Haute Culture: How open culture breaks through old-fashioned work patterns in healthcare

This thesis used a socio-psychological perspective to explore the concept of open culture and how entrenched work patterns influence it. Chapter 1 outlines the current state of organisational culture studies in healthcare and introduces key concepts: organisational culture, patient safety culture, leadership, speaking up, and the healthcare context. The research is guided by five core questions across three parts: Part 1 – What an open culture entails Research question 1: What do we really assess with organisational culture tools in healthcare? Chapter 2 presents a systematic umbrella review of 127 instruments used to assess culture in healthcare. Most tools are quantitative and focus on tangible dimensions such as leadership, communication, and teamwork. However, they often fail to uncover deeper cultural layers—such as trust, psychological safety, power dynamics, and moral values. The chapter concludes that new tools are needed to better identify intangible aspects and diagnose non-open cultures more effectively. Research question 2: What is open culture? What are its elements, and how does it relate to patient safety culture? Chapter 3 describes a modified Delphi study conducted to define the elements of an open culture in hospitals. The resulting framework includes 37 elements—both tangible (e.g. leadership, communication systems, organisational processes) and intangible (e.g. psychological safety, trust, moral values, power). The study shows that open culture extends beyond the scope of patient safety: open culture is a transparent and inclusive organisational environment where employees and leaders adopt an open mindset and attitude. It is defined by transparent structures and processes that engage patients, fostering trust, respect, and appreciation for diverse perspectives, with psychological safety at its core. Leaders serve as supportive role models, maintaining high moral and ethical standards, avoiding abuse of power, blame, or shame, thereby promoting diversity, open communication and continuous training and development. Part 2 – How traditional hierarchies undermine open culture and what leadership is needed Research question 3: Which leadership style is needed in the evolving healthcare landscape? Chapter 4 examines stakeholder perspectives on the “Physicians in the Lead” (PIL) strategy, a leadership model rooted in value-based care. Although PIL aims to improve efficiency, it often reinforces a biomedical focus and excludes psychosocial perspectives. Stakeholders report that PIL limits openness and suggest a “team in the lead” model that includes broader input—from nurses, patients, and others. They also recommend extramural coordination centres to support patients holistically, beyond the hospital walls. Part 3 – Elements for successful implementation of open culture Research question 4: What matters most to stakeholders, including patients, during transitions of care? Chapter 5 uses a mixed-methods approach—interviews and surveys—to explore transitions of care. The findings reveal low satisfaction and confusion during handovers. Key improvements include preparing patients earlier, boosting leadership skills among patients and families, and establishing clear interprofessional roles during transitions. Research question 5: Which cultural elements support interprofessional learning and encourage speaking up? Chapter 6 offers insights from a qualitative study in a Dutch hospital. Six cultural elements were identified that influence interprofessional speak-up behaviour: shared vision, functional hierarchy, strong interpersonal relationships, clarity about when to speak up, open-mindedness, and embedding cultural values in learning contexts. Hierarchy itself was not a barrier—when marked by respect, it could support psychological safety. Transformational and humble leadership were seen as crucial enablers. Final reflections Chapter 7 synthesises the findings, concluding that current culture tools fail to detect hidden dynamics like fear or shame. The thesis advocates for new approaches to identify and shift from non-open to open cultures. Strategies such as shared governance, shared leadership, interprofessional learning, and inclusive decision-making are recommended. The ADKAR model is presented as a practical tool for implementation.