Culture

Norms, values, and basic assumptions of a given organization [1]. Most change efforts are targeted at visible, mostly objective, aspects of an organization that include work tasks, structures, and behaviors. One explanation for why so many of these initiatives fail centers on the failure to change less tangible organizational assumptions, thinking, or culture [2]. Some researchers have a relatively narrow definition of culture, while other researchers incorporate nearly every construct related to inner setting. In the next section we highlight the concept of ‘climate.’ As with ‘culture,’ climate suffers from inconsistent definition. Culture and climate can, at times, be interchangeable across studies, depending on the definition used [3]. A recent review found 54 different definitions for organizational climate [1] and, likewise, many definitions exist for culture [3]. Culture is often viewed as relatively stable, socially constructed, and subconscious [3]. The CFIR embraces this latter view and differentiates climate as the localized and more tangible manifestation of the largely intangible, overarching culture [1]. Climate is a phenomenon that can vary across teams or units, and is typically less stable over time compared to culture.

We include Culture in the CFIR because, despite variation in use and definition, it has been shown to have significant influence on implementation effectiveness [4][5]. Employees impart organizational culture to new members, and culture influences in large measure how employees relate to one another (see Networks and Communications) and their work environment [5]. Nearly all change efforts are targeted at visible, largely objective aspects of an organization that include work tasks, structures, and processes. One explanation for why so many of these initiatives fail, centers on the failure to change the less tangible organizational assumptions, thinking, or culture [6]. Theorists propose that organizational culture is among the most critical barriers to leveraging new knowledge and implementing technical interventions. Culture is an important component of the inner setting [7][8]. It is measured by eliciting information from individuals – information can then be consolidated by team or unit and for the organization as a whole (though this is admittedly, a reductionist approach that falls short of describing how culture is defined through very fluid interlacings of people and networks at many levels). The next paragraph describes one measurement approach, the competing values framework (CVF) that has been used in healthcare [4],  and it has been used in the VA with mixed success [5]. However, we do not espouse any particular approach. We include a description of the CVF because of the frequency of its use in healthcare.

The CVF was originally developed by Quinn and Rohrbaugh [9] and is an example of a “variable definition” approach to culture: a quantitative measure that purports to capture key aspects of the complicated dynamics of culture. Often measures of culture are elicited from senior leaders in the organization – not from nonsupervisors. The CVF characterizes organizations along two dimensions, each representing a basic challenge that every organization must resolve in order to function effectively. The first set of competing values is the degree to which an organization emphasizes central control over processes versus decentralization and flexibility. The second set of competing values is the trade-off between focus on its own internal environment and processes versus the external environment and relationships with outside entities. Four archetypical organizational cultures arise: 1) team culture (high internal focus with high flexibility (aka personal)); 2) hierarchical culture (high internal focus with high control (aka formalized and structured)); 3) entrepreneurial culture (high external focus with high flexibility (aka dynamic and entrepreneurial)); and 4) rational culture (high external focus with high control (aka production oriented)) [4][5]. These “archetypes” are not mutually exclusive. In one study, CVF culture was not found to be influential in the number of evidence based practices used by healthcare organizations [4]. However, organizational cohesion and adaptability to change are important [10], which are features found in entrepreneurial-leaning organizations. Formalization is negatively associated with innovation because of lack of flexibility and/or low acceptance of new ideas [11] and can foster continuance of status quo [12]. A “balanced” culture with respect to the Competing Values Framework (how close organizations are to 25-25-25-25% on each of the four archetypical quadrants using a Herfindahl-type measure) contributes to perceptions of team effectiveness and in the number of changes implemented (though not depth of change) [13].