex healthcare

system. This complexity brings many challenges for healthcare staff in continuing to
keep the patient safe. Every day, more than a million people are treated safely and
successfully in the hospitals, but there are times when things can go wrong.

In any given typical surgery, estimated 250 to 300 surgical tools are used. The number
significantly increases to 600 when a larger surgery is performed, thus increasing the
chance of the surgeon losing an instrument. Common instruments are needles, knife
blades, safety pins, scalpels, clamps, scissors, sponges, towels, and electrosurgical
adapters. Also retained are tweezers, forceps, suction tips and tubes, scopes,
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ultrasound tissue disruptors, asepto bulbs, cryotomes and cutting laser guides, and
measuring devices. The single most common left behind the object is a sponge.

Patient safety includes a gamut of initiatives which includes empowering consumers,

engaging patient (and their families) in their own care; healthcare professionals
training; health services improvement; and bolstering the health system. When a
doctor has to go for hundreds of patients a day, due to overburden, he can go wrong in
providing the health services to the patient. This gives birth to a medication error,
where patient safety becomes an obligatory discipline to be followed.
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2.27 Patient Safety Culture in Indian Hospitals

The 1995 Supreme Court declaration bringing hospitals under the purview of the
Consumers Protection Act (CPA) of 1986 was possibly the start of the movement for
the safety of the patient in India. Even though the phrase ‘patient safety’ did not
become a part of common medical vocabulary until the late 1990s, the CPA made the
members of the profession realize that they would be held accountable for shortfalls
in care.

Since then, there have been several high-profile incidents in which the safety of
patients was grossly neglected. These include the deaths of 14 patients in the J.J.
Group of Hospitals following the administration of contaminated glycerol, an incident
that was probed by the 1997 Lentin Commission, the report of which held the
physicians liable; the Hepatitis B epidemic in the district of Sabarkantha, Gujarat in
which 94 persons died; the deaths of 18 pregnant women at Umaid Hospital in
Jodhpur; and most recently, the fire at the AMRI hospital in Kolkata. While there
have been such large incidents, as well as regular newspaper reports of individual
cases, there is little scientific data on the extent of the problem of patient safety in
India.

The one major study by the International Clinical Epidemiology Network, New Delhi
(INCLEN), on injection safety showed that nearly two-thirds of the injections given in
Indian hospitals were potentially unsafe. Elsewhere in the world, it has been reported
that the risk of acquiring a healthcare-associated infection or neonatal infection is
estimated to be 2–20 times higher in developing countries than in industrialized ones
(http://www.who.int/features/factfiles/patient_safety/en/ index.html). A recent study in
26 hospitals in eight developing countries in the Eastern Mediterranean, Asia, and
Africa showed that there was an adverse event in 2.5percent–18.5percent of
hospitalized patients. So, patient safety is clearly a major public health issue in India,
and some would argue that the problem is likely to be much more serious, given the
concerns about counterfeit drugs, faulty medical equipment, unsafe blood banks or
unregulated organ donation, for example.

Are we doing enough to tackle the problem and ensure safer care? And what else
should we be doing to speed up progress? Since the publication of the Institute of
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Medicine’s seminal report6 in 1999, which showed that healthcare itself, was the
eighth leading cause of death, after AIDS, breast cancer and motor vehicle accidents,
in the USA, there has been a growing interest in patient safety internationally. The
WHO launched the World Alliance on Patient Safety (WAPS) to help stimulate
further research to ascertain the extent and root causes of the problem and, more
importantly, develop innovative solutions to reduce the burden of harm due to unsafe
healthcare. Much progress has since been made, in the past decade, but it is equally
clear from some high-profile instances, for example, in the National Health Service
(NHS) in the UK that a lot more needs to be done (http://www.midstaffsinquiry.com/).

In India, while the CPA was a stimulus that made doctors aware of the problem and
encouraged safe practice, it also led to ‘defensive’ medicine, causing an overall rise
in litigation, though with few doctors being penalized. Further, it led to an increase in
healthcare costs. The tendency to resort to litigation, and harsher sanctions, received
another impetus in 2003 with the Mashelkar Committee on Spurious and Counterfeit
Drugs, which suggested the death penalty for offenders. However, such measures are
not enough and given the slow judicial system, they cannot bring about the sea change
that is necessary for medical practice. For the moment, they have only set in motion a
negative trend of blaming and shaming individuals, which is seldom appropriate,
given that most inquiries into adverse incidents show that there are systemic
problems.

The current approach has also made it difficult, nay impossible, for doctors to report
adverse incidents and thus learn from errors. There is a vicious cycle whereby the lack
of reporting makes it difficult to understand the root causes and fix the systemic
problems, which, in turn, perpetuates the situation and causes it to worsen. All this is
further compounded by our society’s general ‘laissez-faire’ approach to safety,
whereby in almost all spheres of our daily lives, we accept that things go wrong and
attribute them to ‘divine intention’.

On the other hand, though it is not right to blame a single person, we should resist
the temptation of glossing over the problem by proclaiming that the ‘system is rotten’
or there are ‘no resources’. We can, and should, fix things by formulating a standard
operating protocols for treatment and procedures, introducing physical barriers and
training for the use of technology, for example. Atul Gawande’s work on a surgical
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safety checklist is a good example of a simple and low-cost intervention. Of course,

not all complex medical practices can be oversimplified into checklists, but the
evidence shows that most errors are fairly elementary. The final collapse is usually a
the result of glitches in communication, over-reliance on human memory, inadequate
access to information, not knowing whom to ask and non-standardized operating
guidelines. None of these gaps requires the investment of too many resources, and
money is not the concrete that can fill the cracks in the patient care pathway.

Bringing about the hanges mentioned above is easier said than done. History
shows that medical
practice does not change fast: it was in 1847 that Ignaz
Semmelweis (Hungarian physician; known as an early pioneer of antiseptic
procedures.) emphasized the importance of hand-washing to save pregnant mothers,
yet hand hygiene remains the first global priority for patient safety in the 21st century.
So, we need to avoid gimmicks and quick fixes, and while we can learn a lot from the
developed world, we should recognize that the Indian context is different and create
appropriate solutions.

Source: from a German book; Semmelweis' Germ Theory, 1861

Healthcare is a burgeoning industry in India. The early experience with the ‘knee
replacement-with-a-free-trip-to-the-Taj’ medical tourism model shows that patients
are not easily seduced by glossy interiors and good catering. They would like to see
more attention being paid to the important but invisible interventions of the
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committees for hospital infection control, as well as to operation theatre safety

standards. While private hospital patients may be more educated and discerning and
may help create the necessary pressure for change, patients in the public hospital
system are unlikely to be either demanding or effective. The recent proposal to
introduce universal healthcare coverage under the 12th Five-Year Plan will mean a
massive growth, given the huge unmet need for healthcare in India. When the
floodgates open, the provision of more care, without the creation of systems for safer
care, will result in more harm and the policy may turn out to be a lose-lose
proposition.

The purpose of patient safety culture is to tackle and control patient unsafe issues
across hospitals in the country but very few research or publications exist on the vital
issue of patient safety or safety culture in India, as observed during a search of several
medical databases. Indian healthcare is at the crossroads and with government’s
minuscule 1 percent GDP allocation, there is a serious disparity of hospitals in the
rural and urban areas. Adding to these woes is the high unsafe patient safety practices.

India accounts for 40 percent of patient unsafe practices. In Bengaluru alone which is
the hub of healthcare majors, reports 68 percent of hospitals with no adequate patient
safety measures which includes the absence of handlebars in washrooms for patients
to grasp. Adhering to the basic patient care measures would drastically improve the
overall healthcare delivery in India. In fact, simple and low-cost infection prevention
and control measures, such as appropriate hand hygiene, can reduce the frequency of
hospital-acquired infections by over 50 percent. Now the practice of hand hygiene
which is the most neglected in India needs to be mandated where the use of soap and
water after which application of alcohol-based hand sanitizers should be compulsory
not just for doctors and nurses but also patient, and their caregivers.

Another critical component in the patient safety agenda listed in the 6 point agenda of
WHO is the communication between the patient and doctor where adequate time is set
aside to comprehend the health condition. This would prevent incorrect diagnosis and
medication which could control the patient’s healthcare expenses. The reason for
mistaken disease detection by doctors is largely driven by stress and fatigue.
According to a WHO study, which states that doctors and nurses in some hospitals in
India work for 30 hours continuously as against 16 hours of working in the west make
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these medical professionals in India far more strained with lack of sleep. This led to
36 percent of medical errors, of which 21 percent were serious medication
blunders. Further, illegible handwriting also let wrong medication dispensing at
pharmacy outlets.

Last year, nearly 45000 foreigners sought medical treatment in India as medical
tourists. Indian healthcare industry is seen to be growing at a rapid pace and is
expected to become a US$280 billion industry by 2020. Recently, medical tourism
has been a spur for select institutions to strive for the highest international standards.

But still, information relevant to drugs is not very common among Indian people. The
health sector is severely affected by the increasing production and promotion of
certain banned and fake drugs in all across the country. There are multitudes of drugs
which are banned in many western countries, due to their side effects, but not in India.

There is a widening gap between doctors and patients due to asymmetry in

knowledge, socioeconomic status, and educational levels. Increased reporting of
medical errors in the media has also contributed to the polarization. Times of India
stated medication error as a top ten causes of death in the world. Doctors stereotyped
the patients as irresponsible for their own health, as they do not follow the medical
instruction, and do not consult a doctor until the disease reached to the advanced
stage, and finally want quick and cheap cures. Patients, in turn, found doctors
intimidating and did not dare to express their concerns or ask questions. Doctors do
not get the proper medical history they require a proper diagnosis and to order
appropriate tests. Patients did not understand the doctor’s instructions regarding their
medicines or follow-up.

This creates a huge communication gap between the doctor and the patient which in
turn hampers care. Blame and frustration on both sides have resulted in a downward
spiral with, in extreme cases, patients physically threatening doctors and of doctors
going on strike. In the end, it is the patient who had to suffer. This results in a poor
healthcare system in India.

Common and main characteristics of Indian Government Hospitals are chronic

overcrowding, pathetic infrastructures, underfunding, and facilities perpetually
stretched to the limit. The major reason for this is our economy which spends less
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than 2percent of its Gross Domestic Product on health. That turns out bright young
doctors and looks after a workload of patients with a spectrum of diseases far broader
than found in the private sector, yet are at times the unfair target of criticism during
health care crises. Their circumstances seldom allow quality and safety to appear on
their radar.

Today, two-thirds of the population seek the private sector for their health needs.
There are burgeoning private hospitals and private teaching colleges in the past 30
years, showing the demand of students for a medical education, and of a public
seeking more personal and patient-friendly treatment at the time of sickness. Indian
business also sees a profit from investing in healthcare. Recently, medical tourism has
been a spur for select institutions to strive for the highest international standards.

Although there are scanty data on medical errors in India, a research detected 457
errors in pediatric practice at a single teaching hospital over a period of six months.
The problem is compounded by the fact that the culture of reporting and recording
medical errors is virtually absent in India. Pluralities of cases of medication error in
Indian health system have been reported but still not come into limelight. In a civil
hospital of Mohali, a lady doctor was carrying out the stitching for episiotomy, during
which 40-mm needle broke. Lady Doctor said the patient had hard skin that led the
needle to break and the patient’s family has not given any complaint and are satisfied
with their treatment. Kalsoom Rehman suffered a severe abdominal pain because of a
towel which doctor forgot to take out while doing a delivery operation.

A Harvard study by Prof Jha shows that 5.2 million medical errors are happening in
India annually. Similarly, the British Medical Journal quoted that India like any other
developing country is recording a lot of medical errors. The reason behind this is that
we have not trained doctors and nurses to measure the clinical outcomes.

Many cases of these medication errors like a pair of surgical scissors in hysterectomy
operation, a piece of medicated gauze in abdomen, a large surgical clamp in chest, a
ten-inch steel retractor lodged in abdomen, pieces of plastic, sponges, and gauze in
benign tumor operation, surgical scissor blade left in abdomen, surgeons left a
laparotomy pad inside abdomen, and surgical sponge left behind the sternum has been
reported.
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Last year in 2017, the Union health ministry has come up with a draft framework
aimed at ensuring patient safety while undergoing any medical intervention and it
proposes measures such as setting up of an online grievance system. The draft
National Patient Safety Implementation Framework (NPSIF) states that patient safety
is a fundamental element of healthcare and is defined as freedom for a patient from
unnecessary harm or potential harm associated with the provision of healthcare.

It is about safe drugs dispensing, surgical care, safe childbirth, injection safety, blood
safety, medication safety, medical device safety, safe organ, tissue and cell
transportation and donation, said a senior health ministry official. It is also about bio-
medical waste management, prevention of healthcare-associated infections and much
more, the official said. Failure to deliver safe care is attributed to unsafe clinical
practices, unsafe processes and poor systems and processes.

According to the senior health ministry official, the framework is based on six main
pillars–health system strengthening, improvement in adverse events reporting,
training of healthcare personnel, research, vertical campaigns which include injection
safety, blood safety, surgical safety, maternal and child healthcare and quality of
healthcare services through accreditation.

“The provisions of healthcare services have significantly grown in the public sector
over the past few years and there is a largely unregulated private sector. Therefore, the
quality of services and its legal aspects need to be taken up at this point,” the official
said. Challenges in patient safety in India are numerous, ranging from unsafe
injections and biological waste management to medication and medical device safety,
high rates of healthcare-associated infections, anti-microbial resistance etc, and the
draft states. There is a wide range of initiatives in patient safety being implemented in
India at different levels of care in both public and private sectors, and there is a
multiplicity of national and international stakeholders working in this area.

The draft NPS proposes setting up of a web-based grievance system and toll-free
helplines for patient safety in all healthcare facilities and introducing anonymous
reporting system in healthcare facilities to be used by healthcare facility staff,
students, patients and their families.
 114

It also suggests setting up of a national-level steering committee as a central

coordinating mechanism for patient safety on the basis of a patient safety expert
group. The draft proposes incorporating patient safety principles and concepts in the
Public Health Act and streamlining patient safety in different insurance schemes. To
strengthen quality assurance mechanisms, including accreditation system, the draft
suggests incorporating selected patient safety indicators within the accreditation
system for hospitals and laboratories.

It also proposes the establishment of a culture of safety and improving

communication, patient identification and handing over transfer protocols in
healthcare facilities. The draft calls for ensuring that patient safety processes are
clearly communicated to patients and caregivers prior, during and after the medical
intervention using different communication means such as videos, mobile apps,
leaflets, brochures, etc
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2.28 Patient Safety studies in India

Table 2.8

Patient Safety studies in India

Sr. Different Title / Different Study Findings

No Authors Areas of Research
Study
1. Madhok et al., Promoting patient Using five international case studies the
2014 safety in India: study describes experiences of promoting
Situational analysis patient safety in various ways to inform
and the way forward future developments in India. We offer a
roadmap for 2020, which contains
suggestions on how India could build a
culture of patient safety.
2. Balamurugan E A study on patient The understanding of culture and creating
and Josephine safety culture among a given type of culture within a healthcare
Little Flower nurses in a Tertiary organization can be elusive, baffling, and
care hospital of challenging. Yet, the success of providing
Puducherry patients with the safest and highest quality
of care is becoming recognized as being
dependent upon a strong cultural
foundation at the unit level. Policy makers
and leaders should develop acceptable
standards for the patient safety system.
This can be achieved through initiated and
supported an effective safety culture
assessment among all working nurses
while providing patient care.
3. Abhijit A study of No variation was observed in the Patient
Chakravarty, assessment of patient Safety Index score among the study
Maj Anupam safety climate in hospitals. However, significant variations
Sahu, Manash Tertiary care were observed among different categories
Biswas, hospitals of healthcare workers across dimensions
 116

Kaustuv of Teamwork, Perception of Management

Chatterjee, and Stress Recognition. Multiple
Subrata Rath Regression models identified Teamwork
and Perception of Management to have a
significant correlation with Patient Safety
Index Score.
4. Gaurav Patient safety risk The major drawback of this ‘blame game’
Sharma, assessment and risk judgmental attitude is that it makes
Swapnil management: A healthcare workers hesitate to report
Awasthi, review of Indian errors for fear of losing their own jobs or
Anuj Dixit and hospitals fear of some other form of reprisal.
Garima Sharma As a result of underreporting, hospital
managers and others concerned with
patient safety often do not have an
accurate picture of the frequency of
occurrence of some types of medical
errors.
5. Chandrakant Patient safety in Patient safety could be used as an entry
Lahariya, maternal health care point for bringing attention on the overall
Ankita Choure, at secondary and quality of healthcare services in India. The
and Baljit Singh tertiary level facilities momentum and opportunity to bring
in Delhi, India improvement in the quality of health
services has to be sustained by more
funding, capacity building, and strong
leadership with clearly outlined intentions
through policy proposals. The quality has
to be a mainstream discourse in public
policy and programmatic discourses, as
India intends to advance toward Universal
Health Coverage.
6. M.V. Rao, A Study to Assess Patient safety is a concern for every
Dayakar Thota Patient Safety Culture healthcare institution both ethically and
and amongst a Category legally and hence instilling Patient safety
 117

P. Srinivas of Hospital Staff of a cultures amongst all staff involved in

Teaching Hospital healthcare delivery is of vital importance.
The tool, “Hospital Survey on Patient
Safety Culture (HSOPSC) Questionnaire”
helps in measuring this culture in a
healthcare organization, to implement
effective interventions towards achieving
a high level of patient safety.
The paramedical and administrative staff
would be necessary to understand the
overall safety culture in the organization
towards patient safety.
7. Rajan Madhok, Patient Safety in Lobbying and assisting institutions and
Nobhojit Roy, India: Time to speed the government with the creation of
and Sukhmeet up our systems for recording, learning and
Panesar efforts to reduce reporting on the quality of services and
avoidable harm adverse events in a ‘balanced’ manner
(neither too heavy-handed, nor too light),
and making it possible to set up such
systems given the concerns of such
documentation.
Accelerating the implementation of
proven patient safety interventions, such
as the Global Patient Safety Challenges
work on hand hygiene and a surgical
checklist
8. F.D. Dastur Quality and Safety in New technologies create new methods for
Indian Hospitals producing errors and constant vigilance is
required to track these. One powerful tool
that can be used is anonymous incident
reporting by doctor’s nurses and
technicians working in high-risk areas.
Lapses of discipline, errors or incidents
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are noted and dropped into a ‘ballot box’.

The head of the department opens the box
at intervals and uses the reports to
generate a discussion on how practices
can be improved. Free dialogue is
encouraged and no one need feel
threatened.
9. Anupama Institutionalizing The safety systems are impacted by a
Shetty and Patient Safety culture which also set limits to structural
Harshad Culture: A Strategic and procedural changes. Taking a cue, an
Thakur Priority for amalgamation of structural-procedural-
Healthcare in India cultural efforts at the national, State and
local levels would foster greater gains in
the safety outlook of Indian healthcare
organizations. Policy makers and
healthcare administrators in the Indian
context need to consider the concept of
safety culture as the critical link binding
myriad safety efforts in the organization.
Source: Compilation from various studies by researcher
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2.29 Dimensions of Patient Safety Culture

A brief explanation of 12 Dimensions of Patient Safety Culture used in this research

study is presented in the given below Table 2.9.

Table 2.9

Dimensions (12) of PSC used in this research study

Sr. Dimensions Brief Explanation

No of Patient Safety Culture

1. Communication Openness The communication openness domain refers to

whether staffs freely speak up if they see something
that may negatively affect patient care, feel free to
question those with more authority and afraid to
speak up if something does not seem right.
2. Feedback and The feedback and communication about errors
communication
domain measures whether staffs are informed about
errors that happen, given feedback about changes put
into place based on event reports, and discuss ways
to prevent errors occurring again.
3. Teamwork within hospital The teamwork within hospital units’ domain
units
measures whether staff supports one another and
treats each other with respect and also works
together as a team.
4. Hands-offs and transitions This domain refers to patient care and patient
information transfer across hospital units and during
shift changes. This domain measures; problems
during patient transfer from one unit to another, loss
of patient care information, and problems in
information exchanges between units.
5. Management support for This domain measures whether hospital management
patient safety
provides a work climate that promotes patient safety
and shows if patient safety is a top priority or is only
of interest after an adverse event occurs.
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6. Non-punitive response to This domain measures whether staff feels free to

errors
report adverse events and that their mistakes are not
held against them.
7. Organizational learning This domain refers to whether staffs are doing things
and continuous
to improve patient safety by learning from their
improvement
mistakes and evaluate the effectiveness of new
interventions put in place.
8. Overall perceptions of This domain refers to how staff thinks about work
patient safety
procedures and systems in preventing errors in
hospital units as well as how they deal with work
pressure in relation to preventing medical errors.
9. Staffing This domain refers to whether there are enough
staffs and appropriate working hours to handle the
workload.
10. Supervisor/manager This domain refers to whether leadership considers
expectations and actions
staff suggestions, praise staff for following patient
promoting safety
safety procedure for improving patient safety and do
not encourage faster work by taking shortcuts.
11. Teamwork across hospital This domain refers to whether hospital units
unit
cooperate, coordinate with one another and
encourage teamwork among staff from other units to
provide the best care for patients.
12. The frequency of events This domain refers to how often staff report all types
reported
of mistakes, such as latent errors, accidents, and near
misses.
Source: Compilation from various studies by researcher
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2.30 Consolidated Literature Review

A consolidated Literature Review of different research studies on Patient Safety

Culture presented by various Authors is presented in given below Table 2.10

Table 2.10

Consolidated Literature Review

Different
Subculture of Different Properties
Studies from Different Authors
Patient Safety Studied

1.Leadership Accountability Frankel, Gandhi, & Bates (2003)

Johnson & Maultsby (2007)
Yates et al. (2005)
Change management DiBella (2001)

Commitment Cook et al. (2004)

Ketring & White (2002)
Singer et al. (2002)
Executive rounds Frankel, Gandhi, & Bates (2003)
Thomas et al. (2005)
Wittington & Cohen (2004)
Governance Clarke, Lerner, & Marella (2007)
Connor, Ponte, & Conway (2002)
Hader (2007)
Open relationships AORN (2006)
Cohen, Eustis, & Gribbins (2003)
Morath & Leary (2004)
Physician engagement Cohen, Eustis, & Gribbins (2003)
Priority Yates et al. (2005)
Resources Clarke, Lerner, & Marella (2007)
Cook et al. (2004)
Frankel, Gandhi, & Bates (2003)
Singer et al. (2002)
Yates et al. (2005)
Role model Kaissi (2006)
Support Ballard (2006)
Blake et al. (2006)
Odwazny et al. (2005)
Vigilance Kaissi (2006)
Lindblad, Chilcott, & Rolls (2004)
McCarthy & Blumenthal (2006)
Yates et al. (2005)
Visibility Pronovost et al. (2003)
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Vision/mission
Different
Subculture of
Different Properties Studied
Patient Safety
2.Teamwork Alignment
Deference to expertise
wherever
Found
Flattened hierarchy
Multidisciplinary/mutigenerati
onal
Mutual respect
Psychological safety
Readiness to adapt/flexibility
Supportive
Watch each other’s back
3.Evidence-based Best practices
High reliability/zero defects
Outcomes are driven
Science of safety
Standardization: protocols,
Checklists, guidelines
Technology/automation
Clarke, Lerner, & Marella (2007)
Cook et al. (2004)
Pronovost et al. (2003)
Studies from Different Authors
Frankel, Gandhi, & Bates (2003)
Frankel & Haraden (2004)
Clarke, Lerner, & Marella (2007)
AORN (2006)
Connor, Ponte, & Conway (2002)
Gelinas & Loh (2004)
Hansen et al. (2003)
AORN (2006)
Cohen, Eustis, & Gribbins (2003)
Frankel, Gandhi, & Bates (2003)
Morath & Leary (2004)
AORN (2006)
McCarthy & Blumenthal (2006)
AORN (2006)
Weinstock (2007)
Apold, Daniels, & Sonneborn (2006)
Ballard (2006)
Clarke, Lerner, & Marella (2007)
Frankel, Gandhi, & Bates (2003)
Hansen et al. (2003)
Ketring & White (2002)
Clarke, Lerner, & Marella (2007)
Ketring & White (2002)
Pronovost et al. (2003)
Johnson & Maultsby (2007)
Frankel, Gandhi, & Bates (2003)
McCarthy & Blumenthal (2006)
Pronovost et al. (2003)
Frankel, Gandhi, & Bates (2003)
Ketring & White (2002)
McCarthy & Blumenthal (2006)
Pronovost et al. (2006)
Johnson & Maultsby (2007)
Nadzam (2005)
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Different
Subculture of Different Properties
Studies from Different Authors
Patient Safety Studied

4.Communication Assertion/speak-up Clarke, Lerner, & Marella (2007)

Weinstock (2007)
Bottom-up approach Farrell & Davies (2006)
McCarthy & Blumenthal (2006)
Clarity Weinstock (2007)
Hand-offs Blake et al. (2006)
Weinstock (2007)
Linkages between Blake et al. (2006)
executives and
Front Morath & Leary (2004)
line/resolution/feedback
Singer et al. (2002)
Wittington & Cohen (2004)
Safety briefings/debriefings Frankel, Gandhi, & Bates (2003)
Leonard, Graham, & Bonacum (2004)
Wittington & Cohen (2004)
Structured techniques: Joint Commission
SBAR,
Time-out, read-back Weinstock (2007)
Transparency DiBella (2001)
Frankel, Gandhi, & Bates (2003)

5.Learning Culture Awareness/informed Blake et al. (2006)

McCarthy & Blumenthal (2006)
Celebrate success/rewards Kaissi (2006)
Yates et al. (2005)
Data-driven Ballard (2006)
Frankel, Gandhi, & Bates (2003)
Johnson & Maultsby (2007)
McCarthy & Blumenthal (2006)
Paine et al. (2004)
Education/training Blake et al. (2006)
including
Physicians Cook et al. (2004)
Frankel, Gandhi, & Bates (2003)
Johnson & Maultsby (2007)
Pronovost et al. (2003)
Weinstock (2007)
Learn from Blake et al. (2006)
mistakes/evaluation Farrell & Davies (2006)
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Monitor/benchmark Chavanu (2005)

Clarke, Lerner, & Marella (2007)
Johnson & Maultsby (2007)

Different
Subculture
Different Properties
of Patient Studies from Different Authors
Studied
Safety

6.Learning Performance
Culture improvement Clarke, Lerner, & Marella (2007)
Reiling (2004)
Wittington & Cohen (2004)
Yates et al. (2005)
Proactive Kaissi (2006)
Reiling (2004)
Wittington & Cohen (2004)
Root-cause analysis Apold, Daniels, & Sonneborn (2006)
Connor, Ponte, & Conway (2002)
Farrell & Davies (2006)
Nadzam et al. (2005)
Yates et al. (2005)
Share lessons learned Apold, Daniels, & Sonneborn (2006)
DiBella (2001)
Pronovost et al. (2003)
7.Just Culture Blame-free Blake et al. (2006)
DiBella (2001)
Reiling (2004)
Disclosure Clarke, Lerner, & Marella (2007)
Connor, Ponte, & Conway (2002)
Johnson & Maultsby (2007)
Pronovost et al. (2003)
Non-punitive reporting Blake et al. (2006)
Johnson & Maultsby (2007)
Nadzam et al. (2005)
Pronovost et al. (2003)
Reiling (2004)
Wittington & Cohen (2004)
No at-risk behaviors
Clarke, Lerner, & Marella (2007)
Systems—not
individuals Apold, Daniels, & Sonneborn (2006)
Kaissi (2006)
Wittington & Cohen (2004)
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Trust AORN (2006)

Morath & Leary (2004)

Different
Subculture
of Patient Different Properties Studied Studies from Different Authors
Safety

8.Patient- Community/grassroots Apold, Daniels, & Sonneborn (2006)

Centred Involvement
Compassion/caring
Empowered patients/families
Exemplary patient experiences
Focus on patient
Formal participation in care
Health promotion
Informed patients/families
Patient stories
Source: Compilation from various studies by researcher
Ketring & White (2002)
Morath & Leary (2004)
Rose et al. (2006)
Reiling (2004)
Gelinas & Loh (2004)
Connor, Ponte, & Conway (2002)
Hansen et al. (2003)
McCarthy & Blumenthal (2006)
Connor, Ponte, & Conway (2002)
Hansen et al. (2003)
Clarke, Lerner, & Marella (2007)
Pronovost et al. (2003)
Reiling (2004)
Morath & Leary (2004)

2.31 Summary

Safety culture is an important aspect of patient safety. There are well-validated tools
that can be used to measure safety culture but it is recommended that mixed methods
are used to fully understand its complexity in a wider cultural context, embracing both
organizational and national contexts. Reviewed studies on Patient Safety culture
indicate the strengths and weakness of different methods for investigating patient
safety; the study design, methodology, and methods were subsequently derived from
this review and are discussed in later sections.
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Part IV: Theoretical Framework

‘Well, it may be all right in practice, but it will never work in theory.’

--Warren Buffett

In Part IV of this chapter, this research study uses a combination of eight theoretical
bases in order to identify and design the key research questions. It firstly uses the
Theories of Organizational Culture as. Secondly, it uses the Theories of Patient Safety
Culture. It is followed by the Conceptual Framework used for the study.

2.32 Theories of Organizational Culture

The main function of organizational culture is to define the way of doing things in
order to give meaning to organizational life (Arnold, 2005). Making meaning is an
issue of organizational culture because organizational members need to benefit from
the lessons of previous members. As a result, organizational members are able to
profit from whatever trials and errors regarding knowledge others have been able to
accumulate (Johnson, 1990). Organizational culture also determines organizational
behavior, by identifying principal goals; work methods; how members should interact
and address each other; and how to conduct personal relationships (Harrison, 1993).
Brown (1998, p 89- 91) states the following functions of organizational culture:

 Conflict reduction. A common culture promotes consistency of perception,

problem definition, evaluation of issues and opinions, and preferences for action.

 Coordination and control. Largely because culture promotes consistency of

outlook it also facilitates organizational processes of coordination and control.

 Reduction of uncertainty. Adopting of the cultural mind frame is an anxiety-

reducing device which simplifies the world of work, makes choices easier and
rational action seem possible.
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 Motivation. An appropriate and cohesive culture can offer employees a focus on

identification and loyalty, foster beliefs, and values that encourage employees to
perform.

 Competitive advantage. Strong culture improves the organization’s chances of

being successful in the marketplace.

In addition to the above functions, Martins and Martins (2003, p382) also mentioned
the following as functions of organizational culture:

 It has a boundary-defining role, that is, it creates distinctions between one

organization and the other organizations.

 It conveys a sense of identity to organizational members.

 It facilitates commitment to something larger than individual self-interests.

 It enhances social system stability as the social glue that helps to bind the
organization by providing appropriate standards for what employees should say
and do.

 It serves as a meaningful control mechanism that guides or shapes the attitudes

and behaviors of employees.

These functions of organizational culture suggest that an organization cannot operate

without a culture because it assists the organization to achieve its goals. In general
terms, organizational culture gives organizational members direction towards
achieving organizational goals (Martins and Martins, 2003).

There continues to be varying perspectives on how organizational culture is

conceptualized and subsequently defined in the literature (Jung et al., 2009). Many
papers outline these issues and provide an overview of theories and their definitions
and dimensions (e.g., Schein, 2010; Jung et al., 2009). Therefore, the further elaborate
discussion here would be redundant. As a brief overview, Jung et al. (2009) in their
review of organizational culture instruments examined 877 references and found 70
different instruments and over 100 dimensions used in the study of organizational
culture, which varied based on the theoretical underpinnings and methodological
 128

approach. However, the aim at this point is to provide an overview of the major
theorists that have informed the conceptualization of the current projects.

Embarking on a culture study requires the researcher to first address the purpose of
the project as formative, summative or diagnostic (Jung et al., 2009), which derives
from the objectives of the project or cultural investigation and guides the method of
inquiry. The formative purpose is defined as the exploration as an end in itself, which
provides details about the culture (Jung et al., 2009). In a formative assessment view,
the methods would follow qualitative techniques such as interviews and observation.
A summative approach focuses more on providing a value on dimensions or questions
related to culture. This view is linked to the singular use of surveys to obtain data
scores that allow for a point in time assessments of the culture. The diagnostic focus
identifies and assesses existing cultures and modifies them with the goal of realigning
specific cultural values with those seen to be associated with better performance (Jung
et al., 2009). The diagnostic view could be used both to uncover and understand
issues relating to culture with the goal of creating change. The view of culture in a
corporation such as a healthcare organization would be that culture can be managed
and changed to become safer. In this corporate perspective, leaders believe that by
understanding the current state of the cultural attributes, adjustments can be made,
thus the approach to assessing culture should be from the diagnostic view. This view
would then lend to the researchers or practitioners evaluating the culture with a
variety of tools to gather an in-depth understanding of the culture.

Given this diagnostic orientation to studying culture, the three leading frameworks
that aided in the conceptualization of the projects here came from Martin and
Meyerson‟s (1988) three perspectives of differentiation, integration, and
fragmentation; Schein‟s three levels of culture (2004; 2010) and the use of typologies
by Westrum (2004). These theorists follow a research orientation that believes that
culture is a complex phenomenon of the organization but that it can be managed and
changed to enhance the organization‟s performance. The following discussion will
provide an outline of these frameworks and the utility of these perspectives for the
study of the culture of safety in the proposed project.
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1. Organizational Learning Theory

Organizational learning is a field of academic research and professional practice with

a relatively recent development. Organizational learning is understood here, from an
academic point of view, as the study of learning processes of and within an
organization. Particularly, organizational learning is a process based on individual
learning through private and public organizations engaged in creating and obtaining
knowledge for the purpose of institutionalizing it in order to adapt as an organization
to the changing conditions of the environment or to change the environment
proactively, depending on its level of development (Argyris, 1998).

The Organizational Learning Theory of Crossan, Lane, and White (1999)

The theory of Crossan, et. al. (1999) of organizational learning is well-known and
often used in academic contexts. The value of the proposal lies in its integration of
three levels of learning into the same model, namely individual, group and
organizational learning, and of two routes of learning: from the individual to the
organization and from the organization to the individual. Individual learning itself
does not guarantee organizational learning; it is necessary a transference process of
knowledge among people, with the purpose of institutionalization. The theory
identifies four processes of learning: intuiting, interpreting, integrating and
institutionalizing.

The first process, intuiting, takes place at the individual level. Crossan et al. (1999),
defined intuiting as “the preconscious recognition of the pattern and/or possibilities
inherent in a personal stream of experience”. It is critical to understand the
subconscious in order to understand how people comprehend something new for
which there was no prior explanation. A limitation of the model, however, is the
belief that intuiting is the unique process that explains individual learning; most of the
human learning is a conscious process. Later on in this chapter, the relevance of
conscious processes in organizational learning will be defended from the perspective
of the social cognitive theory of Bandura (1986).

The second process, interpretation, occurs at the individual and group levels. It is
defined by Crossan et al. (1999) as “the explaining through words and/or actions, of
an insight or idea to one’s self and to others. This process goes from the pre-verbal to
the verbal, resulting in the development of language”. Individuals think about their
 130

intuitions and share them with others, thus transferring them to individual and
collective interpretation (Crossan, et al, 1999). Preverbal intuitions are shaped and
shared through conversation, imagery, and metaphors (Crossan, et al., 1999). In a
broad vision, Huff (1990) suggests that individuals develop cognitive maps from their
context while at the same time these maps affect what part of the context is selected
and interpreted. This conception is compatible with the concepts of social cognitive
theory previously called the theory of social learning and later changed to social
cognitive theory (Bandura, 1986), which proposes a more comprehensive explanation
of individual learning.

The social cognitive theory of Bandura (1986) has some advantages. On the one hand,
it describes and integrates human cognitive capabilities and their relation to learning,
which goes beyond the concepts of intuition and interpretation; on the other hand, it
explains the reciprocal influence between cognition, behavior, and environment.
Additionally, it explains how learning occurs in a social context.

The third process of the model of Crossan, Lane, and White (1999) is integrating,
defined as “the process of developing a shared understanding among individuals and
of taking coordinated action through mutual adjustment. Dialogue and joint action are
crucial to the development of shared understanding”.

The fourth concept, institutionalizing, “is the process of ensuring that routinized
actions occur. This is the process of embedding learning that has occurred by
individuals and groups into the organization and it includes systems, structures,
procedures and strategy” (Crossan, et al., 1999, p.525).

The learning organization is an ideal organization and in order to achieve this sort of
organization Peter Senge (1990) identify five key disciplines that need to be
considered: personal mastery; mental models; shared vision; team learning and
systems thinking. Systemic thinking is the conceptual cornerstone of the learning
organization; it is the discipline that integrates the others and fusing them into a
coherent body of theory and practice (Senge 1994). Systems theory’s ability to
comprehend and address the whole and to examine the interrelationship between the
parts provides a solid framework. The concept of relations, control, feedback, and
delays are often mentioned in order to “see the whole picture”. Personal Mastery.
‘Organizations learn only through individuals who learn. Individual learning does not
 131

guarantee organizational learning. But without it, no organizational learning occurs’

(Senge 1990: 139). Mental models. These are ‘deeply ingrained assumptions,
generalizations, or even pictures and images that influence how we understand the
world and how we take action’ (Senge 1990: 8). Team learning. Such learning is
viewed as ‘the process of aligning and developing the capacities of a team to create
the results its members truly desire’ (Senge 1990: 236). Building shared the vision.
Peter Senge starts from the position that if anyone idea about leadership has inspired
organizations for thousands of years, ‘it’s the capacity to hold a shared picture of the
future we seek to create’ (1990: 9). Such a vision has the power to be uplifting – and
to encourage experimentation and innovation.

In the book “The fifth discipline” there are several concepts presented that relate to
the five key disciplines: reflection; transformation; learning; expand capacity;
sustainability, employee involvement, shared values and open dialogue. Reflection
has its basis in the work of Donald Schön, which has in turn been expanded on by
Pete Senge (Schön 1983; Senge 1994). The practitioner’s ability to reflect in and on
the action by turning the mirror inwards in order to bring the internal pictures of the
world to the surface is an important issue. People are viewed as agents able to act
upon the structures and systems of which they are apart. The learning organization is
presented as an organization that continuously transforms; continually expand its
capacity by continually learning activities in order to reach sustainability in an ever-
changing market. Team learning and building shared vision activities are related to
employee involvement, understanding of shared values and a free flow dialogue.
 132

Figure 2.7 Organizational Learning

Source: Peter Senge (1990)

2. The Social Cognitive Theory of Bandura

According to the social cognitive theory of Bandura (2001), individuals are not
governed by internal forces or by external stimuli. The human function is explained
by a triadic reciprocity where personal factors, environment, and behavior interact.
Bandura (2001) declares that people are producers as well as products of their social
environment. Internal personal factors (in the form of cognitive, affective, and
biological events), behavior and environmental events all operate as interacting
determinants that influence each other (Bandura, 2001).

With regard to organizational learning, Bandura (2001) states that organizations are
changed by people’s behavior. The impact of socio-structural factors on
organizational performance is mediated by individual learning. Organizational
 133

learning occurs through interactive psychosocial processes, not only in the context of
organizational attributes operating independently of human behavior. Organizational
learning is a collaborative effort where individuals create new ideas by sharing their
knowledge through interaction with others.

According to Bandura (2001), there is the component of the process governing

observational learning. He further states that most of the human behavior is learned in
a conscious way by observing others. Observational learning is governed by four
component processes: attention, retention, motor preproduction and motivation. First,
an individual cannot learn much by observation alone unless he or she attends to and
perceives accurately the significance of reality. Second, what it is learned has to be
represented in memory in symbolic form. Thirdly, symbolic representations have to
be converted into appropriate actions. Finally, people do not work without motivation.

Attention is a cognitive process which regulates exploration and perception. Attention

determines in a selective way what is chosen and depends on the characteristics of
observers, on the situation and models. Perceptions are guided by preconceptions so
that the cognitive skills of the observer and their perceptive tendencies lead the
individual to observe some things and ignore others. At the same time, observational
skills influence the amount and quality of learning. People learn not only activities or
tasks but also rules. Retention is the second process which consists of transforming
the information of an event in order to be represented to memory as rules or concepts.
Learning is supported by two systems of representation: image and verbal
constructions. Bandura, (2001) has demonstrated that learning involves the active
construction of symbols by the individual and also that codification structures affect
retention.

Motor reproduction or production is the third process and it is about the conversion of
symbolic representations into actions. In order to act, it is necessary for the individual
to organize answers in space and time. Finally, motivation is the fourth process.
Bandura (2001) distinguishes between cognitive acquisition and behavior. An existing
learning turns into behavior depending on the importance of the perceived
consequences. All of the following play an important role in human motivation:
external social and tangible incentives, modeled incentives, (that is, observed benefits
awarded to others for their behavior), as well as self-initiated incentives. Bandura
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(2001) found that in the presence of incentives a not yet shown learning can be
transformed into action. Employees can act on everything they learn but behave
according to their motivation.

Figure 2.8 Social Cognitive Theory of Bandura

Source: Bandura (2001)

Cooper used Bandura‟s Model of Reciprocal Determinism (Bandura, 1977) to explain

safety culture (Cooper, 2000).The model contains three elements including person
(internal psychological factors), and behavior and situation (external observable
factors) (Bandura, 1977) (Fig.1).The model of Reciprocal Determinism (RD) explains
the interactions between the three elements and how they influence one another. The
model also demonstrates that people are neither deterministically controlled by their
environments nor entirely self-determining. Bandura proposed that behavior and
personality are shaped by the interaction between cognitive factors and environmental
factors.

Cooper (2000) stated that Bandura‟s RD model recognizes the dynamic and
interactive relationships between a person, situation, and behavior. Cooper noted there
are three major elements of safety culture consistent with Bandura‟s RD model
(Bandura, 1977). The person represents the psychological components aligned with
intrinsic cultural elements of values, beliefs, and assumptions. Behaviors and
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situations align with extrinsic elements of norms, rituals, and symbols that make up
the safety behaviors of workers and management. Cooper (2000) developed the
Reciprocal Safety Culture Model [RSCM] (e.g Cooper et al. 1994; Cooper, Philips,
Sutherland, & Makin 1994; Cohen, 1977; Duff et al., 1993) as shown in Fig 2.9. The
model is multi-layered with a person, job and organization being represented by three
main measurable dimensions of safety climate (a substitute measure for safety
culture), safety behavior, and safety management system.

Figure 2.9 M del of Reciprocal Determinism from Bandura (1977)

Source: Bandura (1977; 1966)

Cooper (2000) stated that Bandura‟s RD model recognizes the dynamic and
interactive relationships between a person, situation, and behavior. Cooper noted there
are three major elements of safety culture consistent with Bandura‟s RD model
(Bandura, 1977). The person represents the psychological components aligned with
intrinsic cultural elements of values, beliefs, and assumptio s. Behaviors and
situations align with extrinsic elements of norms, rituals, and symbols that make up
the safety behaviors of workers and management.
 136

Cooper (2000) developed the Reciprocal Safety Culture Model [RSCM] (e.g Cooper
et al. 1994; Cooper, Philips, Sutherland, & Makin 1994; Cohen, 1977; Duff et al.,
1993) as shown in Fig 2.10. The model is multi-layered with a person, job and
organization being represented by three main measurable dimensions of safety climate
(a substitute measure
for safety culture), safety behavior, and safety management
system.

Figure 2.10 Reciprocal Safety Culture Model from Cooper (2000)

Source: Cooper (2000)

3. Martin and Meyerson’s Three Perspectives on Organizational Culture

Martin and Meyerson (1988) outlined a framework for analyzing culture focused on
three perspectives. First, the integration perspective view assumes that a strong
culture is characteristic of consistency, clarity, and consensus across the organization.
The culture is seen as having clear and consistent values as well as interpretations
and/or assumptions that are shared on an organization-wide basis. In contrast, the
differentiation perspective is more in tune with the inconsistencies that occur in the
culture with a particular focus on subculture differences. These subcultures are
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important to understanding as they are the sources of cultural clarity or ambiguity for
the members (Frost et al., 1991). The third view, the fragmentation perspective views
ambiguity as inevitable and as part of contemporary life. This perspective examines
issues that are not clearly defined and how this impacts the overall culture. Some
believe that all three perspectives should be addressed in order to truly understand the
culture (Frost et al., 1991). Typically, however, researchers have approached the study
of culture from a single perspective to which they feel most connected based on their
personal experiences and preferences. Yet, Frost et al. (1991) maintain that using all
these perspectives will provide for an approach that is both parsimonious yet
comprehensive and takes into account important issues of culture that the single
perspective may exclude. As outlined by Martin and Meyerson (1988), an
examination of the culture from only one perspective provides only one piece of the
cultural puzzle to the neglect of others.

Figure 2.11 Martin & Meyerson’s Three Perspectives on Organizational

Culture

Source: Martin (1992)

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4. Schein’s Theory of Culture

Schein’s theory of organizational culture has been characterized b Scott et al. (2003)
as the corporate culture view where culture is an internal variable that is closely
associated with organizational development. This theoretical perspective views
“culture as a product of human enactment…searches for predictable methods of
organizational control” (Scott et al., 2003, pg. 19).

The conceptual fram

work (See Figure 3), proposed by Schein (1990; 1992) and
detailed in terms of safety by Guldenmund (2000) provides an overview of the basic
tenets of culture. Schein (1990) has defined culture as:

“… (a) a pattern of basic assumptions, b) invented, discovered, or developed by a

given group, c) as it learns to cope with its problems of external adaptation and
internal integration, d) that has worked well enough to be considered valid e) and
therefore is to be taught to new members as the f) correct way to perceive, think and
feel in relation to those problems.” (p. 111)

Figure 2.12 Uncovering the levels of Culture

Source: Schein's Three Levels of Organizational Culture

(Adapted from Schein 1992)
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There are three fundamental levels of culture: observable artifacts, values, and basic
underlying assumptions. At level 1, artifacts are the visible, tangible and/or audible
results of behavior such as the physical layout of the organization, statements,
meetings and personal protective equipment (Guldenmund, 2000). Values are the next
level of the organizational culture which refers to the reason why certain observed
phenomena happen the way they do. Values are the conscious, affective desires and
want (Schein, 1990; Ott, 1989). Examples of these in a safety context are policies,
training manuals, incident reporting and job descriptions (Guldenmund, 2000). The
third level of the organizational culture is the basic underlying assumptions, defined
as perceptions, thought processes, feelings, and behavior (Schein, 1990). Basic
assumptions are unconscious, relatively unspecific and permeate the whole
organization. These are outlined by Guldenmund (2000) as having to be deduced from
artifacts and espoused values.

Subcultures are reported to be the result of shared assumptions among a functional

group of individuals (Schein, 1996). These subcultures are reported to emerge as a
natural evolution of the organization due to functional and occupational
differentiation, geographical decentralization, and differentiation by product, market
or technology, divisionalisation, or hierarchical level (Schein, 2004). Even though
individuals will enter into the organization and be socialized with the culture of the
organization (e.g., the hospital), they will also bring with them certain cultural
assumptions that have been ingrained through their previous professional experiences
and education. In addition, while initially, the main hospital introduces individuals to
the overall culture, these individuals will ultimately be socialized around the culture
of the unit in the hospital (e.g., the intensive care unit) that will also have its own
subculture (Schein, 1996).

At another level, within this unit there exist differences among the members of certain
occupations as to the assumptions that they hold because they are “doing
fundamentally different things, have been trained differently and have acquired a
certain identity in practicing their occupation” (Schein, 2010; (p.261). This
occupational and unit diversity is said to create the challenge of integration and
coordination among the members around the mutual understanding of cultural
variables that must cross the boundaries of all the subcultures. This is an important
consideration in the way healthcare is organized. Since many health professionals
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(e.g., nurses, physicians, surgeons, nutritionists, social workers) must all work
together and patient safety can be viewed as a cultural attribute that must permeate all
of these cultures, there must be some shared consensus about the importance of
safety.

In Schein’s (1988) theory, culture exists on three levels:

1. Artifacts – Artifacts are difficult to measure and they deal with organizational
attributes that can be observed, felt and heard as an individual enters a new
culture.
2. Espoused Values – This level deals with the espoused goals, ideals, norms,
standards, and moral principles and is usually the level that is usually measured
through survey questionnaires.
3. Underlying assumptions – This level deals with phenomena that remain
unexplained when insiders are asked about the values of the organizational
culture. Information is gathered at this level by observing behavior carefully to
gather underlying assumptions because they are sometimes taken for granted and
not recognized. According to Schein, the essence of organizational culture lies in
this level.

The levels of organizational culture and their relationship

Schein (2004) states that artifacts are the surface level of an organizational culture,
tangible, easily seen and felt manifestations such products, physical environment,
language, technology, clothing, myths and stories, published values, rituals, and
ceremonies, etc. Espoused beliefs and values are the next level of organizational
culture, including strategies, goals, shared perceptions, shared assumptions, norms,
beliefs, and values instilled by founders and leaders. Basic underlying assumptions
are the base level of organizational culture and are the deeply-embedded,
unconscious, taken for granted assumptions that are shared with others. Any challenge
of these assumptions will result in anxiety and defensiveness.

The most visible symbols should not be the only aspects used to interpret culture, due
to the ease with which they can be misinterpreted. Focusing only on visible symbols
will result in a failure to grasp the underlying basic assumptions that are fundamental
to understanding the culture. Similarly, it is important to recognize that even espoused
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beliefs and values may only reflect the aspirations of a culture, and not the actuality
(Schein, 2004).

The Purpose of Organizational Culture

The main function of organizational culture is to define the way of doing things in
order to give meaning to organizational life (Arnold, 2005). Making meaning is an
issue of organizational culture because organizational members need to benefit from
the lessons of previous members. As a result, organizational members are able to
profit from whatever trials and errors regarding knowledge others have been able to
accumulate (Johnson, 1990). Organizational culture also determines organizational
behavior, by identifying principal goals; work methods; how members should interact
and address each other; and how to conduct personal relationships (Harrison, 1993).

Brown (1998, p 89- 91) states the following functions of organizational culture:

a) Conflict reduction. A common culture promotes consistency of perception,

problem definition, evaluation of issues and opinions, and preferences for action.
b) Coordination and control. Largely because culture promotes consistency of
outlook it also facilitates organizational processes of coordination and control.
c) Reduction of uncertainty. Adopting of the cultural mind frame is an anxiety-
reducing device which simplifies the world of work, makes choices easier and
rational action seem possible.
d) Motivation. An appropriate and cohesive culture can offer employees a focus on
identification and loyalty, foster beliefs, and values that encourage employees to
perform.
e) Competitive advantage. Strong culture improves the organization’s chances of
being successful in the marketplace.
In addition to the above functions, Martins and Martins (2003, p382) also mentioned
the following as functions of organizational culture:

a) It has a boundary-defining role, that is, it creates distinctions between one

organization and the other organizations.
b) It conveys a sense of identity to organizational members.
c) It facilitates commitment to something larger than individual self-interests.
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d) It enhances social system stability as the social glue that helps to bind the
organization by providing appropriate standards for what employees should say
and do.
e) It serves as a meaningful control mechanism that guides or shapes the attitudes
and behaviors of employees.
These functions of organizational culture suggest that an organization cannot
operate without a culture because it assists the organization to achieve its goals. In
general terms, organizational culture gives organizational members direction
towards achieving organizational goals (Martins and Martins, 2003).

5. Westrum’s Typologies of Organizational Culture

Westrum (2004) defined organizational culture as the pattern of responses to the

problems and opportunities that arise. Three types of patterns have been
described/observed; 1) pathological, which is power oriented with a focus on needs
and glory; 2) bureaucratic, which is preoccupied with rules, positions and
departmental turf and 3) generative, which concentrates on the mission itself as
opposed to being concerned with positions and people (Westrum, 2004). These types
have been conceptualized under the assumptions that the leaders in the organization
shape the culture and through their actions, rewards, and punishment, are able to
communicate to their employees what is important, thus fostering a certain type of
culture. To change the culture one must have a typology of the environment and
understand how information is processed across the organization.

A number of theories can be used to study an organizational culture. These five

frameworks are used as the basis for this study as they each propose unique
approaches to culture but can be integrated to create a comprehensive view of
organizational culture. The work of Martin and Meyerson (1988) provides an
understanding of the need to look at the data from differing perspectives, whereas
Schein`s (2010) work lends to an understanding of where and what to look at and how
this can be interpreted in a cultural framework. Westrum (2004) allows for the
information to be grouped in a way that would provide a comprehensive
understanding of the information from a typology perspective.

These organizational culture theories are used as the basis from which to understand
and explore the concept of culture and, more specifically, to understand how the
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current workaround patient safety culture is being framed. Each theory is based on
underlying assumptions about the nature of organizational and patient safety culture
and draws our attention to important issues. No one framing or theory trumps the
others; there is a utility to all of these approaches in offering guidance as to how to
conceptualize and measure culture. These major theories of organizational culture are
used in the current study to inform the understanding of culture and explore the ways
in which patient safety culture is measured and the efforts needed to improve this
culture to create a platform for safer care.

As healthcare service researchers began to examine patient safety culture dimensions

that would ideally be seen in this organizational culture, the focus was on theories
stemming from research on HROs.
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2.33 Theories of Patient Safety

Historically, the explanation of how and why medical errors and adverse events occur
focused on the individual clinician’s human error. The tendency to blame individuals
perpetuated a culture of punishment and individual accountability among medical
professionals (Cook & Woods, 1994; Weinberg, 2002). As a result of the heightened
attention toward improving patient safety over the past decade, health authorities have
looked to the safety science literature to help explain safety culture and provide
direction for creating safety management systems (Flin, 2007).

In the safety science literature, there is a focus on the culture of safety as a starting
point from which to create a safer system. As outlined by the Advisory Committee on
the Safety of Nuclear Installations (ACSNI) the safety culture of an organization:

“ is the product of the individual and group values, attitudes, competencies, and
patterns of behavior that determine the commitment to and the style and proficiency
of, an organization’s health and safety programmes. Organizations with a positive
safety culture are characterized by communications founded on mutual trust, by
shared perceptions of the importance of safety and by confidence in the efficacy of
preventive measures.” (Vincent, 2006, as cited in Vincent, 2010, p.273 )

1. The Swiss Cheese Model

The safety culture of the organization is an encompassing concept that is drawn from
High-Reliability Organization (HRO) theory. It has been most notably translated by
Reason (1997) and Weick (2001) into guiding dimensions and constructs. This focus
on the culture of safety is linked to Reason’s (1990b) description of the “Swiss
Cheese” model as seen in Figure 2.13 below. The figure depicts the idea of multi-
causation to describe how numerous organizational and individual layers result in
structural holes; the alignment of these holes at one time subsequently allow for an
error to occur.
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Figure 2.13 The Swiss Cheese Model

Source: Reason's Accident Causation Model (Reason, 1997)

Reason (1997) also discusses organizational factors that impact adverse events and
emphasizes that organizations should not persist with the historical perspective of
blaming 4 individuals for poor safety outcomes. Within this discussion, the distinction
between active and latent failures in the environment are described. Active failures are
those errors and failures at the “sharp end” of the system where there are interaction
and contact between the human and the system in which he or she is working. In
contrast, latent conditions are those organizational factors that impact the trajectory of
the error; these include poor design, shortfalls in training and inadequate tools, all of
which allow for active failures to occur. These latent conditions “lie dormant for a
time causing no particular harm until they interact with the local circumstances to
defeat the system’s defense” (Reason, 1997, p.11). Reason (1997) further outlines
aspects of a culture that is important in the formation of organizational practices such
as values and beliefs, which include reporting, learning, justice, and flexibility. These
cultural aspects will, in turn, create defenses in the latent conditions, which can
subsequently protect against active failures.
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Complementary to the research by Reason (1997), Weick (2001) outlines concepts of

mindfulness that create a culture of safety. According to Weick (2001), mindfulness is
seen in five core characteristics of high-reliability organizations (HROs). These core
characteristics are a preoccupation with failure, reluctance to simplify, sensitivity to
operations, commitment to resilience and deference to expertise, all of which need to
be integrated within the everyday work of the organization in order to facilitate
optimal safety management.

Looking to foundational theories such as these, health leaders and researchers suggest
HRO theories be applied to healthcare given the similarities in procedures and
practices that have evolved to contend with the “dynamic, the variable and the
unexpected” (Vincent, 2010, p.279). Such theories have enabled HROs to automate
their procedures, create policies and engrain specific safety-related actions within
their systems, all of which aid in creating a culture focused on safety. Using these
lessons learned and considering dimensions from HROs provides guidance and “raise
the bar” for the expectations in healthcare.

Prior to applying theories and concepts from HROs, it is important to consider the
differing nature of healthcare organizations in comparison to HROs (Vincent, 2010).
A great deal of HRO theory and practice is carried out in an environment that can be
viewed as highly disciplined in nature and focused on strict training and adherence to
procedures, protocols, and routine (Reason, 1997; Vincent, 2010). Many of these
characteristics are not as evident in a healthcare setting due to the variable nature of
the work and tasks. As outlined by Vincent (2010), hierarchies in healthcare, due to
various professions, can create relationship problems complicated by power and
status; such a characteristic can create difficulties in applying a concept from HRO
such as deference to expertise (Weick, 2001).

Another impediment to achieving high reliability in the healthcare industry is that

failed processes are uniquely characterized as “noncatastrophic events”, which do not
result in great suffering or loss, given that most events only affect one individual.
Thus, low levels of reliability are commonly accepted and remain unquestioned
(Resar, 2006). Due to these characteristics of healthcare, it is possible that
understanding and studying culture in a healthcare setting is even more important.
Given the variability in human interactions that occur in healthcare, as well as the
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influence that underlying values, beliefs, and behaviors of individuals have on

everyday behaviors in these interactions, further research on safety culture is
important.

Focusing on safety science research has provided some direction to healthcare leaders
and researchers as to the essential aspects to consider for enhancing safety culture.
However, there exists a gap in our understanding of the best methods for studying,
evaluating and subsequently making changes to culture. There is an urgent need to
address this gap, given that applied efforts are underway to implement safety culture
change, though researchers have only offered a few insights as to how to monitor and
evaluate changes of this nature.

There has been a great deal of interest from leaders and practitioners in understanding
how processes inherent to HROs could be applied to the healthcare sector (e.g., Hines
et al., 2008; Dixon & Shofer, 2006; Pronovost et al., 2006; Wilson et al., 2005).
HROs are defined as organizations that function within hazardous environments and
have been characterized as complex and tightly coupled (Roberts, 1990). A
complementary definition of HROs states that they are organizations in which errors
can have catastrophic consequences but which consistently avoid errors (Roberts et
al., 2005). The main focus within these HROs is the culture of safety, and elements
from this work have been drawn upon in an attempt to apply concepts from these
industries to healthcare. To this end, safety culture changes and measurements tools
have been predicated on much of the work that has been done in this area.

2. High-Reliability Organization Theory & Normal Accident Theory

Two theories have dominated the literature in relation to understanding or making

sense of, accidents and failure. Perrow’s (1984) Normal Accident Theory (NAT)
focused on high-risk organizations and technology, and Weick (1987) highlights
aspects of the theory of HROs based on the notion of collective mindfulness. These
two theories are discussed in more detail below to provide a foundational
understanding of this area of research.

After analyses of the Three Mile Island accident and numerous accidents between
ships at sea, Perrow (1984) outlined, “Our technological progress has outrun our
administrative capabilities.” This was sparked by the defining characteristics of high-
 148

risk organizations proposed by Perrow which included a) the potential to create a

catastrophe, b) complexity seen as having large numbers of interdependent
subsystems with many possible combinations and c) tightly coupled, meaning that
perturbations are transmitted rapidly between subsystems with little attenuation (as
cited in Bierly & Spender, 1995). These latter two characteristics made important
contributions to this field as they provide for the understanding that as efforts to
improve safety increase, this adds to the complexity of the work and can lead to more
accidents.

The theory of HRO focuses on reliability as compared to high risk. Reliability is

defined as the capacity to continuously and effectively manage working conditions,
including those that fluctuate widely and are extremely hazardous and unpredictable
(Bigley & Roberts, 2001). Weick and Roberts (1993) note that an organization’s
ability to exhibit “a pattern of heedful interrelations of actions” is what allows them to
reach the high status of reliability. Weick and Sutcliffe (2001) highlighted that the key
to the success of HROs is the focus on collective mindfulness - cognitive processes
enacted at the organizational level. Five key processes that guide the collective
mindfulness of HRO operations that are pertinent to the maintenance of this level of
reliability include: 1) preoccupation with error (always worrying that something will
go wrong), 2) reluctance to simplify interpretations (being mindful of all factors
involved in the problems), 3) sensitivity to operations (situational awareness), 4)
cultivation of resilience (focus on rapid learning and minimizing error impact) and 5)
willingness to organize around expertise (letting decisions migrate to those with the
relevant expertise). These processes work together to help create an awareness of
operational details and to facilitate discovery and correction of errors (Weick,
Sutcliffe & Obstfeld, 1999). HROs continuously enhance their focus on reliability
through certain actions that are based on the principles of 1) actively seeking
knowledge about what they do not know, 2) designing reward systems that recognize
both the cost of failures and the benefits of reliability and 3) communicating the
whole picture to all levels of the organization (Roberts & Bea, 2001; Roberts, Yu &
van Stralen, 2004; Shapiro & Jay, 2003; Vogus & Welbourne, 2003).

There is a conceptual divergence in the way Perrow and Weick (and other HRO
theorists) understand the higher level of collective knowledge and the impact on
individuals operating the systems (Bierly & Spender, 1995). Bierly and Spender
 149

(1995) emphasize that Perrow is focused on the failures in the

technological and
administrative systems by tracing failure from the incident to
the major event,
whereas Weick is more interested in the people who attempt to operate in the system.
Weick (1987) states that “accidents occur because the human beings who manage and
are integrated into these complex systems are insufficiently complex to sense and
therefore anticipate the system’s problems.” (p. 112). Further to this point is the need
to focus on HRO processes that enable organizations to function at a high level of
reliability that takes in to account the insufficient human interactions in the system.
The development of the NAT is found in the conceptualization of the origin and
context of the accidents at a macro level and was technology driven (Weick et al.,
1999). HRO theory works to further explain the set of cognitive processes that interact
with the work processes by which reliable structures are enacted.

Figure 2.14 Schematic Illustration of Normal Accident Theory (NAT)

Source: Special Communication (Improving Patient Safety in Clinical Oncology by

Bhishamjit S. Chera)

Explanation: The NAT concepts of linear vs interactively complex and loosely

coupled vs tightly coupled are plotted in quadrants. Several nonmedical systems from
Perrow’s original descriptions (italics) and approximate plot locations for oncology-
 150

related activities are shown in boxes (adapted from Marks et al19). BMT indicates
bone-marrow transplant; chemo, chemotherapy; RT, radiation therapy.

3. Normal Accident Theory

Substantial work in non–healthcare settings have been performed to better understand

the causes of errors and investigate potential mitigation strategies. One of the nation’s
leading theorists in the area of safety, Dr. Charles Perrow, has developed NAT, a
framework for analyzing failure potential within and between systems. He argues that
errors in systems occur often and are indeed expected as part of normal operations. He
categorizes systems based on how these errors propagate and interact within the larger
system. Systems in which failures propagate and interact predictably are
considered linear, and those in which failures behave unpredictably are interactively
complex.

He further categorizes systems by their ability to detect and respond to failures.

Systems that are relatively slow allowing relatively more opportunity to detect and
respond to failures are termed loosely coupled, while those that are fast offering less
opportunity to detect and respond to failures are termed tightly coupled.

For example, the US Post Office system is linear (errors have predictable
consequences) and is loosely coupled (errors are largely detected and corrected, and
most of the mail ultimately gets delivered). A dammed river system is also linear but
is tightly coupled. A dam breach will often lead to a flood because the timescale for
fixing the breach is too long to mitigate the rapid downstream effects. A university is
interactively complex because events occurring within its many varied components
(eg, multiple departments, schools, social events, and athletics) can interact in
unforeseen ways (Figure 1.6).

Perrow argues that systems that are both interactively complex and tightly coupled
have a particular propensity for catastrophic failure. Since errors in subsystems are
assuredly going to occur and since these will propagate in unforeseen ways that
cannot be fully understood or mitigated, major global system failures are probable. In
other words, complex systems cannot be fully understood, and thus their behavior will
always have some element of chaos. He argues that only a change in their structure—
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reducing coupling or reducing interactive complexity—can reduce the probability of a

catastrophic event.

Given that complexity is inevitable in today’s society due to advancing technology,

work needs to be structured properly to reduce the likelihood of error. A focus on
processes that will help to ensure, or at the minimum, reduce the opportunity for error,
is required. As the goal is to understand what changes are required to obtain reliable
structures and subsequently improve safety, Weick and colleagues‟ theories of HRO
appear to be applicable to healthcare settings.

One of the core aspects of the development of these reliable structures is a focus on
culture. It has been suggested that due to the fact that HROs share common
characteristics (5 processes outlined above), then cultural characteristics should be
shared as well. Weick (1987) has stated that the culture can be seen as the source of
reliability in these organizations as the culture is where these higher-level collective
knowledge processes are manifested – in the behaviors, values, beliefs, and
assumptions.

Reason’s (1997) description of the attributes of a culture supporting safety reflects

many of the HRO elements. According to Reason (1997), a safety culture is, first of
all, an informed culture. An informed culture is one in which those who manage and
operate the system have current knowledge about the human, technical, organizational
and environmental factors that determine the safety of a whole system. Informed
culture can be more specifically broken down into the underlying constructs of
reporting, learning, justice, and flexibility.

A reporting culture is one in which people are prepared to report their errors and near
misses (Reason, 1997). Some scholars of high-reliability research view reporting as
one of the essential aspects of a safety culture (Amalberti, 2001; Battles & Lilford,
2003). Singer et al. (2003) suggest that the organization must have a frequent and
open communications approach across all levels of the organization with a policy
about errors that promotes reporting and learning from these errors as key to
improvement.

A learning culture is characterized by individuals‟ willingness and ability to

understand and make changes based on the safety information that is provided by the
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system (Reason, 1997). As outlined by Tucker and Edmondson (2003), it is essential

to acknowledge failures and reframe them into learning opportunities so that
employees can engage in system improvements.

Developing the cultural aspect of justice is done by providing an atmosphere of trust

in which people are encouraged, even rewarded, for providing essential safety-related
information (Reason, 1997; Beyea, 2004). The important aspect to note in this just
culture is that the objective is not that the focus would be on a “no blame” atmosphere
but a “just” culture where individuals understand the delineation of what is
unacceptable, thus “blameful” behavior (Reason, 1997; Shaw, 2004; Walton, 2004).

A flexible culture is defined as the ability of the organization to reconfigure itself in

the face of high-risk operations or certain kinds of danger (Reason, 1997). This
flexible nature of the organization allows members to adapt to a crisis by transferring
control to those who are the task experts, regardless of the hierarchical model of the
organization. This description is similar to the concept of decision migration outlined
by Roberts (1993) and Weick (2002) where organizations allow for instantaneous
movement from centralized to local control in a crisis situation. As well, the attribute
of management by exception outlined by Roberts (1993) permits the fast
identification of a problem where individuals at all levels of organization are trained
and able to make decisions. This issue of achieving flexibility in the culture arose in a
study which found that there were differing perceptions of teamwork among team
members and reluctance of senior staff to accept input from junior members (Sexton,
Thomas & Helmreich, 2000), which was reported to impact on the culture of safety.

In summary, by examining the concepts of culture that are inherent to HROs and in
Reason’s assessment of a safety culture, it appears that a number of dimensions can
be extracted and used to formulate practices and measures of safety culture in a
healthcare setting. This has been done to a certain extent and continues to be a focal
area of healthcare service research.

A number of theories can be used to study an organizational culture. These three

frameworks are used as the basis for this study as they each propose unique
approaches to culture but can be integrated to create a comprehensive view of
organizational culture. The work of Martin and Meyerson (1988) provides an
understanding of the need to look at the data from differing perspectives, whereas
 153

Schein`s (2010) work lends to an understanding of where and what to look at and how
this can be interpreted in a cultural framework. Westrum (2004) allows for the
information to be grouped in a way that would provide a comprehensive
understanding of the information from a typology perspective. These organizational
culture theories are used as the basis from which to understand and explore the
concept of culture and, more specifically, to understand how the current workaround
patient safety culture is being framed. Each theory is based on underlying
assumptions about the nature of organizational and patient safety culture and draws
our attention to important issues. No one framing or theory trumps the others; there is
a utility to all of these approaches in offering guidance as to how to conceptualize and
measure culture. These major theories of organizational culture are used in the current
study to inform the understanding of culture and explore the ways in which patient
safety culture is measured and the efforts needed to improve this culture to create a
platform for safer care. As healthcare service researchers began to examine patient
safety culture dimensions that would ideally be seen in this organizational culture, the
focus was on theories stemming from research on HROs.
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2.34 Summary of Theoretical Understanding

A brief summary of the Organizational Culture and Patient Safety Culture Theories
which forms the base of this research study is mentioned in the below-given Table
2.11.

Table 2.11

Summaries of Different Theories

Implications for
Key components of the
Name of Theory Author this Research
Theory
Study
Organizational Crosman, It is a study of Learning It is two routes of
Learning Theory Lane and processes of and within an learning; from
White, 1999 organization. individual to the
organization and
It deals with or is based on from organization to
individual learning through the individual.
private and public
organizations engaged in For OL it is
creating and obtaining necessary a
knowledge for the purpose transference process
of institutionalizing it in of knowledge among
order to adapt as an people with the
organization to the changing purpose of
conditions of the institutionalization
environment or to change (law or pattern of
the environment proactively behavior).
depending on its level of
development. The theory identifies
four processes of
learning: intuiting,
interpreting,
integrating and
institutionalizing
Social Cognitive Bandura, According to the SCT of The impact of the
Theory of 2001 Bandura, individuals are not socio-structural
Bandura governed by internal forces factors on
or by external stimuli. organizational
performance is
Bandura declares that mediated by
people are producers as well individual learning.
as products of their social
environment. OL occurs through
interactive
Internal personal factors (in psychosocial
the form of cognitive, processes, not only
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affective and biological in the context of

events), behavior and organizational
environmental events all attributes operating
operate as interacting independently of
determinants that influence human behavior.
each other.
Employees can act
Observational learning is a on everything they
collaborative effort where learn but behave
individuals create new ideas according to their
by sharing their knowledge motivation. People
through interaction with do not work without
others. motivation.

Observational
learning is governed
by four component
processes: attention,
retention, motor
reproduction and
motivation.
Schein’s Theory Schein’s, Culture exists on three Artifacts are the
of Culture 1998 levels: surface level of an
organizational
1. Artifacts: which are culture, tangible,
difficult to measure and easily seen and felt
they deal with manifestations such
organizational attributes that products, physical
can be observed, felt and environment,
heard as an individual enters language,
a new culture. technology, clothing,
myths and stories,
2. Values: This deals with published values,
espoused goals, ideals, rituals, and
norms, standards and moral ceremonies, etc.
principles.
Espoused beliefs and
3. Underlying assumptions: values are the next
This deals with the level of
phenomenon that remained organizational
unexplained when insiders culture, including
are asked about the values strategies, goals,
of the organizational shared perceptions,
culture. shared assumptions,
norms, beliefs, and
values instilled by
founders and
leaders.
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Basic underlying
assumptions are the
base level of
organizational
culture, & are the
deeply-embedded,
unconscious, taken
for granted
assumptions that are
shared with others.
Any challenge of
these assumptions
will result in anxiety
and defensiveness.
The Swiss James It describes the idea of This model uses to
Cheese Model Reason, multi-causation that how provide a mean to
1997 numerous organizational conceptualize the
and individual layers result complexity of the
and in structural holes; process and supports
alignment of these holes at identifying the
Weick, one time subsequently allow vulnerability of the
2001 for an error to occur. organization.
This model
Service Failures occur when visualizes the gap
hazards penetrate the holes between the
within the layers of the functional areas of
process, piercing multiple the hospital.
defense barriers to cause
service failure. By being mindful of
the sensitivity to
operations, the
organization can
address early signals
with the appropriate
response.
High-Reliability Charles Theory of HRO focuses on HRO achieve
Organization Perrow, reliability as compared to reliability and
Theory 1984 high risk. effectively deal with
the unexpected
and The key to the success of situations.
HROs is the focus on
collective mindfulness - It deals with
Karleen cognitive processes enacted anticipation in form
Roberts at the organizational level. of a preoccupation
1990 with failure,
Five key processes that Reluctance to
and guide the collective simplify, and
mindfulness of HRO Sensitivity to
operations that are pertinent Operations.
Weick & to the maintenance of this
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Roberts, level of reliability include: It deals with

1993 containment and
1) preoccupation with error includes a
and (always worrying that commitment to
something will go wrong), relicense and
2) reluctance to simplify deference to
Weick & interpretations (being expertise.
Sutcliffe, mindful of all factors
2007 involved in the problems), HRO helps
3) sensitivity to operations to disseminate
(situational awareness), 4) knowledge and
cultivation of resilience to develop
(focus on rapid learning and cultural
minimizing error impact) 5) awareness on the
willingness to organize importance of
around expertise mindfulness.
Normal Accident Charles Normal Accident theory This theory will help
Theory Perrow, delves into how people to study in the
1984 interact with complex hospital the human-
technological systems to machine interface,
create a whole or a unitary particularly for
system. decision making
under varying
It examines the interactive abilities and
complexity and compiling demands.
of components within
complex organizations. To understand the
incidences of
The complexity and Normal Accidents in
compiling whether by hospitals whose
design or happenstance occurrence is
determine the systems’ unpredictable and
susceptibility to accidents anticipated?
and make accidents not only
inevitable but normal. Also, it will help to
determine the
occurrence of
unfamiliar,
unexplained or
unexpected
sequences of events
in the working
environment of the
hospital at the
executive or
operational level.

Source: Compilation of various studies by researcher

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2.35 Conceptual Framework

Based on the Literature Review and Theoretical understanding mentioned the key
variables are identified for this research design in the below Figure. Further, the
relationships between the Safety Culture Dimensions (12) and Background Variables
(8) and Outcome measures (4) are developed as Conceptual Framework for this
research study. This Conceptual Framework will be a source for the entire process of
the research study. It helps to clarify the relationships between the twelve Independent
key variables; Safety Culture Dimensions and Dependent variable; Outcome
Measures. All the key variables identified in the below Figure will be examined in the
below discussion. The Figure also shows components of Patient Safety in Hospitals
that have been selected through an intensive search of the literature on Organization
Behavior and HRM by using Swiss Cheese Model, High-Reliability Organization
theory, and Normal Accident theory.

The Demographic / Control variables used for this research study such as gender, age,
education, designation, experience, and pay are taken as control variables. The Patient
Safety Theories such as Swiss Cheese Model, High-Reliability Organization theory
and Normal Accident theory also affect Patient Safety Culture of Hospital. This above
relationship is represented in the below Figure. In this conceptual framework the
twelve Independent variables of Patient Safety in Hospitals which in turn will affect
the outcome of patient safety culture; Frequency of Events, Overall Perception of
Safety, Patient Safety Grade and No of Events Reported. This will result as or are
likely to act as the Factors, Barriers & Facilitators to enhance the Patient Safety
Culture in Hospital. This will also be supported by the in-depth views of the
caregivers (distributed in 4 different strata) on the existing patient safety culture and
prevailing practices, the inferences of this will help to enrich the outcome of the
study.
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Figure 2.15 Conceptual Framework

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2.36 Summary

This methodology chapter discussed the positivistic and interpretive research

paradigms and justified the selection of philosophy that acted as a basis for the study.
Furthermore, the explanation was given for the chosen study design and the methods
and the data collection and sampling procedures in detail which are used to address
the study aims and research questions/objectives. Finally, the explanation was given
of the ethical considerations required to conduct the study and lastly the conceptual
framework for the study was elaborated.
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Chapter Three