Influence of organizational culture in the quality management of a teaching hospital*

Objective: to analyze the influence of symbolic elements of organizational culture in quality management and patient safety. Methods: qualitative research, using the case study strategy. A total of 18 intentionally chosen managers participated. Data collection took place through observation, document analysis and interviews and, subsequently, it was subjected to thematic content analysis. Results: the following symbolic elements were identified: the strength of the university’s culture, the power of the doctor, the power of the teacher, the steadiness and professional autonomy and collegiate decisions. Such elements influence the management of patient quality and safety, as there is low adherence to change proposals. Conclusion: the symbolic elements maintain the traditional work practices, shared by the group, which make it difficult to adhere to the proposals for quality management and patient safety. Descriptors: Organizational Culture; Quality Management; Hospitals, University. RESUMO Objetivo: analisar a influência dos elementos simbólicos da cultura organizacional na gestão da qualidade e segurança do paciente. Métodos: pesquisa qualitativa, utilizando a estratégia de estudo de caso. Participaram 18 gestores escolhidos de forma intencional. Os dados foram coletados por meio de observação, análise documental e entrevistas e, posteriormente, submetidos à análise de conteúdo temática. Resultados: identificaram-se os seguintes elementos simbólicos: a força da cultura da universidade, o poder do médico, o poder do professor, a estabilidade e a autonomia profissional e as decisões colegiadas. Tais elementos influenciam na gestão da qualidade e segurança do paciente, pois há baixa adesão às propostas de mudança. Conclusão: os elementos simbólicos mantêm as práticas tradicionais de trabalho, compartilhadas pelo grupo, que dificultam a adesão às propostas de gestão da qualidade e segurança do paciente. Descritores: Cultura Organizacional; Gestão da Qualidade; Hospitais Universitários. *Extracted from the Doctoral Thesis “Influência da cultura organizacional na gestão da qualidade e segurança do paciente em um hospital público universitário”, Universidade Federal de Minas Gerais, 2020. 1Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brazil. Corresponding author: Palloma Fernandes Estanislau Vaz Ventura Avenida Alfredo Balena, 190, sala 514, Santa Efigênia. CEP: 30130-100. Belo Horizonte, MG, Brazil. E-mail: pallomavaz@hotmail.com EDITOR IN CHIEF: Ana Fatima Carvalho Fernandes ASSOCIATE EDITOR: Francisca Diana da Silva Negreiros Palloma Fernandes Estanislau Vaz Ventura1 Isabela Silva Cancio Velloso1 Marília Alves1 How to cite this article: Ventura PFEV, Velloso ISC, Alves M. Influence of organizational culture in the quality management of a teaching hospital. Rev Rene. 2020;21:e43996. DOI: https://doi.org/10.15253/2175-6783.20202143996 Ventura PFEV, Velloso ISC, Alves M Rev Rene. 2020;21:e43996. 2 Introduction Currently in Brazil, as all over the world, the health sector is facing challenges, such as the recurrence of previously eradicated diseases, financial struggles, political crises, the growing demand for care in the public health system and the collapse in the social security model. This context requires challenges to the health system in terms of ensuring resolutive and humanized care, with quality and safety for the patient(1). Thus, the implementation of quality management becomes, increasingly, an alternative to guarantee the creation of a system that ensures the principles of universalization, equity, and integrality in the Unified Health System responsible for serving 80% of the Brazilian population(2). In the health care scenario, teaching hospitals, public institutions, linked to federal universities, responsible for high complexity care in a variety of clinical and surgical specialties, are included for users of the Unified Health System. Besides their commitment to assistance, teaching hospitals focus on teaching and research, assigning themselves to the training of human resources and the development of health technologies, which reflects in their daily lives and their culture(3). The organizational culture of health institutions can be a central element of the quality of care and patient safety, encouraging them or favoring their failure(4). Organizational culture is defined as a set of basic assumptions that worked properly at a given time to solve problems of external adaptation and internal integration of the organization(5). These assumptions are learned and shared by individuals and, in this sense, they are legitimized and passed on to new members of the organization(5). Thus, the organizational culture can be related to the direction of people’s actions, consolidate the behavior expected by the group, outlining hierarchical characteristics and structures(5-7). However, the political dimension expressed through the power relations in the organization is an important element to be considered in discussions about organizational culture. In this context, organizational culture encompasses symbolic elements, that is, a set of basic values and assumptions, with their characteristics and dynamics, which allow it to order, give meanings and build organizational identity(6). Examples of symbolic elements in the daily work are the feeling of collaboration and the myths of the big family, the love for the institution and its social recognition, as well as the affection among employees. Striking historical facts told and passed on by certain subjects, such as directors or coordinators, who have promoted improvements in the work process or recognition of the importance of employees for the institution are also included in the roll of symbolic elements(5-6). It is important to consider that the symbolic elements are collective constructions that give meaning and build the organization’s identity, causing a feeling of belonging to the group and driving the subjects’ actions(6). Also, these elements act as communication and consensus instruments, being capable to hide and operate power relations. In this sense, the symbolic elements are built on the relationships that are established in the daily lives of organizations, at moments of interaction, such as work routines, celebration rites and socializing. They can also be observed in rites of passage, such as promotions, transfers and dismissals, moments in which experiences are shared and the meaning in collective actions are created(6). Concerning quality management in the health context, the literature addresses the organizational culture, pointing out its importance in the implementation of successful improvement cycles(4,8-9). Besides, it is important to consider that the success of proposals that promote changes in the organizational processes of health institutions depends on their cultures. Therefore, the interface between organizational culture and the performance of health organizations needs to be continuously studied(8). This article is based on the assumption that the organizational culture influences the management of quality and patient safety, although, in general,


Introduction
Currently in Brazil, as all over the world, the health sector is facing challenges, such as the recurrence of previously eradicated diseases, financial struggles, political crises, the growing demand for care in the public health system and the collapse in the social security model. This context requires challenges to the health system in terms of ensuring resolutive and humanized care, with quality and safety for the patient (1) . Thus, the implementation of quality management becomes, increasingly, an alternative to guarantee the creation of a system that ensures the principles of universalization, equity, and integrality in the Unified Health System responsible for serving 80% of the Brazilian population (2) .
In the health care scenario, teaching hospitals, public institutions, linked to federal universities, responsible for high complexity care in a variety of clinical and surgical specialties, are included for users of the Unified Health System. Besides their commitment to assistance, teaching hospitals focus on teaching and research, assigning themselves to the training of human resources and the development of health technologies, which reflects in their daily lives and their culture (3) .
The organizational culture of health institutions can be a central element of the quality of care and patient safety, encouraging them or favoring their failure (4) . Organizational culture is defined as a set of basic assumptions that worked properly at a given time to solve problems of external adaptation and internal integration of the organization (5) . These assumptions are learned and shared by individuals and, in this sense, they are legitimized and passed on to new members of the organization (5) . Thus, the organizational culture can be related to the direction of people's actions, consolidate the behavior expected by the group, outlining hierarchical characteristics and structures (5)(6)(7) .
However, the political dimension expressed through the power relations in the organization is an important element to be considered in discussions about organizational culture. In this context, organizational culture encompasses symbolic elements, that is, a set of basic values and assumptions, with their characteristics and dynamics, which allow it to order, give meanings and build organizational identity (6) . Examples of symbolic elements in the daily work are the feeling of collaboration and the myths of the big family, the love for the institution and its social recognition, as well as the affection among employees. Striking historical facts told and passed on by certain subjects, such as directors or coordinators, who have promoted improvements in the work process or recognition of the importance of employees for the institution are also included in the roll of symbolic elements (5)(6) .
It is important to consider that the symbolic elements are collective constructions that give meaning and build the organization's identity, causing a feeling of belonging to the group and driving the subjects' actions (6) . Also, these elements act as communication and consensus instruments, being capable to hide and operate power relations. In this sense, the symbolic elements are built on the relationships that are established in the daily lives of organizations, at moments of interaction, such as work routines, celebration rites and socializing. They can also be observed in rites of passage, such as promotions, transfers and dismissals, moments in which experiences are shared and the meaning in collective actions are created (6) .
Concerning quality management in the health context, the literature addresses the organizational culture, pointing out its importance in the implementation of successful improvement cycles (4,(8)(9) . Besides, it is important to consider that the success of proposals that promote changes in the organizational processes of health institutions depends on their cultures. Therefore, the interface between organizational culture and the performance of health organizations needs to be continuously studied (8) .
This article is based on the assumption that the organizational culture influences the management of quality and patient safety, although, in general, managers are not aware of this in the organizational routine (7)(8) .
The study aimed at analyzing the influence of the symbolic elements of organizational culture in the quality management and patient safety.

Methods
This is a qualitative research, using the case study strategy (10) . The theoretical framework of organizational culture was used, through the analysis of symbolic elements, which are created and maintained in daily work in a single symbolic universe, with multiple facets, capable of maintaining status and preventing unwanted changes by groups, without that, in practice, the reason for the failure of the proposals is identified (6) .
The Hospital das Clínicas of the Universidade Federal de Minas Gerais was chosen to carry out this research due to the history of implementing the quality management system, which began in 2001, the challenges still faced today for its full implementation, its historical importance and to the fact that it is a reference for high complexity care in the state. The study was carried out in the medical units of the hospital.
The participants' inclusion criteria were: to be a manager in the hospital and work in the quality management and patient safety and exclusion criteria were to be managers of the surgical, pediatrics, maternity and outpatient units and/or to be on a leave at the time of data collection. The managers of the hospital's chief management, human resources, quality and Patient Safety Center, epidemiological surveillance and the medical unit were intentionally selected due to their status in the quality management and patient safety. A manager identified as a key informant was included during the interviews, for responsible of implementing quality management. Thus, 19 managers met the inclusion criteria and were invited to parti-cipate in the study. Of these, 18 comprised the study sample and a quality manager refused to participate in the research, due to the high work demand at the time.
Initially, the researcher contacted the head of the medical unit and the nursing coordination to present the research project. Participants were contacted, in person, to schedule the interviews. Data collection took place from May to September 2018 through observation, document analysis and semi-structured script interviews, previously submitted to a pilot test. The semi-structured script addressed questions related to the hospital's history, the decision-making process, the entry of the Brazilian Hospital Services Company in the hospital management, the planning of care and the process of quality management and patient safety in the units. The interviews were conducted in rooms available at the unit, with an average duration of 40 minutes, being recorded on media player equipment and, later, transcribed in full by the researcher. The data saturation criterion (11) was used to end the interviews, when no new information was added on the theme.
The observations were recorded in a field diary, with 68 pages, using Word program, in A4 sheet, single space, Arial 12 typeface, performed in the work environment of the managers and meetings of the collegiate managers, of the quality management, of the Nucleus for Patient Safety and the Nursing Division. In the results, the records of the observations are identified by the acronym NO, followed by the location of the observation. The data from the interviews were submitted to thematic content analysis, following the stages of pre-analysis, exploration of the material, treatment, and data interpretation (12) . Documentary analysis of institutional documents was carried out and the result was a description of the biography, the hierarchical and functional structure and the construction of the quality management and patient safety system at the Hospital das Clínicas, of the Universidade Federal de Minas Gerais, supporting the apprehension of the origin of the symbolic elements of organizational culture. The observations comprised the data analysis, as they enabled to understand reality and enrich the analysis of cultural phenomena. The data from the interviews and the field diary were organized using the MAXQDA program, version 2018.2. The Consolidated Criteria for Reporting Qualitative Research checklist (13) was used to conduct the research.

Results
Among the 18 managers who participated in the study there was one manager of the medical unit, two nursing coordinators, five coordinators of the multidisciplinary team, a manager of epidemiological surveillance, a manager of the Patient Safety Center, three managers of human resources, one manager of the Diagnostic and Therapeutic Support Unit, a health care manager, two managers from the care division/ sector and the chief.
From the data analysis, five symbolic elements were identified: the strength of the university's culture, power of the doctor, the power of the teacher, the steadiness and professional autonomy and collegiate decisions.
The strength of the university's culture was built as a symbolic element in the history of the The new organizational structure created three hierarchical levels that previously did not exist in the hospital, namely: management, division, and the unit, with their respective managers (D2). However, the coordination of the specialties that made up the multi-professional team was not included in the organization chart (D2) of the Brazilian Hospital Services Company. However, in practice, the medical coordination, done by the professors, the nursing coordination and the multidisciplinary team, held by university professionals were kept: Even after the effectiveness of the management of the Brazilian Hospital Services Company, the doctor's power remained a symbolic element. The first workers hired by the Brazilian Hospital Services Company were the ones from the medical team. As many professionals approved in the public tendering already worked in the hospital, under contract with a foundation, there were no major changes in these teams, only changes in the relationship and work regime: We made choices for the call for tenders by the Brazilian Hospital Services Company. The doctors entered first, which ended their autonomous payment (M9).
After, nursing professionals were hired causing a significant change in the team and the occurrence of several conflicts. The multi-professional team was the last one to be settled, with a significant reduction in the proposed number of professionals, since the Federal Court of Accounts blocked the hiring of new employees, due to the economic crisis:

Discussion
The limitation of the research refers to the fact that it was carried out only in medical units. As it is a qualitative study, the results cannot be generalized. New research on organizational culture in teaching hospitals, in its different units and services, considering the complexity and the existence of subcultures, may favor the discussion about the implementation of quality and patient safety.
The approach of organizational culture in health is focused on the creation of questionnaires and quantitative scales or climate surveys seeking to apprehend the culture (5)(6) . Thus, the main contribution of this study is the understanding of culture and symbolic elements from an anthropological approach, which seeks to understand the subjective meanings attributed to signs and symbols by the subjects and built collectively, allowing the apprehension of the elements of culture that promote or hinder the implementation of quality management and patient safety.
Culture and organizations power are connected, influencing each other, although they have practices that are little-known, complex, and inexplicable. Considering the dynamics and complexity of health organizations and federal universities, the study of culture permeates the political game of social forces, which affects organizations and, consequently, labor relations, controlling the terms of these relations in a dialectical way (6) .
Federal universities play an important role in the national scenario, as a place for discussion and opinion-forming centers. In the Brazilian democratic opening, mechanisms were created to protect the rights of public servants (14) , which ensured steadiness to them, establishing a symbolic element of the university.
Adherence to the management of the Brazilian Hospital Services Company triggered conflicts from the strategic to the operational level, since the hospital is an extension of the university, reflecting its principles, beliefs, and relationships between people. Even today, resistance can be observed, highlighting conflicts and disagreements between two groups of workers, especially when they have leadership positions: the statutory employees of the Universidade Federal de Minas Gerais and the employees of the Brazilian Company of Hospital Services. Also, influenced by the economic context, the Brazilian Company of Hospital Services was unable to keep the expected staff, except for the medical team, which shows the power of this symbolic element. This caused a segregated hospital, with power relations controlling the work process, unit management and hierarchy. The exercise of power is not only a relationship between individuals, but a way in which the actions of some can change those of others and, still, power relations establish work and interfere in the performance of professionals, being reproduced in their speeches (15) .
Thus, daily practices go beyond understanding the actions restricted to the main rules in work routines (15) , resulting in implicit and explicit practices, outlining behaviors and the work organization. In this sense, power and culture are connected, replacing the norms, guidelines, and rules in multiple relations of forces present in all domains of the institution. Therefore, they reach all individuals, expressing themselves in heterogeneous forms, sometimes different from one another, as they are historically established, and their effectiveness is based on the ability to hide existing inconsistencies (6) . The change in the organizational structure, the management model of the Brazilian Hospital Services Company and the hiring of new workers did not change the organizational culture due to the incorporation of symbolic elements by the Company's employees, mainly because they were trained by the statutory employees of the Universidade Federal de Minas Gerais.
Socialization is an important instrument for spreading the set of concepts and interpretations of the organization's dynamics, that is, of the symbolic elements of organizational culture, in movements of confirmation and adaptation to the onset of new elements, seeking the maintenance of culture (6) . The conventional training process puts more pressure on newcomers, influencing their attitudes and values. Therefore, the organization shows itself to the newcomer as a complex object with many viewpoints: what is perceived, what the training says and what the senior employees perceive, the three views being different (6) . However, the symbolic elements of culture tell how things work and worked out in the organization, favoring their incorporation into a movement of denial, adaptation, and acceptance. As standards are established in relationships and ways of solving problems are consolidated, it becomes difficult for symbolic elements to be questioned (6) .
The symbolic elements are so strong and powerful and so entrenched in the hospital's culture that exchanging workers has not been able to change them. The history of enlarging services in search of sustainability in times of economic crises strengthened the university's identity as a symbolic element. In this system composed of several elements, with heterogeneous characteristics, making changes becomes complex (16) . Quality management aims at patient-centered care with interdisciplinary actions, demanding to modify the current rationality, with planning that considers the reality of the hospital, and not only the decisions based on the medical power, a symbolic element present since the creation of the hospital (4) . In this sense, it is emphasized that the organizational culture can create a barrier to the implementation of quality, considering its particularities and historical legacies as opposed to changes in the production of new values and practices (4) .
The management of the previous nursing service did not adhere to the activities of the quality program, such as analysis of care indicators, training of patient safety protocols and reporting of adverse events, agreed upon by the collegiate of functional units, making it difficult to incorporate administrative and care processes. In this context, it is worth noting that the leaderships play an important role in the creation and maintenance of the organizational culture, so resistance to changes cannot be considered generically as obstacles to institutional development projects, as the basic ideas of the culture of the organization remain valid and incorporated (6) , and quality projects and strategic priorities are not feasible.
It is noteworthy that culture manifests itself in daily actions, consolidating behaviors expected by the group, creating cultural identity and a sense of belonging (7) , not yet achieved by nursing. It is in the cultural field that the capacity for adaptation is developed and influences the decision to comply with rules (7) , to which nursing is subjected.
The implementation of quality management began ten years ago in the hospital. In the perception of managers, there was an improvement in professionals' practice, but it is not yet fully implemented, showing advances and setbacks. This is because of some typical aspects of the public service and teaching hospitals identified by the interviewees, such as difficulty for the information to reach students and residents and, afterward, to maintain themselves, since the exchanges of these professionals are frequent; there is the insufficient staff; lack of adherence by some groups; discussion in collegiate bodies, which, on the one hand, makes the decision-making process clear and autonomous, on the other hand, slows it down and takes time. International studies relate care quality and patient safety with staff shortage and overload, especially of the nursing team (15,17) .
Thus, quality and patient safety are processes under construction. They depend, mostly, on the organizational culture and its symbolic elements, as they are little known and valued, reinforcing its legitimized way of operating. Changing organizational culture permeates human resource management, with relationships between workers and the development of organizational culture being the key to success (9) .

Conclusion
The symbolic elements are powerful and ensure the maintenance of traditional practices shared by the group, making it difficult to adhere to the proposals for quality management and patient safety while preserving its legitimized ways of operating in the organizational culture.