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  3. Governance and Leadership
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    • Open access
  • Cited by 16
Publisher:
Cambridge University Press
Online publication date:
November 2023
Print publication year:
2023
Online ISBN:
9781009309578
DOI:
https://doi.org/10.1017/9781009309578
Creative Commons:
Creative Common License - CC Creative Common License - BY Creative Common License - NC Creative Common License - ND
This content is Open Access and distributed under the terms of the Creative Commons Attribution licence CC-BY-NC-ND 4.0 https://creativecommons.org/creativelicenses
Subjects:
Medicine: General Interest, Medicine
Series:
Elements of Improving Quality and Safety in Healthcare
Information

Book description

Lessons from service and system failures describe the pivotal roles played by governance and leadership in delivering high-quality, safe care. This Element sets out what the terms governance and leadership mean and how thinking about them has developed over time. Using real-world examples, the authors analyse research evidence on the influence of governance and leadership on quality and safety in healthcare at different levels in the health system: macro level (what national health systems do), meso level (what organisations do), and micro level (what teams and individuals do). The authors describe behaviours that may help boards focus on improving quality and show how different leadership approaches may contribute to delivering major system change. The Element presents some critiques of governance and leadership, including some challenges that can arise and gaps in the evidence, and then draws out lessons for those seeking to strengthen governance and leadership for improvement. This title is also available as Open Access on Cambridge Core.

References

References

1.Brown, A, Dickinson, H, Kelaher, M. Governing the quality and safety of healthcare: A conceptual framework. Soc Sci Med 2018; 202: 99–107. https://doi.org/10.1016/j.socscimed.2018.02.020.
2.Kennedy, I. The Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984–1995: Learning from Bristol. London: The Stationery Office; 2002. https://psnet.ahrq.gov/issue/learning-bristol-report-public-inquiry-childrens-heart-surgery-bristol-royal-infirmary-1984 (accessed 22 May 2023).
3.Mohammed, MA. Statistical process control. In: Dixon-Woods, M, Brown, K, Marjanovic, S, et al., eds. Elements of Improving Quality and Safety in Healthcare. Cambridge: Cambridge University Press; forthcoming.
4.Mannion, R. Making culture change happen. In: Dixon-Woods, M, Brown, K, Marjanovic, S, et al., eds. Elements of Improving Quality and Safety in Healthcare. Cambridge: Cambridge University Press; 2022. https://doi.org/10.1017/9781009236935.
5.Travaglia, JF, Debono, D, Spigelman, AD, Braithwaite, J. Clinical governance: A review of key concepts in the literature. Clin Gov 2011; 16: 62–77. https://doi.org/10.1108/14777271111104592.
6.Walshe, K, Offen, N. A very public failure: Lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary. BMJ Qual Saf 2001; 10: 250–6. https://doi.org/10.1136/qhc.0100250.
7.Public Health England. Newborn hearing screening programme (NHSP) operational guidance. Clinical Governance. www.gov.uk/government/publications/newborn-hearing-screening-programme-nhsp-operational-guidance/4-clinical-governance (accessed 22 May 2023).
8.Francis, R. Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust January 2005–March 2009. London: The Stationery Office; 2010. www.gov.uk/government/publications/independent-inquiry-into-care-provided-by-mid-staffordshire-nhs-foundation-trust-january-2001-to-march-2009 (accessed 22 May 2023).
9.Francis, R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office; 2013. www.gov.uk/government/publications/report-of-the-mid-staffordshire-nhs-foundation-trust-public-inquiry (accessed 22 May 2023).
10.Kirkup, B. The Report of the Morecambe Bay Investigation: An Independent Investigation into the Management, Delivery and Outcomes of Care Provided by the Maternity and Neonatal Services at the University Hospitals of Morecambe Bay NHS Foundation Trust from January 2004 to June 2013. London: The Stationery Office; 2015. www.gov.uk/government/publications/morecambe-bay-investigation-report (accessed 22 May 2023).
11.Fulop, NJ, Ramsay, AIG. How organisations contribute to improving the quality of healthcare. BMJ 2019; 365: l1773. https://doi.org/10.1136/bmj.l1773.
12.Ferlie, E, Baeza, JI, Addicott, R, Mistry, R. The governance of pluralist health care systems: An initial review and typology. Health Serv Manage Res 2017; 30: 61–71. https://doi.org/10.1177/0951484816682395.
13.Department of Health. High Quality Care for All: NHS Next Stage Review Final Report. London: Department of Health; 2008. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/228836/7432.pdf (accessed 22 May 2023).
14.Walshe, K. The rise of regulation in the NHS. BMJ 2002; 324: 967–70. https://doi.org/10.1136/bmj.324.7343.967.
15.Lipunga, AM, Tchereni, BM, Bakuwa, RC. Emerging structural models for governance of public hospitals. Int J Health Gov 2019; 24: 98–116. https://doi.org/10.1108/IJHG-03-2019-0018.
16.Barbazza, E, Tello, JE. A review of health governance: Definitions, dimensions and tools to govern. Health Policy 2014; 116: 1–11. https://doi.org/10.1016/j.healthpol.2014.01.007.
17.Cornforth, C, Chambers, N. The Role of Corporate Governance and Boards in Organisational Performance. Cambridge: Cambridge University Press; 2010. http://oro.open.ac.uk/23907/5/Chapter_on_governance_boards_and_performance_020709.pdf (accessed 22 May 2023).
18.Lynn, LE Jr, Heinrich, CJ, Hill, CJ. Improving Governance: A New Logic for Empirical Research. Washington, DC: Georgetown University Press; 2001.
19.Davies, C, Anand, P, Artigas, L, et al. Links between Governance, Incentives and Outcomes: A Review of the Literature. London: National Co-ordinating Centre for NHS Service Delivery and Organisation R&D; 2005. https://njl-admin.nihr.ac.uk/document/download/2008497 (accessed 22 May 2023).
20.Hartley, J. Ten propositions about public leadership. Int J Public Leadersh 2018; 14: 202–17. https://doi.org/10.1108/IJPL-09-2018-0048.
21.Irvine, D. A short history of the General Medical Council. Med Educ 2006; 40: 202–11. https://doi.org/10.1111/j.1365-2929.2006.02397.x.
22.Bradshaw, A. Competence and British nursing: A view from history. J Clin Nurs 2000; 9: 321–9. https://doi.org/10.1046/j.1365-2702.2000.00399.x.
23.Exworthy, M, Powell, M, Mohan, J. Markets, bureaucracy and public management: The NHS: Quasi-market, quasi-hierarchy and quasi-network? Public Money Manag 1999; 19: 15–22. https://doi.org/10.1111/1467-9302.00184.
24.Ferlie, E. The new public management and public management studies. In: Aldag, R, ed. Oxford Research Encyclopedia of Business Management. New York: Oxford University Press; 2017. https://doi.org/10.1093/acrefore/9780190224851.013.129.
25.Provan, KG, Kenis, P. Modes of network governance: Structure, management, and effectiveness. J Public Adm Res Theory 2008; 18: 229–52. https://doi.org/10.1093/jopart/mum015.
26.Caffrey, L, Ferlie, E, McKevitt, C. The strange resilience of new public management: The case of medical research in the UK’s National Health Service. Public Adm Rev 2019; 21: 537–58. https://doi.org/10.1080/14719037.2018.1503702.
27.Addicott, R, McGivern, G, Ferlie, E. The distortion of a managerial technique? The case of clinical networks in UK health care. Br J Manag 2007; 18: 93–105. https://doi.org/10.1111/j.1467-8551.2006.00494.x.
28.Addicott, R, Ferlie, E. Understanding power relationships in health care networks. J Health Organ Manage 2007; 21: 393–405. https://doi.org/10.1108/14777260710778925.
29.Ferlie, E, McGivern, G, Fitzgerald, L. A new mode of organizing in health care? Governmentality and managed networks in cancer services in England. Soc Sci Med 2012; 74: 340–7. https://doi.org/10.1016/j.socscimed.2011.03.021.
30.Osipovič, D, Allen, P, Sanderson, M, Moran, V, Checkland, K. The regulation of competition and procurement in the National Health Service 2015–2018: Enduring hierarchical control and the limits of juridification. Health Econ Policy Law 2020; 15: 308–24. https://doi.org/10.1017/S1744133119000240.
31.Kjaer, PF, Vetterlein, A. Regulatory governance: Rules, resistance and responsibility. Contemp Politics 2018; 24: 497–506. https://doi.org/10.1080/13569775.2018.1452527.
32.Beaussier, A-L, Demeritt, D, Griffiths, A, Rothstein, H. Accounting for failure: Risk-based regulation and the problems of ensuring healthcare quality in the NHS. Health Risk Soc 2016; 18: 205–24. https://doi.org/10.1080/13698575.2016.1192585.
33.Stogdill, RM. Leadership, membership and organization. Psychol Bull 1950; 47: 1–14. https://doi.org/10.1037/h0053857.
34.Wood, M. The fallacy of misplaced leadership. J Manage Stud 2005; 42: 1101–21. https://doi.org/10.1111/j.1467-6486.2005.00535.x.
35.Kumar, RD. Leadership in healthcare. Anaesth Intensive Care Med 2013; 14: 39–41. https://doi.org/10.1016/j.mpaic.2012.11.006.
36.Belrhiti, Z, Giralt, AN, Marchal, B. Complex leadership in healthcare: A scoping review. Int J Health Policy Manage 2018; 7(12): 1073–84. www.ncbi.nlm.nih.gov/pmc/articles/PMC6358662/ (accessed 22 May 2023).
37.Plsek, PE, Wilson, T. Complexity, leadership, and management in healthcare organisations. BMJ 2001; 323(7315): 746–9. www.bmj.com/content/323/7315/746.1.short (accessed 22 May 2023).
38.Hartley, J, Benington, J. Leadership for Healthcare. Bristol: Policy Press; 2010.
39.Reichenpfader, U, Carlfjord, S, Nilsen, P. Leadership in evidence-based practice: A systematic review. Leadersh Health Serv 2015; 28: 298–316. https://doi.org/10.1108/LHS-08-2014-0061.
40.Øvretveit, J. Leading Improvement Effectively: Review of Research. London: The Health Foundation; 2009. www.health.org.uk/publications/leading-improvement-effectively (accessed 22 May 2023).
41.Griffiths, R. NHS Management Inquiry. London: Department of Health and Social Security; 1983. www.sochealth.co.uk/national-health-service/griffiths-report-october-1983 (accessed 22 May 2023).
42.Klein, R. The National Health Service (NHS) at 70: Bevan’s double-edged legacy. Health Econ Policy Law 2019; 14: 1–10. https://doi.org/10.1017/S1744133117000354.
43.Gorsky, M. ‘Searching for the people in charge’: Appraising the 1983 Griffiths NHS Management Inquiry. Med Hist 2013; 57: 87–107. https://doi.org/10.1017/mdh.2012.82.
44.Vindrola-Padros, C, Ledger J, Hill M, et al. The special measures for quality and challenged provider regimes in the English NHS: A rapid evaluation of a national improvement initiative for failing healthcare organisations. Int J Health Policy Manag 2022; 11(12): 2917. https://doi.org/10.34172/ijhpm.2022.6619.
45.Jones, L, Pomeroy, L, Robert, G, et al. How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England. BMJ Qual Saf 2017; 26: 978–86. https://doi.org/10.1136/bmjqs-2016-006433.
46.Waring, J. Restratification, hybridity and professional elites: Questions of power, identity and relational contingency at the points of ‘professional–organisational intersection’. Sociol Compass 2014; 8: 688–704. https://doi.org/10.1111/soc4.12178.
47.Currie, G, Burgess, N, Hayton, JC. HR practices and knowledge brokering by hybrid middle managers in hospital settings: The influence of professional hierarchy. Hum Resour Manage 2015; 54: 793–812. https://doi.org/10.1002/hrm.21709.
48.Currie, G, Lockett, A. Distributing leadership in health and social care: Concertive, conjoint or collective? Int J Manage Rev 2011; 13: 286–300. https://doi.org/10.1111/j.1468-2370.2011.00308.x.
49.Gronn, P. Distributed leadership as a unit of analysis. Leadersh Q 2002; 13: 423–51. https://doi.org/10.1016/S1048-9843(02)00120-0.
50.Bolden, R. Distributed leadership in organizations: A review of theory and research. Int J Manage Rev 2011; 13: 251–69. https://doi.org/10.1111/j.1468-2370.2011.00306.x.
51.Best, A, Greenhalgh, T, Lewis, S, et al. Large-system transformation in health care: A realist review. Milbank Q 2012; 90: 421–26. https://doi.org/10.1111/j.1468-0009.2012.00670.x.
52.Baker, GR. The Roles of Leaders in High-Performing Health Care Systems. London: The King’s Fund; 2011. www.kingsfund.org.uk/sites/default/files/roles-of-leaders-high-performing-health-care-systems-ross-baker-kings-fund-may-2011.pdf (accessed 22 May 2023).
53.Aufegger, L, Shariq, O, Bicknell, C, Ashrafian, H, Darzi, A. Can shared leadership enhance clinical team management? A systematic review. Leadersh Health Serv 2019; 32: 309–35. https://doi.org/10.1108/LHS-06-2018-0033.
54.Currie, G, Spyridonidis, D. Sharing leadership for diffusion of innovation in professionalized settings. Hum Relations 2019; 72: 1209–33. https://doi.org/10.1177/0018726718796175.
55.Chambers, N, Harvey, G, Mannion, R. Who should serve on health care boards? What should they do and how should they behave? A fresh look at the literature and the evidence. Cogent Bus Manage 2017; 4: 1–14. https://doi.org/10.1080/23311975.2017.1357348.
56.Bennington, L. Review of the corporate and healthcare governance literature. J Manage Organ 2010; 16: 314–33. https://doi.org/10.5172/jmo.16.2.314.
57.Eeckloo, K, Delesie, L, Vleugels, A. Where is the pilot? The changing shapes of governance in the European hospital sector. J R Soc Promot Health 2007; 127: 78–86. https://doi.org/10.1177/1466424007075457.
58.Chambers, N, Harvey, G, Mannion, R, Bond, J, Marshall, J. Towards a framework for enhancing the performance of NHS boards: A synthesis of the evidence about board governance, board effectiveness and board development. Health Serv Deliv Res 2013; 1: 6. https://doi.org/10.3310/hsdr01060.
59.Thiel, A, Winter, V, Büchner, VA. Board characteristics, governance objectives, and hospital performance: An empirical analysis of German hospitals. Health Care Manage Rev 2018; 43: 282–92. https://doi.org/10.1097/HMR.0000000000000153.
60.Ramsay, AIG, Fulop, N, Fresko, A, Rubenstein, S. The Healthy NHS Board: Review of Guidance and Research Evidence. Leeds: NHS Leadership Academy; 2013. www.yumpu.com/en/document/view/39165116/healthy-nhs-board-a-review-of-nhs-leadership-academy (accessed 22 May 2023).
61.Dixon-Woods, M, Baker, R, Charles, K, et al. Culture and behaviour in the English National Health Service: Overview of lessons from a large multimethod study. BMJ Qual Saf 2014; 23: 106–15. https://doi.org/10.1136/bmjqs-2013-001947.
62.Chambers, N. Healthcare board governance. J Health Organ Manage 2012; 26: 6–14. https://doi.org/10.1108/14777261211211133.
63.Baker, GR, Denis, J-L, Pomey, M-P, MacIntosh-Murray, A. Designing effective governance for quality and safety in Canadian healthcare. Healthc Q 2010; 13: 38–45. https://doi.org/10.12927/hcq.2013.21244.
64.Mannion, R, Davies, H, Freeman, T, et al. Overseeing oversight: Governance of quality and safety by hospital boards in the English NHS. J Health Serv Res Policy 2015; 20: 9–16. https://doi.org/10.1177/1355819614558471.
65.Mannion, R, Freeman, T, Millar, R, Davies, H. Effective board governance of safe care: A (theoretically underpinned) cross-sectioned examination of the breadth and depth of relationships through national quantitative surveys and in-depth qualitative case studies. Health Serv Deliv Res 2016; 4: 4. https://doi.org/10.3310/hsdr04040.
66.Parand, A, Dopson, S, Renz, A, Vincent, C. The role of hospital managers in quality and patient safety: A systematic review. BMJ Open 2014; 4: e005055. https://doi.org/10.1136/bmjopen-2014-005055.
67.Mannion, R, Davies, H. Understanding organisational culture for healthcare quality improvement. BMJ 2018; 363: k4907. https://doi.org/10.1136/bmj.k4907.
68.West, MA, Lyubovnikova, J, Eckert, R, Denis, J-L. Collective leadership for cultures of high quality health care. J Organ Eff People Perf 2014; 1: 240–60. https://doi.org/10.1108/JOEPP-07-2014-0039.
69.Millar, R, Mannion, R, Freeman, T, Davies, HT. Hospital board oversight of quality and patient safety: A narrative review and synthesis of recent empirical research. Milbank Q 2013; 91: 738–70. https://doi.org/10.1111/1468-0009.12032.
70.Martin, GP, Aveling, E-L, Campbell, A, et al. Making soft intelligence hard: A multi-site qualitative study of challenges relating to voice about safety concerns. BMJ Qual Saf 2018; 27: 710–7. https://doi.org/10.1136/bmjqs-2017-007579.
71.Freeman, T, Millar, R, Mannion, R, Davies, H. Enacting corporate governance of healthcare safety and quality: A dramaturgy of hospital boards in England. Sociol Health Illn 2016; 38: 233–51. https://doi.org/10.1111/1467-9566.12309.
72.Ramsay, AIG, Fulop, N, Fresko, A, Rubenstein, S. The Healthy NHS Board: A Review of Guidance and Research Evidence. London: Department of Health; 2010. www.leadershipacademy.nhs.uk/wp-content/uploads/2013/06/NHSLeadership-HealthyNHSBoard-2010-LiteratureReview.pdf (accessed 22 May 2023).
73.Tsai, TC, Jha, AK, Gawande, AA, et al. Hospital board and management practices are strongly related to hospital performance on clinical quality metrics. Health Aff 2015; 34: 1304–11. https://doi.org/10.1377/hlthaff.2014.1282.
74.Jha, A, Epstein, A. Hospital governance and the quality of care. Health Aff 2010; 29: 182–7. https://doi.org/10.1377/hlthaff.2009.0297.
75.Jha, AK, Epstein, AM. A survey of board chairs of English hospitals shows greater attention to quality of care than among their US counterparts. Health Aff 2013; 32: 677–85. https://doi.org/10.1377/hlthaff.2012.1060.
76.Brown, A. Understanding corporate governance of healthcare quality: A comparative case study of eight Australian public hospitals. BMC Health Serv Res 2019; 19: 725. https://doi.org/10.1186/s12913-019-4593-0.
77.Bate, P, Mendel, P, Robert, G. Organizing for Quality: The Improvement Journeys of Leading Hospitals in Europe and the United States. Abingdon: Radcliffe; 2007.
78.Care Quality Commission. Quality Improvement in Hospital Trusts: Sharing Learning from Trusts on a Journey of QI. London: Care Quality Commission; 2018. www.cqc.org.uk/publications/evaluation/quality-improvement-hospital-trusts-sharing-learning-trusts-journey-qi (accessed 22 May 2023).
79.Baker, GR, MacIntosh-Murray, A, Porcellato, C, et al. High Performing Healthcare Systems: Delivering Quality by Design. Toronto: Longwoods; 2008. www.longwoods.com/publications/books/571/1/high-performing-healthcare-systems-delivering-quality-by-design (accessed 22 May 2023).
80.Nembhard, IM, Cherian, P, Bradley, EH. Deliberate learning in health care: The effect of importing best practices and creative problem solving on hospital performance improvement. Med Care Res Rev 2014; 71: 450–71. https://doi.org/10.1177/1077558714536619.
81.Burnett, S, Mendel, P, Nunes, F, et al. Using institutional theory to analyse hospital responses to external demands for finance and quality in five European countries. J Health Serv Res Policy 2016; 21: 109–17. https://doi.org/10.1177/1355819615622655.
82.Damschroder, LJ, Aron, DC, Keith, RE, et al. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implement Sci 2009; 4: 50. https://doi.org/10.1186/1748-5908-4-50.
83.Dixon-Woods, M, McNicol, S, Martin, G. Ten challenges in improving quality in healthcare: Lessons from the Health Foundation’s programme evaluations and relevant literature. BMJ Qual Saf 2012; 21: 876–84. https://doi.org/10.1136/bmjqs-2011-000760.
84.Martin, GP, McKee, L, Dixon-Woods, M. Beyond metrics? Utilizing ‘soft intelligence’ for healthcare quality and safety. Soc Sci Med 2015; 142: 19–26. https://doi.org/10.1016/j.socscimed.2015.07.027.
85.Brown, A. Communication and leadership in healthcare quality governance: Findings from comparative case studies of eight public hospitals in Australia. J Health Organ Manag 2020; 34: 144–61. https://doi.org/10.1108/JHOM-07-2019-0194.
86.Curry, LA, Spatz, E, Cherlin, E, et al. What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study. Ann Intern Med 2011; 154: 384–90. https://doi.org/10.7326/0003-4819-154-6-201103150-00003.
87.Veronesi, G, Kirkpatrick, I, Vallascas, F. Clinicians on the board: What difference does it make? Soc Sci Med 2013; 77: 147–55. https://doi.org/10.1016/j.socscimed.2012.11.019.
88.Sarto, F, Veronesi, G. Clinical leadership and hospital performance: Assessing the evidence base. BMC Health Serv Res 2016; 16: 169. https://doi.org/10.1186/s12913-016-1395-5.
89.Sarto, F, Veronesi, G, Kirkpatrick, I. Organizing professionals and their impact on performance: The case of public health doctors in the Italian SSN. Publ Manage Rev 2019; 21: 1029–51. https://doi.org/10.1080/14719037.2018.1544270.
90.Braithwaite, J. Changing how we think about healthcare improvement. BMJ 2018; 361: k2014. https://doi.org/10.1136/bmj.k2014.
91.Barbosa, EC, Jones, L, Pomeroy, L, et al. A board level intervention to develop organisation-wide quality improvement strategies: Cost-consequences analysis in 15 healthcare organisations. Int J Health Policy Manag 2022; 11: 173–82. https://doi.org/10.34172/IJHPM.2020.91.
92.Mannion, R, Braithwaite, J. Unintended consequences of performance measurement in healthcare: 20 salutary lessons from the English National Health Service. Intern Med J 2012; 42: 569–74. https://doi.org/10.1111/j.1445-5994.2012.02766.x.
93.Lapsley, I. New public management: The cruellest invention of the human spirit? Abacus 2009; 45: 1–21. https://doi.org/10.1111/j.1467-6281.2009.00275.x.
94.Bevan, G, Hood, C. What’s measured is what matters: Targets and gaming in the English public health care system. Public Adm 2006; 84: 517–38. https://doi.org/10.1111/j.1467-9299.2006.00600.x.
95.Busse, R, Klazinga, N, Panteli, D, Quentin, W, eds. Improving Healthcare Quality in Europe: Characteristics, Effectiveness and Implementation of Different Strategies. Brussels: European Observatory on Health Systems and Policies; 2019. https://apps.who.int/iris/bitstream/handle/10665/327356/9789289051750-eng.pdf (accessed 22 May 2023).
96.Pollitt, C. Performance management 40 years on: A review. Some key decisions and consequences. Publ Money Manag 2018; 38: 167–74. https://doi.org/10.1080/09540962.2017.1407129.
97.Lebas, MJ. Performance measurement and performance management. Int J Prod Econ 1995; 41: 23–35. https://doi.org/10.1016/0925-5273(95)00081-X.
98.Ramsay, AIG, Magnusson, C, Fulop, N. The relationship between external and local governance systems: The case of health care associated infections and medication errors in one NHS trust. Qual Saf Health Care 2010; 19: e45. https://doi.org/10.1136/qshc.2009.037473.
99.Boyne, GA, Chen, AA. Performance targets and public service improvement. J Publ Adm Res Theory 2007; 17: 455–77. https://doi.org/10.1093/jopart/mul007.
100.Kelman, S, Friedman, JN. Performance improvement and performance dysfunction: An empirical examination of distortionary impacts of the emergency room wait-time target in the English National Health Service. J Publ Adm Res Theory 2009; 19: 917–46. https://doi.org/10.1093/jopart/mun028.
101.Reason, J. Safety paradoxes and safety culture. Inj Control Saf Promot 2000; 7: 3–14. https://doi.org/10.1076/1566-0974(200003)7:1;1-V;FT003.
102.Weaver, SJ, Lubomksi, LH, Wilson, RF, et al. Promoting a culture of safety as a patient safety strategy: A systematic review. Ann Intern Med 2013; 158: 369–74. https://doi.org/10.7326/0003-4819-158-5-201303051-00002.
103.Braithwaite, J, Westbrook, MT, Travaglia, JF, Hughes, C. Cultural and associated enablers of, and barriers to, adverse incident reporting. BMJ Qual Saf 2010; 19: 229–33. https://doi.org/10.1136/qshc.2008.030213.
104.Campanella, P, Vukovic, V, Parente, P, et al. The impact of public reporting on clinical outcomes: A systematic review and meta-analysis. BMC Health Serv Res 2016; 16: 296. https://doi.org/10.1186/s12913-016-1543-y.
105.Jones, L, Pomeroy, L, Robert, G, et al. Explaining organisational responses to a board-level quality improvement intervention: Findings from an evaluation in six providers in the English National Health Service. BMJ Qual Saf 2019; 28: 198–204. https://doi.org/10.1136/bmjqs-2018-008291.
106.Behrendt, K, Groene, O. Mechanisms and effects of public reporting of surgeon outcomes: A systematic review of the literature. Health Policy 2016; 120: 1151–61. https://doi.org/10.1016/j.healthpol.2016.08.003.
107.Williams, MP, Modgil, V, Drake, MJ, Keeley, F. The effect of consultant outcome publication on surgeon behaviour: A systematic review and narrative synthesis. Ann R Coll Surg Engl 2018; 100: 428–35. https://doi.org/10.1308/rcsann.2018.0052.
108.Sutton, M, Nikolova, S, Boaden, R, et al. Reduced mortality with hospital pay for performance in England. N Engl J Med 2012; 367: 1821–8. https://doi.org/10.1056/NEJMsa1114951.
109.Kristensen, SR, Meacock, R, Turner, AJ, et al. Long-term effect of hospital pay for performance on mortality in England. N Engl J Med 2014; 371: 540–8. https://doi.org/10.1056/NEJMoa1400962.
110.Jha, AK, Joynt, KE, Orav, EJ, Epstein, AM. The long-term effect of premier pay for performance on patient outcomes. N Engl J Med 2012; 366: 1606–15. https://doi.org/10.1056/NEJMsa1112351.
111.Ryan, AM, Krinsky, S, Kontopantelis, E, Doran, T. Long-term evidence for the effect of pay-for-performance in primary care on mortality in the UK: A population study. Lancet 2016; 388: 268–74. https://doi.org/10.1016/S0140-6736(16)00276-2.
112.Harrison, MJ, Dusheiko, M, Sutton, M, et al. Effect of a national primary care pay for performance scheme on emergency hospital admissions for ambulatory care sensitive conditions: Controlled longitudinal study. BMJ 2014; 349: g6423. https://doi.org/10.1136/bmj.g6423.
113.Khan, N, Rudoler, D, McDiarmid, M, Peckham, S. A pay for performance scheme in primary care: Meta-synthesis of qualitative studies on the provider experiences of the quality and outcomes framework in the UK. BMC Fam Pract 2020; 21: 142. https://doi.org/10.1186/s12875-020-01208-8.
114.Hartley, J, Sancino, A, Bennister, M, Resodihardjo, SL. Leadership for public value: Political astuteness as a conceptual link. Publ Admin 2019; 97: 239–49. https://doi.org/10.1111/padm.12597.
115.Alderwick, H, Charles, A, Jones, B, Warburton, W. Making the Case for Quality Improvement: Lessons for NHS Boards and Leaders. London: The King’s Fund; 2017. www.kingsfund.org.uk/publications/making-case-quality-improvement (accessed 22 May 2023).
116.McKean, EL, Snyderman, CH. Leadership driving safety and quality. Otolaryngol Clin North Am 2019; 52: 11–22. https://doi.org/10.1016/j.otc.2018.08.002.
117.Kool, M, van Dierendonck, D. Servant leadership and commitment to change, the mediating role of justice and optimism. J Organ Chang Manag 2012; 25: 422–33. https://doi.org/10.1108/09534811211228139.
118.Kempster, S, Jackson, B, Conroy, M. Leadership as purpose: Exploring the role of purpose in leadership practice. Leadership 2011; 7: 317–34. https://doi.org/10.1177/1742715011407384.
119.Künzle, B, Kolbe, M, Grote, G. Ensuring patient safety through effective leadership behaviour: A literature review. Saf Sci 2010; 48: 1–17. https://doi.org/10.1016/j.ssci.2009.06.004.
120.Donovan, S-L, Salmon, PM, Lenné, MG. Leading with style: A literature review of the influence of safety leadership on performance and outcomes. Theor Issues Ergonomics Sci 2016; 17: 423–42. https://doi.org/10.1080/1463922X.2016.1143986.
121.Caldwell, C, Dixon, RD, Floyd, LA, et al. Transformative leadership: Achieving unparalleled excellence. J Bus Ethics 2012; 109: 175–87. https://doi.org/10.1007/s10551-011-1116-2.
122.Ramsay, AIG, Morris, S, Hoffman, A, et al. Effects of centralizing acute stroke services on stroke care provision in two large metropolitan areas in England. Stroke 2015; 46: 2244–51. https://doi.org/10.1161/STROKEAHA.115.009723.
123.Morris, S, Ramsay, AIG, Boaden, R, et al. Impact and sustainability of centralising acute stroke services in English metropolitan areas: Retrospective analysis of hospital episode statistics and stroke national audit data. BMJ 2019; 364: l1. https://doi.org/10.1136/bmj.l1.
124.Morris, S, Hunter, RM, Ramsay, AIG, et al. Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: Difference-in-differences analysis. BMJ 2014; 349: g4757. https://doi.org/10.1136/bmj.g4757.
125.Fulop, NJ, Ramsay, AIG, Hunter, RM, et al. Evaluation of reconfigurations of acute stroke services in different regions of England and lessons for implementation: A mixed-methods study. Health Serv Deliv Res 2019; 7: 7. https://doi.org/10.3310/hsdr07070.
126.den Heede K, Van, Dubois, C, Mistiaen, P, et al. Evaluating the need to reform the organisation of care for major trauma patients in Belgium: An analysis of administrative databases. Eur J Trauma Emerg Surg 2019; 45: 885–92. https://doi.org/10.1007/s00068-018-0932-9.
127.Moran, CG, Lecky, F, Bouamra, O, et al. Changing the system: Major trauma patients and their outcomes in the NHS (England) 2008–17. eClinicalMedicine 2018; 2: 13–21. https://doi.org/10.1016/j.eclinm.2018.07.001.
128.Vindrola-Padros, C, Ramsay, AIG, Perry, C, et al. Implementing major system change in specialist cancer surgery: The role of provider networks. J Health Serv Res Policy 2020; 26: 4–11. https://doi.org/10.1177/1355819620926553.
129.Fulop, NJ, Ramsay, AI, Vindrola-Padros, C, et al. Reorganising specialist cancer surgery for the twenty-first century: A mixed methods evaluation (RESPECT-21). Implement Sci 2016; 11: 155. https://doi.org/10.1186/s13012-016-0520-5.
130.Turner, S, Ramsay, AI, Perry, C, et al. Lessons for major system change: Centralisation of stroke services in two metropolitan areas of England. J Health Serv Res Policy 2016; 21: 156–65. https://doi.org/10.1177/1355819615626189.
131.McKevitt, C, Ramsay, AIG, Perry, C, et al. Patient, carer and public involvement in major system change in acute stroke services: The construction of value. Health Expect 2018; 21: 685–92. https://doi.org/10.1111/hex.12668.
132.Fraser, A, Baeza, JI, Boaz, A. ‘Holding the line’: A qualitative study of the role of evidence in early phase decision-making in the reconfiguration of stroke services in London. Health Res Policy Syst 2017; 15: 45. https://doi.org/10.1186/s12961-017-0207-7.
133.Fraser, A, Stewart, E, Jones, L. The importance of sociological approaches to the study of service change in health care. Sociol Health Illn 2019; 41: 1215–20. https://doi.org/10.1111/1467-9566.12942.
134.Fulop, NJ, Ramsay, AI, Vindrola-Padros, C, et al. Centralisation of specialist cancer surgery services in two areas of England: The RESPECT-21 mixed-methods evaluation. Health Soc Care Deliv Res 2023; 11(2). https://doi.org/10.3310/QFGT2379.
135.Black, GB, Wood, VJ, Ramsay, AIG, et al. Loss associated with subtractive health service change: The case of specialist cancer centralization. J Health Serv Res Policy 2022; 27: 301–12. https://doi.org/10.1177/13558196221082585.
136.Smith, T, Fowler-Davis, S, Nancarrow, S, Ariss, SMB, Enderby, P. Leadership in interprofessional health and social care teams: A literature review. Leadersh Health Serv 2018; 31: 452–67. https://doi.org/10.1108/LHS-06-2016-0026.
137.Lyubovnikova, J, West, MA. Why teamwork matters: Enabling health care team effectiveness for the delivery of high-quality patient care. In: Salas, E, Tannenbaum, S, Cohen, D, Latham, G, eds. Developing and Enhancing Teamwork in Organizations. San Francisco, CA: Jossey Bass; 2013: 331–72. www.researchgate.net/profile/Michael_West12/publication/285218775_Team_working_and_effectiveness_in_health_care/links/593696fda6fdccb0996184d4/Team-working-and-effectiveness-in-health-care.pdf (accessed 22 May 2023).
138.West, MA, Lyubovnikova, J. Illusions of team working in health care. J Health Organ Manag 2013; 27: 134–42. https://doi.org/10.1108/14777261311311843.
139.Lyubovnikova, J, West, MA, Dawson, JF, Carter, MR. 24-karat or fool’s gold? Consequences of real team and co-acting group membership in healthcare organizations. Eur J Work Organ Psychol 2015; 24: 929–50. https://doi.org/10.1080/1359432X.2014.992421.
140.Wranik, WD, Price, S, Haydt, SM, et al. Implications of interprofessional primary care team characteristics for health services and patient health outcomes: A systematic review with narrative synthesis. Health Policy 2019; 123: 550–63. https://doi.org/10.1016/j.healthpol.2019.03.015.
141.West, M, Almo-Metcalfe, B, Dawson, J, et al. Effectiveness of Multi-Professional Team Working (MPTW) in Mental Healthcare. Southampton: National Institute for Health Research; 2012. https://njl-admin.nihr.ac.uk/document/download/2008984 (accessed 22 May 2023).
142.Austin, JM, Demski, R, Callender, T, et al. From board to bedside: How the application of financial structures to safety and quality can drive accountability in a large health care system. Jt Comm J Qual Patient Saf 2017; 43: 166–75. https://doi.org/10.1016/j.jcjq.2017.01.001.
143.Maben, J, Ball, J, Edmondson, AC. Workplace conditions. In: Dixon-Woods, M, Brown, K, Marjanovic, S, et al., eds. Elements of Improving Quality and Safety in Healthcare. Cambridge: Cambridge University Press; 2022. https://doi.org/10.1017/9781009363839.
144.Smith, T, Fowler Davis, S, et al. Towards a theoretical framework for integrated team leadership (IgTL). J Interprof Care 2019; 34: 726–36. https://doi.org/10.1080/13561820.2019.1676209.
145.Warwick-Giles, L, Checkland, K. Integrated care: Using ‘sensemaking’ to understand how organisations are working together to transform local health and social care services. J Health Organ Manag 2018; 32: 85–100. https://doi.org/10.1108/JHOM-03-2017-0057.
146.Edmondson, AC, Harvey, J-F. Cross-boundary teaming for innovation: Integrating research on teams and knowledge in organizations. Hum Resour Manag Rev 2018; 28: 347–60. https://doi.org/10.1016/j.hrmr.2017.03.002.
147.Øvretveit, J. Improvement leaders: What do they and should they do? A summary of a review of research. BMJ Qual Saf 2010; 19: 490–2. https://doi.org/10.1136/qshc.2010.041772.
148.Bate, P, Robert, G, Fulop, N, Øvretveit, J, Dixon-Woods, M. Perspectives on Context: A Selection of Essays Considering the Role of Context in Successful Quality Improvement. London: The Health Foundation; 2014. www.health.org.uk/publications/perspectives-on-context (accessed 22 May 2023).
149.Fulop, N, Robert, G. Context for Successful Quality Improvement. London: The Health Foundation; 2015. www.health.org.uk/publications/context-for-successful-quality-improvement (accessed 22 May 2023).
150.Nicolini, D, Waring, J, Mengis, J. Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap. Soc Sci Med 2011; 73: 217–25. https://doi.org/10.1016/j.socscimed.2011.05.010.
151.Smithson, R, Richardson, E, Roberts, J, et al. Impact of the Care Quality Commission on Provider Performance: Room for Improvement? London: The King’s Fund; 2018. www.kingsfund.org.uk/publications/impact-cqc-provider-performance (accessed 22 May 2023).
152.Steward, K. Exploring CQC’s Well-Led Domain: How Can Boards Ensure a Positive Organisational Culture. London: The King’s Fund; 2014. www.kingsfund.org.uk/sites/default/files/field/field_publication_file/exploring-cqcs-well-led-domain-kingsfund-nov14.pdf (accessed 22 May 2023).
153.Care Quality Commission. A New Strategy for the Changing World of Health and Social Care: Our Strategy from 2021. London: CQC; 2021. www.cqc.org.uk/sites/default/files/Our_strategy_from_2021.pdf (accessed 22 May 2023).
154.Rayner, M. The Care Quality Commission: A regulatory evolution. Judicial Rev 3 April 2022; 27(2): 126–31. https://doi.org/10.1080/10854681.2022.2111965.
155.Care Quality Commission. Single Assessment Framework. www.cqc.org.uk/about-us/how-we-will-regulate/single-assessment-framework (accessed 22 May 2023).
156.NHS England, NHS Improvement. NHS System Oversight Framework 2021/22. London: NHS England, NHS Improvement; 2021. www.england.nhs.uk/wp-content/uploads/2021/06/B0693-nhs-system-oversight-framework-2021-22.pdf (accessed 22 May 2023).
157.Barnett, RC, Weidenfeller, NK. Shared leadership and team performance. Adv Dev Hum Resour 2016; 18: 334–51. https://doi.org/10.1177/1523422316645885.
158.Ansell, C, Sørensen, E, Torfing, J. The COVID-19 pandemic as a game changer for public administration and leadership? The need for robust governance responses to turbulent problems. Publ Manag Rev 2021; 23: 949–60. https://doi.org/10.1080/14719037.2020.1820272.
159.Scognamiglio, F, Sancino, A, Caló, F, Jacklin‐Jarvis, C, Rees, J. The public sector and co‐creation in turbulent times: A systematic literature review on robust governance in the COVID‐19 emergency. Publ Admin 2 August 2022. www.ncbi.nlm.nih.gov/pmc/articles/PMC9350016/ (accessed 22 May 2023).
160.Mintz, LJ, Stoller, JK. A systematic review of physician leadership and emotional intelligence. J Grad Med Educ 2014; 6: 21–31. https://doi.org/10.4300/JGME-D-13-00012.1.
161.Marchal, B, Westhorp, G, Wong, G, et al. Realist RCTs of complex interventions: An oxymoron. Soc Sci Med 2013; 94: 124–8. https://doi.org/10.1016/j.socscimed.2013.06.025.
162.Moore, G, Audrey, S, Barker, M, et al. Process evaluation of complex interventions. BMJ 2015; 350: h1258. https://doi.org/10.1136/bmj.h1258.
163.Greenhalgh, T, Papoutsi, C. Studying complexity in health services research: Desperately seeking an overdue paradigm shift. BMC Med 2018; 16: 95. https://doi.org/10.1186/s12916-018-1089-4.
164.Fletcher, A, Jamal, F, Moore, G, et al. Realist complex intervention science: Applying realist principles across all phases of the Medical Research Council framework for developing and evaluating complex interventions. Evaluation 2016; 22: 286–303. https://doi.org/10.1177/1356389016652743.
165.Chambers, N, Smith, J, Proudlove, N, et al. Roles and behaviours of diligent and dynamic healthcare boards. Health Serv Manage Res 2020; 33: 96–108. https://doi.org/10.1177/0951484819887507.

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