Design and objectivesEvery organisation has a unique culture. There is a widely held view that a positive organisational culture is related to positive patient outcomes. Following the Preferred Reporting Items for Systematic Review and Meta-Analyses statement, we systematically reviewed and synthesised the evidence on the extent to which organisational and workplace cultures are associated with patient outcomes.SettingA variety of healthcare facilities, including hospitals, general practices, pharmacies, military hospitals, aged care facilities, mental health and other healthcare contexts.ParticipantsThe articles included were heterogeneous in terms of participants. This was expected as we allowed scope for wide-ranging health contexts to be included in the review.Primary and secondary outcome measuresPatient outcomes, inclusive of specific outcomes such as pain level, as well as broader outcomes such as patient experience.ResultsThe search strategy identified 2049 relevant articles. A review of abstracts using the inclusion criteria yielded 204 articles eligible for full-text review. Sixty-two articles were included in the final analysis. We assessed studies for risk of bias and quality of evidence. The majority of studies (84%) were from North America or Europe, and conducted in hospital settings (89%). They were largely quantitative (94%) and cross-sectional (81%). The review identified four interventional studies, and no randomised controlled trials, but many good quality social science studies. We found that overall, positive organisational and workplace cultures were consistently associated with a wide range of patient outcomes such as reduced mortality rates, falls, hospital acquired infections and increased patient satisfaction.ConclusionsSynthesised, although there was no level 1 evidence, our review found a consistently positive association held between culture and outcomes across multiple studies, settings and countries. This supports the argument in favour of activities that promote positive cultures in order to enhance outcomes in healthcare organisations.

Rationale, aims, and objectives: The field of implementation science has developed in response to slow and inconsistent translation of evidence into practice. Despite utilizing increasingly sophisticated approaches to implementation, including applying a complexity science lens and conducting realist evaluations, challenges remain to getting the kinds of outcomes hoped for by implementation efforts. These include gaining access and buy-in from those implementing the change and accounting for the influence of local context. One emerging approach to address these challenges is embedded implementation research-a collaborative, adaptive approach to improvement. It involves researchers and implementers working together in situ from the outset of, and throughout, an implementation project. Both groups can benefit from the collaboration: it increases the rigor of evaluation, provides opportunities to improve the intervention through direct feedback, and promotes better on-the-ground understanding of the change process. We aimed to examine the potential benefits, and some of the challenges, of increased embeddedness. Method:We performed a multi-case analysis of implementation research projects that varied by degree of embeddedness.Results: Embedded implementation research may offer a range of advantages over dichotomized research-practice designs, including better understanding of local context and direct feedback to improve the implementation along the way. We present a model that spans four approaches: dichotomized research-practice, collaborative linking-up, partially-embedded, and deep immersion. Conclusion: Embedded implementation research approaches hold promise in comparison to traditional dichotomized-research practice designs, where the research is external to the implementation and conducts a summative evaluation. We are only beginning to understand how such partnerships operate in practice and what makes them successful. Our analysis suggests the time has come to consider such approaches. Box 1 : Terminology Action research (or participatory action research): Researchers engage health professionals in the design and implementation of research,working with them as opposed to externally studying them. 42,43 Co-located: The researcher is physically located within the setting of the implementation initiative to conduct collaborative research with implementers and end-users. 44 Co-creation: See Co-production of knowledge. 10Co-production of knowledge: Concerns the production and spread of knowledge in the context it will be used through the collaboration of relevant stakeholders. Co-production may occur at the design, implementation, or evaluation stages of a program (co-design, co-evaluation, and co-implementation, respectively). 19,22 Engaged scholarship: Research conducted in collaboration with stakeholders, eg, implementers and practitioners, to gain insight into the context and phenomenon being studied. 45 Insider academic research: Research carried out by someone employed within the organization under study. ...

IntroductionThe sustainability of healthcare delivery systems is challenged by ageing populations, complex systems, increasing rates of chronic disease, increasing costs associated with new medical technologies and growing expectations by healthcare consumers. Healthcare programmes, innovations and interventions are increasingly implemented at the front lines of care to increase effectiveness and efficiency; however, little is known about how sustainability is conceptualised and measured in programme evaluations.ObjectivesWe aimed to describe theoretical frameworks, definitions and measures of sustainability, as applied in published evaluations of healthcare improvement programmes and interventions.DesignSystematic integrative review.MethodsWe searched six academic databases, CINAHL, Embase, Ovid MEDLINE, Emerald Management, Scopus and Web of Science, for peer-reviewed English journal articles (July 2011–March 2018). Articles were included if they assessed programme sustainability or sustained outcomes of a programme at the healthcare system level. Six reviewers conducted the abstract and full-text review. Data were extracted on study characteristics, definitions, terminology, theoretical frameworks, methods and tools. Hawker’s Quality Assessment Tool was applied to included studies.ResultsOf the 92 included studies, 75.0% were classified as high quality. Twenty-seven (29.3%) studies provided 32 different definitions of sustainability. Terms used interchangeably for sustainability included continuation, maintenance, follow-up or long term. Eighty studies (87.0%) clearly reported the timepoints at which sustainability was evaluated: 43.0% at 1–2 years and 11.3% at <12 months. Eighteen studies (19.6%) used a theoretical framework to conceptualise or assess programme sustainability, including frameworks that were not specifically designed to assess sustainability.ConclusionsThe body of literature is limited by the use of inconsistent definitions and measures of programme sustainability. Evaluations of service improvement programmes and interventions seldom used theoretical frameworks. Embedding implementation science and healthcare service researchers into the healthcare system is a promising strategy to improve the rigour of programme sustainability evaluations.

ObjectivesTo examine the basis of multidisciplinary teamwork. In real-world healthcare settings, clinicians often cluster in profession-based tribal silos, form hierarchies and exhibit stereotypical behaviours. It is not clear whether these social structures are more a product of inherent characteristics of the individuals or groups comprising the professions, or attributable to a greater extent to workplace factors.SettingControlled laboratory environment with well-appointed, quiet rooms and video and audio equipment.ParticipantsClinical professionals (n=133) divided into 35 groups of doctors, nurses and allied health professions, or mixed professions.InterventionsParticipants engaged in one of three team tasks, and their performance was video-recorded and assessed.Primary and secondary measuresPrimary: teamwork performance. Secondary, pre-experimental: a bank of personality questionnaires designed to assess participants’ individual differences. Postexperimental: the 16-item Mayo High Performance Teamwork Scale (MHPTS) to measure teamwork skills; this was self-assessed by participants and also by external raters. In addition, external, arm's length blinded observations of the videotapes were conducted.ResultsAt baseline, there were few significant differences between the professions in collective orientation, most of the personality factors, Machiavellianism and conservatism. Teams generally functioned well, with effective relationships, and exhibited little by way of discernible tribal or hierarchical behaviours, and no obvious differences between groups (F (3, 31)=0.94, p=0.43).ConclusionsOnce clinicians are taken out of the workplace and put in controlled settings, tribalism, hierarchical and stereotype behaviours largely dissolve. It is unwise therefore to attribute these factors to fundamental sociological or psychological differences between individuals in the professions, or aggregated group differences. Workplace cultures are more likely to be influential in shaping such behaviours. The results underscore the importance of culture and context in improvement activities. Future initiatives should factor in culture and context as well as individuals’ or professions’ characteristics as the basis for inducing more lateral teamwork or better interprofessional collaboration.