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RCGP Quick guide: Context and Culture

Context can be defined as the ‘environment’ in which your quality improvement intervention is to be introduced.
It includes the culture of your organisation, which reflects the values, beliefs and behaviours of the people you work with, which have developed slowly over years.
Download RCGP Quick guide: Context and Culture
Variations in context influence the success or failure of your intervention, no matter how well planned it may be. Breaking down ‘context’ into its component parts can help you to understand it.
One way of doing this is to consider context as ‘Inner’ (related to the practice or organisation in which the intervention is introduced) and ‘External’ (related to factors in the world at large).
‘Inner Context’ Factors
Culture – A culture that is conducive to quality improvement is one where people:

  • Support each other.
  • Are satisfied with their work.
  • Give high priority to quality and are prepared to recognise when things could be improved.
  • Welcome patient feedback in all its forms – compliments, complaints and experiences – as an opportunity to see their service through the eyes of the users, and to learn from this.
  • Operate a ‘no blame’ system when looking for root causes when things go wrong.
  • Are happy to be involved in looking for solutions.
  • Are prepared to experiment with new ideas.
  • Believe it is worth investing time to improve.

Leadership – Quality improvement is more likely if the leaders of the practice or organisation:

  • Believe that involving staff and patients in planning improvements will create a better outcome.
  • Have skills that allow for maximum participation and effective meetings.
  • Inspire and motivate the team.
  • Encourage members of the team to take the lead.
  • Can support the team through challenging times that often accompany change.

Team working – Success is more likely if the practice or organisation:

  • Recognises that good teamwork is essential and that each individual has a role to play.
  • Invests time in developing the skills of the whole team.

Capacity – Success is more likely if the practice or organisation has:

  • The financial and human resources needed to undertake the improvement.
  • Methods of identifying those resources.
  • Suitable equipment available.
  • The time available for the programme to realistically achieve its goals. You may need to consider your time management.

‘External Context’ Factors
Evidence base – Success is more likely when:

  • Planning the intervention has included looking for what has worked in other organisations. You may need to critically appraise such evidence, looking in particular at how a given context might differ from your own.
  • Evidence-based guidelines are followed.

Political/regulatory – Success is more likely when:

  • Your quality improvement intervention is compatible with the wider political priorities. Consider, for example, changes to contracts, performance measures, national frameworks and policies.
  • Your intervention is compatible with the requirements of regulatory bodies, such as the Care Quality Commission (CQC), General Medical Council (GMC), and GP contract.

Technological – Success is more likely when:

  • Effective IT and communication devices support your intervention, e.g. for data analysis and visual displays of progress.
  • Wide use is made of all media systems to sustain and spread your learning.

Social/demographics – Success is more likely when:

  • Your quality improvement intervention is appropriate for the demographics of age, gender, race, religion, and socio-economic status of the population affected.
  • It follows a social trend. An example of this would be a general move towards ‘patient-centred’ care either from multiple organisations or from a wave of enthusiasm on social media for patient involvement in service design.
  • Your quality improvement intervention is appropriate for the prevailing economic climate.

Understanding your context at the very outset of your initiative will help it to thrive.
Where you identify elements with the potential to be detrimental to your success, you can devise strategies to accommodate or ameliorate them.
Organisational culture can sometimes be slow to change, but a consistent approach from the leaders of the organisation will have a positive impact over time.
How to
Taking part in exercises to explore your context can help to influence organisational culture positively. They provide an opportunity to achieve a shared understanding of the challenges facing the organisation so that people at all levels can feel heard and valued.
During the sessions it is important to allocate enough time to explore the solutions to the context challenges. Optimism is an important driver for a successful outcome.
These four help to consider and understand context and culture. Choose those most relevant to the given situation.
Context checklist
This breaks down context into eleven elements. Consider each in turn and decide whether they are applicable to your situation, and whether any action is required.
Forcefield analysis
This assesses which aspects of context are aiding or hindering the project. The chart is made up of two columns: one for driving forces and one for restraining forces. Brainstorm what the forces are and score the strength of each from 1 – 10. Then use the forcefield analysis to devise a strategy that accommodates or increases the driving forces and that either mitigates or decreases the strength of the restraining forces
SWOT Analysis
This involves considering your organisation or team in terms of its ‘Strengths’, ‘Weaknesses’, ‘Opportunities’ and ‘Threats’. This exercise is very useful in bringing together individuals with different viewpoints, so that they can air their opinions and concerns and at the same time hear why others are excited by a project. It gives all involved a chance to try to address the weakness and avoid the threats.
When administered within the practice these can help assess the culture. Although most have been designed with safety in mind, they are still relevant for quality as a whole. Examples like the Manchester Patient Safety Framework and Safequest tool can be found on the RCGP Patient Safety Toolkit webpage.