Organizational culture and quality improvement in healthcare: A qualitative case study using the competing values framework

This study examines how organizational culture shapes the effectiveness and sustainability of Quality Improvement (QI) initiatives in healthcare. We conducted a qualitative embedded case study at a Danish university hospital, exploring six clinical units across surgery, internal medicine, and related specialties. Participants included managers, frontline staff, and QI facilitators. Guided by the Competing Values Framework (CVF), we analyzed how four cultural archetypes: Clan, Adhocracy, Market, and Hierarchy—influenced QI processes across initiation, execution, and evaluation phases. Data included 15 semi-structured interviews and internal QI documents. Reflexive thematic analysis combined deductive CVF-based coding with inductive insights, while researcher positionality and reflexivity were addressed through team dialogue and systematic documentation of interpretive choices. Findings show that culture shaped implementation pathways. In Clan-oriented units, staff involvement fostered ownership: “The more we involve staff in shaping the process, the more ownership they take, and the changes stick.” Market cultures emphasized performance metrics but risked shallow engagement, while Hierarchy and Adhocracy cultures provided structure and innovation but faced limits in sustainability. The study demonstrates that tailoring QI strategies to cultural contexts enhances engagement and outcomes. We reflect on the CVF’s limits in capturing cultural complexity and suggest complementary frameworks such as CFIR to strengthen conceptual grounding.