title: Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study.
abstract: BACKGROUND
  Problems of quality and safety persist in health systems worldwide. We conducted a large research programme to examine culture and behaviour in the English National Health Service (NHS).
  
  
  METHODS
  Mixed-methods study involving collection and triangulation of data from multiple sources, including interviews, surveys, ethnographic case studies, board minutes and publicly available datasets. We narratively synthesised data across the studies to produce a holistic picture and in this paper present a high-level summary.
  
  
  RESULTS
  We found an almost universal desire to provide the best quality of care. We identified many 'bright spots' of excellent caring and practice and high-quality innovation across the NHS, but also considerable inconsistency. Consistent achievement of high-quality care was challenged by unclear goals, overlapping priorities that distracted attention, and compliance-oriented bureaucratised management. The institutional and regulatory environment was populated by multiple external bodies serving different but overlapping functions. Some organisations found it difficult to obtain valid insights into the quality of the care they provided. Poor organisational and information systems sometimes left staff struggling to deliver care effectively and disempowered them from initiating improvement. Good staff support and management were also highly variable, though they were fundamental to culture and were directly related to patient experience, safety and quality of care.
  
  
  CONCLUSIONS
  Our results highlight the importance of clear, challenging goals for high-quality care. Organisations need to put the patient at the centre of all they do, get smart intelligence, focus on improving organisational systems, and nurture caring cultures by ensuring that staff feel valued, respected, engaged and supported.
authors.affiliation: Department of Health Sciences, University of Leicester, , Leicester, UK.
authors.forename: Mary
authors.initials: M
authors.lastname: Dixon-Woods
authors.forename: Richard
authors.initials: R
authors.lastname: Baker
authors.forename: Kathryn
authors.initials: K
authors.lastname: Charles
authors.forename: Jeremy
authors.initials: J
authors.lastname: Dawson
authors.forename: Gabi
authors.initials: G
authors.lastname: Jerzembek
authors.forename: Graham
authors.initials: G
authors.lastname: Martin
authors.forename: Imelda
authors.initials: I
authors.lastname: McCarthy
authors.forename: Lorna
authors.initials: L
authors.lastname: McKee
authors.forename: Joel
authors.initials: J
authors.lastname: Minion
authors.forename: Piotr
authors.initials: P
authors.lastname: Ozieranski
authors.forename: Janet
authors.initials: J
authors.lastname: Willars
authors.forename: Patricia
authors.initials: P
authors.lastname: Wilkie
authors.forename: Michael
authors.initials: M
authors.lastname: West
mesh_terms: D006801:Humans; D009313:National Health Programs / Q000592:standards*; D015279:Organizational Culture; D061214:Patient Safety; D011787:Quality of Health Care / Q000458:organization & administration* / Q000592:standards*
keywords: Health policy; Health services research; Management; Patient safety; Patient-centred care
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