La identidad corporativa: elementos esenciales

There is a growing body of evidence pointing towards the effect of leadership on the culture or climate of an organisation or team. This, in turn, has been shown to have an important impact on outcomes, and in some cases, on quality.

In a detailed investigation into this area, Ogbonna and Harris (2000) studied organisations in the private sector. They found that leadership style was not directly associated with organisational performance, but that it did affect organisational culture, which in turn had a significant impact on organisational performance.

Several other studies indicate a link between a leader’s approach and the safety of care. Firth-Cozens & Mowbray (2001) reviewed the evidence and concluded that:

‘One important way in which leaders affect patient care and satisfaction is through their management of teams.’ (pii5)

A meta-analytical study by Hogan et al (1990) indicated that the prime cause of stress in the workplace is the ‘boss’, inferring that good leadership produces good teams with lower stress and higher quality patient care. Corrigan and colleagues (2000) found that team leadership ratings independently accounted for 40% of the total variance in client satisfaction amongst mental health patients. Another study within mental health services (Aarons 2006) found there was a relationship between the willingness of staff to adopt evidence-based practice and transformational leadership.

According to a report into public sector leadership by the government’s Performance and Innovation Unit (2000), the climate within a team can account for 30% of a team’s performance, and the leader has a critical influence on this team climate, with up to 70% of the climate being influenced by the leadership style adopted in the team. Leggat and Dwyer (2003) completed a review of the literature on factors associated with high performance in healthcare organisations and other industries. Unsurprisingly, leadership consistently emerged as a necessary factor for high

performance. More pertinent was that the difference made by leaders was specifically in the influence they could have on setting the tone for the rest of the team or organisation:

‘The contribution that organisational leaders make to organisational climate, culture and team working suggested that effective leadership is an important prerequisite.’ (p.11)

Powell (1995) showed the importance of leadership and culture in relation to performance outcomes in his examination of TQM as a potential source of competitive advantage. He concluded that the key to QI performance appeared to lie more with factors like leadership and organisational culture than in tools or techniques such as process improvement, quality training and benchmarking.

This reaffirms findings from research into high-performing teams (Larson and Lafasto 1989), which proposed a causal chain between improvement and leadership:

● To achieve an elevated goal or vision, change must occur;

● For change to occur, a risk must be taken;

● To encourage risk-taking, a supportive climate must exist;

● A supportive climate is demonstrated by day-to-day leadership behaviour Firth-Cozens and Mowbray (2001) cite studies from the airline industry (Chidester and Helmreick 1991) which show a correlation between airline captain behaviour and the number of crew errors. They conclude:

‘It therefore seems that leaders are able directly to affect the safety of their teams’ actions and outcomes—an extremely important finding for patient care.’ (pp ii3–ii7)

While healthcare contexts vary enormously, the delivery of critical care is an area where patient safety is of paramount importance. In their literature review into leadership strategies in critical care teams, Kunzle et al (2010) conclude that effective leaders play a ‘pivotal role in promoting team performance and safety’. (p.1).

Dickinson and Ham (2008) cite an established evidence base from high-reliability industries (e.g.Weick 1987; Reason 2000; Ojha 2005) which point to the role that leadership plays in shaping organisational culture, and the consequences of this for safety. In a healthcare context, Edmondson’s much-cited work (1996) demonstrated a correlation between nursing team leadership, the quality of teamwork and staff willingness to record errors.

In a study of community health centres, Xirasagar et al (2005) discovered a significant association between transformational leadership and success in achieving organisation-wide changes in clinician behaviour.

One study (Shipton et al. 2008) produced evidence that leadership effectiveness can have an impact on a range of hospital performance measures. The research team examined relationships between perceptions of leadership effectiveness and measures from the Commission for Health Improvement (CHI), external Clinical Governance Review ratings and the number of patient complaints received. They found that the higher the rating of leadership effectiveness, the more highly each healthcare

organisation was rated. Shipton et al. suggest that although they are unable to attribute causality from their study, an interesting link is evident between leadership and performance:

‘it may be that leaders influence performance outcomes to the extent that they shape employees’ collective belief that patients need to come first. Perhaps the relationship between leadership and performance in a health-care environment is mediated by some factor of climate that reflects a universal determination to achieve high standards of patient care. ‘(p. 439)

As these examples from the literature show, there is sufficient evidence from a range of perspectives to support the assertion that leadership and culture are both associated with effective and sustainable quality improvement. When the literature is further scrutinised, some commonalities begin to emerge, defining and describing the type of leadership and cultures which foster enhanced quality or performance. It is worth rehearsing these here, as the evidence suggests an important relationship between these two factors and quality improvement. In Schein’s (1985) words:

‘Leadership and culture are so central to understanding organisations and making them effective that we cannot afford to be complacent about either one’ (p.327)

Accordingly, the next two sections present insights provided by the literature into the type of leadership and the type of culture which appear to be associated with improvement.