Organizational Culture in an Academic Health Center: An Exploratory Study Using a Competing Values Framework

Ovseiko, Pavel V. DPhil; Buchan, Alastair M. DSc

Academic Medicine:
doi: 10.1097/ACM.0b013e3182537983
Institutional Issues

Purpose: Implementing cultural change and aligning organizational cultures could enhance innovation, quality, safety, and job satisfaction. The authors conducted this mixed-methods study to assess academic physician–scientists’ perceptions of the current and preferred future organizational culture at a university medical school and its partner health system.

Method: In October 2010, the authors surveyed academic physicians and scientists jointly employed by the University of Oxford and its local, major partner health system. The survey included the U.S. Veterans Affairs Administration’s 14-item Competing Values Framework instrument and two extra items prompting respondents to identify their substantive employer and to provide any additional open-ended comments.

Results: Of 436 academic physicians and scientists, 170 (39%) responded. Of these, 69 (41%) provided open-ended comments. Dominant hierarchical culture, moderate rational and team cultures, and underdeveloped entrepreneurial culture characterized the health system culture profile. The university profile was more balanced, with strong rational and entrepreneurial cultures, and moderate-to-strong hierarchical and team cultures. The preferred future culture (within five years) would emphasize team and entrepreneurial cultures and—to a lesser degree—rational culture, and would deemphasize hierarchical culture.

Conclusions: Whereas the university and the health system currently have distinct organizational cultures, academic physicians and scientists would prefer the same type of culture across the two organizations so that both could more successfully pursue the shared mission of academic medicine. Further research should explore strengthening the validity and reliability of the organizational culture instrument for academic medicine and building an evidence base of effective culture change strategies and interventions.

Author Information

Dr. Ovseiko is research fellow in health systems and innovation, Nuffield Department of Clinical Medicine, Medical Sciences Division, University of Oxford, Oxford, England.

Prof. Buchan is professor of stroke medicine, Nuffield Department of Clinical Medicine, Medical Sciences Division, University of Oxford; honorary consultant neurologist, Oxford University Hospitals National Health Service Trust; dean, Medical School, and head, Medical Sciences Division, University of Oxford, Oxford, England.

Correspondence should be addressed to Prof. Buchan, Office of the Head of Division, Medical Sciences Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU; telephone: (+44) 1865-220346; e-mail:

Article Outline

An enduring question in academic medicine the world over is what makes for a high-performing academic–clinical partnership between a medical school and a health system.1 Put another way, what distinguishes a “great” academic health center (AHC) from a “good” one?2 Whereas the importance of organizational structure, strong leadership, and effective policies is well documented, the subject of organizational culture in academic medicine has so far attracted only limited attention.3–10 Yet, a growing body of literature demonstrates that organizational culture contributes to variation between health care organizations in performance and outcomes, including innovation,11,12 patient satisfaction,13,14 health care quality and safety,15–19 and employee job satisfaction.20–24 Further, research on partnerships in industries outside of the health care sector demonstrates that cultural alignment between partners positively influences the partners’ individual and collective performance.25,26

Policy documents, too, evince an increasing recognition of organizational culture as a lever for improving health services, education, and research.27,28 The National Health Service (NHS) in the United Kingdom recently set out plans in a government white paper for “a challenging and far-reaching set of reforms, which will drive cultural changes in the NHS.”29 The report of the UK Academy of Medical Sciences proposes a new pathway for the regulation and governance of health research to increase innovation and eliminate bureaucracy.30 This report further suggests that success is “highly dependent on cultural changes.”30

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Defining and Assessing Organizational Culture

Although many definitions of organizational culture exist, one set of investigators has defined it, in a nutshell, as “how things are around here.”31 More specifically, organizational culture is an organizational-level construct constituted by the assumptions, ideas, beliefs, values, norms, and rules that are shared by an organization’s members. Cameron and Quinn31 write,

An organization’s culture is reflected by what is valued, dominant leadership styles, the language and symbols, the procedures and routines, and the definitions of success that make an organization unique.

Some believe that culture controls interaction not only internally among an organization’s members but also externally with outside stakeholders.32,33 Organization members are often unaware of their culture until something or someone challenges it or until research or assessment reveals it.31

Unpacking the notion of organizational culture and assessing it empirically can help the entire academic medicine community learn about the culture that underpins the delivery of health services, education, and research, which, in turn, helps the community to better understand how to effect positive change on the institutional and national level. There are more than a dozen ways and tools to measure and assess organizational culture,34–37 of which the Competing Values Framework (CVF) is the most frequently used instrument in health services research.38 The CVF distinguishes between two dimensions representing an organization’s competing or opposite values/priorities: (1) the horizontal dimension, which reflects the extent to which an organization emphasizes centralization and control versus decentralization and flexibility and (2) the vertical dimension, which reflects the extent to which an organization focuses on its own internal environment and processes versus the external environment and relationships with outside stakeholders.31,38 The resulting four quadrants of the CVF framework represent four cultural archetypes, known as (1) the entrepreneurial (also known as the developmental or adhocracy) type, (2) the team (group or clan) type, (3) the hierarchical (bureaucratic) type, and (4) the rational (market) type. Figure 1 depicts the major characteristics of these archetypes. An organization’s culture usually possesses characteristics relating to all four archetypes, but one of them may be dominant.

The main advantage of using the CVF is that it reduces the complexity of organizational culture for analytical and practical purposes by focusing on an organization’s key cultural characteristics. It measures organizational culture in a standardized way—that is, the CVF provides for the collection of data from numerous individuals, the comparison of the results across different organizations, and the creation of “a rich visual representation of an organization’s culture.”20 It is also connected to a large body of theoretical and empirical literature,11–24 which allows for the formulation of hypotheses on organizational culture and performance. Importantly, organizations can use the framework to diagnose both their current and the preferred cultures and, if necessary, to initiate a culture change process. Often, cultural change does not occur because “it is difficult to know what to talk about and what to focus on”; this framework helps the conversation get started.31

Herein, we describe our study, applying the CVF, of the organizational culture at the University of Oxford Medical Sciences Division and its local, major partner health system.

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Oxford’s Academic and Clinical Partners

Academic medicine in England is characterized by the “unlinked partners” model of academic–clinical relationships, whereby universities are neither fiscally nor structurally linked to teaching hospitals, all of which belong to the NHS.39,40 The United Kingdom’s Department of Health administers the NHS in England, which is funded primarily through general taxation. Local hospitals are organized into NHS trusts authorized by the government to operate one or more hospitals or health centers. Given that the NHS is funded and administered by the government, no direct cross-subsidization of academic and clinical missions occurs in English AHCs. Either a university or an NHS trust provides academic physicians and scientists with employment on a salaried basis (substantive employment), and, in addition, these academic physician–scientists hold paid or unpaid honorary appointments with the other organization. Usually, those who focus mostly on research and teaching hold substantive academic contracts with a university and honorary physician consultant (i.e., attending physician) contracts with the NHS; likewise, those who focus mainly on clinical practice hold substantive physician consultant contracts of employment with the NHS and honorary research or teaching appointments with a university. Although academic physicians and scientists contribute substantially to the provision of NHS patient services, to health-related research, and to the education of tomorrow’s physician workforce, they are dependent on the NHS for access to clinical facilities, patients, data, and tissues. As a result, many university teaching and research facilities are embedded in NHS hospitals, and a large number of faculty are, as explained, employed jointly by the NHS and a university. Thus, the success of the tripartite mission of academic medicine in England strongly depends on an effective working partnership between the NHS and universities.

The University of Oxford Medical Sciences Division (henceforth, “University”) comprises a medical school, academic departments, and translational and basic science research institutes, most of which were collocated within the Oxford Radcliffe Hospitals NHS Trust (henceforth, “NHS Trust”) when we conducted this study in October 2010. The University and NHS Trust share a rich history, including the introduction of modern bedside teaching in England by Sir William Osler and the development of penicillin. Today, the two partners are pursuing the ambitious strategies of organizational transformation and ever-closer collaboration. The impetus for pursuing these strategies is multifactorial. The partners are facing financial pressure to reduce the overhead costs of care and research as well as growing demands for high-quality care. In addition, the United Kingdom’s National Institute for Health Research (NIHR) has provided incentives to accelerate translational research, and new government policies are promoting academic–clinical integration.40,41 The goal, ultimately, is to integrate academic departments and hospital divisions more closely in order to provide improved health services for patients and to enhance clinical research and teaching. Both organizations have made structural adjustments to facilitate better alignment of academic and clinical areas.

For its part, the University is integrating smaller departments and units into larger groupings in an effort to generate more opportunities for research cross-fertilization and to capitalize on shared facilities. For example, the Departments of Clinical Neurology and Anaesthetics, the Laboratory of Ophthalmology, and the Centre for Functional MRI of the Brain have merged into the new Department of Clinical Neuroscience, and the Departments of Medical Oncology and Clinical Pharmacology and the Institute for Radiation Oncology and Biology have come together to form the new Department of Oncology. Likewise, the NHS Trust has reconfigured its clinical services and introduced a new management structure based on clinical leadership: Divisions and their structural units are led by practicing physicians, the majority of whom are academic physicians. For example, five out of seven hospital divisions are now led by professors, three of whom are both chiefs of clinical services and chairs of matching academic departments. Because the hospital belongs to the NHS and because the University is an independent, public (like private in U.S. parlance), not-for-profit entity, neither the medical school dean nor the hospital’s CEO report to each other. To ensure strategic cooperation at a high level, the partners established a strategic partnership board with a joint executive group. Whereas the strategic partnership board is responsible for developing the strategic objectives of the partner organizations in pursuit of excellence in patient care, research, and education, the joint executive group is responsible for overseeing the operation and implementation of such objectives both generally and through four specialist committees dealing with buildings and estates; personnel; education and training; and research and development. To administer research activity seamlessly and efficiently across the organizational divide, the partners created a joint research office, which pools the resources and collocates the staff of the University’s and the NHS Trust’s research governance teams so that they can better share their experience and expertise, reduce unnecessary or duplicative effort, and streamline the research approval process.

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We designed this study as part of a greater effort to enhance the working partnership between the University and the NHS Trust. Our purpose was to assess and measure the perceptions of the academic physicians and scientists at the NHS Trust and the University regarding the current and preferred future culture of the two partner organizations.

We sent, via e-mail, a link to an online CVF survey instrument in October 2010 (and, four weeks later, we sent a reminder e-mail) to the entire population of Oxford-based academic physicians and scientists jointly employed by the NHS Trust and the University (N = 436). To ensure the homogeneity of the population studied, we excluded research nurses jointly employed by the NHS Trust and the University. We also excluded University teaching and research faculty without NHS Trust honorary contracts because, given that organizational culture is an organizational-level construct,31 we assumed that only substantive employment (see above) would influence respondents’ perceptions of organizational culture in their academic and clinical organizations. Some evidence suggests that managers and nonmanagers perceive organizational culture differently,38 but we deliberately concentrated on investigating the perception of organizational culture by academic physicians and scientists—regardless of whether they have formal managerial responsibilities or not—because of their strong desire for professional autonomy and leadership.

The survey instrument42 included 14 organizational culture items from the U.S. Veterans Health Administration All Employee Survey with a minor wording change (“organization” replaced “facility”).38 The items corresponded to four subscales representing the four cultural archetypes: entrepreneurial, team, hierarchical, and rational. We asked respondents to indicate on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) the extent of their agreement or disagreement with the statements concerning both the current culture in their academic and clinical organizations and the preferred future NHS Trust/University culture (i.e., what the culture across the two organizations should be like in five years in order to more successfully pursue the mission of academic medicine). The survey42 also included two extra items prompting respondents to identify their substantive employer (University or NHS Trust) and to provide any additional open-ended comments or thoughts. Instructions stated that participation was voluntary and anonymous. We deemed submission of the survey to be sufficient for consent, and we offered no incentives. We used Survey Monkey (Palo Alto, California) to collect all responses, downloaded them as a Microsoft Excel file (version 2010, Redmond, Washington), edited the file, and then uploaded the quantitative responses to IBM SPSS Statistics (version 19, Chicago, Illinois) for statistical analysis, and the qualitative responses to Microsoft Word (version 2010, Redmond, Washington) for thematic analysis.

Our analyses of the responses to the 14 Likert items included averaging scores, first, for individual items within archetype subscales and, then, overall for each archetype subscale; computing Cronbach’s α coefficient to measure reliability for each culture subscale; and performing independent-sample t tests on the means for the four culture subscales to determine whether respondents perceived culture in their academic and clinical organizations differently on the basis of their substantive employment.

We identified common themes and trends in the open-ended responses by consensus. We also derived example quotations from the whole set of open-ended responses to illustrate discrepancies between the current culture and the preferred future culture. We selected and classified these qualitative responses according to the culture subscales.

The University of Oxford Clinical Trials and Research Governance Team reviewed the study; no ethics committee approval was necessary.

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We received a total of 170 duly completed questionnaires for a response rate of 39%. We accepted all of them for analysis. We have presented the individual scores for each item, as well as the aggregate scores and Cronbach’s α for each of the culture archetypes, in Table 1.

The reliability of our results was highest for the entrepreneurial subscale (α = 0.72–0.90), moderate for the team (α = 0.53–0.78) and rational (α = 0.55–0.67) subscales, and lowest for the hierarchical subscale (α = 0.50–0.53).

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Variation by substantive employer

Of 170 respondents, 106 (62%) had substantive employment contracts with the University and honorary contracts with the NHS Trust, and 64 (38%) had substantive employment contracts with the NHS Trust and honorary appointments with the University. We detected no significant difference in the overall distribution of responses by substantive employer compared with the population to whom the questionnaire was administered (65% University and 35% NHS Trust).

The results of the t tests we performed to determine whether substantive employment affected perception of culture revealed that, in 9 of 12 cases, the difference was not significant (P > .05; Table 2), suggesting that substantive employment did not have an influence on the perception of organizational culture. Notably, we detected no statistically significant differences in any of the four cases assessing perception of the preferred future culture. The three cases where employer-based differences occurred were all related to the current culture in the NHS Trust and the University. We found that respondents rated the organization of their nonsubstantive employment closer to the organization of their substantive employment. For example, academic physicians and scientists substantively employed by the University rated the University highly on the entrepreneurial subscale, and they also rated the NHS Trust on this subscale slightly higher than their colleagues substantively employed by the NHS Trust. These slight differences, however, did not affect the organizational culture profiles of either organization.

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Organizational culture profiles

To demonstrate the current organizational culture profiles of the NHS Trust and the University as perceived by their members, as well as the preferred future culture across the two organizations, we plotted the combined means of NHS Trust and University substantive employees for the culture subscales (Table 1) on the CVF axes (Figure 2). The current perceived NHS Trust cultural profile is characterized by dominant hierarchical culture, moderate rational and team cultures, and underdeveloped entrepreneurial culture. No dominant culture is evident in the current University profile as perceived by respondents; it is relatively balanced, with strong rational and entrepreneurial cultures, and moderate-to-strong hierarchical and team cultures. The shared NHS Trust/University culture that respondents would prefer to develop across the two organizations within the next five years emphasizes team and entrepreneurial cultures and—to a lesser degree—rational culture; the preferred future culture deemphasizes the hierarchical culture archetype. Therefore, the areas of discrepancy, from greatest to least, between the current culture of both organizations—particularly the NHS Trust—and the preferred future culture of both organizations, are entrepreneurial, team, hierarchical, and rational culture.

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Discrepancies between the current and the preferred future cultures

In addition to quantitative data, 69 out of 170 respondents (41%) provided open-ended qualitative responses, which tended either to focus on individual cultural items from the questionnaire or to address the issues that seemed to be of most concern to each respondent. Below, we provide a selection of the most informative respondent quotations to illustrate the range and depth of respondents’ perspectives, some of which may be overlapping or even contradictory. All quotations (edited minimally for punctuation and readability) within each section are from different respondents.

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Entrepreneurial culture.

Notable entrepreneurial culture discrepancies included different research time horizons and reward structures in the NHS Trust and the University, as well as barriers to innovation across the two organizations. Several respondents believed that whereas the NHS Trust had a short investment time horizon for research and focused too much on the bottom line, the University was predominantly interested in long-term basic research and did not provide adequate reward for translational research:

Lack of innovation and risk taking in the NHS versus lack of understanding for the importance of SOPs [standard operating procedures] and governance around patient care in the University, lack of reward for translational research achievements in the university versus lack of scientific understanding of translational research in the NHS.

A number of respondents suggested that the processes of assessing the costs of clinical trials, gaining ethical approval, and demonstrating compliance with patient care procedures could be reorganized to be simpler, faster, and better coordinated with patient care:

* A significant barrier to successful research across university and NHS is gaining ethical approval. At present, I believe that this process stifles innovation. The ethics approval process needs to be streamlined, the process less onerous, and time from submission to approval sped up.

* There is a culture of “bean counting” when calculating costings for clinical trials [in the NHS]. This causes substantial delays and as a result clinical trial contracts may be lost.

* [O]bviously some rules are important (ethics of research with patients), but it’s easy for the paper trail required to show compliance to become over-onerous and degenerate into box-ticking. In the NHS, staff sometimes seem to see researchers as trying to “get away with” exploiting their patients; they are not thinking how much patients have to gain from research.

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Team culture.

Key discrepancies in perception of team culture concerned divides between academic, clinical, and managerial roles: individualism and internal competition in the University, top-down goals and frequent reorganizations in the NHS Trust, and a perceived lack of institutional support and reward for hard work in both. Respondents observed a divided, overly competitive, and individualistic environment which they felt was incongruent with the preferred team culture:

NHS goals are not always shared, but production is valued … the University prizes winners, cohesion is only valued if you have attracted the funding; and internal competition is valued. Cohesion is superficial, we are all on our own really; it’s up to the individual to succeed.

Several respondents felt that the pressures related to research funding and to service delivery had adverse effects on their morale and their ability to fulfill all three missions of academic medicine in concordance with each other:

* My NHS work is dominated by an excessive, largely unrecognised, service commitment…. The “academic” subspecialist aspects of my work have been submerged by the overall pressure of work.

* The University is driven by financial considerations that … have lowered morale in staff by pressurising them into applying for funding in increasingly ferociously competitive conditions that militate against success and divert them from actually getting on with research.

Although respondents were proud of and committed to their organizations, they would have preferred a more supportive and human-oriented culture:

* There is a need to support staff who work hard. Loyalty to the organisation may be easily fractured.

* We need to balance “being first” with maintaining integrity and being people-centric.

Especially, respondents stressed a need for more support and recognition for women’s advancement in academic medicine:

The single issue on which the university is strikingly traditional is the absence of women in tenured clinical chairs…. I think it probably arises because the university policy is to look for a productive person who is able to move, and women are less able to move. Nevertheless it is time that steps were taken to remedy this.

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Hierarchical culture.

Respondents stressed the differences between management structures in the NHS Trust and the University, and they emphasized the importance of academic and clinical autonomy. They perceived the NHS Trust management structure as vertical and subject to frequent reorganizations, and the University as too devolved, yet sometimes overly concerned about economics and politics at higher levels:

* The NHS has been constrained by top-down targets, financial restrictions, and constant reorganisation. In contrast the University has no discernible management structure—each department acts autonomously and only responds corporately when it is financially expedient so to do. Great improvements have been made on the back of the BRC [NIHR Biomedical Research Centre] and recent NHS reorganisation but there is a long way to go to embed genuine cooperation.

* Our lead [NHS unit deleted] manager is outstanding, but in general the NHS is being drained of all goodwill by massive management structure that is far removed from patient care.

* [The] Univ[ersity] is bottom-up; hospital is top-down; they both need to change.

* The University has been excessively dirigiste in the past and has concentrated too much on original research outputs at the expense of other scholarly activities, such as teaching, clinical work, national and international policy formulation, and authorial and editorial work.

Respondents felt that, in general, the NHS had an excessive number and high turnover of managers, whereas University leaders were overstretched and did not delegate as much as they could:

* University has centralised many areas which are taken on by senior staff, highly competent staff, beyond their limits of time, yet [who] will not delegate to those more familiar with the NHS areas.

* University is not restrictive at an individual level, but very restrictive at higher levels of organisation. Mostly this means that you can operate reasonably freely in the middle. The NHS has had constantly changing targets and management.

* Managers [in the NHS] do not have to live with the results of their decisions. In three years they move and are no longer accountable for their actions.

Several respondents expressed a strong desire for more autonomy and noted the importance of balancing managerial responsibilities with professional expertise:

Academics and doctors have been put under the control of unqualified managers … [who] just do not have a grasp on what we do. One of the characteristics of a senior academic or clinician is that he is the expert in charge. The second problem is that increasingly some clinicians are turning into almost full-time management losing touch with frontline academic life and clinical work…. I think we need to get back our autonomy and do not worry: We will keep working!!!

Respondents valued academic and clinical freedom above financial incentives and suggested that significant performance gains could be achieved through the alignment of institutional and personal goals:

Staff like myself are vocational not commercial. That means our main driver is “belief” in what we are doing not “fee for service.” If we are doing what we “want” to do we will give far more than 100%, but if we perceive that the organisational structure is forcing us to do something that we do not want to do (or do not believe in), our productivity will drop dramatically…. You obviously cannot let doctors just do what they want, but a little more effort devoted to trying to align institutional goals with personal ones might yield a lot.

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Rational culture.

Rational culture discrepancies mainly concerned alignment and integration between the NHS Trust and the University, as well as joint mission-management and accountability. A number of respondents articulated a common desire for a stronger alignment between the partners and a joint, long-term vision:

* Getting the agendas and vision aligned is critical…. There must be an emphasis on achieving international clinical academic excellence and this must be rewarded. The NHS side need[s] to [be] reassured that this does not mean that their agenda (e.g., patient safety and financial stability) is ignored.

* Breaking the barriers between the two organisations is essential, as [is] sharing a common vision.

Respondents provided ideas for a few specific mechanisms through which closer integration could allow efficiency gains, including joint mission–management and joint accountability for academic and clinical missions:

* There appears to be very little recognition from the NHS regarding training and time spent educating and nurturing students. Many wonderful individuals take their role and duty as a doctor very seriously and will always try to support students, but managerially there is no recognition that this may slow down a list or clinic, etc.

* Teaching must have a separate budget line within departmental budgets…. This would create an incentive to record and measure teaching activity, which is currently a completely unknown quantity.

Respondents suggested that the institutional partners should pursue closer integration to increase overall efficiency, although there was no agreement on the organizational form of the partnership:

* Need to avoid waste and bureaucracy between organisations by becoming much more closely integrated.

* [W]e can and should bring the NHS and University closer together. However, we must remember that they still each have their independent roles, and that some aspects of the academic health sciences [center] concept are flawed.

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Discussion and Conclusion

We used the CVF to assess and measure the actual current and the preferred future organizational cultures in an AHC, specifically at the University of Oxford. To our knowledge, no other investigators have examined the organizational cultures of a medical school and its related teaching hospitals in such a systematic way. The results of this study support our premise that although the NHS Trust and the University have overlapping missions, they have distinct organizational cultures. The results also showed that regardless of their substantive employment—with either the NHS Trust or the University—academic physicians and scientists shared preferences for what sort of culture should develop across the two organizations within the next five years if the academic medicine mission is to be more successfully pursued.

We have presented reliable and valid quantitative data demonstrating that the preferred future culture emphasizes team and entrepreneurial cultures and—to a lesser degree—rational culture, and deemphasizes hierarchical culture. Drawing on qualitative survey data, we further identified discrepancies between the actual current and the preferred future cultures, and we have highlighted the areas in which faculty challenged the current culture and preferred changes. The findings have important implications for devising and implementing specific change strategies at Oxford and for our understanding of AHCs more generally. Many of these findings could be relevant to academic and clinical leaders, in England and elsewhere, who are contemplating cultural change to enhance their AHCs.

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Other related research

Our findings align with organizational culture research from the U.S. Veterans Health Administration showing that the cultural profile of the VA is very similar to that of the NHS,38 both of which are centrally (i.e., federally) funded and administered health care systems. Evidence from previous research suggests that the changes preferred by Oxford academic physicians and scientists are associated with higher performance and better outcomes:

* The relationship between team culture and patient satisfaction is positive while the relationship between hierarchical culture and patient satisfaction is negative13;

* higher levels of team and entrepreneurial cultures and lower levels of hierarchical culture are associated with higher levels of safety18; and

* team culture is positively related to physician job satisfaction, whereas hierarchical culture is negatively related to physician job satisfaction.22

Also, research from partnerships outside health care suggests that improving the cultural alignment of partner organizations positively influences the performance of the partnership by creating common reference points, understandings, practices, and behaviors and by reducing the level of uncertainty.25 Given these findings, we believe that change strategies and interventions aimed at promoting team and entrepreneurial cultures and at deemphasizing hierarchical culture could improve the cultural alignment of Oxford’s academic and clinical partners and, in turn, enhance the overall performance of the partnership.

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Bottom-up versus top-down cultural change

Given that the NHS is a centrally funded and administered health system, local organizational culture cannot be comprehensively addressed in isolation from central government policies. On the one hand, it is laudable that the United Kingdom’s government has advanced a bold vision to transform the NHS in England into “the largest social enterprise sector in the world”; to “free staff from excessive bureaucracy and top-down control”; to achieve “high productivity, greater innovation, better care, and greater job satisfaction”; to ensure “clear accountability at every level in the NHS”; and to develop “a culture of evaluation and learning.”29 Our findings demonstrate that Oxford physicians and scientists’ preferences are congruent with the government vision. On the other hand, to achieve this vision the government proposes a top-down reorganization of the NHS. Our research demonstrates that such reorganizations have a negative effect on culture that is contrary to the very objectives to which the government aspires. Further, AHCs and other NHS/university partnerships can, themselves, make a significant contribution to transforming the NHS from the bottom up. To add more value to the nation’s patient care, research, and education outcomes, AHCs and other NHS/university partnerships should assume a more prominent role in the transformation of the NHS.

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Limitations and future research

Our study is exploratory in nature, and we urge caution in generalizing its results beyond the population studied. The faculty of any single AHC is relatively small. Additionally, to increase the homogeneity of the population studied, we focused only on one, of several, of the University’s partner NHS organizations, and we surveyed only Oxford-based academic physicians and scientists. Our response rate was 39%, which is relatively good for online voluntary surveys involving physicians,22,43 although higher response rates have been achieved elsewhere using paper questionnaires.13,18,38 Our survey was representative of the entire population studied in terms of substantive employment, but we did not control for any sociodemographic and professional factors (e.g., age, gender, race, seniority, specialty); therefore, we cannot rule out the possibility of bias in our survey.

The reliability of some of our culture subscales, in particular the hierarchical subscale (α = 0.50), is rather modest compared with some other studies that have used the same instrument.38 The closer Cronbach’s α is to 1.0, the higher the amount of variance captured by the construct, and the less accounted for by measurement error. Opinion on the minimum level of reliability varies, with some investigators recommending 0.70 as the minimum44 and others accepting 0.50 or above as an indicator of good internal consistency.45 For exploratory research, group comparisons, and scales with fewer than 10 items, modest reliability usually suffices; therefore, in this study we used 0.50 as a cutoff for a reliable culture subscale. We note that modest reliability for hierarchical, team, and rational subscales (<0.70) may indicate potentially serious limitations of the CVF subscales in the context of Oxford specifically, or in academic medicine generally. Answers to open questions added to the CVF survey, which offered valuable insights, provided some face validity, and future work would benefit from similarly fine granularity. Employing qualitative methods more broadly would help to triangulate quantitative findings and to explore their implications with respondents and others.

We used the CVF instrument from the U.S. Veterans Affairs Health Administration because it is validated, connected to a large body of theoretical and empirical literature, and less onerous than other instruments. However, several respondents felt that the instrument was not specifically designed for academic medicine. Also, Helfrich and colleagues38 have raised concerns about the validity of the instrument when applied to nonmanagers, as the rank-and-file members of an organization do not seem to distinguish between the four types of culture. They suggested that a two-factor scale could be a better solution to the conventional four-factor scale, noting, however, that significant further research would be required to confirm whether the two-factor solution is valid and whether it is associated with actual performance measures. Lacking a two-factor scale, we applied the conventional four-factor scale to academic physicians and scientists. This population’s strong desire for professional autonomy and leadership makes taking into account their perception of organizational culture absolutely imperative. Future investigations may apply the results reported in our study to test the two-factor solution and develop a better instrument for academic medicine.

Finally, our study highlights the areas where change is needed without prescribing a particular course of action. Currently, no rigorous evidence suggests which cultural change strategies are most effective.27 A recent systematic review found a lack of studies that both meet the quality criteria set by the Cochrane Effective Practice and Organization of Care Group and evaluate the effectiveness of strategies to change organizational culture to improve health care performance.46 Future research should employ rigorous methodologies and focus on finding, developing, and evaluating cultural strategies and interventions that support the advancement of academic medicine’s missions for the benefit of local and global communities.

Overall, in addition to having important implications for devising and implementing specific change strategies at Oxford, the findings of our study point to an untapped and potentially transformative area of research. An increased understanding of the actual current and the preferred future cultures in their academic and clinical organizations could help AHC leaders and staff on both sides of the Atlantic implement cultural change and align organizational cultures to enhance innovation, quality, safety, and job satisfaction. We hope that this study provides a stimulus for further research into organizational culture in academic medicine.

Acknowledgments: The authors gratefully acknowledge the academic physicians and scientists who responded to the survey and shared their thoughts. They thank several people who advised and assisted during various stages of the project and/or contributed various efforts, including Glyn Allington, Caroline Armitage, Pauline Batterby, Jeffrey Braithwaite, Sue Donaldson, Miguel Farias, Ingunn Haugen, Heather House, Hasneen Karbalai, Karen Melham, Justin O’Toole, Brad Sutherland, and Susan Tonks. The authors are particularly grateful to Katerine Osatuke, research director, Veterans Health Administration National Center for Organization Development, for the permission to use the Veterans Affairs instrument, and to Christian Helfrich, research assistant professor, Department of Health Services, University of Washington, for invaluable comments and suggestions. The authors would also like to acknowledge two anonymous reviewers and a member of Academic Medicine’s professional editorial staff for their constructive remarks to improve the manuscript.

Funding/Support: This study is supported by Professor Buchan’s National Institute for Health Research Senior Investigator Award.

Other disclosures: Prof. Buchan is professor of stroke medicine, Nuffield Department of Clinical Medicine, Medical Sciences Division, University of Oxford; honorary consultant neurologist, Oxford University Hospitals National Health Service Trust; dean, Medical School, and head, Medical Sciences Division, University of Oxford, Oxford, England. Dr. Ovseiko is research fellow in health systems and innovation, Nuffield Department of Clinical Medicine, Medical Sciences Division, University of Oxford, Oxford, England.

Ethical approval: The University of Oxford Clinical Trials and Research Governance Team reviewed the study; no ethics committee approval was necessary.

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