Overcoming barriers to leadership and cultural transformation in health

Overcoming barriers to leadership and cultural transformation in health


By Penelope Cottrill and Richard Ainley

Directors of companies and not-for-profits need new skills. Where previously boards had focused on strategy, performance and appointing the CEO, they now need to do all that as well as dive deep into the leadership and the culture of the organisation they oversee.

For health services organisations, culture and leadership are challenging to monitor and change because they have been a lower priority than patient outcomes and are not consistently captured by existing performance metrics. But health services boards that fail to think seriously about culture and leadership are doing their organisation a disservice, and associated governance failures may put the organisation in reputational and even legal jeopardy.

Thankfully for health services organisations there is tremendous upside to investing in culture and leadership, beyond minimising risks. There is strong evidence that empathetic leadership and a positive collaborative culture lead to better patient outcomes as well as improved quality and safety.

UK health researcher The King’s Fund in 2015 linked leadership with patient satisfaction, patient mortality, organisational financial performance, staff well-being, engagement, turnover and absenteeism, and overall quality of care.[1] It is no surprise many health services organisations are exploring ways to strengthen their culture and leadership, within the tight operational, financial and other constraints of the health sector.

For some organisations efforts to improve culture and leadership are piecemeal – a seminar here and an online training module there – without an ongoing focus that will improve performance. A sustained uplift in clinical, financial and organisational outcomes requires local focus and a coordinated investment of resources.

But achieving those sustained improvements is not easy. Despite the best intentions, many health services organisations have found significant barriers to strengthening their leadership and cultural development.

From Nous Group’s extensive work with health services organisations, including health networks, hospitals and bureaucracies, we have found pathways to overcome eight common barriers to change. Each give guidance to health sector leaders looking for somewhere to start.

Time and funds are scarce

1. Leadership and cultural development should be considered an investment rather than an expense. In a cost-constrained environment, many health services organisations lack the resources to support leadership and cultural development. The people functions that tend to commission this kind of work lack a budget allocation for that purpose. Health services leaders tend to perceive that a dollar spent on staff development is a dollar not spent elsewhere, so they would rather direct funds to areas that have an unambiguous impact on improving patient experience.

Organisations might be better off conceptualising their leadership development as an investment rather than an expense, with organisational culture and patient outcomes going hand in hand. For example, a large Victorian private health service has invested in identifying talent and developing leadership. The opportunities it has created have become a strength of its employee value proposition and helped it to retain high-performing leaders. Ultimately good leaders provide safe quality care and better patient outcomes.

2. Professional development needs to fit the tempo of health service organisations. The service demand and operating tempo of health services mean it is impractical for health workers to take time away from their patients for, say, a multi-day offsite leadership development seminar. Staff lack time for professional development, which means traditional development in which participants can immerse themselves free from business-as-usual concerns are not suited to the health context.

Far more achievable is development that fits the rhythm of staff, such as bite-sized learning at the start or end of a shift, or online learning that can be done during quiet times. This is likely to increase engagement, while also giving staff peace-of-mind that they are meeting their obligations to patients. For example, one Australian healthcare provider is using evidence-informed culture-shaping interventions at either end of each shift to strengthen culture with a focused and ongoing light touch. Another is piloting the use of a microlearning platform that pushes out learning scenarios and takes staff just a few minutes a day.

3. Smaller workforces can collaborate to overcome lack of scale for cost-effective development. For many smaller healthcare organisations, particularly with staff in regional areas, it can be prohibitively expensive to source and make available quality leadership and organisational development. The small number of staff mean the cost per participant is higher, and this expenditure becomes harder to justify.

These smaller organisations may find it beneficial to work together, possibly under guidance from their state or territory health department, to develop bulk training activities that can be rolled out to smaller workplaces. For example, a health training and education provider is exploring the use of virtual reality and other technologies to deliver training using scenarios at workplaces across the state. And the UK’s National Health Service has chosen to invest considerable amounts at a system level in its compassionate leadership training despite operating with a tight budget and a high level of public scrutiny.[2]

Suitable tools are difficult to access

4. Organisations need to know the current state of their culture. The boards and leadership of health services organisations are often only vaguely aware of the culture in their organisation, partly because metrics for an organisation’s culture are underdeveloped. But things are changing, and in future health leaders may be held to account for patient experience and cultural indicators in the same way they are for clinical measures.

These organisations could benefit from a cultural diagnostic tool, matched to the size of their organisation, that takes the pulse of the workforce, giving board members greater oversight of culture. For example, NSW Health has prioritised developing a cultural diagnostic tool to give leaders greater visibility and control, while South West Sydney, a local health district, engaged with over 1,200 people to chart a five-year road map to transform how its patients, consumers, staff and communities experience the organisation and services.

5. Overseas and generic modules must be adapted to the Australian health context. Around the world health services organisations are creating tools that seek to develop culture and leadership, but these typically reflect local circumstances, and have limited relevance for health service organisations in Australia unless they are tailored. As well as obvious cultural differences between countries, there is also the different context for delivering healthcare – while some countries have a commercially driven system, others have a community model. This means that rolling out overseas training may have limited effectiveness and face staff resistance.

Learning modules, diagnostics and tools from overseas need to be adapted to Australian culture, conditions and work environment in order to resonate with a local workforce. This may involve changing the messages, examples and terminology, while keeping the essence of the training. For example, Western Health in Victoria adapted a US program to promote civility in the workplace, prompting a magazine cover story that wrote of how it “re-energised its workforce with kindness”.[3]

Implementation can face resistance

6. Deliver leadership and cultural interventions as the new pathway to meet compliance obligations. Given the high stakes involved, health work faces strict compliance obligations and rising expectations regarding safety and quality. Compliance and reporting are part of life for health services. Fulfilling these obligations can feel like a straightjacket, stunting innovation and leaving limited scope for exploring different ways of working.

It may be more helpful to think of leadership and cultural transformation as a new pathway to achieve better compliance, given they have been found to achieve clinical improvements. Innovation and strict compliance need not be in conflict. For example, an Australian cancer control organisation is rolling out a three-year cultural transformation program, which is helping it to achieve strong compliance through a culture that includes clear accountabilities.

7. Overcome workforce resistance by challenging traditional mandatory participation approaches. Often staff are reluctant to engage in development activities if they are mandatory, especially if they involve commitments outside regular work hours. While the resistance may be blunted if the exercise is an essential requirement for accreditation, it may remain acute for leadership and culture development. There is evidence that cultural programs need to be opt-in to be successful.

Many organisations have found they get strong engagement in their development activities by using an executive leadership group (for which participation is voluntary) to drive it. This allows staff with an interest in the topic to act on it, while minimising the mandatory obligations for reluctant staff. For example, when the Cleveland Clinic in the United States was rolling out its cultural change program, its training was launched by invitation, rather than by a mandate, to executives, leaders and managers.[4]

8. Align, rather than unify, sub-cultures within the organisation. Many health workforces are spread across multiple sites and/or services, each with their own sub-culture that reflects local demographics (of staff and consumers), history and conditions. Within a hospital, each ward and each team within a ward can have its own subculture. And medical hierarchies mean that changing the culture in just one part of the workforce is unlikely to be effective. It can be tempting to seek to unify them all into a single culture determined centrally, but this can be unrealistic given that operating context and leadership styles vary.

Instead, organisations should focus on aligning sub-cultures to its defined strategy, values and cultural vision. Recognising the unique starting point of the organisation’s sub-cultures, and their relative strengths and levers for change, will significantly impact on the achievability of initiatives, targets and desired states. In other words, it may be more effective to encourage multiple worksites or services to orient themselves in the same direction, even while they preserve local elements.

Many health service organisations experience a combination of these barriers and will for some time ahead, so it is essential to develop strategies to make leadership and cultural development robust enough to withstand them.

One way organisations are achieving this is by experimenting with agile and adaptive leadership and cultural development programs, which typically deliver more faster and at lower cost. By testing at a small scale through pilot programs, organisations can build the case for further investment.

Another successful alternative is to invest in leadership and culture as hallmark of the organisation, so it is understood by stakeholders including clients, staff and potential future staff. Both approaches benefit from actively leveraging investments at the health-system level and translating them into benefits for the organisation.

By staying firm on the expected outcomes, but being flexible and iterative on the process, health organisations are overcoming common barriers to leadership and cultural transformation. Done right, these approaches to culture and leadership will deliver benefits to patients and staff, and ensure that board members are fulfilling their emerging obligations.

Get in touch to find out how Nous can help with your healthcare organisation’s cultural and leadership development.

Written by Penelope Cottrill and Richard Ainley during their time as Nous Principals.


[1] The King’s Fund, “Leadership and leadership development in health care: The evidence base”, 25 February 2015

[2] Richards, Sir Mike, “Driving improvement through compassionate leadership and staff engagement”, NHS, 11 July 2017

[3] HRM magazine, September 2018

[4] O’Connell, Michael, “Cleveland Clinic’s Culture Focuses on Patients First”, Association for Talent Development, 24 August 2015