Importance of organizational culture: a model for increased engagement.

Dear editor

We read with great interest the article by Nilsen et al,1 discussing how nursing leaders perceive their interactions and support levels from both peers and those in more senior leadership positions – in this case the municipal health director. Of particular interest was the conclusion of the paper, calling for greater coherence between different levels of leadership in the Norwegian health care setting.

The paper highlights a key difficulty in ensuring a cohesive leadership unit, to effectively manage increasingly scarce health care resources. The “disconnect” between leadership levels is not an uncommon situation in health care settings.2 One particularly interesting method to overcome this disconnect has been highlighted in the health care management literature in the use of written commitments or “compacts”.3,4

These compacts have been used in the Virginia Mason Medical Centre achieving increased engagement from clinical staff following a call from the upper-level management to turn around this struggling hospital. Leaders insisted on a “written physician compact” and separate “management compact” ensuring that both leaders and lower-level staff had an understanding of what was required of them and a psychological stake in organizational success, thus increasing engagement between all levels of staff. The success of these compacts, coupled with the introduction of the Toyota production system, resulted in better staff satisfaction and also in large financial savings for the organization.5,6

The use of compacts – written and signed statements declaring what is expected of a certain group of employees – is a cheap and potentially effective way of ensuring that each group of staff knows what is expected of them, and when used correctly has the potential to bridge the disconnect between different levels of leaders.3

Dear editor,

Thank you very much for your very interesting and highly relevant comment on our article.1 We acknowledge the organizational challenge in the health care field, especially in the municipal health care service, where 1) the geographical distance between peers and between the management levels in itself forms a barrier, and 2) there is a lack of regular and natural meeting places for both planned and ad hoc contact.

We welcome suggestions for interventions to ease the communication and cooperation between the management levels and, at the same time, we anticipate that multiple interventions of both structural and cultural nature will be necessary. Your suggested intervention will, in our opinion, raise consciousness with regard to the importance of mutual information and increase the level of engagement and possibly the support from senior management. However, it represents a focus on the information and reflections that can be codified. As such, it only partly solves the problem since it omits focus on unplanned exchange and on the sharing of tacit knowledge.

Furthermore, our empirical material is drawn from a municipality, whereas your example is from a hospital. As such, these two contexts are quite different, and we assert that it complicates the issue even more in a municipality, which is an umbrella organization, made up of several geographically dispersed organizations.

More research is needed, and we anticipate that the same challenges apply to other contexts such as schools, and that the health care field may learn from research in these other fields.