The culture of an organization consists of its norms, values, and beliefs, and is reflected by its stories, rituals and rites, symbols, and language (Daft 2000
). The notion that organizations have a culture is a relatively new idea, with the concept first entering the academic literature in 1979. In 1982, two books popularized the concept, Corporate Culture
by Deal and Kennedy and In Search of Excellence
by Peters and Waterman. In much of the writings on culture assumptions about the importance of culture in organizational settings have been made, yet little empirical work has been conducted to support such claims.
Early research on culture focused on developing measures of culture or on empirically describing the culture of various organizational settings. Recent interest in the culture of health care organizations, however, has begun to address the importance of culture for key organizational outcomes. For example, some have argued that the culture of physician organizations is important in the care of chronic illnesses, in that culture may be related to the ability of these organizations to support quality improvement efforts and develop needed information systems to provide better patient care (Rundall et al. 2002
). In a study of ICUs, “caregiver interaction” (culture, leadership, coordination, conflict management abilities, and communication) was found to be significantly related to several measures of organizational effectiveness. However, the reporting methods prevent one from distinguishing the effects of culture on clinical effectiveness from the effects of other components of caregiver interaction (Shortell et al. 1994
). In a study of culture and patient outcomes for CABG, a supportive group culture was associated with shorter postoperative intubation time (a positive outcome), but also associated with longer operating room times (a negative outcome) (Shortell et al. 2000
). When examining whether implementation of evidenced-based medicine in physician organizations was related to organizational culture, no significant relationships were found (Shortell, Zazzali et al. 2001
). Others have examined attitudinal measures of effectiveness, like job satisfaction, as a function of group culture, and demonstrated that organizational “culture” is a determinant of physician job satisfaction (Williams et al. 2002
). However, the measures of culture and satisfaction were assessed at a global level, and do not provide a fine-grained understanding of how culture and satisfaction are related. Two other studies found positive relationships between culture and organizational outcomes in mental health services settings (Morris and Bloom 2002
; Morris, Bloom, and Wang 2006
), using measures that jointly assessed dimensions of the organization's climate and culture.
In the broader management literature, several empirical studies have linked organizational culture with individual-level attitudes, such as job satisfaction and organizational commitment. These studies have been conducted in diverse organizational and country settings among a variety of occupational groups. Many of these studies utilize typologies of cultures, such as (1) Wallach's (1983)
distinction between bureaucratic, innovative, and supportive cultures, (2) Cameron and Freeman's (1991)
distinction between clans, adhocracies, markets, and hierarchies (which are conceptually similar to the group, developmental, rational, and hierarchical cultural types in the Competing Values framework), (3) Quinn and Rohrbaugh's (1983)
distinction between group, developmental, rational, and hierarchical cultures, and (4) Hofstede et al.'s (1990)
measurement of six cultural practices (results versus process orientation, job versus employee orientation, professional versus parochial, closed versus open system, tight versus loose control, and pragmatic versus normative). As evident from the labels, the cultural types resemble one another across typologies. Not surprisingly, these studies find that similar types of cultures have positive impacts on employee job satisfaction. Thus, satisfaction is higher in organizations with innovative, supportive, group, clan, and adhocracy cultures. Conversely, some studies find that satisfaction is lower in organizations with rational, hierarchical, and market cultures (Cameron and Freeman 1991
; Quinn and Spreitzer 1991
; Zammuto and Krakower 1991a
; Nystrom 1993
; Lok and Crawford 1999
; Goodman, Zammuto, and Gifford 2001
; Lund 2003
; Chen 2004
Two major issues face those interested in examining organizational culture in the health care sector. The first concerns the conceptualization and measurement of organizational culture and the second involves the inconsistency of findings to date. On the first point, the field of health care organizational research has both benefited and been hindered by the plurality of frameworks available for conceptualizing organizational culture and the attendant instruments used to measure it. This plurality has been beneficial in that no one framework is valid across all organizational settings. A recent review of instruments used in health care settings demonstrated differences in validity and the types of settings in which these instruments have been used (Scott et al. 2003
). Furthermore, examination of existing instruments raises issues of whether culture is being measured or other organizational constructs like climate or structure.
In regard to the second issue, much of the work to date has failed to clearly demonstrate consistent statistically significant relationships between culture and key organizational outcomes. When looking at this body of work, lack of consistent findings could suggest that culture is not relevant to organizational outcomes, that researchers have yet to examine outcomes relevant to physician group culture, that an appropriate set of measures for culture, or organizational outcomes has yet to be used, and/or that the appropriate statistical methods have not been used.
Conceptual Framework and Hypothesis Development
There are numerous ways to conceptualize and measure organizational culture (Scott et al. 2003
). Because of the well established divergence between organizational and professional principles, the Competing Values framework is particularly relevant for assessing the organization culture of physician groups (Quinn and Rohrbaugh 1983
). The Competing Values framework, pictured in , specifies two axes: the extent to which a culture is internally or externally focused, and the degree to which it emphasizes stability/control or adaptability/change. The resulting four quadrants reflect ideal cultural types: group, developmental, hierarchical, and rational. Every organization has elements of each ideal cultural type and this instrument thus allows one to assess the degree to which each ideal type is represented relative to the other types. This framework has been previously used in health care settings (Goodman, Zammuto, and Gifford 2001
; Shortell, Zazzali et al. 2001
Competing Values Framework of Organizational Culture
There are several advantages in using this framework, but perhaps the most important is that it explicitly incorporates multiple dimensions of an organization's culture (group, developmental, hierarchical, and rational), which allows one to formulate targeted hypotheses in relating dimensions of culture to physician satisfaction or other organizational outcomes. Because of the ease of administration and scoring and the quantitative nature of the instrument, it also allows for the assessment of culture and cross-organizational comparisons that other, particularly qualitative frameworks, make more difficult to achieve.
A group culture emphasizes teamwork, cohesiveness, and participation. It places a high emphasis on commitment and morale, mentoring, and rewarding team players. The developmental culture is characterized by the promotion of innovation and risk-taking. It is oriented towards growth; entrepreneurial, and risk-taking leaders are supported, and people are rewarded for taking and sharing risk. The rational culture emphasizes achieving competitive advantage and people are rewarded for acquiring the needed resources to meet organizational goals. Finally, the hierarchical culture emphasizes stability, rules, policies, and regulations. People are rewarded for adhering to rules and regulations, and leaders are supported for emphasizing order and achieving predictability in operations. Every organization's culture will be reflective of these four ideal types to some degree, and the Competing Values framework allows one to assess where a particular organization stands with regard to these different dimensions.
In understanding how organizational culture is related to physician satisfaction, it is important to recognize that physicians are a highly professionalized group. Cultures that conflict with the norms and values of the medical profession are likely to be associated with low levels of physician satisfaction because there will be a dissonance between the cultures of the organization and how physicians have been socialized to operate as professionals. One of the key hallmarks of any profession is autonomy or control (Abbott 1988
; Freidson 1994
). The degree to which the medical profession has defended its professional authority has been well documented (Starr 1982
). As professionals, physician's value autonomy over how they do their work, freedom from external control, and voice in how the organizations they work in are managed.
Accordingly, group culture will be positively associated with physician satisfaction, because such cultures emphasize inclusion and shared decision making authority. Such forms of participation and authority are likely to be consistent with physicians' professional values and norms. Certainly, a case could be made that physicians would prefer work environments where they could function as nonparticipants in organizational life, and that a group culture may run contrary to this desire. However, given those physicians who work in group practice settings self-selected into such organizational arrangements, we believe that group culture will have a positive effect on physician satisfaction. Therefore:
- H1: A group-oriented culture in physician group practices will be positively associated with all dimensions of satisfaction of individual physicians who work in such groups.
A hierarchical culture emphasizes stability, rules, and regulations and can be thought of as the degree to which the organization's culture reflects the norms and values of a bureaucracy. This culture, with its emphases on structure, formalization, rule-enforcing, and stability, conflicts with the professional status of physicians, and the attendant need for physician autonomy and control.
- H2: A more hierarchically oriented culture in physician group practices will be negatively associated with all dimensions of satisfaction of individual physicians who work in such groups.
The developmental, entrepreneurial, or risk-taking aspects of the culture of a group practice may be congruent with the ability of the group to effectively respond to environmental changes. Given the competitive environment of many group practices, and the increased demands on physician practices to incorporate more technology, an organization whose culture emphasizes change and adaptation to the external environment may lead to increased physician satisfaction, particularly with respect to the technological and competitive capabilities of the groups.
- H3: A more developmental culture in physician group practices will be positively associated with satisfaction with the technological and competitive capabilities of the group among individual physicians who work in such groups.
A rational or task-oriented culture emphasizes efficiency and productivity. Such values may run counter to the desire of physicians to control their allocation of time, particularly with respect to the amount of time they spend with patients. For example, a more rational culture might pressure physicians to “churn” their patients. Practice competitiveness and price competition are two dimensions of satisfaction that may be affected by a rational culture. Practice competitiveness, which emphasizes the group's image, reputation, quality, uniqueness, skill of its physicians, and loyalty of patients and referring physicians, is likely to be negatively associated with a culture that stresses productivity and efficiency because such a culture will make these objectives harder to achieve in a manner consistent with the professional norms and interests of physicians. On the other hand, satisfaction with price competition, which relates to a group's service costs and its ability to compete on price, is likely to be positively associated with a rational culture because such a culture may allow the groups to achieve lower service costs and a greater ability to compete on price.
- H4: A more rational culture in physician group practices will be negatively associated with satisfaction with practice competitiveness and positively associated with satisfaction with price competition among individual physicians practicing in such groups.