To read this content please select one of the options below:

Sustaining organizational culture change in health systems

Cameron David Willis (Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, School of Population and Public Health, University of British Columbia, Vancouver, Canada and School of Population Health, The University of Adelaide, Australia)
Jessie Saul (Associate, North American Research and Analysis, InSource Research Group, Vancouver, Canada)
Helen Bevan (Chief Transformation Officer, NHS Improving Quality, NHS Horizons team, National Health Service, Coventry, UK)
Mary Ann Scheirer (Consultant, Scheirer Consulting, Princeton, New Jersey, USA)
Allan Best (InSource Research Group)
Trisha Greenhalgh (Barts and the London School of Medicine and Dentistry, London, UK)
Russell Mannion (University of Birmingham)
Evelyn Cornelissen (Department of Family Practice, Faculty of Medicine, University of British Columbia, Kelowna, Canada)
David Howland (Senior Policy Analyst, Strategy and Innovation Branch, Saskatchewan Ministry of Health, Canada)
Emily Jenkins (School of Nursing, University of British Columbia, Vancouver, Canada)
Jennifer Bitz (InSource Research Group)

Journal of Health Organization and Management

ISSN: 1477-7266

Article publication date: 21 March 2016




The questions addressed by this review are: first, what are the guiding principles underlying efforts to stimulate sustained cultural change; second, what are the mechanisms by which these principles operate; and, finally, what are the contextual factors that influence the likelihood of these principles being effective? The paper aims to discuss these issues.


The authors conducted a literature review informed by rapid realist review methodology that examined how interventions interact with contexts and mechanisms to influence the sustainability of cultural change. Reference and expert panelists assisted in refining the research questions, systematically searching published and grey literature, and helping to identify interactions between interventions, mechanisms and contexts.


Six guiding principles were identified: align vision and action; make incremental changes within a comprehensive transformation strategy; foster distributed leadership; promote staff engagement; create collaborative relationships; and continuously assess and learn from change. These principles interact with contextual elements such as local power distributions, pre-existing values and beliefs and readiness to engage. Mechanisms influencing how these principles sustain cultural change include activation of a shared sense of urgency and fostering flexible levels of engagement.

Practical implications

The principles identified in this review, along with the contexts and mechanisms that influence their effectiveness, are useful domains for policy and practice leaders to explore when grappling with cultural change. These principles are sufficiently broad to allow local flexibilities in adoption and application.


This is the first study to adopt a realist approach for understanding how changes in organizational culture may be sustained. Through doing so, this review highlights the broad principles by which organizational action may be organized within enabling contextual settings.



The authors wish to acknowledge Craig Mitton and Mimi Doyle-Waters for their help in shaping the directions of this project and searching/retrieving relevant publications/ documents. The authors also wish to acknowledge the members of this project ' s expert and reference panels for their help in guiding this review and interpreting study findings.

Competing interests: The methodology described in this paper is designed to bridge multisectoral barriers to knowledge use. Although the authors have academic interest in this methodology, they also engage in the methodology as consultants on a range of projects. Some of these projects are funded by grants managed by universities, some through contracts to the InSource Research Group. InSource was created to provide a vehicle for responding to policy maker needs for knowledge synthesis in a more timely way than is possible through the normal grant funding process. In the interests of transparency and to address conflict of interest concerns, it is very possible that publication of this paper could enhance InSource ' s reputation and could result in future contracts for the company. It must also be noted that two of the 11 authors ( JB and AB) are InSource directors, and another two ( JS and CW) have worked, or in the future may work, under contract to InSource. In sum, the authors may receive financial gain in the future from the publication of this manuscript. In our view, the conflict between academic and business interest in this area is unavoidable, and bridging the gap between these interests is vital to supporting the research to policy and practice process. The evidence is clear that knowledge uptake is poor without effective structures to support the process. No other authors have any conflicts of interest to declare.

Author contributions: CDW assisted in establishing reference and expert panels, developing research questions and directions, developing the search strategy, screening relevant articles, extracting data, developing/validating synthesized themes and led the drafting/revisions of the manuscript. JS assisted developing research questions and directions, led the development of data extraction tools, extracted data, synthesized themes across included studies and helped draft/revise the manuscript. EC and EJ assisted in developing data extraction tools, extracted data using these tools, assisted in interpreting synthesized themes and contributed to the drafting of the manuscript. JB provided project management support, assisted in establishing reference and expert panels, screened documents, extracted data and helped draft/revise the manuscript. AB assisted in establishing reference and expert panels, assisted in developing research questions and directions, finalizing data collection and extraction processes, and contributed to the drafting/revising of the manuscript. MAS, HB and RM assisted in interpreting results from the thematic synthesis and drafting/revising of the manuscript. TG chaired the expert panel for the duration of the project and assisted in interpreting results from the thematic synthesis and drafting/revising of the manuscript. DH chaired the reference panel, assisted in interpreting results from the thematic synthesis and drafting/revising of the manuscript.

Funding: This study was supported through a Knowledge Synthesis Grant from the Canadian Institutes of Health Research (Project ID: FRN 119789).


Willis, C.D., Saul, J., Bevan, H., Scheirer, M.A., Best, A., Greenhalgh, T., Mannion, R., Cornelissen, E., Howland, D., Jenkins, E. and Bitz, J. (2016), "Sustaining organizational culture change in health systems", Journal of Health Organization and Management, Vol. 30 No. 1, pp. 2-30.



Emerald Group Publishing Limited

Copyright © 2016, Emerald Group Publishing Limited

Related articles