Implementing strategic change in a health care system: The importance of leadership and change readiness

Beyond implementation: A collective case study exploring the conceptions and facilitators of sustainability in a quality improvement collaborative

Chronic Obstructive Pulmonary Disease (COPD) is a primary cause of adult hospitalizations and imposes substantial burdens on patients and healthcare systems. Initiatives that support providers and patients in addressing needs at each stage of this illness are needed. The INSPIRED COPD Outreach Program™ was introduced in 2010 in Halifax, Nova Scotia, Canada to improve care for those with advanced COPD. The huge success of the program led to its expansion to various contexts and geographic locations through a pan-Canadian quality improvement collaborative (QIC). Our study explored early elements of program planning and practice with an aim to understand factors that influence program sustainability. We evaluated the implementation process of 19 teams across Canada; post-collaborative team reports, focus groups, interviews and self-ratings of progress were collected from all teams. Analysis of data revealed three phases important to fostering sustainability (facilitating implementation, keeping the momentum, and securing sustainability) and each phase had unique supporting themes. Not surprisingly, teams that planned for sustainability early in the implementation process were more likely to successfully achieve program sustainability. However, teams also benefited more broadly from sustainability planning; this included being better able to plan for program spread as well as skill retention and knowledge transfer. This was also seen for quality improvement skills introduced early in the program that were more likely to be maintained and used through other contexts when sustainability planning was present. This study highlights that a QIC can be effective in not only influencing program sustainability but also beyond program implementation through improving knowledge and skill acquisition.

The potential of patient-based nurse staffing - a queuing theory application in the neonatal intensive care setting

Faced by a severe shortage of nurses and increasing demand for care, hospitals need to optimally determine their staffing levels. Ideally, nurses should be staffed to those shifts where they generate the highest positive value for the quality of healthcare. This paper develops an approach that identifies the incremental benefit of staffing an additional nurse depending on the patient mix. Based on the reasoning that timely fulfillment of care demand is essential for the healthcare process and its quality in the critical care setting, we propose to measure the incremental benefit of staffing an additional nurse through reductions in time until care arrives (TUCA). We determine TUCA by relying on queuing theory and parametrize the model with real data collected through an observational study. The study indicates that using the TUCA concept and applying queuing theory at the care event level has the potential to improve quality of care for a given nurse capacity by efficiently trading situations of high versus low workload.

Qualitative realist evaluation of an occupational therapy intervention programme (ABLE), addressing ability to perform activities of daily living among persons with chronic conditions

BACKGROUND

Chronic conditions are associated with problems related to performance of activities of daily living (ADL) stressing a need to develop and evaluate intervention programmes addressing such problems. Hence, the ABLE programme was developed, and its feasibility evaluated. Implementing intervention programmes in community-based rehabilitation settings requires understanding of how the programme works in various contexts. Applying a realist evaluation approach, the aim of this study was to identify and evaluate interactions between contexts, mechanisms, and outcomes in the ABLE 2.0, to confirm, refine, or reject aspects of the initial programme theory.

METHODS

Realist evaluation using qualitative data collected in the ABLE 2.0 randomised controlled trial (n = 78). Based on the ABLE 2.0 initial programme theory, qualitative realist interviews were conducted among receivers (n = 8) and deliverers (n = 3) of the ABLE 2.0 in a Danish municipality. Transcripts were coded, and context-mechanism-outcome configurations were extracted and grouped into contiguous themes. Results were then held up against the initial programme theory.

RESULTS

Four contiguous themes were identified including a total of n = 28 context-mechanism-outcome configurations: building a foundation for the entire intervention; establishing the focus for further intervention; identifying and implementing relevant compensatory solutions; and re-evaluating ADL ability to finalise intervention. Overall, the ABLE 2.0 initial programme theory was confirmed. The evaluation added information on core facilitating mechanisms including active involvement of the client in the problem-solving process, a collaborative working relationship, mutual confidence, and a consultative occupation-based process using compensatory solutions. Several contextual factors were required to activate the desired mechanisms in terms of supportive management, referral procedures encouraging the problem-solving process, delivery in the client's home, skilled occupational therapists, and clients feeling ready for making changes.

CONCLUSIONS

The ABLE 2.0 represents a coherent problem-solving occupational therapy process, applicable across sex, age, and diagnoses with the potential to enhance ADL ability among persons with chronic conditions, when delivered as part of community-based rehabilitation services. Knowledge about the interactions between contextual factors, mechanisms, and outcomes in the ABLE 2.0 is central in case of future implementation of the programme in community-based rehabilitation settings.

TRIAL REGISTRATION

The trial was prospectively registered on www.

CLINICALTRIALS

gov (registration date: 05/03/2020; identifier: NCT04295837 ) prior to data collection that occurred between August 2020 and October 2021.

Lessons Learned About System-Level Improvement in Serious Illness Communication: A Qualitative Study of Serious Illness Care Program Implementation in Five Health Systems

BACKGROUND

Serious illness communication is a key element of high-quality care, but it is difficult to implement in practice. The Serious Illness Care Program (SICP) is a multifaceted intervention that contributes to more, earlier, and better serious illness conversations and improved patient outcomes. This qualitative study examined the organizational and implementation factors that influenced improvement in real-world contexts.

METHODS

The authors performed semistructured interviews of 30 health professionals at five health systems that adopted SICP as quality improvement initiatives to investigate the organizational and implementation factors that appeared to influence improvement.

RESULTS

After SICP implementation across the organizations studied, approximately 4,661 clinicians have been trained in serious illness communication and 56,712 patients had had an electronic health record (EHR)-documented serious illness conversation. Facilitators included (1) visible support from leaders, who financially invested in an implementation team and champions, expressed the importance of serious illness communication as an institutional priority, and created incentives for training and documenting serious illness conversations; (2) EHR and data infrastructure to foster performance improvement and accountability, including an accessible documentation template, a reporting system, and customized data feedback for clinicians; and (3) communication skills training and sustained support for clinicians to problem-solve communication challenges, reflect on communication experiences, and adapt the intervention. Inhibitors included leadership inaction, competing priorities and incentives, variable clinician acceptance of EHR and data tools, and inadequate support for clinicians after training.

CONCLUSION

Successful implementation appeared to rely on multilevel organizational strategies to prioritize, reward, and reinforce serious illness communication. The insights derived from this research may function as an organizational road map to guide implementation of SICP or related quality initiatives.

Improving serious illness communication: a qualitative study of clinical culture

OBJECTIVE

Communication about patients' values, goals, and prognosis in serious illness (serious illness communication) is a cornerstone of person-centered care yet difficult to implement in practice. As part of Serious Illness Care Program implementation in five health systems, we studied the clinical culture-related factors that supported or impeded improvement in serious illness conversations.

METHODS

Qualitative analysis of semi-structured interviews of clinical leaders, implementation teams, and frontline champions.

RESULTS

We completed 30 interviews across palliative care, oncology, primary care, and hospital medicine. Participants identified four culture-related domains that influenced serious illness communication improvement: (1) clinical paradigms; (2) interprofessional empowerment; (3) perceived conversation impact; (4) practice norms. Changes in clinicians' beliefs, attitudes, and behaviors in these domains supported values and goals conversations, including: shifting paradigms about serious illness communication from 'end-of-life planning' to 'knowing and honoring what matters most to patients;' improvements in psychological safety that empowered advanced practice clinicians, nurses and social workers to take expanded roles; experiencing benefits of earlier values and goals conversations; shifting from avoidant norms to integration norms in which earlier serious illness discussions became part of routine processes. Culture-related inhibitors included: beliefs that conversations are about dying or withdrawing care; attitudes that serious illness communication is the physician's job; discomfort managing emotions; lack of reliable processes.

CONCLUSIONS

Aspects of clinical culture, such as paradigms about serious illness communication and inter-professional empowerment, are linked to successful adoption of serious illness communication. Further research is warranted to identify effective strategies to enhance clinical culture and drive clinician practice change.

A Qualitative Analysis of Management Perspectives on Seeking to Implement the Foster Cat Project in Residential Aged Care in the Context of COVID-19

This study explores the challenges facing a pilot project aiming to foster homeless cats in an Australian residential aged care facility. The global COVID-19 pandemic stalled the project but also presented an opportunity to gain reflective insights into the perceived barriers, enablers and tensions involved in seeking to implement pet animal inclusion in residential aged care. Perspectives from aged care management, animal welfare services and researchers/project managers were all sought using semi-structured interviews, and themes developed using a qualitative descriptive analysis. Perceived barriers to the project before and after the pandemic were not dissimilar with four key themes emerging: competing priorities, risk and safety, resources, and timing. All existed differently across stakeholder groups creating tensions to be negotiated. These themes are then mapped to the competencies established by the International Union of Health Promotion and Education (IUHPE) for undertaking health promotion, demonstrating that this skill base can be drawn on when seeking to implement human-animal inclusive projects. Creating supportive healthful environments for frail older persons is a moral imperative of extended lives. Health Promotion skills as outlined in the Ottawa Charter and IUHPE competencies for health promotion workers need to be extended to include animal services, agendas and cultures to promote multi-species health promotion into the future.

Use of a Sterile Collection Process to Reduce Contaminated Peripheral Blood Cultures

BACKGROUND

Contaminated blood cultures pose a significant burden by subjecting children to unnecessary testing, procedures, and antibiotics and increasing health care costs. The aim of our quality improvement (QI) initiative was to decrease the percentage of contaminated peripheral blood cultures in our pediatric emergency department (ED) from an average of 6.7% to <3% over a 16-month period.

METHODS

The QI initiative was implemented in the pediatric ED of a tertiary care children's hospital. Interventions included change of the peripheral blood culture collection from a clean to a sterile process, nursing education, and individualized feedback. The primary outcome measure was the percentage of contaminated peripheral blood cultures. The process measure was the percentage of nurses who completed 75% to 100% of the steps of the sterile collection process, as measured by self-reporting in audit cards. The balancing measures were time from antibiotic ordering to time of administration and ED length of stay.

RESULTS

We decreased the percentage of contaminated peripheral blood cultures threefold from a baseline (June 2, 2018, to December 31, 2018) of 6.7% to 2.1% during the intervention period (January 1, 2019, to April 30, 2020). Ninety-eight percent of nurses who completed audit cards reported performing 75% to 100% of the steps of the new sterile process. There was no significant difference in the average time from antibiotic ordering to antibiotic administration or ED length of stay between the baseline and intervention periods.

CONCLUSIONS

Use of a sterile blood culture collection process, in addition to nursing education and individualized feedback, is an effective method to decrease peripheral blood culture contamination rates in a pediatric ED.

Overcoming Obstacles to Develop High-Performance Teams Involving Physician in Health Care Organizations

Many health care organizations struggle and often do not succeed to be high-performance organizations that are not only efficient and effective but also enjoyable places to work. This review focuses on the physician and organizational roles in limiting achievement of a high-performance team in health care organizations. Ten dimensions were constructed and a number of competencies and metrics were highlighted to overcome the failures to: (i) Ensure that the goals, purpose, mission and vision are clearly defined; (ii) establish a supportive organizational structure that encourages high performance of teams; (iii) ensure outstanding physician leadership, performance, goal attainment; and (iv) recognize that medical team leaders are vulnerable to the abuses of personal power or may create a culture of intimidation/fear and a toxic work culture; (v) select a good team and team members—team members who like to work in teams or are willing and able to learn how to work in a team and ensure a well-balanced team composition; (vi) establish optimal team composition, individual roles and dynamics, and clear roles for members of the team; (vii) establish psychological safe environment for team members; (viii) address and resolve interpersonal conflicts in teams; (xi) ensure good health and well-being of the medical staff; (x) ensure physician engagement with the organization. Addressing each of these dimensions with the specific solutions outlined should overcome the constraints to achieving high-performance teams for physicians in health care organizations.

Barriers To Strategy Implementation In Turkey's Healthcare Industry: Hospital Manager Perspectives

Although strategy implementation has profound implications for delivering efficient service, it has been largely neglected in the healthcare management literature. This study explores the barriers to effective implementation of strategic plans in healthcare organizations. To achieve this end, empirical data were collected from 185 hospital managers in Turkey using a survey-based methodology. A descriptive analysis was undertaken of the survey responses to determine the most important barriers to strategy implementation. The most significant barriers undermining strategy implementation efforts were found to be: low employee motivation, an exclusive focus on financial performance and lack of consensus among decision makers.

Hospital reorganization and its effects on physicians' network churn: The role of past ties

Hospital reorganizations are difficult and often fail to produce their intended benefits. Prior research has investigated how and under which contingencies changes in organizational structure affect the modification of clinician behaviors, yet we know little about how organizational redesign interventions affect physicians' collaborative networks. This paper explores how hospital reorganizations affect physicians' network churn. We developed hypotheses on the relationship between structural characteristics of networks before reorganization and the formation of cross-unit network ties after reorganization. We tested our hypotheses on a sample of 175 physicians in a large teaching hospital. The hospital had recently adopted a new organizational model aimed at enhancing a process-based approach to care delivery. Our findings revealed that the physicians' propensity to form cross-unit ties after the change was related to the structure of their collaborative networks before the change. In particular, the formation of cross-unit relations was negatively related to the size of advice networks before the reorganization. Furthermore, we found that the diversity of network ties along with the presence of structural holes in the physicians' networks before the change moderated this relationship. We discussed the theoretical and practical implications of our findings. In particular, our results may inform organizational redesign interventions within hospitals.

Lessons on integrated knowledge translation through algorithm's utilization in homecare services: a multiple case study

AIM

Integrated knowledge translation (IKT) is an increasingly recommended collaborative approach to minimize knowledge translation gap. Still, few studies have documented the impact of IKT to optimize knowledge uptake in healthcare settings. An IKT-based clinical algorithm (Algo) was deployed in Quebec (Canada) homecare services to support skill mix for selecting bathing equipment for community-dwelling adults. The objective of this study was to document the characteristics related to Algo's IKT process.

METHODS

A multiple-case study with a nested concurrent mixed design was conducted in provincial homecare services. Based on Knott and Wildavsky's seven-stage classification and the integrated-Promoting Action on Research Implementation in Health Services model, Innovation, Recipients, and Context, characteristics related to Algo's levels of utilization were documented. Quantitative (electronic questionnaire) and qualitative (semistructured interviews and focus groups) data were collected for each case (i.e., homecare service). Descriptive statistics and thematic analysis were performed to describe each case through a mixed methods matrix, for intra/intercase analyses.

RESULTS

Knowledge translation characteristics of five Algo's levels of utilization were documented: reception, cognition, reference, effort, and impact. Innovation characteristics (e.g., underlying knowledge) were found to facilitate its dissemination and its use. However, the Recipients (e.g., unclear mechanisms to implement change) and Context (e.g., organizational mandates nonaligned with skill mix) characteristics hampered its application through intermediate and advanced levels of utilization.

CONCLUSION

The knowledge translation analysis of Algo allowed for documenting the IKT-based benefits in terms of utilization in healthcare settings. Although an IKT approach appears to be a strong facilitator for initiating the implementation process, additional characteristics should be considered for promoting and sustaining its use on local, organizational, and external levels of context. Facilitation strategies should document the administrative benefits related to Algo's utilization and contextualize it according to homecare services' characteristics.

Dynamic waitlisted design for evaluating a randomized trial of evidence-based quality improvement of comprehensive women's health care implementation in low-performing VA facilities

Background

Women’s Health Services (WHS) in the Veterans Health Administration (VA) has long partnered with VA researchers to evaluate how VA care is organized for women veterans. This partnership has yielded substantial evidence of (1) variations in women veterans’ access to comprehensive healthcare services that contribute to disparities in quality and patient experience and (2) the positive impacts of gender-specific care models for women veterans’ quality and satisfaction. In an effort to provide support specifically to sites that were low-performing in women’s health, WHS and the VA Quality Enhancement Research Initiative co-funded an effort to roll out and evaluate evidence-based quality improvement (EBQI), an implementation strategy with demonstrated effectiveness in a prior cluster randomized trial in women’s health clinics.

Methods

We will identify 21 low-performing VA facilities through a combination of practice data, VA quality metrics (by gender), and other indicators. In partnership with WHS, an EBQI contractor will deliver the EBQI “package”—local consensus development and priority setting using stakeholder panels, multilevel stakeholder engagement, practice facilitation, local EBQI team training, and formative feedback—to participating sites. We propose a dynamic wait-listed design to evaluate the WHS plans for seven EBQI launches per year over 3 years. The goal is to evaluate (1) barriers and facilitators to achieving delivery of comprehensive women’s health care in low-performing VA facilities; (2) effectiveness of EBQI in supporting low-performing VA facilities to achieve improved practice features (e.g., level of comprehensive services available, care coordination arrangements, Patient Aligned Care Team (PACT) features implemented, environment of care improvements), provider/staff attitudes (e.g., improved gender awareness, women’s health knowledge and practice), quality of care, and patient experience; and (3) contextual factors, local implementation processes, and organizational changes over time.

Discussion

Access to comprehensive women’s health care reduces fragmentation of care, improves patient satisfaction, and results in better patient outcomes. We hypothesize that EBQI implementation will result in changes in leadership awareness and buy-in, multilevel engagement in problem-solving, an enhanced culture of quality improvement, structural changes in care, improved provider/staff attitudes, and better quality and patient experience.

Trial registration

ClinicalTrials.gov, NCT03238417. Registered 3 August 2017. Retrospectively registered, https://clinicaltrials.gov/ct2/show/study/NCT03238417

A systematic scoping review of change management practices used for telemedicine service implementations

BACKGROUND

Telemedicine improves access to health care services enabling remote care diagnosis and treatment of patients at a distance. However, the implementation of telemedicine services often pose challenges stemming from the lack of attention to change management (CM). Health care practitioners and researchers agree that successful telemedicine services require significant organizational and practice change. Despite recognizing the importance of the "people-side" of implementation, research on what constitutes best practice CM strategies for telemedicine implementations remains fragmented, offering little cohesive insight into the specific practices involved in the change process. We conducted a systematic scoping review of the literature to examine what and how CM practices have been applied to telemedicine service implementation, spanning a variety of health care areas and countries.

METHODS

Three bibliographic databases (CINAHL, PubMed, and ISI Web of Science) and four specialist telehealth journals were searched. To keep the review manageable and relevant to contemporary telemedicine technologies and contexts, the search was limited to articles published from 2008 to 2019. Forty-eight articles were selected for inclusion.

RESULTS

From the 48 articles, 16 CM practices were identified relating to either strategic or operational aspects of telemedicine implementations. We identify the key CM practices that are recognized in the broader CM literature as essential for successful and sustained change but are not commonly reported in telemedicine implementation studies. We draw on the CM literature to provide a comprehensive process-based, researched-informed, organizing framework to guide future telemedicine service implementations and research.

CONCLUSIONS

Our findings suggest that the slow rate of adoption of telemedicine may be due to a piecemeal approach to the change process, and a lack of understanding of how to plan, manage and reinforce change when implementing telemedicine services.

Logic model framework for considering the inputs, processes and outcomes of a healthcare organisation-research partnership

BACKGROUND

The published literature provides few insights regarding how to develop or consider the effects of knowledge co-production partnerships in the context of delivery system science.

OBJECTIVE

To describe how a healthcare organisation-university-based research partnership was developed and used to design, develop and implement a practice-integrated decision support tool for patients with a physician recommendation for colorectal cancer screening.

DESIGN

Instrumental case study.

PARTICIPANTS

Data were ascertained from project documentation records and semistructured questionnaires sent to 16 healthcare organisation leaders and staff, research investigators and research staff members.

RESULTS

Using a logic model framework, we organised the key inputs, processes and outcomes of a healthcare organisation-university-based research partnership. In addition to pragmatic researchers, partnership inputs included a healthcare organisation with a supportive practice environment and an executive-level project sponsor, a mid-level manager to serve as the organisational champion and continual access to organisational employees with relevant technical, policy and system/process knowledge. During programme design and implementation, partnership processes included using project team meetings, standing organisational meetings and one-on-one consultancies to provide platforms for shared learning and problem solving. Decision-making responsibility was shared between the healthcare organisation and research team. We discuss the short-term outcomes of the partnership, including how the partnership affected the current research team's knowledge and health system initiatives.

CONCLUSION

Using a logic model framework, we have described how a healthcare organisation-university-based research team partnership was developed. Others interested in developing, implementing and evaluating knowledge co-production partnerships in the context of delivery system science projects can use the experiences to consider ways to develop, implement and evaluate similar co-production partnerships.

The state-of-play in physician health systems leadership research

Purpose

This paper aims to review a decade of evidence on physician participation in health system leadership with the view to better understand the current state of scholarship on physician leadership activity in health systems. This includes examining the available evidence on both physicians’ experiences of health systems leadership (HSL) and the impact of physician leadership on health system reform.

Design/methodology/approach

A state-of-the-art review of studies (between 2007 and 2017); 51 papers were identified, analyzed thematically and synthesized narratively.

Findings

Six main themes were identified in the literature as follows: (De)motivation for leadership, leadership readiness and career development, work demands and rewards, identity matters: acceptance of self (and other) as leader, leadership processes and relationships across health systems and leadership in relation to health system outcomes. There were seemingly contradictory findings across some studies, pointing to the influence of regional and cultural contextual variation on leadership practices as well entrenched paradoxical tensions in health system organizations.

Research limitations/implications

Future research should examine the influence of varying structural and psychological empowerment on physician leadership practices. Empirical attention to paradoxical tensions (e.g. between empowerment and control) in HSL is needed, with specific attention to questions on how such tensions influence leaders’ decision-making about system reform.

Originality/value

This review provides a broad synthesis of diverse papers about physician participation in health system leadership. Thus, it offers a comprehensive empirical synthesis of contemporary concerns and identifies important avenues for future research.

Turning the oil tanker: a novel approach to shifting perspectives in medical practice

Although health care is encouraged to follow an evidence-based approach, there are perceived instances where suboptimal practice persists in the presence of better options due to an inherent resistance to change within many health care systems. To continue striving for clinical excellence, it is important to identify deficient practices and make appropriate corrections by implementing new and improved techniques and treatments. Bringing about change, however, tends to be a long, arduous process consisting of several small and successive deviations from the norm, analogous to "turning the oil tanker". Analyzing the methods employed by successful health care innovators has allowed the development of a "three-pronged" approach to overcoming resistance to change: 1) a determined opinion leader with a network or like-minded opinion leaders; 2) the presentation of hard evidence with adequate praise for current practice and the generation of clearly worded, specific guidelines; and 3) the use of simple reminders and continuous analysis of outcomes. Employing this three-pronged approach could lead to faster and more successful implementation of change within the health care system.

The role of change readiness and colleague support in the role stressors and withdrawal behaviors relationship among health care employees

Purpose

The purpose of this paper is to investigate the impact of role stressors (role ambiguity, role conflict and role overload) on change readiness and in turn their effects on the withdrawal process. In addition, it explores the moderating role of colleague support in the relationship between role stressors and change readiness.

Design/methodology/approach

Data were collected from health care workers (n=457) in a large Canadian hospital undergoing large scale change.

Findings

The results revealed that role ambiguity and role conflict had a significant negative association with change readiness. Change readiness was related to turnover intentions which was related to higher levels of absenteeism and actual turnover. Change readiness partially mediated the relationship between role ambiguity and turnover intentions but not for role conflict and role overload. Turnover intentions partially mediated the relationship between change readiness and actual turnover but not for absenteeism. Role conflict had a direct rather than an indirect effect via change readiness on turnover intentions. Finally, colleague support moderated the relationship between all three role stressors and change readiness.

Originality/value

Little is known about the limiting factors of change as well as the factors that protect against them. The authors identify role stressors as a limiting factor for change and highlight their impact on change readiness and the overall withdrawal process. The results, however, also show that some demands are more commonly experienced by health care workers thereby not posing a threat to their change readiness. Colleague support is identified as a coping mechanism for mitigating against the detrimental effects of role stressors.

'Doing more with less': a qualitative investigation of perceptions of South African health service managers on implementation of health innovations

Building resilience in health systems is an imperative for low- and middle- income countries. Health service managers' ability to implement health innovations may be a key aspect of resilience in primary healthcare facilities, promoting adaptability and functionality. This study investigated health service managers' perceptions and experiences of adopting health innovations. We aimed to identify perceptions of constraints to adoption and emergent behaviours in response to these constraints. A convenience sample of 34 facility, clinical service and sub-district level managers was invited to participate. Six did not respond and were not contactable. In-depth individual interviews in a private space at participants' place of work were conducted with 28 participants. Interviews were audio recorded and transcribed verbatim. NVivo 11 was used to store data and facilitate framework analysis. Study participants described constraints to innovation adoption including: staff lack of understanding of potential benefits; staff personalities, attitudes and behaviours which lead to resistance to change; high workload related to resource constraints and frequent policy changes inducing resistance to change; and suboptimal communication through health system structures. Managers reported employing various strategies to mitigate these constraints. These comprised (1) technical skills including participatory management skills, communication skills, community engagement skills and programme monitoring and evaluation skills, and (2) non-technical skills including role modelling positive attitudes, understanding staff personalities, influencing perceptions of innovations, influencing organizational climate and building trusting relationships. Managers have a vital role in the embedding of service innovations into routine practice. We present a framework of technical and non-technical skills that managers need to facilitate the adoption of health innovations. Future efforts to build managers' capacity to implement health innovations should target these competencies.

Framework to Enhance Nurses' Use of EMR

The ability of nurses to adopt and successfully use EMR is expected to have a significant impact on achieving benefits such as reduction in healthcare costs and improvement in healthcare quality. A review of the current research literature reveals issues and concerns relating to the adoption and use of EMR by nurses in hospital environments. This article presents a literature review of such issues and concerns, and suggests a framework for enhancing the adoption and use of EMR by nurses and hospitals.

Predictors of nutrition care process and terminology use, applicability and importance within Asia-Pacific dietitians

AIM

Many dietitians are yet to incorporate the Nutrition Care Process and Terminology (NCPT) into practice. The present study investigated factors predicting (i) NCPT use, (ii) perceived importance of NCPT implementation and (iii) perceived NCPT applicability to personal dietetic practice among dietitians in the Asia-Pacific region.

METHODS

Dietetic association members from Australia, New Zealand and Singapore were invited to participate in an online survey assessing NCPT implementation, knowledge, and self-rated familiarity, attitudes, benefits, concerns, barriers, and enablers. Forward stepwise logistic regression used all factors to identify predictive dietetic characteristics for current NCPT use, importance or applicability to practice.

RESULTS

A total of 377 dietitians (5%-55% of national dietetic memberships surveyed) completed at least one survey question. In logistic regression models, independent positive predictors of current NCPT users were knowledge (P = 0.003), confidence to implement (P = 0.036), confidence to write nutrition diagnoses (P = 0.002) and experiencing managerial support (P = 0.004). Not seeing a reason to change was a significant negative predictor of NCPT use (P = 0.003). An independent positive predictor of dietitians viewing NCPT implementation as important was feeling that it will improve patient care (P < 0.001), while negative predictors were seeing minimal benefit in changing (P < 0.001) and a preference to continue with current routine (P = 0.015). Independent positive predictors of dietitians viewing NCPT as applicable to their practice were NCPT knowledge (P = 0.009), seeing the value of NCPT (P < 0.001) and attendance at workshops or conferences (P = 0.014).

CONCLUSIONS

NCPT implementation may be enhanced thorough activities building confidence, gaining managerial corroboration and demonstration of NCPT benefits, including improved patient care.

LADDERS: A dynamic paradigm for planning, implementing, and evaluating sustainable change in learning health systems

The science of learning health systems borrows and adapts models from many fields. One in particular is implementation science which has been experiencing a flourishing of new theories, models, and frameworks, some of which are generating sufficient evidence as to their effectiveness and applicability to emerge as candidates for wide adoption as useful tools for the field. In reviewing these, a common paradigm can be described which is a synthesis of those elements regularly cited by health systems implementing successful transformational change activities. As a paradigm, it offers a practical bridge to these models, concepts, and frameworks that are often hard to operationalize and are used with varying degrees of completeness. These elements can be arranged in a memorable acronym-LADDERS-Leadership, Alignment, Data, Demonstration, Evaluation, Replication, and Sustainability. LADDERS identifies the multiple elements and dimensions recognized by persons involved in leading health system change activities. It provides a simple, useful way to assess progress by health systems in planning, implementing, evaluating, and sustaining change. There is ample organizational and systems change literature to fully describe the actual LADDERS elements individually; therefore, this article describes characteristics and functions of each element and the dynamics represented in a DNA image to reflect that in learning health systems change is recursive, constant, and happens in complex environments that are always readjusting to new stimuli and directions, and this is often not accounted for in a framework, model, or theory. It concludes with several examples of application of the LADDERS paradigm and suggests how it is a complementary approach to accomplishing Institute of Medicine Learning Health Systems goals.

What roles do middle managers play in implementation of innovative practices?

BACKGROUND

Middle managers play key roles in hospitals as the bridge between senior leaders and frontline staff. Yet relatively little research has focused on their role in implementing new practices.

PURPOSE

The aim of this study was to expand the understanding of middle managers' influence in organizations by looking at their activities through the lens of two complementary conceptual frameworks.

METHODOLOGY/APPROACH

We analyzed qualitative data from 17 Veterans Affairs Medical Centers with high and low potential to change organizational practices. We analyzed 98 interviews with staff ranging from senior leaders to frontline staff to identify themes within an a priori framework reflecting middle manager activities.

FINDINGS

Analyses yielded 14 emergent themes that allowed us to classify specific expressions of middle manager commitment to implementation of innovative practices (e.g., facilitate improvement innovation, garner staff buy-in). In comparing middle manager behaviors in high and low change potential sites, we found that most emergent themes were present in both groups. However, the activities and interactions described differed between the groups.

PRACTICE IMPLICATIONS

Middle managers can use the promising strategies identified by our analyses to guide and improve their effectiveness in implementing new practices. These strategies can also inform senior leaders striving to guide middle managers in those efforts.

Mental challenges of nurses in the face of unlearning situations in hospitals: A qualitative study

BACKGROUND

The unlearning process is complex and sometimes painful in nature. This process usually occurs in social interactions and is very dependent on social contexts and the work environment.

OBJECTIVE

To explore the concerns and mental challenges in facing unlearning situations in nurses.

METHODS

This qualitative study using content analysis was conducted in 2013-2015. Participants were 25 people, and research environment was hospitals in Mashhad and Gonabad. The method of data collection was unstructured interview, and sampling was continued until data saturation. First, the recorded interviews were transcribed and reviewed several times. Then open codes were extracted and after reviewing several times, were classified into subcategories based on semantic similarity. Finally, the similar subcategories were put into the main categories semantically.

RESULTS

Data analysis led to the emergence of 1,180 initial codes and 8 categories and 3 themes. Our themes were discouraging/encouraging situation, double-edged sword colleagues, and organizational policies paradox, that the central theme of progressive and suppressor organizational climate paradox were derived from them.

CONCLUSION

Exposure to unlearning situations is a complex process of which its adoption and implementation is difficult and challenging. This suggests that supporting nurses and attention to their mental concerns and providing favorable learning conditions is required.

Strengths-Based Nursing: A Process for Implementing a Philosophy Into Practice

Strengths-Based Nursing (SBN) is both a philosophy and value-driven approach that can guide clinicians, educators, manager/leaders, and researchers. SBN is rooted in principles of person/family centered care, empowerment, relational care, and innate health and healing. SBN is family nursing yet not all family nursing models are strengths-based. The challenge is how to translate a philosophy to change practice. In this article, we describe a process of implementation that has organically evolved of a multi-layered and multi-pronged approach that involves patients and families, clinicians, educators, leaders, managers, and researchers as well as key stakeholders including union leaders, opinion leaders, and policy makers from both nursing and other disciplines. There are two phases to the implementation process, namely, Phase 1: pre-commitment/pre-adoption and Phase 2: adoption. Each phase consists of distinct steps with accompanying strategies. These phases occur both sequentially and concurrently. Facilitating factors that enable the implementation process include values which align, readiness to accept SBN, curiosity-courage-commitment on the part of early adopters, a critical mass of early adopters, and making SBN approach both relevant and context specific.

Quality improvement in large healthcare organizations

PURPOSE

The purpose of this paper is to investigate the obstacles and challenges associated with organizational monitoring and follow-up (M & F) processes related to health care quality improvement (QI) and development.

DESIGN/METHODOLOGY/APPROACH

A longitudinal case study of a large health care organization during a system-wide QI intervention. Content analysis was conducted of repeated interviews with key actors and archival data collected over a period of four years.

FINDINGS

The demand for improved M & F strategies, and what and how to monitor were described by the respondents. Obstacles and challenges for achieving M & F strategies that enables system-wide and coherent development were found in three areas: monitoring, processing, and feedback and communication. Also overarching challenges were found.

PRACTICAL IMPLICATIONS

A model of important aspects of M & F systems is presented that can be used for analysis and planning and contribute to shared cognition of such systems. Approaches for systematic analysis and follow-up of identified problems have to be developed and fully incorporated in the organization's measurement systems. A systematic M & F needs analytic and process-oriented competence, and this study highlights the potential in an organizational function with capacity and mandate for such tasks.

ORIGINALITY/VALUE

Most health care systems are flooded with a vast amount of registers, records, and measurements. A key issue is how such data can be processed and refined to reflect the needs and the development process of the health care system and how rich data can be used for improvement purposes. This study presents key organizational actor's view on important factors to consider when building a coherent organizational M & F strategy.

What’s organization knowledge management strategy for successful change implementation?

Purpose

In recent times, progression of technology and growing demands of customers have substantially influenced the services sector to introduce fast real-time mechanisms for providing up-to-mark services. To meet these requirements, organizations are going to change their end-user operating systems but success rate of change is very low. The purpose of this paper is to address one of the practitioners’ complaint “no one tells us how to do it” and uncovers the indirect effects of knowledge management (KM) strategies: personalization and codification, toward organizational change via organizational learning and change readiness. The current study also highlights how organizational learning and change readiness are helpful to reduce the detrimental effects of organizational change cynicism toward success of a change process.

Design/methodology/approach

Temporal research design is used to get the appropriate responses from the targeted population in two stages such as pre-change (Time-1) and post-change (Time-2). In cumulative, 206 responses have been obtained from the banking sector of Pakistan.

Findings

The results of the current study are very promising as it has been stated that KM strategies have an indirect effect on successful organizational change through organizational learning and change readiness. Moreover, change cynicism has a weakening effect on a change process and can be managed through effective learning orientation of employees and developing readiness for change in organizations.

Research limitations/implications

Change agents have to use an optimal mix of personalization and codification strategies to develop learning environment and readiness for change in organizations that are beneficial for implementing a change successfully. Moreover, change readiness and organizational learning in the context of change are equally beneficial to reduce organizational change cynicism as well.

Originality/value

This study is introducing a unique model to initiate a change with the help of KM strategies, organizational learning and readiness for change.

The medical leadership challenge in healthcare is an identity challenge

Purpose

– The purpose of this article is to describe and analyse the identity challenges that physicians with medical leadership positions face.

Design/methodology/approach

– Four qualitative case studies were performed to address the fact that identity is processual, relational and situational. Physicians with managerial roles were interviewed, as well as their peers, supervisors and subordinates. Furthermore, observations were made to understand how different identities are displayed in action.

Findings

– This study illustrates that medical leadership implies identity struggles when physicians have manager positions, because of the different characteristics of the social identities of managers and physicians. Major differences are related between physicians as autonomous individuals in a system and managers as subordinates to the organizational system. There are psychological mechanisms that evoke the physician identity more often than the managerial identity among physicians who are managers, which explains why physicians who are managers tend to remain foremost physicians.

Research limitations/implications

– The implications of the findings, that there are major identity challenges by being both a physician and manager, suggest that managerial physicians might not be the best prerequisite for medical leadership, but instead, cooperative relationships between physicians and non-physician managers might be a less difficult way to support medical leadership.

Practical implications

– Acknowledging and addressing identity challenges can be important both in creating structures in organizations and designing the training for managers in healthcare (both physicians and non-physicians) to support medical leadership.

Originality/value

– Medical leadership is most often related to organizational structure and/or leadership skills, but this paper discusses identity requirements and challenges related to medical leadership.

Emotional exhaustion in primary care during early implementation of the VA's medical home transformation: Patient-aligned Care Team (PACT)

OBJECTIVE

Transformation of primary care to new patient-centered models requires major changes in healthcare organizations, including interprofessional expectations and organizational policies. Emotional exhaustion (EE) among workers can accompany major organizational change, threatening its success. Yet little guidance exists about the magnitude of associations with EE during primary care transformation. We assessed EE during the initial phase of national primary care transformation in the Veterans Health Administration.

RESEARCH DESIGN

Cross-sectional online surveys of primary care clinicians (PCCs) and staff in 23 primary care clinics within 5 healthcare systems in 1 veterans administration administrative region. We used descriptive, bivariate, and multivariable analyses adjusted for clinic membership and weighted for nonresponse.

PARTICIPANTS

515 veterans administration employees (191 PCCs and 324 other primary care staff).

MEASURES

Outcome is the EE subscale of the Maslach Burnout Inventory. Predictors include clinic characteristics (from administrative data) and self-reported efficacy for change, experiences with transformation, and perspectives about the organization.

RESULTS

The overall response rate was 64% (515/811). In total, 53% of PCCs and 43% of staff had high EE. PCCs (vs. other primary care staff), female (vs. male), and non-Latino (vs. Latino) respondents reported higher EE. Respondents reporting higher efficacy for change and participatory decision making had lower EE scores, adjusting for sex and race.

CONCLUSIONS

Recognition by healthcare organizations of the potential for clinician and staff EE during primary care transformation is critical. Methods for reducing EE by increasing clinician and staff change efficacy and opportunities to participate in decision making should be considered, with attention to PCCs, and women.

Achieving excellence in private intensive care units: The effect of transformational leadership and organisational culture on organisational change outcomes

Orientation: Organisational change outcomes in private intensive care units are linked to higher patient satisfaction, improved quality of patient care, family support, cost-effective care practices and an increased level of excellence. Transformational leadership and fostering a positive organisational culture can contribute to these change outcomes.Research purpose: The study determined whether transformational leadership and a supportive organisational culture were evident in six private intensive care units in the Eastern Cape, South Africa. A conceptual framework to investigate the relationship between transformational leadership, organisational culture, and organisational change outcomes, was proposed and tested.Motivation for the study: The prevalence of transformational leadership, a positive organisational culture and their effect on organisational change outcomes in private healthcare industries require further research in order to generate appropriate recommendations.Research design, approach and method: A positivistic, quantitative design was used. A survey was conducted using a questionnaire which, in previous studies, produced scores with Cronbach’s alpha coefficients greater than 0.80, to collect data from a sample of 130 professional nurses in private intensive care units.Main findings: Transformational leadership and a positive organisational culture were evident in the private intensive care units sampled. A strong, positive correlation exists between transformational leadership, organisational culture, and organisational change outcomes. This correlation provides sufficient evidence to accept the postulated research hypotheses. Innovation and intellectual stimulation were identified as the factors in need of improvement.Practical or managerial implications: The findings of the study may be used by managers in intensive care units to promote organisational change outcomes, linked to transformational leadership and a positive organisational culture.Contribution: The study provides evidence of the way in which transformational leadership and a positive organisational culture affect organisational change outcomes in the context of private healthcare in South Africa, thereby addressing a research gap in this area.

Integrating team resource management program into staff training improves staff's perception and patient safety in organ procurement and transplantation: the experience in a university-affiliated medical center in Taiwan

BACKGROUND

The process involved in organ procurement and transplantation is very complex that requires multidisciplinary coordination and teamwork. To prevent error during the processes, teamwork education and training might play an important role. We wished to evaluate the efficacy of implementing a Team Resource Management (TRM) program on patient safety and the behaviors of the team members involving in the process.

METHODS

We implemented a TRM training program for the organ procurement and transplantation team members of the National Taiwan University Hospital (NTUH), a teaching medical center in Taiwan. This 15-month intervention included TRM education and training courses for the healthcare workers, focused group skill training for the procurement and transplantation team members, video demonstration and training, and case reviews with feedbacks. Teamwork culture was evaluated and all procurement and transplantation cases were reviewed to evaluate the application of TRM skills during the actual processes.

RESULTS

During the intervention period, a total of 34 staff members participated the program, and 67 cases of transplantations were performed. Teamwork framework concept was the most prominent dimension that showed improvement from the participants for training. The team members showed a variety of teamwork behaviors during the process of procurement and transplantation during the intervention period. Of note, there were two potential donors with a positive HIV result, for which the procurement processed was timely and successfully terminated by the team. None of the recipients was transplanted with an infected organ. No error in communication or patient identification was noted during review of the case records.

CONCLUSION

Implementation of a Team Resource Management program improves the teamwork culture as well as patient safety in organ procurement and transplantation.

The Quality, Implementation, and Evaluation Model

Major efforts have been directed toward the implementation of sustainable quality improvement. To date, progress has been noted using various metrics and performance measures; however, successful implementation has proven challenging. The Quality, Implementation, and Evaluation (QIE) model, derived from Donabedian’s structure component, presents a framework for implementation of specific activities. The QIE model consists of Policy, Patient Preparedness, Provider Competency, and Performance and Accountability, to guide specific practice initiatives. The implementation of alcohol-based pre-operative skin prep was evaluated in a sample of 17 hospitals and demonstrated that hospitals actively engaged in the components of the model demonstrated a significantly higher use of alcohol-based skin preparation agent than hospitals that did not engage in QIE model activities. The QIE model presents a powerful and actionable implementation model for mid-level management and clinical leadership. Future studies will further evaluate the impact of the specific components of the QIE model.

Optimizing the OR: a bottom-up approach

Efficiency in the operating room (OR) has important implications on finances, access, and patient and staff satisfaction. UC Davis Medical Center (UCDMC) launched an initiative to increase OR efficiency by using multidisciplinary staff-based teams. The initiative freed up 5,500 annual hours-about 1 hr per operating room per day-in the OR by improving the percentage of first case on-time starts, reducing OR turnover times, improving scheduling predictability and reducing the number of controllable cancellations. Importantly, the process also engrained a continuous quality improvement mentality into the medical center's culture.

Evaluation of leadership practices: how to develop a vision

Leadership competencies and more specifically a strategic vision are essential to managing increasingly complex healthcare organisations and change. However, Switzerland, like many other countries, has identified a lack of leadership skills among nurse leaders. Therefore the Royal College of Nursing’s (RCN) Clinical Leadership Programme has been adapted, implemented and evaluated in the Swiss nursing context. The aim of this qualitative study was to evaluate the Leadership Programme’s support for vision development. In-depth interviews with six nurse leaders, who were purposefully selected according to the quantitative results of the overall mixed-methods evaluation project were included. Interviews were audio-recorded and transcribed prior to qualitative content analysis. Findings showed the different approaches used in the process of vision formation. Some used cognitive-analytical techniques and proceeded very methodically and systematically, whereas others described a more intuitive approach. Some also used a combination of both approaches. Participants experienced fostering and hindering factors on different levels – personal as well as organisational. The identified factors in vision development may be helpful in the planning of educational programmes to facilitate visionary skills among nurse leaders. Vision formation requires time for reflection and the ability of creative thinking, which is distinct from day-to-day management tasks.

Evaluation of the implementation of a bowel management protocol in intensive care: effect on clinician practices and patient outcomes

AIMS AND OBJECTIVES

To evaluate the effect of a multifaceted implementation of a bowel management protocol on outcomes for intensive care patients, in particular the incidence of constipation and diarrhoea, and on clinicians' bowel management practices.

BACKGROUND

Complications associated with poor bowel management for critically ill patients result in adverse outcomes. Implementation of protocols requires strategies proven to change clinician behaviour.

DESIGN

Before and after study.

METHODS

Our bowel management protocol was implemented using three evidence-based elements: education sessions, printed educational materials in the form of a fact sheet and reminders. We retrospectively collected data from patients' medical records admitted at two time points within three Sydney metropolitan intensive care units (preimplementation, n = 101; postimplementation, n = 107).

RESULTS

No significant difference was found in the incidence of constipation and diarrhoea pre and postimplementation of the protocol. Seventy-two per cent (n = 73) of patients preimplementation and 70% (n = 75) of patients postimplementation experienced one or more episodes of constipation (bowels not open for 72 hours or greater), and 16% (n = 16) of patients preimplementation and 20% (n = 21) of patients postimplementation experienced one or more episodes of diarrhoea. There was a slight nonsignificant increase in bowel assessment on admission by medical officers postimplementation (pre, 47%, n = 48; post, 60%, n = 64).

CONCLUSION

Targeted multifaceted implementation of a bowel management protocol did not have an impact on the incidence of constipation or diarrhoea for intensive care patients or on clinician practices. The lack of impact on patient outcomes may be due to clinicians' nonadherence to our bowel management protocol. Reasons clinicians' practices did not change may include the influences of clinical decision-making on behaviour.

RELEVANCE TO CLINICAL PRACTICE

This study highlights difficulties inherent in changing clinician behaviour and practices to improve patient outcomes despite using an evidence-based multifaceted implementation strategy. Further research is required to ascertain the most effective implementation strategies.

Hospital restructuring and physician job satisfaction: an empirical study

The adoption of clinical directorates through the internal reconfiguration of hospital organizations has been one of the most widespread restructuring interventions in many Western European countries. Despite its extensive adoption, a lack of knowledge remains on the analysis of how this reorganization affects professionals' job satisfaction. This paper contributes to the debate on clinical directorates by exploring how the structural characteristics of newly adopted organizational models influence physician's job satisfaction. More than 300 physicians in 18 clinical directorates in the Italian National Health Service were surveyed regarding their overall job satisfaction following the introduction of departmental arrangements. Survey results were then linked to another survey that classified newly adopted models according to the criteria used to merge hospital wards into directorates, by recognizing "Process-integration", "Specialty-integration" and "Mixed-integration" types of directorates. Our findings show that structural aspects of change significantly influenced overall job satisfaction, and that a physician's openness to experience moderated the adoption and implementation of new clinical directorates. Specifically, results demonstrate that physicians with high openness to experience scores were more receptive to the positive impacts of change on overall job satisfaction. Implications for how these findings may facilitate organizational shifts within hospital settings are discussed.

The effect of perceived person-job fit on employee attitudes toward change in trauma centers

BACKGROUND

Employee attitudes toward change are critical for health care organizations implementing new procedures and practices. When employees are more positive about the change, they are likely to behave in ways that support the change, whereas when employees are negative about the change, they will resist the changes.

PURPOSE

This study examined how perceived person-job (demands-abilities) fit influences attitudes toward change after an externally mandated change. Specifically, we propose that perceived person-job fit moderates the negative relationship between individual job impact and attitudes toward change.

METHODOLOGY

We examined this issue in a sample of Level 1 trauma centers facing a regulatory mandate to develop an alcohol screening and brief intervention program. A survey of 200 providers within 20 trauma centers assessed perceived person-job fit, individual job impact, and attitudes toward change approximately 1 year after the mandate was enacted.

RESULTS

Providers who perceived a better fit between their abilities and the new job demands were more positive about the change. Further, the impact of the alcohol screening and brief intervention program on attitudes toward change was mitigated by perceived fit, where the relationship between job impact and change attitudes was more negative for providers who perceived a worse fit as compared with those who perceived a better fit.

PRACTICAL IMPLICATIONS

Successful implementation of changes to work processes and procedures requires provider support of the change. Management can enhance this support by improving perceived person-job fit through ongoing training sessions that enhance providers' abilities to implement the new procedures.

Large-system transformation in health care: a realist review

CONTEXT

An evidence base that addresses issues of complexity and context is urgently needed for large-system transformation (LST) and health care reform. Fundamental conceptual and methodological challenges also must be addressed. The Saskatchewan Ministry of Health in Canada requested a six-month synthesis project to guide four major policy development and strategy initiatives focused on patient- and family-centered care, primary health care renewal, quality improvement, and surgical wait lists. The aims of the review were to analyze examples of successful and less successful transformation initiatives, to synthesize knowledge of the underlying mechanisms, to clarify the role of government, and to outline options for evaluation.

METHODS

We used realist review, whose working assumption is that a particular intervention triggers particular mechanisms of change. Mechanisms may be more or less effective in producing their intended outcomes, depending on their interaction with various contextual factors. We explain the variations in outcome as the interplay between context and mechanisms. We nested this analytic approach in a macro framing of complex adaptive systems (CAS).

FINDINGS

Our rapid realist review identified five "simple rules" of LST that were likely to enhance the success of the target initiatives: (1) blend designated leadership with distributed leadership; (2) establish feedback loops; (3) attend to history; (4) engage physicians; and (5) include patients and families. These principles play out differently in different contexts affecting human behavior (and thereby contributing to change) through a wide range of different mechanisms.

CONCLUSIONS

Realist review methodology can be applied in combination with a complex system lens on published literature to produce a knowledge synthesis that informs a prospective change effort in large-system transformation. A collaborative process engaging both research producers and research users contributes to local applications of universal principles and mid-range theories, as well as to a more robust knowledge base for applied research. We conclude with suggestions for the future development of synthesis and evaluation methods.

Understanding and managing organizational change: implications for public health management

Managing organizational change has become a significant responsibility of managers. Managing the change process within public health organizations is important because appropriately and systematically managing change is linked to improved organizational performance. However, change is difficult and the change process poses formidable challenges for managers. Managers themselves face increased pressure to respond to environmental influences and provide the necessary leadership to their organizations in the change process. In fact, managing organizational change has become a key competency for healthcare managers. This article addresses the important topic of organizational change in public health organizations. It provides a conceptual foundation for understanding organizational change and its relationship to healthcare organizational performance, and then discusses the types and nature of change, using some examples and evidence from those organizations that have successfully managed change. A framework for guiding public health managers in the change management process is provided. The article concludes with suggested management competencies to establish a change-oriented organization with the culture and capacity for change.

Change agency in a primary health care context: the case of distributed leadership

BACKGROUND

Integration of services across disciplines and organizations has been pursued increasingly in the primary care sector. Successful integration requires adept leadership of change. There have been questions about the extent to which studies on change agency that focus on a stand-alone leader are applicable in the complex setting of health care. It has been suggested that a model of collective leadership is more appropriate to this setting.

PURPOSE

The objective is to understand the dynamics of collective or distributed leadership by attending to change agency roles in a context involving collaboration across health organizations. The study examines how change agency roles develop, evolve, interact, and complement each other. It also examines the bases of the change agents' ability to exercise influence.

METHODOLOGY

A qualitative, longitudinal case study allowed us to map the evolution of a successful model of leadership. We tracked changes and agents' roles by engaging in extensive observations and conducting 74 interviews over a period of 4 years.

FINDINGS

The findings point to the importance of the distributed change leadership model in contexts where legitimacy, authority, resources, and ability to influence complex change are dispersed across loci. Distributed leadership has both planned and emergent components, and its success in bringing about change is associated with the social capital prevalent in the site.

PRACTICE IMPLICATIONS

Change leaders need to build a winning coalition of agents with complementary skills and resources that support the change. Successful change leadership involves investing time in finding common ground across stakeholders and in building credibility and trust. Having an agent whose main responsibility is to manage the change process is likely to bring more success than asking busy health care practitioners to take on this charge because in the latter case, there is likelihood of dilution of change focus and momentum.

Implementing complex innovations: factors influencing middle manager support

BACKGROUND

Middle manager resistance is often described as a major challenge for upper-level administrators seeking to implement complex innovations such as evidence-based protocols or new skills training. However, factors influencing middle manager support for innovation implementation are currently understudied in the U.S. health care literature.

PURPOSE

This article examined the factors that influence middle managers' support for and participation in the implementation of work-based learning, a complex innovation adopted by health care organizations to improve the jobs, educational pathways, skills, and/or credentials of their frontline workers.

METHODS

We conducted semistructured interviews and focus groups with 92 middle managers in 17 health care organizations. Questions focused on understanding middle managers' support for work-based learning as a complex innovation, facilitators and barriers to the implementation process, and the systems changes needed to support the implementation of this innovation.

FINDINGS

Factors that emerged as influential to middle manager support were similar to those found in broader models of innovation implementation within the health care literature. However, our findings extend previous research by developing an understanding about how middle managers perceived these constructs and by identifying specific strategies for how to influence middle manager support for the innovation implementation process. These findings were generally consistent across different types of health care organizations.

PRACTICE IMPLICATIONS

Study findings suggest that middle manager support was highest when managers felt the innovation fit their workplace needs and priorities and when they had more discretion and control over how it was implemented. Leaders seeking to implement innovations should consider the interplay between middle managers' control and discretion, their narrow focus on the performance of their own departments or units, and the dedication of staff and other resources for empowering their managers to implement these complex innovations.

Towards sustainable traumatic brain injury care systems: healthcare leadership imperatives in Canada

Traumatic brain injuries pose strategic population health challenges in the face of burgeoning clinical demands that continue to tax capital, financial, and social resource capacities. The sustainability of traumatic brain injury care systems depends on paradigmatic shifts in healthcare leadership thinking. In quest for high-performance care and sustained quality of life for traumatic brain injury patients, this article presents a unique paradigm of seven care performance layers and seven health leadership imperatives that together form the paradigm for the systemic sustainability of TBI care systems of the future.