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Communication Dans Un Congrès Année : 2012

A comparative analysis of leadership Norms in National Policy implementation


There is growing understanding of the challenges for effective leadership in healthcare. Cognitive, cultural and social barriers must be managed between involved professional groups (Ferlie et al., 2005; Freidson, 1970) to deliver effective services. In response, organisational and management scholars have considered a variety of structure and agency responses to professional integration in hospitals (Fitzgerald & Dufour 1997; Kitchener, 2000) and clinical management roles (Hoff & McCaffney 1996; McKee et.al 1999). Research on leadership in healthcare has intensified since the late 1990s with recognition of leadership and competencies of leaders (Gilmartin & D'Aunno 2008). The debate hinges around styles and levels of leadership with arguments that fragmented, complex organisations benefit from collective or dispersed leadership, 'to involve all the main structural poles of leadership in the organization' (Denis et al., 1996, p.690). Collective and dispersed leadership at meso and micro- levels of the organisation have been associated with effective change management, quality of care and positive patient outcomes (Buchanan et al., 2007; McKee et. al., 2010). However, less is understood regarding effective leadership at macro organisational and national health policy levels. Health policy is designed at national level and implemented within and across systems but there has been limited comparative work on how leadership is operationalised in national systems.This paper presents findings from two national comparative case studies of patient safety policy implementation. A processual analytic approach (Pettigrew, 1997) was utilised as it takes into account the context (national policy and organisational structures) and processes of quality and safety improvement. This framework allows a textured analysis of contextual factors in relation to the content and coherence of policy; its fit with local organisations; clarity of goals; key interfaces between different groups, as well as the quality and availability of appropriate leadership. The qualitative data were analysed thematically. The approach is especially relevant as it allows a holistic comparison of the institutions of interest and the broader contexts. Understanding the antecedents of effective policy leadership is significant as many public health systems are under severe financial strain. For example, Ireland is facing more than €1 billion cut from healthcare (Donnellan & Wall, 2011). Similarly, the Scottish healthcare system incurred 4,000 job reductions in 2010 and is anticipating more than £4 billion cut from the national budget -a third of which goes to healthcare (Torrance, 2010). Top level leadership effectiveness becomes more urgently necessary as the economic crisis deepens.Method As part of a larger investigation of system factors influencing healthcare policy formation, implementation, and impact, in-depth interviews (N = 29) were conducted with key senior policy informants in Ireland and Scotland. Interviews focused on involvement in policy design and implementation; institutional structures and management; innovative quality and/or safety practices; and perceptions of the healthcare system. Leadership emerged as a strong theme in questions regarding innovative practices and national progression in healthcare quality and patient safety improvement.As a result, the analysis focuses on identifying the antecedents of different leadership approaches and norms in each nation, based on qualitative analysis. Results Preliminary analysis revealed discussion of a norm of strong, proactive, collaborative and dispersed leadership - a common, unprompted theme in the Scottish interviews. Those involved in designing and implementing healthcare policy in Scotland reported that that high level leadership is necessary: "you need executive leadership from the organisation to drive it [quality healthcare]." (Scotland 4) and described leadership at the top executive level designed to galvanise their efforts: "It is a very clear cut that at the highest level in health boards and from government in Scotland to take forward the quality programmes." (Scotland 4) Key people in senior government roles were attributed as being effective leaders in establishing quality healthcare as priority on the national agenda and that governmental leadership acted as a driving force for safe and quality healthcare: "It is a real...and you can see that with [key individual]. He has remained very committed to it... he gives himself as the [key position], their strategies actually have given that impetus to people to believe this is important to do." (Scotland 13) Importantly, leadership was described as permeating down the health board hierarchy with others co-opted as leaders to advance quality and safe healthcare. "We've run a whole set of leadership programmes for staff and health boards in mirror of patient safety." (Scotland 6) Participants were asked to provide examples of innovative quality/safety practices in their country. A common response to what has influenced those practices was leadership: "I would say leadership... I see that the leadership is coming across the whole exec team." (Scotland 13) In marked contrast, discussion in Ireland focused on a deficit of competent, effective leaders willing to take the lead on change initiatives as a norm at national and organisational levels: "The biggest single deficit in the Irish healthcare system...to facilitate competent, effective leaders because we haven't had that." (Ireland 7) "A fundamental part of it (effective healthcare) is clinical leadership, and that's been missing." (Ireland 5) Although there were criticisms of leadership at the national executive level: " I believe we have had a significant failure at a senior civil and public management level." (Ireland 7) there were also concerns regarding leadership throughout the system: "The problem with the Irish health systems is...where I see a serious deficit is in terms of competent, effective, leaders at all levels of the system." (Ireland 7) Both the Scottish and Irish informants made a link between national systems level and its impact on leadership at other levels of organisation. Similarly, when Irish respondents were asked to identify areas of innovative practices leadership was cited as what helped influence success: "...leadership over the people concerned." (Ireland 7) Discussion The preliminary qualitative analysis from interviews of key policy informants from Ireland and Scotland provides evidence of the possible influence leadership norms have on national health systems. This analysis offers pragmatic and theoretical interest by considering the antecedents of leadership norms across two health systems.
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Dates et versions

hal-00840343 , version 1 (02-07-2013)


  • HAL Id : hal-00840343 , version 1


Lauren M. Hamel, Aoife Mcdermott, Patrick C. Flood. A comparative analysis of leadership Norms in National Policy implementation. Communiquer dans un monde de normes. L'information et la communication dans les enjeux contemporains de la " mondialisation "., Mar 2012, France. ⟨hal-00840343⟩


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