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The most widely cited definition of an Learning Health System – from the Institute of Medicine (IoM) [120] – discusses an alignment of science, informatics, incentives and culture for continuous improvement and innovation.

The need for a culture change is often noted to include learning, innovation, information use, sharing and implementation and research [146]. More broadly, there are frequent calls to change the culture of health and society [147]. Organisational culture has been categorised in three layers [147]:

  • Visible manifestations: The distribution of services and roles, the physical layout of facilities, established pathways of care, staffing practices, reporting arrangements, dress codes, reward systems, established ways of tackling quality improvement and clinical governance.
  • Shared ways of thinking: Values and beliefs used to justify the visible manifestations and the rationales for doing things differently, such as prevailing views on autonomy, dignity, evidence and service improvement.
  • Deeper shared assumptions: The unconscious underpinnings of day-to-day practice, such as assumptions about the role of patients, carers and different professionals.

These layers are learned, shaped and reinforced through training and experience. There may be subgroups with different cultures within any given system (eg clinicians and managers). Such cultures can help deliver organisational goals; on the other hand, they can undermine drives for change. This is a fundamental source of complexity within healthcare. The multidisciplinary, often multi-agency nature of a Learning Health System increases the risk of culture clashes [19].

There are many quantitative tools for assessing organisational culture, but they often lack evidence. There is no one tool that is appropriate in all circumstances [148]. Another approach, which recognises the constraints of measuring complex systems, is to explore culture through narrative [149].

While culture is clearly important, it is not always possible to determine a causal relationship with performance within a complex system. Equally, it is not easy to influence culture in a predictable way. Even so, the King’s Fund has produced a tool to help organisations assess their culture and identify targets for improvement in six areas [150]:

  • Inspiring vision and values: Leaders should communicate an inspiring, ambitious vision.
  • Goals and performance: Goals should be set at every level, from board to frontline staff, then measured on patient outcomes and patient feedback.
  • Support and compassion: Everyone should treat colleagues with respect, care and compassion.
  • Learning and innovation: Teams should take time to review, debate and improve performance. Quality and safety improvement should be a priority for all. Everyone should welcome feedback.
  • Effective teamwork: Leaders should ensure effective teamwork and inter-teamwork, within and across organisational boundaries.

Collective leadership: Everyone (including patients) should take responsibility for the success of the organisation, not just a few leaders a the top.