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

Building a systems-thinking community workforce to scale action on determinants of health in New Zealand

This article describes findings from the evaluation of Healthy Families NZ (HFNZ), an equity-driven, place-based community health initiative. Implemented in nine diverse communities across New Zealand, HFNZ aims to strengthen the systems that can improve health and well-being. Findings highlight local needs and priorities including the social mechanisms important for reorienting health and policy systems towards place-based communities. Lessons encompass the importance of local lived experience in putting evidence into practice; the strength of acting with systems in mind; the need for relational, learning, intentional, and well-resourced community organisation; examples of how to foster place-based 'community-up' leadership; and how to enable responsiveness between communities and local and national policy systems. A reconceptualisation of scaling in the context of complexity and systems change is offered, which recognises that relationships and agency are key to making progress on the determinants of health.

Physician Leadership and Burnout: The Need for Agency; a Qualitative Study of an Academic Institution

Purpose

Organizational approaches to physician burnout are limited. Training physician leaders to influence the organizational environment is a growing area of study. This study explored perceived physician leadership behaviors in response to burnout from the viewpoint of faculty physicians not in formal leadership positions. Understanding physician leadership behaviors from the viewpoint of those faculty being led can inform organizational strategy and leadership training to address physician burnout.

Subjects and Methods

Interview requests were sent to 70 randomly identified faculty physicians from a roster containing all 1145 physician faculty that excluded the Pediatric Department, at an academic health care institution in Southern California. The first ten respondents were asked to participate in a 30-to-40-minute semi-structured virtual interview via Zoom. The interviewees were asked two questions pertaining to burnout and their perception of how leadership responded. The two questions were "What has leadership done to address burnout?" and "If you had five minutes to advise your leaders on burnout, what would you say?" The recorded interviews were transcribed, redacted, and then sent to two reviewers. Thematic analysis through iterative coding was completed, and categories were constructed that aligned with the two interview questions.

Results

Overall, five themes were identified. These themes were organized according to the interview questions and broadly categorized as physician leadership behaviors observed that corresponded to the interview question of what leadership had done to address burnout and physician leadership behaviors desired corresponding to the second interview question of what advice should be given. Leadership behaviors observed in the context of burnout included three themes; referral to individual wellness programs, increased number of meetings and events, and a lack of agency in addressing wellness issues. The two themes of leadership behaviors desired were the obtainment of more resources and the granting of greater appreciation and recognition for work done through enhanced communication.

Conclusion

This small study of faculty physician perceptions of leadership behaviors identified several themes that had been identified in previous studies of leadership and burnout; need for relationship building through communication, need for resources to address work issues, and referral to wellness programs. However, the identification of a lack of agency in addressing factors in the wellness environment has not been identified in the previous burnout and physician leadership literature. Further study into the causes of this perceived lack of agency should be explored. Understanding the root causes of physician leaders' lack of agency can further inform physician leadership education as an organizational approach to burnout.

Four System Enablers of Large-System Transformation in Health Care: A Mixed Methods Realist Evaluation

Policy Points The implementation of large-scale health care interventions relies on a shared vision, commitment to change, coordination across sites, and a spanning of siloed knowledge. Enablers of the system should include building an authorizing environment; providing relevant, meaningful, transparent, and timely data; designating and distributing leadership and decision making; and fostering the emergence of a learning culture. Attention to these four enablers can set up a positive feedback loop to foster positive change that can protect against the loss of key staff, the presence of lone disruptors, and the enervating effects of uncertainty.

CONTEXT

Large-scale transformative initiatives have the potential to improve the quality, efficiency, and safety of health care. However, change is expensive, complex, and difficult to implement and sustain. This paper advances system enablers, which will help to guide large-scale transformation in health care systems.

METHODS

A realist study of the implementation of a value-based health care program between 2017 and 2021 was undertaken in every public hospital (n = 221) in New South Wales (NSW), Australia. Four data sources were used to elucidate initial program theories beginning with a set of literature reviews, a program document review, and informal discussions with key stakeholders. Semistructured interviews were then conducted with 56 stakeholders to confirm, refute, or refine the theories. A retroductive analysis produced a series of context-mechanism-outcome (CMO) statements. Next, the CMOs were validated with three health care quality expert panels (n = 51). Synthesized data were interrogated to distill the overarching system enablers.

FINDINGS

Forty-two CMO statements from the eight initial program theory areas were developed, refined, and validated. Four system enablers were identified: (1) build an authorizing environment; (2) provide relevant, authentic, timely, and meaningful data; (3) designate and distribute leadership and decision making; and (4) support the emergence of a learning culture. The system enablers provide a nuanced understanding of large-system transformation that illustrates when, for whom, and in what circumstances large-system transformation worked well or worked poorly.

CONCLUSIONS

System enablers offer nuanced guidance for the implementation of large-scale health care interventions. The four enablers may be portable to similar contexts and provide the empirical basis for an implementation model of large-system value-based health care initiatives. With concerted application, these findings can pave the way not just for a better understanding of greater or lesser success in intervening in health care settings but ultimately to contribute higher quality, higher value, and safer care.

Fostering collective leadership to improve integrated primary care: lessons learned from the PriCARE program

Case management (CM) is an intervention for improving integrated care for patients with complex care needs. The implementation of this complex intervention often raises opportunities for change and collective leadership has the potential to optimize the implementation. However, the application of collective leadership in real-world is not often described in the literature. This commentary highlights challenges faced during the implantation of a CM intervention in primary care for people with complex care needs, including stakeholders' buy-in and providers' willingness to change their practice, selection of the best person for the case manager position and staff turnover. Based on lessons learned from PriCARE research program, this paper encourages researchers to adopt collective leadership strategies for the implementation of complex interventions, including promoting a collaborative approach, fostering stakeholders' engagement in a trusting and fair environment, providing a high level of communication, and enhancing collective leadership attitudes and skills. The learnings from the PriCARE program may help guide researchers for implementing complex healthcare interventions.

Exploring the Challenges for Universal Health Coverage: A Call to Africa by AfroPHC

The primary health care (PHC) system in Africa faces many challenges AND opportunities. To date, human resources for health in PHC are grossly insufficient in number, often inefficiently and inequitably distributed, lacking adequate training for delivering fully responsive and comprehensive frontline care and are treated inequitably within the health system. There has been a lack of solidarity among key role players in healthcare to create adequate PHC funding in Africa. Resources do not appropriately or adequately reach the frontline PHC service platform due to outdated service delivery and payment models. Patients experience PHC as numbers in a queue, with poor comprehensiveness, continuity, and coordination. Health workers are also treated like numbers in a bureaucracy that fragments and undermines training and service for integrated care around patient and population needs. However, opportunities abound with global PHC milestones, increasing political will for investment in PHC, and proven mechanisms for achieving a stronger workforce such as community health workers, clinical task-sharing, and the integration of family doctors into PHC. The African Forum for PHC (AfroPHC) has a vision for PHC and UHC that is team-based with skills mix appropriate to Africa, including family doctors, family nurse practitioners, clinical officers, community health workers and others that are empowered to take care of an empaneled population in high-quality people centred PHC. AfroPHC is making a call on stakeholders to develop and implement a regional forward-looking plan to 1) build robust PHC systems, 2) train, recruit and maintain a sufficient frontline PHC workforce, and 3) support PHC with appropriate financing. This can all come together easily in a nationally defined PHC contract using risk-adjusted blended capitation payment to decentralised PHC teams empanelled to enrolled populations, coordinated by district health services and easily administered at national or sub-national level for empowered public and private providers.

The Impact of Change Management in the Greek National Health System: A Quantitative Study

INTRODUCTION

 Serious changes took place in Greece due to the economic crisis of 2008, which led to significant changes in Greece's health sector. The reforms and changes that were made to the National Health System (NHS) aimed to improve it, provide quality services to its users, and adapt it to Greece's new external environment. The aim of this study was to assess the management of these changes by the leadership of the NHS and to examine their effectiveness.

MATERIAL AND METHODS

The survey was based on quantitative research methods, using a questionnaire as a research tool. The sample population comprised employees of a tertiary-care public hospital in northern Greece.

RESULTS

 We recruited a sample size of 100 participants for the survey. The questionnaire's Cronbach's alpha was equal to 0.724. The overall change management was moderate, and Greece's NHS did not follow a specific change-management model that provided principles facilitating the success of the effort. The most serious problems identified by using the questionnaire were the following: the changes were not structured and clear, the management set unrealistic goals and objectives, the changes to the NHS were made without the appropriate financial support, and there is uncertainty about the future of health care in Greece.

CONCLUSION

The present study showed that changes cannot be made randomly; rather, they require careful planning and organization. Further changes, continuous feedback, and development are required to improve the status of Greece's healthcare system.

Successes, weaknesses, and recommendations to strengthen primary health care: a scoping review

BACKGROUND

Primary health care (PHC) is a roadmap for achieving universal health coverage (UHC). There were several fragmented and inconclusive pieces of evidence needed to be synthesized. Hence, we synthesized evidence to fully understand the successes, weaknesses, effective strategies, and barriers of PHC.

METHODS

We followed the PRISMA extension for scoping reviews checklist. Qualitative, quantitative, or mixed-approach studies were included. The result synthesis is in a realistic approach with identifying which strategies and challenges existed at which country, in what context and why it happens.

RESULTS

A total of 10,556 articles were found. Of these, 134 articles were included for the final synthesis. Most studies (86 articles) were quantitative followed by qualitative (26 articles), and others (16 review and 6 mixed methods). Countries sought varying degrees of success and weakness. Strengths of PHC include less costly community health workers services, increased health care coverage and improved health outcomes. Declined continuity of care, less comprehensive in specialized care settings and ineffective reform were weaknesses in some countries. There were effective strategies: leadership, financial system, 'Diagonal investment', adequate health workforce, expanding PHC institutions, after-hour services, telephone appointment, contracting with non-governmental partners, a 'Scheduling Model', a strong referral system and measurement tools. On the other hand, high health care cost, client's bad perception of health care, inadequate health workers, language problem and lack of quality of circle were barriers.

CONCLUSIONS

There was heterogeneous progress towards PHC vision. A country with a higher UHC effective service coverage index does not reflect its effectiveness in all aspects of PHC. Continuing monitoring and evaluation of PHC system, subsidies to the poor, and training and recruiting an adequate health workforce will keep PHC progress on track. The results of this review can be used as a guide for future research in selecting exploratory and outcome parameters.

Distributed Leadership in Projects: The Contributions of Stakeholders

This article examines how stakeholders contribute to leading a project. Using a longitudinal study of a project embedded in a public project portfolio, the article uncovers a leadership configuration in which project portfolio and project actors come together in four patterns: top-down influence, transactional exchange, pooled leadership, and co-leadership. This configuration reveals integrated leadership units, the possibility of senior managers to both constrain and channel project manager contributions, and a wider variety of leadership patterns in horizontal and vertical relationships. These insights offer a more comprehensive account of distributed leadership that contributes to the development of leadership capacity in projects.

Transformational health-care leaders in collaborative entrepreneurial model to achieve UNSDG: a qualitative study

PURPOSE

The agglomeration of specialist health-care facilities has often been restricted to metropolitan areas. This study aims to understand how health-care professionals with transformational leadership behaviors and entrepreneurial aims with a similar vision and expertise play pertinent roles in providing essential specialized health care in rural and semi-urban areas and achieving the United Nations Sustainable Development Goals (UNSDGs).

DESIGN/METHODOLOGY/APPROACH

Qualitative synthesis using focused-group discussions and interviews was conducted in a phased manner. For this, this study has used stakeholder-theory, and dynamic-capabilities approaches.

FINDINGS

This study explores the intricacies of collaborative entrepreneurship (CE)-based health-care ventures in developing regions and reveals five pertinent attributes: strategic control, synergy, commitment, empathy and satisfaction. This study recommends that entrepreneurial collaboration, especially by transformational health-care leaders, can significantly contribute to creating an endogenous health-care ecosystem with advanced facilities and technology-enabled modern infrastructure and augmenting regional development.

RESEARCH LIMITATIONS/IMPLICATIONS

This study was conducted in semi-urban settings in India. Future research should include other sectors and regions to generalize the findings.

PRACTICAL IMPLICATIONS

This study benefits health-care professionals having an analogous vision, skills and entrepreneurial aims.

SOCIAL IMPLICATIONS

Collaboration of health-care professionals and using transformational leadership behaviors can considerably contribute to providing specialist health care in developing areas and enhance patient satisfaction.

ORIGINALITY/VALUE

To the best of the authors' knowledge, this is the first study to discuss the importance of CE in health care in developing areas. In addition, it discusses the benefits of the CE model in achieving the UNSDGs and offers valuable suggestions for health-care professionals and administrators.

General practitioners' perceptions of distributed leadership in providing integrated care for elderly chronic multi-morbid patients: a qualitative study

Background

Distributed Leadership (DL) has been suggested as being helpful when different health care professionals and patients need to work together across professional and organizational boundaries to provide integrated care (IC). This study explores whether General Practitioners (GPs) adopt leadership actions that transcend organizational boundaries to provide IC for patients and discusses whether the GPs’ leadership actions in collaboration with patients and health care professionals contribute to DL.

Methods

We interviewed GPs (n = 20) of elderly multimorbid patients in a municipality in Norway. A qualitative interpretive case design and Gioia methodology was applied to the collection and analysis of data from semi-structured interviews.

Results

GPs are involved in three processes when contributing to IC for elderly multimorbidity patients; the process of creating an integrated patient experience, the workflow process and the process of maneuvering organizational structures and medical culture. GPs take part in processes comparable to configurations of DL described in the literature. Patient micro-context and health care macro-context are related to observed configurations of DL.

Conclusion

Initiating or moving between different configurations of DL in IC requires awareness of patient context and the health care macro-context, of ways of working, capacity of digital tools and use of health care personnel.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08460-x.

Shared accountability in distributed leadership for improved healthcare access: a study of a US dental institution

PURPOSE

Accountability within distributed leadership (DL) is critical for DL to drive positive outcomes in health services organizations. Despite this, how accountability emerges in DL is less clear. This study aims to understand how accountability emerges in DL so that distributed leaders can drive improvements in healthcare access - an increasingly important outcome in today's health services environment.

DESIGN/METHODOLOGY/APPROACH

The authors use an instrumental case study of a dental institution in the USA, "Environ," as it underwent a strategic change to improve healthcare access to rural populations. The authors focused on DL occurring within the strategic change and collected interview, observation and archival data.

FINDINGS

The findings demonstrate accountability in DL emerged as shared accountability and has three elements: personal ownership, agentic actions and a shared belief system. Each of these was necessary for DL to advance the strategic change for improved healthcare access.

PRACTICAL IMPLICATIONS

Top managers should be cognizant of the emergence processes driven by DL. This includes enabling pockets of employees to connect, align and link up so that ideas, processes and practices can emerge and allow for shared accountability in DL.

ORIGINALITY/VALUE

The overarching contribution of this research is identifying shared accountability in DL and its three elements: personal ownership, agentic actions and a shared belief system. These elements serve as a platform to demonstrate "how DL works" in a healthcare organization.

The Perioperative Steering Committee as an Accountable Infrastructure to Enable and Sustain Change

Leaders in perioperative and interventional procedure areas need to be able to initiate and sustain change to improve operational processes in their departments or service lines. Although available literature discusses change in health care organizations, there is a lack of published articles on the implementation and sustainment of change. This article provides a review of supporting literature on change management and an infrastructure model that we have successfully implemented to sustain change. An organizational case study focused on creating sustained improvements for first procedure on-time starts and turnover times details the process of creating the accountability system for actualizing the performance targets in a perioperative environment. The case study examines the existing process and initial challenges with creating sustainable and quantifiable outcomes, describes the process of implementing the infrastructure discussed in the article, and evaluates the results. Perioperative leaders can use the information to improve processes in their work environments.

Implementing Coordinated Care Networks: The Interplay of Individual and Distributed Leadership Practices

How does leadership emerge and function when multiple health care organizations come together to form a network? In this qualitative comparative case study, we draw on distributed leadership theory to examine the leadership practices that manifested during the implementation of three coordinated care networks. Thirty leaders and care providers participated in semistructured interviews. Interview data were inductively analyzed using thematic analysis. Although established in response to the same policy initiative, each case differed in its leadership approach and implementation strategy. We found that manifestation of distributed leadership was contingent on the presence of an individual leader who acted as a unifying force across their respective network. Our findings suggest that policies to encourage the development of interorganizational networks should include sufficient resources to support an individual leader who enables distributed leadership.

What does Success Look Like for Leaders of Integrated Health and Social Care Systems? a Realist Review

Introduction

Health and social care services in England are moving towards greater integration, yet little is known about how leadership of integrated care teams and systems can be supported and improved. This realist review explores what works about the leadership of integrated care teams and systems, for whom, in what circumstances and why.

Methods

A realist synthesis approach was undertaken in 2020 to explore English language literature on the leadership of integrated care teams and systems, complemented by ongoing stakeholder consultation.

Results

Evidence was identified for seven potentially important components of leadership in integrated care teams and systems: 'inspiring intent to work together'; 'creating the conditions'; 'balancing multiple perspectives'; 'working with power'; 'taking a wider view'; 'a commitment to learning and development' and 'clarifying complexity'.

Discussion

Research into the leadership of integrated care teams and systems is limited, with ideas often reverting to existing framings of leadership, where teams and organisations are less complex. Research also often focuses on the importance of who the leader is rather than what they do.

Conclusion

This review has generated new perspectives on the leadership of integrated care teams and systems that can be built upon, developed, and tested further.

Implementing Asset-Based Integrated Care: A Tale of Two Localities

BACKGROUND

To date, few studies have examined the implementation of asset-based integrated care in the UK. This paper aims to address this gap in knowledge through examining the implementation of one model of asset-based integrated care, Local Area Coordination (LAC), within two localities in England.

METHODS

This paper draws upon data collected from two local authorities (site A and site B), which had both implemented LAC. Using a case study approach, qualitative data was collected from interviews with relevant stakeholders both internal and external to the local authorities. Data was analysed thematically.

RESULTS

The findings demonstrate the marked differences between the two sites' approaches to LAC, especially in relation to: the implementation process; impact; and their collaboration with other agencies and communities.

DISCUSSION

The evidence presented in this paper demonstrates that the implementation of LAC, as with most complex service innovations, is dependent on the interplay of organisational and people-based components. In particular, successful implementation depends on maintaining a common vision of what an intervention will achieve and how it will work in practice, continual engagement with the political and organisational leaders of influence, positively addressing the anxieties of existing services and professions, and working with community groups.

Family Doctor Leadership in African Primary Health Care

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Distributed leadership in healthcare: leadership dyads and the promise of improved hospital outcomes

PURPOSE

This paper aims to extend the consideration of distributed leadership in health-care settings. Leadership is typically studied from the classical notion of the place of single leaders and continues to examine distributed leadership within small teams or horizontally. The purpose is to develop a practical understanding of how distributed leadership may occur vertically, between different layers of the health-care leadership hierarchy, examining its influence on health-care outcomes across two hospitals.

DESIGN/METHODOLOGY/APPROACH

Using semi-structured interviews, data were collected from 107 hospital employees (including executive leadership, clinical management and clinicians) from two hospitals in Australia and the USA. Using thematic content analysis, an iterative process was adopted characterized by alternating between social identity and distributed leadership literature and empirical themes to answer the question of how the practice of distributed leadership influences performance outcomes in hospitals?

FINDINGS

The perceived social identities of leadership groups shaped communication and performance both positively and negatively. In one hospital a moderating structure emerged as a leadership dyad, where leadership was distributed vertically between hospital hierarchal layers, observed to overcome communication limitations. Findings suggest dyad creation is an effective mechanism to overcome hospital hierarchy-based communication issues and ameliorate health-care outcomes.

ORIGINALITY/VALUE

The study demonstrates how current leadership development practices that focus on leadership relational and social competencies can benefit from a structural approach to include leadership dyads that can foster these same competencies. This approach could help develop future hospital leaders and in doing so, improve hospital outcomes.

Time to get serious about distributed leadership: lessons to learn for promoting leadership development for non-consultant career grade doctors in the UK

COVID-19 has exposed the National Health Service (NHS) to the greatest challenge in its existence, highlighting the need for nimble, reactive and inclusive leadership. It is set against a backdrop of a workforce recruitment and retention crisis predicted to worsen in coming years. There is a need to do things differently in healthcare, including better diversity and distribution of leadership. We make the case for senior non-consultant doctors, in the UK more usually referred to as specialty and associate specialist or locally employed doctors. These skilled, experienced medics have much to offer yet are frequently overlooked, with little guidance or support from central organisations and medical colleges or within NHS Trusts themselves. In this commentary, we suggest ways this workforce might be better tapped into, to the benefit of patients and healthcare systems, as well as the doctors themselves.

How are empowering leadership, self-efficacy and innovative behavior related to nurses' agency in distributed leadership in Denmark, Italy and Israel?

AIM

The purpose of the study was to introduce the concept of distributed leadership to international nursing management by conducting a cross-national investigation of its relationships with empowering nursing leadership, nurses' work self-efficacy and nurses' innovative behaviour.

BACKGROUND

Distributed leadership theory suggests that when more people lead processes together, innovation will be superior to solo leadership. However, we need knowledge about how nurse managers may enhance nurses' distributed leadership agency (DLA), and whether such results are generalizable across countries.

METHOD

The cross-national survey with an overall purposeful sampling method used questionnaire data from hospital nurses from Israel (n = 239), Italy (n = 226) and Denmark (n = 709). We used validated scales measuring Empowering Leadership, Self-efficacy, Innovative Work Behavior and DLA.

RESULTS

The results from all three countries showed that empowering leadership and work self-efficacy were positively related to DLA, which, in turn, was also related to more innovation.

CONCLUSION

The results may imply that nursing managers can increase workplace innovativeness by adopting an empowering leadership style that supports nurses' self-efficacy and distributes leadership tasks.

IMPLICATIONS FOR NURSING MANAGEMENT

The cross-country robustness of the results may encourage further research in distributed leadership in nurse management, notably with a focus on causal mechanisms.

Contextual Analysis for Practical Action (CAPA): a framework for understanding how context works and how to apply it for practical learning and implementing change in complex systems

Background: This concept paper presents Contextual Analysis for Practical Action or ‘CAPA’ as an action-oriented tool to understand and implement interventions in real-life service delivery contexts. Understanding how contexts work is a critical challenge for Health and Social Care Systems seeking to become more integrated. CAPA is a tool for understanding and empowering agents in local contexts. The local context is understood here as a key factor in implementation success. This concept paper offers rich theorising to underpin the translation of systems reform initiatives into meaningful local engagement and change. Methods: Analysis of the ‘implementation conundrum’ highlights the problem, while a review of the organisational learning literature identifies ‘sensemaking in organisation’ as a powerful mechanism to address it. Based on earlier phenomenological research the dynamics of organisational sensemaking are presented.  Finally, applications for CAPA are explored and next steps outlined. Results: CAPA makes tangible the implicit and interpretive nature of organisational life as ‘sensemaking in context’. This phenomenon is analysed as a determinant of implementation success. As such, CAPA opens a path to working with contextual complexity by framing it as a dialectic pattern of topical, ecological, dialogical, and pragmatic modes that ‘contextualise’. CAPA is a tool for researchers and practitioners to explore the complexity of local contexts and their implementation challenges, and working-with local agents for learning and change. Conclusions: Health reform needs new approaches for understanding implementation in context. CAPA is a tool for understanding and working-with contextual factors central to the complexity of policy or knowledge translation for example. This paper outlines its rationale, principles, and functionality. Possible applications are explored for co-designed practical learning experiences. It concludes with a call to policy makers, service managers and researchers to use the approach in specific settings so it can be developed and refined.

Distributive Leadership Within an Emerging Network of Integrated Youth Health Centres: A Case Study of Foundry

Background

Distributive leadership has been proposed as an effective means towards achieving integrated health services. This study draws from the case of Foundry, a network of integrated youth health centres in British Columbia, Canada, and explores the function and impact of distributive leadership in the context of a large-scale effort towards integrated service delivery for youth experiencing mental health and substance use challenges.

Methods

Qualitative data was obtained from a developmental evaluation of Foundry using a longitudinal, ethnographic approach. Over 150 participants involved in the development of six Foundry centres were interviewed individually or in focus groups. Purposive and theoretical sampling strategies were used to maximize the diversity of perspectives represented in the data set.

Results and Discussion

Distributive leadership was observed to be a facilitator for achieving service and system-level integration. Distributive leadership was effective in promoting streamlined service provision, and coordinating efforts towards optimized access to care. A new culture of leadership emerged through collaboration and relationship-building based on a common value system to prioritize youth needs.

Conclusion

As Foundry, and other integrated youth services, continues to expand, distributive leadership shows promise in assuring diverse and coordinated input for integrating services.

Issues and Challenges in Implementing Care Coordinator in Primary Healthcare in Malaysia: A Qualitative Study

BACKGROUND

Primary healthcare is the earliest gateway for patient care, and improvisations are often needed to accommodate the ever-increasing demand in public health. The Enhanced Primary Healthcare (EnPHC) initiative is aimed at improving such needs, and one core intervention is the introduction of a care coordinator (CC). The purpose of this study was to identify barriers and facilitators in implementing a new intervention in primary healthcare clinics.

METHODS

This qualitative exploration study. All healthcare providers who were involved in EnPHC at the intervention clinics were selected as participants. In-depth interviews and focus group discussions were carried out among healthcare providers working in the intervention clinic. Thematic analysis was used to categorize data, based on the consolidated framework for implementation research (CFIR) theoretical framework domains.

RESULTS

A total of 61 healthcare providers participated. All 5 domains with 19 CFIR constructs emerged from the analysis. Inner setting played a significant role in facilitating CC intervention, in which culture, networking, and collaboration and leadership engagement played an essential role in supporting CC activities. Although CC tasks are complex, concerns of losing clinical skill and resource constraints were identified as potential barriers in CC implementations. Criteria for appointing new CCs emerged from the characteristics of individual constructs, in which the individual must be familiar and interested in community health, have good communication skills, and at least 3 years' experience in the primary healthcare setting.

CONCLUSION

The implementation of the CC intervention faces varying challenges in different settings. This is partially resolved through teamwork, guidance from mentors, and support from superiors. The complexity of the responsibility of the CC intervention is perceived as both a validation and a burden. Above all, it is seen as paramount in EnPHC intervention.

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.

Leadership in Integrated Care Networks: A Literature Review and Opportunities for Future Research

Introduction

In many countries, elderly patients with chronic conditions require a web of services delivered by several providers collaborating in inter-organisational networks. In view of their global importance, it is surprising how little we know how these networks are led. Like traditional organisations, networks require leadership to function effectively. This paper reviews central characteristics of leadership in integrated care networks and proposes opportunities for future research.

Theory and methods

Analysing 73 studies published in leading academic journals, this paper consolidates research on leadership media, practices, activities and outcomes, covering the network, policy and organisation levels of analysis.

Results

Findings indicate that the field has focused on leadership media and outcomes at the network level. They also suggest that leadership in integrated care networks faces multiple tensions. Future research could usefully provide a fuller picture by examining leadership practices, activities and outcomes at the policy and organisation level, integrating advances in the wider leadership literature.

Discussion and conclusion

These findings contribute to the debate on leadership in integrated care networks. They also inform practice, drawing attention to persistent tensions as a core leadership challenge and offering latest scholarly evidence practitioners can use to reflect on and advance their own leadership practice.

Leading Innovative Practice: Leadership Attributes in LEAP Practices

Policy Points An onslaught of policies from the federal government, states, the insurance industry, and professional organizations continually requires primary care practices to make substantial changes; however, ineffective leadership at the practice level can impede the dissemination and scale-up of these policies. The inability of primary care practice leadership to respond to ongoing policy demands has resulted in moral distress and clinician burnout. Investments are needed to develop interventions and educational opportunities that target a broad array of leadership attributes.

CONTEXT

Over the past several decades, health care in the United States has undergone substantial and rapid change. At the heart of this change is an assumption that a more robust primary care infrastructure helps achieve the quadruple aim of improved care, better patient experience, reduced cost, and improved work life of health care providers. Practice-level leadership is essential to succeed in this rapidly changing environment. Complex adaptive systems theory offers a lens for understanding important leadership attributes.

METHODS

A review of the literature on leadership from a complex adaptive system perspective identified nine leadership attributes hypothesized to support practice change: motivating others to engage in change, managing abuse of power and social influence, assuring psychological safety, enhancing communication and information sharing, generating a learning organization, instilling a collective mind, cultivating teamwork, fostering emergent leaders, and encouraging boundary spanning. Through a secondary qualitative analysis, we applied these attributes to nine practices ranking high on both a practice learning and leadership scale from the Learning from Effective Ambulatory Practice (LEAP) project to see if and how these attributes manifest in high-performing innovative practices.

FINDINGS

We found all nine attributes identified from the literature were evident and seemed important during a time of change and innovation. We identified two additional attributes-anticipating the future and developing formal processes-that we found to be important. Complexity science suggests a hypothesized developmental model in which some attributes are foundational and necessary for the emergence of others.

CONCLUSIONS

Successful primary care practices exhibit a diversity of strong local leadership attributes. To meet the realities of a rapidly changing health care environment, training of current and future primary care leaders needs to be more comprehensive and move beyond motivating others and developing effective teams.

Factors influencing interprofessional team collaboration when delivering care to community-dwelling seniors: A metasynthesis of Canadian interventions

The rapid growth in the proportion of adults over the age of 65 translates into greater need of complex, highly specialized care. Hence, coupled with other factors, healthcare expenditures in Canada have grown exponentially, creating tension for a high-quality care while managing costs. Interventions with community-based interprofessional teams have been piloted across Canada as a means to provide efficient specialized care. These teams must, however, work collaboratively for a more comprehensive and patient-centered care. This metasynthesis aimed to identify common factors or characteristics found to be essential for a collaborative practice among members of an interdisciplinary team delivering coordinated care to community-dwelling seniors in both rural and urban centers in Canada. Six databases (Medline, CINAHL, Sage, JSTOR, ProQuest, Web of Science) were searched for qualitative peer-reviewed articles on community-based interventions with interprofessional teams in Canada and published between 2005-2018. Six articles were included and appraised using the COREQ guidelines for quality, followed by a thematic analysis for common themes related to team collaboration. Overarching themes related to practices of interprofessional collaboration were trust and respect, communication, and shared vision. Sub-themes included trust in the relationship between health care professional, professional identity and role clarity, interprofessional communication, communication with the client or family, and common goals. Interprofessional teams work collaboratively when trust and respect, communication, and shared vision are valued and present. Agencies coordinating interprofessional teams for community-based care could be pivotal in ensuring an environment conducive to collaboration, such as learning and team building opportunities.

Sharing leadership: current attitudes, barriers and needs of clinical and non-clinical managers in UK’s integrated care system

Background

As systems become more complex, shared leadership (SL) has been suggested to have a dominant role in improving cross-functional working tailored to organisational needs. Little, however, is known about the benefits of SL in healthcare management, especially for UK’s recently formed integrated care system (ICS). The aim of this study was to understand current attitudes, barriers and needs of clinical and non-clinical managers sharing leadership responsibilities in the ICS.

Method

Twenty clinical and non-clinical leaders in 15 organisations were interviewed to understand current cross-functional leadership collaborations, and the potential SL may have on the recently established ICS in the National Health Service (NHS). The data were transcribed and analysed thematically.

Results

Findings showed perceptions and experiences of clinical and non-clinical healthcare management in relation to: (1) motivation to execute a leadership position, including the need to step up and a sense of duty; (2) attitudes towards interdisciplinary working, which is reflected in conflicts due to different values and expertise; (3) SL skills and behaviours, including the need for mutual understanding and cooperative attitudes by means of effective communication and collaboration; and (4) barriers to achieve SL in the ICS, such as bureaucracy, and a lack of time and support.

Conclusions

SL may help improve current leadership cultures within the NHS; however, for SL to have a tangible impact, it needs to be delivered as part of leadership development for doctors in postgraduate training, and development programmes for aspiring, emerging and established leaders, with clear lines of communication.

Distributed Leadership Agency and Work Outcomes: Validation of the Italian DLA and Its Relations With Commitment, Trust, and Satisfaction

Forms of collective leadership, such as distributed leadership, have become increasingly important. The need for measurement of the variables involved in the delegation processes represents a new challenge for organizations that want to ensure high-level working. The present study aimed to validate the Italian version of the distributed leadership agency (DLA). The study was carried out on 704 employees (doctors, nurses, clerks, staff workers, healthcare assistants, consultants, management) of an Italian public hospital, who were selected to complete a survey on organizational perceptions. Multiple confirmatory factor analyses (maximum likelihood) have been computed to explore the factorial structure of the DLA, along with associations with other work outcomes. Results about the Italian DLA confirmed the original trifactorial structure of the construct, suggested by Yukl (2002), through good fit indexes and reliability scores; moreover, consistent with the literature, DLA was strongly related to satisfaction, commitment, and trust. Results contribute to underline the robustness of the construct of DLA in different cultural sectors and provide a useful tool to be adopted in the Italian context.

Leadership for integrated care: a case study

Purpose

Integration of health services involves multiple interdependent leaders acting at several levels of their organisation and across organisations. This paper aims to explore the complexities of leadership in an integrated care project and aims to understand what leadership arrangements are needed to enable service transformation.

Design/methodology/approach

This case study analysed system and organisational leadership in a project aiming to integrate primary and specialist care. To explore the former, the national policy documents and guidelines were reviewed. To explore the latter, the official documents from the transformation team meetings and interview data from 17 health-care professionals and commissioners were analysed using thematic analysis with the coding framework derived from the comprehensive and multilevel framework for change (Ferlie and Shortell, 2001).

Findings

Although integration was supported in the narratives of the system and organisational leaders, there were multiple challenges: insufficient support by the system level leadership for the local leadership, insufficient organisational support for (clinical) leadership within the transformation team and insufficient leadership within the transformation team because of disruptions caused by personnel changes, roles ambiguity, conflicting priorities and insufficient resources.

Practical implications

This study provides insights into the interdependencies of leadership across multiple levels and proposes steps to maximise the success of complex transformational projects.

Originality/value

This study’s practical findings are useful for those involved in the bottom-up integrated projects, especially the transformation teams’ members. The case study highlights the need for a toolkit enabling local leaders to operate effectively within the system and organisational leadership contexts.

Contextual Conditions and Performance Improvement in Primary Care

BACKGROUND

Although organizational context can affect the implementation of quality initiatives, we know less about the influence of contextual conditions on quality outcomes. We examined organizational features of primary care clinics that achieved greatest performance improvements after implementing Lean redesigns.

METHODS

We used operational data and baseline (ie, pre-Lean implementation) surveys of 1333 physicians and staff in 43 primary care clinics located across a large ambulatory care system. Segmented regression with interrupted time series analysis was used to identify clinics with highest improvements in workflow efficiency, physician productivity, and patient satisfaction following Lean redesign. We conducted independent-samples t tests to identify contextual features of clinics that showed greatest improvements in performance outcomes.

RESULTS

Clinics with highest increases in efficiency had most prior experience with quality improvement, compared with all other clinics. Efficiency gains were also found in clinics reporting highest levels of burnout and work stress prior to redesign. Highest improvements in physician productivity were associated with a history of change, staff participation, and leadership support for redesigns. Greatest improvements in patient satisfaction occurred in least stressful environments with highest levels of teamwork, staff engagement/efficacy, and leadership support.

CONCLUSIONS

Our findings encourage careful evaluation of clinic characteristics and capacity to effectively implement redesigns. Such evaluations may help leaders select interventions most appropriate for certain clinics, while identifying others that may need extra support with implementing change.

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.

Sustainment of Lean Redesigns for Primary Care Teams

BACKGROUND

Quality improvements are notoriously followed by "backsliding" or relapse to the status quo. This mixed-methods study examined the sustainment of Lean workflow redesigns for primary care teams several years after being implemented in a large, ambulatory care delivery system.

METHODS

We conducted qualitative interviews of 57 leaders and frontline providers, and fielded post-Lean implementation surveys to 1164 physicians and staff in 17 primary care clinics across the system. We analyzed interviews and conducted independent sample t tests to identify key factors that facilitated the sustainment of new workflows among primary care teams. All analyses were conducted after Lean redesigns were implemented and scaled across the system in 3 consecutive phases.

RESULTS

Adherence to Lean redesigns was highest in the pilot clinic, despite having the longest postdesign measurement period. Members of the pilot clinic reported greatest participation in designing workflows, were most highly engaged in quality improvement efforts, and held most favorable beliefs about Lean changes. Adherence to redesigns was lowest among clinic members in the second phase of implementation; these members also reported highest levels of burnout.

CONCLUSIONS

Staff participation in Lean redesign is a key to facilitating buy-in and adherence to changes. Change ownership and continued availability of time for improvement activities are also critical to the long-term success of Lean implementation in primary care.

Integrated Palliative Care for Nursing Home Residents: Exploring the Challenges in the Collaboration between Nursing Homes, Home Care and Hospitals

INTRODUCTION

Nursing home residents are a vulnerable and frail segment of the population, characterised by their complex and palliative care needs. To ensure an integrated approach to palliative care for this target group, working on a collaborative basis with multiple providers across organisational boundaries is necessary. Considering that coordinators of palliative networks support and coordinate collaboration, the research question is: 'how do network coordinators perceive the process of collaboration between organisations in Flemish palliative networks?'

METHODS

A dual-phase sequential mixed-methods design was applied. First, the coordinators of each of the fifteen palliative networks in Flanders completed a survey in which they evaluated ten aspects of collaboration for two types of cooperation: between nursing homes and home care, and between nursing homes and hospitals. Next, the survey results thus obtained were discussed to improve understanding in a focus group composed of the above coordinators, and which was analysed on the basis of content analysis.

RESULTS

In both forms of cooperation, the 'formalisation' and 'governance' were the aspects that yielded the lowest mean scores. The coordinators in the focus group expressed a need for more formalised interaction among organisations with regard to palliative care, the establishment of formal channels of communication and the exchange of information, as well as the development of shared leadership.

CONCLUSIONS

The perspectives of the coordinators on inter-organisational collaboration are a valuable starting point for interventions directed at the stronger integration of palliative care for residents of long term-care facilities.

Examining clinical leadership in Kenyan public hospitals through the distributed leadership lens

Clinical leadership is recognized as a crucial element in health system strengthening and health policy globally yet it has received relatively little attention in low and middle income countries (LMICs). Moreover, analyses of clinical leadership tend to focus on senior-level individual leaders, overlooking a wider constellation of middle-level leaders delivering health care in practice in a way affected by their health care context. Using the theoretical lens of ‘distributed leadership’, this article examines how middle-level leadership is practised and affected by context in Kenyan county hospitals, providing insights relevant to health care in other LMICs. The article is based on empirical qualitative case studies of clinical departmental leadership in two Kenyan public hospitals, drawing on data gathered through ethnographic observation, interviews and focus groups. We inductively and iteratively coded, analysed and theorized our findings. We found the distributed leadership lens useful for the purpose of analysing middle-level leadership in Kenyan hospitals, although clinical departmental leadership was understood locally in more individualized terms. Our distributed lens revealed medical and nursing leadership occurring in parallel and how only doctors in leadership roles were able to directly influence behaviour among their medical colleagues, using inter-personal skills, power and professional expertize. Finally, we found that Kenyan hospital contexts were characterized by cultures, norms and structures that constrained the way leadership was practiced. We make a theoretical contribution by demonstrating the utility of using distributed leadership as a lens for analysing leadership in LIMC health care contexts, revealing how context, power and inter-professional relationships moderate individual leaders’ ability to bring about change. Our findings, have important implications for how leadership is conceptualized and the way leadership development and training are provided in LMICs health systems.

Managing Healthcare Integration

Healthcare integration projects typically involve significant organizational change, with the intention of providing improved patient services and outcomes through the integration of healthcare services. Some of the management needs of healthcare integration arguably go past the traditional domain of project management, leading practitioners in these projects to use change management in combination with project management. The focus of this article is on the ways that project managers, responsible for merging and integrating healthcare services, have used project management and change management approaches in combination when delivering these projects. The article involves an inductive analysis of data from the integration of 10 healthcare networks. The aim of this article is to contribute to the growing stream of project management literature that explores the blending of both project management and change management. Analysis of these healthcare integration projects led to five key themes, which can be summarized as: (1) traditional project management only partly aligns to the needs of healthcare integration projects; (2) benefits were found in combining project management with change management; (3) change management was particularly beneficial if used early in the project life cycle; (4) the life cycles of these two disciplines did not align, causing complications in practice, and (5) practitioners used an intuitive and improvisational approach to combining the disciplines.

Dynamics of distributed leadership during a hospital merger

Purpose Mergers have become an influential part of public hospital development, and the successful implementation of such mergers requires skillful management. Recent studies have pointed to the impact of the distribution of leadership tasks amongst employees for implementing planned radical changes, yet this lacks examination with regard to hospital mergers. The purpose of this paper is to investigate the emergence of distributed leadership and this leadership's influence on the implementation of a hospital merger. Design/methodology/approach The emergence of distributed leadership is examined through a qualitative case study of two Danish hospital units in the context of a large hospital merger. The data consist of 21 interviews and documents collected over a three-year period. Findings The findings suggest dynamics of widened and restricted distributed leadership being influenced by and influencing the merger at hospital and local-unit levels, respectively. Importantly, the perceived purpose of widened and restricted distributed leadership mediated the actual effects of widened and restricted distributed leadership on the implementation of a merger. Moreover, the findings show that mergers on both the hospital and local level lead to variations in top-down and bottom-up distributed leadership across pre-merger organizational boundaries. Practical implications Perceived purposeful widening and restriction of distributed leadership at various hospital levels enables merger integration and collaboration across organizational boundaries and hierarchies. Originality/value The paper addresses the need to understand the complex dynamics of widened and restricted leadership distribution in a merger context.

The international knowledge base for new care models relevant to primary care-led integrated models: a realist synthesis

Background

The Multispecialty Community Provider (MCP) model was introduced to the NHS as a primary care-led, community-based integrated care model to provide better quality, experience and value for local populations.

Objectives

The three main objectives were to (1) articulate the underlying programme theories for the MCP model of care; (2) identify sources of theoretical, empirical and practice evidence to test the programme theories; and (3) explain how mechanisms used in different contexts contribute to outcomes and process variables.

Design

There were three main phases: (1) identification of programme theories from logic models of MCP vanguards, prioritising key theories for investigation; (2) appraisal, extraction and analysis of evidence against a best-fit framework; and (3) realist reviews of prioritised theory components and maps of remaining theory components.

Main outcome measures

The quadruple aim outcomes addressed population health, cost-effectiveness, patient experience and staff experience.

Data sources

Searches of electronic databases with forward- and backward-citation tracking, identifying research-based evidence and practice-derived evidence.

Review methods

A realist synthesis was used to identify, test and refine the following programme theory components: (1) community-based, co-ordinated care is more accessible; (2) place-based contracting and payment systems incentivise shared accountability; and (3) fostering relational behaviours builds resilience within communities.

Results

Delivery of a MCP model requires professional and service user engagement, which is dependent on building trust and empowerment. These are generated if values and incentives for new ways of working are aligned and there are opportunities for training and development. Together, these can facilitate accountability at the individual, community and system levels. The evidence base relating to these theory components was, for the most part, limited by initiatives that are relatively new or not formally evaluated. Support for the programme theory components varies, with moderate support for enhanced primary care and community involvement in care, and relatively weak support for new contracting models.

Strengths and limitations

The project benefited from a close relationship with national and local MCP leads, reflecting the value of the proximity of the research team to decision-makers. Our use of logic models to identify theories of change could present a relatively static position for what is a dynamic programme of change.

Conclusions

Multispecialty Community Providers can be described as complex adaptive systems (CASs) and, as such, connectivity, feedback loops, system learning and adaptation of CASs play a critical role in their design. Implementation can be further reinforced by paying attention to contextual factors that influence behaviour change, in order to support more integrated working.

Future work

A set of evidence-derived ‘key ingredients’ has been compiled to inform the design and delivery of future iterations of population health-based models of care. Suggested priorities for future research include the impact of enhanced primary care on the workforce, the effects of longer-term contracts on sustainability and capacity, the conditions needed for successful continuous improvement and learning, the role of carers in patient empowerment and how community participation might contribute to community resilience.

Study registration

This study is registered as PROSPERO CRD42016039552.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Population health management guiding principles to stimulate collaboration and improve pharmaceutical care

Purpose A range of strategies to improve pharmaceutical care has been implemented by population health management (PHM) initiatives. However, which strategies generate the desired outcomes is largely unknown. The purpose of this paper is to identify guiding principles underlying collaborative strategies to improve pharmaceutical care and the contextual factors and mechanisms through which these principles operate. Design/methodology/approach The evaluation was informed by a realist methodology examining the links between PHM strategies, their outcomes and the contexts and mechanisms by which these strategies operate. Guiding principles were identified by grouping context-specific strategies with specific outcomes. Findings In total, ten guiding principles were identified: create agreement and commitment based on a long-term vision; foster cooperation and representation at the board level; use layered governance structures; create awareness at all levels; enable interpersonal links at all levels; create learning environments; organize shared responsibility; adjust financial strategies to market contexts; organize mutual gains; and align regional agreements with national policies and regulations. Contextual factors such as shared savings influenced the effectiveness of the guiding principles. Mechanisms by which these guiding principles operate were, for instance, fostering trust and creating a shared sense of the problem. Practical implications The guiding principles highlight how collaboration can be stimulated to improve pharmaceutical care while taking into account local constraints and possibilities. The interdependency of these principles necessitates effectuating them together in order to realize the best possible improvements and outcomes. Originality/value This is the first study using a realist approach to understand the guiding principles underlying collaboration to improve pharmaceutical care.

Distributed leadership in health care teams: Constellation role distribution and leadership practices

BACKGROUND AND PURPOSE

Recent literature has been critical of research that adopts a narrow focus on single leaders and on leadership attributes and has called for attention to leadership that is distributed among individuals and to practices in which leaders engage. We conducted a study of health care teams where we attended to role distribution among leadership constellation members and to loose or tight coupling practices between leaders and the remainder of the team. This focus provides insights into how leadership can be practiced and structured to enhance team functioning.

METHODOLOGY

A qualitative, multicase study of four teams was conducted. Data collection involved 44 interviews with almost all the members of the teams and 18 team meeting observations. Thematic analysis was conducted by the two authors.

FINDINGS

Leadership constellations can give rise to leadership role overlaps and gaps that may create ambiguity within teams, ambiguity is diminished if the leaders can agree on which leader assumes ultimate authority in an area, the presence of more leaders does not necessarily entail more comprehensive fulfillment of team needs, and teams' needs for tight or loose leadership practices are influenced by contextual factors that we elaborate.

PRACTICE IMPLICATIONS

(a) It is important to recognize areas of overlap and gaps in leadership roles and to provide clarity about role boundaries to avoid ambiguity. Role mapping exercises and open discussions should be considered. (b) Attempting to spread formal leadership responsibilities informally among individuals is not always a workable strategy for addressing team needs.

Impact of Empowering Leadership on Antimicrobial Stewardship: A Single Center Study in a Neonatal and Pediatric Intensive Care Unit and a Literature Review

Background: Antimicrobial stewardship (AMS) is an important strategy of quality improvement for every hospital. Leadership is an important factor for implementation of quality improvement and AMS programs. Recent publications show successful AMS programs in children's hospitals, but successful implementation is often difficult to achieve and literature of AMS in neonatal and pediatric intensive care units (NICU/PICU) is scarce. Lack of resources and prescriber opposition are reported barriers. A leadership style focusing on empowering frontline staff to take responsibility is one approach to implement changes in health care institutions. Aim: Literature review regarding empowering leadership and AMS in health care and assessment of the impact of such a leadership style on AMS in a NICU/PICU over 3 years. Methods: Assessment of the impact of a leadership change September 1, 2015 from control-driven to an empowering leadership style on antibiotic use and hospital acquired infections. Prospective analysis and annual comparison of antibiotic use, rate of suspected and confirmed ventilator-associated pneumonia (VAP) and central-line associated blood stream infection (CLABSI) including antibiotic use overall, antibiotic therapy for culture-negative and culture-proven infections including correct initial choice and streamlining of antibiotics in the NICU/PICU of the Children's Hospital of Lucerne between January 1, 2015 and December 31, 2017. Results: Five articles were included in the literature review. All five studies concluded that an empowering leadership style may lead to a higher engagement of physicians. Three out of five studies reported improved AMS as reduced rate in hospital-acquired infections and improved prevention of MRSA infections. From 2015 to 2017, antibiotic days overall and antibiotic days for culture-negative situations (suspected infections and prophylaxis) per 1000 patient days declined significantly from 474.1 to 403.9 and from 418.2 to 309.4 days, respectively. Similar, the use of meropenem and vancomycin declined significantly. Over the 3 years, suspected and proven VAP- and CLABSI-episodes decreased with no confirmed episodes in 2017. Conclusion: An empowering leadership style which focuses on enabling frontline physicians to take direct responsibilities for their patients may be a successful strategy of antimicrobial stewardship allowing to overcome reported barriers of AMS implementation.

Measuring distributed leadership agency in a hospital context

Purpose The purpose of this paper is to develop and validate an instrument that can measure distributed leadership (DL) as employees' active participation in DL tasks. The authors designate this as the distributed leadership agency (DLA). Design/methodology/approach Data were collected throughout all departments and occupational groups at a merged centralized hospital setting in Denmark. A total of 1,774 employees from 24 hospital departments and 16 occupational groups completed our survey. Structural equation model and confirmatory factor analyses were applied to identify appropriate items and a test for measurement invariance, predictive, discriminant and convergent validity, and ANOVAs were applied to analyse group differences in DLA. Findings The identified unidimensional questionnaire consists of seven items, as it is different from, but associated with, empowering leadership, organizational influence, attitude to participation and trust in management. As theoretically predicted, DLA is positively related to self-efficacy, job satisfaction and innovative behaviour. Chief physicians, permanent employees and employee representatives scored higher on the scale than the rest of their respective counterparts. Practical implications The survey offers a method to assess a distribution of leadership agency in hospital organizations. Such assessment may provide a basis for organizational and leadership development. Originality/value The present study provides a reliable and valid quantitative instrument that measures how much employees at all hierarchical levels are involved in concrete leadership activities in the hospital context. Taking a normative perspective the authors could show that DL - measured with the DLA-questionnaire - has positive effects on employees' behaviour.

Making sense of effective partnerships among senior leaders in the National Health Service

BACKGROUND

Changing health care systems depend on strong organizational leadership that realizes the collaborative potential of both physician and nonphysician leaders.

PURPOSE

The aim of this study was to seek insight into the everyday health care leader experience by examining 24 physician and nonphysician leaders working in the U.K. National Health Service. We explored (a) how they make sense of and act with respect to specific collaborative tensions in their interactions and (b) which aspects of their everyday leadership contexts heighten the probability for producing and resolving such tensions.

METHODOLOGY

We conducted 24 in-depth interviews with physician and nonphysician leaders in job titles including Chief Operating Officer, Managing Director, Medical Director, and Clinical Director. Ideas from the social psychological perspectives of sensemaking, organizational role theory, and organizational citizenship behavior helped frame the study.

RESULTS

We identified four areas of ongoing tension between senior leaders. Each of these was linked to a set of underlying drivers, with the strongest support for drivers with interpersonal roots. Effective strategies for resolving tensions involved significant effort by leaders at improving the interpersonal dynamics associated with everyday interaction and forging relational connections through enhanced trust within the leadership team.

CONCLUSION

This study outlines the organizational and individual characteristics that lend to effective collaboration among senior health care leadership and the types of collaborative tensions likely to be experienced by senior health care leaders.

PRACTICE IMPLICATIONS

Organizations should provide greater role clarity for senior leadership roles, promote "soft" interpersonal competencies within them, and better assess potential leaders for success in senior roles. Organizational support in the form of facilitation, time, and spaces to learn together can provide a better context for collaborative decision-making.

Value in the middle: cultivating middle managers in healthcare organizations

Purpose

Senior executives in healthcare organizations increasingly display preference for a closer handling of operational levels, bypassing middle managers, and de-emphasizing the need to cultivate the next cadre of leaders, creating the potential for leadership and performance gaps. The authors argue that middle managers are a vital resource for healthcare organizations and review the benefits for including them in leadership development and succession planning programs. The paper aims to discuss these issues.

Design/methodology/approach

Current theories and common practices in addition to data collected from government sources (e.g. BLS), business and industry surveys and reports (e.g. Moody’s, Witt/Kieffer, Deloitte, American Hospital Association) are used to classify the roles, skills, and strategic value of middle managers in healthcare organizations.

Findings

The combination of a greater executive span with less hierarchical depth creates a dual effect of devaluing middle management, and a decrease in middle managers’ autonomy. Healthcare middle managers who stay away or lay low further trigger perceptions of low expectations leading to low morale and high levels of stress. Others become hypereffective or develop exit strategies. Major problems are: rising turnover costs; and insufficient attention to succession planning, internal promotion, and leadership development.

Practical implications

The outcomes of this study are useful for management development, particularly at times of change. Practitioners and researchers can have a better understanding of the value of middle managers and their development needs as well as the factors and dynamics that can influence their motivation and affect retention.

Originality/value

Understanding and implementing the ideas developed in this paper by healthcare organizations and other companies can lead to a drastic change in the current perceptions of the importance of middle managers and should lead to long-term retention, well-being, and extrinsic benefits for both the company and its employees.

Distributed leadership in health care: The role of formal leadership styles and organizational efficacy

Management and health care literature is increasingly preoccupied with leadership as a collective social process, and related leadership concepts such as distributed leadership have therefore recently gained momentum. This paper investigates how formal, i.e. transformational, transactional and empowering, leadership styles affect employees’ perceived agency in distributed leadership, and whether these associations are mediated by employees’ perceived organizational efficacy. Based on large-scale survey data from a study at one of Scandinavia’s largest public hospitals (N = 1,147), our results show that all leadership styles had a significant positive impact on employees’ perceived agency in distributed leadership. Further, organizational efficacy related negatively to employees’ perceived agency in distributed leadership; however, a mediatory impact of this on the formal leadership styles-distributed leadership relationship was not detected. These results emphasize the importance of formal leaders to enhance employee involvement in various leadership functions; still, employees might prefer to participate in leadership functions when they perceive that the organization is struggling to achieve its goals.

Sustaining organizational culture change in health systems

Purpose

– The questions addressed by this review are: first, what are the guiding principles underlying efforts to stimulate sustained cultural change; second, what are the mechanisms by which these principles operate; and, finally, what are the contextual factors that influence the likelihood of these principles being effective? The paper aims to discuss these issues.

Design/methodology/approach

– The authors conducted a literature review informed by rapid realist review methodology that examined how interventions interact with contexts and mechanisms to influence the sustainability of cultural change. Reference and expert panelists assisted in refining the research questions, systematically searching published and grey literature, and helping to identify interactions between interventions, mechanisms and contexts.

Findings

– Six guiding principles were identified: align vision and action; make incremental changes within a comprehensive transformation strategy; foster distributed leadership; promote staff engagement; create collaborative relationships; and continuously assess and learn from change. These principles interact with contextual elements such as local power distributions, pre-existing values and beliefs and readiness to engage. Mechanisms influencing how these principles sustain cultural change include activation of a shared sense of urgency and fostering flexible levels of engagement.

Practical implications

– The principles identified in this review, along with the contexts and mechanisms that influence their effectiveness, are useful domains for policy and practice leaders to explore when grappling with cultural change. These principles are sufficiently broad to allow local flexibilities in adoption and application.

Originality/value

– This is the first study to adopt a realist approach for understanding how changes in organizational culture may be sustained. Through doing so, this review highlights the broad principles by which organizational action may be organized within enabling contextual settings.

Configurations of leadership practices in hospital units

Purpose

– The purpose of this paper is to explore how leadership is practiced across four different hospital units.

Design/methodology/approach

– The study is a comparative case study of four hospital units, based on detailed observations of the everyday work practices, interactions and interviews with ten interdisciplinary clinical managers.

Findings

– Comparing leadership as configurations of practices across four different clinical settings, the author shows how flexible and often shared leadership practices were embedded in and central to the core clinical work in all units studied here, especially in more unpredictable work settings. Practices of symbolic work and emotional support to staff were particularly important when patients were severely ill.

Research limitations/implications

– Based on a study conducted with qualitative methods, these results cannot be expected to apply in all clinical settings. Future research is invited to extend the findings presented here by exploring leadership practices from a micro-level perspective in additional health care contexts: particularly the embedded and emergent nature of such practices.

Practical implications

– This paper shows leadership practices to be primarily embedded in the clinical work and often shared across organizational or professional boundaries.

Originality/value

– This paper demonstrated how leadership practices are embedded in the everyday work in hospital units. Moreover, the analysis shows how configurations of leadership practices varied in four different clinical settings, thus contributing with contextual accounts of leadership as practice, and suggested “configurations of practice” as a way to carve out similarities and differences in leadership practices across settings.

The framework of the practice of innovation in primary healthcare: a case study

The objective of this study was to identify the practice of innovation in primary healthcare in the second-largest county, by population, in the state of Rio Grande do Sul, Brazil. The methodology employed case studies of multiple units of analysis, where various studies were simultaneously conducted. Forty-five semi-structured interviews were carried out with the directors of basic health clinics, followed by content analysis, beginning with the construction of a system of categories based on the literature. Fifty-six innovations in total were identified: Eighteen were innovations of products (goods and/or services), fifteen in processes, eleven in marketing, and twelve were organizational innovations. Studies that focus on and highlight innovation in primary healthcare facilitate changes, improvements, and alternatives in the form of services provided to the population, serving as a basis for the formulation of public health policy. Finally, we also highlight the limitations and opportunities of future research.