There is general agreement among people who research and write about management and leadership that of the three elements of an organisation – structure, systems and culture – it is culture which is the most important. The definition of Edgar Schein, one of the most highly respected writers on management, is that the culture of a group can be defined as a

pattern of shared basic assumptions that was learned by a group as it solved its problems of external adaptation and internal integration, that has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those problems.

Source:Schein, E.H.   (2004)   Organizational Culture and Leadership.  John Wiley & Sons Inc. (p.17).

Furthermore, there is agreement that what distinguishes leadership from management is that leadership’s unique role and responsibility is to create and shape culture:

“Leadership and a company’s culture are inextricably intertwined.”

Source:  Morgan, J.M. and Liker, J.K.   (2006)   The Toyota Product Development System.   Integrating people, process, and technology.   Productivity Press, (pp. 217, 218).

And, to quote Edgar Schein again:

“When we examine culture and leadership closely, we see that they are two sides of the same coin; neither can really be understood by itself.   If one wishes to distinguish leadership from management or administration, one can argue that leadership creates and changes cultures, while management and administration act within a culture.”
Source:  Schein, E.H.   (2004)   Organizational Culture and Leadership.  John Wiley & Sons Inc. (pp.10-11).

There are many different types of culture, for example, the quality culture; but there is one type of culture particularly relevant to value based healthcare – the culture of stewardship, a culture with a long history, going back to the Bible but which re-entered society when concern about the future of the planet surfaced and Elinor Ostrom was awarded the Nobel prize for Economic Science.

Elinor Ostrom studied the management of scarce resources, such as fishing resources and water and grazing lands and came to the conclusion that “If those using the resources are allowed to manage those common pooled resources themselves, then sustainability is possible. They become stewards”.  She was joint winner of the Nobel Prize for Economics in 2009 with Oliver Williamson who convinced the world of economists and business that neither bureaucracies nor markets alone or together could meet complex challenges like healthcare. What is needed is an integrated system with the culture of stewardship.

The term stewardship also came into use about the future of the planet and here are two definitions.

“Stewardship is to hold something in trust for another.”

“The stewardship concept demands that we constantly ask the question: Will the resource be in better shape after my stewardship?”

Holmgren D (2002) Permaculture. Principles and pathways beyond sustainability. Holmgren Design Services. Page 5.

The same concept is highly relevant to the stewardship of healthcare and a very good description of its relevance was provided by two young doctors who co-ordinated and produced the 2014 Report from the UK Academy of Medical Royal Colleges on Protecting Resources and Promoting Value which emphasised that:

“But this is not simply about costs.  It is about supporting doctors and other clinicians to ensure that the resources of the NHS are used in the most effective way possible to provide the best possible quality and quantity of care for patients.  This process creates a higher value health care system where resources: cash, carbon and staff time, are released from some parts of the system to develop a new services or support struggling services.  Reducing waste in today’s climate of constrained resource is really about creating the health care system that we want to have.  It is not just about cutting corners or reducing spending.  As responsible stewards, doctors can provide a more effective use of constrained economic and environmental resources. If clinicians do not make good use of the resources there may not be a health service of the type they value for the generations to come, Doctors should embrace the values of resource stewardship in their clinical practice …”

Maughan D, Ansell J (2014) Protecting resources, promoting value: a doctor’s guide to cutting waste in clinical care.  Academy of Medical Royal Colleges. November 2014. Page 8.

The OVSP Learning Programme

This is the fourth of the five modules in our online learning opportunity to help you develop the understanding and skill to

  • Improve healthcare systems by increasing value and reducing waste (Module 1)
  • Shift the focus from bureaucracies to populations (Module 2)
  • Design population based systems and deliver care through networks (Module 3)
  • Create a culture of stewardship (Module 4)
  • Optimise personal value (Module 5)

As a result of learning from this module, and from other people learning with you, you will be able:

  • To assess the part that language plays in shaping and changing a culture
  • To use examples from industry to convince colleagues of the importance of culture in the transformation of healthcare
  • To explain how to create the culture necessary to minimise waste and optimise value
  • To explain the importance of leadership in creating the ‘right’ culture in healthcare organisations
  • To appraise the culture of a healthcare organisation
  • To take steps to influence the culture or subcultures of an organisation