Organizational Values: Importance and Implementation

In this importance of values essay I will critically analyse the theory, practice and importance of organisational values and engaging stakeholders when working to improve care quality and patient experience; analysing their relationship and the role of leaders in values-based decision making, engagement, and leading for change and improvement.

Introduction

Change is necessary to adapt to the well-documented system and sustainability challenges currently faced by the National Health Service (NHS). The recently published NHS Long Term Plan sets out an ambitious agenda for change including development of new service models, reduction of inequalities, improvements to quality and outcomes, and technological upgrades. At a local level, King’s College Hospital, which has an ever-increasing budget deficit, is actively engaged in programs to increase the efficiency if healthcare delivery. Healthcare organisations are often said to be resistant to change, however. Large-scale change has been known to impact negatively on the organisational commitment of staff and result in change fatigue. It is necessary therefore that any leader involved in initiating a change program seeking to improve quality and patient care attends to matters of organisational culture and staff engagement to maximise the likelihood that the program will result in sustained improvements. Organisational values, values-based leadership and stakeholder engagement have a theoretical basis in the development of programs for organisational development, including improvement of care quality and patient experience. Whilst there is often appreciable anecdotal evidence and evidence from case studies relating to these aspects of planned change, the empirical evidence is less convincing. Nonetheless, the arguments for value-based leadership and stakeholder engagement as vital to successful quality improvement programs are vital.

Care Quality

The National Quality Board’s ‘Shared commitment to quality’ document distinguishes between high quality care as it is experienced by the patient and by those providing services. For patients, high quality care is said to be safe, effective and provided a positive end-user experience. For service-providers it is defined as being well-led, sustainable and equitable. The Health Foundation defines care quality as safe, efficient, patient-centred, timely, efficient and equitable. For the purposes of this essay the definition of care quality will draw together both definitions since positive end-user experience is lacking from the latter and patient-centredness from the former yet, both can be reasonably said to be necessary to the concept.

Organisational Values

Brown defines values as “belief[s] upon which a person acts by preference; an enduring belief that a specific mode of conduct or end-state of existence is personally or socially preferable to an opposite or converse mode of conduct or end-state existence”. Hofetede et al similarly define values as the preference of a particular state over another, as well as being the most profound level of organisaitonal culture. Definitions of organisational values may include an ethical dimension, in that they help decision makers to distinguish between “right” and “wrong”. They are also said to be “rules” of organisational culture that assist adaptation to external challenges and help guide new members on correct behaviour. The empirical evidence supports the view that organisational values serve an ethical purpose; a global study involving senior executives found that, of the public companies surveyed, it was most common for values statements of “financial leaders” to highlight ethical behaviour.

The NHS was founded on values of equity, inclusivity and universality of care. The values of the NHSnow include notions of care quality, patient-centredness, compassion, professionalism and excellence amongst others. The public inquiry into the failings that allowed unacceptably poor standards of care to develop at Mid Staffordshire NHS Foundation Trust from 2005 to 2008 found that the local culture had become overly concerned with protecting the reputation of the system, such that there was loss of focus on the risk to patients. One of the recommendations of the report was that there should be greater prominence given to common values to ensure focus is maintained on prioritising the needs of the patient and commitment to patient safety. Values were therefore felt to help ensure ethical decision making in the face of testing circumstances. Such an approach underpins the work that has been performed to embed values at Guy’s and St Thomas’ NHS Foundation Trust where the Executive Board applies the local organisational values in situations where it is obliged to make problematic choices relating to allocation of scarce resources.

The theoretical basis for the importance of organisational values may be understood through the distinction between an organisation’s internal and external dimensions. Wilber posits that there four quadrants of organisational reality derived from the interior-exterior dimension, which refers to the association between subjective inner and objective outer worlds, and an individual-communal dimension, which relates to the association between individual and communal identity. From the interactions between these dimension Wilber derives four interdependent fundamental quadrants with which all organisation development can be characterised. They are the consciousness (individual-interior), behavioural (individual-exterior), cultural (communal-interior) and social (communal-exterior). Change in one domain necessarily impacts the others. Thus, implementation of organisational strategies that seek to affect improvement by focusing only on changing the exterior, visible structure of the organisation are unlikely to be successful. The interdependency of the domains of organisational reality necessitates that a balance be struck between interior culture (of which values may be said to be at the core) and external functional realms.

The importance of values when implementing change initiatives may be best demonstrated through examination of empirical evidence. Kiriakidou and Millward’s study of the business unit of a large electronics and telecommunications products and services organisation examined the relationship between the internal stakeholder perception of the way that the company projected itself and their perception of the operational reality. The company’s values were identified by analysing corporate documents and a questionnaire was administered to employees to assess 'actual' and 'ideal' corporate identity, and staff commitment to organisational goals. They found that employees were significantly less likely to commit to changes that do not fit with their personal values or the present identity and values of the organisation. Under these circumstances, changes which aim at improving patient care and quality are likely to be successful only if employees subscribe to the values that underpin the desired state. The study also found that there were differences in perception of existing and ideal identities between different sub-groups of employees, indicative of the existence of diverse sub-cultures with their own distinct views about organisation’s culture and values. Similarly, there are likely to be sub-cultures in healthcare organisations, which are often made up of numerous distinct hierarchical and occupational sub-groups, working in different divisions, services and teams, sometimes in competition with one-another. This has led some to argue that attempts to achieve value congruence in the face of such complexity may not be completely achievable. Davies, Nutley and Mannion, for example, point to the difficulty in realising widespread adoption of patient-centred care.

If an organisation has an engaged workforce that values care quality and patient experience, then it seems likely that change initiatives with objectives that feed into these already established behaviours will be more likely to succeed. If, as in Kiriakidou and Millward’s study, there is a disjunction between the proposed future state and the existing one, then the evidence suggests that the initiative will probably fail. Unfortunately the evidence presented in the NHS Institute for Innovation and Improvement’s Value of Values document, as it relates to the importance of values as an enabler of organisational change, was not carried out in healthcare organisations. Leaving aside methodological issues, this raises questions about the generalisability of the findings when talking about matters of improving quality and patient care. One might reasonably wonder whether there is something about healthcare organisations, their employees, their roles and their values that differs fundamentally from other types of organisation and the professions they employ. To the author’s knowledge there have been no specific, robust studies looking at values and how they are applied in healthcare organisations undergoing change, particularly in relation to quality of care and patient experience, which makes the link between them somewhat uncertain.

Values Based Leadership

Leadership plays an important role in ensuring that staff are engaged in change programs both by linking the intervention to shared values and by modelling desired behaviour. If the drive for change rests solely with the leader of the team, division or organisation then it will be difficult to sustain. Leaders can generate the energy needed to sustain change by harnessing the power of many individuals across the organisation. Transformational leaders inspire their colleagues into action by demonstrating that change is important and necessary by invoking emotion, intellect and shared values. By ensuring that change is driven and shaped by employees at every level, leaders also leverage the diversity of the organisation.

Transformation leadership has four components: 

1. individualised consideration, which involves attention to the distinct and evolving needs of the individual employees and, as such, implicitly taps into the diversity of groups;  
2. intellectual stimulation, which involves encouragement of employees to consider the reasons for changing their personal approach to work-related challenges, attitudes and values; 
3. inspirational motivation occurs when employees are inspired by their leader's status in the organisation, past accomplishments, ability as a communicator or role modelling behaviour; 
4. idealised influence refers to the power and influence that follows when a leader successfully inspires confidence and trust in the directions set.

The empirical evidence suggests that inspirational motivation may be of importance when leading change initiatives. Bevan posits that employees lose interest in change initiatives when the values espoused by leaders within the organisation do not match their lived experience of how leaders behave in practice. This view is supported by studies conducted by Kiriakidou and Millward, and Zipparo. Zipparo’s large-scale survey study 1314 employees from 15 state agencies and local councils in New South Wales found that leaders who did not act in accordance with values were trusted less by employees who in turn had lower organisational commitment.

Bass and Steidlmeier argue that each of the attributes of transformational leadership have an ethical component. It is the moral underpinning the behaviour it relates to these attributes which determines whether the leader is truly transformational or simply pseudo-transformational. That is to say, the behaviour of the leader may look the same on the surface, buy to be truly transformational leaders must act in accordance with values that are morally uplifting. Inauthentic or pseudo-transformational leadership, it is argued, may produce results in the long-term but is unlikely to be sustained. Indeed, Copeland’s survey study of 175 leadership students and employees from a range of other industries assessed the relationship between leadership styles (authentic leadership, ethical leadership and transformational leadership) and the dependent variable, leadership effectiveness. It found that all three leadership traits are individually predictive of leader effectiveness, with ethical leadership being the strongest predictor. The strongest relationship was observed when all three traits were included in the regression analysis, indicating that the most effective leaders possess all three of these characteristics.

References

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