An integrated model of organizational culture and climate : a case study in obstetrics practice in Ontario

The goal of this study was to determine whether a training intervention would be sufficient to produce a cultural change. A comprehensive review of literature on culture and climate indicated that these separately studied constructs could be integrated; thus, an integrated model of culture and climate, and the associated theory, was developed. Three studies were conducted within the obstetrics practice in Ontario, Canada. The specific training intervention used in this study was the MOREOB program (Managing Obstetric Risks Efficiently), which was a proprietary program developed by the Salus Global Corporation, Canada. This program sought to improve safety culture in the field of obstetrics through a strategic approach to knowledge-building and team-training. Over the past decade, more than 300 hospitals across Canada have implemented this program. However, the impact of this program on the culture of respective obstetrics units had not been evaluated. The sample for this research consisted of 68 hospitals from Ontario that had implemented the MORE-OB program. 
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\nOverall, this study used a mixed-methods approach, consisting of both quantitative and qualitative analyses, and explored five research questions and two hypotheses. The study was structured in terms of three sub-studies: Study#1 focused on quantitative assessment of knowledge gained through the training intervention, changes in clinical outcomes, and changes in the patient safety climate; Study #2 focused on qualitative assessment aimed at analyzing interview narratives and artifacts to develop a deeper understanding of how various external influences as well as internal factors and the MORE-OB training may have shaped the organizational culture at the subject hospitals. Study #3 took a longitudinal approach and presented an integrated analysis of culture and climate at two subject hospitals.
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\nUltimately, the three studies arrived at the following conclusions:
\n1.\tContemporary environmental factors such as economics, geo-social conditions, legal requirements, and professional coalitions played a vital role in influencing organizational values as well operationalizing them. By asking the study participants how external environmental factors might have influenced their organizational culture, the researcher was able to map the role played by the changing external conditions in shifting the participants’ unquestioned assumptions. 
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\n2.\tLeadership’s role in shaping organizational culture was not limited to imprinting of his/her personal values on the organization. First, key influencers outside the organization raised awareness about critical issues, questioned the norms, and presented ideas and test-cases about best practices that could be used to solve the issues. Next, formal leaders within the organization interpreted these external signals in the context of local conditions and engaged internal mechanisms to revise or reinforce corresponding organizational values. Internal key influencers, on the other hand, took the signal from their formal leaders and developed group-level standards of practice, enforced those standards, and served as role models.
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\n3.\tThree levels of shared experiences were noted: (a) experiences resulting from external influences (e.g., the experiences resulting from placing one subject hospital under supervisory control); (b) experiences resulting from internal implementation mechanism (e.g., the use of the Lean methodology across one of the subject hospitals); and (c) experiences resulting from the MOREOB program as a training intervention aimed at improving the patient safety culture in obstetrics. 
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\n4.\tA 2x2 matrix of internal versus external and formal versus informal feedback mechanisms was noted. External mechanisms, whether formal or informal, were aligned with external influence factors. For example, overall transparency regarding every hospital’s clinical performance provided means to compare hospital performance across peers and enabled patients to choose their care providers based on quality of care metrics. Since patient volume was linked with financial health of the hospital, the benchmarked performance measures received significant attention from senior management. Thus, the study of feedback mechanisms revealed how such mechanisms could work in concert with external factors and have substantial impact on the organizational culture.
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\n5.\tThere was a positive influence of training on participants’ knowledge, clinical outcomes, and safety climate factors. Additionally, the training was aligned with shared organizational values. However, it was evident from the low-to-moderate relationship between improvements in clinical knowledge (the focus of the training intervention) and the safety climate improvements that training alone was not sufficient to cause a climatic or cultural change. Results of the qualitative analysis were helpful in understanding the influence of MOREOB training on shared values, practices, leadership commitment, and use of feedback mechanisms. Thus, while training may improve the organizational climate, its impact on culture is dependent on its alignment with shared organizational values, leadership commitment, and appropriate use of feedback mechanisms (including alignment of incentives). 
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\nThe emergent model of culture and climate was revised to better represent the various mechanisms that influence organizational culture and climate. As a macro-level integrative model, it presents an alternate perspective compared to other models that generally tend to focus on specific elements like values or leadership. Future studies should consider different domains and different planned interventions in order to test the transferability of the proposed integrated model of culture and climate. 
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