ArticlePDF Available

Abstract

Purpose – The purpose of this paper is to explore the nature and impact of leadership in relation to the local implementation of quality improvement interventions in health care organisations. Design/methodology/approach – Using empirical data from two studies of the implementation of The Productive Ward: Releasing Time to Caret in English hospitals, the paper explores leadership in relation to local implementation. Data were attained from in-depth interviews with senior managers, middle managers and frontline staff (n¼79) in 13 NHS hospital case study sites. Framework Approach was used to explore staff views and to identify themes about leadership. Findings – Four overall themes were identified: different leadership roles at multiple levels of the organisation, experiences of “good and bad” leadership styles, frontline staff having a sense of permission to lead change, leader’s actions to spread learning and sustain improvements. Originality/value – This paper offers useful perspectives in understanding informal, emergent, developmental or shared “new” leadership because it emphasises that health care structures, systems and processes influence and shape interactions between the people who work within them. The framework of leadership processes developed could guide implementing organisations to achieve leadership at multiple levels, use appropriate leadership roles, styles and behaviours at different levels and stages of implementation, value and provide support for meaningful staff empowerment, and enable leader’s boundary spanning activities to spread learning and sustain improvements.
Exploring the nature and impact
of leadership on the local
implementation of
The Productive Ward Releasing
Time to Caret
Elizabeth Morrow, Glenn Robert and Jill Maben
National Nursing Research Unit, Florence Nightingale School of Nursing and
Midwifery, King’s College London, London, UK
Abstract
Purpose – The purpose of this paper is to explore the nature and impact of leadership in relation to
the local implementation of quality improvement interventions in health care organisations.
Design/methodology/approach – Using empirical data from two studies of the implementation of
The Productive Ward: Releasing Time to Caretin English hospitals, the paper explores leadership in
relation to local implementation. Data were attained from in-depth interviews with senior managers,
middle managers and frontline staff (n¼79) in 13 NHS hospital case study sites. Framework
Approach was used to explore staff views and to identify themes about leadership.
Findings – Four overall themes were identified: different leadership roles at multiple levels of
the organisation, experiences of “good and bad” leadership styles, frontline staff having a sense
of permission to lead change, leader’s actions to spread learning and sustain improvements.
Originality/value – This paper offers useful perspectives in understanding informal, emergent,
developmental or shared “new” leadership because it emphasises that health care structures,
systems and processes influence and shape interactions between the people who work within
them. The framework of leadership processes developed could guide implementing organisations
to achieve leadership at multiple levels, use appropriate leadership roles, styles and behaviours
at different levels and stages of implementation, value and provide support for meaningful
staff empowerment, and enable leader’s boundary spanning activities to spread learning and
sustain improvements.
Keywords Leadership, Productivity, Quality improvement
Paper type Research paper
Introduction
Health care organisations all over the world face challenges of improving safety,
quality and efficiency. Initiatives based on Lean thinking (Lean) have shown promise
for achieving these goals in a range of health care contexts (see e.g. Savary and
Crawford-Mason, 2006; Bem-Tovim et al., 2007; Jones and Mitchell, 2006; Fillingham,
The current issue and full text archive of this journal is available at
www.emeraldinsight.com/1477-7266.htm
Journal of Health Organization and
Management
Vol. 28 No. 2, 2014
pp. 154-176
rEmerald Group Publishing Limited
1477-7266
DOI 10.1108/JHOM-01-2013-0001
The studies which inform this work were commissioned and supported by Helen Bevan and
Lynn Callard and Kristy Parnell at the National Health Service Institute for Innovation
and Improvement (NHS Institute) in England. Diane Ketley provided helpful comments and
suggestions on an earlier version of this paper. Professor Peter Griffiths, University of
Southampton contributed to the design and conduct of the studies. The views expressed here are
those of the authors, not of the NHS Institute. The authors thank all those who participated in the
studies whether by participating in interviews, facilitating access to organisations or providing
other information. Thank you to the two anonymous reviewers of this paper who provided
helpful suggestions and comments.
154
JHOM
28,2
2007). Lean has a long history of development and use in the commercial sector
and manufacturing industry where it is a well-established improvement approach
(Young and McClean, 2008; Radnor and Boaden, 2008). It provides organisations with
principles and tools to focus on the values which drive systems (Rooney and Rooney,
2005) and realign or refine processes or practices to cut out “waste” (e.g. interruptions,
delays, mistakes or replication) and achieve the desired values (e.g. effective treatment,
safe high quality care) (Womack et al., 1990; Crump, 2008). Now, to maximise on these
benefits, there is a need to build evidence and strategies to support implementation in
health care (Eccles et al., 2009). One important factor for driving improvement work is
leadership (Ferlie and Shortell, 2001; Miller, 2006; Øvretveit, 2009; Barr and Dowding
2012) sometimes called “improvement leadership”, however little is known about the
most effective forms of leadership in this context (Øvretveit, 2009; Buchanan et al.,
2007b; Denis et al., 2012).
The aim of this paper is to explore issues about leadership in relation to
implementation of improvement initiatives in health care. The paper draws upon
perspectives of Lean thinking and leadership from the health care literature to explore
the issues from the perspectives of staff in implementing organisations. Specifically,
the paper explores the following research questions:
RQ1. What type of leadership roles do organisations need to successfully
implement interventions like The Productive Ward?
RQ2. What type of leadership styles and behaviours should leaders use?
RQ3. How can leaders engage and energise frontline staff?
RQ4. How can leaders act to ensure implementation is spread and sustained?
The paper explores these questions in a real case of Lean implementation
by drawing upon empirical data from two studies of the implementation of
The Productive Ward: Releasing Time to Caret(The Productive Ward) in English
hospitals. The aim of The Productive Ward programme is to increase the proportion of
time nurses spend on direct patient care, to improve experiences for staff and patients,
and to make structural changes to the use of ward spaces to improve efficiency. It is a
useful test ground to explore issues of leadership as the programme has been widely
and rapidly adopted by many health care organisations in England (Robert et al., 2011)
as well as in hospitals across the UK and Republic of Ireland, Canada, the USA, the
Netherlands and Denmark. Internationally the programme is sometimes referred
to as Releasing Time to Care or RTC; variations in national/regional strategies for
implementation of The Productive Ward are themselves interesting but outside of the
scope of this paper.
The structure of the paper is as follows. The background section presents current
knowledge on Lean thinking and leadership in health care from the research literature.
The methods section provides information about the empirical studies that inform the
paper and the methods of analysis used in this paper. The findings are presented
according to themes and the discussion examines these findings in relation to the four
research questions above to develop a framework of leadership processes. Conclusions
for research and practice are presented.
155
Impact of
leadership
Background
Different approaches to Lean in health care have been classified (Brandao de Souza,
2009) as “manufacturing like” approaches which usually involve streamlining
departments within a hospital that typically deal with the physical flow of materials
(such as pharmacy, radiology or pathology). “Managerial and support service”
approaches to Lean concern the flow of information within the organisation (such as
finance, medical secretaries, or other managerial departments and divisions). “Patient
flow” approaches attempt to improve the patient journey within the hospital (or system)
by streamlining the patient pathway. While “organisational” approaches emphasise the
importance of designing a strategic and cultural plan from an organisational perspective
in order to successfully implement Lean. Differences in approaches to Lean have been
described by Emiliani (2008) as “fake” or “real” Lean. Fake Lean is where an organisation
uses just the tools with an emphasis on rapid improvement rather than long-term change.
Real Lean means showing a “commitment to continuous improvement” using tools
and methods to improve productivity, as well as “showing respect for people through
leadership behaviours and business practices” (Radnor and Boaden, 2008). Thus a key
perspective that informs our exploration is that leadership shapes and influences
approaches to Lean implementation.
Leadership of change, improvement and innovation in health care is not always a
smooth process and “improvement leaders” (Øvretveit, 2009) face at least four types of
challenges in relation to implementing Lean initiatives. First, staff perception is known
to play an important role in receptivity to Lean and staff may be resistant to what they
perceive to be commercial ideas based on productivity values (Young and McClean,
2009). There are associated challenges of how leaders can engage staff in meaningful
ways (Mumford et al., 2000) and build workforce capacity for implementation (Eccles
et al., 2009). Second is the complexity of decisions about implementation of any
particular initiative or innovation (McNulty and Ferlie, 2002): in organisations made
up of different health-care providers, local strategies, structures and professional
groupings, the “innovation journey” may be a fuzzy or contentious process (Van de Ven
et al., 1999) characterised by ambiguity about roles and responsibilities (Ham et al.,
2003). Third, generating evidence about any particular innovation faces challenges
of attributing, documenting and interpreting the implementation costs and benefits in
a way that is meaningful to different audiences (Berwick, 2003). Many organisations
may decide to hold-off implementation until there is convincing evidence from other
organisations about such investment (Rogers, 1995). Fourth, challenges of spreading
and embedding change within organisations include replacing old ways of working
and developing appropriate policy, practice and research to embed and sustain
improvements (Buchanan et al., 2007b; Ham et al., 2003). A key perspective that
underpins these challenges is the role of leaders in creating organisational conditions
for effective implementation.
The Productive Ward was devised and developed in this wider context of multiple
approaches to Lean and challenges to implementation in health care. The National
Health Service Institute for Innovation and Improvement (NHS Institute) (now part of
NHS Improving Quality) worked with industrial partners from Toyota to look at how
care delivered in hospital ward settings could be streamlined and create a clear set of
tools, resources and support for health care organisations. The programme was
developed at four hospital test sites in 2006, before being rolled-out to ten Learning
Partners in 2007. The programme frames Lean in language and examples that are
intended to appeal to health care staff and enable them to bring about changes at ward
156
JHOM
28,2
level (Morrow et al., 2012). It comprises 13 modules and tools designed for self-directed
learning at ward level, beginning with three foundation modules called Knowing
How We are Doing, Well-Organised Ward and Patient Status at a Glance; and
further modules which focus on a range of ward processes including admissions,
discharge and shift handovers. The design and development of the programme itself
are important factors in implementation (NNRU&NHSI, 2010) but our focus here is
on leadership.
In the case of The Productive Ward “involved leadership” of senior executive
leaders and ward leaders has been identified as being an important facilitating
factor in implementation (White et al., 2013). This assertion corresponds with
well-established findings in the literature on leadership that show senior
organisational/executive leaders of health care organisations can help to “challenge
the process, inspire a shared vision, enable others to act, model the way, and encourage
the heart” (Kouzes and Posner, 1988). Formal organisational hierarchies can provide
coordinated and strategic leadership of organisations and organisational change
(Dickson, 2009). It is also known that appointed senior leaders can drive organisational
change by initiating the adoption and implementation of innovation (Rogers, 1995),
including applying improvement principles and replicating actions that other
senior organisational leaders have found to be successful (Øvretveit, 2009). A key
perspective that informs our exploration is that leadership from the “top down” (Sabatier,
1986) directed towards sharing knowledge can support a receptive organisational
context for implementation and routinisation of innovation (Greenhalgh et al., 2005; May
et al., 2009).
At the same time it is known that leaders do not only operate at the “top” of
organisations. Leaders may operate at different macro (health-care system), meso
(organisation) and micro (frontline clinical team) levels to carry out different leadership
functions (House et al., 1995). Similarly, leadership can be perceived according to
individual, team and organisational perspectives (Barr and Dowding, 2012). The notion
of “leadership in the plural” (Denis et al., 2012) suggests that leadership can take on
different forms, including being shared in teams, pooled at the top of organisations,
spread (or distributed) across boundaries over time, or produced through interaction.
Thus a key perspective is that implementation of any Lean initiative in health care
takes place in the context of different perceptions and understandings of who leaders
are and what leadership means (Hartley and Benington, 2010).
Individuals in clearly defined leadership roles can help to work across boundaries
between professional groups, departments, divisions, teams and localities to convey
goals, share information or learning (Pearce, 2004; Goodwin, 2000). Boundary spanning
leadership has been defined as “the capability to establish direction, alignment, and
commitment across boundaries (vertical, horizontal, stakeholder, demographic and
geographic) in service of a higher vision or goal” (Ernst and Chrobot-Mason, 2010).
In relation to implementation of innovation leader’s boundary spanning activities
(Fleming and Waguespack, 2007) are known to be an important factor in the spread of
initiatives across disciplinary fields and sectors (Greenhalgh et al., 2005). Another key
perspective that we explore in this paper is how staff in recognised leadership positions
can support spread and sustained implementation across an organisation.
Engaging influential individuals (who may or may not perceive themselves to be
leaders) across an organisation can help to secure credibility for an innovation
( Jacobson and Goering, 2006), and strategies to develop “role models” and “opinion
leaders” have shown to be effective in implementing changes at the clinical level
157
Impact of
leadership
(MA, 2005). Hence implementation strategies in health care now recognise and seek
to engage with staff groups who have not traditionally been perceived as leaders
(Doumit et al., 2011) and from different communities of practice (Kislov et al., 2011).
Spreading leadership roles through organisations can support implementation by
attracting followers from different disciplinary backgrounds and service localities
(Grimshaw et al., 2006). However, the notion of leadership as something to be
distributed across complex systems and boundaries (Benington and Hartley, 2010;
Hartley, 2012) can be problematic in health care organisations with established
institutional structures and norms (Martin and Waring, 2013). Staff may also question
whether the underlying intention of initiatives to distribute leadership is to support
“democratic organization” or to gain greater control through “instrumental delegation”
(Mayrowetz, 2008). Changing existing patterns of leadership in health care is challenging
because of contextual issues such as interprofessional barriers and patterns of knowledge
exchange or “brokering” (Currie, 2012). Attempts to promote distributed leadership
in health care, for example through public service networks, have faced challenges of
organisational bureaucracy, power differentials, and a strong centralised performance
management policy regime (Currie and Lockett, 2011).
As Edmonstone (2011) argues, perhaps a rebalancing is needed – from an
over-concentration on individual leaders to an emphasis on the contexts and
relationships in health care organisations that enable leadership to happen. Such
perspectives consider leadership and its outcomes to extend beyond the actions of
individuals to include the multiple roles and dynamics between different “leaders” and
“followers” in different decision-making contexts (Pedersen and Hartley, 2008). As such
“post-heroic” (Dickson, 2009) perspectives of leadership suggest that leadership is not
only attributable to the actions and behaviours of senior leaders but is “a social process
that occurs in and through human interactions” (Fletcher, 2004).
Insights from leadership of change in health care suggest that leaders need to
cultivate a strong culture of engagement for patients and staff and to deploy a range
of leadership styles and behaviours (The King’s Fund, 2012). Leadership that enables
perspectives and needs of different staff groups to be shared helps to generate knowledge
of problems or issues from the “bottom-up” (Sabatier, 1986), co-produce viable solutions
(Gough and Masterson, 2009), and support wider organisational learning and
improvement (Brown and Duguid, 1991). Accordingly the notion of a transformational
leadership approach (Burns, 1978) has become popular in health care organisations
(Bass and Riggio, 2006) as it emphasises leadership behaviours that engage and
motivate frontline staff to bring about change for themselves (Govier and Nash, 2009).
A further key perspective which can be taken from the literature is the notion of
leadership being generated through engagement and interaction.
Drawing on these perspectives, in this paper we suggest the process of
implementing Lean can help to critically examine different forms of leadership and
create conditions for leadership to emerge. In particular Lean offers useful perspectives
in understanding “new” leadership (i.e. informal, emergent, developmental or shared)
because it emphasises that health care structures, systems and processes influence and
shape interactions between the people who work within them (Radnor et al., 2012).
By examining the processes of health care Lean highlights the presence of organisational
rhetoric, ritual and resistance in the discourse of leadership (Waring and Bishop, 2010).
In this respect Lean can perhaps help to understand the values which drive systems and
prompt questions about how “old” (i.e. formal, autocratic, directive) leadership can help to
orientate the organisation towards achieving such values.
158
JHOM
28,2
Method
Thefocusofthispaperistoexplorethenatureandimpactofleadershipfrom
the perspective of health service leaders, managers and frontline staff working
to implement an improvement initiative (The Productive Ward programme).
We chose to use Framework Approach (Richie and Spencer, 1994) to explore
staff experiences because it is particularly suited to analysing descriptive data
from multiple sources, thereby enabling different aspects of the phenomena under
investigation to be captured (Ritchie and Lewis, 2003). Using this approach the
context of participant’s experiences can be retained, while also exploring
associations and explanations in the data and drawing on existing theories and
established literature (Richie and Spencer, 1994). Data were drawn from two studies
of The Productive Ward described below.
Study 1:undertaken in 2009 using mixed methods (NNRU&NHSI, 2010) and an
evidence-based diffusion of innovations framework (Greenhalgh et al., 2005) the study
aimed to examine key factors which had helped to promote rapid programme adoption
(Robert et al., 2011). Data were collected from three different “stakeholder” groups
(Golden-Biddell and Locke, 1997), these were: policymakers (15 in-depth interviews not
used in this paper), hospital managers and health care practitioners who had personal
experience of implementing the programme (web-based survey of 150 self selecting
staff from 96 different NHS acute hospitals, this data has previously been published in
Robert et al., 2011); and frontline staff working on the programme (58 in-depth
interviews) within five hospital case study sites (see Table I). The interview schedule
covered questions about professional role, involvement in implementation, views
about the work/progress, factors helping/hindering implementation and perceptions of
types of impact.
Study 2: undertaken a year later (in 2010) the study focused on examining
theorised circumstances of “non-spread” (NNRU&NHSI, 2011) these were:
discontinuation when people (or organisations) decide to reject an innovation after
adopting it, islands of improvement where pockets of excellence remain isolated and
unknown to others, improvement evaporation when change is not sustained leading
to the decay of organisational change (Ferlie et al., 2005). Eight hospitals were
selected for case study (using Yin’s, 2008 method) on the basis that they were known
to have purchased a Productive Ward package from the NHS Institute and to have
initiated implementation (see Table I). In-depth interviews were undertaken with 21
hospital staff who held a formal leadership role in programme implementation (staff
were senior organisational leads or programme leads/coordinators). Semi-structured
interviews covered questions on the person’s involvement in the work, current
activity, future plans, where things are going well/not so well, staff engagement,
“energy levels” like behind the work, factors that have helped/hindered the work,
fit with other initiatives, monitoring.
This paper focuses on the in-depth interviews conducted with hospital staff during
study 1 (n¼58) and study 2 (n¼21). In both study 1 and study 2, leadership was a
recurrent issue for staff at all levels and we recognised the need to develop more
informed understanding of leadership in this context by exploring “what works and
why” (Walshe, 2007). Drawing on Framework Approach we used qualitative analytic
techniques (Denzin and Lincoln, 2000) to explore staff views. The analysis aimed to be
context sensitive, iterative and flexible (Holloway and Todres, 2003) but it involved a
number of stages. These were: re-familiarisation: reading case study summaries and
interview transcripts; immersion: to explore the data in relation to the focus of the
159
Impact of
leadership
Adoption
Support
package Approach to implementation Resourcing Study participants
Study 1 (2009)
S1H1 Aug 2007 Learning
partner
Whole hospital implementation
rolled out in stages; wards
undergo selection process to
join
As an original learning partner
received support from NHS
Institute. Have dedicated
Productive Ward team skilled
in change management
Executive/board member (1); the
Productive Ward team, e.g.
programme lead/facilitator (5);
clinical team (6), non-clinical/support
staff (1) total ¼13 participants
S1H2 Jun 2007 Accelerated Whole-organisation
implementation (one of first two
whole-hospital pilots)
Dedicated service development
team with extensive clinical
experience
Executive/board member (2); the
Productive Ward team, e.g.
programme lead/facilitator (2);
clinical team (7), non-clinical/support
staff (1) total ¼12 participants
S1H3 Oct 2007 None Phased whole hospital
implementation; initially
launched using previous
service improvement
experience rather than NHSI
package; subsequent phases
using package
Key executives and staff
experienced in improvement
methodologies; in-house service
improvement team, but no
dedicated PW facilitators at
launch; June 08 two dedicated
facilitators appointed
Executive/board member (2); the
Productive Ward team e.g.
programme lead/facilitator (3);
clinical team (4), non-clinical/support
staff (1) total ¼10 participants
S1H4 Mar 2008 Accelerated Focused implementation with
selected wards supported by
dedicated Productive Ward
facilitator
Project lead and facilitator, both
clinically qualified
Executive/board member (3); the
Productive Ward team e.g.
programme lead/facilitator (2);
clinical team (4), non-clinical/support
staff (2) total ¼11 participants
S1H5 Feb 2008 Accelerated Planned and organised strategy
for implementation at stages
across organisation
Dedicated PW implementation
team including service
improvement and clinical
specialists
Executive/board member (-); the
Productive Ward team, e.g.
programme lead/facilitator (3);
clinical team (6), non-clinical/support
staff (3) total ¼12 participants
(continued )
Tabl e I.
Summary of hospital
case study sites
160
JHOM
28,2
Adoption
Support
package Approach to implementation Resourcing Study participants
Study 2 (2010)
S2H1 Oct 2008 Standard Originally implemented on six
wards but work lapsed due to
move to new building. Roll-out
initiated in April 2010
Seconded PW lead nurse for
first year. A year later a service
improvement facilitator
identified to lead the work. Two
full-time facilitators appointed
for 18 months
Service improvement facilitator/PW
lead (1), service improvement
facilitator/PW facilitator (1) total ¼2
participants
S2H2 Jan 2009 Accelerated Lean work running two years
before PW was replaced by PW.
Initially implemented on 7
wards then roll-out over
hospital
PW programme lead and PW
Support Officer appointed in
early 2009. A support nurse
was appointed to provide ward
cover for nurses to participate
in training
PW coordinator surgery (1), former
PW facilitator (1) total ¼2
participants
S2H3 Jun 2008 Accelerated Initial implementation on two
surgical wards. Officially
launched on both hospital sites
in April 2009
PW programme lead was
identified from an existing
organisation and development
team. PW coordinator
communicated plans to all of
the ward areas and PW
programme lead supported
training
PW lead (1), service improvement
facilitator (1), sister surgery (1),
matron surgery (1) total ¼4
participants
S2H4 May 2008 Accelerated Planned to implement PW
Foundation modules on 20
wards (of 30) across the
hospital
Two senior nurses were
seconded to lead
implementation. Part of the
remit was to work with the PW
facilitator in delivering
Productive Ward. A PW
facilitator was employed for
three days a week until
March 2009
Associate head of nursing/PW
lead (1), PW facilitator (1) total ¼2
participants
(continued )
Tabl e I.
161
Impact of
leadership
Adoption
Support
package Approach to implementation Resourcing Study participants
S2H5 Feb 2008 Accelerated Three pilot wards started the
programme in April 2008. Plan
for whole hospital (24 wards) to
have some support and
engagement with the
programme
A full-time practice
development nurse for 18
months, and administrative
support from within the Service
Improvement Department.
Another member of staff from
the Service Improvement
Department working as PW
facilitator almost full-time
Service improvement facilitator/PW
lead (1), practice development nurse/
PW facilitator (1), ward manager
general medical ward (1), sister for
PW in trauma (1) total ¼4
participants
S2H6 Jun 2008 Accelerated 13 wards were selected to work
on PW foundation modules
Appoint a full-time lead to
implement the programme over
a two-year period. A ward sister
was appointed for six months.
Two matrons since provide
support
1 (for mer PW lead) total ¼1
participant
S2H7 Oct 2008 Accelerated Two showcase wards followed
by staged roll-out to whole
hospital
PW facilitator and a PW lead
appointed in 2009
Director of nursing (1), PW lead (1),
PW facilitator (1) total ¼3
participants
S2H8 Oct 2008 Accelerated Implementation of PW
foundation modules on all
wards, then process modules
Team of five nurses (four
seconded) worked full-time on
the programme for 12 months.
Senior nurse continued to
support implementation as part
of their quality improvement
role
PW lead (1), department manager (1),
clinical nurse manager (1) total ¼3
participants
Note: PW, The Productive Ward programme
Tabl e I.
162
JHOM
28,2
issues (e.g. leadership, control, decision-making power), the types of language or ways
of talking about issues, and the types of information used to substantiate claims/views
(e.g. direct experience, policy, research evidence); coding and extraction: selection
of passages of text and coding according to themes (Braun and Clarke, 2006);
and refinement of themes: members of the research team examined the coherency
of the meaning of each theme (Holloway and Todres, 2003) (supporting validity of the
analysis), the assumptions underpinning it (Walshe, 2007), the possible implications
and the overall story the different themes reveal about leadership and staff
perspectives of the issues. Using a staged approach enables researchers to track
decisions, which ensures links between the original data and findings are maintained
and transparent. This adds to the rigour of the research process and enhances the
validity of the findings, described below (Ritchie and Lewis, 2003).
Findings
The findings are presented according to four interrelated themes about leadership that
we identified across study 1 and study 2 data. Quotes from interviews with staff
working to implement the programme are used to illustrate each of these themes.
Different leadership roles at multiple levels of the organisation
The first theme we identified was that to implement and spread The Productive Ward
organisations needed to have leadership in place at multiple levels. This “multi-level
leadership” was consistently described as involving staff within four distinct types of
leadership roles, described below and illustrated by Table II.
The first distinct leadership role was senior executive and senior clinical leaders.
In study 1 we found that senior clinical leaders were perceived by both senior executives
and frontline staff to play an important role in aligning programme implementation with
clinical goals and priorities (all five case study hospitals in study 1). This work included
alignment of The Productive Ward with ongoing patient safety initiatives, infection
control and falls prevention strategies (see final report for further information
NNRU&NHSI, 2010). In study 2 the importance of visible executive/senior leadership
was again held by staff at all levels as being important for continuing to engage staff as
the programme was rolled-out to new wards:
The Deputy Director of Nursing attends steering group meetings and there have been
walkabouts from the Chairman and the Chief Executive. This support helps the areas that are
being visited to see that PW is important and that the work they are doing is being recognised
(Productive Ward (PW) programme lead, study 2, hospital 3).
The second leadership role was programme lead (also called PW facilitators in some
organisations). In study 1 all five case study hospitals had appointed one or more
programme leads for the organisation or funded secondments for senior nurses
or members of existing improvement teams (see Table I, study 1 hospitals 1-5). The
programme lead role was characterised by planning implementation at an organisational
level and facilitating ward teams to move forward with implementation and encourage
progress: which included: maintaining connections with external change agents to learn
about the programme and plan implementation; linking with staff in other implementing
hospitals to share learning; securing support from executive/senior managers by linking
the programme with broader organisational goals and; linking with ward staff to
provide training and to facilitate implementation. Study 2 revealed how in later stages
of implementation securing funding for this role proved critical as to whether
163
Impact of
leadership
Role Formal/informal Leadership styles and behaviours
Executive/senior manager
lead
Senior staff formally
appointed to a position of
authority within the
organisation
Championing the programme
Strategic alignment of the programme with organisational goals or priorities
Securing resources/allocating funds
Visioning and conveying potential gains to staff
Designating overall targets for programme implementation
Engaging with staff who are actively involved in implementing the programme
Programme lead Formally appointed,
nominated or seconded
(often time-limited) lead for
organisational
implementation
Planning implementation across the whole organisation with senior leaders
Linking work with external networks and inter nal quality improvement teams
Facilitating training or learning of staff at unit/team level
Monitoring implementation and outcomes at organisational level
Middle manager Formally appointed middle
manager/ward manager
Managing decisions about whether/when/how to engage in the programme
Informing ward staff about the programme
Enabling and encouraging staff to work on the programme (releasing staff to training)
Linking the programme to quality improvement work at ward/unit level
Local Productive Ward lead Selected or self-nominated
individual who leads on
implementation at ward/
unit level
Participating in the work, arranging ward-level meetings and sharing learning
Encouraging frontline staff to monitor the improvements and record their achievements
Explaining to frontline staff how to use tools and modules
Discussing plans and progress at ward/unit level
Documenting work at a local (ward/unit) level
Table II.
Multiple leadership roles
164
JHOM
28,2
implementation was sustained and spread through organisations (hospitals 2, 4 and 7), or
whether only a few enthusiastic wards participated in the programme (hospitals 3, 6, 8):
The energy and the motivation in the first instance was tremendously high, particularly on
the showcase wards. Staff were very keen and welcomed the initiative. Some staff came in to
the ward on their days off to do the activity follow in their own time. But now, staff motivation
has disappeared because of the lack of facilitator support (PW facilitator (programme lead),
study 2, hospital 4).
The third leadership role, that of middle managers/ward managers, involved showing
“commitment to the vision” of The Productive Ward and “being prepared to empower
staff” by releasing their time, delegate or share decision making and encouraging staff
to learn about the programme (see Table II). Understandably some ward managers felt
they needed to direct the work and ensure the programme was implemented swiftly
and efficiently. We found that in hospitals where middle managers and ward managers
focused on creating opportunities for staff engagement rather than trying to direct staff
in an authoritarian way, this instilled a sense of team ownership and changes were
more likely to be sustained (study 1, hospitals 1, 2 and 4).
The fourth type of leadership role was local Productive Ward leads at ward level.
Successful local leads used a participative style to engaging themselves and others,
to bring a sense of credibility to the project and share knowledge and experiences
of implementation (study 1, hospitals 1-5). Although local “informal” leaders did not
generally describe themselves as leaders they did talk about leading the work in terms
of ensuring frontline staff were aware of the programme and changes colleagues were
making to their working practices e.g. facilitating staff from “showcase” wards to
present their work to other staff working on other hospital wards (hospitals 2-5). In this
respect local leaders did recognise their leadership role in championing the programme
or changes initiated through the work. For example:
One healthcare assistant had a huge involvement in the programme and she was able to say
what a difference it had made to her working day [y] she’s getting all these accolades
and suddenly the other healthcare assistants who weren’t interested at all were all on board
(PW trainer, study 1, hospital 4)
Some senior/formal leaders described the importance of recognising the work of local
leads as leadership “so that we can help to develop and encourage these types of skills
in nurses and other frontline staff” (Matron, study 1, hospital 5). In all organisations
(study 1 hospitals 1-5) there was evidence of the potential for skills development as
staff across the organisation took on implementation work:
[y] they don’t realise that in fact, by implementing this in their clinical areas, they in fact go
on a leadership programme – and I don’t think they realise it until they’ve finished
implementing the Releasing Time To Caretfor their area (Senior nurse, study 1, hospital 2).
In relation to the numbers of staff filling these four leadership roles, these varied across
the five hospitals in study 1 according to the size of an organisation, the approach and
stage of implementation. For example, in hospitals 1 and 2 where the programme was
being implemented across the whole-organisational, local leads had been identified for
every ward, whereas there were far fewer identifiable ward-level and local leaders
where the programme was being piloted on a few wards (study 1, hospitals 4 and 5).
In some hospitals ward managers were the staff group that were given/took on the
role of local Productive Ward lead (study 1, hospitals 3 and 5), and this “duality” of
leadership roles was sometimes a point of tension, as discussed in the next section.
165
Impact of
leadership
Experiences of good and badleadership styles
The second theme related to how leaders enacted their role through different styles
and behaviours. In study 1 there was agreement across all sources of data about
the necessity of strategic leadership. Senior leaders expressed strong views about the
importance of strategic leadership – suggesting this was necessary to “create vision”,
“champion the programme”, “align the initiative with strategic goals” and to “connect
the work with other initiatives, targets and local priorities”. Interviews with frontline
staff showed that for many staff working to implement the programme at ward level
encouragement and support for their own participation was a direct indication of
whether there was strong leadership behind the programme. Frontline staff expressed
their positive experiences in terms of being “involved”, “encouraged” and “enabled” by
senior leaders. Programme leads described the need for “keen” wards and staff groups
to participate in ways and at a pace that suited them. The realisation for many
programme leads was that successful implementation required them to use a degree of
free-reign to their approach to leading implementation whilst also facilitating local leads
and frontline staff to adapt Productive Ward work to their own contexts and needs:
With a project of this size, it’s probably something – you have to make your mistakes, learn
from them and move on (PW programme lead, study 1, hospital 4).
For many frontline staff the best way of understanding The Productive Ward was
“learning by experience”, which included making mistakes and learning how to
resolve issues and avoid problems in the future. In three case study sites (study 1,
hospitals 1, 2 and 5) frontline staff were encouraged by programme leaders to interpret
and develop modules in the way they considered most appropriate for them and
encouraging sharing of learning between wards (study 1, hospitals 3 and 6). At some
sites they were even encouraged to take the principles of the modules and toolkit and
apply them to projects or issues not covered in the modules, if appropriate for their
needs. However not all organisations or leaders were confident to delegate leadership
or control. Some senior managers noted that because of the high profile of Productive
Ward, ward managers often rushed to take up the role of local lead without fully
understanding the implications of this particular leadership role. The reality of
facilitating rather than directing staff proved challenging for some ward leaders:
I went to the first event, so we were told we were on cohort two, and we went to the initiation
event and I sat there and I thought, ‘Oh my God, what have I come to? I should have done a bit
more research into this. I was like leafing through the toolkit and all of that, thinking, ‘Okay,
lots of work here (Ward sister, study 1, hospital 3).
Managerial staff often needed to develop skills and knowledge for implementation that
differed from the leadership style and behaviours associated with their managerial role.
Within all five case study sites (study 1) this led to recognition of the need for
leadership training and development for programme leads, managers and local leads;
and in one hospital the initiation of a custom designed leadership training course to
help prepare staff to lead:
Traditionally in nursing we’ve not been fantastic at giving all managers leadership training
before they go in to post. And this is giving them a real clear focus about how to lead (PW
facilitator, study 1, hospital 2).
This head-start was important, because programme leads and others had realised that
in order to lead change at ward level, local leads needed to gain knowledge about the
programme and how best to engage rather than direct frontline staff.
166
JHOM
28,2
Frontline staff having a sense of permission to lead change
The third theme related to issues of frontline staff feeling a sense of permission to
change established practices and routines at ward level. In general interviews with senior
organisational leaders (executives and clinical directors) indicated that they recognised
that they are not necessarily the best people to address ward-level problems and that ward
staff have a better understanding of the day-to-day problems they encounter. An important
factor in enabling senior leaders to delegate control about implementation decisions was
confidence in the programme itself and understanding of how Lean principles can help
frontline staff to bring their observations and ideas for change to the fore:
It’s enabled them to use an established structure and process to harvest the good ideas many
staff have had on their minds for years, and we’ve never actually been able to harvest them
(Chief executive, NHS hospital, study 1, hospital 1).
Case study data from study 1 shows that staff in non-traditional leadership roles
(such as lower grade nurses and health care assistants) can have several advantages
when influencing frontline staff to engage with the programme, based on their
credibility amongst colleagues. However, in some cases individual ward managers
admitted initially feeling concerned about handing over decision-making power to
their staff (study 1, hospitals 3 and 5), fearing a resulting lack of consistency that could
make it difficult to enforce standards. As previously mentioned, it was often this sense
of freedom to adapt the programme to local needs (expressed by staff in study 1,
hospitals 1 and 2) that engaged frontline staff interest and drove progress:
I think it’s that free-rein and people being able to develop the modules as they want [y] that’s
helped people to move on as far as they have done [y] because they’re the people that really
know (PW facilitator (programme lead), study 1, hospital 1).
Indeed, for some ward managers who had taken on the role of local Productive
Ward lead (study 1, hospitals 3 and 5) there was a sense that responsibility remained
with them personally to lead implementation rather than supporting the process of
implementation to be led by the potential insights, drive and enthusiasm of frontline staff:
I’m still leading it and I haven’t been able to completely pull away. And if, for example,
I wasn’t here for a long period of time, they would sustain everything that I do. They would
make some small changes, but they wouldn’t make dramatic changes without coming to me
almost to seek permission to do so (Ward sister, study 1, hospital 3).
At these two hospitals frontline staff had not become as involved in leading
implementation as they had done at other sites. The reasons why seemed to be related
to how resources for implementation had been allocated, in particular having sufficient
resources to free up staff time (“backfill” for nurses’ time away from the ward), access
to training and support provided by the NHS Institute, and allocated budgets for
changes to ward storage areas or layouts. In study 2, differences were noted in whether
ward teams were receptive to change and wanted to take ownership of implementation:
Wards with staff that express a ‘can do attitude’ take on the programme with interest. Wards
where the general attitude is less positive are harder to motivate. Some wards require a lot
more support and encouragement than others before they perceive benefits and become
committed to the programme (PW programme lead, study 2, hospital 6).
Interviews with frontline staff showed that they were often very aware and irritated by
having to work around problems and cope with disorganisation (all hospitals study 1).
What generally held them back from initiating change is that they did not see it as part
of their job or something that they will be encouraged to do, or rewarded for. Or, as one
167
Impact of
leadership
senior leader explained, frontline staff were sometimes unwilling to challenge existing
ways of working because of a fear of repercussions:
Part of what you ask your staff to do in Productive Ward programme – is take some risk – the
staff feel that if they take a risk and it goes wrong, they’re going to be punished. And they
won’t want to do it (Chief executive, study 1, hospital 2).
At this hospital (study 1, hospital 2) it had been found that rather than anarchy, giving
frontline staff guidance and support to tackle issues themselves resulted in similar
solutions from different wards, which could then be combined and developed into a
hospital-wide standard.
Leader’s actions to spread learning and sustain improvements
The fourth theme was the importance of leader’s actions to spread learning and sustain
improvements. Across the data it was possible to identify seven ways in which leaders
connected, these were: leader’s connections with each other; with different staff and
professional groups across the organisation; with existing organisational structures/
systems; with other/external organisations; with information and knowledge resources;
with skills development/training, and support networks; and with systems to evaluate
impact/improvement and share learning. In organisations where the programme had
spread well (in particular study 1, hospitals 1 and 2) programme leads had sought to
connect with different staff, professional and cultural groups by actively linking
implementation with staff interests, goals and priorities. Findings from study 2 (all eight
hospitals) also showed that leaders’ activities were important for spreading
implementation through organisations but many executive and programme leaders did
not prioritise/invest time in creating opportunities to spread learning to other staff
groups. Consequently in six of the eight case study sites (study 2, hospitals 1-5 and 7)
islands of improvement occurred where improvement was isolated and failed to spread:
Generally the energy is present in the organisation but improvement has taken longer on some
wardsthanothersbecauseofcommunicationissues (Programme lead, study 2, hospital 3).
In contrast, leaders in organisations where the programme had spread well had taken
steps to use existing organisational structures, such as staff orientation and induction
programmes to spread knowledge and learning about the programme to new employees.
Another factor was that leaders sustained connections within other leaders in
implementing organisations to gain emergent knowledge and learning (study 1,
hospitals 1-5), rather than disconnecting from intra-organisational networks once
implementation had begun (study 2, hospitals 1, 5, 6, 8). In study 2 dwindling senior
leadership engagement at three case study sites (study 2, hospitals 1, 3 and 6) had led
to the breakdown of vertical connections between senior leadership and leaders
working to implement the programme at lower levels. Local leaders reported feeling
disappointed that the organisation had “lost interest” or had moved on to new
priorities. At hospital 6 there had been limited executive buy-in for the first three
months at which point the organisation’s steering group was disbanded leading to
implementation being discontinued. In one hospital (study 2, hospital 5), reluctance
to share information or learning between wards contributed to discontinuation
of the programme’s implementation. For these respondents, there was a general sense
of failure and missed opportunity to encourage and support leadership development
in others (contrasting with positive examples of mentorship, clinical supervision
and peer-education described by staff in study 1). Another reason for leadership
connections breaking down in three hospital sites (study 2, hospitals 2, 3 and 6) was
168
JHOM
28,2
that a lack of continuation funding for the programme lead had contributed to
discontinuation of implementation across the organisation.
Discussion
Our findings add to the growing body of evidence that suggest improvement programmes
based on Lean thinking can assist with the challenges health care organisations face in
both improving quality and developing effective leadership. The scope of the study –
nationally representative of NHS hospitals in England – and depth of the study data
means our findings are likely to be transferable to cases of implementation of Lean
initiatives in other hospital settings and internationally. Overall the findings illustrate
the dynamic nature of leadership in organisations that are implementing Lean and
development of leadership through undertaking Lean improvement work. We found
evidence that the Productive Ward is helping to develop leadership skills within the health
care workforce in England; which has been shown elsewhere (BHSCT, 2009; NHSL, 2009;
NHSS, 2008) by acting as a learning system to try out new skills and approaches on real
projects within health care environments (Balle and Regnier, 2007).
What type of leadership roles do organisations need to successfully implement
interventions like The Productive Ward?
Senior organisational leaders need to give consideration to leadership at multiple levels
and how interactions between these levels shape outcomes. Such consideration could help
to overcome ambiguity about responsibility for implementation (Ham et al., 2003) and
spread leadership functions vertically through the organisation (Bathurst and Morin,
2010). A proposition for future research is that multi-level leadership enables outcomes by
aligning “top-down” and “bottom-up” leadership of Lean. We suggest that considering
“leadership processes” (rather than just looking at leadership roles) is a useful approach.
Taking this broader view, leadership processes involve not only leaders, but also
followers, interactions (e.g. communication, information, decision making), contexts (e.g.
situations, events, environments, resources, timescales) and outcomes (e.g. results, impact,
organisational learning, and staff morale). Our findings and perspectives from the
literature enable us to put forward a framework of “leadership processes”, illustrated by
Figure 1. This framework could inform strategic and cultural development from an
organisational perspective in order to successfully implement Lean (Brandao de Souza,
2009); as well as offering directions for future research about the challenges of leading
change, innovation and improvement in health care (Hartley and Benington, 2010).
What type of leadership styles and behaviours should leaders use?
Part of strong leadership is understanding the need for different and contextually
appropriate leadership roles, styles and behaviours at different levels and stages of
implementation. Leaders’ contributions to each leadership process are summarised
in Table III. In the early stages of implementation executive/senior organisational
leaders are often best equipped to gain support, information or resources from external
stakeholders and involve other formal leaders (e.g. board members, clinical directors,
service managers, appointed programme leads) in creating a vision and allocating or
securing resources for implementation. In the later stages of implementation programme
leadership and managerial level leadership can help to create the conditions for informal
leadership to emerge (Mumford et al., 2000). This might involve providing information
and support to those who do not necessarily recognise themselves as leaders – typically
health care assistants and junior/student nurses (Cummings et al., 2008). For example,
169
Impact of
leadership
providing information about transformational and relational approaches to leadership
required at a local level of implementation ( Davis and Adams, 2011).
How can leaders engage and energise frontline staff?
Valuing and providing support for meaningful staff empowerment is a key leadership
process. In the case of The Productive Ward, for executive/senior leads valuing the
contributions of frontline staff and providing support for staff to engage in meaningful
ways were felt to be crucial factors to sustained implementation (Table III). The main
contribution of programme leads was providing information and improvement resources
National
(macro)
context
c
d
b
aOrganisational
(meso)
context
Frontline
(micro)
context
Formal leader
Project/programme leader
Informal leader
Notes: (a), Multi-level leadership: senior leaders plan and are committed to multi-level
leadership; project/programme leaders are appointed; managers are aware and supportive;
local (informal) leaders are identified; (b), leadership styles and behaviours: all leaders
understand what type of style to use for their role and types of skills and knowledge they
need; (c), staff empowerment: formal leaders know when and how to relinquish control
through encouraging and supporting informal leaders; informal leaders use their credibility
to engage andinform colleagues; all leaders have access to necessary resources, information,
guidance and support; (d), boundary spanning: leaders communicate well with each other,
reach different staff and professional groups, use existing organisational structures/systems,
link and learn from other organisations, share information and knowledge resources, use
skills development/training, and support networks, evaluate impact/improvement and share
learning
Figure 1.
Framework of leadership
processes
170
JHOM
28,2
Leadership processes (a) Multi-level leadership
(b) Leadership styles and
behaviours (c) Staff empowerment (d) Boundary spanning
Executive/senior manager
lead
Valuing multi-level
leadership, securing
funding and constructing
formal leadership posts at
lower levels
Communicating vision/
strategic goals from
organisational perspective
(strategic)
Allocating resources to
cover staff time to
participate
Acknowledging staff
achievements and successes
Communication beyond the
organisation (stakeholders)
and at board/executive level
to gain support and
resources
Programme lead Planning and monitoring
implementation, developing
local strategies to engage
staff groups
Facilitating access to
training and skills
development at lower levels
(facilitative/planning)
Providing information and
improvement resources
across organisations,
providing feedback about
achievements
Planning, collating and
sharing information across
localities/sites, evaluation of
impact with other leaders,
creating opportunities to
spread learning to other
staff groups
Middle manager Management of frontline
staff participation and
engagement
Allowing frontline staff to
lead change (free-reign/
delegation)
Freeing up staff time and
encouraging staff to
participate
Communicating and
sharing information,
explaining goals of the
work at ward level
Local lead Identifying areas for change
at local level, leading
change with staff in teams
Developing personal skills
and knowledge in
leadership
(transformational/
facilitative)
Communication,
coordination of work and
monitoring team
achievements
Sharing experiences of
implementation and local
learning
Table III.
Leaders’ contributions to
leadership processes
171
Impact of
leadership
across organisations and providing feedback about achievements. While frontline
staff expressed their commitment to the programme according to personal and emotive
aspects of belonging to a “team” or “professional group”; which corresponds with a
mutual understanding of leadership (Denis et al., 2012). It would therefore seem
appropriate to place these types of values at the centre of organisational strategies
for implementation. Future research could explore interactions between leaders and
followers that lead to a sense of empowerment and the impact on outcomes.
How can leaders act to ensure implementation is spread and sustained?
Connecting vertical and horizontal boundary spanning leadership activities helps to
spread learning and sustain improvements. The term the “nexus effect” has been
used to describe the collaborative, transformational outcomes that can be achieved
when leaders span boundaries that are above and beyond what different groups could
achieve on their own (Yip et al., 2008). Adding to this notion, in the present study
leaders’ boundary spanning activities were found to be an indicator of the impact of
leadership on outcomes, and this is an interesting area for future research on long-term
impact. Leaders therefore need to understand the different types of boundaries
and possible meeting places across boundaries (the nexus) that might exist in the
organisations that they work within. Otherwise, as our findings clearly show, even in
organisations where leaders are fully committed to implementation “islands of
improvement”, “discontinuation” or “improvement evaporation” occur when leaders
underestimate the importance of their boundary spanning activities.
Conclusion
This study aimed to explore the nature and impact of leadership in relation to the local
implementation of quality improvement interventions in health care organisations.
By drawing on staff experiences of implementing The Productive Ward in English
hospitals insights were gained into leadership processes as related to lean health care.
A framework for leadership processes is presented which could be applied, tested and
developed in other contexts. The framework includes: consideration of leadership at
multiple levels and how interactions between these levels shape outcomes; reflection on
the need for different and contextually appropriate leadership roles, styles and
behaviours at different levels and stages of implementation; valuing and providing
support for meaningful staff empowerment; and connecting vertical and horizontal
boundary spanning leadership activities to spread learning and sustain improvements.
Further research is needed to explore potential differences in leadership within late
adopting or non-adopting health care organisations; to better define and understand
the longer term impact of spread and sustainability (beyond three years post-
implementation); and to examine the influence of external driving factors such as health
service policy and resourcing, external change agencies and patient groups.
Authors’ contributions: All of the authors made substantial contributions to conception
and design of the reported studies and to the perspectives put forward in this paper. E.M.
led study 1 and study 2 and led the secondary analysis and writing of the paper. G.R.
provided advice and insights into the literature on quality improvement in health care,
implementation research and supported the secondary analysis. J.M. provided guidance
on study design and analysis and contributed thoughts on the nature and potential for
development of leadership in this context. All authors have given final approval of the
version to be published.
Competing interests: The authors declare that they have no competing interests.
172
JHOM
28,2
References
Balle, M. and Regnier, A. (2007), “Lean as a learning system in a hospital ward”, Leadership in
Health Services, Vol. 20 No. 1, pp. 33-41.
Barr, J. and Dowding, L. (Eds) (2012), Leadership in Health Care, Sage, London.
Bass, B. and Riggio, R. (Eds) (2006), Transformational Leadership, Routledge, New York, NY.
Bathurst, R. and Morin, N. (2010), “Shaping leadership for today: Mary Parker Follett’s aesthetic”,
Leadership, Vol. 6 No. 2, pp. 115-131.
Bem-Tovim, D., Bassham, J., Bolch, D. and Al, E. (2007), “Lean thinking across a hospital:
redesigning care at the Flinders Medical Centre”, Australian Health Review, Vol. 31 No. 1,
pp. 10-15.
Benington, J. and Hartley, J. (2010), “Knowledge and capabilities for leadership across the whole
public service system”, in Brookes, S. and Grint, K. (Eds), The New Public Leadership
Challenge, Basingstoke, Palgrave Macmillan, pp. 187-198.
Berwick, D. (2003), “Disseminating innovations in health care”, Journal of American Medical
Association, Vol. 289 No. 15, pp. 1969-1975.
BHSCT (2009), Belfast Health and Social Care Trust Productive Ward – Releasing Time to Care
Evaluation Report, Belfast Health and Social Care Trust, Belfast.
Brandao de Souza, L. (2009), “Trends and approaches in lean healthcare”, Leadership in Health
Services, Vol. 22 No. 2, pp. 121-139.
Braun, V. and Clarke, V. (2006), “Using thematic analysis in psychology”, Qualitative Research in
Psychology, Vol. 3 No. 2, pp. 77-101.
Brown, J. and Duguid, P. (1991), “Organizational learning and communities-of-practice: toward a
unified view of working, learning, and innovating”, Organization Science: A Journal of the
Institute of Management Sciences, Vol. 2 No. 1, pp. 40-57.
Buchanan, D., Fitzgerald, L. and Ketley, D. (Eds) (2007b), The Sustainability and Spread of
Organisational Changes, Routledge, Oxon.
Burns, J. (Ed.) (1978), Leadership, Harper & Row, New York, NY.
Crump, B. (2008), “How can we make improvement happen?”, Clinical Governance an International
Journal,Vol.13No.1,pp.45-50.
Cummings, G., Lee, H., Macgregor, T., Davey, M., Wong, C., Paul, L. and Stafford, E. (2008),
“Factors contributing to nursing leadership: a systematic review”, Journal of Health
Service Research and Policy, Vol. 13 No. 4, pp. 240-248.
Currie, G. and Lockett, A. (2011), “Distributing leadership in health and social care: concertive,
conjoint or collective?”, International Journal of Management Reviews, Vol. 13 No. 3,
pp. 286-300.
Currie, G. (2012), “Inter-professional barriers and knowledge brokering in an organizational
context: the case of healthcare”, Organization Studies, Vol. 33 No. 7, pp. 937-962.
Davis, J. and Adams, J. (2011), “The releasing time to care – the productive ward programme:
participants perspectives”, Journal of Nursing Management, Vol. 20 No. 3, pp. 354-360.
Denis, J., Langley, A. and Sergi, V. (2012), “Leadership in the plural”, The Academy of Management
Annals,Vol.6No.1,pp.211-283.
Denzin, N. and Lincoln, Y. (Eds) (2000), Handbook of Qualitative Research, 2nd ed., Sage,
Thousand Oaks, CA.
Dickson, G. (2009), “Transformations in Canadian health systems leadership: an analytical
perspective”, Leadership in Health Services, Vol. 22 No. 4, pp. 292-305.
Doumit, G., Wright, F., Graham, I., Smith, A. and Grimshaw, J. (2011), “Opinion leaders and
changes over time: a survey”, Implementation Science, Vol. 6, October, p. 117.
173
Impact of
leadership
Eccles,M.,Armstrong,D.,Baker,R.,Cleary,K.,Davies,H.,Davies,S.,Glasziou,P.,Ilott,I.,Kinmoth,A.,
Leng, G., Logan, S., Mareau, T., Michie, S., Rogers, H., Rycroft-Malone, J. and Sibbald, B. (2009),
“An implementation research agenda”, Implementation Science,Vol.4,April,p.18.
Edmonstone, J. (2011), “Developing leaders and leadership in health care: a case for
rebalancing?”, Leadership in Health Services, Vol. 24 No. 1, pp. 8-18.
Emiliani, B. (2008), Real Lean; Understanding The Lean Management System, Published by
The Centre for Lean Business Management, Kensington, CT.
Ernst, C. and Chrobot-Mason, D. (2010), Boundary Spanning Leadership: Six Practices for
Solving Problems, Driving Innovation, and Transforming Organizations, McGraw-Hill
Professional, New York, NY.
Ferlie, E., Fitzgerald, L., Wood, M. and Hawkins, C. (2005), “The non-spread of innovations:
the mediating role of professionals”, Academy of Management Journal, Vol. 48 No. 1,
pp. 117-134.
Ferlie, E. and Shortell, S. (2001), “Improving the quality of health care in the United Kingdom
and the United States: a framework for change”, Milbank Quarterly, Vol. 79 No. 2,
pp. 281-315.
Fillingham, D. (2007), “Can lean save lives?”, Leadership in Health Services, Vol. 20 No. 4, pp. 231-241.
Fleming, L. and Waguespack, D. (2007), “Brokerage, boundary spanning, and leadership in open
innovation communities”, Organization Science: A Journal of the Institute of Management
Sciences, Vol. 18 No. 2, pp. 165-180.
Fletcher, J. (2004), “The paradox of postheroic leadership: an essay on gender, power and
transformational change”, Leadership Quarterly, Vol. 15 No. 5, pp. 647-661.
Golden-Biddell, K. and Locke, K. (Eds) (1997), Composing Qualitative Research, Sage, Thousand
Oaks, CA.
Goodwin, N. (2000), “Leadership and the UK health service”, Health Policy, Vol. 51 No. 1,
pp. 49-60.
Gough, P. and Masterson, A. (2009), “Co-operation leads the way (editorial)”, Nursing Older
People, Vol. 21 No. 2, p. 3.
Govier, I. and Nash, S. (2009), “Examining transformational approaches to effective leadership in
healthcare settings”, Nursing Times, Vol. 105 No. 18, pp. 24-27.
Greenhalgh, T., Robert, G., Bate, P., Macfarlane, F. and Kyriakidou, O. (2005), Diffusion of
Innovations in Health Service Organisations: A Systematic Literature Review, BMJ Books,
Blackwell, Oxford.
Grimshaw, J., Eeccles, M., Greener, J., Maclennan, G., Ibbotson, T., Kahan, J. and Sullivan, F.
(2006), “Is the involvement of opinion leaders in the implementation of research findings a
feasible strategy?”, Implementation Science, Vol. 1, February, p. 3.
Ham, C., Kipping, R. and Mcleod, H. (2003), “Redesigning work processes in health care: lessons
from the National Health Service”, The Milbank Quarterly, Vol. 81 No. 3, pp. 415-439.
Hartley, J. (2012), “Leadership across complex systems and boundaries”, in Spurgeon, P.,
Burke, R.J. and Cooper, C.L. (Eds), The Innovation Imperative in Health Care Organisations:
Critical Role of Human Resource Management in the Cost, Quality and Productivity Equation,
Edward Elgar Publishing Ltd, Cheltenham, pp. 187-204.
Hartley, J. and Benington, J. (2010), Leadership for Healthcare, The Policy Press, Bristol.
Holloway, I. and Todres, L. (2003), “The status of method: flexibility, consistency and coherence”,
Qualitative Research, Vol. 3 No. 3, pp. 345-357.
House, R., Rousseau, D. and Thomas-Hunt, M. (1995), “The meso-paradigm: a framework for
the integration of micro and macro organizational behaviour”, in Staw, B.M. and
Cummings, L.L. (Eds), Research in Organizational Behaviour, Vol. 17, pp. 71-114.
174
JHOM
28,2
Jacobson, N. and Goering, P. (2006), “Credibility and credibility work in knowledge transfer”,
Evidence and Policy, Vol. 2 No. 2, pp. 1151-1165.
Jones, D. and Mitchell, A. (2006), LEAN thinking for the NHS, NHS Confederation, London.
Kislov, R., Harvey, G. and Walshe, K. (2011), “Collaborations for leadership in applied health
research and care: lessons from the theory of communities of practice”, Implementation
Science, Vol. 6, June, p. 64.
Kouzes, J. and Posner, B. (1988), The Leadership Challenge, Jossey-Bass, San Francisco, CA.
McNulty, T. and Ferlie, E. (2002), Reengineering Healthcare: The Complexities of Organizational
Transformation, Oxford University Press, Oxford.
MA (2005), “New improvement wheel”, NHS Modernisation Agency Research into Practice team,
Modernisation Agency, Coventry.
Martin, G. and Waring, J. (2013), “Leading from the middle: constrained realities of clinical
leadership in healthcare organisations”, Health, Vol. 2013 No. 17, pp. 358-374.
May, C., Mair, F., Finch, T., Macfarlane, A., Dowrick, C., Treweek, S., Rapley, T., Ballini, L., Ong, B.,
Rogers,A., Murray, E., Elwyn, G., Legare, F., Gunn, J. and Montori, V. (2009), “Development of
a theory of implementation and integration: Normalization Process Theory”, Implementation
Science, No. 4, p. 29.
Mayrowetz, D. (2008), “Making sense of distributed leadership: Exploring the multiple
uses of the concept in the field”, Educational Administration Quarterly, Vol. 44 No. 3,
pp. 424-435.
Miller, K. (2006), “Leaders for change review evaluation report”, The Health Foundation, London.
Morrow, E., Robert, G., Maben, J. and Griffiths, P. (2012), “Implementing large-scale quality
improvement – lessons from The Productive Ward: releasing time to care”, International
Journal of Health Care Quality Assurance, Vol. 25 No. 4, pp. 237-253.
Mumford, M., Zaccaro, S., Harding, F., Jacobs, T. and Fleishman, E. (2000), “Leadership skills
for a changing world solving complex social problems”, The Leadership Quarterly, Vol. 11
No. 1, pp. 11-35.
NHSL (2009), “Evaluation of releasing time to care”, summary report, NHS London, London.
NHSS (2008), Releasing Time to Care Evaluation, NHS Scotland, Edinburgh.
NNRU&NHSI (2010), The Productive Ward: Releasing Time to Care. Learning and Impact Review,
NHS Institute & National Nursing Research Unit, Warwick.
NNRU&NHSI (2011), Improving Healthcare Quality at Scale and Pace Lessons From The
Productive Ward: Releasing Time to Care, NHS Institute & National Nursing Research
Unit, Warwick.
Øvretveit, J. (2009), Leading Improvement Effectively. Review of Research, The Health Foundation,
London.
Pearce, C. (2004), “The future of leadership: combining vertical and shared leadership to
transform knowledge work”, Academy of Management Executive, Vol. 18 No. 1, pp. 47-57.
Pedersen, D. and Hartley, J. (2008), “The changing context of public leadership and management:
implications for roles and dynamics”, International Journal of Public Sector Management,
Vol. 21 No. 4, pp. 327-339.
Radnor, Z., Holweg, M. and Waring, J. (2012), “Lean in healthcare: the unfilled promise?”, Social
Science & Medicine, Vol. 74 No. 3, pp. 364-371.
Radnor, Z. and Boaden, R. (2008), “Lean in the public services: panacea or paradox? (Editorial)”,
Public Money and Management, Vol. 28 No. 1, pp. 3-6.
Richie, J. and Spencer, L. (1994), “Qualitative data analysis for applied policy research”, in Bryman, A.
and Burgess, R. (Eds), Analyzing Qualitative Data, Routledge, London, pp. 173-194.
175
Impact of
leadership
Ritchie, J. and Lewis, J. (Eds) (2003), Qualitative Research Practice: A Guide for Social Science
Students and Researchers, Sage Publications, London.
Robert, G., Morrow, E., Maben, J. and Griffiths, P. (2011), “The adoption, local implementation and
assimilation into routine practice of a national quality improvement programme: The
Productive Ward in England”, Journal of Clinical Nursing, Vol. 20 Nos. 7/8, pp. 1196-1207.
Rogers, E. (1995), Diffusion of Innovations, The Free Press, New York, NY.
Rooney, S. and Rooney, J. (2005), “Lean glossary”, Quality Progress, Vol. 38 No. 6, pp. 41-47.
Sabatier, P. (1986), “Top-down and bottom-up approaches to implementation research: a critical
analysis and suggested synthesis”, Journal of Public Policy, Vol. 6 No. 1, pp. 21-48.
Savary, L. and Crawford-Mason, C. (2006), “The nun and the bureaucrat: how they found and
unlikely cure for America’s sick hospitals.
The King’s Fund (2012), Leadership and Engagement for Improvement in the NHS: Together We
Can, The King’s Fund, London.
Van de Ven, A., Polley, D., Garud, R. and Venkataraman, S. (1999), The Innovation Journey,
Oxford University Press, Oxford.
Walshe, K. (2007), “Understanding what works – and why – in quality improvement: the need for
theory-driven evaluation”, International Journal for Quality in Health Care, Vol. 19 No. 2,
pp. 57-79.
Waring, J. and Bishop, S. (2010), “Lean healthcare: rhetoric, ritual, resistance”, Social Science and
Medicine, Vol. 71 No. 7, pp. 1332-1340.
White, M., Wells, J.S. and Butterworth, T. (2013), “The Productive Ward: releasing time to caret
what we can learn from the literature for implementation”, Journal of Nursing
Management, Early view published online June 2013.
Womack, J., Jones, D. and Roos, D. (1990), The Machine That Changed the World: The Story of
Lean Production, Harper Collins Publishers, New York, NY.
Yin, R. (2008), Case Study Research: Design and Methods, Sage Publications, Thousand Oaks,
CA.
Yip, J., Wong, S. and Ernst, C. (2008), “The nexus effect: when leaders span boundaries”,
Leadership in Action, Vol. 28 No. 4, pp. 13-17.
Young, T. and McClean, S. (2008), “A critical look at lean thinking in healthcare”, Quality and
Safety in Health Care, Vol. 17 No. 5, pp. 382-386.
Young, T. and McClean, S. (2009), “Some challenges facing lean thinking in healthcare”,
International Journal of Quality in Health Care, Vol. 5, pp. 309-310.
Further reading
Buchanan, D., Addicott, R., Fitzgerald, L., Ferlie, E. and Baeza, J. (2007a), “Nobody in charge:
distributed change agency in healthcare”, Human Relations, Vol. 60 No. 7, pp. 1065-1090.
Mehra, A. and Schenkel, M. (2008), “The price Chameleons pay: self-monitoring, boundary
spanning and role conflict in the workplace”, British Journal of Management, Vol. 19,
pp. 138-144.
Corresponding author
Dr Elizabeth Morrow can be contacted at: elizabethmmorrow@hotmail.co.uk
To purchase reprints of this article please e-mail: reprints@emeraldinsight.com
Or visit our web site for further details: www.emeraldinsight.com/reprints
176
JHOM
28,2
... The percentage of VRIII episodes associated with at least one hypoglycaemic event (glucose <4 mmol/L) declined from 25% at baseline, 13% peri-intervention (p=0.07), 19.7% post-intervention (0=0.28) and 22.2% at follow-up (p=0.71). For hyponatraemias (sodium <135 mmol/L), the corresponding improvement was more marked, from 26% at baseline to 20.8% peri-intervention (p=0.45) and 12% post-intervention (p<0.01). ...
... For success in sustainability and spread of improvement, current literature highlight the requirements of leadership which would include alignment of the initiative with strategic goals of the organisation, multiple levels of leadership for the project, facilitative leadership and leaders' boundary spanning activities. 19 Our limitations were probably not being able to include this high impact project in organisational QI priority list, not being able to have leadership responsibilities for this project through existing Trust governance structures, not being able to encourage sufficient champions to own up local leaderships in ward areas. Our projects leads have made horizontal connections with specialist societies (Association of British Clinical Diabetologists, Diabetes UK, RCPQI Faculty) and the project was presented in national conference but the vertical connections within the organisation could have been better. ...
Article
Full-text available
Variable rate intravenous insulin infusions (VRIII) are frequently used in hospitals and incorrect use can lead to electrolyte imbalance, hypoglycaemia and adverse outcomes. The Joint British Diabetes Societies (JDBS) published guidelines in 2014 and recommended the use of a balanced fluid as substrate. There was no published data to demonstrate the superiority of this fluid in reducing adverse events. This quality improvement project aimed to review the existing practice at our Trust in accordance with JDBS guidelines. We predicted introducing this fluid would reduce adverse events and demonstrating this was a prerequisite condition from our Trust Medicines Management Committee to approve its long-term availability. We carried out an audit of our practice in 2015, at which time the JBDS recommended fluid (0.45% sodium chloride/5% dextrose with 0.15% potassium chloride) was not available in our Trust. Our VRIII guideline was re-written with recommendation for use of the balanced fluid, after procurement from pharmacy. Our primary areas for improvement as highlighted from the 2015 audit were correct substrate prescription and rate reduction of hypokalaemia (potassium <3.5 mmol/L) and hypoglycaemia (glucose <4 mmol/L) during VRIII use. Analysis of the pre-intervention (December 2016) and post-intervention (September–November 2017) data showed a significant increase in correct fluid use; 11% pre-intervention to 76% post-intervention (χ ² , p<0.0001). The number of hypoglycaemic events per VRIII reduced from 0.73 (±1.78) to 0.28 (±0.84) (p<0.05) peri-intervention. Similarly, the number of hypokalaemic events per VRIII reduced from 0.15 (±0.54) pre-intervention to 0.05 (±0.25) post-intervention. There was also a significant reduction in number of VRIII episodes associated with a hyponatraemia event from 26% at baseline to 12% post-intervention (p<0.01). Some of these marked improvements were not sustained at 1-year post follow-up. We reduced adverse outcomes with a substantial net-cost saving during this period, through implementation of new and accessible guidelines, trust-wide education programmes and posters to raise awareness.
... Informal leaders were viewed as more influential based on their credibility amongst colleagues. This same phenomenon has been found in similar work [62]. ...
... Engaging influential individuals across organizations can help to secure the credibility of interventions and strategies to develop "informal leaders" have shown to be effective in implementing changes at the clinical level [62]. Hence, implementation strategies should recognize and seek to engage with and develop individuals who have not traditionally been perceived as leaders. ...
Article
Full-text available
Background In 2012, Alberta Health Services created Strategic Clinical NetworksTM (SCNs) to develop and implement evidence-informed, clinician-led and team-delivered health system improvement in Alberta, Canada. SCNs have had several provincial successes in improving health outcomes. Little research has been done on the sustainability of these evidence-based implementation efforts. Methods We conducted a qualitative realist evaluation using a case study approach to identify and explain the contextual factors and mechanisms perceived to influence the sustainability of two provincial SCN evidence-based interventions, a delirium intervention for Critical Care and an Appropriate Use of Antipsychotics (AUA) intervention for Senior’s Health. The context (C) + mechanism (M) = outcome (O) configurations (CMOcs) heuristic guided our research. Results We conducted thirty realist interviews in two cases and found four important strategies that facilitated sustainability: Learning collaboratives, audit & feedback, the informal leadership role, and patient stories. These strategies triggered certain mechanisms such as sense-making, understanding value and impact of the intervention, empowerment, and motivation that increased the likelihood of sustainability. For example, informal leaders were often hands-on and influential to front-line staff. Learning collaboratives broke down professional and organizational silos and encouraged collective sharing and learning, motivating participants to continue with the intervention. Continual audit-feedback interventions motivated participants to want to perform and improve on a long-term basis, increasing the likelihood of sustainability of the two multi-component interventions. Patient stories demonstrated the interventions’ impact on patient outcomes, motivating staff to want to continue doing the intervention, and increasing the likelihood of its sustainability. Conclusions This research contributes to the field of implementation science, providing evidence on key strategies for sustainability and the underlying causal mechanisms of these strategies that increases the likelihood of sustainability. Identifying causal mechanisms provides evidence on the processes by which implementation strategies operate and lead to sustainability. Future work is needed to evaluate the impact of informal leadership, learning collaboratives, audit-feedback, and patient stories as strategies for sustainability, to generate better guidance on planning sustainable improvements with long term impact.
... These process-orientated approaches underpin well-known QI initiatives in health care settings such as releasing time to care, the productive ward and model for improvement (Scoville and Little, 2014;Morrow et al., 2014;White et al., 2014). Despite their industrial origins, health-care organisations (HOs) favour such QI initiatives as they can provide action-oriented frameworks that lead to incremental and breakthrough improvements to quality and patient safety issues (Niñerola et al., 2020;Standiford et al., 2019). ...
... HOs, especially those who have adopted and adapted QI methodologies and frameworks from other industries such as automotive and engineering-intense manufacturing systems are always seeking a guiding hand in their QI initiatives. The health-care sector has been inundated with methodologies and frameworks that provide a step-by-step guide in improvement initiatives (Scoville and Little, 2014;Morrow et al., 2014;White et al., 2014). However, some of them require affiliation with an improvement methodology such as lean thinking. ...
Article
Purpose The various quality improvement (QI) frameworks and maturity models described in the health services literature consider some aspects of QI while excluding others. This paper aims to present a concerted attempt to create a quality improvement maturity model (QIMM) derived from holistic principles underlying the successful implementation of system-wide QI programmes. Design/methodology/approach A hybrid methodology involving a systematic review (Phase 1) of over 270 empirical research articles and books developed the basis for the proposed QIMM. It was followed by expert interviews to refine the core constructs and ground the proposed QIMM in contemporary QI practice (Phase 2). The experts included academics in two academic conferences and 59 QI managers from the New Zealand health-care system. In-depth interviews were conducted with QI managers to ascertain their views on the QIMM and its applicability in their respective health organisations (HOs). Findings The QIMM consists of four dimensions of organisational maturity, namely, strategic, process, supply chain and philosophical maturity. These dimensions progress through six stages, namely, identification, ad-hoc, formal, process-driven, optimised enterprise and finally a way of life. The application of the QIMM by the QI managers revealed that the scope of QI and the breadth of the principles adopted by the QI managers and their HOs in New Zealand is limited. Practical implications The importance of QI in health systems cannot be overstated. The proposed QIMM can help HOs diagnose their current state and provide a guide to action achieving a desirable state of quality improvement maturity. This QIMM avoids reliance on any single QI methodology. HOs – using the QIMM – should retain full control over the process of selecting any QI methodology or may even cherry-pick principles to suit their needs as long as they understand and appreciate the true nature and scope of quality overstated. The proposed QIMM can help HOs diagnose their current state and provide a guide to action achieving a desirable state of quality improvement maturity. This QIMM avoids reliance on any single QI methodology. HOs – using the QIMM – should retain full control over the process of selecting any QI methodology or may even cherry-pick principles to suit their needs as long as they understand and appreciate the true nature and scope of quality. Originality/value This paper contributes new knowledge by presenting a maturity model with an integrated set of quality principles for HOs and their extended supply networks.
... While this may work towards becoming an even better clinician, such a state is detrimental for leadership skill development. For instance, Morrow et al. (2014) and Giri (2017) found that physicians would benefit from leadership development in order to become more effective at their job. Leadership development would help boost not only "technical" skills in the field but also the leadership identity of physician leaders. ...
... Because of this, physician leaders do not want to fail in leadership work either and can compensate for shortcomings by taking part in patient work for which they are highly trained and able to excel in. However, instead of compensating for handicaps in leadership skills through clinical skills, more emphasis should be placed on leadership education and leadership work to allow physicians to benefit from leadership development (Morrow et al., 2014;Giri, 2017). ...
Article
Full-text available
Available as an Open Access article at: https://www.emerald.com/insight/content/doi/10.1108/JHOM-10-2020-0421/full/html Purpose This study seeks to improve the understanding of physician leaders' leadership work challenges. Design/methodology/approach The subjects of the empirical study were physician leaders ( n = 23) in the largest central hospital in Finland. Findings A total of five largely identity-related, partially paradoxical dilemmas appeared regarding why working as “just a leader” is challenging for physician leaders. First, the dilemma of identity ambiguity between being a physician and a leader. Second, the dilemma of balancing the expected commitment to clinical patient work by various stakeholders and that of physician leadership work. Third, the dilemma of being able to compensate for leadership skill shortcomings by excelling in clinical skills, encouraging physician leaders to commit to patient work. Fourth, the dilemma of “medic discourse”, that is, downplaying leadership work as “non-patient work”, making it inferior to patient work. Fifth, the dilemma of a perceived ethical obligation to commit to patient work even if the physician leadership work would be a full-time job. The first two issues support the findings of earlier research, while the remaining three emerging from the authors’ analysis are novel. Practical implications The authors list some of the practical implications that follow from this study and which could help solve some of the challenges. Originality/value This study explores physician leaders' leadership work challenges using authentic physician leader data in a context where no prior empirical research has been carried out.
... Informal leaders were viewed as more in uential based on their credibility amongst colleagues. This same phenomenon has been found in similar work (52). ...
... Engaging in uential individuals across organizations can help to secure the credibility of interventions and strategies to develop "informal leaders" have shown to be effective in implementing changes at the clinical level (52). Hence, implementation strategies should recognize and seek to engage with and develop individuals who have not traditionally been perceived as leaders. ...
Preprint
Full-text available
Background: In 2012, Alberta Health Services created Strategic Clinical NetworksTM (SCNs) to develop and implement evidence-informed, clinician-led and team-delivered health system improvement in Alberta, Canada. SCNs have had several provincial successes in improving health outcomes. Little research has been done on the sustainability of these evidence-based implementation efforts. Methods: We conducted a qualitative realist evaluation using a case study approach to identify and explain the contextual factors and mechanisms perceived to influence the sustainability of two provincial SCN evidence-based interventions, a delirium intervention for Critical Care and an Appropriate Use of Antipsychotics (AUA) intervention for Senior’s Health. The context (C) + mechanism (M) = outcome (O) configurations (CMOcs) heuristic guided our research. Results: We conducted thirty realist interviews in two cases and found four important mechanisms facilitating sustainability: the use of a collaborative approach, audit & feedback, the informal leadership role, and patient stories. Informal leaders were often hands-on and influential to front-line staff. Learning collaboratives broke down professional and organizational silos and encouraged collective sharing and learning, motivating participants to continue with the intervention. Continual audit & feedback interventions motivated participants to want to perform and improve on a long-term basis, increasing the likelihood of sustainability of the two scaled, multi-component interventions. Patient stories demonstrated the interventions’ impact on patient outcomes, motivating staff to want to continue doing the intervention, and increasing the likelihood of its sustainability. Conclusions: There are important contextual factors and mechanisms within sustainability processes that may apply to systems change implementers and decision makers. Our research revealed the causal relationship between implementation and sustainability and how outcomes from implementation shape sustainability contexts. Future work is needed to evaluate the effectiveness of informal leadership, learning collaboratives, audit-feedback, and patient stories as strategies for sustainability, to generate better guidance on planning sustainable improvements with long term impact.
... Informal leaders were viewed as more in uential based on their credibility amongst colleagues. This same phenomenon has been found in similar work (51). ...
... Engaging in uential individuals across organizations can help to secure the credibility of initiatives and strategies to develop "informal leaders" have shown to be effective in implementing changes at the clinical level (51). Hence, implementation strategies should recognize and seek to engage with and develop individuals who have not traditionally been perceived as leaders. ...
Preprint
Full-text available
Background: In 2012, Alberta Health Services created Strategic Clinical NetworksTM (SCNs) to develop and implement evidence-informed, clinician-led and team-delivered health system improvement in Alberta, Canada. SCNs have had several provincial successes in improving health outcomes. Little research has been done on the sustainability of these efforts. Methods: We conducted a qualitative realist evaluation using a case study approach to identify and explain the contextual factors and mechanisms perceived to influence the sustainability of two provincial SCN initiatives. The context (C) + mechanism (M) = outcome (O) configurations (CMOcs) heuristic guided our research. Results: We conducted thirty realist interviews in two cases and found four important mechanisms facilitating sustainability: the use of a collaborative approach audit & feedback, the informal leadership role, and patient stories. Informal leaders were often hands-on and influential to front-line staff. Learning collaboratives broke down professional and organizational silos and encouraged collective sharing and learning, motivating participants to continue with the initiative. Continual audit-feedback interventions motivated participants to want to perform and improve on a long-term basis, increasing the likelihood of initiative sustainability. Patient stories demonstrated the initiatives’ impact on patient outcomes, motivating staff to want to continue doing the initiative, and increasing the likelihood of its sustainability. Conclusions: There are important contextual factors and mechanisms within sustainment processes that may apply to systems change implementers. Our research revealed the causal relationship between implementation and sustainability and how outcomes from implementation shape sustainability contexts. Future work is needed to evaluate the effectiveness of informal leadership, learning collaboratives, audit-feedback, and patient stories as sustainability interventions, to generate better guidance on planning sustainable improvements with long term impact.
... An IPMS encourages traditional models, in which leadership resides in a single individual, to evolve into leadership development efforts that extend to all levels of the organization. Transformational leadership and transactional leadership are powerful concepts for improving organizational performance [17,18]. However, distributed leadership is potentially a more useful solution for team management compared to hierarchical and vertical leadership [19,20]. ...
Article
Full-text available
Background Performance management systems have been introduced in health and social services institutions to improve organizational performance, supporting the emergence of new management behaviors that are more rooted in collaborative management practices. This study aims to understand how different leadership styles emerge through the implementation of a performance management system and its related tools, and how these can foster distributed leadership. Methods Over two years, the implementation of an integrated performance management system supporting the integration of social services for children, youth, and families was studied at a recently merged Canadian healthcare organization. Qualitative analysis of data collected from 15 interviews, 3 focus groups, and over 350 h of non-participant observation was conducted. Results The results show that leadership evolved to adapt to the context of organizational integration and was no longer confined to a single manager. Transformational leadership was needed to encourage the emergence of a new integrated performance management system and new behaviors among middle managers and team members. Transactional leadership was legitimized through the use of a status sheet when the integration project did not deliver the expected results. Both transformational and transactional leadership paved the way to distributed leadership, which in turn promoted collaborative practices associated with activities in control rooms and dialogue stemming from the status sheets. Distributed leadership among team members made a difference in the outcome of the integration project, which became a driver of collaboration. Conclusions The integrated performance management system and the use of its tools can help renew leadership in health and social service organizations. The results lend credence to the importance of distributed leadership in promoting collaborative practices to improve services for children, youth, and families. The results also highlight how various leadership styles can contribute to the emergence of distributed leadership over time.
... Furthermore, when a RUSON was on shift, staff identified the positive lift in morale associated with their presence. Increase in morale was also an outcome of the productive ward and improved workflow ( Morrow et al., 2014 ). This project highlighted that enabling RNs to undertake other work, whilst knowing that quality care can be maintained through delegation of some of the fundamental aspects of care contributed to work satisfaction. ...
Article
Problem Undergraduate nursing students remain an underutilised workforce within healthcare. This paper explores the establishment of a Registered Undergraduate Students of Nursing (RUSON) model through a university and healthcare partnership. Background Nursing continues to adapt to increasingly complex patient populations. Initiatives are needed to enable nurses to focus on patients’ care needs amidst increasing healthcare costs. This study identifies opportunities and strategies for engaging undergraduate nursing students as part of the healthcare workforce through the RUSON model, from the perspective of nurse leaders. Aim This project aimed to explore nurse leaders’ perspectives surrounding implementation of a RUSON model. Method A qualitative exploratory design was employed for this study. Thematic analysis from a focus group with the nurse leaders was undertaken. Findings Two key themes were identified from the analysis, i) Establishing the RUSON; with sub-themes: “Who are RUSONs?”, “You are not on clinical placement” and “The importance of inclusivity” and ii) Benefits of the RUSONs; with sub-themes: “Addressing patient care needs”, “Value to the nursing team” and “Creating future ready employees”. Participants identified barriers that were overcome, subsequently leading to the model being considered advantageous to the clinical environment. Discussion The establishment of a RUSON workforce in acute care settings brings with it benefits to the nursing staff and the RUSONs themselves. In order to successfully embed a RUSON model in an organisation, it is important to collaborate with the nursing leadership team in the implementation process. Conclusion A RUSON workforce is an appropriate human resource strategy, both at the immediate point of implementation and longitudinally, as a recruitment strategy for future employment. Successful implementation of a RUSON model requires engagement and collaboration with nursing leaders.
... The Lean healthcare literature expounds the importance of providing staff with protected time to support their involvement in Lean initiatives (Morrow et al., 2014;Noori, 2015;White et al., 2017). What this study highlights is that provision of protected time (in this case to attend the five-day workshop) is insufficient in terms of supporting staff to participate in an RPIW. ...
Purpose This research aims to contribute to the literature on Lean implementation in healthcare by studying the emotional experiences of the relevant actors related to a Rapid Process Improvement Workshop (RPIW) in a UK healthcare context. The purpose of this study was to go beyond what people think about Lean and towards an exploration of their subjective, emotional and “feeling” experience and whether that emotional experience influenced Lean implementation. Design/methodology/approach A phenomenological and symbolic interactionist qualitative case study was undertaken. Data related to participants' emotional experience were collected through non-participant observation and semi-structured interviews. Data were analysed using thematic network analysis. Findings This paper provides novel insights into the emotional experience of Lean as experienced through an RPIW. The findings reveal that participation in an RPIW is much more than a technical process. It influences how people feel about themselves, is based on relationships with others, and requires mental, physical and emotional effort. All of these factors influence engagement with, initiation of and sustainability of the RPIW. Research limitations/implications A new conceptual framework for the planning and implementation of RPIWs has been developed. However, because of the chosen research approach, the results may lack generalisability. Therefore, researchers are encouraged to test the framework and proposed practice implications. Originality/value Despite emotions being an integral part of individual and social everyday life, emotional experience has not been studied in relation to Lean. This study is the first to explore emotions in relation to Lean, with implications for practice as to how RPIWs are managed with a new framework for implementation being proposed.
Article
Purpose Extant research documents the importance of lean thinking for organizations, however, as prior research has largely focused on hard lean practices, but little is known about the effects or the significance of soft lean practices. This research attempts to address this issue by examining how soft lean practices enhance organizational lean readiness, and in turn increase the success of lean implementation. Design/methodology/approach This research adopts a single case study design in a small-medium enterprise livestock feed manufacturing organization, and investigates the period from late 2011 through the end of 2019 covering two attempts at lean implementation – an initial failed attempt followed by a successful introduction of lean within the case organization. The research analyzes interviews with 29 managers and employees from all organizational levels and departments within the case organization. Secondary data including organizational documents and performance measures and metrics were also incorporated into the research design. Findings Drawing on agency theory, the authors advance a principal-agent interaction perspective to conceptualize organizational lean readiness – specifically, the authors consider the “state or condition” of four agency factors (goal conflict, information asymmetry, risk aversion and length of relationship), and explore if these four agency factors can be utilized as proxies for organizational readiness for lean implementation. The authors identify the formation of a shared vision and identity within the organization as an effective mechanism through which soft lean practices enhance organizational lean readiness. Finally, the analysis offers an understanding of how the long-term success of lean implementation is improved by the introduction of soft lean practices as a prerequisite to create organizational readiness for the implementation of hard lean practices. Originality/value The study is unique in the sense that it empirically links agency theory and the role of soft lean practices in developing organizational lean readiness in a small-medium enterprise context by defining the ideal state of four agency factors as proxies for organizational readiness.
Article
Full-text available
This is a systematic review on how innovations in health service practice and organisation can be disseminated and implemented. This is an academic text, originally commissioned by the Department of Health from University College London and University of Surrey, using a variety of research methods. The results of the review are discussed in detail in separate chapters covering particular innovations and the relevant contexts. The book is intended as a resource for health care researchers and academics.
Article
Full-text available
Knowledge work is becoming increasingly team-based. The reason is clear. It is becoming ever more difficult for any one person to be an expert on all aspects of the work that needs to be done, and this is true in a wide variety of contexts ranging from the R&D lab to the executive suite. With the shift to team-based knowledge work comes the need to question more traditional models of leadership. Traditionally, leadership has been conceived around the idea that one person is firmly "in charge" while the rest are simply followers-what is termed vertical leadership. However. recent research indicates that leadership can be shared by team leaders and team members-rotating to the person with the key knowledge, skills, and abilities for the particular issues facing the team at any given moment. In fact, research indicates that poor-performing teams tend to be dominated by the team leader, while high-performing teams display more dispersed leadership patterns, i.e., shared leadership.(1) This is not to suggest that leadership from above is unnecessary. On the contrary, the role of the vertical leader is critical to the ongoing success of the shared-leadership approach to knowledge work. Thus, this article addresses the following questions: (1) when is leadership most appropriately shared? (2) how is shared leadership best developed? and (3) how does one effectively utilize both vertical and shared leadership to leverage the capabilities of knowledge workers?
Chapter
This chapter addresses the question: ‘What are the knowledge and capabilities necessary for effective leadership across the whole public service system?’
Article
Lean thinking is a method for organising complex production processes so as to encourage flow and reduce waste. While the principles of lean thinking were developed in the manufacturing sector, there is increasing interest in its application in health care. This case history documents the introduction and development of Redesigning Care, a lean thinking-based program to redesign care processes across a teaching general hospital. Redesigning Care has produced substantial benefits over the first two-and-a-half years of its implementation, making care both safer and more accessible. Redesigning Care has not been aimed at changing the specifics of clinical practice. Rather, it has been concerned with improving the flow of patients through clinical and other systems. Concepts that emerged in the manufacturing sector have been readily translatable into health care. Lean thinking may play an important role in the reform of health care in Australia and elsewhere.
Article
The glossary for lean manufacturing is discussed. The glossary is presented in an alphabetical order with various terms related to lean manufacturing. Activity based costing is described as an accounting system that assigns costs to a product based on the amount of resources used to design, order or make it. Six Sigma is described as a methodology that provides organizations tools to improve the capability of their business processes.
Article
Our study examines brokering of situated knowledge within an organizational context, characterized by professional hierarchy. We examine how professional affiliation and associated power differentials impact upon knowledge brokering at the individual and group levels within an organization. Our empirical case, which combines social network analysis and qualitative fieldwork, is set in healthcare with a focus upon integration of management, psychosocial and clinical component knowledge domains deemed necessary for treatment of a long-term condition. Our study shows that peer-to-peer knowledge brokering, which is framed by professional hierarchy, remains pervasive with respect to medical knowledge brokering. However, social structures might be mediated through developing architectural knowledge, reflected in both formal and informal organizational routines and schema, which engenders community tendencies that transcend professional hierarchy, so that knowledge brokering is more widely distributed to benefit patients.
Article
The creation of new roles commonly threatens the power and status of elite professionals through the substitution of their labour. In this paper we examine the institutional work carried out by elite professionals to maintain their professional dominance when threatened. Drawing on 11 case sites from the English National Health Service (NHS) where new nursing or medical roles have been introduced, threatening the power and status of specialist doctors, we observed the following. First, the professional elite respond through institutional work to supplant threat of substitution with the opportunity for them to delegate routine tasks to other actors and maintain existing resource and control arrangements over the delivery of services in a way that enhances elite professionals' status. Second, other professionals outside the professional elite, but relatively powerful within their own professional group, are co-opted by the professional elite to engage in institutional work to maintain existing arrangements. Our work extends Lawrence and Suddaby's typology of institutional work in three ways. First, we reveal how different types of institutional work interact, and how different types of institutional work cross categories of creating or maintaining institutions. Second, we show how an actor's social position or status, both intra-professionally as well as inter-professionally, in the institutional field frame the institutional work they engage in. Third, the institutional work of 'theorizing' by professional elites appears particularly significant, specifically the focus of the institutional work to invoke the concept of 'risk' associated with any change in service delivery, which maintains the model of medical professionalism.