Exploring the nature and impact of leadership on the local

implementation of The Productive Ward Releasing

Time to Caret Elizabeth Morrow, Glenn Robert and Jill Maben

National Nursing Research Unit, Florence Nightingale School of Nursing and Midwifery, King’s College London, London, UK

Abstract

Purpose – The purpose of this paper is to explore the nature and impact of leadership in relation to the local implementation of quality improvement interventions in health care organisations. Design/methodology/approach – Using empirical data from two studies of the implementation of The Productive Ward: Releasing Time to Caret in English hospitals, the paper explores leadership in relation to local implementation. Data were attained from in-depth interviews with senior managers, middle managers and frontline staff (n¼ 79) in 13 NHS hospital case study sites. Framework Approach was used to explore staff views and to identify themes about leadership. Findings – Four overall themes were identified: different leadership roles at multiple levels of the organisation, experiences of “good and bad” leadership styles, frontline staff having a sense of permission to lead change, leader’s actions to spread learning and sustain improvements. Originality/value – This paper offers useful perspectives in understanding informal, emergent, developmental or shared “new” leadership because it emphasises that health care structures, systems and processes influence and shape interactions between the people who work within them. The framework of leadership processes developed could guide implementing organisations to achieve leadership at multiple levels, use appropriate leadership roles, styles and behaviours at different levels and stages of implementation, value and provide support for meaningful staff empowerment, and enable leader’s boundary spanning activities to spread learning and sustain improvements. Keywords Leadership, Productivity, Quality improvement Paper type Research paper

Introduction Health care organisations all over the world face challenges of improving safety, quality and efficiency. Initiatives based on Lean thinking (Lean) have shown promise for achieving these goals in a range of health care contexts (see e.g. Savary and Crawford-Mason, 2006; Bem-Tovim et al., 2007; Jones and Mitchell, 2006; Fillingham,

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Journal of Health Organization and Management Vol. 28 No. 2, 2014 pp. 154-176 r Emerald Group Publishing Limited 1477-7266 DOI 10.1108/JHOM-01-2013-0001

The studies which inform this work were commissioned and supported by Helen Bevan and Lynn Callard and Kristy Parnell at the National Health Service Institute for Innovation and Improvement (NHS Institute) in England. Diane Ketley provided helpful comments and suggestions on an earlier version of this paper. Professor Peter Griffiths, University of Southampton contributed to the design and conduct of the studies. The views expressed here are those of the authors, not of the NHS Institute. The authors thank all those who participated in the studies whether by participating in interviews, facilitating access to organisations or providing other information. Thank you to the two anonymous reviewers of this paper who provided helpful suggestions and comments.

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2007). Lean has a long history of development and use in the commercial sector and manufacturing industry where it is a well-established improvement approach (Young and McClean, 2008; Radnor and Boaden, 2008). It provides organisations with principles and tools to focus on the values which drive systems (Rooney and Rooney, 2005) and realign or refine processes or practices to cut out “waste” (e.g. interruptions, delays, mistakes or replication) and achieve the desired values (e.g. effective treatment, safe high quality care) (Womack et al., 1990; Crump, 2008). Now, to maximise on these benefits, there is a need to build evidence and strategies to support implementation in health care (Eccles et al., 2009). One important factor for driving improvement work is leadership (Ferlie and Shortell, 2001; Miller, 2006; Øvretveit, 2009; Barr and Dowding 2012) sometimes called “improvement leadership”, however little is known about the most effective forms of leadership in this context (Øvretveit, 2009; Buchanan et al., 2007b; Denis et al., 2012).

The aim of this paper is to explore issues about leadership in relation to implementation of improvement initiatives in health care. The paper draws upon perspectives of Lean thinking and leadership from the health care literature to explore the issues from the perspectives of staff in implementing organisations. Specifically, the paper explores the following research questions:

RQ1. What type of leadership roles do organisations need to successfully implement interventions like The Productive Ward?

RQ2. What type of leadership styles and behaviours should leaders use?

RQ3. How can leaders engage and energise frontline staff?

RQ4. How can leaders act to ensure implementation is spread and sustained?

The paper explores these questions in a real case of Lean implementation by drawing upon empirical data from two studies of the implementation of The Productive Ward: Releasing Time to Caret (The Productive Ward) in English hospitals. The aim of The Productive Ward programme is to increase the proportion of time nurses spend on direct patient care, to improve experiences for staff and patients, and to make structural changes to the use of ward spaces to improve efficiency. It is a useful test ground to explore issues of leadership as the programme has been widely and rapidly adopted by many health care organisations in England (Robert et al., 2011) as well as in hospitals across the UK and Republic of Ireland, Canada, the USA, the Netherlands and Denmark. Internationally the programme is sometimes referred to as Releasing Time to Care or RTC; variations in national/regional strategies for implementation of The Productive Ward are themselves interesting but outside of the scope of this paper.

The structure of the paper is as follows. The background section presents current knowledge on Lean thinking and leadership in health care from the research literature. The methods section provides information about the empirical studies that inform the paper and the methods of analysis used in this paper. The findings are presented according to themes and the discussion examines these findings in relation to the four research questions above to develop a framework of leadership processes. Conclusions for research and practice are presented.

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Impact of leadership

Background Different approaches to Lean in health care have been classified (Brandao de Souza, 2009) as “manufacturing like” approaches which usually involve streamlining departments within a hospital that typically deal with the physical flow of materials (such as pharmacy, radiology or pathology). “Managerial and support service” approaches to Lean concern the flow of information within the organisation (such as finance, medical secretaries, or other managerial departments and divisions). “Patient flow” approaches attempt to improve the patient journey within the hospital (or system) by streamlining the patient pathway. While “organisational” approaches emphasise the importance of designing a strategic and cultural plan from an organisational perspective in order to successfully implement Lean. Differences in approaches to Lean have been described by Emiliani (2008) as “fake” or “real” Lean. Fake Lean is where an organisation uses just the tools with an emphasis on rapid improvement rather than long-term change. Real Lean means showing a “commitment to continuous improvement” using tools and methods to improve productivity, as well as “showing respect for people through leadership behaviours and business practices” (Radnor and Boaden, 2008). Thus a key perspective that informs our exploration is that leadership shapes and influences approaches to Lean implementation.

Leadership of change, improvement and innovation in health care is not always a smooth process and “improvement leaders” (Øvretveit, 2009) face at least four types of challenges in relation to implementing Lean initiatives. First, staff perception is known to play an important role in receptivity to Lean and staff may be resistant to what they perceive to be commercial ideas based on productivity values (Young and McClean, 2009). There are associated challenges of how leaders can engage staff in meaningful ways (Mumford et al., 2000) and build workforce capacity for implementation (Eccles et al., 2009). Second is the complexity of decisions about implementation of any particular initiative or innovation (McNulty and Ferlie, 2002): in organisations made up of different health-care providers, local strategies, structures and professional groupings, the “innovation journey” may be a fuzzy or contentious process (Van de Ven et al., 1999) characterised by ambiguity about roles and responsibilities (Ham et al., 2003). Third, generating evidence about any particular innovation faces challenges of attributing, documenting and interpreting the implementation costs and benefits in a way that is meaningful to different audiences (Berwick, 2003). Many organisations may decide to hold-off implementation until there is convincing evidence from other organisations about such investment (Rogers, 1995). Fourth, challenges of spreading and embedding change within organisations include replacing old ways of working and developing appropriate policy, practice and research to embed and sustain improvements (Buchanan et al., 2007b; Ham et al., 2003). A key perspective that underpins these challenges is the role of leaders in creating organisational conditions for effective implementation.

The Productive Ward was devised and developed in this wider context of multiple approaches to Lean and challenges to implementation in health care. The National Health Service Institute for Innovation and Improvement (NHS Institute) (now part of NHS Improving Quality) worked with industrial partners from Toyota to look at how care delivered in hospital ward settings could be streamlined and create a clear set of tools, resources and support for health care organisations. The programme was developed at four hospital test sites in 2006, before being rolled-out to ten Learning Partners in 2007. The programme frames Lean in language and examples that are intended to appeal to health care staff and enable them to bring about changes at ward

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level (Morrow et al., 2012). It comprises 13 modules and tools designed for self-directed learning at ward level, beginning with three foundation modules called Knowing How We are Doing, Well-Organised Ward and Patient Status at a Glance; and further modules which focus on a range of ward processes including admissions, discharge and shift handovers. The design and development of the programme itself are important factors in implementation (NNRU&NHSI, 2010) but our focus here is on leadership.

In the case of The Productive Ward “involved leadership” of senior executive leaders and ward leaders has been identified as being an important facilitating factor in implementation (White et al., 2013). This assertion corresponds with well-established findings in the literature on leadership that show senior organisational/executive leaders of health care organisations can help to “challenge the process, inspire a shared vision, enable others to act, model the way, and encourage the heart” (Kouzes and Posner, 1988). Formal organisational hierarchies can provide coordinated and strategic leadership of organisations and organisational change (Dickson, 2009). It is also known that appointed senior leaders can drive organisational change by initiating the adoption and implementation of innovation (Rogers, 1995), including applying improvement principles and replicating actions that other senior organisational leaders have found to be successful (Øvretveit, 2009). A key perspective that informs our exploration is that leadership from the “top down” (Sabatier, 1986) directed towards sharing knowledge can support a receptive organisational context for implementation and routinisation of innovation (Greenhalgh et al., 2005; May et al., 2009).

At the same time it is known that leaders do not only operate at the “top” of organisations. Leaders may operate at different macro (health-care system), meso (organisation) and micro (frontline clinical team) levels to carry out different leadership functions (House et al., 1995). Similarly, leadership can be perceived according to individual, team and organisational perspectives (Barr and Dowding, 2012). The notion of “leadership in the plural” (Denis et al., 2012) suggests that leadership can take on different forms, including being shared in teams, pooled at the top of organisations, spread (or distributed) across boundaries over time, or produced through interaction. Thus a key perspective is that implementation of any Lean initiative in health care takes place in the context of different perceptions and understandings of who leaders are and what leadership means (Hartley and Benington, 2010).

Individuals in clearly defined leadership roles can help to work across boundaries between professional groups, departments, divisions, teams and localities to convey goals, share information or learning (Pearce, 2004; Goodwin, 2000). Boundary spanning leadership has been defined as “the capability to establish direction, alignment, and commitment across boundaries (vertical, horizontal, stakeholder, demographic and geographic) in service of a higher vision or goal” (Ernst and Chrobot-Mason, 2010). In relation to implementation of innovation leader’s boundary spanning activities (Fleming and Waguespack, 2007) are known to be an important factor in the spread of initiatives across disciplinary fields and sectors (Greenhalgh et al., 2005). Another key perspective that we explore in this paper is how staff in recognised leadership positions can support spread and sustained implementation across an organisation.

Engaging influential individuals (who may or may not perceive themselves to be leaders) across an organisation can help to secure credibility for an innovation ( Jacobson and Goering, 2006), and strategies to develop “role models” and “opinion leaders” have shown to be effective in implementing changes at the clinical level

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(MA, 2005). Hence implementation strategies in health care now recognise and seek to engage with staff groups who have not traditionally been perceived as leaders (Doumit et al., 2011) and from different communities of practice (Kislov et al., 2011). Spreading leadership roles through organisations can support implementation by attracting followers from different disciplinary backgrounds and service localities (Grimshaw et al., 2006). However, the notion of leadership as something to be distributed across complex systems and boundaries (Benington and Hartley, 2010; Hartley, 2012) can be problematic in health care organisations with established institutional structures and norms (Martin and Waring, 2013). Staff may also question whether the underlying intention of initiatives to distribute leadership is to support “democratic organization” or to gain greater control through “instrumental delegation” (Mayrowetz, 2008). Changing existing patterns of leadership in health care is challenging because of contextual issues such as interprofessional barriers and patterns of knowledge exchange or “brokering” (Currie, 2012). Attempts to promote distributed leadership in health care, for example through public service networks, have faced challenges of organisational bureaucracy, power differentials, and a strong centralised performance management policy regime (Currie and Lockett, 2011).

As Edmonstone (2011) argues, perhaps a rebalancing is needed – from an over-concentration on individual leaders to an emphasis on the contexts and relationships in health care organisations that enable leadership to happen. Such perspectives consider leadership and its outcomes to extend beyond the actions of individuals to include the multiple roles and dynamics between different “leaders” and “followers” in different decision-making contexts (Pedersen and Hartley, 2008). As such “post-heroic” (Dickson, 2009) perspectives of leadership suggest that leadership is not only attributable to the actions and behaviours of senior leaders but is “a social process that occurs in and through human interactions” (Fletcher, 2004).

Insights from leadership of change in health care suggest that leaders need to cultivate a strong culture of engagement for patients and staff and to deploy a range of leadership styles and behaviours (The King’s Fund, 2012). Leadership that enables perspectives and needs of different staff groups to be shared helps to generate knowledge of problems or issues from the “bottom-up” (Sabatier, 1986), co-produce viable solutions (Gough and Masterson, 2009), and support wider organisational learning and improvement (Brown and Duguid, 1991). Accordingly the notion of a transformational leadership approach (Burns, 1978) has become popular in health care organisations (Bass and Riggio, 2006) as it emphasises leadership behaviours that engage and motivate frontline staff to bring about change for themselves (Govier and Nash, 2009). A further key perspective which can be taken from the literature is the notion of leadership being generated through engagement and interaction.

Drawing on these perspectives, in this paper we suggest the process of implementing Lean can help to critically examine different forms of leadership and create conditions for leadership to emerge. In particular Lean offers useful perspectives in understanding “new” leadership (i.e. informal, emergent, developmental or shared) because it emphasises that health care structures, systems and processes influence and shape interactions between the people who work within them (Radnor et al., 2012). By examining the processes of health care Lean highlights the presence of organisational rhetoric, ritual and resistance in the discourse of leadership (Waring and Bishop, 2010). In this respect Lean can perhaps help to understand the values which drive systems and prompt questions about how “old” (i.e. formal, autocratic, directive) leadership can help to orientate the organisation towards achieving such values.

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Method The focus of this paper is to explore the nature and impact of leadership from the perspective of health service leaders, managers and frontline staff working to implement an improvement initiative (The Productive Ward programme). We chose to use Framework Approach (Richie and Spencer, 1994) to explore staff experiences because it is particularly suited to analysing descriptive data from multiple sources, thereby enabling different aspects of the phenomena under investigation to be captured (Ritchie and Lewis, 2003). Using this approach the context of participant’s experiences can be retained, while also exploring associations and explanations in the data and drawing on existing theories and established literature (Richie and Spencer, 1994). Data were drawn from two studies of The Productive Ward described below.

Study 1: undertaken in 2009 using mixed methods (NNRU&NHSI, 2010) and an evidence-based diffusion of innovations framework (Greenhalgh et al., 2005) the study aimed to examine key factors which had helped to promote rapid programme adoption (Robert et al., 2011). Data were collected from three different “stakeholder” groups (Golden-Biddell and Locke, 1997), these were: policymakers (15 in-depth interviews not used in this paper), hospital managers and health care practitioners who had personal experience of implementing the programme (web-based survey of 150 self selecting staff from 96 different NHS acute hospitals, this data has previously been published in Robert et al., 2011); and frontline staff working on the programme (58 in-depth interviews) within five hospital case study sites (see Table I). The interview schedule covered questions about professional role, involvement in implementation, views about the work/progress, factors helping/hindering implementation and perceptions of types of impact.

Study 2: undertaken a year later (in 2010) the study focused on examining theorised circumstances of “non-spread” (NNRU&NHSI, 2011) these were: discontinuation when people (or organisations) decide to reject an innovation after adopting it, islands of improvement where pockets of excellence remain isolated and unknown to others, improvement evaporation when change is not sustained leading to the decay of organisational change (Ferlie et al., 2005). Eight hospitals were selected for case study (using Yin’s, 2008 method) on the basis that they were known to have purchased a Productive Ward package from the NHS Institute and to have initiated implementation (see Table I). In-depth interviews were undertaken with 21 hospital staff who held a formal leadership role in programme implementation (staff were senior organisational leads or programme leads/coordinators). Semi-structured interviews covered questions on the person’s involvement in the work, current activity, future plans, where things are going well/not so well, staff engagement, “energy levels” like behind the work, factors that have helped/hindered the work, fit with other initiatives, monitoring.

This paper focuses on the in-depth interviews conducted with hospital staff during study 1 (n¼ 58) and study 2 (n¼ 21). In both study 1 and study 2, leadership was a recurrent issue for staff at all levels and we recognised the need to develop more informed understanding of leadership in this context by exploring “what works and why” (Walshe, 2007). Drawing on Framework Approach we used qualitative analytic techniques (Denzin and Lincoln, 2000) to explore staff views. The analysis aimed to be context sensitive, iterative and flexible (Holloway and Todres, 2003) but it involved a number of stages. These were: re-familiarisation: reading case study summaries and interview transcripts; immersion: to explore the data in relation to the focus of the

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te he

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nu rs

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le ad

(1 ),

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fa ci

lit at

or (1

) to

ta l¼

2 p

ar ti

ci p

an ts

(c on

tin ue d )

Table I.

161

Impact of leadership

A do

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pp ro

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to im

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en ta

ti on

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ou rc

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ci p

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5 F

eb 20

08 A

cc el

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ed T

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pi lo

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pr il

20 08

.P la

n fo

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(2 4

w ar

ds )t

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1 (f

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l¼ 1

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ct 20

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ed T

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ed by

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20 09

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(1 ),

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(1 ),

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) to

ta l¼

3 p

ar ti

ci p

an ts

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8 O

ct 20

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ed Im

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of P

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un da

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l w

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m of

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) w

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m e

on th

e pr

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e fo

r 12

m on

th s.

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d to

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im pl

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on as

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of th

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it y

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(1 ),

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(1 ),

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3 p

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ci p

an ts

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: P

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ro du

ct iv

e W

ar d

pr og

ra m

m e

Table I.

162

JHOM 28,2

issues (e.g. leadership, control, decision-making power), the types of language or ways of talking about issues, and the types of information used to substantiate claims/views (e.g. direct experience, policy, research evidence); coding and extraction: selection of passages of text and coding according to themes (Braun and Clarke, 2006); and refinement of themes: members of the research team examined the coherency of the meaning of each theme (Holloway and Todres, 2003) (supporting validity of the analysis), the assumptions underpinning it (Walshe, 2007), the possible implications and the overall story the different themes reveal about leadership and staff perspectives of the issues. Using a staged approach enables researchers to track decisions, which ensures links between the original data and findings are maintained and transparent. This adds to the rigour of the research process and enhances the validity of the findings, described below (Ritchie and Lewis, 2003).

Findings The findings are presented according to four interrelated themes about leadership that we identified across study 1 and study 2 data. Quotes from interviews with staff working to implement the programme are used to illustrate each of these themes.

Different leadership roles at multiple levels of the organisation The first theme we identified was that to implement and spread The Productive Ward organisations needed to have leadership in place at multiple levels. This “multi-level leadership” was consistently described as involving staff within four distinct types of leadership roles, described below and illustrated by Table II.

The first distinct leadership role was senior executive and senior clinical leaders. In study 1 we found that senior clinical leaders were perceived by both senior executives and frontline staff to play an important role in aligning programme implementation with clinical goals and priorities (all five case study hospitals in study 1). This work included alignment of The Productive Ward with ongoing patient safety initiatives, infection control and falls prevention strategies (see final report for further information NNRU&NHSI, 2010). In study 2 the importance of visible executive/senior leadership was again held by staff at all levels as being important for continuing to engage staff as the programme was rolled-out to new wards:

The Deputy Director of Nursing attends steering group meetings and there have been walkabouts from the Chairman and the Chief Executive. This support helps the areas that are being visited to see that PW is important and that the work they are doing is being recognised (Productive Ward (PW) programme lead, study 2, hospital 3).

The second leadership role was programme lead (also called PW facilitators in some organisations). In study 1 all five case study hospitals had appointed one or more programme leads for the organisation or funded secondments for senior nurses or members of existing improvement teams (see Table I, study 1 hospitals 1-5). The programme lead role was characterised by planning implementation at an organisational level and facilitating ward teams to move forward with implementation and encourage progress: which included: maintaining connections with external change agents to learn about the programme and plan implementation; linking with staff in other implementing hospitals to share learning; securing support from executive/senior managers by linking the programme with broader organisational goals and; linking with ward staff to provide training and to facilitate implementation. Study 2 revealed how in later stages of implementation securing funding for this role proved critical as to whether

163

Impact of leadership

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on in

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at ed

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at w

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w or

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d- le

ve l

m ee

ti ng

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d sh

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ou ra

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fr on

tl in

e st

af f

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or th

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pr ov

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ts an

d re

co rd

th ei

r ac

hi ev

em en

ts E

xp la

in in

g to

fr on

tl in

e st

af f

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to us

e to

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an d

m od

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cu ss

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og re

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w ar

d/ un

it le

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um en

ti ng

w or

k at

a lo

ca l

(w ar

d/ un

it )

le ve

l

Table II. Multiple leadership roles

164

JHOM 28,2

implementation was sustained and spread through organisations (hospitals 2, 4 and 7), or whether only a few enthusiastic wards participated in the programme (hospitals 3, 6, 8):

The energy and the motivation in the first instance was tremendously high, particularly on the showcase wards. Staff were very keen and welcomed the initiative. Some staff came in to the ward on their days off to do the activity follow in their own time. But now, staff motivation has disappeared because of the lack of facilitator support (PW facilitator (programme lead), study 2, hospital 4).

The third leadership role, that of middle managers/ward managers, involved showing “commitment to the vision” of The Productive Ward and “being prepared to empower staff” by releasing their time, delegate or share decision making and encouraging staff to learn about the programme (see Table II). Understandably some ward managers felt they needed to direct the work and ensure the programme was implemented swiftly and efficiently. We found that in hospitals where middle managers and ward managers focused on creating opportunities for staff engagement rather than trying to direct staff in an authoritarian way, this instilled a sense of team ownership and changes were more likely to be sustained (study 1, hospitals 1, 2 and 4).

The fourth type of leadership role was local Productive Ward leads at ward level. Successful local leads used a participative style to engaging themselves and others, to bring a sense of credibility to the project and share knowledge and experiences of implementation (study 1, hospitals 1-5). Although local “informal” leaders did not generally describe themselves as leaders they did talk about leading the work in terms of ensuring frontline staff were aware of the programme and changes colleagues were making to their working practices e.g. facilitating staff from “showcase” wards to present their work to other staff working on other hospital wards (hospitals 2-5). In this respect local leaders did recognise their leadership role in championing the programme or changes initiated through the work. For example:

One healthcare assistant had a huge involvement in the programme and she was able to say what a difference it had made to her working day [y] she’s getting all these accolades and suddenly the other healthcare assistants who weren’t interested at all were all on board (PW trainer, study 1, hospital 4)

Some senior/formal leaders described the importance of recognising the work of local leads as leadership “so that we can help to develop and encourage these types of skills in nurses and other frontline staff” (Matron, study 1, hospital 5). In all organisations (study 1 hospitals 1-5) there was evidence of the potential for skills development as staff across the organisation took on implementation work:

[y] they don’t realise that in fact, by implementing this in their clinical areas, they in fact go on a leadership programme – and I don’t think they realise it until they’ve finished implementing the Releasing Time To Caret for their area (Senior nurse, study 1, hospital 2).

In relation to the numbers of staff filling these four leadership roles, these varied across the five hospitals in study 1 according to the size of an organisation, the approach and stage of implementation. For example, in hospitals 1 and 2 where the programme was being implemented across the whole-organisational, local leads had been identified for every ward, whereas there were far fewer identifiable ward-level and local leaders where the programme was being piloted on a few wards (study 1, hospitals 4 and 5). In some hospitals ward managers were the staff group that were given/took on the role of local Productive Ward lead (study 1, hospitals 3 and 5), and this “duality” of leadership roles was sometimes a point of tension, as discussed in the next section.

165

Impact of leadership

Experiences of “good and bad” leadership styles The second theme related to how leaders enacted their role through different styles and behaviours. In study 1 there was agreement across all sources of data about the necessity of strategic leadership. Senior leaders expressed strong views about the importance of strategic leadership – suggesting this was necessary to “create vision”, “champion the programme”, “align the initiative with strategic goals” and to “connect the work with other initiatives, targets and local priorities”. Interviews with frontline staff showed that for many staff working to implement the programme at ward level encouragement and support for their own participation was a direct indication of whether there was strong leadership behind the programme. Frontline staff expressed their positive experiences in terms of being “involved”, “encouraged” and “enabled” by senior leaders. Programme leads described the need for “keen” wards and staff groups to participate in ways and at a pace that suited them. The realisation for many programme leads was that successful implementation required them to use a degree of free-reign to their approach to leading implementation whilst also facilitating local leads and frontline staff to adapt Productive Ward work to their own contexts and needs:

With a project of this size, it’s probably something – you have to make your mistakes, learn from them and move on (PW programme lead, study 1, hospital 4).

For many frontline staff the best way of understanding The Productive Ward was “learning by experience”, which included making mistakes and learning how to resolve issues and avoid problems in the future. In three case study sites (study 1, hospitals 1, 2 and 5) frontline staff were encouraged by programme leaders to interpret and develop modules in the way they considered most appropriate for them and encouraging sharing of learning between wards (study 1, hospitals 3 and 6). At some sites they were even encouraged to take the principles of the modules and toolkit and apply them to projects or issues not covered in the modules, if appropriate for their needs. However not all organisations or leaders were confident to delegate leadership or control. Some senior managers noted that because of the high profile of Productive Ward, ward managers often rushed to take up the role of local lead without fully understanding the implications of this particular leadership role. The reality of facilitating rather than directing staff proved challenging for some ward leaders:

I went to the first event, so we were told we were on cohort two, and we went to the initiation event and I sat there and I thought, ‘Oh my God, what have I come to? I should have done a bit more research into this. I was like leafing through the toolkit and all of that, thinking, ‘Okay, lots of work here (Ward sister, study 1, hospital 3).

Managerial staff often needed to develop skills and knowledge for implementation that differed from the leadership style and behaviours associated with their managerial role. Within all five case study sites (study 1) this led to recognition of the need for leadership training and development for programme leads, managers and local leads; and in one hospital the initiation of a custom designed leadership training course to help prepare staff to lead:

Traditionally in nursing we’ve not been fantastic at giving all managers leadership training before they go in to post. And this is giving them a real clear focus about how to lead (PW facilitator, study 1, hospital 2).

This head-start was important, because programme leads and others had realised that in order to lead change at ward level, local leads needed to gain knowledge about the programme and how best to engage rather than direct frontline staff.

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Frontline staff having a sense of permission to lead change The third theme related to issues of frontline staff feeling a sense of permission to change established practices and routines at ward level. In general interviews with senior organisational leaders (executives and clinical directors) indicated that they recognised that they are not necessarily the best people to address ward-level problems and that ward staff have a better understanding of the day-to-day problems they encounter. An important factor in enabling senior leaders to delegate control about implementation decisions was confidence in the programme itself and understanding of how Lean principles can help frontline staff to bring their observations and ideas for change to the fore:

It’s enabled them to use an established structure and process to harvest the good ideas many staff have had on their minds for years, and we’ve never actually been able to harvest them (Chief executive, NHS hospital, study 1, hospital 1).

Case study data from study 1 shows that staff in non-traditional leadership roles (such as lower grade nurses and health care assistants) can have several advantages when influencing frontline staff to engage with the programme, based on their credibility amongst colleagues. However, in some cases individual ward managers admitted initially feeling concerned about handing over decision-making power to their staff (study 1, hospitals 3 and 5), fearing a resulting lack of consistency that could make it difficult to enforce standards. As previously mentioned, it was often this sense of freedom to adapt the programme to local needs (expressed by staff in study 1, hospitals 1 and 2) that engaged frontline staff interest and drove progress:

I think it’s that free-rein and people being able to develop the modules as they want [y] that’s helped people to move on as far as they have done [y] because they’re the people that really know (PW facilitator (programme lead), study 1, hospital 1).

Indeed, for some ward managers who had taken on the role of local Productive Ward lead (study 1, hospitals 3 and 5) there was a sense that responsibility remained with them personally to lead implementation rather than supporting the process of implementation to be led by the potential insights, drive and enthusiasm of frontline staff:

I’m still leading it and I haven’t been able to completely pull away. And if, for example, I wasn’t here for a long period of time, they would sustain everything that I do. They would make some small changes, but they wouldn’t make dramatic changes without coming to me almost to seek permission to do so (Ward sister, study 1, hospital 3).

At these two hospitals frontline staff had not become as involved in leading implementation as they had done at other sites. The reasons why seemed to be related to how resources for implementation had been allocated, in particular having sufficient resources to free up staff time (“backfill” for nurses’ time away from the ward), access to training and support provided by the NHS Institute, and allocated budgets for changes to ward storage areas or layouts. In study 2, differences were noted in whether ward teams were receptive to change and wanted to take ownership of implementation:

Wards with staff that express a ‘can do attitude’ take on the programme with interest. Wards where the general attitude is less positive are harder to motivate. Some wards require a lot more support and encouragement than others before they perceive benefits and become committed to the programme (PW programme lead, study 2, hospital 6).

Interviews with frontline staff showed that they were often very aware and irritated by having to work around problems and cope with disorganisation (all hospitals study 1). What generally held them back from initiating change is that they did not see it as part of their job or something that they will be encouraged to do, or rewarded for. Or, as one

167

Impact of leadership

senior leader explained, frontline staff were sometimes unwilling to challenge existing ways of working because of a fear of repercussions:

Part of what you ask your staff to do in Productive Ward programme – is take some risk – the staff feel that if they take a risk and it goes wrong, they’re going to be punished. And they won’t want to do it (Chief executive, study 1, hospital 2).

At this hospital (study 1, hospital 2) it had been found that rather than anarchy, giving frontline staff guidance and support to tackle issues themselves resulted in similar solutions from different wards, which could then be combined and developed into a hospital-wide standard.

Leader’s actions to spread learning and sustain improvements The fourth theme was the importance of leader’s actions to spread learning and sustain improvements. Across the data it was possible to identify seven ways in which leaders connected, these were: leader’s connections with each other; with different staff and professional groups across the organisation; with existing organisational structures/ systems; with other/external organisations; with information and knowledge resources; with skills development/training, and support networks; and with systems to evaluate impact/improvement and share learning. In organisations where the programme had spread well (in particular study 1, hospitals 1 and 2) programme leads had sought to connect with different staff, professional and cultural groups by actively linking implementation with staff interests, goals and priorities. Findings from study 2 (all eight hospitals) also showed that leaders’ activities were important for spreading implementation through organisations but many executive and programme leaders did not prioritise/invest time in creating opportunities to spread learning to other staff groups. Consequently in six of the eight case study sites (study 2, hospitals 1-5 and 7) islands of improvement occurred where improvement was isolated and failed to spread:

Generally the energy is present in the organisation but improvement has taken longer on some wards than others because of communication issues (Programme lead, study 2, hospital 3).

In contrast, leaders in organisations where the programme had spread well had taken steps to use existing organisational structures, such as staff orientation and induction programmes to spread knowledge and learning about the programme to new employees. Another factor was that leaders sustained connections within other leaders in implementing organisations to gain emergent knowledge and learning (study 1, hospitals 1-5), rather than disconnecting from intra-organisational networks once implementation had begun (study 2, hospitals 1, 5, 6, 8). In study 2 dwindling senior leadership engagement at three case study sites (study 2, hospitals 1, 3 and 6) had led to the breakdown of vertical connections between senior leadership and leaders working to implement the programme at lower levels. Local leaders reported feeling disappointed that the organisation had “lost interest” or had moved on to new priorities. At hospital 6 there had been limited executive buy-in for the first three months at which point the organisation’s steering group was disbanded leading to implementation being discontinued. In one hospital (study 2, hospital 5), reluctance to share information or learning between wards contributed to discontinuation of the programme’s implementation. For these respondents, there was a general sense of failure and missed opportunity to encourage and support leadership development in others (contrasting with positive examples of mentorship, clinical supervision and peer-education described by staff in study 1). Another reason for leadership connections breaking down in three hospital sites (study 2, hospitals 2, 3 and 6) was

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that a lack of continuation funding for the programme lead had contributed to discontinuation of implementation across the organisation.

Discussion Our findings add to the growing body of evidence that suggest improvement programmes based on Lean thinking can assist with the challenges health care organisations face in both improving quality and developing effective leadership. The scope of the study – nationally representative of NHS hospitals in England – and depth of the study data means our findings are likely to be transferable to cases of implementation of Lean initiatives in other hospital settings and internationally. Overall the findings illustrate the dynamic nature of leadership in organisations that are implementing Lean and development of leadership through undertaking Lean improvement work. We found evidence that the Productive Ward is helping to develop leadership skills within the health care workforce in England; which has been shown elsewhere (BHSCT, 2009; NHSL, 2009; NHSS, 2008) by acting as a learning system to try out new skills and approaches on real projects within health care environments (Balle and Regnier, 2007).

What type of leadership roles do organisations need to successfully implement interventions like The Productive Ward? Senior organisational leaders need to give consideration to leadership at multiple levels and how interactions between these levels shape outcomes. Such consideration could help to overcome ambiguity about responsibility for implementation (Ham et al., 2003) and spread leadership functions vertically through the organisation (Bathurst and Morin, 2010). A proposition for future research is that multi-level leadership enables outcomes by aligning “top-down” and “bottom-up” leadership of Lean. We suggest that considering “leadership processes” (rather than just looking at leadership roles) is a useful approach. Taking this broader view, leadership processes involve not only leaders, but also followers, interactions (e.g. communication, information, decision making), contexts (e.g. situations, events, environments, resources, timescales) and outcomes (e.g. results, impact, organisational learning, and staff morale). Our findings and perspectives from the literature enable us to put forward a framework of “leadership processes”, illustrated by Figure 1. This framework could inform strategic and cultural development from an organisational perspective in order to successfully implement Lean (Brandao de Souza, 2009); as well as offering directions for future research about the challenges of leading change, innovation and improvement in health care (Hartley and Benington, 2010).

What type of leadership styles and behaviours should leaders use? Part of strong leadership is understanding the need for different and contextually appropriate leadership roles, styles and behaviours at different levels and stages of implementation. Leaders’ contributions to each leadership process are summarised in Table III. In the early stages of implementation executive/senior organisational leaders are often best equipped to gain support, information or resources from external stakeholders and involve other formal leaders (e.g. board members, clinical directors, service managers, appointed programme leads) in creating a vision and allocating or securing resources for implementation. In the later stages of implementation programme leadership and managerial level leadership can help to create the conditions for informal leadership to emerge (Mumford et al., 2000). This might involve providing information and support to those who do not necessarily recognise themselves as leaders – typically health care assistants and junior/student nurses (Cummings et al., 2008). For example,

169

Impact of leadership

providing information about transformational and relational approaches to leadership required at a local level of implementation ( Davis and Adams, 2011).

How can leaders engage and energise frontline staff? Valuing and providing support for meaningful staff empowerment is a key leadership process. In the case of The Productive Ward, for executive/senior leads valuing the contributions of frontline staff and providing support for staff to engage in meaningful ways were felt to be crucial factors to sustained implementation (Table III). The main contribution of programme leads was providing information and improvement resources

National (macro) context

c

d

b

a Organisational (meso) context

Frontline (micro) context

Formal leader Project/programme leader

Informal leader

Notes: (a), Multi-level leadership: senior leaders plan and are committed to multi-level leadership; project/programme leaders are appointed; managers are aware and supportive; local (informal) leaders are identified; (b), leadership styles and behaviours: all leaders understand what type of style to use for their role and types of skills and knowledge they need; (c), staff empowerment: formal leaders know when and how to relinquish control through encouraging and supporting informal leaders; informal leaders use their credibility to engage andinform colleagues; all leaders have access to necessary resources, information, guidance and support; (d), boundary spanning: leaders communicate well with each other, reach different staff and professional groups, use existing organisational structures/systems, link and learn from other organisations, share information and knowledge resources, use skills development/training, and support networks, evaluate impact/improvement and share learning

Figure 1. Framework of leadership processes

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L ea

de rs

hi p

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ul ti

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of im

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ar ni

ng

Table III. Leaders’ contributions to

leadership processes

171

Impact of leadership

across organisations and providing feedback about achievements. While frontline staff expressed their commitment to the programme according to personal and emotive aspects of belonging to a “team” or “professional group”; which corresponds with a mutual understanding of leadership ( Denis et al., 2012). It would therefore seem appropriate to place these types of values at the centre of organisational strategies for implementation. Future research could explore interactions between leaders and followers that lead to a sense of empowerment and the impact on outcomes.

How can leaders act to ensure implementation is spread and sustained? Connecting vertical and horizontal boundary spanning leadership activities helps to spread learning and sustain improvements. The term the “nexus effect” has been used to describe the collaborative, transformational outcomes that can be achieved when leaders span boundaries that are above and beyond what different groups could achieve on their own (Yip et al., 2008). Adding to this notion, in the present study leaders’ boundary spanning activities were found to be an indicator of the impact of leadership on outcomes, and this is an interesting area for future research on long-term impact. Leaders therefore need to understand the different types of boundaries and possible meeting places across boundaries (the nexus) that might exist in the organisations that they work within. Otherwise, as our findings clearly show, even in organisations where leaders are fully committed to implementation “islands of improvement”, “discontinuation” or “improvement evaporation” occur when leaders underestimate the importance of their boundary spanning activities.

Conclusion This study aimed to explore the nature and impact of leadership in relation to the local implementation of quality improvement interventions in health care organisations. By drawing on staff experiences of implementing The Productive Ward in English hospitals insights were gained into leadership processes as related to lean health care. A framework for leadership processes is presented which could be applied, tested and developed in other contexts. The framework includes: consideration of leadership at multiple levels and how interactions between these levels shape outcomes; reflection on the need for different and contextually appropriate leadership roles, styles and behaviours at different levels and stages of implementation; valuing and providing support for meaningful staff empowerment; and connecting vertical and horizontal boundary spanning leadership activities to spread learning and sustain improvements. Further research is needed to explore potential differences in leadership within late adopting or non-adopting health care organisations; to better define and understand the longer term impact of spread and sustainability (beyond three years post- implementation); and to examine the influence of external driving factors such as health service policy and resourcing, external change agencies and patient groups.

Authors’ contributions: All of the authors made substantial contributions to conception and design of the reported studies and to the perspectives put forward in this paper. E.M. led study 1 and study 2 and led the secondary analysis and writing of the paper. G.R. provided advice and insights into the literature on quality improvement in health care, implementation research and supported the secondary analysis. J.M. provided guidance on study design and analysis and contributed thoughts on the nature and potential for development of leadership in this context. All authors have given final approval of the version to be published.

Competing interests: The authors declare that they have no competing interests.

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Further reading

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Corresponding author Dr Elizabeth Morrow can be contacted at: elizabethmmorrow@hotmail.co.uk

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