International Journal of Health Care Quality Assurance

Culture and quality care perceptions in a Pakistani hospital

Fauziah Rabbani S.M. Wasim Jafri Farhat Abbas Firdous Jahan Nadir Ali Syed Gregory Pappas Syed Iqbal
Azam Mats Brommels Göran Tomson
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Fauziah Rabbani S.M. Wasim Jafri Farhat Abbas Firdous Jahan Nadir Ali Syed Gregory Pappas Syed Iqbal
Azam Mats Brommels Göran Tomson, (2009),"Culture and quality care perceptions in a Pakistani hospital",
International Journal of Health Care Quality Assurance, Vol. 22 Iss 5 pp. 498 - 513
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IJHCQA
22,5 Culture and quality care
perceptions in a Pakistani
hospital
498
Fauziah Rabbani, S.M. Wasim Jafri, Farhat Abbas,
Received 18 March 2008
Firdous Jahan, Nadir Ali Syed, Gregory Pappas
Accepted 7 May 2008 and Syed Iqbal Azam
Aga Khan University Hospital, Karachi, Pakistan, and
Mats Brommels and Göran Tomson
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Karolinska Institutet, Stockholm, Sweden

Abstract
Purpose – Organizational culture is a determinant for quality improvement. This paper aims to
assess organizational culture in a hospital setting, understand its relationship with perceptions about
quality of care and identify areas for improvement.
Design/methodology/approach – The paper is based on a cross-sectional survey in a large clinical
department that used two validated questionnaires. The first contained 20 items addressing
perceptions of cultural typology (64 respondents). The second one assessed staff views on quality
improvement implementation (48 faculty) in three domains: leadership, information and analysis and
human resource utilization (employee satisfaction).
Findings – All four cultural types received scoring, from a mean of 17.5 (group), 13.7 (developmental),
31.2 (rational) to 37.2 (hierarchical). The latter was the dominant cultural type. Group (participatory) and
developmental (open) culture types had significant positive correlation with optimistic perceptions about
leadership (r ¼ 0:48 and 0.55 respectively, p , 0:00). Hierarchical (bureaucratic) culture was
significantly negatively correlated with domains; leadership (r ¼ 20:61; p , 0:00), information and
analysis (20:50; p , 0:00) and employee satisfaction (r ¼ 20:55; p , 0:00). Responses reveal a need for
leadership to better utilize suggestions for improving quality of care, strengthening the process of
information analysis and encouraging reward and recognition for employees.
Research limitations/implications – It is likely that, by adopting a participatory and open
culture, staff views about organizational leadership will improve and employee satisfaction will be
enhanced. This finding has implications for quality care implementation in other hospital settings.
Originality/value – The paper bridges an important gap in the literature by addressing the
relationship between culture and quality care perceptions in a Pakistani hospital. As such a new and
informative perspective is added.
Keywords Organizational culture, Leadership, Employee involvement, Quality improvement, Pakistan,
Hospitals
Paper type Research paper

Background
International Journal of Health Care Structural changes in health care alone, have failed to deliver anticipated
Quality Assurance improvements in quality and performance in health care (Le Grand et al., 1999;
Vol. 22 No. 5, 2009
pp. 498-513 Shortell et al., 1998). To unravel this paradox researchers (Davies, 2002) ask a different
q Emerald Group Publishing Limited
0952-6862
question: what are the structures that matter the most – those that are formal and
DOI 10.1108/09526860910975607 explicit as in organization charts, accountability relationships and contracts or those
 that comprise the informal psychological and social structures governing how we Culture and
think, what we value, and what we see as legitimate? Much of health system reform quality care
has tackled the former, while that which impedes change is concerned with the latter
and may be considered as the “culture” of an organization. perceptions
Organizational culture is defined as the values, beliefs, and norms of an
organization that shape its behavior (Davies et al., 2000). High hazard industries such
as aviation, nuclear energy, and shipping pay considerable attention to assessing their 499
organizational climate (Colla et al., 2005). As healthcare organizations undergo major
redesign of their care delivery processes, more emphasis is now increasingly being
placed on organizational culture and its role in facilitating change, driving innovation
and transforming a healthcare system (Ingersoll et al., 2000; Shortell et al., 1995a).
Successful implementation of quality care initiatives requires a significant
commitment to a culture emphasizing empowerment, autonomy and risk taking
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(Shortell et al., 1995b). Existing research suggests that such cultures are associated
with high performing organizations (Shortell et al., 1994). There is also evidence that
culture can act as a means for improving quality, efficiency, patient focus in addition to
broader organizational performance (Scott et al., 2003a, c). While no “ideal” instruments
exist for cultural assessment (Scott et al., 2003b), tools have been described which use
predetermined categories and questions (Mallak et al., 2003b). Four cultural types
(group, developmental, hierarchical, rational) have been broadly defined. They are
based on competing values framework and measured by assessing the underlying
values of organizational members (Quinn and Kimberly, 1984).
In most countries hospitals provide both advanced and basic care for the
population, therefore organizational culture in hospitals is receiving increasing
attention as an important determinant of quality of care (Mckee and Healy, 2000). As a
result calls are heard for “cultural transformation” to deliver improvements in quality
and performance, prominent especially in the USA and the UK. NHS trusts show
organizational culture varying across hospitals, and that at least some of this variation
is associated in consistent and predictable ways with the variety found in
organizational characteristics and measures of performance (Davies et al., 2007).
Other studies in high-income countries have indicated that group (participatory) and
development (risk-taking) cultures are important for quality care implementation,
reducing patient care unit costs and materializing change (Brewer, 2006; Coeling and
Simms, 1993; Shortell et al., 1996). Key factors that relate to culture with regard to
quality implementation include supportive leadership, employee empowerment and
satisfaction, appropriate information and analysis system, patient outcomes and
sub-cultural diversity (Scott et al., 2003c; Wakefield et al., 2001). Staff perception about
their organization’s quality improvement efforts is an important indicator and assists
in encouraging staff involvement in all quality care processes (Arnetz, 1999).
Employees’ views and experiences regarding their organization’s culture and services
are reported from hospitals in Finland and Italy (Kasila et al., 2006; Vernero et al., 2007).
Despite the previously mentioned evidence, defining quality of healthcare and
determining how to improve organizational performance is still an unresolved issue
among health-care professionals (Ruiz et al., 1999). The situation is even dismal in
many low- and middle-income countries (LMIC) where unsatisfactory quality of health
services continues to be reported (Jonsson et al., 2007). Therefore if health care
organizations are to deliver to expectations in the twenty-first century then we need to
 IJHCQA identify ways to improve quality of care and address this knowledge gap. There is some
22,5 evidence from UAE where perceptions of hospital employees related to transformational
leadership and the relationship between the dimensions of service quality and those of
leadership were analyzed (Jabnoun and Rasasi, 2005). Though some importance has been
given to cultural knowledge for health planning in Nepal (Justice, 1999), a clear
understanding of existing organizational culture needs to be developed in order that
500 plans can be defined for improving quality of care and organizational effectiveness
(Forsythe, 2005). The influence of the overriding societal culture in these settings has to
be considered in context. In Pakistan (a country with strong cultural traditions, going
back to the early Indus Valley civilizations), health care organizations have had rigid
hierarchical structures, ineffective administrative and weak financial controls. Hospital
reforms have aimed to improve managerial autonomy and financial accountability
coupled with performance agreements (Ghaffar et al., 2000). The lack of
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performance-based incentives however, contributes towards inefficient resource

management, low productivity and unprofessional patient care in the country
(Abdullah and Shaw, 2007). Given the scarcity of studies on cultural assessment and
quality care in the country and the region, we aimed to assess the type of organizational
culture in a hospital setting in Pakistan, examine its link with staff perceptions about
quality of care and identify some areas for improvement (see Figure 1).

Methods
Study site
This study was conducted at a large private university hospital in Karachi (largest and
most populous city of Pakistan). The hospital offers quality care to outpatients and
inpatients of all socio-economic classes (Rafique et al., 2006). It operates with 542 beds in
operation and offers a broad range of secondary and tertiary services annually to over
38,000 hospitalized patients and to over 500,000 outpatients annually. Inpatients have an
average length of stay of 3.9 days (Aga Khan University Hospital Quality Manual, 2007).
There are currently 400 trainees (interns, residents, fellows) affiliated with the hospital.
Clinical services offered by this university hospital are listed in Table I.
The clinical department in which this study was conducted has 54 full-time faculty
members (49 male, five female) and 67 trainee residents (40 male, 27 female),

Figure 1.
Conceptual framework of
the study: Culture and
quality care perceptions in
a Pakistani hospital
 Culture and
Specialty Subspecialties
quality care
Anaesthesia perceptions
Family medicine
Medicine Cardiology
Diabetes, endocrinology and metabolism
Gastroenterology 501
General internal medicine
Haematology and oncology
Neurology
Pulmonary and critical care medicine
Emergency medicine
Obstetrics and gynaecology
Paediatrics
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Pathology and microbiology

Psychiatry
Surgery Cardiothoracic surgery
Dental-oral and maxillofacial surgery
General surgery
Neurosurgery
Ophthalmology
Orthopaedic surgery
Otolaryngology
Paediatric surgery
Urology
Ambulatory care services
Allied health services Pharmacy
Physiotherapy
Nutrition Table I.
Diagnostic services Cardiopulmonary Organization of clinical
Clinical laboratories services in the university
Neurophysiology hospital by various
Radiology subspecialties

distributed across all eight sub-specialties. The department has a strategic plan
consistent with the vision of the institution and works in close collaboration with other
university departments.

Study design and sampling

The study design was descriptive and cross-sectional and used written surveys assessing
respondent’s perceptions. Data collection was conducted between April and October 2006
using convenient sampling. We chose this particular clinical department as:
.
it is one of the largest clinical departments, both in terms of human resources and
variety of care offered through its subspecialty divisions;
.
it has a functional strategic plan;
.
its staff members were willing to perform a baseline cultural assessment; and
.
there was motivation to test innovative performance management approaches
and to improve quality of care.
 IJHCQA Cultural assessment
22,5 Presentations were made by the research team to all faculty and residents (clinical
trainees), regarding the aim and purpose of the cultural assessment. The assessment
comprised of establishing a cultural typology, based on a questionnaire that was
completed when faculty and residents were gathered for their routine monthly
meetings. It comprised a validated 20-item self-administered questionnaire (Zammuto
502 and Krakower, 1991), based on competing values framework (CVF) involving
underlying dimensions of flexibility/control and external versus internal orientation
(Quinn and Kimberly, 1984). The CVF questionnaire articulates four basic cultural
types. Based on norms of affiliation, group (clan) culture seeks to secure compliance
with organizational mandates through trust and tradition. It emphasizes the
development of potential, value participation in decision-making, and implementing
change through consensus building and teamwork. Predicated upon change,
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developmental (open) cultures seek to motivate individuals through appeals to the

importance of required tasks and agility, emphasizing growth, risk taking and
innovation. In contrast, hierarchical (bureaucratic) cultures reflect the values and
norms of bureaucracy. They assume stability, seeking to ensure compliance with
mandates via formal rules enforced by sanctions and regulations. Finally,
rational/market cultures assume achievement through planning, productivity, task
completion and efficiency; seeking to motivate individuals through the belief that
competency leads to rewards (Cameron and Quinn, 2006).
The respondents (faculty and residents) were required to indicate the extent to
which their department reflects characteristics associated with each culture type
mentioned previously. They were asked to “share 100 points” between the four
descriptions (copy of questionnaire available from the authors). Pretesting of this
questionnaire was done with 22 faculty in another clinical department of this hospital
and no changes were made. We used a standard formula for calculating the typology,
which has also been used in other studies in high-income settings (Cameron and
Freeman, 1991; Davies et al., 2007; Deshpande et al., 1993; Lee et al., 2002; Shortell
et al., 1995a, b, 1996, 2000, 2001, 2004). Collating these point allocations provided a
score (in the range 0 to 100) for each individual on the four cultural types. Mean,
range, and inter-quartile values for each typology were computed using SPSS (SPSS
14.0 for Windows, Chicago, IL USA).

Quality improvement perceptions

We used quality improvement implementation survey II (QIIS) questionnaire
developed by Shortell to measure perceptions about quality care implementation
(Shortell, 2001). This questionnaire has been used in previous studies in high-income
countries (Shortell et al., 1995b, 2000). Based on US Chambers of Commerce 1993,
Baldrige Award Criteria, the instrument uses 58 items to define seven dimensions
measuring employee perceptions about quality of care implementation. These are:
leadership, information and analysis, human resource utilization, strategic quality
planning, quality management, quality results and customer satisfaction. After
pretesting this questionnaire (in another clinical department), it was decided to abridge
the questionnaire, make the exercise simpler, and administer it to a more experienced
group familiar with quality care implementation processes such as the faculty.
 Therefore we chose to collect information (from faculty only) on the first three domains. Culture and
These were: quality care
(1) Leadership: ten items measuring the extent to which senior executives’ personal perceptions
leadership and involvement creates and sustains clear visible quality values.
(2) Information and analysis: six items measuring the extent to which the scope,
management and use of data was perceived to drive quality excellence.
503
(3) Human resource utilization: eight items measuring the extent to which
employees were educated and trained on quality improvement.
This exercise also serves as a proxy for employee satisfaction. No change in the content
of the scale items was made from the original validated instrument.
As in the previous study (Shortell et al., 1995b), participants were asked to respond to
a series of scale items within each domain, indicating the extent to which they agreed or
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disagreed with the statement by ticking in the appropriate box (1 ¼ strongly disagree,
5 ¼ strongly agree). We used a standard formula for calculating individual scores for
each domain, which has been used in other studies in high-income settings (Lee et al.,
2002; Shortell et al., 1995b, 2000, 2004). SPSS (SPSS 14.0 for Windows, Chicago, IL USA)
was later used to calculate means scores and Cronbach Alpha for each of the three
domains. Later using the same statistical software correlation coefficients were
computed for mean culture typology and average quality care domain scores.
Ethical clearance to conduct this study was obtained from university ethical committee
as part of a larger package of studies on performance evaluation. For this particular study
special clarification was made that this was not biomedical research on human subjects
and only staff perceptions were being sought in order to ultimately improve organizational
performance. It was also explained that results would only be reported and analyzed at
group level and that individual identity of respondents, their gender, designation and
sub-specialty affiliation would not be revealed. Those completing the questionnaires
participated purely on a voluntary basis, which served as a proxy for their consent.

Results
Culture typology
Out of the 50-faculty present at the meeting 47 (94 per cent) completed the
questionnaire on culture typology. There were 22 residents attending the meeting and
17 (77 per cent) completed the form. None of the respondents disclosed their gender or
associated sub-specialty. All four-culture types were represented. The predominant
perceived cultural type was hierarchical for which the mean was 37.2 (range 0-87). The
means of other cultural types were: group 17.5 (range 0-80), developmental 13.7 (range
0-100), and rational 31.7 (range 0-66). The inter quartile range of various culture
typologies is shown in Figure 2.

Quality improvement perceptions

Out of 50-faculty present at the meeting, 48 (96 per cent) completed the questionnaire
assessing quality improvement measures in three domains:
(1) Leadership.
(2) Information and analysis.
(3) Human resource utilization.
 IJHCQA
22,5

504
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Figure 2.
Interquartile range of
cultural types: study in a
Pakistani hospital

Of these 48 faculty members, 44 also provided information on their designation and

period of service at the institution; 13 had service less than five years while 31 had been
serving the institution for greater than five years. Regarding their designation 40 per
cent were junior faculty (senior instructors), 32 per cent midlevel (assistant professors)
while the remaining 28 per cent were senior faculty (associate professors and
professors). None of the faculty disclosed their gender or sub-specialty affiliation.
Separate mean scores for each of the three domains were computed (see Table II).
Human resource utilization got a mean score of 3.39 (relatively low) as compared to

Domains Mean Median Mode Std dev. Quartile Cronbach alpha

Leadership 3.65 4 4.00 0.94 3.04 4.00 4.14 0.80

Information and analysis 3.50 4 4.00 0.83 3.00 4.00 4.00 0.81
Table II. Human resource utilization 3.39 3.60 4.00 0.68 2.84 3.60 4.00 0.80
Measuring perceptions
about quality Notes: These domains are part of the quality implementation improvement survey (QIIS II), which
improvement used a validated questionnaire (Shortell, 2001). Please refer to text for content and method of scoring of
implementation in a these domains. Permission to use the QIIS-II questionnaire was obtained from Robin Gillies
Pakistani hospital c/o Dr Stephen M. Shortell at the University of California, Berkeley; n ¼ 48
 3.65 for leadership, and 3.50 for information and analysis. In previous research, the Culture and
Cronbach alpha for the domains ranged from 0.79 to 0.93 (Shortell et al., 1995b). In our quality care
study Cronbach alpha for the three domains ranged from 0.80-0.81. This suggests a
high degree of internal consistency (Bland and Altman, 1997; Nunnally, 1978). perceptions
Items within each domain were analyzed and percentages computed (see Table III).
Some of the strong areas (based on a combined percentage of “agree” and “strongly
agree”) were: leadership, in terms of providing a conducive environment for improving 505
quality (73 per cent); employees being provided training in quality improvement (75
per cent); and wide range of data being collected about quality of care (60 per cent).
Similarly, some of the key areas of action that emerged (based on combined percentage
of “strongly disagree” and “disagree”) were: leadership to act on suggestions for
improving quality of care (21 per cent), ensuring a continuous process to improve
accuracy and relevance of data (21 per cent) and provision of reward and recognition to
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employees for improving quality of care (28 per cent).

The relationship of the three domains with perceived culture types is shown in
Table IV. High scores of leadership corresponded positively with group
(r ¼ 0:48; p , 0:00) and developmental culture (r ¼ 0:55; p , 0:00). This means that
those who rated leadership on the higher side of the scale also perceived the culture to
be more participatory and open. Similarly group culture was positively correlated with
human resource utilization (r ¼ 0:43; p , 0:00), showing that this culture type is
positively linked with aspects of employee satisfaction with quality of care
implementation. Development culture type was also positively correlated with
human resource utilization (r ¼ 0:52; p , 0:00) and information and analysis
(r ¼ 0:47; p , 0:00). On the other hand, hierarchical (bureaucratic) culture was
significantly negatively correlated with all three domains; leadership
(r ¼ 20:61; p , 0:00), information and analysis (20:50; p , 0:00) and employee
satisfaction (r ¼ 20:55; p , 0:00). The latter is an evidence that those who perceived
the culture to be bureaucratic also gave lower rating to leadership in maintaining a
quality culture and employee’s satisfaction with quality care implementation.

Discussion
We believe (based on a comprehensive Medline and Google search) that this may be one
of the first few efforts to measure culture and quality care implementation in a hospital in
low-income setting. An important finding in our study is that there is a mix of all four
cultural types (group, developmental, hierarchical and rational). This is similar to studies
on organizational cultural assessment in high income countries (HICs), which observed
that the operating environment and local variables of an organization lead with varying
degrees of emphasis toward maintaining mixed characteristics of the four cultural types.
Moreover these studies found it unrealistic to fit an organization into only one cultural
type (Deshpande et al., 1993; Lee et al., 2002). Recent evidence suggests that all four
typologies are collectively important and that it is the relative balance and interplay
among them that is most likely to be associated with perceived organizational
effectiveness (Shortell et al., 2004). Of interest, other studies have also demonstrated that
organizational’ cultures that combine flexibility (group culture) and control-oriented
values (hierarchical culture) are less likely to experience implementation failure (Bloor
and Dawson, 1994; Shortell et al., 2004; Zammuto and O’Connor, 1992).
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22,5

506

hospital
Table III.
IJHCQA

improvement

domains in a Pakistani
implementation in three
Perceptions about quality
Strongly Neither disagree Strongly Do not Not
Domain items disagree Disagree nor agree Agree agree know applicable

I. Leadership
Leadership encourages supportive environment for quality
improvement 8 6 13 42 31
Leadership acts on suggestions to improve quality of care 6 15 8 42 23 4
Adequate organizational resources to improve quality are allocated 10 8 10 35 21 10 2
II. Information and analysis
Wide range of data about quality of care collected 6 6 10 50 10 10 4
Data is used for making improvements in quality of care 13 22 48 8 6 2
Continuous process exists to improve accuracy and relevance of data 4 17 10 38 4 17 6
III. Human resource utilization
Education and training on quality improvement opportunities
provided to employees 4 2 19 35 40
Education and training to improve job skills and performance
provided to employees 4 6 15 35 38 2
Reward and recognition provided to employees for improving service
quality 8 20 8 30 31
Notes: These domain items are the same as used in QIIS II validated questionnaire (Shortell, 2001). Few items have been selected from each domain for
this table to show the range of responses in this study. For detail of domains please refer to text; 48 respondents answered these and responses are
converted to percentages; All percentages may not add to 100 due to some missing values; all 48 respondents did not answer each statement; n ¼ 48
 We observed an emphasis on hierarchical culture. This is not an unexpected finding. Culture and
Studies in high-income settings have also reported relatively high hierarchical mean quality care
scores: 28.5 and 32.3 respectively (Shortell, 2001), while conducting cultural
assessments in hospital settings. Large variation in scoring in our study is perceptions
suggestive of a variation in individual experience. In our sample some individual
respondents characterized the department as being one type (by giving a score of 100
to one cultural type instead of distributing it across the four options). This is consistent 507
with previous reports of subgroups within organizations maintaining competing
values with more-or-less stronger pull to one particular quadrant (Davies et al., 2007).
Perhaps, elements of relatively predominant hierarchical culture (as compared to other
cultural types) may be a necessary prerequisite for optimal functioning in the face of
the current cultural style of governance and management. It has also been reported
that health systems of the LICs frequently operate in impermanent, inconsistent, and
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turbulent environments (Abdullah and Shaw, 2007). Therefore our results could also be
reflective of the operating environment at a regional level. For example, Pakistan has
experienced unbalanced power structures and frequent changes in government, which
has disturbed health resources and has resulted in a centralized health system that
hinders wider participation and disrupts health policy-making, planning and
implementation (Khan and Van Den Heuvel, 2007).
A relationship between perceived culture type and quality care implementation was
observed. Hierarchical culture in our study was negatively correlated with the three
quality improvement domains under study. These domains measure perceptions about:
(1) Leadership being supportive of quality implementation.
(2) Timely utilization of quality care data.
(3) Provision of appropriate quality improvement training for employees and
recognition for their quality implementation work.
On the other hand individuals who gave high scores to quality implementation
domains also rated culture as being more participatory (group) and open
(developmental). This finding could be reflective of diversity among individuals in
their perceptions of met or unmet needs. Other studies have reported that individual
perceptions of the organization are related to job attitudes, and the respondent’s level
within the hierarchy of the organization (Morris and Bloom, 2002). Hence our findings
confirm previous studies linking group (participatory) and developmental (open)

Correlation coefficient Culture typologies

Domains Group Developmental Hierarchical Rationale

Leadership Pearson correlation 0.48 * 0.55 * 2 0.61 * 20.14

Sig. (two-tailed) 0.00 0.00 0.00 0.36
Information and analysis Pearson correlation 0.24 0.47 * 2 0.50 * 0.05
Sig. (two-tailed) 0.13 0.00 0.00 0.72 Table IV.
Employee satisfaction Pearson correlation 0.43 * 0.52 * 2 0.55 * 20.13 Correlation of culture
Sig. (two-tailed) 0.00 0.00 0.00 0.39 typologies with
perceptions about quality
Notes: Data analyzed in SPSS and imported in Excel software. * Significant correlations care implementation
 IJHCQA cultures with better quality improvement work (Shortell et al., 1995b, 2000). It has also
22,5 been reported that associations exist between cultural types and satisfaction with
managerial decision-making and between leadership behaviour, work climate and job
satisfaction (Sellgren et al., 2007). It is therefore recommended that more participatory
decision-making and teamwork be encouraged in our setting. Transitioning from
traditional hierarchical to more partnership-based (group culture) structures especially
508 between point-of-service staff and administrators is the foundation for creating a
progressive evidence-based culture (Crow, 2006).
Analysis of quality improvement measures helps us to identify the strengths and
challenges in implementation. Although leadership was rated high (mean score 3.65)
with a concurrence that it provides a supportive environment, there was a perception
that not enough resources are allocated towards quality improvement. It has been
demonstrated previously that employees want a leader with a clearer leadership style
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than what the manager (leader) personally perceives as being accurate (Sellgren et al.,
2006). We suggest that senior leadership be more visible to frontline staff and that
managers put support systems and resources into place that empower employees. The
same has been recommended elsewhere (Kane-Urrabazo, 2006; Pronovost et al., 2003).
The quality improvement measure information and analysis had a good rating (mean
score: 3.50). This domain has been rated in a similar range in other reports (Lee et al.,
2002; Shortell et al., 1995b, 2000). Work environments that provide access to information,
resources, and opportunity to learn are empowering and influence employee work
attitudes, productivity, and organizational effectiveness (Laschinger et al., 2001). There
was agreement in our study that a wide range of quality care information was being
collected: however the need for a continuous process to improve accuracy and relevance
of data was felt. Other studies have also shown that effective implementation of
information technology in health care requires physicians to be continuously involved in
selection and modification of health data for their departmental needs (Øvretveit et al.,
2007). We recommend better coordination between collectors and users of information
and that data being used are appropriate to the objective of the exercise.
The measure human resource utilization got a relatively low mean score (3.39 on a
scale of 1-5). Other studies also report relatively low scores in this domain (Shortell et al.,
1995b, 2000). Although there was a satisfaction with regard to training in quality care,
there was an expressed need among employees for improving reward and recognition
process. This is important, as concerns about employee satisfaction are just as critical in
the health care industry as they are in other business sectors (Mcbride, 2002).
Organizational culture should be able to support work environments where members
have positive colleague interactions, where they can approach tasks in a manner that
helps them attain high-order personal expectations and needs, and where they can also
meet organizational goals (Patrick and Laschinger, 2006; Wooten and Crane, 2003).
This study had some limitations. As always, generalizability is an issue. However
other studies have demonstrated that it is possible to assess different subunit cultures,
to identify the common dominant attributes of the subunits, and to aggregate them.
This combination can provide an approximation of the overall organization’s culture.
In addition, certain questions included in the survey required subjective judgments to
be made, or they relied upon the perceived values of the individual respondents, and,
therefore, there is a risk that the answers do not correctly reflect the reality. However
both cultural typology and quality care implementation were measured using
 validated instruments and our results therefore provide a very close estimate of the real Culture and
situation. Since our findings are based on cross-sectional analysis, they must be quality care
considered as net associations and not cause-and-effect relationships.
In general having conducted our study in this setting has laid the foundation for perceptions
establishing a relationship between perceived organizational culture type and specific
staff- reported aspects of quality improvement implementation. This is consistent with
previous reports (Wakefield et al., 2001; Shortell et al., 1995b) and recommendations from 509
earlier findings that suggest the need for cultural assessment prior to implementing
interventions aimed at improving quality of care and organizational performance
(Rabbani et al., 2007). If it is the case that a group oriented/developmentally oriented
culture promotes greater implementation of quality improvement work, then this
particular hospital needs to address the challenge of being hierarchically organized.
However, the direction of the causal relationship, if any, is not known in our study. It
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represents a snapshot of individual views of culture and quality improvement measures

at a single period in time. For these findings to be useful for other hospital settings, it will
be important to differentiate between whether successful quality care implementation
leads to a change in the organizational culture, or whether such success depends on the
existing culture. Longitudinal studies with larger samples are advocated.

Acknowledgements
The authors would like to thank the senior Aga Khan University (AKU) leadership,
Mohammad Khurshid, Dean of the Medical College; president Firoz Rasul; and director
general and CEO Nadeem Khan, for encouraging them to proceed with the work related
to the balanced scorecard (BSC) at AKU. This study is a component of BSC studies.
From AKU, they thank Mairaj Shah, manager clinical affairs and CME and Wasif
Shahzad, manager, Department of Medicine for assisting in the initial meetings. They
also express their gratitude to Riffat Moazzam-Zaman, professor, Department of
Psychiatry, for sharing some previous experience of culture assessment at AKU, Saira
Nigar and Iqbal Azam for assisting in data analysis and Shafaq Ambreen,
administrative officer for her untiring secretarial assistance.
The authors thank Bo Badr Saleem Lindblad, professor emeritus of International
Child Health, Department of Public Health Sciences, Division of International Health
(IHCAR), Karolinska Institutet Medical University, Stockholm, Sweden, and visiting
professor, AKU, Karachi, Pakistan, for his overall support.
They extend their gratitude to Robin R. Gillies, PhD director, research projects,
University of California, Berkeley Health Policy and Management School of Public
Health for granting permission to use the validated questionnaires and also answering
queries related to data entry and analysis.
Thanks also go to Thomas Mellin at IHCAR, Department of Public Health Sciences,
Karolinska Institutet, for connecting the authors to various information technology
resources.
They wish to acknowledge their grant sources: Swedish South Asian Network
(SASNET), WHO EMRO, Swedish Institute (Si), AKU Faculty Development Award
(FDA) and AKU University Research Council (URC).
 IJHCQA References
22,5 Abdullah, M.T. and Shaw, J. (2007), “A review of the experience of hospital autonomy in
Pakistan”, International Journal of Health Planning and Management, Vol. 22 No. 1,
pp. 45-62.
Aga Khan University Hospital Quality Manual (2007), AKUH Quality Improvement and Patient
Safety Manual, 4th ed., Aga Khan University Hospital, Karachi.
510 Arnetz, B.B. (1999), “Staff perception of the impact of health care transformation on quality of
care”, International Journal for Quality in Health Care, Vol. 11 No. 4, pp. 345-51.
Bland, J.M. and Altman, D.G. (1997), “Cronbach’s alpha”, British Medical Journal, Vol. 314
No. 7080, p. 572.
Bloor, G. and Dawson, P. (1994), “Understanding professional culture in organizational context”,
Organization Studies, Vol. 15 No. 2, p. 275.
Downloaded by SELCUK UNIVERSITY At 07:05 29 January 2015 (PT)

Brewer, B.B. (2006), “Relationships among teams, culture, safety, and cost outcomes”, Western
Journal of Nursing Research, Vol. 28 No. 6, pp. 641-53.
Cameron, K. and Freeman, S.J. (1991), “Cultural congruence, strength, and type: relationship to
effectiveness”, Research in Organization Change and Development, Vol. 5, pp. 23-58.
Cameron, K.S. and Quinn, R.E. (2006), Diagnosing and Changing Organizational Culture: Based
on the Competing Values Framework, rev. ed., Jossey-Bass, San Francisco, CA.
Coeling, H.V. and Simms, L.M. (1993), “Facilitating innovation at the unit level through cultural
assessment, part 2: adapting managerial ideas to the unit work group”, The Journal of
Nursing Administration, Vol. 23 No. 5, pp. 13-20.
Colla, J.B., Bracken, A.C., Kinney, L.M. and Weeks, W.B. (2005), “Measuring patient safety
climate: a review of surveys”, British Medical Journal, Vol. 14 No. 5, p. 364.
Crow, G. (2006), “Diffusion of innovation: the leaders’ role in creating the organizational context
for evidence-based practice”, Nursing Administration Quarterly, Vol. 30 No. 3, pp. 236-42.
Davies, H.T.O. (2002), “Understanding organizational culture in reforming the National Health
Service”, Journal of the Royal Society of Medicine, Vol. 95 No. 3, pp. 140-2.
Davies, H.T., Nutley, S.M. and Mannion, R. (2000), “Organisational culture and quality of health
care”, Quality in Health Care, Vol. 9 No. 2, pp. 111-19.
Davies, H.T., Mannion, R., Jacobs, R., Powell, A.E. and Marshall, M.N. (2007), “Exploring the
relationship between senior management team culture and hospital performance”, Medical
Care Research and Review, Vol. 64 No. 1, pp. 46-65.
Deshpande, R., Farley, J.U. and Webster, F.E. Jr (1993), “Corporate culture, customer orientation,
and innovativeness in Japanese firms: a quadrad analysis”, Journal of Marketing, Vol. 57
No. 1, pp. 23-37.
Forsythe, L.L. (2005), “Using an organizational culture analysis to design interventions for
change”, AORN Journal, Vol. 81 No. 6, pp. 1288-302.
Ghaffar, A., Kazi, B.M. and Salman, M. (2000), “Health care systems in transition III. Pakistan,
part I. An overview of the health care system in Pakistan”, Journal of Public Health, Vol. 22
No. 1, p. 38.
Ingersoll, G.L., Kirsch, J.C., Merk, S. and Lightfoot, J. (2000), “Relationship of organizational
culture and readiness for change to employee commitment to the organization”, The
Journal of Nursing Administration, Vol. 30 No. 1, pp. 11-20.
Jabnoun, N. and Rasasi, A. (2005), “Transformational leadership and service quality in UAE
hospitals”, Managing Service Quality, Vol. 15 No. 1, pp. 70-81.
 Jonsson, K., Tomson, G., Jonsson, C., Kounnavong, S. and Wahlstrom, R. (2007), “Health systems Culture and
research in Lao PDR: capacity development for getting research into policy and practice”,
Health Research Policy and Systems, Vol. 5 No. 11, pp. 1-10.
quality care
Justice, J. (1999), “Neglect of cultural knowledge in health planning: Nepal’s assistant perceptions
nurse-midwife program”, Anthropology and Public Health: Bridging Differences in Culture
and Society, Oxford University Press, New York, NY.
Kane-Urrabazo, C. (2006), “Management’s role in shaping organizational culture”, Journal of 511
Nursing Management, Vol. 14 No. 3, pp. 188-94.
Kasila, K., Poskiparta, M. and Villberg, J. (2006), “Cultural and communicational traits of oral
health care: results of a Finnish case study”, Journal of Health, Organisation and
Management, Vol. 20 No. 6, pp. 537-50.
Khan, M.M. and Van Den Heuvel, W. (2007), “The impact of political context upon the health
policy process in Pakistan”, Public Health, Vol. 121 No. 4, pp. 278-86.
Downloaded by SELCUK UNIVERSITY At 07:05 29 January 2015 (PT)

Laschinger, H.K., Finegan, J. and Shamian, J. (2001), “The impact of workplace empowerment
and organizational trust on staff nurses, work satisfaction and organizational
commitment”, Health Care Management Review, Vol. 26 No. 3, pp. 7-23.
Le Grand, J., Mays, N. and Mulligan, J.A. (1999), “Learning from the NHS internal market: a
review of the evidence”, British Medical Journal, Vol. 318 No. 7182, p. 543.
Lee, S., Choi, K., Kang, H., Cho, W. and Chae, Y. (2002), “Assessing the factors influencing
continuous quality improvement implementation: experience in Korean hospitals”,
International Journal for Quality in Health Care, Vol. 14 No. 5, pp. 383-91.
Mcbride, E.L. (2002), “Employee satisfaction: code red in the workplace?”, Seminars for Nurse
Managers, Vol. 10 No. 3, pp. 157-63.
Mckee, M. and Healy, J. (2000), “The role of the hospital in a changing environment”, Bulletin of
the World Health Organization, Vol. 78, pp. 803-10.
Mallak, L.A., Lyth, M.D., Olson, D.S., Ulshafer, M.S. and Sardone, J.F. (2003b), “Diagnosing
culture in health-care organizations using critical incidents”, International Journal of
Health Care Quality Assurance, Vol. 16 No. 4, pp. 180-90.
Morris, A. and Bloom, J.R. (2002), “Contextual factors affecting job satisfaction and
organizational commitment in community mental health centers undergoing system
changes in the financing of care”, Mental Health Services Research, Vol. 4 No. 2, pp. 71-83.
Nunnally, J. (1978), Psychometric Theory, McGraw-Hill, New York, NY.
Øvretveit, J., Scott, T., Rundall, T.G., Shortell, S.M. and Brommels, M. (2007), “Improving quality
through effective implementation of information technology in healthcare”, International
Journal for Quality in Health Care, Vol. 19 No. 5, p. 259.
Patrick, A. and Laschinger, H.K. (2006), “The effect of structural empowerment and perceived
organizational support on middle level nurse managers’ role satisfaction”, Journal of
Nursing Management, Vol. 14 No. 1, pp. 13-22.
Pronovost, P.J., Weast, B., Holzmueller, C.G., Rosenstein, B.J., Kidwell, R.P., Haller, K.B., Feroli,
E.R., Sexton, J.B. and Rubin, H.R. (2003), “Evaluation of the culture of safety: survey of
clinicians and managers in an academic medical center”, Quality & Safety in Health Care,
Vol. 12 No. 6, pp. 405-10.
Quinn, R.E. and Kimberly, J.R. (1984), “Paradox, planning, and perseverance: Guidelines for
managerial practice”, in Quinn, R.E. and Kimberly, J.R. (Eds), Managing Organizational
Transitions, Dow Jones-Irwin, Homewood, IL, pp. 295-313.
 IJHCQA Rabbani, F., Jafri, W., Abbas, F., Pappas, G., Brommels, M. and Tomson, G. (2007), “Reviewing
the application of the balanced scorecard with implications for low-income health
22,5 settings”, Journal for Healthcare Quality, Vol. 29 No. 5, pp. 21-34.
Rafique, G., Azam, S.I. and White, F. (2006), “Diabetes knowledge, beliefs and practices among
people with diabetes attending a university hospital in Karachi, Pakistan”, Eastern
Mediterranean Health Journal, Vol. 12 No. 5, pp. 590-8.
512 Ruiz, U., Simon, J., Molina, P., Jimenez, J. and Grandal, J. (1999), “A two-level integrated approach
to self-assessment in healthcare organisations”, International Journal of Health Care
Quality Assurance, Vol. 12 No. 9, pp. 135-42.
Scott, T., Mannion, R., Marshall, M. and Davies, H. (2003a), “Does organisational culture
influence health care performance? A review of the evidence”, Journal of Health Services
Research and Policy, Vol. 8 No. 2, pp. 105-17.
Scott, T., Mannion, R., Davies, H. and Marshall, M. (2003b), “The quantitative measurement of
Downloaded by SELCUK UNIVERSITY At 07:05 29 January 2015 (PT)

organizational culture in health care: a review of the available instruments”, Health

Services Research, Vol. 38 No. 3, pp. 923-45.
Scott, T.I.M., Mannion, R., Davies, H. and Marshall, M.N. (2003c), “Implementing culture change
in health care: theory and practice”, International Journal for Quality in Health Care, Vol. 15
No. 2, pp. 111-8.
Sellgren, S., Ekvall, G. and Tomson, G. (2006), “Leadership styles in nursing management:
preferred and perceived”, Journal of Nursing Management, Vol. 14 No. 5, pp. 348-55.
Sellgren, S., Ekvall, G. and Tomson, G. (2007), “Nursing staff turnover: does leadership matter?”,
Leadership in Health Services, Vol. 20 No. 3, pp. 169-83.
Shortell, S.M. (2001), Quality Improvement Implementation Survey II, University of California,
Berkeley, CA, available at: http://shortellresearch.berkeley.edu/CABG-THR.htm (accessed
March 4, 2008).
Shortell, S.M., Bennett, C.L. and Byck, G.R. (1998), “Assessing the impact of continuous quality
improvement on clinical practice: what it will take to accelerate progress”, The Milbank
Quarterly, Vol. 76 No. 4, pp. 593-624.
Shortell, S.M., Levin, D.Z., O’Brien, J.L. and Hughes, E.F. (1995a), “Assessing the evidence on
continuous quality improvement: is the glass half empty or half full?”, Hospital Health and
Service Administration, Vol. 40 No. 1, pp. 4-24.
Shortell, S.M., Gillies, R.R., Anderson, D.A., Erickson, K.M. and Mitchell, J.B. (1996), “Remaking
health care in America”, Hospitals & Health Networks, Vol. 70 No. 6, pp. 43-8.
Shortell, S.M., O’Brien, J.L., Carman, J.M., Foster, R.W., Hughes, E.F., Boerstler, H. and
O’Connor, E.J. (1995b), “Assessing the impact of continuous quality improvement/total
quality management: concept versus implementation”, Health Services Research, Vol. 30
No. 2, pp. 377-401.
Shortell, S.M., Marsteller, J.A., Lin, M., Pearson, M.L., Wu, S.Y., Mendel, P., Cretin, S. and
Rosen, M. (2004), “The role of perceived team effectiveness in improving chronic illness
care”, Medical Care, Vol. 42 No. 11, pp. 1040-8.
Shortell, S.M., Zazzali, J.L., Burns, L.R., Alexander, J.A., Gillies, R.R., Budetti, P.P., Waters, T.M.
and Zuckerman, H.S. (2001), “Implementing evidence-based medicine: the role of market
pressures, compensation incentives, and culture in physician organizations”, Medical Care,
Vol. 39 No. 7, Suppl. 1, pp. 162-78.
Shortell, S.M., Zimmerman, J.E., Rousseau, D.M., Gillies, R.R., Wagner, D.P., Draper, E.A.,
Knaus, W.A. and Duffy, J. (1994), “The performance of intensive care units: does good
management make a difference?”, Medical Care, Vol. 32 No. 5, pp. 508-25.
 Shortell, S.M., Jones, R.H., Rademaker, A.W., Gillies, R.R., Dranove, D.S., Hughes, E.F.X., Culture and
Budetti, P.P., Reynolds, K.S.E. and Huang, C.F. (2000), “Assessing the impact of total
quality management and organizational culture on multiple outcomes of care for coronary quality care
artery bypass graft surgery patients”, Medical Care, Vol. 38 No. 2, pp. 207-17. perceptions
Vernero, S., Nabitz, U., Bragonzi, G., Rebelli, A. and Molinari, R. (2007), “A two-level EFQM
self-assessment in an Italian hospital”, Quality Assurance, Vol. 20 No. 3, pp. 215-31.
Wakefield, B.J., Blegen, M.A., Uden-Holman, T., Vaughn, T., Chrischilles, E. and Wakefield, D.S. 513
(2001), “Organizational culture, continuous quality improvement, and medication
administration error reporting”, American Journal of Medical Quality, Vol. 16 No. 4, p. 128.
Wooten, L.P. and Crane, P. (2003), “Nurses as implementers of organizational culture”, Nursing
Economics, Vol. 21 No. 6, pp. 275-9, 259.
Zammuto, R.F. and Krakower, J.Y. (1991), “Quantitative and qualitative studies of organizational
culture”, Research in Organizational Change and Development, Vol. 5, pp. 83-114.
Downloaded by SELCUK UNIVERSITY At 07:05 29 January 2015 (PT)

Zammuto, R.F. and O’Connor, E.J. (1992), “Gaining advanced manufacturing technologies’
benefits: the roles of organization design and culture”, The Academy of Management
Review, Vol. 17 No. 4, pp. 701-28.

About the authors

Fauziah Rabbani, MBBS, MPH, FCPS, FRCP is Noordin M. Thobani Professor in the Department
of Community Health Sciences, Aga Khan University, Karachi, Pakistan. Fauziah Rabbani is the
corresponding author and can be contacted at: fauziah.rabbani@aku.edu
S.M. Wasim Jafri, FRCP FACP FACG, is chair and professor of medicine and head of the
Gastroenterology Department at Aga Khan University, Karachi, Pakistan.
Farhat Abbas, MD FRCS FCPS FEBU, is an associate professor in the Section of Urology and
Department of Surgery at Aga Khan University, Karachi, Pakistan.
Firdous Jahan, MBBS, MCPS, FCPS is an assistant professor, Department of Family
Medicine, Aga Khan University Hospital, Karachi, Pakistan.
Nadir Ali Syed, MBBS, Diplomate American Board of Psychiatry, Diplomate Clinical
Neurophysiology, Diplomate American Board of Electrodiagnostic Medicine is an associate
dean, postgraduate medical education, associate professor and head of Neurology section, section
of Neurology, Department of Medicine, Aga Khan University Karachi.
Gregory Pappas, MD PhD, is professor and chairman of the Department of Community
Health Sciences at Aga Khan University, Karachi, Pakistan.
Syed Iqbal Azam, BSc (honors statistics), MSc (statistics) University of Karachi is assistant
professor, Department of Community Health Sciences, Aga Khan University, Karachi.
Mats Brommels, MD PhD, is professor of Health Services Management in the Department of
Public Health at the University of Helsinki, Finland. He is also a guest professor and director of
Medical Management Centre at Karolinska Institutet, Stockholm, Sweden.
Goran Tomson, MD PhD, is a professor of International Health Systems Research at IHCAR
in the Department of Public Health Sciences and Director of the doctoral program at the Medical
Management Centre, Karolinska Institutet, Stockholm, Sweden.

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