Pilot Test of an OrganizationalCulture Model in a Medical Setting

The authors conducted a pilot test of the organizational culture model in a health care setting. The study was basedon a questionnaire with mixed quantitative and qualitative analysis. Quantitative analysis confinned the expecteddistribution of responses among the subcultures for all ihree questions, with significant differences in [woof thethree. Qualitative analysi.s further strengthened these results. The authors believe the organizational culture modeltnay be a useful tool for making subcultural differences explicil, showing opportunities for better informationexchange and opening dialogue between groups. These data should be confirmed with larger studie.s usingpsychometric ally sound outcome instruments. Key words: organizational culltire. qtialitative, quantitative,validity

C. Scott Smith, MDCo-DirectorNorthwest Regional Faculty Development

CenterVA Medical CenterBoise, IdahoAssociate Professor of Medicine and

Medical EducationUniversity of WashingtonSeattle, Washington

Chris Francovich, EdDEducational AnalystNorthwest Regional Faculty Development

CenterVA Medical CenterBoise, Idaho

Janet Gieselman, MS, BSNResearch AssociateNorthwest Regional Faculty Development

CenterVA Medical CenterBoise, Idaho

AN ACADEMIC medical clinic is a com-plex organization. It is also a system

made up of diverse groups of individualswith specific language, artifacts, rules, anddivisions of labor interacting to achieve acommon purpose. These parts of a systemoperate interdependently so tbat smallchanges in one part can cause large changesfor the whole system.

One of the fundamental characteristics of asystem is its culture. Schein' described orga-nizational culture as

"... a pattern of basic assumptions—invented, dis-

covered or developed by a given group as it learns tocope with its problems of external adaptation or inter-

nal integration—that has worked well enough to beconsidered valid, and therefore, to be taught to new

members as the correct way to perceive, think and feelin relation to those

Supported in part by a grant from the VA Northwest Region(VISN 20).

Send con-espondence to C. Scott Smith, MD, Medicine (111),VAMC, 500 W. Fort Street. Boise. ID 83702; (208) 422-1325;fax: (208) 422-1319; e-mail: Scott.Smith2@med.va.gov.

Health Care Manager. 2000, 19(2), 68-77©2000 Aspen Publishers, Inc.

Pilot Test of an Organizational Culture Model 69

Organizational culture also has been de-scribed simply as "the way we do thingsaround here."-'!"-"' An understanding of or-ganizational culture has been validated foruse as a model to predict and manage changeswithin manufacturing organizations.''*While the model has not been validated in amedical setting, we believe this constructalso may provide useful insights into thebehavior of health care organizations as theyface conflicting pressures and respond withrapid change. This article reports on an ex-ploratory study to assess the value of theorganizational culture model in the academicmedical clinic of a Veterans Affairs (VA)Medical Center. We hypothesized that orga-nizational subcultures existed at the medicalcenter and that tensions between and amongthese subcultures were responsible for someof the conflict seen as the center converted toa capitated model,

ORGANIZATIONAL CULTUREMODEL

Schein takes the view that culture developson the basis of shared experience and com-mon history of a definable, stable group.Therefore, Schein theorizes that within agiven organizational culture, there exist sev-eral subcultures. A change in any one of thesesubcultures can threaten the stability of anyof the other subcultures, which then organizeto defend themselves against the effects ofchange. Schein states that there are threesubcultures in any organization that are par-ticularly important to understand the dynam-ics of change,"*'̂ These three cultures are

1. Operator culture—This consists of thepeople on the front line who deliver theproducts or services promised by theorganization. Applying Schein's con-

cepts to the academic medical center,this group consists of clinic staff,nurses, trainees, and faculty; their fo-cus is on health maintenance and ill-ness prevention in their patient popu-lation. The operator culture relies onhigh levels of communication, trust,and teamwork to get things done. Thisculture's daily experience is that nomatter how well specified rules andprocedures might be, there always willbe unpredictable contingencies andsurprise. They recognize that individualpeople make the difference and are theorganization's ultimate asset.

2. Engineer culture—This group designsthe processes by which the organiza-tion delivers its products and servicesand by which it maintains itself. Theengineers share a common worldviewbased on education, shared technol-ogy, and work experience. They relyon technological elegance to achievereliable and efficient operations. Ap-plying these concepts to a medicalclinic, the engineer culture includesinformation systems managers, clini-cal guideline developers, and somesubspecialists (to the extent that theyapply algorithmic approaches ratherthan individual approaches). While theoperator culture recognizes its interde-pendence with others in their group,the engineer culture views itself on aglobal basis, identifying with its pro-fessional groups outside the institutionrather than with colleagues within theorganization.

3. Executive culture^—Executives are re-sponsible for the strategic survival oftheir organization and concem them-selves with decreasing costs and maxi-

70 THE HEALTH CARE MANAGER/DECEMBER 2000

mizing profits. The executives believethat hierarchy is intrinsic to organiza-tional control and coordination andthey generally are far removed fromfront-line operations. Theirworldis com-posed of imperfect infonnation that theymust act on, often trading long-termgoals (e.g., adaptability, innovation, orcohesiveness)forshort-tenn coping strat-egies (e.g., increased market share, de-creased costs). They may feel isolated,alone, and responsible. Like tbe engi-neers, the executives often identify witbtheir counterparts outside the organiza-tion rather than their colleagues withinthe organization.

Tbe differences among these three culturesprovide checks and balances that are es.sentialto the health of the organization. However,there is also a potential for conflict between thethree cultures that can affect adversely thesense of inclusion, commitment, and sharedmission for the organization.

The executive and engineer cultures havedifferent viewpoints about "how good isgood enough." While the engineers seek toinnovate toward technological solutions thatare reliable, efficient, and free of humanerror, the executives see technology as ex-pensive and limiting, focused only on thekinds of information that can be packagedand transmitted electronically. When expertsystems are approved, the executives feelpressure to balance the high costs that ac-company reengineering design. They maynot allow sufficient time for training opera-tors to use the systems or may initiatedownsizing efforts as the technology designshumans out of the system. The operators mayrebel against the impersonal programs of theengineer and executive cultures, using theirteamwork to defeat management. They may

resi.st and covertly do things their own way,bending rules and procedures. The operatorsmay underutilize technology. Engineers maybe impatient with the operators' resistance tochange and the executives may see operatorsas too costly. The executive and engineercultures may not value the innovations of theoperators and their efforts may be ignored,subverted, or punished. Understanding thesethree cultures and how they sometimes workat cross purposes with each other is the firststep in dealing with organizational issues.

METHODS

Questionnaire development andsubculture predictions

Our hospital was under pressure to addnew patients because the VA system wasswitching to capitated reimbursement.Schein's organizational culture modelseemed to explain several difficulties wewere experiencing during this change. Wehypothesized that the executive, engineer,and operator cultures existed within our or-ganization and that their views about thecapitated model would be aligned withintheir own subculture but would be at oddswith the other two groups.

To demonstrate this, we developed threetest questions that positioned one sub-culture's assumptions against another's.

We hypothesized that the executive^engineer, and operator culturesexisted within our organization andthat their views about the capitatedmodel would be aligned within theirown subculture but would be atodds with the other two groups.

Pilot Test of an Organizational Culture Model 71

These three test questions were inserted intoa larger clinic questionnaire. Each questionhad a five-point scale with anchors for eachpoint appropriate to that question (e.g., from"strongly agree" to "strongly disagree" orfrom "should be much more" to "should bemuch less"). Respondents were asked tocircle a descriptor and support their beliefswith a brief written statement. We expectedthat members from one culture would bepolarized toward one end, members from thecompeting culture would be polarized to-ward the other end. and members from thethird culture would be less homogeneous andgrouped near the middle because the ques-tion did not address any of their criticalvariables.

To validate the questionnaire, we con-ducted a pilot test in a focus group of person-nel that were excluded from the final testingsample. The focus group (n = 6) includedmembers of all subcultures and the resultssupported the existence of the organizationalculture model. Following discussion with thesame focus group, the questionnaire wasrevised to decrease ambiguity. In the finalversion, question one stated, "Increasingworkload is negatively affecting quality andsatisfaction," question two stated "Guide-lines and models are practical to use for dailyactivities in clinic." and question three stated"The Boise VAMC devotes just the rightamount of resources to support guidelinesand models." The questionnaire was distrib-uted to the entire clinic staff, residents, fac-ulty, and administration (n = 60) with anoverall response rate of 65 percent.

Before analyzing the questionnaire, theauthors (with more than 40 years of com-bined experience at the medical center) pre-dicted into which culture each respondentwould best fit based on job description and

familiarity with the individual's role in theinstitution. There was near perfect interrateragreement about these assignments. The ex-ecutive culture (n = 6) included the hospitaldirector, administrative assistant to the direc-tor, chief of staff, staff assistant to the chief ofstaff, associate chief of staff for administra-tive medicine, and executive secretary to thechief of staff. The engineer culture {n = 5)included a physician who headed a team forcreation of clinical guidelines, a nurse and anurse practitioner who were involved in cre-ation of the interdisciplinary firm system,^and a physician and physician assistant in-volved in a computer-generated preventivemedicine reminder project for the chnic.While one author also would fall in thisgroup, all authors were excluded from theanalysis. All others {n = 49) had frequentpatient care duties, no significant duties in-volving prediction and control, and wereconsidered to be part of the operator culture.

RESULTS AND ANALYSIS

Quantitative analysis

Overall response rate was 65 percent. Theresponse rate was 67 percent (4/6) for theexecutive culture, 100 percent (5/5) for theengineer culture, and 61 percent (30/49) forthe operator culture. A few executives at thehighest levels did not respond, leading to apossible source of error. The average scorefor all respondents on all questions was 3,4(1-5 pcssible) with a standard deviation of0.92. This suggests a low likelihood of aceiling or floor effect on the questionnaireand shows, as hypothesized, a wide variabil-ity in responses. Question .scores by pre-dicted group were computed using analysisof variance.

72 THE HEALTH CARE MANAGER/DECEMBER 2000

Executive versus operator

As mentioned above, the statement, "In-creasing workload is negatively affectingquality and satisfaction," was designed toseparate the executive and operator cultures,pitting desire to increase market shareagainst time pressures and perception ofquality. Figure 1 shows the results of quanti-tative analysis of this question.

Engineer versus operator

The statement "Guidelines and models arepractical to use for daily activities in clinic"was designed to separate the engineer andoperator cultures, pitting control measuresagainst pragmatic usefulness. Figure 2shows the results of quantitative analysis ofthis question.

Executive versus engineer

The statement "The Boise VAMC devotesjust the right amount of resources to supportguidelines and models" was designed toseparate the engineer and operator cultures,pitting incremental cost against increasedprecision. Figure 3 shows the results of quan-titative analysis of this question.

Qualitative analysts

Respondents provided brief statements insupport of their beliefs in 42 percent of theresponses. There was no difference amonggroups in willingness to offer qualitativeresponses. Statements were analyzed blindlyby recursively grouping them into concep-tual bins using Non-numerical, UnstructuredData - Indexing, Structuring and Theorizing

= 0.05

STRONGLYDISAGREE

NEUTRAL STRONGLYAGREE

EXECUTIVE •

ENGINEER

• OPERATOR

Figure 1. Analysis of the questioti. "Increased workload is negatively affecting quality and satisfac-tioti." The executive and operator cultures were separated widely in their responses and the engineerculture was more neutral and tnore diverse.

Pilot Test of an Organizational Culture Model 73

p = 0.08

STRONGLYDISAGREE

NEUTRAL STRONGLYAGREE

[^EXECUTIVE

ENGINEER

• OPERATOR

Figure 2. Analysis of the question, "Guidelines and models are practical to use for daily activities inclinic." The engineer and operator cultures were separated widely in their responses and the executiveculture was situated between them and slightly more diverse in their answers.

(NUD*IST) 4.0 qualitative analysis soft-ware. Two investigators created a prelimi-nary coding system by picking out recurrentthemes and important concepts. Initial agree-ment was low to moderate (inter-rater agree-ment was 50%). The investigators sharedtheir coding schemes and negotiated discrep-ancies. The data then were analyzed withinthe new coding system until new discrepan-cies were found and negotiated. This itera-tive process continued (six iterations) untilthe following stable set of coding conceptswas created: cost; market share; efficiency;variability; guideline; poor quality; goodquality; capacity; increased resources; timepressure; stress; and not work (meaning theconcept didn't or wouldn't work). Codingwith this stable set of concepts showed a final

inter-rater agreement of 85 percent, whichwas consistent across subcultures.

Executive versus operator

The following are selected qualitativestatements made in response to the question"Increasing workload is negatively affectingquality and satisfaction." These statements,which are representative of each group, arefollowedby the corresponding statement thatwas circled on the questionnaire (used forquantitative analysis) and the qualitativecoding concept assigned to that statement,both in parentheses.

E.xecutive• "It will be important to add new patients

to support a healthy budget in a

74 THE HEALTH CARE MANAGER/DECEMBER 2000

p < 0.001

SHOULD BEMUCH MORE

NEUTRAL SHOULD BEMUCH LESS

I ^EXECUTIVE

^ENGINEER

I OPERATOR

Figure 3. Analysis of the question "The Boise VAMC devotes just the right amount of resources tosupport guidelines and tnodels." The executive and engineer cultures were separated widely in theiranswers. While the operator culture was more neutral, it did not show the expected increase invariability.

capitated model" (disagree, coded asmarket share)

• "Recent satisfaction surveys suggestthat we do well." (strongly disagree,coded as good quality)

Engineer• "1 feel there should be more staff to

accommodate these patients" (neutral,coded as increased resources)

• "We need to continue to maintain apatient base. This means increasingworkload and efficiency" (neutral,coded as efficiency)

Operator• "I feel that the amount of workload is

quickly impacting patient satisfactionand contributing to staff burnout"

(clinic nurse-strongly agree, coded asstress)

• "Faculty seem much more burdenedthan in the past" (resident-agree, codedas time pressure)

• "Patients do not seem to get the extratime they need and patients need to waitlonger" (clinic clerk-agree, coded astime pressure)

• "Employees are more stressed. Patientsneed to wait longer" (faculty-stronglyagree, coded as stress)

Engineer versus operator

The following are selected qualitativestatements made in response to the question"Guidelines and models are practical to use

Pilot Test of an Organizational Culture Model 75

for daily activities in clinic," These state-ments, again chosen to be representative ofeach group, also are followed by the corre-sponding statement that was circled on thequestionnaire (used for quantitative analy-sis) and the qualitative coding concept as-signed to that statement, both in parentheses.

Executive• "And need ongoing review to assess the

value and worth of the model" (neutral,coded as guideline)

Engineer• "Clinic preventive care models are

helpful. Other approaches could be em-ployed" (agree, coded as guideline/good quality)

Operator• "Teamwork is what makes a clinic run"

(clinic clerk-strongly disagree, codedas guideline/not work)

• "Some models are more practical thanothers. Each team is different" (faculty-disagree, coded as guideUne/variability)

Engineer versus executive

The following are selected qualitative state-ments made in response to the question "TheBoise VAMC devotes just the right amount ofresources to support guidelines and models."These statements, again chosen to be represen-tative of each group. al.so are followed by thecorresponding statement that was circled onthe questionnaire (used for quantitative analy-sis) and the qualitative coding concept assignedto that statement, both in parentheses.

Executive• "I agree we devote enough resources to

the excellent computer system"(strongly agree, coded as cost)

Engineer• "Computer support needs to be beefed

up greatly. Better models for care could

be developed" (strongly disagree,coded as increased resources)

Operator• "Seems to be a good balance" (faculty-

neutral, coded as cost)' "More of our resources should go di-

rectly to patient care" (nurse-stronglydisagree, coded as not work)

CONCLUSIONS

These data agree with predictions based onSchein's organizational culture model.

We explored Schein's organizational cul-ture model in a VA academic medical clinic.An instrument was designed surrounding acultural change issue specific to our organi-zation and questions were written to pit theassumptions of Schein's three subcultures(executive, engineer, and operator) againsteach other and to polarize individuals withina group. The critical variables for these threecultures, based on Schein's work, were as-sumed to be cost and market share (Execu-tive), prediction and control (Engineer), andsufficient resources to maintain quality ofpatient care (Operator), The questionnairewas pilot tested, revised, administered, andreturned by 39 (65%) of all administrativeand staff personnel.

We predicted that members from opposingcultures would be polarized at opposite de-scriptive anchors while members from thethird culture would have increased varianceand would have been located near the middleof each question (based on which criticalvariables were included in each question).Quantitative analysis confirmed this ex-pected pattern for the "Executive versusOperator" and "Engineer versus Operator"questions (see Figures 1 and 2), In the "Engi-neer versus Executive" question, the scoreswere arranged in the predicted order but the

76 THE HEALTH CARE MANAGER/DECEMBER 2000

middle group did not show increased vari-ance (see Figure 3). In addition, the "Execu-tive versus Operator" and "Engineer versusExecutive" questions showed statisticallysignificant differences in scores byANOVA.

Qualitative analysis further strengthenedthese results. Each hypothesized culture fo-cused on statements that reflected their pre-dicted critical variables. The executive cultureproduced 83 percent of all statements aboutcost, market share, and efficiency. The engi-neer culture produced 60 percent of all state-ments abotit variability, capacity, and in-creased quality using guidelines. The operatorculture produced 100 percent of all the state-ments (eight) about time pressure and stressand also had four statements suggesting guide-lines would not or did not help. The classifica-tion of statements and the statements them-selves are compelling further evidence of thevalidity of the model in this setting.

The context (the change to a capitated sys-tem) within which this questionnaire was ad-ministered may have exaggerated the magni-tude of cultural polarization. Other limitationsof this study include the small sample size, useof single-item unvalidated scales, the possibil-ity of selection bias In the assignment of cul-tures, and the relative theory-driven nature ofthe qualitative analysis.

In clinic as in life, different cultures havedifferent values and these can act as barriersto understanding between cultures. For in-stance, there is intrinsically nothing to pre-vent the executive culture from continuing to

add patients to the clinic. The information(feedback) that limits this behavior comesfrom a different culture, the time pressure onthe operator culture, and the effect of thattime pressure on the quality of care. Thisinfonnation may be distorted, delayed, or noteven available to the executive culture.

Similarly, the operator culture has no intrin-sic reason to limit its spending on diagnosing apatient illness but rather prefers to maximizehealth outcomes. The information (feedback)that limits this behavior again comes from adifferent culture, the costs monitored by theexecutive culture. Once again, this informationmay be distorted, delayed, or not even availableto the operator culture.

In our own institution, when these datawere presented to executives, it clearlyopened new areas of discussion and led totighter coupling between clinic capacity andtherecruitmentof new patients. Thepowerofthe organizational culture model is its abilityto make cultural differences explicit, showopportunities for better information ex-change and feedback, and open a dialoguebetween and among the members of differentcultures.

This pilot study shows promise for theorganizational culture model in medical set-tings. Further research should focus on largerstudies using psychometrically sound out-come instruments, refinement of the modelas it relates to the dual products of academicclinics (education and health care), and vali-dating and applying this model in otherhealth care settings.

Pilot Test of an Organizational Culture Model 77

REFERENCES

1. E.H. Schein. Orgatiizational Culture and Leadership: ADynamic View. San Francisco: Jossey-Bass, 198.5.

2. W.W. Burke and G. Litwin, "A Causal Model of Organi-zational Perfomiance," in The 19^9 Annual: DevelopingHuman Resources.i."^. Pfeiffer, ed, San Diego: Univer-sity Associates. 1989.

3. J, Van Maaiien and S.R. Barley, "Occupational Cotnmu-nities: Culture and Control in Organizaiions," in Re-search in Organizational Behavior, vol, 6, B.M. Stawand L.L. Cummings, ed.s, Greenwich, CT: JAI Press,19S4.

4. E.H. Schein, "Three Cultures of Management: The Keyto Organizational Leaming in the 21.st Century." http://learning.mlt.edu/res/wp/IOOI2.html (13 November1997), accessed on March 12. 1998.

5. E.H. Schein. "CuJture: The Missing Concept in Organi-;̂ ational Studies," Admin, Science Quarterly 41, no. 2(1996): 229-240.

6. C.S. Smith. "The Impact of an Atnbulatory Firm Systemon Quality and Continuity of Care," Medical Care 33, no.3 (1995); 221-226.