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Volume 20 Supplement 2

Peer Teacher Training in health professional education

Open access
Published: 03 December 2020

Leadership in healthcare education

Christie van Diggele 1 , 2 ,
Annette Burgess 2 , 3 ,
Chris Roberts 2 , 3 &
Craig Mellis 4

BMC Medical Education volume 20 , Article number: 456 ( 2020 ) Cite this article

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Effective leadership is a complex and highly valued component of healthcare education, increasingly recognised as essential to the delivery of high standards of education, research and clinical practice. To meet the needs of healthcare in the twenty-first century, competent leaders will be increasingly important across all health professions, including allied health, nursing, pharmacy, dentistry, and medicine. Consequently, incorporation of leadership training and development should be part of all health professional curricula. A new type of leader is emerging: one who role models the balance between autonomy and accountability, emphasises teamwork, and focuses on improving patient outcomes. Healthcare education leaders are required to work effectively and collaboratively across discipline and organisational boundaries, where titles are not always linked to leadership roles. This paper briefly considers the current theories of leadership, and explores leadership skills and roles within the context of healthcare education.

Leadership has many interpretations, and has been likened to “ the abominable snowman whose footprints are everywhere but who is nowhere to be seen” [ 1 ]. It is an influential process, through which groups of people work towards the achievement of a common goal [ 2 ]. Leaders have the ability to shape and influence their followers’ values, attitudes and behaviours through a dyadic relationship. They are able to gain and enlist the support of others in order to achieve shared goals [ 3 , 4 ]. Effective leadership is a complex and highly valued component of healthcare education, increasingly recognised as essential to the delivery of high standards of education, research and clinical practice [ 3 ]. In order to achieve more effective outcomes, leadership and management skills are now an expectation and requirement in the healthcare education setting [ 5 ]. However, leaders within healthcare education should not rely on formal positions of authority, but instead, utilise their own appropriate leadership qualities irrespective of their level within the organisation [ 3 ]. A new type of leader is emerging: one who role models the balance between autonomy and accountability, emphasises teamwork, and focuses on improving patient outcomes [ 3 ]. This paper briefly considers the theories of leadership, and explores leadership skills and roles within the context of healthcare education.

Management versus leadership

Management and leadership are considered just as important as each other in accomplishing organisational goals. However, there are differences in the functions of the two roles. Management produces order and consistency, while leadership produces change and movement [ 2 ]. Management has the responsibility of organising all elements within the organisation, so that the leader’s vision and goals are successfully achieved. If poor management is in place, then goals cannot be achieved; and if poor leadership is in place, then there is no clear goal or vision to work towards. Leadership is seen as “setting direction, influencing others and managing change: with management concerned with the marshalling and organisation of resources and maintaining stability” [ 6 ]. These differences are summarised in Table 1 [ 6 , 7 ].

Transactional and transformational leadership

Leadership is a social construct, and there are many different leadership models [ 6 ]. Two broad types of leadership are identifiable: “transactional” and “transformational”. And their respective features are a useful way to think about the many types of leadership. Transactional and transformational leadership models are normally amalgamated within organisations to “empower others” (transformational) while holding individuals “accountable” (transactional) for their actions [ 7 , 8 , 9 ]. While it is clear that both transformational and transactional leadership paradigms are needed for an organisation to be effective, the optimal leader predominantly practices the transformational aspects of leadership, rather than transactional [ 10 ].

Transactional leadership

The transactional model is seen as an authoritative relationship that is transaction based, where exchanges occur between a leader and follower, once specific goals are identified or decided upon. Transactional leaders value order and structure, and have formal authority, with positions of responsibility within organisations. They achieve organisational goals through a rewards system and through positive reinforcement. A weakness of this model is the lack of innovation, as individuals are driven by predetermined outcomes, and there is lack of incentive and motivation to perform beyond what is expected [ 6 ].

Transformational leadership

Since the introduction of transformational leadership, the concept of leadership has undergone a major shift from representing an authoritative relationship (transactional), to a process of influencing individuals (transformational). Transformational leadership involves leadership through the transformation of individuals or ‘followers’, to work towards a common organisational goal [ 9 , 10 , 11 ]. This contemporary form of leadership is based on inspiring individuals, and forming teams to achieve goals. Transformational leaders define organisations through the articulation of a clear vision and clear values. The four “I”s of transformational leadership are outlined in Table 2 [ 9 ].

Team leadership

More recently, the focus has shifted towards “team leadership” , with distributed leadership becoming more prevalent within healthcare education, where different professions share influence [ 12 , 13 ]. Increasingly, leadership involves a collaborative role, with an emphasis on shared leadership and thoughtful allocation of responsibilities. Team-based organisations shift central control from the one leader, to the team. Teams are comprised of members who are interdependent, needing to coordinate their activities in order to accomplish their shared goals [ 14 , 15 ]. Personal autonomy, accountability, appropriate recognition, and clarity of roles, are all elements that contribute to optimal team performance. However, to ensure success, the organisational culture needs to support the involvement of individuals in these teams, and encourage leadership qualities [ 15 ]. Teams often fail when they exist in a traditional authority structure, where organisational culture is not supportive of collaborative work, and lower level decision making. Distributed leadership entails sharing of influence by team members, who step forward, or take a step back as needed. Leadership is provided by the person who meets the specific needs of the team at the time, hence providing faster responses to more complex issues in today’s organisations [ 15 , 16 , 17 ]. Effective leaders have an understanding of the conditions needed for teams to function well. For a team to achieve its potential, the operational roles of its members should be matched to their members’ abilities [ 18 ]. Belbin (1991) classified nine roles of team members that contribute to its process and function [ 19 ], outlined in Table 3 . Importantly, within team leadership, no single team role should be regarded as more important than another. Successful teams thrive on their diversity, drawing from the strengths of each member [ 13 ].

Effective leadership

Leaders need to have good time management and organisational skills, the ability to network professionally, display political nous and most importantly, they need to have strong communication skills [ 4 , 20 , 21 ]. Ready acceptance of feedback and self-awareness are important in development of leadership skills [ 20 , 21 ]. Behaviour, habits and biases can be deliberately corrected by utilising received feedback. Although there is not one set of qualities that apply to being an effective leader, certain competencies are valued and contribute to the leadership model in different ways [ 5 ]. Leadership competencies relevant for all health professional educators are outlined in Table 4 [ 3 ].

Language of leadership

Just as education and healthcare organisations have evolved, so too has the team leader. The role of the modern leader reinforces the tenets of stepping forward, collaborating and contributing. This role involves encouraging others by practising followership, and lending meaningful support to other leaders. As already stated, when it comes to leadership, excellent communication skills are a must. In order for successful communication to occur, both the sender and receiver must understand the message. This means that active listening is just as important as active talking [ 22 ]. Language used needs to be [ 22 ]:

Communicate with clarity of your purpose and the role of others

Stimulating

Deliver messages in a powerful, inspiring and dramatic way

Lead by example and walk the talk

Include active listening

Acknowledge what has been communicated, and use questioning skills

Show that you value others and their contributions

Challenges for leaders in healthcare education

There are a number of unique challenges in healthcare education. Healthcare education is delivered across professional disciplines, and notably, across organisational boundaries, involving universities, hospitals, and healthcare services. In turn, these organisations are bound by their own systems, structures, policies, cultures and values. At some point, most leaders in healthcare education need to make a decision about their leadership direction, and whether it lies predominantly in higher education or the clinical setting; and whether it lies in undergraduate education or postgraduate education. It can be difficult to merge roles between organisations, and McKimm (2004) has identified a number of issues and challenges specific to health education leaders, outlined in Table 5 [ 22 , 23 ]. Throughout a career, it may be necessary to maintain an awareness of available opportunities within organisations, and match these to the required experiences and capabilities [ 22 , 23 ] (see Fig. 1 ).

Reflection task

Development of leadership skills

Workforce data indicates that many experienced clinicians and healthcare educators will retire over the next ten years [ 24 , 25 ]. The need for effective succession planning and leadership training is well recognised [ 25 , 26 , 27 ], with a current shortage of emerging leaders moving into leadership roles. Effective leaders need to be nurtured and supported by the organisations in which they are educated, train and work [ 6 ]. As a learned skill, the topic of leadership is gathering momentum as a key curriculum area. Leadership development, assessment and feedback are necessary throughout the education and training of health professionals. Aspiring and current leaders can be identified, trained and assessed through formal leadership development programs, and through supportive organisational cultures. This requires embedding leadership training programs, opportunities for leadership practice, and promotion of professional networks within and beyond the organisation. The importance of mentorship within healthcare education is well recognised, offering a means to further enhance leadership and engagement within the workforce [ 28 ].

While many are assigned as leaders through their job title, it is important to identify, support and develop emerging leaders [ 2 ]. Leadership consists of a learnable set of practices and skills that can be developed by reading literature and attending leadership courses [ 29 ]. Additionally, investment in the social capital of organisations, fostering interprofessional learning and communication in the work setting, and collaboration across organisations assists in leadership development. Developing leadership skills is a life-long process [ 21 ]. Resources and opportunities should be considered to assist in the development of leadership skills. Some examples include:

Reading about leadership e.g. theories on leadership styles

Attending leadership training workshops

Participating in mentorship programs either as mentee or mentor

Joining small group seminars on leadership development

Accepting more responsibilities when required, or when opportunities arise.

Process for effective leadership

A title is not required to enable effective leadership. Leadership may occur in everyday work, and occurs in collaboration with other professionals within the education and healthcare systems. For example, leadership in teaching, administration, research, and/or excellence in clinical practice.

Leadership roles include the important concept of management of both personal and professional practice. Priorities need to be set and time managed to integrate work and personal life. Tools can be used to stay organised, and deliberately manage busy schedules. Effective delegation may be used to share the work of new projects:

Organisation to ensure an understanding of tasks, priorities and deadlines

Establish steps and a sequence to achieve the desired outcomes

List required resources, considering the competencies of individual team members, and match tasks appropriately (also consider skill development needs)

Communicate with team members, monitor progress in activities and provide guidance to team members.

Leadership competencies, and the incorporation of leadership development as part of curricula, are identified as important across all health professions, including allied health, nursing, pharmacy, dentistry, and medicine, in meeting the needs of healthcare in the twenty-first century [ 30 ]. With an increase in interprofessional teams and an emphasis on collaboration, more effective outcomes are achieved [ 5 ]. Healthcare education leaders are required to work effectively and collaboratively across discipline and organisational boundaries, where titles are not always linked to leadership roles, but may occur in everyday work. Good leadership also means knowing when, and how to support others in their endeavours. Provision of opportunities for leadership development is crucial in improving education sectors and health services, and effecting change. The future belongs to healthcare education leaders who demonstrate excellence in teamwork, clinical skills, patient centred care [ 3 ], and responsibly balance accountability with autonomy.

Take-home message

• Titles are not always linked to leadership roles.

• The role of today’s leader requires stepping forward, collaborating and contributing.

• A good leader is a good team player who values and seeks the opinions of others.

• Leadership requires clear, respectful communication that acknowledges the input and achievements of others.

Availability of data and materials

Not applicable.

Abbreviations

Human Resources

Bennis W, Nanus. Leaders: the strategies for taking charge. New York: Harper & Row; 1985.

Google Scholar

Northouse P. Leadership: theory and practice. 6th ed. London: Sage; 2011.

Oates K. The new clinical leader. J Paediatr Child Health. 2012;48(6):472–5.

Article Google Scholar

Laverack G. The pocket guide to health promotion. McGraw-Hill Education: Maidenhead; 2014.

Clarke J. In: Patole S, editor. Management and Leadership – A Guide for Clinical Professionals. Switzerland: Springer International Publishing; 2015.

Swanwick T, McKimm J. What is clinical leadership and why is it important. Clin Teach. 2011;8:22–6.

Byrman A. Leadership in organisations. In: Clegg SR, Harvey C, Nord WR, editors. Handbook of Organisational studies. London: Sage; 2006.

Westley F, Minztberg H. Visionary leadership and strategic management. Strateg Manag J. 1989;10:17–37.

Bass B, Avolio B. Improving Organisational effectiveness through transformational leadership. Thousand Oaks, CA: Sage; 1994.

Coulson A. The managerial work of Headteachers. Sheffield: Sheffield City Polytechnic; 1986.

Alimo-Metcalfe B, Alban-Metcalfe J. Leadership in public organisations. In: Storey, editor. Leadership in Organisations: current issues and key trends. London: Routledge; 2004.

McKimm J, Swanwick T. Educational leadership. Scotland, Edinburgh: Associate for the Study of Medical Education; 2007.

Levi D. Group dynamics for teams. Thousand Oaks, CA: Sage; 2011.

Burgess A, McGregor D, Mellis C. Applying guidelines in a systematic review of team-based learning in medical schools. Acad Med. 2014;89(4):678–88.

Pearce CL, Manz CC, Sims HP. Where do we go from here? Is shared leadership the key to team success? Orgnisational Dynamics. 2009;38(3):234–8.

Morgeson FP, DeRue DS, Karan EP. Leadership in teams: a functional approach to understanding leadership structures and processes. J Manag. 2010;36(1):5–39.

Kozlowski SWJ, Gully SM, Salas E, Cannon-Bowers JA. Team leadership and development: theory, principles, and guidelines for training leaders and teams. Dallas, TX: Third Symposium on Work Teams, University of North Texas; 1995.

Tuckman B. Developmental sequence in small groups. Psychol Bull. 1965;63:384–9.

Belbin RM. Management teams: why they succeed or fail. London: Heinmann; 1991.

Glover Takahshi S, Abbott C, Oswalk A, Frank JR. CanMEDS Teaching and Assessment Tools Guide. Royal College of Physicians and Surgeons of Canada; 2015.

Clawson J. Level three leadership: Getting below the surface (3rd ed.). Saddle River, N.J: Pearson Prentice Hall; 2006.

McKimm J. Developing tomorrow’s leaders in health and social care education. Case studies in leadership in medical and health care education. Special report 5. Newcastle-upon-Tyne: Higher Education Academy, Medicine Dentistry and Veterinary Medicine, 2004.

McKimm J, Swanwick T. Leadership development for clinicians: what are we trying to achieve? Clin Teach. 2011;8:181–5.

Norcini JJ, Banda SS. The global health workforce shortage: role of surgeons and other providers. Adv Surg. 2008;42:63–85.

Kim T. Succession planning in hospitals and association with organizational performance. Nurs Econ. 2012;30(1):14–20.

Swanwick T, McKimm J. Clinical leadership development requires system-wide interventions, not just courses. Clin Teach. 2012;9:89–93.

Matthews JH, Morley GL, Crossley E, Bhanderi S. Teaching leadership: the medical student society model. Clin Teach. 2017;15:2.

Burgess A, van Diggele C, Mellis C. Mentorship in the health professions: a review. Clin Teach. 2018;14:1–6.

Burgess A, Dornan T, Clarke A, Menezes A, Mellis C. Peer tutoring in a medical school: perceptions of tutors and tutees. BMC Medical Education. 2016;16:85.

Druker PF. What makes an effective executive? Harv Bus Rev. 2004;82(6):58–63 136.

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Leadership in Healthcare: A Review of the Evidence

In Healthmanagement
Mon, 11 May 2015

HealthManagement, Volume 15 - Issue 2, 2015

The delivery of clinical care is based on careful research to determine the most effective way of providing care for patients. At the same time the UK National Health Service (NHS) spends huge amounts on leadership development without a clear understanding of what kind of leadership and leadership development has most impact on patient outcomes.

The Leadership Task

The leadership task is to ensure direction, alignment and commitment within teams and organisations (Drath et al. 2008). Direction ensures agreement among people in relation to the organisation’s vision, values and strategy. Alignment refers to effective coordination of the work. Commitment is manifested by everyone in the organisation taking responsibility and making it a personal priority to ensure the success of the organisation as a whole, rather than focusing only on their individual or immediate team’s success in isolation.

Research Evidence

Despite thousands of publications on the topic of leadership in healthcare, a recent review (West et al. 2015) reveals relatively little research conducted to a high academic standard. In addition, much of what is written about leadership and much effort on leadership development in the NHS is based on fads and fashions rather than theory-driven evidence. Moreover, successive government reviews often fail to draw on the evidence base, only adding confusion via strong opinion to the vast body of writing on what constitutes good leadership in healthcare. The evidence is clear though: leadership at every level – from frontline leadership in wards, primary care and community mental health teams, to board leadership in trusts, to national leadership in overseeing bodies – is influential in determining organisational performance. The evidence points towards the need for what we call collective leadership. Collective leadership is characterised by shared leadership, where there is still a formal hierarchy, but power is more dependent on who has the expertise at each moment. Leadership is most effective w hen all staff, e specially doctors, nurses and other clinicians, accept responsibility for their leadership roles. Collective leadership is characterised by leaders working together to nurture a shared culture, adopting leadership styles that are consistent across the organisation, and cooperating and supporting each other across boundaries within the organisation to deliver continually improving, high quality and compassionate patient care.

We conducted a literature review across a large number of databases, including Business Source Complete (EBSCO), Web of Science, British Nursing Index (BNI), CINAHL (Cumulative Index to Nursing and Allied Health Literature), and JSTOR. We limited our search terms to articles published in the last 10 years, in English, and peer-reviewed. A separate review was conducted, which looked at the grey literature and trade press. Below, we briefly summarise some of the evidence we found from our review, in relation to key leadership groups.

Nurse Leaders

Nurses prefer managers who are participative, facilitative and emotionally intelligent, and such styles are in turn linked to team cohesion, lower stress, and higher empowerment and self-efficacy. Effective nurse leaders are characterised as flexible, collaborative, power-sharing, and as using personal values to promote high quality performance. Van Bogaert et al. (2010) examined the effects of nursing environments and burnout on job outcomes and quality of care. Nursing management was positively related to perceived quality of care and staff satisfaction in this study, while other studies found relationships with medication errors and staff levels of wellbeing, burnout and turnover intention. In their literature review Wong et al. (2013) also note a relationship between nurses’ relational leadership styles and lower levels of mortality rates and medication errors.

Katrinli et al. (2008) examined the quality of nurse managers’ relationships with their staff, nurses’ organisational identification, and whether job involvement mediated any relationship between these factors. When nurse leaders gave nurses opportunities for participation in decision-making, nurses reported high levels of organisational identification and job performance as a consequence. Empowerment of nurses to bring about quality improvement emerges from the literature as a possible key factor. Wong and Laschinger (2013) describe how authentic leadership can influence job satisfaction and outcomes through empowerment. Authentic leadership is characterised by honesty, altruism, kindness, fairness, accountability, and optimism; authenticity implies consistency with values of providing high quality and compassionate patient care.

Medical Leaders

In a large scale review of medical leadership models Dickinson et al. (2013) found that medical or clinical leadership varied across the case study sites they assessed. There were reported variations both between and within organisations in the extent to which doctors felt engaged in the work of their organisations. Those organisations with high levels of medical engagement performed better on available measures of organisational performance than others. In an earlier study Hamilton et al. (2008) found that in high-performing trusts, interviewees consistently identified higher levels of medical engagement. Additionally, Veronesi et al. (2013) examined strategic governance in NHS hospital trusts, and found that the greater the percentage of clinicians on governing boards the better the performance, patient satisfaction and morbidity rates (inversely) were.

Team Leaders in Healthcare

Effective team working is an essential factor for organisational success, frequently cited in the grey literature. The largest study to date used team member ratings of leadership in an NHS sample of 3,447 respondents. The results revealed that leadership clarity was associated with clear team objectives, high levels of participation, commitment to quality of care and support for innovation. Where there was conflict about leadership within the team, team processes and outcomes were poor. However, more recent metaanalyses of research consistently indicate that, across sectors, shared leadership in teams predicts team effectiveness (eg D’Innocenzo et al. 2014; Wang et al. 2014). These findings are not inconsistent, because having a clearly designated team leader may be associated with less conflict over leadership and as a consequence the enhanced ability of team members to smoothly assume leadership roles and responsibilities when their expertise is relevant.

Organisational Leaders

In one of the few studies examining the relationship between leadership and organisational outcomes in healthcare, Shipton et al. (2008) investigated the impact of leadership and climate for high quality care on hospital performance. The research revealed that top management team leadership predicted the performance of hospitals. Specifically, top management team leadership was strongly and positively associated with clinical governance review ratings, hospital ‘star’ ratings, and significantly lower levels of patient complaints.

Leadership, Culture and Climate in Healthcare

In the largest study of culture in the English National Health Service (NHS), Dixon-Woods et al. (2014) concluded that six key elements were necessary for sustaining cultures that ensure high quality, compassionate care for patients: inspiring visions operationalised at every level by leaders; leaders ensuring clear aligned objectives for all teams, departments and individual staff; supportive and enabling people management; high levels of staff engagement; leaders focused on ensuring learning, innovation and quality improvement in the practice of all staff; and effective team working.

Another large scale, longitudinal study, involving all 390 NHS organisations in England, identified a link between aspects of climate (eg working in wellstructured team environments, support from immediate managers, opportunities for contributing toward improvements at work) and a variety of indicators of healthcare organisation performance (West et al. 2011). Climate scores were linked to outcomes such as patient mortality, patient satisfaction, staff absenteeism, turnover intentions, quality of patient care and financial performance. The results revealed (among many other relevant relationships) that patient satisfaction was highest in organisations that had clear goals, and whose staff saw their leaders in a positive light. Staff satisfaction was directly related to subsequent patient satisfaction.

Leader and Leadership Development

Leader and leadership development are vital for healthcare, with considerable resources dedicated from budgets always under great pressure. In the UK, NHS England has invested many tens of millions of pounds through the NHS Leadership Academy in order to increase leadership capabilities across the NHS. Summative figures for local and regional investment are lacking, but estimates are between 20 and 29 percent of an organisation’s training and development budget is dedicated to leadership development.

One approach relies on the definition of leadership competencies. Numerous competency frameworks, competency libraries and assessments are available off-the-shelf, and organisations have been using them for many years to map the leadership competencies required for the success of their organisations. The UK NHS competency orientation derives from the multiple and overlapping competency frameworks and career structures developed over recent years. A wide range of programmes based on these competency models have been delivered, and varied instruments are used to underpin these competency frameworks, with the majority having, at best, poor psychometric properties and unclear theoretical underpinnings. Consequently there is little evidence that the use of these competency frameworks translates into improved leader effectiveness or evidence about which framework is most appropriate. The research literature on leadership generally does not yet show that competency frameworks are potent in enabling leaders to improve their effectiveness.

Evidence of the effectiveness of leader development in healthcare mainly derives from research with medical and other clinical leaders. One-off programmes generally do not provide the sustained support and continual improvement in leadership training likely to be necessary to ensure impact on key outcomes, such as quality of care. However, there are examples of more successful programmes from within the NHS such as the Royal College of Nursing Clinical Leadership Programme (CLP), which has been offered since 1995, and which has been shown as successful in improving nurses’ transformational leadership competencies. There is no evidence of benefits to patient care, however.

In comparison with the focus on leader development, leadership development – the development of the capacity of groups and organisations for leadership as a shared and collective process – is far less well explored and researched. However, as previously noted much of the available evidence, particularly in the NHS, highlights the importance of collective leadership, and advocates a balance between individual skill-enhancement and organisational capacity building. Research evidence suggests the value of this, particularly at team level: meta analyses demonstrate that shared leadership in teams predicts team effectiveness, particularly, but not exclusively, within healthcare.

The need for leadership cooperation across boundaries is not only intra organisational. Health and social care services must be integrated in order to meet the needs of patients, service users and communities both efficiently and effectively. Healthcare has to be delivered increasingly by an interdependent network of organisations. This requires that leaders work together, spanning organisational boundaries both within and between organisations, prioritising overall patient care rather than the success of their component of it. That means leaders working collectively and building a cooperative, integrative leadership culture – in effect collective leadership at the system level.

The implication of this new understanding of leadership is that our approach to leader and leadership development is distorted by a preoccupation with individual leader development (important though it is), often provided by external providers in remote locations. Developing collective leadership for an organisation depends crucially on context and is likely to be best done ‘in house’ with expert support, highlighting the important contribution of Organisation Development and not just Leader Development.

Evidence-based approaches to leadership development in healthcare are needed to ensure a return on the huge investments made. It remains true that experience in leadership is demonstrably the most valuable factor in enabling leaders to develop their skills, especially when they have appropriate guidance and support. Focusing on how to enhance such learning from experience should also be a priority.

National Level Leadership

National level leadership plays a major role in influencing the cultures of NHSorganisations. Many reports have called for the bodies that provide national leadership to develop a single integrated approach, characterised by a consistency of vision, values, processes and demands. The approach of national leadership bodies is most effective when it is supportive, developmental, appreciative and sustained; when health service organisations are seen as partners in developing health services; and when health service organisations are supported and enabled to deliver ever improving high quality patient care. The cultures of these national organisations should be collective models of leadership and compassion for the entire service.

Conclusions

The key challenge facing all NHS organisations is to nurture cultures that ensure the delivery of continuously improving high quality, safe and compassionate care. Leadership is the most influential factor in shaping organisational culture, so ensuring the necessary leadership behaviours, strategies and qualities are developed is fundamental. There is clear evidence of the link between leadership and a range of important outcomes within health services. The challenges that face healthcare organisations are too great and too many for leadership to be left to chance, to fads and fashions or to piecemeal approaches. This review suggests that approaches to developing leaders, leadership and leadership strategy can and should be based on robust theory with strong empirical support and evidence of what works in healthcare. Healthcare organisations can confidently face the future and deliver the high quality, compassionate care that is their mission by developing and implementing leadership strategies that will deliver the cultures they require to meet the healthcare needs of the populations they serve.

Leadership in NHS organisations needs to ensure direction, alignment and commitment to the core task of developing cultures that deliver continually improving, high-qualit y and compassionate patient care.
Leaders need to wor k together, spanning boundaries within and between organisations, prioritisingoverall patient care rather than the success of individual components, and to build a cooperative, integrative leadership culture – in ef fect collective leadership.
Developing collective leadership for an organisation depends crucially on local contexts and is likely to be done best ‘in house’ with exper t suppor t , integrating both organisational development and leadership development .
Evidence-based approaches to leadership development in healthcare are needed to ensure a return on the huge investments made.

References:

Dickinson H, Ham C, Snelling I et al. (2013). Are we there yet ? Models of medical leadership and their effectiveness: An exploratory study. Final report. NIHR Service Delivery and Organisation programme. [Accessed: 7 April 2015] Available from http://www.netscc.ac.uk/hsdr/files/project/SDO_FR_08-1808-236_V07.pdf

D’Innocenzo L, Mathieu JE, Kukenberger MR (2014) A meta-analysis of different forms of shared leadership–team performance relations. Journal of Management 0149206314525205, doi:10.1177/0149206314525205.

Dixon-Woods M, Baker R, Charles K et al. (2014) Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Qual Saf, 23(2): 106-15.

Drath WH, McCauley CD, Palus CJ et al. (2008) Direction, alignment, commitment: Toward a more integrative ontology of leadership. The Leadership Quarterly, 19(6): 635-53.

Hamilton P, Abraham R, Bamford C et al. (2008) Engaging doctors: can doctors influence organisational performance. Coventry: NHS Institute for Innovation and Improvement. [Accessed: 7 April 2015] Available from http://www.institute.nhs.uk/images//documents/BuildingCapability/Medical_Leadership/49794_Engaging_Doctors.pdf

Katrinli A, Atabay G, Gunay G et al. (2008) Leadermember exchange, organizational identification and the mediating role of job involvement for nurses.Journal Adv Nurs, 64(4): 352-62.

Shipton H, Armstrong C, West M et al. (2008) The impact of leadership and quality climate on hospital performance. Int J Qual Health Care, 20(6): 439–45.

Van Bogaert P, Kowalski C, Weeks SM et al. (2013) Impacts of unit-level nurse practice environment, workload and burnout on nurse-reported outcomes in psychiatric hospitals: a multilevel modelling approach. Int J Nurs Stud, 50(3): 357–65.

Veronesi G, Kirkpatrick I, Vallascas F (2013) Clinicians on the board: what difference does it make? Soc Sci Med, 77: 147-55.

Wang D, Waldman DA, Zhang Z (2014) A meta-analysis of shared leadership and team effectiveness. J Appl Psychol, 99(2): 181–98.

West M, Armit K, Lowenthal L et al. (2015) Leadership and leadership development in health care: the evidence base. [Accessed: 7 April 2015] Available from http://www.kingsfund.org.uk/publications/leadership-and-leadership-developmenthealth-care

West M, Dawson J, Admasachew L et al. (2011) NHS staff management and health service quality: results from the NHS staff survey and related data. [Accessed: 7 April 2015] Available from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215455/dh_129656.pdf

Wong C, Cummings GG, Ducharme L (2013) The relationship between nursing leadership and patient outcomes: a systematic review update. J Nurs Manag, 21(5): 709–24.

Wong CA, Laschinger HK (2013) Authentic leadership, performance, and job satisfaction: the mediating role of empowerment. J Adv Nurs, 69(4): 947–59.

Prof. Michael West

Thomas West

Latest articles, most regrettable business decisions.

Journal Article

Regrettable healthcare management decisions—errors, missed opportunities, and resource allocation pitfalls—can be profoundly costly and impactful. The ripple effects of such missteps can strain operational efficiency, compromise patient care, and erode the essential trust that underpins the re

Why Do So Many Healthcare Innovation Initiatives Fail?

Successful healthcare innovation requires more than technical and clinical expertise; it demands a deep understanding of the ecosystem, including regulatory requirements, reimbursement systems, and organisational dynamics. Embracing a holistic approach, fostering continuous feedback, and enga

How Cultural Differences Can Make or Break Mergers and Acquisitions

Organisational culture has a pivotal impact on M&A success. Neglecting cultural differences can lead to reduced productivity, operational hurdles, and strategic misalignments. Proactive strategies like cultural assessments and effective communication foster integration and enhance overal

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Communication and leadership in healthcare quality governance

Affiliation.

1 School of Business, University of New South Wales, Canberra, Australian Capital Territory, Australia.
PMID: 32239875
DOI: 10.1108/JHOM-07-2019-0194

Purpose: The importance of hospital board engagement in the work of governing healthcare quality has been demonstrated in the literature. Research into influences on effective corporate governance has traditionally focused on board architecture. Emerging research is bringing to light the importance of governance dynamics. This paper contributes to emerging research through highlighting how communication and leadership underpin effective engagement in governing healthcare quality.

Design/methodology/approach: A comparative case study of eight Australian public hospitals was undertaken involving document review, interviews and observations. Case studies were allocated into high- or low-engagement categories based on evidence of governance processes being undertaken, in order to compare and contrast influencing factors. Thematic analysis was undertaken to explore how communication and leadership influence healthcare governance.

Findings: Several key components of communication and leadership are shown to influence healthcare quality governance. Clear logical narratives in reporting, open communication, effective questioning and challenge from board members are important elements of communication found to influence engagement. Leadership that has a focus on healthcare excellence and quality improvement are aligned and promote effective meeting processes is also found to foster governance engagement. Effective engagement in these communication and leadership processes facilitate valuable reflexivity at the governance level.

Practical implications: The findings highlight the way in which boards and senior managers can strengthen governance effectiveness through attention to key aspects of communication and leadership.

Originality/value: The case study approach allows the exploration of communication and leadership in greater depth than previously undertaken at the corporate governance level in the healthcare setting.

Keywords: Clinical governance; Communication; Governance; Healthcare; Leadership; Quality healthcare.

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Health Care Strategy

Understand business strategy to facilitate health care success.

In this course, Harvard Business School faculty teach learners to align business strategy with the challenges and structures of the health care industry in the United States.

What You'll Learn

What can business strategy teach us about health care innovation in the United States? Why is a strategic vision important to implement in health care organizations? How do health care providers and institutions create value — and, more importantly, how do they capture value?

When you think of health care organizations, do the terms sustainable advantage or strategic differentiation come to mind? In an industry with increasing competition and innovation, leaders of U.S. health care organizations, and those delivering care, need to understand how their success depends on these key principles. This includes understanding health care business strategy and market development, the forces that make it easy or difficult to capture value, and how you can successfully compete against rivals. You must go beyond creating value to develop the critical thinking and analytical skills to develop a health care business strategy which will allow you to evaluate the needs of your business, optimize business decisions, and develop new or innovative health care ventures.

Balancing the needs of multiple parties—patients, purchasers, and providers—can be daunting and many decision makers struggle to meet the growing demands of an evolving industry. By exploring different health care business models through real-world case studies, you will step into the shoes of business leaders and learn to face these problems directly, identifying both opportunities and challenges, to derive actionable insights for your own business. Further, you will use economic and policy frameworks to seek ways to improve efficiency in the health care sector, particularly as it relates to spending.

This online health care management course is primarily focused on U.S. health care and institutions; however, the business strategies and principles can be applied broadly in health care settings around the world to identify sources of competitive advantage.

Led by Harvard Business School professor Leemore Dafny, Health Care Strategy will help you align the principles of business strategy with the unique challenges and structures of U.S. health care organizations. The course is fundamental to health care executive education will enable you to define the mission of your organization, develop a strategy to create and capture value, and lead your organization to success with confidence.

Combine the best business strategies with the fundamentals of the health care sector in the United States.

The Harvard Medical School is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been approved for 24 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Upon successful completion of the course, participants will have access to claim their credits through the Harvard Medical School’s continuing education platform.

The course is part of the Health Care Leadership Learning Path and will be delivered via HBS Online’s course platform . Learners will be immersed in real-world examples from experts at industry-leading organizations. By the end of the course, participants will be able to:

Understand core business, economic, and policy principles and how they apply to the health care sector in the U.S.
Apply the building blocks for creating a strategy: industry analysis, sustainable advantage, and developing a plan to sustain profits in the face of competition
Appreciate the perspectives of key health care stakeholders, improving business decision making and analysis skills
Develop a framework using the health care business strategies applied in the course that can be used to advance your organization and career
Evaluate the intersection of strategy and develop firm boundaries to make better build versus buy decisions
Align incentives of the health care chain and where their organization fits in the industry, focusing on specialized services or approaches to gain market share

Your Instructor

Leemore Dafny is the Bruce V. Rauner Professor of Business Administration at the Harvard Business School, where she teaches courses in healthcare strategy and co-directs to PhD Program in Business Economics. Professor Dafny also serves on the faculties of the John F. Kennedy School of Government and the interdisciplinary Program in Health Policy.

Who Will Benefit

Rising Managers

Grow your career and explore various strategies from the perspective of clinical providers, payer organizations, and purchasers.

Clinical and Administrative Leaders

Learn the fundamentals of strategy, including value creation and capture, competitive analysis, and organizational structure and definition.

Health Care Executives

With or without clinical experience, better understand how the health care ecosystem within your organization operates and learn how to define a successful business strategy.

Learner Experience

"The course completely fulfilled all I wanted to learn about the health care industry in the United States. I would highly recommend it to anyone starting out in the health care industry as a business leader. I particularly enjoyed the case studies because it gave real world application examples of how business is done. I also learned about pioneers that I was able to discuss with my manager at work."

Tracy Lyn De Silva Consultant CWH Advisors

The majority of Health Care Strategy learners who participated in our post-course survey report:

They can immediately apply their learnings to upcoming projects or projects that they are currently working on.
The most valuable aspect of the course to be the perspectives from industry leaders and Professor Leemore Dafny.
They are likely to recommend this course to a colleague friend.

"I enjoyed the style of presentation for this online course, which was a combination of case studies and brief video discussions in the context of highly selected rich educational materials. The questions asked for discussions and peer-engagement platform helped the course look like a live lecture, while participants benefit from the comfort of their personalized schedules. I not only recommend Harvard Online courses to my friends and colleagues, but also look forward to future opportunities to joining other courses ."

Payam Tarighi Lead Data Analyst Sunnybrook Health Sciences Centre

"It is super valuable to see health care from another perspective other than clinically, and to realize that clinical and financial goals can align with the right people working together."

Holly D. Health Care Strategy Learner

"I thought this was a n amazing course with extremely relevant content . Coming from the clinical support and product development side of medical device startup companies, this course really opened my eyes to some of the decisions that the c-suite individuals would make on the business side. A lot of things were brought to light from this course and I will continue to review the content until I no longer am able. It was also very nice to hear people from the industry speak to how they put these practices into play in the business world."

Michael Adams Product Specialist Aesculap, Inc.

“This course was extremely significant in my learning about healthcare business industry standards , expectations, and ways to implement to healthcare strategy into a consulting role, which is what I am moving into. This course sets a phenomenal foundation in to my professional pivot into this role.”

Jane Canter Nurse Care Coordination

"I already had some theoretical and practical knowledge of the topics covered in the course. However, the way the content is given throughout the course and the participation stimulated by the methodology, expanded my knowledge and my vision on the subject. Real cases are very good for understanding and learning the topics. A real feast."

Adelino de Melo Freire Jr. Medical Director Target Medicina de Precisão

"If you are looking to learn the basic dynamics of the health care industry as well as understand how to define a strategy to be successful in improving patient outcomes and reducing overall health care costs, then this is the class for you."

Joshua M. Health Care Strategy Learner

Available Discounts and Benefits for Groups and Individuals

Experience Harvard Online by utilizing our wide variety of discount programs for individuals and groups.

Past participant discounts.

Learners who have enrolled in at least one qualifying Harvard Online program hosted on the HBS Online platform are eligible to receive a 30% discount on this course, regardless of completion or certificate status in the first purchased program. Past Participant Discounts are automatically applied to the Program Fee upon time of payment. Learn more here .

Learners who have earned a verified certificate for a HarvardX course hosted on the edX platform are eligible to receive a 30% discount on this course using a discount code. Discounts are not available after you've submitted payment, so if you think you are eligible for a discount on a registration, please check your email for a code or contact us .

Nonprofit, Government, Military, and Education Discounts

For this course we offer a 30% discount for learners who work in the nonprofit, government, military, or education fields.

Eligibility is determined by a prospective learner’s email address, ending in .org, .gov, .mil, or .edu. Interested learners can apply below for the discount and, if eligible, will receive a promo code to enter when completing payment information to enroll in a Harvard Online program. Click here to apply for these discounts.

Gather your team to experience Health Care Strategy and other Harvard Online courses to enjoy the benefits of learning together:

Single invoicing for groups of 10 or more
Tiered discounts and pricing available with up to 50% off
Growth reports on your team's progress
Flexible course and partnership plans

Learn more and enroll your team !

Real World Case Studies

Affiliations are listed for identification purposes only.

Beth Zoneraich

Beth Zoneraich is the CEO of a health care fertility organization, however did not begin her career in the health care industry. Explore how business analysis aided her in entering the health care business.

Kevin Tabb is the CEO of Beth Israel Lahey Health, a system of academic and teaching hospitals in Massachsetts. He will share his first hand experience on how business strategy is affecting the health care industry

Dr. Jorge Plutzky

Dr. Jorge Plutzky is the Director of The Vascular Disease Prevention Program and on faculty at Harvard Medical School. As an expert on capturing value in competitive health care markets, he will describe his methods and strategies.

Syllabus and Upcoming Calendars

Health Care Strategy features authentic business examples, interactive lessons, and conversations with industry experts. This course will help you align the principles of business strategy with the unique challenges and structures of health care organizations, enabling you to create and capture value for your organization, and lead your organization to sustainability.

Learning requirements: There are no prerequisites to enroll in this course. To earn a Certificate of Completion from Harvard Online, participants must thoughtfully complete modules 1-4, including satisfactory completion of the associated quizzes, by stated deadlines.

Download Full Syllabus

Download March 2024 Calendar

Study the Statins case on creating and capturing value by selling products.
Study the Livongo case on creating and capturing value by selling a complex service.
Apply a framework that illustrates value creation and value capture.
Determine how much value a seller can capture by considering the competitive environment and the value created for different stakeholders.
Study the Advanced Fertility Care case on assessing industry attractiveness.
Study the Oak Street Health case on positioning within an industry to achieve sustainable success.
Perform a "five forces” analysis.
Assess the strength of different forces in different industries.
Evaluate the tradeoffs made by an entrant in elder care, and how this informs their decisions about growth.
Study the Choose and Book case on choice and competition in the British National Health Service .
Study the Geisinger Health case on expanding the market.
Study the Surgical Institute of Reading case on when regulators step in.
Evaluate the results of a “natural experiment” involving the NHS.
Assess opportunities provided by destination medicine for both providers and employers.
Analyze business and regulatory moves that reduce and enhance competition in different markets.
Study the Consolidation in Eastern Massachusetts case on expanding to defeat or enhance competition.
Study the Civica Rx case on a novel solution to a long-term problem.
Dissect an organization’s decision to vertically integrate.
Assess the effects of vertical integration on pricing, under different assumptions.
Examine the effects of provider- insurer integration on competition, prices, and access for patients.

Earn Your Certificate

Enroll today in Harvard Online's Health Care Strategy course.

Still Have Questions?

What are the learning requirements? How do I list my certificate on my resume? Learn the answers to these and more in our FAQs.

Related Courses

Health care economics.

Taught by Harvard Medical School faculty, this course provides insights into the interactions between industries in the US health care sector and teaches what economic forces are shaping health care.

Digital Health

Digital technologies and big data offer tremendous opportunities to improve health care.

Innovations in Teamwork for Health Care

In this course, experts from Harvard Business School and the T.H. Chan School of Public Health teach learners to implement a strategy for organizational teamwork in health care.

Related Blogs and Learner Resources

How to earn cme credits with harvard online courses on health.

Harvard University faculty guide you through topics with a focus on the current state of the US health care system and how you can apply innovative approaches to make improvements within your organization.

The Business of Health Care in the United States

The business of health care in the United States is complicated. How can we ensure that patients have access to care while still adopting important, life-saving innovations that have the potential to improve health and health care?

U.S. Health Care Spending: Myths, Facts, and Strategies

A discussion on the current state of health care spending in the United States with Harvard Professors Leemore Dafny and Michael Chernew.

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“Case Studies in Healthcare: Success Stories and Lessons Learned”

The healthcare industry is an ever-evolving field with innovations and improvements happening daily. As healthcare providers strive to deliver the best care possible, case studies have become a valuable resource for learning and growth. In this article, we will explore various case studies in healthcare, highlighting both success stories and the lessons learned along the way. By analyzing what works and why, we can gain insight into the practices that lead to triumphs in healthcare and potentially replicate these successes in our own organizations.

Case Studies in Healthcare: A Closer Look at Triumphs and Takeaways

Healthcare case studies provide a unique opportunity to dissect real-world scenarios, understand the decisions made, and measure the outcomes of those choices. One notable success story is the implementation of telemedicine in rural areas. By leveraging technology, healthcare providers have successfully expanded access to care for patients who would otherwise have to travel long distances for treatment. Lessons learned include the importance of investing in reliable technology and training staff to effectively use telemedicine platforms.

Another critical case study involves the management of electronic health records (EHRs). When a large hospital system transitioned to a new EHR system, they faced significant resistance from physicians who were accustomed to the old way of doing things. However, by involving physicians in the planning and implementation process, the hospital successfully integrated the new system, leading to improved efficiency and patient care. This case study highlights the value of stakeholder engagement and effective change management.

In the fight against infectious diseases, case studies have shown the significance of swift and coordinated responses. An example of this is the containment of Ebola in West Africa. Through international collaboration and the rapid deployment of healthcare resources, the spread of the virus was effectively limited. This case study underscores the importance of preparedness, communication, and teamwork in tackling healthcare crises.

Success Stories in Healthcare: Analyzing What Works and Why

Understanding why certain strategies succeed is crucial for replicating positive results in the healthcare industry. For instance, one hospital’s initiative to reduce patient readmissions focused on comprehensive discharge planning and follow-up care. By ensuring patients had clear instructions and support after leaving the hospital, readmission rates dropped significantly. This case study emphasizes the role of thorough patient education and post-discharge care in improving outcomes.

In the realm of preventive care, a primary care clinic introduced a program to increase vaccination rates among its patient population. By actively reaching out to patients due for immunizations and offering flexible scheduling options, the clinic saw a dramatic increase in vaccination rates. The takeaway from this case study is the impact of proactive patient engagement and removing barriers to care.

Lastly, a healthcare organization’s embrace of continuous quality improvement (CQI) led to enhanced patient safety and satisfaction. By fostering a culture of open communication and ongoing learning, the organization identified areas for improvement and systematically implemented changes. This case study demonstrates the power of a commitment to CQI as a driver for excellence in healthcare.

The healthcare industry is rich with case studies that provide valuable insights and lessons learned. By analyzing and understanding these success stories, healthcare providers can apply similar strategies to achieve positive outcomes in their own organizations. Whether it’s through technology, stakeholder engagement, or quality improvement initiatives, these case studies offer a blueprint for triumph and provide a roadmap for future success in the ever-changing landscape of healthcare.

Why are case studies valuable in the healthcare industry, and how do they provide insights into successful decision-making and problem-solving within healthcare organizations?

Case studies are valuable as they offer real-world examples of challenges and solutions in healthcare. They provide insights into successful decision-making, problem-solving, and strategies that can be applied by healthcare professionals and organizations facing similar scenarios.

How does the article select and present case studies, and what criteria are considered to ensure the relevance and applicability of the showcased success stories to a diverse audience?

The article discusses the criteria for selecting case studies, such as their impact on healthcare outcomes, innovation, or overcoming significant challenges. It highlights the diversity of cases to ensure relevance to a broad audience, considering different healthcare settings, specialties, and contexts.

Can you provide examples of healthcare case studies featured in the article, and how do these stories illustrate successful decision-making or lessons learned that can benefit readers in the healthcare field?

Certainly! Examples may include cases where innovative technologies improved patient outcomes, or instances where strategic decisions enhanced operational efficiency. The article presents these stories to illustrate valuable lessons learned and best practices that readers can apply in their own healthcare settings.

In what ways do case studies contribute to professional development and learning opportunities for healthcare professionals, and how can organizations leverage these stories for continuous improvement and staff training?

The article explores how case studies offer learning opportunities, allowing healthcare professionals to gain insights from others’ experiences. Organizations can leverage these stories for staff training, fostering a culture of continuous improvement and encouraging employees to apply lessons learned to their daily practices.

For healthcare leaders seeking to implement successful strategies within their organizations, what recommendations and actionable insights does the article provide based on the analysis of the showcased case studies?

The article offers recommendations based on the case studies, such as the importance of collaboration, data-driven decision-making, and embracing innovation. It provides actionable insights that healthcare leaders can use to inform their decision-making processes and drive positive outcomes within their organizations.

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HAP Summer Sale - Order any book now through September 16 and receive a 20% discount off the member and non-member price when you use the promo code SUMMER24 at checkout. This discount excludes any multi-book sets that are already discounted and the Board of Governors Exam flashcards.

Essentials of Healthcare Management: Cases, Concepts, and Skills, Second Edition

Leigh cellucci, phd, mba michael r. meacham, jd, mph tracy j. farnsworth, edd, mba, mhsa.

Member Price: $73.50
Non Member Price: $105.00

Book Description

A Brief History of the Development of Healthcare in America
Health Policy: Cost, Quality, and Access
The Healthcare System Today
Medical and Healthcare Environments
Table of Contents (PDF)
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Transition Guide
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The Future of Healthcare: Global Trends Worth Watching

Principles of Healthcare Leadership

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Published: 28 July 2024

A rapid realist review on leadership and career advancement interventions for women in healthcare

Doreen Mucheru 1 ,
Eilish McAuliffe 1 ,
Anosisye Kesale 2 &
Brynne Gilmore 1

BMC Health Services Research volume 24 , Article number: 856 ( 2024 ) Cite this article

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Women represent 70% of the global health workforce but only occupy 25% of health and social care leadership positions. Gender-based stereotypes, discrimination, family responsibilities, and self-perceived deficiencies in efficacy and confidence inhibit the seniority and leadership of women. The leadership inequality is often compounded by the intersection of race and socio-economic identities. Resolving gender inequalities in healthcare leadership brings women’s expertise to healthcare decision making, which can lead to equity of healthcare access and improve healthcare services. With the aim of enhancing women’s advancement to leadership positions, a rapid realist review (RRR) was conducted to identify the leadership and career advancement interventions that work for women in healthcare, why these interventions are effective, for whom they are effective, and within which contexts these interventions work. A RRR ultimately articulates this knowledge through a theory describing an intervention’s generative causation. The Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) for conducting a realist synthesis guided the methodology. Preliminary theories on leadership and career advancement interventions for women in healthcare were constructed based on an appraisal of key reviews and consultation with an expert panel, which guided the systematic searching and initial theory refinement. Following the literature search, 22 studies met inclusion criteria and underwent data extraction. The review process and consultation with the expert panel yielded nine final programme theories. Theories on programmes which enhanced leadership outcomes among women in health services or professional associations centred on organisational and management involvement; mentorship of women; delivering leadership education; and development of key leadership skills. The success of these strategies was facilitated by accommodating programme environments, adequacy and relevance of support provided and programme accessibility. The relationship between underlying intervention entities, stakeholder responses, contexts and leadership outcomes, provides a basis for underpinning the design for leadership and career advancement interventions for women in healthcare.

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“Healthcare is delivered by women but led by men”— women are grossly underrepresented in leadership relative to their participation in the health workforce [ 1 ]. They represent 70% of the global healthcare workforce and 59% of medical, biomedical and health science degree holders [ 1 , 2 ]. Nonetheless, women only occupy 25% of health and social care leadership positions [ 3 ]. Moreover, women typically assume lower-status and lower-paying jobs in health and social care [ 1 ]. Gender-based stereotypes and discrimination inhibit the leadership and seniority of women, which may be compounded by intersection with race and socio-economic identities [ 1 ]. These inequalities reduce career satisfaction, morale and lifetime income among women [ 1 ].

Gender inequality is a pressing human right and socioeconomic issue with downstream outcomes such as poorer health among women [ 1 , 3 ]. Addressing gender inequalities may increase the number of role models and mentors for women [ 1 , 3 ]. Women role models and mentors influence career advancement as they can advise on balancing career and family and counsel on career progression opportunities [ 4 ]. Instituting women leaders may also improve the attitude towards their leadership, and enhance identification of leadership with women peers [ 5 ]. The presence of women leaders creates a platform for greater emphasis on issues that impact women and girls such as sexual and reproductive health [ 1 , 3 ]. Projections from the World Health Organization (WHO) Gender Equity Hub of the Global Health Workforce Network indicate that addressing gender inequalities will accelerate the attainment of Universal Health Coverage (UHC) and Sustainable Development Goal (SDG) targets [ 1 ]. Progression towards gender parity will also fuel economic growth, and has been estimated as translating to a global gross domestic product increase of US$12 trillion within a decade [ 6 ]. More broadly, increasing opportunity for the participation of women is an investment towards organisational success, national prosperity, and quality of life [ 2 ].

Extant literature in the field of gender and leadership primarily focuses on barriers that hinder the uptake of leadership positions among women, with a smaller subset focusing on potentially effective strategies to advance women’s leadership [ 2 , 7 , 8 , 9 , 10 , 11 , 12 , 13 ]. Barriers that inhibit women’s leadership include decreased capacity owing to career disruption and family responsibilities, unfavourable credibility assumptions, and perceived deficiencies in self-efficacy and confidence [ 2 ]. The literature on interventions which advance women’s leadership highlights that these interventions engender career advancement among women, promote knowledge and skill acquisition, enhance wellbeing and morale, encourage staff retention, augment remuneration, and progress organisational culture and practices towards gender equity [ 2 , 7 , 8 , 9 , 10 , 11 , 12 , 13 ].

Systematic reviews and literature summaries on this topic exhibit certain oversights, such as insufficient description of primary studies, inadequate focus on research in the healthcare context, and lack of a standardised approach in evaluating the research [ 2 , 7 , 8 , 9 , 10 , 11 , 12 , 13 ]. Further limitations are that many studies focus on single intervention strategies (i.e., mentoring, networking), insufficiently describe intervention components, use variable terminology to define similar intervention concepts, have poor methodological rigour, display wide heterogeneity in outcomes measured, and exhibit missing process evaluations [ 2 , 7 , 8 , 9 , 10 , 11 , 12 , 13 ]. Moreover, there is little to no research in low and middle-income contexts (LMICs) and a paucity of system-based or culture focused interventions [ 2 , 7 , 8 , 9 , 10 , 11 , 12 , 13 ].

With these limitations in mind, evidence synthesis on leadership and career advancement interventions for women needs to examine why certain programmes are more or less likely to work in certain ways, for specific people and in particular circumstances through contributing to theory [ 14 ]. A theory is transferable and applicable across a range of circumstances [ 14 ]. The links between interventions, contexts in which these interventions are implemented, participant responses to interventions, and outcomes of interventions are not evident in the existing literature [ 14 ]. This gap is consequential to the design of reviews that do not provide insight on how programmes work and how this may change based on settings or circumstances of key actors [ 14 ].

Establishing evidence-based programme theories on women’s leadership and career advancement interventions, especially, for healthcare workers is relevant for global and national policy [ 15 , 16 ]. Gender equality is an objective and driver for attaining the United Nation’s Sustainable Development Goals [ 15 ]. Accordingly, the aim of our research is to identify what leadership and career advancement interventions work for women in healthcare, why exactly these interventions are effective, for whom specifically they are effective, and the contexts of operation. Although not part of the current research, review findings will partially inform the development of a leadership and career advancement intervention for women within the Tanzanian healthcare setting.

A rapid realist review (RRR) was conducted to answer the research question, “What leadership and career advancement interventions work for women in healthcare, why exactly are these interventions effective, for whom specifically are they effective, and in what contexts?”. The RRR is described as ‘rapid’ because the search is expedited by reducing the number of databases searched and decreasing iterations within the synthesis [ 14 ]. A RRR ultimately provides a theory that indicates what programmes are likely to work, for a specific target group and under a particular set of circumstances [ 14 ]. Uncovering theories can improve the effectiveness, acceptability, transferability, and sustainability of programmes [ 17 ]. A key advantage of the RRR methodology is that it is responsive to local policy needs, and results are utility-focused [ 14 ]. The RRR approach is appropriate because this methodology effectively dissects complex programmes by scrutinising what components work, for whom exactly, under what circumstances, and why this is the case [ 18 ].

A RRR uncovers the generative causation of a phenomenon, which is expressed as a context mechanism and outcome configuration (CMOc) [ 18 ]. Context (C) can be defined as environments and pre-existing conditions within which interventions are introduced [ 18 ]. Mechanisms (M) are underlying intervention entities, processes, and structures that operate to generate outcomes (O) [ 18 ]. Mechanisms are a combination of resources (R1) introduced and the stakeholder’s reasoning (R2) in response to the resource [ 18 ]. Outcomes are consequential to mechanisms acting in contexts [ 18 ].

The RRR aims to uncover generative causation – the underlying causal processes that generate an outcome, either intended or unintended [ 14 ]. Generative causation which is expressed as a CMOc, describes the mechanisms triggered within specific contexts and outcomes this interaction generates [ 18 ]. Elucidating the link between these components uncovers the programme theory, which explains how the interventions work [ 18 ]. This theory is tested and continuously refined throughout the RRR [ 14 ]. The theory generated is not prescriptive but takes an explanatory approach [ 14 ].

This RRR was conducted between December 2022 and November 2023. The review design comprised of the phases: identifying existing theories, literature searching, document selection, data extraction, appraisal for richness and rigour, data synthesis, validation and programme theory refinement, and dissemination of findings [ 19 ]. Figure 1 details the steps taken within this RRR.

Key steps in the rapid realist review [ 14 , 20 ]

Expert panel

Aligned to RRR guidance and best practice, the expert panel was convened to help inform the research direction, ensure the relevance of the review to low and middle-income settings and more particularly to the Tanzanian healthcare context, and contextualise findings to ensure that the findings have real-world input. The expert panel consisted of 16 people. Tanzanian members of the expert panel were recruited during a visit to Tanzania, where a presentation was made to government officials and healthcare staff on the necessity of a contextually befitting leadership and career advancement intervention. Non-Tanzanian members of the expert panel were recruited through existing networks and by identifying key individuals involved in policy, programme implementation and research who could support this work.

Members of the expert panel included:

Doctors, nurses and allied health professionals (nutrition and social welfare officers, diagnostic health service employees) from Tanzania – 8 members.

International experts in gender, health systems and global health — 8 members.

The expert panel were consulted during the defining stages of the review, including the drafting of initial programme theories and refinement of final programme theories. Meetings were thus held during these two critical timepoints. The panel were asked to provide feedback after reviewing theories during in-person and online meetings (Zoom). These meetings were of varying sizes as they were based on the schedules of expert panel members. The expectation was for expert panel members to participate in at least two key meetings lasting no more than 1.5 h. Where expert panel members could not attend the meetings, feedback was solicited via email. Expert panel feedback was implemented after consultation and consensus with the core research team.

Identifying candidate and initial programme theories

Key systematic reviews on leadership and career advancement among women were identified using the keywords leadership, career, interventions, and women in the Google Scholar search engine. This initial literature scope was not meant to be exhaustive but rather to inform the research disposition. In concordance with this, five key reviews pertinent to the topic under scrutiny were identified and reviewed to identify the candidate programme theories—see Appendix 1 for information on these reviews [ 2 , 7 , 8 , 9 , 13 ].

From these five reviews, three candidate programme theories were constructed. These were then presented to the RRR expert panel and the wider research team, who both provided feedback. The candidate programme theories were then refined into initial programme theories (IPTs) [ 18 , 20 ]. The resulting IPTs were:

Interventions targeting women’s leadership should take a multi-component approach that targets different systems levels and different genders across different sectors. Multicomponent interventions result in the greatest skill development and career advancement for women when they combine individual growth (training, education, mentoring and networking) with wider organisational gender equity strategies (changes in organisational processes or culture) in the context of government and societal strategies.

Mentoring with a multidimensional focus (career and other aspects of life) is central to the success of multicomponent interventions targeting skill development and career advancement among women. Mentoring produces the greatest skill development and career advancement among women when the relationship between mentor and mentee is organic/genuine, within a supportive network and the actual mentoring enacted by more experienced colleagues.

Leadership development intervention programmes should be structured and supported by wider organisational, societal and government gender equity strategies. Using tools, resources and action plans for implementation and monitoring can support accountability and commitment, and produce measurable outcomes at the organisational level.

Literature searching

Study search terms were developed from keywords identified in the IPTs. Aligned to RRR methodology where database searches are limited, databases were restricted to CINAHL and Web of Science because the subject matter covered relevant topic areas including nursing and allied health research, healthcare sciences, and social sciences [ 14 ]. Search terms addressed the four areas of interest: leadership, interventions, healthcare, and gender. The comprehensive search strategy is detailed in Table 1 . Searches were run for studies conducted among adults and published in English between January 2000 until 7th March 2023. The 2000 cut-off date was chosen because this coincided with the release of the United Nations Millennium Development Goals on the promotion of gender equality and the empowerment of women [ 21 ]. Members of the expert panel were also contacted twice via email with requests to recommend potentially relevant literature.

Selecting documents

Citations identified during searching were exported into software (Covidence) where duplicates were removed. Search results were initially screened by title and abstract, then by full text based on definitive criteria pertinent to the research topic (see Table 2 for relevance criteria). This screening was completed by DM, and 10% of the studies screened were counter-checked by AK at the title and abstract stage. There were less than 5% of conflicts for studies screened by DM and AK; BG acted as the arbitrator where the two reviewers could not resolve conflicts.

Evaluating richness and rigour

Papers and documents deemed relevant to the research topic were reviewed for richness. Richness assessments were based on the inclusion of sufficient depth to meaningfully contribute to theory building as indicated by having traceable CMOcs; theories of interest were either the initial programme theories or other theories relevant to the topic under scrutiny [ 22 ]. Studies were scored 1 point for each CMOc that was evident.

Rigour was applied to assess the methodological conduct of the included papers and documents. Rigour was assessed based on a yes (1) or no (0) dichotomy for the credibility of the source, appropriateness and trustworthiness of methodology used, and plausibility of the information reported [ 22 ]. Summary of richness and rigour scores can be found in Appendix 2.

Data extraction

The first phase of data extraction entailed collating information on the paper’s aims, setting, participants, design, intervention details, findings, and theoretical frameworks and models. After this data had been gathered, the richness and rigour of the papers were determined.

Data pertinent to generative causation including the context, mechanism and outcome of each CMOc was extracted and aggregated. This process entailed reading each paper and extracting information pertaining to the environmental and pre-existing conditions where interventions were introduced which was identified as the context. The details on the resources introduced, stakeholders and their responses to introduction of a resource was extracted and categorised as the mechanism. Finally, the resulting outcomes of the interaction between the introduction of resources and stakeholder responses were also identified. This information was utilised to draft CMOcs for each paper which can be found in Appendix 3.

Data synthesis

The IPTs were tested and revised in light of the newly emerging data from the CMOcs. Strategies used to test and refine programme theories included [ 23 ]:

a) Juxtaposing- contrasting evidence on mechanisms in one source to elaborate outcome patterns in another source.

b) Reconciling- identifying explanations for different outcomes by unveiling contextual differences.

c) Adjudication- clarifying reasons for contradictory study outcomes based on methodological variances.

d) Consolidation- constructing explanations for how and why dissimilar outcomes occur as pertinent to a specific context.

e) Situating- distinguishing which mechanisms were activated in specific contexts.

A total of 3,600 records were retrieved after searching the databases. Sixty-four duplicates were removed, leaving 3,536 papers which were screened at the title and abstract stage, after-which 3,472 were excluded. 64 papers underwent full text screening of which ten were automatically excluded due to the absence of a full text. During full text screening, 32 papers were excluded for various reasons (see Fig. 2 ), leaving a total of 22 studies that met inclusion criteria and underwent data extraction.

After the first phase of data extraction, only 12 studies were appraised as rich because they contributed to CMOcs, subsequently supporting theory development. These 12 studies were also rated for rigour. Appendix 2 presents a summary of ratings for richness and rigour.

A total of 29 CMOcs were extracted from the included 12 studies. Appendix 3 presents a full list of CMOcs. From these CMOcs, nine demi-regularities or patterns were identified, which supported the refinement of the programme theories into nine final programme theories after consultative meetings with the expert panel.

PRISMA flow chart for studies evaluated for the rapid realist review

This RRR describes the robust and iterative process of developing programme theories on leadership and career advancement interventions for women in healthcare. By applying the RRR methodology, literature on the topic was appraised and the twenty nine CMOcs which were extracted pointed to the relationship between the programme components, participant responses, programme settings, and resulting outcomes [ 17 ]. Demi regularities or patterns were identified within the CMOcs, which led to the construction of 9 programme theories [ 17 ].

It was evident that programmes which applied leadership education, training and mentorship for healthcare workers who were women, and were undergirded by management buy-in, inclusion of all genders, alignment with organisational goals and workplace roles, were linked to superior outcomes. Involvement of multiple parties within the organisation and considering organisational dynamics corroborates systems theory which conveys the significance of a wholistic approach [ 36 ]. Some organisational entities support, and influence others as is the case with management and other organisational members [ 36 ]. It is therefore unsurprising that the women within the health services and professional associations demonstrated improvements in leadership skills, knowledge, confidence, along with greater access to leadership positions [ 24 , 25 , 26 , 27 , 28 , 29 ]. Management buy-in such as their endorsement, allocation of resources, and provision of advice regarding the best course of action, minimised planning and execution obstacles [ 24 , 27 ]. On occasion, management’s endorsement was through integration of the programme to the employment role and pay, which inspired added participant commitment [ 24 , 27 ].

Obtaining management buy-in provides a level of accountability from the organisation which may motivate women to participate because they view the programme positively [ 24 ]. Management’s involvement through nomination of prospective participants potentially had a validating effect on the women [ 25 ]. Managers and supervisors at work are powerful agents for demonstrating organisational support, thus their role is indispensable in programmes seeking to establish organisational backing [ 37 ].

Mentoring emerged as a core constituent of leadership and career development programmes for women in health services or professional associations [ 24 , 25 , 27 , 30 , 32 , 33 ]. Pre-training on how to approach and relate with mentors seemed to contribute towards leadership skills and self-efficacy [ 24 , 30 , 31 ]. The mentorship enactment theory proposes that proactive communication strategies are essential for initiating, developing, maintaining and repairing mentorship relationships [ 38 ]. This pre-training likely aligned mentees and mentors to the process of mentoring, enabling them to reap the maximum benefits because it boosted their engagement and effectiveness [ 24 , 30 , 31 ]. The mentor-mentee dynamic is characterised by an unequal power dynamic between the duo, and some preparatory skills may be required by both parties [ 38 ].

The actual mentoring was enacted by senior or more experienced staff who role modelled, provided a sounding board for ideas and assisted mentees with identifying and developing organisationally relevant leadership competencies [ 27 , 32 , 33 ]. It was articulated in some studies that mentors were from different organisations or units thus were not their line managers, and the benefit of this approach is minimised conflict of interest between the mentoring pairs which may contribute constructively towards outcomes [ 24 , 30 ]. This type of guidance also provided new opportunities for mentees via the network connection of mentors and guided them in the navigation of new opportunities [ 25 ]. Benefits of mentorship extended beyond the mentee, and sometimes augmented the mentor’s leadership abilities due to novelty of the role [ 27 ].

It was also apparent that providing mentees and mentors with latitude over some aspects of the mentoring boosted leadership outcomes [ 24 ]. Two of the interventions indicated that mentorship dyads met monthly however this approach was not consistent across all other studies applying mentorship [ 24 , 30 ]. Decisions on frequency and scheduling of mentoring meetings, the specific focus areas of the mentoring sessions, overall expectations, and goals was often left to the discretion of the participating dyad after providing general programmatic guidelines on the mentorship process and anticipated outcomes [ 31 ]. The self-determination theory posits that humans have a need for autonomy, competence, connection and belonging [ 39 ]. When these desires are satisfied, individuals are more likely to be motivated, engaged and successful [ 39 ]. Giving mentees and mentors some autonomy may give them a sense of programmatic ownership, which may contribute positively to programme engagement and ultimately towards participant leadership competency.

Leadership education and training was the most notable focus of the interventions [ 24 , 25 , 26 , 27 , 28 ]. This was characterised by leadership and discipline-specific education delivered by content experts which led to leadership self-efficacy, confidence, knowledge, skills, desire for leadership and acquisition of leadership [ 24 , 25 , 26 , 27 , 28 ]. Learning was time-tabled, structured, and assumed majority of programmatic time and resources [ 24 , 25 , 26 , 27 , 28 ]. Delivery of leadership education is congruent with the behavioural leadership theory which asserts that the traits that distinguish leaders can be learnt [ 40 ]. Focal areas for the education included transformational leadership, communication, conflict resolution, leadership styles, project management, differences between leading and managing, belonging, quality improvement, wellness and equity [ 24 , 25 , 26 , 27 , 28 ]. Broadly, the leadership topics delivered are relevant to healthcare leadership and perpetuate productivity and growth, which may have inspired additional engagement and commitment [ 40 ]. Moreover, delivering this content via in-person and online platforms reinforced positive outcomes because the multiplicity of learning avenues improved accessibility and engagement [ 41 ].

This didactic leadership education was typically coupled with practical components, such as action learning sets, experiential learning, implementation of a project and interactive sessions [ 26 , 27 , 32 , 34 ]. Although these elements differ quite significantly in execution, they afford an opportunity and context for participants to implement lessons from the education sessions which fortifies leadership knowledge [ 26 , 27 , 32 , 34 ]. This is the key message conveyed in the experiential learning theory which postulates that practical experiences facilitate knowledge retention and deeper grasp of ideas [ 42 ]. This mode of training is akin to learning by doing where direct instruction is coupled with practical training, and this is superior to traditional learning that is primarily theoretical [ 43 ].

Acquisition of skills in negotiation, collaboration, networking, reflection and goal setting among the women healthcare workers was resourced in the leadership education and training, which buttressed leadership outcomes [ 24 , 25 , 28 , 33 , 34 ]. Relevance of these skills to participants’ workplace roles likely evoked engagement and commitment, contributing to favourable leadership outcomes. Leadership literature cites the importance of communication, negotiation, planning, and problem solving, which parallels the skills cited in the current programmes [ 44 ]. Relevance of these leadership skills differs based on the level of organisational responsibility, for instance, planning and problem solving are more requisite at advanced leadership levels [ 44 ]. Consequently, it is crucial for programmes to impart leadership skills which are relevant to present and proximal roles [ 44 ].

Bespoke learning aims, programme activities, leadership styles and schedule of activities were available within the leadership education and training [ 32 , 33 , 35 ]. This approach enhanced leadership because the programme was tailored to the interests and goals of participants which ignited motivation. Tailored education and training gained traction in recent years due to the impact on knowledge, self-efficacy and behaviour change [ 35 , 45 ]. Proponents also highlight that the specificity of meeting participant and organisational needs is efficient and time sensitive [ 46 ]. Consideration of participant needs and preferences favourably impacts leadership and career development programme outcomes among women healthcare workers.

Limitations

There were ostensible limitations associated with the conduct of this review. Firstly, the leadership and career development programme components were often interlinked, and it was not always clear which components led to certain outcomes and the response of key actors within the scope of the intervention. This therefore hampered information that could be meaningfully extracted from the included studies. Additionally, detailed description of intervention methodology was not always given by the authors which rendered some of the included studies obsolete for the purpose of a RRR, which relies on meticulous reporting and appraisal of intervention mechanisms [ 18 ]. Furthermore, the interventions which were explored here generated several theories which may elicit more questions for those implementing the theories due to nuances that may emerge, however these may only be plausible to interrogate at each local level. Lastly, none of the reviewed interventions were set in a low- and middle-income context, which raised questions about the relevance of the theories generated to the Tanzanian healthcare context. The authors attempted to counter this drawback by appraising theories generated with expert panel members from the Tanzanian context to ascertain applicability but clearly more research is needed in these contexts.

Conclusions

This RRR highlights theories which may be effectual in addressing the underrepresentation of women in leadership through applying leadership and career development programmes in health services or professional associations. Following the literature review process and consultation with an expert panel, 9 theories were developed to guide the development of effective programmes which enhanced leadership outcomes pertinent to acquisition of skills, knowledge, confidence, self-efficacy, fulfillment of existing roles, leadership participation, desire for and attainment of new roles. In general, these programmes comprised of leadership education and training, alongside mentoring. Key strategies applied in the delivery of the leadership and mentorship components was alignment with the organization’s direction and involvement of personnel from management; providing mentorship pretraining, allocating mentors and allowing for co-creation during mentorship; delivering general and discipline-specific leadership education; incorporation of practical components to support leadership education; integration of hybrid learning through utility of in-person and online platforms; development of key leadership skills and creating opportunity for self-tailoring within the programme. These strategies were generally successful because of the supportive programmatic environments, adequacy and relevance of support offered and accessibility of the programmes. The finding that none of the reviewed interventions were set in a low- and middle-income countries underlines an opportunity for testing the theories in this context to comprehensively crystalise features that are suitable. The theories presented underline why, how, for whom and the contexts related to the success of leadership and career development programmes for women in healthcare and can be tested and refined further especially as it pertains to long-term outcomes such as gender equality in leadership.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Rapid realist review

Realist and Meta-narrative Evidence Syntheses: Evolving Standards

World Health Organization

Universal Health Coverage

Sustainable Development Goal

Low- and middle-income contexts

Context mechanism and outcome configuration

World Health Organization. Closing the leadership gap: gender equity and leadership in the global health and care workforce: policy action paper, June 2021. In: Closing the leadership gap: gender equity and leadership in the global health and care workforce: policy action paper, June 2021 edn.; 2021.

Mousa M, Boyle J, Skouteris H, Mullins AK, Currie G, Riach K, Teede HJ. Advancing women in healthcare leadership: a systematic review and meta-synthesis of multi-sector evidence on organisational interventions. EClinicalMedicine. 2021;39:101084.

Article PubMed PubMed Central Google Scholar

World Health Organization. Gender, equity and leadership in the global health and social workforce. In.; 2020.

Downs JA, Reif LK, Hokororo A, Fitzgerald DW. Increasing women in leadership in global health. Acad Med. 2014;89(8):1103–7.

Casad BJ, Oyler DL, Sullivan ET, McClellan EM, Tierney DN, Anderson DA, Greeley PA, Fague MA, Flammang BJ. Wise psychological interventions to improve gender and racial equality in STEM. Group Processes Intergroup Relations. 2018;21(5):767–87.

Article Google Scholar

Woetzel J. The power of parity: How advancing women’s equality can add $12 trillion to global growth. In.; 2015.

House A, Dracup N, Burkinshaw P, Ward V, Bryant LD. Mentoring as an intervention to promote gender equality in academic medicine: a systematic review. BMJ Open. 2021;11(1):e040355.

Laver KE, Prichard IJ, Cations M, Osenk I, Govin K, Coveney JD. A systematic review of interventions to support the careers of women in academic medicine and other disciplines. BMJ Open. 2018;8(3):e020380.

Alwazzan L, Al-Angari SS. Women’s leadership in academic medicine: a systematic review of extent, condition and interventions. BMJ Open. 2020;10(1):e032232.

Barfield WL, Plank-Bazinet JL, Austin Clayton J. Advancement of women in the Biomedical workforce: insights for success. Acad Med. 2016;91(8):1047–9.

Plank-Bazinet JL, Bunker Whittington K, Cassidy SKB, Filart R, Cornelison TL, Begg L, Austin Clayton J. Programmatic efforts at the National Institutes of Health to promote and support the careers of women in Biomedical Science. Acad Med. 2016;91(8):1057–64.

Ovseiko PV, Taylor M, Gilligan RE, Birks J, Elhussein L, Rogers M, Tesanovic S, Hernandez J, Wells G, Greenhalgh T, et al. Effect of Athena SWAN funding incentives on women’s research leadership. BMJ. 2020;371:m3975.

Article PubMed Google Scholar

Lydon S, Dowd E, Walsh C, Dea A, Byrne D, Murphy AW, Connor P. Systematic review of interventions to improve gender equity in graduate medicine. Postgrad Med J. 2022;98(1158):300.

Saul JE, Willis CD, Bitz J, Best A. A time-responsive tool for informing policy making: rapid realist review. Implement Sci. 2013;8(1):1–15.

THE SUSTAINABLE DEVELOPMENT GOALS IN ACTION. [ https://www.undp.org/sustainable-development-goals ]

MINISTRY OF COMMUNITY DEVELOPMENT GENDER AND CHILDREN. NATIONAL STRATEGY FOR GENDER DEVELOPMENT. In. Tanzania 2022.

Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist review – a new method of systematic review designed for complex policy interventions. J Health Serv Res Policy. 2005;10:21–34.

Pawson R, Tilley N. Realist evaluation. In.; 2004.

Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist synthesis-an introduction. ESRC Res Methods Programme. 2004;2:55.

Google Scholar

Corey J, Vallières F, Frawley T, De Brún A, Davidson S, Gilmore B. A rapid realist review of group psychological first aid for humanitarian workers and volunteers. Int J Environ Res Public Health. 2021;18(4):1452.

Millennium Development Goals (MDGs.) [ https://www.who.int/news-room/fact-sheets/detail/millennium-development-goals-(mdgs )#:~:text=The%20United%20Nations%20Millennium%20Declaration,are%20derived%20from%20this%20Declaration.].

Dada S, Dalkin S, Gilmore B, Hunter R, Mukumbang FC. Applying and reporting relevance, richness and rigour in realist evidence appraisals: advancing key concepts in realist reviews. Res Synthesis Methods. 2023;14(3):504–14.

Vareilles G, Pommier J, Marchal B, Kane S. Understanding the performance of community health volunteers involved in the delivery of health programmes in underserved areas: a realist synthesis. Implement Sci. 2017;12(1):22.

Brown-DeVeaux D, Jean-Louis K, Glassman K, Kunisch J. Using a Mentorship Approach to address the underrepresentation of ethnic minorities in senior nursing Leadership. J Nurs Adm. 2021;51(3):149–55.

Kelly EH, Miskimen T, Rivera F, Peterson LE, Hingle ST. Women’s wellness through equity and leadership (WEL): a program evaluation. Pediatr (Evanston). 2021;148(Suppl 2):1.

Bradd P, Travaglia J, Hayen A. Developing allied health leaders to enhance person-centred healthcare. J Health Organ Manag. 2018;32(7):908–32.

Dyess S, Sherman R. Developing the leadership skills of new graduates to influence practice environments: a novice nurse leadership program. Nurs Adm Q. 2011;35(4):313–22.

Fitzpatrick JJ, Modic MB, Van Dyk J, Hancock KK. A Leadership Education and Development Program for Clinical nurses. J Nurs Adm. 2016;46(11):561–5.

Miskelly P, Duncan L. I’m actually being the grown-up now’: leadership, maturity and professional identity development. J Nurs Adm Manag. 2014;22(1):38–48.

Leggat SG, Balding C, Schiftan D. Developing clinical leaders: the impact of an action learning mentoring programme for advanced practice nurses. J Clin Nurs. 2015;24(11–12):1576–84.

Vatan F, Temel AB. A leadership development program through mentorship for clinical nurses in Turkey. Nurs Economic. 2016;34(5):242–50.

Hewitt AA, Watson LB, DeBlaere C, Dispenza F, Guzmán CE, Cadenas G, Tran AGTT, Chain J, Ferdinand L. Leadership Development in Counseling psychology: voices of Leadership Academy alumni. Couns Psychol. 2017;45(7):992–1016.

MacPhee M, Skelton-Green J, Bouthillette F, Suryaprakash N. An empowerment framework for nursing leadership development: supporting evidence: empowerment framework for nursing leadership development. J Adv Nurs. 2012;68(1):159–69.

Leslie LK, Miotto MB, Liu GC, Ziemnik S, Cabrera AG, Calma S, Huang C, Slaw K. Training Young pediatricians as leaders for the 21st Century. Pediatr (Evanston). 2005;115(3):765–73.

Cleary M, Freeman A, Sharrock L. The development, implementation, and evaluation of a clinical leadership program for mental health nurses. Issues Ment Health Nurs. 2005;26(8):827–42.

OECD. Systems Approaches to Public Sector Challenges; 2017.

Sumathi GN, Kamalanabhan TJ, Thenmozhi M. Impact of work experiences on perceived organizational support: a study among healthcare professionals. AI Soc. 2015;30:261.

Ragins BR, Kram KE. The handbook of mentoring at work: theory, research, and practice. Sage; 2007.

Ryan RM, Deci EL. Self-determination theory: Basic Psychological needs in motivation. Development, and Wellness: Guilford; 2018.

Deshwal V, Ali MA. A systematic review of various leadership theories. Shanlax Int J Commer. 2020;8(1):38–43.

10 Hybrid Learning Benefits. [ https://www.edapp.com/blog/hybrid-learning-benefits/ ]

Kolb DA, Boyatzis RE, Mainemelis C. Experiential Learning Theory: Previous Research and New Directions. In: Perspectives on Thinking, Learning, and Cognitive Styles edn. Edited by Sternberg RJ, Zhang L-f. United States: Routledge; 2001: 227–248.

Gil-Lacruz M, Gracia-Pérez ML, Gil-Lacruz AI. Learning by doing and training satisfaction: an evaluation by health care professionals. Int J Environ Res Public Health. 2019;16(8):1397.

Mumford TV, Campion MA, Morgeson FP. The leadership skills strataplex: Leadership skill requirements across organizational levels. Leadersh Q. 2007;18(2):154–66.

Kravitz RL, Tancredi DJ, Grennan T, Kalauokalani D, Street RL Jr, Slee CK, Wun T, Oliver JW, Lorig K, Franks P. Cancer Health empowerment for living without Pain (Ca-HELP): effects of a tailored education and coaching intervention on pain and impairment. PAIN ® . 2011;152(7):1572–82.

Baker R, Camosso-Stefinovic J, Gillies C, Shaw EJ, Cheater F, Flottorp S, Robertson N, Wensing M, Fiander M, Eccles MP. Tailored interventions to address determinants of practice. Cochrane Database Syst Reviews 2015(4).

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Acknowledgements

We would like to thank Mr. Diarmuid Stokes (University College Dublin librarian) for supporting development of the search strategy. We would also like to extend our sincere thanks to the members of the expert panel who provided feedback on the theories. Finally, we are thankful for the support of President office regional authorities and local government (PO-RALG) in Tanzania who endorsed the review and were keen to provide feedback during various stages.

The research is funded by the Irish Research Council grant reference number COALESCE/2022/1714.

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D.M. led writing of the manuscript and execution of the review. B.G. led in providing guidance on technical aspects of the rapid realist review methodology. A.K. was a second reviewer in the review process and supported selection of key papers. E.M. contributed to drafting and reviewing programme theories. All authors (D.M., B.G., A.K. and E.M.) were involved in drafting of the manuscript and approved the final version.

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Mucheru, D., McAuliffe, E., Kesale, A. et al. A rapid realist review on leadership and career advancement interventions for women in healthcare. BMC Health Serv Res 24 , 856 (2024). https://doi.org/10.1186/s12913-024-11348-7

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A Patient-Driven Mobile Health Innovation in Cystic Fibrosis Care: Comparative Cross-Case Study

Authors of this article:

Original Paper

Pamela Mazzocato 1, 2 , PhD ;
Jamie Linnea Luckhaus 1, 3 , MPH ;
Moa Malmqvist Castillo 1 , MPhil ;
Johan Burnett 4 , RN ;
Andreas Hager 4 , LLM ;
Gabriela Oates 5 , PhD ;
Carolina Wannheden 1 , PhD ;
Carl Savage 1 , PhD

1 Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden

2 Södertälje Hospital, Södertälje, Sweden

3 Participatory e-Health and Health Data, Department of Women’s and Child’s Health, Uppsala University, Uppsala, Sweden

4 Upstream Dream, Bromma, Sweden

5 Pulmonary, Allergy and Critical Care Medicine, The University of Alabama at Birmingham, Birmingham, AL, United States

Corresponding Author:

Pamela Mazzocato, PhD

Department of Learning, Informatics, Management and Ethics

Medical Management Centre

Karolinska Institutet

Tomtebodavägen 18 A

Phone: 46 8 524 83 696

Email: [email protected]

Background: Patient-driven innovation in health care is an emerging phenomenon with benefits for patients with chronic conditions, such as cystic fibrosis (CF). However, previous research has not examined what may facilitate or hinder the implementation of such innovations from the provider perspective.

Objective: The aim of this study was to explain variations in the adoption of a patient-driven innovation among CF clinics.

Methods: A comparative multiple-case study was conducted on the adoption of a patient-controlled app to support self-management and collaboration with health care professionals (HCPs). Data collection and analysis were guided by the nonadoption, abandonment, spread, scale-up, and sustainability and complexity assessment tool (NASSS-CAT) framework. Data included user activity levels of patients and qualitative interviews with staff at 9 clinics (n=8, 88.9%, in Sweden; n=1, 11.1%, in the United States). We calculated the maximum and mean percentage of active users at each clinic and performed statistical process control (SPC) analysis to explore how the user activity level changed over time. Qualitative data were subjected to content analysis and complexity analysis and used to generate process maps. All data were then triangulated in a cross-case analysis.

Results: We found no evidence of nonadoption or clear abandonment of the app. Distinct patterns of innovation adoption were discernable based on the maximum end-user activity for each clinic, which we labeled as low (16%-23%), middle (25%-47%), or high (58%-95%) adoption. SPC charts illustrated that the introduction of new app features and research-related activity had a positive influence on user activity levels. Variation in adoption was associated with providers’ perceptions of care process complexity. A higher perceived complexity of the value proposition, adopter system, and organization was associated with lower adoption. In clinics that adopted the innovation early or those that relied on champions, user activity tended to plateau or decline, suggesting a negative impact on sustainability.

Conclusions: For patient-driven innovations to be adopted and sustained in health care, understanding patient-provider interdependency and providers’ perspectives on what generates value is essential.

Introduction

Patient-driven innovation in health care is an emerging phenomenon. An example of coproduction and prosumerism (where consumers produce what they consume), patient-driven innovations can be seen as the next logical step in health care evolution [ 1 , 2 ] and could fundamentally challenge the essence of what it means to be a professional health care provider. The number of publications about patient-driven or informal caregiver-driven innovations (ie, innovations that are both initiated and driven by patients or informal caregivers or both) mostly concern chronic conditions and have increased substantially in recent years [ 3 ]. However, the current literature does not examine the factors that influence the adoption, spread, and scale-up of patient-driven innovations in health care organizations [ 3 ]. The paucity of research studies evaluating and reporting the outcomes of patient-driven innovations has been suggested as a potential obstacle to their adoption in health care [ 4 ].

Cystic fibrosis (CF) is a complex chronic and genetic condition that affects respiratory and other organ systems [ 5 ]. Disease activity varies over time, and treatment requires a high degree of discipline and self-care outside of the clinical microsystem [ 6 , 7 ]. Patient-driven innovations in CF care have resulted in the development and dissemination of mobile health (mHealth) apps that support patients with CF and their caregivers in self-care and information sharing with health care providers [ 8 - 11 ]. Sharing of patient-generated health data has been associated with improved symptom control and quality of life and reduced health care use [ 12 ]. The COVID-19 pandemic has further demonstrated the value of and opportunity for patient-generated health data [ 13 ], as well as the importance of actively involving patients with CF and caregivers in critical conversations about care and self-care management [ 14 ].

However, implementing innovations in health care can be challenging [ 9 , 15 - 18 ]. The issue is even more pronounced if innovations are created or driven by patients [ 19 ], as that can challenge traditional hierarchical values and structures and professional identities. When implementation is not appropriately managed, mHealth apps fail to be adopted, are abandoned, or falter when they are scaled up or spread [ 20 , 21 ]. To increase the ability of hospitals, staff, and patients to adopt technological innovations, implementation approaches need to be anchored in the needs of patients and adapted to the organizational context and the wider system in which the new technology is implemented [ 21 , 22 ]. The level of organization and system complexity will influence the level of adoption by patients and providers [ 20 , 21 , 23 - 25 ].

Building on the field of complexity, we see complexity as a characteristic and property that emerges from 3 variables: the number of elements or components, often referred to as nodes (eg, actors and stakeholders); the number of interactions and interdependences between these nodes; and the variation within these nodes and interactions [ 26 - 28 ]. Successful implementation often requires a higher level of alignment between the purpose of the organization and its users [ 20 , 21 , 24 ]. The risk for failure increases with the level of complexity as health care systems respond to changes in unpredictable and nonlinear ways due to fuzzy organizational boundaries and interconnected actions with other actors that are often difficult to predict or even be aware of [ 21 , 29 ].

With patients and informal caregivers playing an increased role in health care, we need to know more about how their potential contributions can be realized through the adoption of patient-driven innovations in health care. Therefore, the aim of this study was to explain variations in the adoption of a patient-driven innovation among CF clinics. We posed the following research questions:

How does the adoption of a patient-driven innovation, based on patterns of patient use, vary among clinics?
What factors influence the level of adoption of the patient-driven innovation over time?

Study Design

This comparative multiple-case study used mixed (quantitative and qualitative) methods to explain differences in the adoption of a patient-driven innovation among patients with CF at 9 clinics. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guideline [ 30 ] was followed in reporting this study ( Multimedia Appendix 1 ). The study is part of the Patient in the Driver’s Seat research program conducted at the Medical Management Centre, Karolinska Institutet, Sweden. It is a 6-year program that studies how 5 patient-driven innovations are implemented in clinical practice and the daily lives of patients and their networks, 1 of which is the subject of this study.

Theoretical Framework

This study was guided by the framework for theorizing and evaluating nonadoption, abandonment, and challenges in the scale-up (ie, building infrastructure to support full-scale implementation across an organization, locality, or health systems), spread (ie, replicating an intervention somewhere else), and sustainability of health and care technologies (nonadoption, abandonment, spread, scale-up, and sustainability [NASSS]) and the NASSS complexity assessment tool (NASSS-CAT) [ 29 ]. We chose the NASSS framework because it was designed to both analyze and prepare for the implementation of technology in health care. Its development process has been well described, lending surface validity to the framework, and it has garnered attention among researchers [ 20 , 31 , 32 ]. According to the framework, the dynamic interactions that influence the nonadoption, abandonment, scale-up, spread, and sustainability of technological innovations are inherent to the complexity within and between 7 domains:

Condition: nature of the condition or illness, comorbidities, sociocultural factors
Technology: material features, type of data generated, knowledge needed to use, supply model
Value proposition: supply-side value for the developer and for the patient
Adopters: staff, patients, caregivers
Organization: capacity to innovate, readiness for technology, nature of adoption/funding decision, extent of change in team routines, work needed
Wider context: political/policy, regulatory/legal, professional and sociocultural
Embedding and adaptation over time: scope, organizational resilience [ 29 ]

Simple systems consist of a few components that interact in straightforward and predicable ways. Complicated systems have multiple components that interact in a predictable fashion. Complex systems have multiple and intricately related interactions that are constantly changing, unpredictable, nonlinear, and difficult to deconstruct [ 29 ]. NASSS and, practically, CAT can be used to distinguish between simple, complicated, and complex elements in the 7 domains [ 29 ]. The intention is to identify the multiple influences that are at play; to determine how complexity once identified can be reduced, addressed, or navigated; and to provide information and guidance to the involved actors on how to do so.

The Patient-Driven Innovation

The technology (innovation) studied was a patient-controlled app (named Genia ) that was originally designed as a patient-facing app to foster self-management. With the addition of a function to generate reports for providers, the app expanded its scope to become a patient-controlled information app for the coproduction of care that places the patient at the center of the decision-making process [ 10 , 11 ]. Founded in 2012 by a father of children with CF, Upstream Dream, which developed the patient-driven innovation, employs individuals with lived experience as patients or informal caregivers of a family member with a rare disease. The innovation was developed in collaboration with the Swedish CF community and upon research conducted at Karolinska Institutet and Dartmouth University. Launched in Sweden in 2015, it was introduced to all CF clinics in the country within a period of a few months. Subsequently, the innovation was piloted (2020-2021) and adopted (2021) as part of routine care in 1 pediatric CF program in the United States and is now the focus of a multicenter study. At launch, the patient-driven innovation was only compatible with the iOS platform. Android support was added later.

Upstream Dream is working to spread the innovation to other clinics in the United States and South America. The innovation has also been tested for use with other chronic medical conditions and has demonstrated improved patient engagement, patient-centered care, and practice-based learning, with the conclusion that the innovation can be recommended for other chronic conditions [ 31 ].

The main features of the patient-driven innovation are related to the tracking of symptoms and medications. What differentiates it from a regular personal health record for patients to record disease progression is that information can be shared with care providers, which is why the app was introduced through the clinics to reach patients with CF. Information that patients wish to share with their multidisciplinary clinical care team is submitted via previsit reports in the form of portable document format (PDF) files. Data are integrated into the Swedish National Cystic Fibrosis Quality Registry. In the United States, data are incorporated into the local electronic health record (EHR) [ 9 ]. Over time, additional features were added based on input from the clinics. These included an antibiotic use–reporting tool, “Antibiotic Check-in,” to support care and research on the use of new antibiotics and therapies; a medication-monitoring tool for the Orkambi medical treatment; and a “Health Check-in” feature to simplify communication of the information used by clinics for planning meetings and patient visits.

In Sweden, clinics were not charged to use the innovation, whereas in the United States, clinics paid an annual fee. The innovation was free for patients to use in both countries. Patients’ user activity can be seen as an outcome that reflects how well clinics integrate the app in their own care processes.

When the study was conducted, 2 generic health information and communication apps were provided by the regions and in use in the Swedish clinics, “1177” and “Always Open.” Neither app provides a comparable service (patient-controlled communication of disease activity) to the innovation; instead, all 3 apps provide complementary functions that did not interfere with one another and could therefore be used simultaneously. The 1177 app is a patient portal that provides information about illnesses and clinics, booking, and electronic medical records. The Always Open app (Swedish Alltid Öppet ) was designed as a secure platform for providing remote care services, such as appointment reminders, prescription renewals, and video visits. Its availability was limited to 1 region, so only 2 clinics had access to it.

Study Setting

The study was conducted at 1 CF center in the United States (referred to as clinic A) and all 8 pediatric and adult CF centers in Sweden (referred to as clinics B-I). All but 1 clinic had used the innovation for 7 years (2 years for the most recent clinic). The clinics were small, with 7-10 staff members (typically including pulmonologists, registered nurses (RNs), physiotherapists or respiratory therapists, psychologists or social workers, and dietitians), and focused specifically on CF. All were located at academic medical centers. One clinic in Sweden provided both pediatric and adult care, and the same staff served both patient populations. However, because adoption levels were different between these 2 patient groups, the data were presented separately.

Based on the inclusion of many different implementation settings, we expected different patterns of adoption. This would allow us to develop an empirical basis for both literal replication (cases that predict similar results) and theoretical replication (cases that predict different results for predictable reasons) [ 32 ]. The US site was selected because it was the first use case outside Sweden. We expected its inclusion to provide further insights into relevant contextual aspects.

Data Collection

Quantitative data were collected to assess the level of adoption based on the number of active users (ie, patient activity). Since the innovation was designed to improve patient-provider communication, patient activity levels can be seen as an indicator of adoption. Anonymous user activity data for each clinic were extracted from Upstream Dream’s monthly reports on user activity for the period from March 2015 (when the innovation was implemented at the first clinic) to March 2022. At clinic A, where the innovation was implemented last, the user activity period was from February 2020 to March 2022.

Qualitative data were collected to understand how the innovation was perceived and used based on the NASSS domains and to identify specific interventions or factors that may have influenced user activity. A semistructured interview guide was developed in both Swedish and English ( Multimedia Appendix 2 ). Questions were designed to elicit information about NASSS domains and their degrees of complexity [ 21 ], as well as to capture information about app integration into care processes. A precursor to the interview guide was first tested in a separate study [ 33 ] and revised based on that experience. Further input was sought from Upstream Dream to ensure that we would capture a holistic understanding of how the innovation was used in daily practice with respect to the different organizational contexts and potential differences in complexity. The interview guide was then piloted twice, with minor changes made to enhance the clarity of the questions in only the Swedish version.

Purposive and snowball sampling strategies were used to identify participants with knowledge of and personal experience with the innovation and who represented the professions involved in CF care. Upstream Dream’s clinical coordinators contacted the staff coordinators at each CF center on our behalf, who then connected us with the staff who expressed an interest to participate in the study. We contacted these individuals via email and followed up by telephone. In total, 21 participants were interviewed, including 2 key members of Upstream Dream, one of whom was interviewed twice (first, to develop a contextual understanding of the innovation and the supplier perspective and then to provide additional information and clarity after the adopter interviews), RNs, physicians, respiratory therapists or physiotherapists, a psychologist, a dietician, and a researcher involved in the development, implementation, and evaluation of the innovation in 1 of the clinics, without being a health care provider. This role distribution reflected typical staff distribution at the clinics. The CF centers involved had a small number of employees, which limited the number of potential participants. The number of participants was also limited by the high workloads brought on by the COVID-19 pandemic. Thus, the participants involved represented between 28% and 40% of working staff. Participants’ experiences with the innovation ranged from 3 months to 7 years.

Interviews were conducted online via the Zoom videoconferencing system due to the ongoing COVID-19 pandemic, in Swedish or English, and lasted 30-60 minutes. Interviews were conducted by 2 authors with training in qualitative research, with support from a senior researcher. The interviewers had no prior relationship with the participants. Audio was digitally recorded and transcribed verbatim.

Data Analysis

Quantitative data on user activity were analyzed using descriptive statistics. We calculated the percentage of active end users per month among the total number of patients and the percentage of active users on average over the entire period. Active users were defined as end users who logged on and used some of the basic app features within a 6-month period. As clinic A first introduced the patient-driven innovation as a pilot study, the percentage of active users for that period was calculated based on the pilot sample size and after the end of the pilot was calculated based on the clinic size. The descriptive statistics (ie, maximum end-user activity and average over the entire period) provided insights into the level of adoption. We defined low (<25%), middle (25-50%), and high (>50%) activity levels based on the maximum percentage of end-user level achieved.

To put user activity data into an organizational context, we complemented the descriptive data with statistical process control (SPC) charts. SPC charts were created for each clinic to identify whether and when statistically significant changes in app adoption levels occurred and whether these were sustained. SPC makes it possible to determine whether a change is a matter of chance (ie, common-cause variation) or due to a specific happening or intervention (ie, special-cause variation) [ 34 - 36 ]. We used P charts with the following rules to identify special-cause variation: rule 1/3 sigma violation (1 point +/– the upper control limit/lower control limit [UCL/LCL], with the control limits set to +/–3 sigma), rule 2/shift (8 successive consecutive points above or below the centerline), rule 3/trend (6 or more consecutive points steadily increasing or decreasing), and rule 5/hugging the centerline (15 or more consecutive points within +/–1 sigma on either side of the centerline) [ 37 ].

Qualitative data were analyzed using content analysis (directed and inductive) [ 38 ], process mapping, and complexity analysis. Interview transcripts were read through repeatedly to develop familiarity and then subjected to directed qualitative content analysis [ 39 ]. Two authors together identified meaning units, which they abstracted to condensed meaning units and added as “sticky notes” to the MIRO online whiteboard for visual collaboration, where they were directed to 1 of the NASSS domains (ie, categories). The condensed meaning units were labeled with descriptive codes. Where the codes did not fit the framework, additional subcategories were created through traditional inductive content analysis [ 39 ]. All codes and the categorization were reviewed and corroborated by 2 other authors. During the analysis, interview data from suppliers and HCPs were kept separate, and the former were used solely to provide contextual information about specific interventions and factors that were integrated in the SPC charts (eg, timeline of interventions that could have influenced user activity).

To support the cross-case comparison, the traditional approach to reporting qualitative analyses was then transformed into tabulated form based on the original NASSS framework and expanded to include the additional subcategories.

Process maps were created for each clinic based on interview data to illustrate how the innovation was integrated into clinical work processes. The process maps and the qualitative analysis were shared with participants in an informant validation process. Five clinics made small adjustments. The suppliers provided additional corroborating feedback, where needed, for the clinics that did not respond.

We diagnosed complexity levels (see the definitions of simple, complicated, complex in the theoretical framework) of the NASSS domains for each clinic by analyzing interview data using the NASSS complexity table ( Multimedia Appendix 3 ) and the NASSS-CAT Short survey, which was specifically designed to assess and differentiate between complexity levels [ 29 ]. Both analyses were combined to generate the complexity assessment. Although the survey was originally intended to spark a reflective discussion, we used the reflective discussion created in the interview setting to diagnose the level of complexity. For the qualitative analyses and the complexity assessment, conflicting interpretations were discussed until consensus was reached.

Qualitative data were first analyzed case by case but then triangulated with quantitative data to develop initial explanations of variation in adoption. These were then tested against the data and the analyses to identify those domains or interacting domains that could explain the observed patterns. In a process akin to modified analytic induction [ 38 ], when falsifying evidence was found, the explanatory model was dropped. This process involved vigorous discussion and iterative cycles to narrow and refine the explanatory models that are presented in the cross-case comparison.

Ethical Considerations

Ethical approval was obtained from the Swedish Ethical Review Authority (approval number 2019-03849). The study followed the Swedish Research Council’s ethical principles for humanities and social science research. Participants were informed orally and in writing about their rights and what study participation would entail. Written and verbal consent was obtained from all participants prior to commencement of interviews. Quantitative data were completely anonymous. Qualitative data were pseudonymized and deidentified prior to coding and analysis. In presenting the findings, we made efforts to maintain participants’ privacy and confidentiality, referencing HCPs only with their pseudonym identifiers and clinic letters (eg, “HCP01, clinic A”). No participant received any compensation for participating in the study.

In this section, we present the triangulation of the qualitative and quantitative data first with user activity levels, and then a cross-case comparison based on the complexity assessment.

Participant Details

In total, 21 participants (n=16, 76.2%, women and n=5, 23.8%, men) were interviewed. Of the 21 participants, 9 (42.9%) were RNs, 5 (23.8%) physicians, 4 (19%) respiratory therapists or physiotherapists, 1 (4.8%) psychologist, 1 (4.8%) dietician, and 1 (4.8%) researcher.

In 2 of the clinics (D and H), we were able to interview only 1 (4.8%) participant each; the remaining 7 clinics were represented by 2 (9.5%) or more participants: clinic A, n=3 (14.3%); clinic B, n=4 (19%); clinic C, n=4 (19%); clinic E, n=2 (9.5%); clinic F, n=2 (9.5%); clinic G, n=2 (9.5%); and clinic I, n=2 (9.5%).

User Activity Level

The end-user activity levels showed that the innovation was adopted by patients at all clinics; there was no evidence of nonadoption. Based on the maximum end-user level achieved, we found 3 clusters: high-adoption clinics A (maximum n=40, 65%), B (maximum n=60, 58%), and C (maximum n=66, 96%); medium-adoption clinics D (maximum n=125, 35%), E (maximum n=30, 47%), and F (maximum n=60, 25%); and low-adoption clinics G (maximum n=120, 19%), H (maximum n=116, 23%), and I (maximum n=155, 16%).

To further explore user activity levels over time, SPC charts were created ( Figure 1 ) for each clinic to plot the user activity level over 81 months. In the SPC charts, specific interventions or events retrieved through the interviews, which may have influenced user activity levels over time, are indicated as vertical dotted lines and labeled as a-g. These included the introduction of new features, research-related activity, and the COVID-19 pandemic.

New features included the launch of Orkambi medication monitoring (intervention a) in month 42, which likely explains the increased use among 5 clinics (B-F), particularly among pediatric clinics. Antibiotic Check-in was launched in Swedish clinics in month 62 (intervention b), which was followed by a campaign (intervention d), which could explain the increased activity in 7 (87.5%) of the 8 Swedish clinics (C-I). The introduction of an Android-compatible version in month 68 (intervention e) opened the innovation up to all patients and caregivers with a smartphone or tablet. Health Check-in (intervention f) may have contributed to the observable increase around month 70 (clinics C, D, F, and H).

The influence of research-related activities was mainly identified in clinic A, in which there was a rapid increase in activity starting month 60, which plateaued. This corresponded to when the innovation was first introduced in clinic A as a year-long single-group pilot study (n=40 participants, pre-post design) [ 40 ]. When the patient quota for the pilot was met (first vertical dotted line, Figure 1 ), 40% of the invited patients were active users. Activity declined after the pilot ended but began to rise again (month 81) when the decision was made to launch the innovation clinic-wide. The consistency of this increase continued after the last point recorded in Figure 1 until activity was halted again in preparation for a new study (data not included in the SPC). Clinic C launched a digitization research project (intervention c), which required participants to use the innovation, and later launched a second digitization project (intervention g) in month 79.

The COVID-19 pandemic also appeared to influence user activity levels. Clinic A partially transitioned to telehealth visits during the pandemic, which made the Health Check-in feature desirable as patients could upload photos and other information. This may have contributed to increased user activity. In contrast, for clinics E, F, H, and I, a deterioration (months 70-78) was concomitant with an active choice not to focus on the innovation due to strained resources.

Cross-Case Comparison: Complexity Assessment Linked to Adoption Level

Specific characteristics of the clinics related to each NASSS domain gleaned from the interviews and the process maps are presented in Multimedia Appendix 4 . In terms of complexity, all clinics viewed the nature of the condition , technology , and wider context domains as complicated ( Figure 2 ). Differences were found in the value proposition , adopter system , organization , and embedding domains. The cross-case comparison presented next was organized around levels of adoption, integrating data from the SPC analysis and exploring differences and similarities in the NASSS domains.

High-Adoption Cluster (Clinics A-C)

The first group perceived the value proposition as simple, the adopter system and organization as complicated, and embedding as either simple or complicated. The staff had a shared perception that there is a clear benefit to using the innovation (ie, the innovation-facilitated meeting of patient and provider creates value in health care for this chronic condition). This was aligned with their view that value in health care for this chronic condition is created in the patient-provider meeting. Although going through reports lengthened the previsit planning process, the innovation was perceived to save time through more concise patient visits.

Just doing that, [opening reports in weekly team meetings] will change it a little bit, it is going to lengthen our [team] meeting a bit (…) So it helps everybody to be prepared ahead of time and hopefully make the visit more concise. [HCP14, clinic A]

For clinics B and C, where Antibiotic Check-in was used, these data were highly valued for research purposes and research was seen as an integral component of high quality care. For clinic C, this was corroborated by SPC analysis (intervention c).

The adopter system was viewed by clinics A-C as complicated. Patient-controlled data were viewed as integral to previsit planning, suggesting a view of patients as active contributors to the cocreation of care and of the staff as having a responsibility to ensure that patients contributed with these data.

Way more attention is being paid now to this patient-generated data rather than the core clinical data. I mean, we still look at lung function and microbiology and what not, but patient-reported symptoms and outcomes are a bigger part of the discussion now, as well as patient preferences and…and goals and what people want to focus on. So that is 1 change that has happened. [HCP15, clinic A]

This person-centered culture was reflected in the organization domain, which the staff perceived as complicated, as organizational routines and care pathways needed to be flexible to reinforce the importance of patient input and the use of the innovation as an integral source of information for previsit planning. For example, if a patient had either not downloaded the innovation or submitted a report, clinics A and C had routines to complete those tasks together with the patient ( Multimedia Appendix 4 ). Even though these clinics saw a clear value in the innovation, they still expressed the difficulties of cultural change and that it requires key drivers.

We often do not have the personnel for this. It needs to be carried out, in addition to the usual work. And there has to be someone driven to be able to push these questions forward. [HCP01, clinic C]

Embedding was seen as simple or complicated based on how mature the routines for incorporating user information (the reports) into the patient pathway were. In clinic B, the continual increase in adoption observed in Figure 1 could be explained by the clinic’s routines of using the innovation with the whole clinical team, as well as its regular communication with the developer. For example, clinic A had clear plans and used collective reflection among the staff for embedding the technology in the short and the long term.

The good thing is that the way we have set up this pragmatic trial is that they are [clinicians] not required to do anything extra than they normally do, so they are not required to log in on a separate platform or a dashboard or anything extra. Everything is embedded and integrated, which makes it an easier sell. [HCP15, clinic A]

Clinics A-C saw a match between what they valued (the patient-provider interaction) and the value proposition of the innovation because it improved the quality and efficiency of the patient-provider encounter. These clinics had existing and further developed their routines to ensure and reinforce patient use of the innovation. Moreover, they behaved as if they “co-owned” the innovation either by conducting research studies or by taking responsibility for patient training. In the adopter system, most of the staff had clearly defined roles in relation to the use of the innovation, as well as established routines for group reflection. Participants valued patients’ role in the cocreation of care.

Middle-Adoption Cluster (Clinics D-F)

The second group perceived the value proposition and adopter system as complicated and organization and embedding as complex. The value proposition was seen as complicated because the technology’s desirability was contested, and the business case for adoption was deemed unclear. The participants experienced a mismatch between the condition and technology that reflected itself in their view of the value proposition: clinics D and F (adult clinics) believed that the technology better serves pediatric patients, who typically receive outpatient care and need to report symptoms, whereas adult patients with CF in Sweden are often hospitalized and their symptomatology easier to track. The staff felt that the graphical user interface is less appropriate for adults.

Regarding the adopter system, clinics E and F questioned the appropriateness of care providers in a public institution to convince their patients to use a product from a private company.

If a patient is completely on top of it with their treatment and medications and everything, then it feels a little like a car salesman if I am to try and sell something that is not a directive of the hospital. And that role we all feel is a bit annoying. But if you can show a direct benefit to using [the innovation], then it feels good. [HCP12, clinic F]

Organization was seen as complex because of difficulties integrating the innovation in the workflow. For example, patient-generated reports were scheduled on the weekly agenda at clinics E and F but seldom discussed. Work routines also included contact with the supplier, who felt that clinic D demonstrated heightened commitment. This was mirrored in the SPC data, which showed a clear increase in adoption toward the end of the data collection period. However, patient workflow processes were not established. Adoption for all 3 clinics was largely the responsibility of individual clinicians and, due to individual levels of enthusiasm or work practices, gave rise to variation ( Figure 1 ). This impacted patients.

We are a center where not everyone is on the team in the same way. I think that is a factor for whether, depending on which doctor one meets, there will be a question about [the innovation] or not (…) It becomes person dependent in a crazy way. [HCP19, clinic E]

It impacted staff as well.

If everyone did it, there would not be any extra work, but since we cannot manage to get everyone here doing it, I end up trying to take the main responsibility (…) Sometimes I sit and go through [the reports] (…) So, I have a bit of extra work, but it is too difficult to create a routine for such a thing if not all patients use it, then it can become forgotten. [HCP18, clinic H]

In clinics E and F, adoption relied heavily on champions, which could explain the decrease observed in months 26-43 ( Figure 1 ), which was also compounded by a severe staff shortage. Embedding was deemed complex at clinics E and F as they were forced to prioritize resources due to the COVID-19 pandemic, which shifted focus away from the innovation and was reflected in the user activity decrease. Moreover, they felt the questions prior to the introduction of Antibiotic Check-in and Health Check-in were too generic.

Low-Adoption Cluster (Clinics G-I)

The third group perceived the value proposition, adopter system, organization, and embedding as complex. Like clinics D-E, these providers had a negative experience of advocating for a privately owned app. They were among the first to adopt the innovation, at a point where app features were minimal and the app was limited to 1 platform. They felt that this effort to get patients to use an underdeveloped app negatively impacted the patient-provider relationship. The SPC analysis for clinics H and I ( Figure 1 ) confirmed that early adopters struggled to maintain adoption as the user activity level either remained stable (clinic H) or decreased (clinic I). The addition of new features, although potentially increasing the value of the innovation, was offset by previous experiences, which had worn them out.

It is now actually that you should start trying to get patients to use [the innovation]. But in [this region], we have sort of worn ourselves out because we already did it 4-5 years ago. [HCP18, clinic H]

The innovation was seen as undesirable by most of the staff at these clinics, and they perceived their patients were equally uninterested. Several providers mentioned that patients do not want to “have their illness in an app,” as symptom tracking can become a reminder of how sick one has been and add yet another task, when patients with CF are already “drowning in health care” (HCP06). Some also felt adults have a hard time changing their ways. These opinions demonstrated a mismatch between the value of the technology and the needs and challenges related to the condition.

Adopter systems were deemed complex because, although at all clinics the staff had to learn new skills, the staff at clinics G-I felt the innovation poses a threat to their professional identity and scope of practice and felt patients find the innovation challenging. Clinicians preferred digital technologies available from the regions, rather than from a private company. Here, they referred to 1177 and Always Open as examples of such tools, which they also perceived served a clearer purpose. Clinicians were skeptical of how the app was introduced and that it did not come from within the clinic.

It was not we as providers who went to an app developer and said, “We want a tool.” Rather, it was they who came from the outside and said, “You need a tool, and here it is.” [HCP03, clinic G]

Clinicians at pediatric clinics believed there is a particular need for medication tracking among adult patients, whereas the staff at adult clinics expressed the opposite. Past experiences with other technological interventions and how well they were received also influenced how hesitant or open clinics were to innovation.

Organizations also demonstrated complexity; none of clinics G-I had integrated the innovation into their clinical workflow, and the innovation was used on an individual rather than on a team basis, which put pressure on the single user ( Multimedia Appendix 3 ). This was reinforced by the special cause variation observable in clinic G (consecutive points below/above the center line, months 69-83), where the activity dipped down before shooting up and could be linked to a champion staff member who led the adoption but left temporarily before returning. The clinics saw funding as a barrier to implementing new technologies, including the innovation. Clinic I mentioned a severe resource pressure, including hiring stops (frozen posts), which halted the use of the innovation, especially under the stress of the pandemic. The embedding system was complex due to the clinic’s inability to adapt the innovation use to critical and unforeseen events (eg, the COVID-19 pandemic).

Principal Findings

In this study, the adoption of a patient-driven innovation was studied using a complexity-based framework and tools for the introduction of technology in health care, NASSS-CAT. The innovation was developed as a patient-controlled information app to support the self-management of CF and communicate disease related–activity with health care providers. Although we found no evidence of nonadoption or clear abandonment of the app, distinct patterns of innovation adoption were discernable based on user activity data (ie, low, medium, and high adoption). The perceived value proposition of the technology and the experienced complexity were associated with different levels of adoption. Research activity and the introduction of new app features positively impacted adoption. In clinics that adopted the innovation early or those that relied on champions, user activity tended to plateau or decline, suggesting a negative impact on sustainability.

Perceived Complexity Influencing Adoption

There was little variation between clinics regarding perceptions of the condition and technology domains. Differences in complexity were seen within the value proposition, adopter system, organization, and embedding and adaptation domains. The more complex these domains were perceived to be, the lower the level of adoption was.

The perceptions of value identified in this study demonstrate a patient-provider interdependency (ie, both the provider and the patient must value and use the patient-driven innovation, or else it will lead to a downward spiral of abandonment). As Floch et al [ 8 ] found, “Self-management enfolds a collaboration between patients and [health care providers].” This suggests that studying providers’ experiences of using patient-driven innovations can be an important perspective as patients’ and providers’ behaviors are 2 sides of the proverbial same coin. One could expect that a patient-driven innovation, as an example of prosumerism, would entail a higher level of acceptance or be more highly valued than an innovation external to the clinical context.

All clinics seemed to agree that there is a clear need to focus clinic visits on what patients value. Where the value proposition was perceived as simple, HCPs saw the innovation as a solution, or at least worth testing as a solution. Although going through reports lengthened weekly previsit planning, the staff saw that the innovation enables shorter and more concise patient visits [ 9 ]. This mirrors the findings for another patient-centered care app for patients with CF [ 8 ]. Clinics with lower adoption described the innovation as interfering with the patient-provider interaction, since they believed they already knew their patients well due to the chronic nature of CF and perceived the app as an affront to their professionalism. The time providers spent with their patients to elicit this information was seen as a demonstration of how they valued their patients. The difference between the 2 interpretations of value could be paraphrased, from the perspective of the professional, as “we value our patients’ time” versus “we value our time with patients.” In the former, providers focus on what matters to the patient with the help of the innovation; in the latter, providers try to find out what is the matter with the patient through a person-to-person conversation without the innovation and the information it provides.

In terms of working with the adopter system and organization, our findings suggest a need to work with the context to integrate a new patient-driven innovation in health care. In this respect, despite prosumerism, this patient-driven innovation is not different from other innovations in health care [ 33 ]. Working with a broader group of adopters, not just champions, and integrating the patient-driven innovation with care processes appeared to facilitate adoption. If context is not addressed by suppliers, there is a risk that the perceived value of the innovation will be influenced by the perceived complexity of the setting. This lived experience of complexity could not be explained in terms of differences in the medical condition or technology. Instead, it appeared to be more dependent on how care processes had evolved and the human (in)ability to deal with variation, uncertainty, complexity, and ambiguity in everyday work life: complexity was in the eye of the beholder.

Co-ownership and Trust

When the app was first launched, the company took responsibility for staff and patient education, with the intention of having as little disturbance as possible in the clinics. However, clinics that took shared responsibility for the patient-driven rollout had higher and sustained adoption levels. As studies in behavioral economics have demonstrated [ 41 ], a higher level of perceived co-ownership leads to a higher evaluation of the object in question. Co-ownership invites the staff to learn and understand more about the patient-driven innovation, which could explain why merely relying on champions can be associated with lower adoption and responsibility for patient training and research with higher adoption.

Most clinics raised questions about the financial motives of the company behind the patient-driven innovation. Two clinics questioned whether it is appropriate for them as medical providers to “sell” a product from a private company. Particularly, during the early rollout, the staff felt that pushing a premature version of the innovation on patients is a violation of their professional integrity. The distrust of a private business overshadowed the patient-driven prosumer nature of the innovation that should have engendered trust. This distrust could be related to a commonly held negative view of privatization in Sweden or may indicate that the company’s patient origins had not been communicated clearly.

Utility of NASSS-CAT

This study used NASSS-CAT as a framework and tool to analyze the implementation of a patient-driven innovation. We found it helpful to characterize single domains but less suitable to explore the interaction between domains. The framework is innovation centric, which risks generating a bias that values innovation per se regardless of its suitability for addressing the challenge at hand or the purpose of the hosting clinic or organization.

Another issue relates to the essence of the complexity captured with CAT. Our findings support the basic tenet of NASSS-CAT that adoption is inversely related to the level of complexity. However, a closer look into the data suggests that what was captured may have been individuals’ perceptions of complexity related to lived experiences rather than the actual contextual complexity related to the level of interdependency. This corroborates preliminary observations of the original CAT [ 29 ]. Thus, results may be more indicative of the maturity of the complexity mindset of individuals [ 42 ] rather than the contextual complexity itself. To develop adoption strategies based on such data would be tantamount to developing treatment strategies based on an incorrect diagnosis.

A more accurate assessment of contextual complexity could be achieved by exploring the level of agreement between understanding the challenge and the proposed response [ 25 , 26 , 43 ]. These 2 questions are simpler to ask and evaluate to generate actionable data: less agreement would suggest a higher degree of complexity and therefore a need for strategies that facilitate learning [ 43 , 44 ]. More direct implementation works when things are simple (ie, greater agreement).

Strengths and Limitations

Directed content analysis inherently has some biases due to the use of a preselected theory [ 39 ]. However, several measures were taken to mitigate this limitation. For example, we used open-ended questions in the interview guide, and multiple authors were involved in all the steps of the qualitative analysis.

There was variation in the number of participants per clinic, which could have influenced the analysis. Clinics where the innovation was perceived more positively and used to a greater degree also tended to yield more interviews. This difference may reflect both resource availability and the perceived value of the innovation. Overall, the number of interview participants was limited by the number of employees at each clinic and the COVID-19 pandemic. The literature suggests that theoretical saturation is usually attained at around 12 interviews [ 45 ]. This exceeds the number of staff members working with the innovation in most of the clinics we studied. Despite our small sample size, the participants’ specific knowledge about the innovation and the care processes in each clinic contributed to strengthening information power [ 46 ]. Moreover, the triangulation of qualitative and quantitative data strengthened the trustworthiness of the findings.

Not all clinics provided feedback on the process maps, although all were given the opportunity. To further improve trustworthiness, process maps were checked again against the transcripts and reviewed by the developer’s clinic coordinator, who had insight into the clinics and staff.

The total number of potential users was limited because the innovation was first released in an iOS version only. As we did not have data on the proportion of potential users who had an iOS smartphone, we may have overestimated the number of potential users, in particular prior to the release of the Android version.

This study did not examine patient outcomes related to the innovation or satisfaction with the innovation. Interviewing patients and informal caregivers would add valuable perspectives to that of providers.

Patient-driven innovations could be highly relevant for health care, but their adoption has seldom been explored from the perspective of health care providers. We found that providers play a significant role in the adoption of patient-driven innovations in health care: patients cannot do it alone. Health care providers who make an effort to reduce the perceived complexity in the adoption process, simplify their processes, take co-ownership of the innovation, and work on its adoption and improvement as a team, rather than relying on change champions, improve their capability to support the adoption and sustainability of innovative ideas developed by patients. For patient-driven innovations to be adopted and sustained in health care, understanding patient-provider interdependency and providers’ perspectives on what generates value is essential.

Acknowledgments

The authors acknowledge the contributions of Rafiq Muhammad to the statistical process control analyses and the valuable input of Henna Hasson and other members of the Patient in the Driver’s Seat research program to the manuscript draft. A hallmark of the research program is that the team, which includes patients and patient-innovators, has involved co-creative efforts throughout all aspects of the research process, including meta-level discussions on how our different perspectives influence the research process.

This work was financially supported by the Swedish Research Council for Health, Working Life and Welfare (grant number 2018-01472). The funders had no involvement in the study design; in the collection, analysis, and interpretation of the data; in the writing of the report; and in the decision to submit the paper for publication.

Data Availability

No additional data are available. The data sets generated and analyzed during this study are available from the corresponding author upon reasonable request.

Authors' Contributions

CS, PM, and AH were responsible for conceptualization, with input from JLL, MMC, CW, JB, GO, and members of the Patient in the Driver’s Seat research program. The interview guide was developed by JLL, MMC, JB, CS, and PM. Data collection was conducted by JLL and MMC, with support from CS. Qualitative data analysis was conducted by JLL, MMC, and CS. Statistical process control (SPC) analysis was conducted and interpreted by JLL, MMC, PM, CS, and Rafiq Muhammad. JB and CW provided input on the interpretation of the results. SPC graphs were compiled by JLL. The manuscript was drafted by CS, JLL, MMC, JB, and PM. The manuscript was revised by CS, JLL, MMC, and PM, with input from JB, AH, CW, and GO. AH and JB were involved in the revision of the manuscript and in the decision to submit the paper for publication. CW, CS, PM, and AH were coapplicants of the funding grant, with Professor Henna Hasson as program lead. CS and PM served as principal investigators.

Conflicts of Interest

AH and JB are employees of Upstream Dream, the company that developed the innovation. Upstream Dream was not involved in the study design but did facilitate data collection, and JB helped interpret the data based on knowledge of the participating CF clinics. To mitigate bias, interviews and preliminary analysis were conducted without participation of the supplier. AH and JB were interviewed, and their transcripts were subjected to the same data analysis methods, kept separate from the analyses of the other participants, and then used for clarification purposes for the statistical process control timeline analysis and complexity analysis.

Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

Interview guide.

Nonadoption, abandonment, spread, scale-up, and sustainability (NASSS) domain areas and case-specific descriptions.

Process maps.

Batalden M, Batalden P, Margolis P, Seid M, Armstrong G, Opipari-Arrigan L, et al. Coproduction of healthcare service. BMJ Qual Saf. Jul 2016;25(7):509-517. [ FREE Full text ] [ CrossRef ] [ Medline ]
Tapscott D, Williams A. Wikinomics: How Mass Collaboration Changes Everything. New York. Portfolio; 2006.
Reinius M, Mazzocato P, Riggare S, Bylund A, Jansson H, Øvretveit J, et al. Patient-driven innovations reported in peer-reviewed journals: a scoping review. BMJ Open. Jan 24, 2022;12(1):e053735. [ FREE Full text ] [ CrossRef ] [ Medline ]
Dahlberg M, Lek M, Malmqvist Castillo M, Bylund A, Hasson H, Riggare S, et al. Objectives and outcomes of patient-driven innovations published in peer-reviewed journals: a qualitative analysis of publications included in a scoping review. BMJ Open. Jun 01, 2023;13(6):e071363. [ FREE Full text ] [ CrossRef ] [ Medline ]
Elborn JS. Cystic fibrosis. Lancet. Nov 2016;388(10059):2519-2531. [ CrossRef ]
Sawicki GS, Sellers DE, Robinson WM. High treatment burden in adults with cystic fibrosis: challenges to disease self-management. J Cyst Fibros. Mar 2009;8(2):91-96. [ FREE Full text ] [ CrossRef ] [ Medline ]
Ziaian T, Sawyer MG, Reynolds KE, Carbone JA, Clark JJ, Baghurst PA, et al. Treatment burden and health-related quality of life of children with diabetes, cystic fibrosis and asthma. J Paediatr Child Health. Oct 08, 2006;42(10):596-600. [ CrossRef ] [ Medline ]
Floch J, Vilarinho T, Zettl A, Ibanez-Sanchez G, Calvo-Lerma J, Stav E, et al. Users' experiences of a mobile health self-management approach for the treatment of cystic fibrosis: mixed methods study. JMIR Mhealth Uhealth. Jul 08, 2020;8(7):e15896. [ FREE Full text ] [ CrossRef ] [ Medline ]
Longacre M, Grande S, Hager A, Montan M, Bergquist RP, Martensson M, et al. Clinical adoption of mHealth technology to support pediatric cystic fibrosis care in Sweden: qualitative case study. JMIR Pediatr Parent. Dec 10, 2018;1(2):e11080. [ FREE Full text ] [ CrossRef ] [ Medline ]
Rutland SB, Bergquist RP, Hager A, Geurs R, Mims C, Gutierrez HH, et al. A mobile health platform for self-management of pediatric cystic fibrosis: qualitative study of adaptation to stakeholder needs and integration in clinical settings. JMIR Form Res. Jan 26, 2021;5(1):e19413. [ FREE Full text ] [ CrossRef ] [ Medline ]
Hager A, Lindblad S, Brommels M, Salomonsson S, Wannheden C. Sharing patient-controlled real-world data through the application of the theory of commons: action research case study. J Med Internet Res. Jan 19, 2021;23(1):e16842. [ FREE Full text ] [ CrossRef ] [ Medline ]
Tiase VL, Hull W, McFarland MM, Sward KA, Del Fiol G, Staes C, et al. Patient-generated health data and electronic health record integration: protocol for a scoping review. BMJ Open. Dec 17, 2019;9(12):e033073. [ FREE Full text ] [ CrossRef ] [ Medline ]
Shaw RJ, Boazak M, Tiase V, Porter G, Wosik J, Bumatay S, et al. Integrating Patient-Generated Digital Health Data into Electronic Health Records in Ambulatory Care Settings: An Environmental Scan. Report No.: AHRQ Publication No. 21-0031. Rockville, MD. Agency for Healthcare Research and Quality; 2021.
Wannheden C, Hasson H, Hager A, Karlgren K, Pukk Härenstam K. Now what? Collective sensemaking and sensegiving in the cystic fibrosis community in Sweden during the initial phase of the COVID-19 pandemic. Health Commun. Dec 17, 2023;38(14):3102-3112. [ CrossRef ] [ Medline ]
Cresswell K, Sheikh A. Organizational issues in the implementation and adoption of health information technology innovations: an interpretative review. Int J Med Inform. May 2013;82(5):e73-e86. [ CrossRef ] [ Medline ]
Standing C, Standing S, McDermott M, Gururajan R, Kiani Mavi R. The paradoxes of telehealth: a review of the literature 2000–2015. Syst Res. Dec 01, 2016;35(1):90-101. [ CrossRef ]
Sligo J, Gauld R, Roberts V, Villa L. A literature review for large-scale health information system project planning, implementation and evaluation. Int J Med Inform. Jan 2017;97:86-97. [ CrossRef ] [ Medline ]
Greenhalgh T, Papoutsi C. Spreading and scaling up innovation and improvement. BMJ. May 10, 2019;365:l2068. [ FREE Full text ] [ CrossRef ] [ Medline ]
Riggare S. Patient researchers — the missing link? Nat Med. Oct 07, 2020;26(10):1507-1507. [ CrossRef ] [ Medline ]
Greenhalgh T, Wherton J, Papoutsi C, Lynch J, Hughes G, A'Court C, et al. Analysing the role of complexity in explaining the fortunes of technology programmes: empirical application of the NASSS framework. BMC Med. May 14, 2018;16(1):66. [ FREE Full text ] [ CrossRef ] [ Medline ]
Greenhalgh T, Wherton J, Papoutsi C, Lynch J, Hughes G, A'Court C, et al. Beyond adoption: a new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies. J Med Internet Res. Nov 01, 2017;19(11):e367. [ FREE Full text ] [ CrossRef ] [ Medline ]
Pettigrew A, Whipp R. Managing Change for Competitive Success. Oxford, UK. Blackwell Publishing; 1991.
Mazzocato P, Thor J, Bäckman U, Brommels M, Carlsson J, Jonsson F, et al. Complexity complicates lean: lessons from seven emergency services. J of Health Org and Mgt. May 13, 2014;28(2):266-288. [ CrossRef ]
Chambers DA, Glasgow RE, Stange KC. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implement Sci. Oct 02, 2013;8(1):117. [ FREE Full text ] [ CrossRef ] [ Medline ]
Storkholm M, Mazzocato P, Savage C. Make it complicated: a qualitative study utilizing a complexity framework to explain improvement in health care. BMC Health Serv Res. Nov 14, 2019;19(1):842. [ FREE Full text ] [ CrossRef ] [ Medline ]
Stacey R. Strategic Management and Organisational Dynamics: The Challenge of Complexity to Ways of Thinking about Organisations (6th Edition). London, UK. Pearson; 2011.
Holland J. Hidden Order: How Adaptation Builds Complexity. Reading, MA. Addison-Wesley; 1995.
Waldrop M. Complexity: The Emerging Science at the Edge of Order and Chaos. New York. Simon & Schuster; 1992.
Greenhalgh T, Maylor H, Shaw S, Wherton J, Papoutsi C, Betton V, et al. The NASSS-CAT tools for understanding, guiding, monitoring, and researching technology implementation projects in health and social care: protocol for an evaluation study in real-world settings. JMIR Res Protoc. May 13, 2020;9(5):e16861. [ FREE Full text ] [ CrossRef ] [ Medline ]
Tong A, Sainsbury P, Craig J. Consolidated Criteria for Reporting Qualitative Research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. Dec 2007;19(6):349-357. [ FREE Full text ] [ CrossRef ] [ Medline ]
Grande SW, Longacre MR, Palmblad K, Montan MV, Berquist RP, Hager A, et al. Empowering young people living with juvenile idiopathic arthritis to better communicate with families and care teams: content analysis of semistructured interviews. JMIR Mhealth Uhealth. Feb 22, 2019;7(2):e10401. [ FREE Full text ] [ CrossRef ] [ Medline ]
Yin RK. Case Study Research: Design and Methods. Third Edition. Thousand Oaks, CA. SAGE Publications; 2003.
Sacchi C, Andersson K, Roczniewska M, Luckhaus JL, Malmqvist M, Rodmalm LP, et al. Mind the gap: analysis of two pilot projects of a home telehealth service for persons with complex conditions in a Swedish hospital. BMC Health Serv Res. May 09, 2023;23(1):463. [ FREE Full text ] [ CrossRef ] [ Medline ]
Benneyan JC, Lloyd RC, Plsek PE. Statistical process control as a tool for research and healthcare improvement. Qual Saf Health Care. Dec 01, 2003;12(6):458-464. [ FREE Full text ] [ CrossRef ] [ Medline ]
Montgomery D. Introduction to Statistical Process Control. Hoboken, NJ. John Wiley & Sons; 2005.
Thor J, Lundberg J, Ask J, Olsson J, Carli C, Härenstam KP, et al. Application of statistical process control in healthcare improvement: systematic review. Qual Saf Health Care. Oct 01, 2007;16(5):387-399. [ FREE Full text ] [ CrossRef ] [ Medline ]
A guide to creating and interpreting run and control charts: turning data into information for improvement. NHS Institute for Innovation and Improvement. 2009. URL: https://www.england.nhs.uk/improvement-hub/wp-content/uploads/sites/44/2017/11/A-guide-to-creating-and-interpreting-run-and-control-charts.pdf [accessed 2024-07-04]
Storkholm MH, Mazzocato P, Savage M, Savage C. Money's (not) on my mind: a qualitative study of how staff and managers understand health care's triple Aim. BMC Health Serv Res. Jan 31, 2017;17(1):98. [ FREE Full text ] [ CrossRef ] [ Medline ]
Hsieh H, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. Nov 2005;15(9):1277-1288. [ CrossRef ] [ Medline ]
Oates G, Mims C, Geurs R, Bergquist R, Hager A, Guimbellot J, et al. Mobile health platform for self-management of pediatric cystic fibrosis: impact on patient-centered care outcomes. J Cyst Fibros. Sep 2023;22(5):823-829. [ FREE Full text ] [ CrossRef ] [ Medline ]
Norton MI, Mochon D, Ariely D. The IKEA effect: when labor leads to love. J Consum Psychol. Sep 09, 2011;22(3):453-460. [ CrossRef ]
Kegan R, Laskow LL, Miller M, Fleming A, Helsing D. An Everyone Culture: Becoming a Deliberately Developmental Organization. Boston, MA. Harvard Business Review Press; 2016.
Heifetz RA. Leadership Without Easy Answers. Cambridge, MA. The Belknap Press of Harvard University Press; 1994.
Snowden D, Boone M. A Leader’s Framework for Decision Making. Boston, MA. Harvard Business Review Press; 2007.
Guest G, Bunce A, Johnson L. How many interviews are enough?: an experiment with data saturation and variability. Field Methods. Jul 21, 2016;18(1):59-82. [ CrossRef ]
Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual Health Res. Nov 27, 2016;26(13):1753-1760. [ CrossRef ] [ Medline ]

Abbreviations

complexity assessment tool

cystic fibrosis

health care professional

lower control limit

mobile health

nonadoption, abandonment, spread, scale-up, and sustainability

registered nurse

statistical process control

upper control limit

Edited by T de Azevedo Cardoso; submitted 04.07.23; peer-reviewed by D Rose, G Akrong; comments to author 06.03.24; revised version received 08.04.24; accepted 20.06.24; published 31.07.24.

©Pamela Mazzocato, Jamie Linnea Luckhaus, Moa Malmqvist Castillo, Johan Burnett, Andreas Hager, Gabriela Oates, Carolina Wannheden, Carl Savage. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 31.07.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research (ISSN 1438-8871), is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.

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Int J Health Policy Manag
v.6(10); 2017 Oct

Professionalizing Healthcare Management: A Descriptive Case Study

Erika l. linnander.

1 Yale School of Public Health, Yale University, New Haven, CT, USA.

2 Yale Global Health Leadership Institute, Yale University, New Haven, CT, USA.

Jeannie M. Mantopoulos

Nikole allen, ingrid m. nembhard, elizabeth h. bradley.

Despite international recognition of the importance of healthcare management in the development of high-performing systems, the path by which countries may develop and sustain a professional healthcare management workforce has not been articulated. Accordingly, we sought to identify a set of common themes in the establishment of a professional workforce of healthcare managers in low- and middle-income country (LMIC) settings using a descriptive case study approach. We draw on a historical analysis of the development of this profession in the United States and Ethiopia to identify five common themes in the professionalization of healthcare management: (1) a country context in which healthcare management is demanded; (2) a national framework that elevates a professional management role; (3) standards for healthcare management, and a monitoring function to promote adherence to standards; (4) a graduatelevel educational path to ensure a pipeline of well-prepared healthcare managers; and (5) professional associations to sustain and advance the field. These five components can to inform the creation of a long-term national strategy for the development of a professional cadre of heathcare managers in LMIC settings.

Effective healthcare management is essential for the creation of a high performing healthcare delivery system. 1 - 3 A number of studies have demonstrated the link between management capacity and health systems performance, 4 - 11 and the lack of managerial capacity at all levels has been cited as a key constraint in the achievement of the Millennium Development Goals and other global health targets. 12 Healthcare management – defined as the process of achieving healthcare objectives through human, financial, and technical resources 13 – includes strategic and operational management activities such as supply chain management, human resources management, performance management and improvement, financial management, and governance, without which resources cannot be effectively deployed to maximize health outcomes. 14

Healthcare management is particularly critical in the public sector of low- and middle-income countries (LMICs) where resources are inadequate and efficiency in their deployment is essential to meet the national and global targets for health outcomes. In many LMIC settings, physicians are called upon to fill healthcare management roles because of their level of education, respected status in society, and clinical/technical expertise related to the services being offered. 15 , 16 However, physicians typically lack previous management-related training, mentorship, and professional development 15 that would prepare them for these roles. Clinicians in managerial roles are often asked to simultaneously continue their clinical practice, a dual role associated with low job satisfaction, burnout, and attrition from the workforce. 17 , 18

Despite international recognition of the importance of healthcare management in the development of high-performing systems, 1 - 3 and the positive association between managerial training programs and healthcare quality, 19 - 22 the path by which countries may develop and sustain a professional healthcare management workforce has not been articulated. Accordingly, we sought to identify a set of common themes for establishing and sustaining a professional workforce of healthcare managers in LMIC settings using a descriptive case study approach. This paper can catalyze reflection on broader efforts to build health care management capacity, and guide LMICs as they consider alternative strategies for health management workforce development as a critical component of health systems strengthening.

Over the past 10 years, Ethiopia has achieved significant progress toward global health targets, and is credited with ambitious investment in both hospital quality and access to primary care. 23 - 25 To promote these improvements, the Ministry of Health prioritized the development of management capacity, with initial emphasis on hospital management. 26 This 10-year arc of national reforms provide an ideal context in which to study the emergence of a professional cadre of health care managers in an LMIC setting.

Using a descriptive case study approach, 27 , 28 we sought to compare the path of the development of the profession of healthcare management in Ethiopia with experiences in the professionalization of healthcare management in the United States. We selected these two countries as paradigmatic cases 29 through which to identify convergent and divergent experiences between country settings, resulting in a set of themes for future testing.

To understand the history of healthcare management in the United States, we conducted a semi-structured review of the peer-reviewed and grey literature, with emphasis on historical descriptions from healthcare management textbooks and published historical syntheses provided by relevant professional associations. To describe the more recent history of healthcare management in Ethiopia, we drew on a decade of our experience implementing and evaluating efforts to build management capacity in Ethiopia. 5 , 7 , 30 - 32 We supplemented this experience with study of the peer-reviewed literature, starting with country-specific searches for “health management” and “healthcare management,” reviewing abstracts to identify relevant resources, and following up on references as appropriate.

Common Themes in Professionalization

Many prominent development organizations, including the World Health Organization (WHO), the World Bank, and numerous others, have attempted to address gaps in healthcare management capacity through in-service training and mentoring programs. 15 , 19 While short-courses and applied training programs can be a helpful stopgap for the healthcare professionals who find themselves in managerial roles, we envision a broader, more strategic set of common themes in the transition toward a comprehensively prepared, professional workforce of health managers ( Box 1 ).

Box 1. Common Themes in the Professionalization of Healthcare Management

A country context in which healthcare management is demanded
A national framework that elevates a professional management role
Standards for healthcare management, and a monitoring function to promote adherence to standards
A graduate-level educational path to ensure a pipeline of well-prepared healthcare managers
Professional associations to sustain and advance the field

Theme 1: A Country Context in Which Management Expertise Is Demanded

The first common theme in the professionalization of healthcare management in the United States and Ethiopia was a shift in country context toward increased demand for the expertise of a cadre of health managers . In the United States, calls for the professionalization of healthcare management began in the early 1900s as medical discoveries (eg, the advent of antisepsis and anesthesia, the development of modern surgery, and the discovery of antibiotics) attracted patients to seek medical care in hospitals as opposed to being treated at home. 33 , 34 During this time, the hospital industry in the United States grew from 4 hospitals and 780 beds per million people in 1875 to about 60 hospitals and 7400 beds per million people in 1925. 33 , 35

The severe economic constraints of the Great Depression in the late 1920s and early 1930s accentuated the need for healthcare administrators who could apply business acumen in the large and growing hospital sector. In 1932, The Committee on the Costs of Medical Care highlighted this evolving need for more sophisticated management of medical care 33 :

“ Hospitals and clinics are not only medical institutions, they are also social and business enterprises, sometimes very large ones. It is important, therefore, that they be directed by administrators who are trained for their responsibilities and can understand and integrate the various professional, economic, and social factors involved. ”

Academics took up the challenge as Michael Davis from the University of Chicago published Hospital Administration, A Career: The Need for Trained Executives for a Billion Dollar Business, and How They May Be Trained in 1929. 33 The hospital industry trade journals followed suit, underscoring the increasing pressure to manage dwindling resources. As Malcom Meacher wrote in 1932 in the Bulletin of the American Hospital Association (AHA):

“Stock crashes, bank failures, frozen assets, depreciated earnings, diminished benefactions, together with lessened payment by patients and decreasing departmental earnings and all that comes in the wake of these, have depleted the hospital treasury. Hospital trustees and executives are staggering under the valiant attempt to maintain adequate standards in order to insure safe and efficient care of their patients.” 36

In Ethiopia, the demand for the expertise in healthcare management was driven by several factors. First, having met basic standards for access to primary care, the Ministry of Health shifted its focus to promoting the quality of medical care, particularly as a growing middle class demanded better healthcare services. Increasing demand for management expertise has also resulted from Ethiopia’s efforts to decentralize governance and control of finances to the hospital and district health office level improve healthcare system responsiveness and efficiency. 37 , 38 Additionally, the increasing complexity of the health sector (eg, the introduction of third party financing, quality monitoring, and growing regulatory efforts) required more nuanced managerial approaches to successfully navigate. Taken together, these contextual factors generated demand for managerial competencies and set the stage for a movement toward professionalization—a movement supported by investment in the next four thematic areas.

Theme 2: A National Framework That Elevates a Professional Management Role

The second common theme in the professionalization of healthcare management in the United States and Ethiopia was a national framework or set of supporting policies that elevated the professional management role to attract, empower, and reward management expertise. As in many LMIC settings today, most hospitals in the United States in the 1920s and 1930s were led by clinicians who acquired administrative responsibilities with no formal training or experience in administration. 33 This later evolved into the esteemed Chief Executive Officer (CEO) position, a highly selective role with authority to lead and affect change in the organization.

An exemplar of this type of reform comes from Ethiopia, where a 10-year investment in hospital management was grounded in reform of civil service regulations to achieve the following: (1) creation of a full-time CEO role with clear and comprehensive job responsibilities, as well as selection and performance review criteria, 26 , 30 , 39 (2) establishment of governing boards to manage CEO performance and hold the position accountable to both the government and the community, 32 and (3) creation of locally-controlled revenue streams to reward good management and entrepreneurialism (eg, the endorsement of private wings in Ethiopia’s public hospitals and policies to allow for local retention of revenue for future health system investment). 40 - 43 This CEO role, shown to be fulfilled successfully by physicians or non-physicians, 44 presumes full-time dedication to management and leadership functions, involving both internal problem solving and strategic management of external community environments. 26 , 30 , 32 , 36 , 39 - 44

Theme 3: Standards for Healthcare Management, and a Monitoring Function to Promote Adherence to Standards

As professions emerge, a set of technical, ethical, and/or performance standards are used to define expectations for the profession. 45 In the United States, the earliest performance standards for healthcare management were codified at the organizational level (hospital accreditation), rather than the individual level (licensure). Professional healthcare managers were expected to create and maintain hospital management systems in compliance with accreditation standards.

Hospital accreditation was first established in the United States by the American College of Surgeons (ACS) in 1917. 46 The ACS’s “Minimum Standard for Hospitals” began as a single page of requirements, and evolved to become today’s Joint Commission, an independent accrediting body which authorizes over 21 000 healthcare organizations and programs in the United States. 47 Since the early 1990s, accreditation has been adopted in a number of LMICs as a strategy to improve basic health service quality. 48 Some of these accreditation programs have been launched as part of larger “pay for performance” financing reforms 49 - 54 ; others have emerged as government-led efforts to directly quantify and improve management capacity in meaningful ways.

In Ethiopia, the first set of hospital management standards (referred to as “the Blueprint”) were derived directly from government hospitals through the collaborative experiences of foreign healthcare management mentors and their local counterparts as part of the “Ethiopian Hospital Management Initiative,” a multi-year collaboration between the Federal Ministry of Health, the Clinton Health Access Initiative, and Yale University to improve hospital quality. 30 These management standards were subsequently endorsed by the Ministry of Health as the “Ethiopian Hospital Reform Implementation Guidelines” (EHRIG). Adherence to the EHRIG standards is now incorporated into Ethiopia’s hospital performance monitoring system as the first of 36 key performance indicators on which hospitals are evaluated by Ministry of Health officials. 55 - 57

Theme 4: A Graduate-Level Educational Path to Sustain a Pipeline of Well-Prepared Healthcare Managers

The fourth common theme in the United States and Ethiopia was the establishment of a well-respected, graduate-level educational path to attract, equip, and sustain a high-level professional cadre . The educational path should provide both didactic and practical preparation. Such a combination of classroom studies and fieldwork was used in the earliest healthcare administration programs in the United States, and continues today. The first bachelors-level program was established at Marquette University in 1926, but the professional status of the field was elevated when, in 1934, the University of Chicago developed the first graduate program in hospital administration based on the model of one year of coursework followed by one year of practical experience called an administrative residency. Other universities replicated this model, and the number of graduate programs in healthcare administration grew from 9 programs in the 1940s to 18 programs by the 1950s and 33 programs by the 1960s. 58 In 1968, the Accrediting Commission on Graduate Education for Hospital Administration, known today as the Commission on Accreditation of Healthcare Management Education, was incorporated as the accrediting agency for graduate programs in health administration. Today, the United States has 88 accredited graduate programs in healthcare management and administration. 59

In many LMICs, graduate-level educational programs in healthcare management are few in number. 19 - 21 , 60 As a cornerstone of their hospital reform efforts, and with initial focus on the newly-created CEOs described above, Ethiopia established its first Masters in Healthcare Administration (MHA) at Jimma University in 2009. By 2016, MHA programs were offered by five public universities across the country. 7 , 22 , 39 These curricula combined didactic education and mentored independent fieldwork, and engaged well-respected national and international academic institutions. As a signal of political commitment to the profession and the individual participants, the Ministry of Health covered the costs of participation in early student cohorts.

Theme 5: Professional Associations to Sustain and Advance the Field

Professional associations provide both the networking and career development opportunities required for a new cadre of professional health managers to continue to elevate, advocate for, and sustain their roles within countries. In the United States, the first professional association in hospital administration dates back to 1899, when hospital superintendents, predecessors to the CEO role, came together to understand and navigate their increasingly complex US healthcare landscape. Even before the creation of the first graduate program in hospital administration in the United States, a group of practicing administrators founded the American College of Hospital Administrators in 1933 (now the American College of Healthcare Executives [ACHE]), with an emphasis on non-clinical administrators. 58 Today, ACHE boasts almost 50 000 members across 79 chapters, offers board certification for healthcare executives, and convenes members for continuing education, networking, and mentoring through both an annual Congress and regional chapter events, all in service to the holistic development of the profession. 61 , 62

In contrast, investments in healthcare management in the Ethiopian context have been driven primarily by the Ministry of Health and development partners. MHA program alumni have come together to form the country’s first Ethiopian Society of Healthcare Administrators to advocate for the profession, influence supporting policy, and promote continuing professional development opportunities. Professional associations like this one may help to promote the continued growth and evolution of the newly-established profession as it gains a foothold, but this potential impact is yet to be demonstrated.

This paper outlines five components that can inform the creation of a long-term national strategy for the development of a professional cadre of healthcare managers in LMIC settings. The five common themes – a demand for management expertise, elevation of the management role, standards for healthcare management systems, a graduate-level educational path, and professional associations – are synergistic. This type of holistic strategy, currently exemplified in Ethiopia, is unlikely to emerge without exceptional country leadership to align health policy reform, development partner investment, and university engagement. Commitment at all levels is critical, as large-scale shifts in professional trajectories take time, and investments in healthcare management capacity challenge the status quo on multiple levels 1 as empowered managers begin to advocate more proactively with government officials and clinical professional groups.

At the same time, it is important to consider the potential for unintended effects of professionalization. A more empowered cadre of healthcare executives has the potential to overpower the community voice in healthcare reform. 63 , 64 That said, community and client engagement is at the heart of effective management practices, and approaches to amplify the perspectives of community members (eg, the use of community scorecards and creation of community member seats on governing boards) are commonly promoted in management education and professional standards. Professionalization may also result in fragmentation in the authority for management and clinical objectives. 65 Accordingly, management education and career development programs must equip healthcare managers to work effectively across boundaries between management and clinical professionals. In high-income countries, healthcare organizations include clinicians and non-clinicians in both senior management and governing board roles, and quality improvement projects and approaches commonly bridge professional and organizational boundaries to address complex challenges in pursuit of more effective healthcare. Ultimately, professionalization requires devolution of managerial authority, a power that could be corrupted. Our hope is that by establishing a national-level strategy, alignment can be found between regulatory, financing, education, and service delivery systems to create checks and balances across functions.

Our findings should be interpreted in light of the limitations of the study design. First, we highlighted a set of common themes rather than a causal explanation of how healthcare management becomes professionalized. Future prospective studies may be useful to assessing causal inferences. Nevertheless, the patterns identified provide useful insights about the professionalizing of healthcare management, and our findings are consistent with sociological study of professionalization in other technical fields, which emphasizes specialized training and expertise, authority and autonomy, regulation, and creation of group identity. 66 - 68 Second, our results are based on historical analysis and implementation experiences in two country settings, and results may differ in other country contexts. We anticipate that the specific design and timing of various components of professionalization must be tailored to the unique context of each country. 23 For example, in the United States, hospital standards generated by the ACS, as well as the establishment of the AHA and ACHE were early drivers of professionalization for healthcare managers. In other country contexts in which professional lobbies are not well developed or even discouraged, reform will likely start through centrally-driven initiatives. Additional implementation science research is required to understand the extent to which these themes are consistent with experiences in other LMIC country settings, and to evaluate the potentially synergistic impact of investment in some or all of these thematic areas. 69

The five interrelated themes presented here, identified through historical analysis and implementation experience across two very different country settings, may serve as guideposts as LMICs seek to move from discrete investments in management capacity toward a more strategic, sustainable plan for the development of a professional healthcare management workforce. A professional cadre of healthcare managers, able to effectively balance broader regulatory, financial, and service delivery reforms, is a solid foundation on which to build better health systems and, ultimately, improved health outcomes.

Ethical issues

Not applicable.

Competing interests

Authors declare that they have no competing interests.

Authors’ contributions

ELL and EHB conceived of the manuscript; all authors made substantive contributions to the perspective and reviewed and approved the final manuscript.

Authors’ affiliations

1 Yale School of Public Health, Yale University, New Haven, CT, USA. 2 Yale Global Health Leadership Institute, Yale University, New Haven, CT, USA.

Citation: Linnander EL, Mantopoulos JM, Allen N, Nembhard IM, Bradley EH. Professionalizing healthcare management: a descriptive case study. Int J Health Policy Manag. 2017;6(10):555–560. doi:10.15171/ijhpm.2017.40

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Betts Farm Case Study – Cover Cropping in Concord Grape Vineyards

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It started as an experiment…

In 2011, Betts planted several middle-row alleys with winter tillage radish in an effort to alleviate soil compaction. Radishes are brassicas that form a thick taproot, like a carrot, and are known to break up soil and scavenge excess nitrate. When the radish dies, the large taproot decays to create soil pores that encourage water infiltration and gas exchange. Betts strategically planted in rows with new tile drainage to see if soil pores would channel water to the tile lines below. The water infiltration improvement was evident, along with an unexpected benefit in the form of high biomass production, or the amount of living material generated from planting the cover crop (Figure 1). The Betts noticed more earthworm activity, soil stability, and a decrease in weed pest pressure in the middle rows where they planted the winter tillage radish.

Figure 1: Bob Betts proudly shows a well aggregated clod from a cover cropped area (left) and a compacted clod from a non-cover cropped area (right).

The success prompted Betts to expand his cover crop repertoire in 2012 by seeding alternating bands of annual ryegrass and radish seven inches apart, for a total of nine bands per middle-row. The ryegrass was intended to complement the large holes left by decayed radishes. which allowed for the water infiltration that they were hoping for, but also created unstable ground for tractor access. Adding the ryegrass species, that has an extensive, soil-holding root system, helps to stabilize the ground during wet periods to allow for easier tractor access. The experiment wasn’t entirely successful, as the radishes crowded out the ryegrass, a common occurrence if radish seeding rate is too high (one extra pound of radish seed per acre can make a huge difference) or there is high residual nitrogen in the soil.

Fortunately, financial help arrived in the form of the Environmental Quality Incentive Program (EQIP), a National Resource Conservation Service (NRCS) subsidy funding cover crop efforts to combat erosion and improve soil health. Betts took advantage of their prescribed mixes of three to seven different seed species, and worked with the Lake Erie Regional Grape Program (LERGP) to alternate mixed planting with fallow plots three panels long by three rows wide (24 X 9ft) to serve as an experimental control. This experiment block has been ongoing for eleven years.

The Betts Farms cover crop program has helped address many practical concerns, including erosion, summer moisture retention, and weed suppression. Betts has further innovated by initiating use of a 5-foot-wide I & J roller crimper in 2015 to terminate cover crops in June, an uncommon practice in Concord grape vineyards. Rolling the aboveground portion of the cover crop protects the soil from rain droplet impact, while cover crop roots hold soil in place during periods of intense rainfall (Figure 2). This decreases the runoff and erosion that may carry pesticides, valuable nutrients, and topsoil away from the grapevines. The roller treatment also addresses the concern that cover crops might compete with vines for soil moisture during times of drought, as the biomass mat created in early June shades the ground, retaining soil moisture. The mat also results in cooler surface temperatures, creating better soil microbe habitat than hot, dry, bare soil.

Both the actively growing cover crop and the biomass mat help suppress weeds, which is especially important for problematic annual species like Marestail ( Condyza canadensis ), a plant commonly resistant to glyphosate (Roundup). While Marestail was a significant problem in Betts Farms’ control rows, it was rare in cover cropped rows that had been rolled and crimped (Figure 2), which reduced his overall reliance on glyphosate. The biomass mat provided adequate weed prevention most years, and if it doesn’t, herbicide can be applied as needed.

field with rain-soaked grass (left), green bushy plants growing between vines (right)

Figure 2: A mat of rolled cover crop biomass protects soil during an intense rainfall event that delivered 5 inches in 2 hours on July 14th 2015 (left), cover crops reduce weed growth, as evident here: Marestail (Condyza canadensis) grows in control area, but not in the cover cropped portion behind it (right).

Soil Health Benefits

In addition to the ‘above ground’ benefits, visual inspection makes it obvious that life below ground has improved, too. Earthworms, nature’s plows, are increasingly prevalent. As earthworms eat, soil and decomposing organic matter are mixed together in their gut, then deposited as ‘casts’—stable assemblages of organic and mineral particles atop their burrows. These casts are more fertile than the surrounding soil and help increase nutrient availability for the shallow-rooted grapevines. Betts has also noticed increased lateral vine root growth in areas of increased earthworm activity.

To confirm the empirical observation of improved soil health, Betts worked with Cornell’s New York Soil Health Initiative in May 2021 to collect four composite soil samples from the cover crop and non-cover crop control treatments for a standard soil health assessment at the Cornell Soil Health Lab. Six, 0-6”soil slices were taken as composite samples from two locations within the experimental area, classified as a Barcelona silt loam, which is comprised of approximately 13% sand, 60% silt, and 27% clay.

The soil samples from the cover-cropped plots had consistently higher soil respiration (27%) and aggregate stability (58%) compared to the non-cover cropped plots (Table 1, Figure 2). Higher soil respiration indicates that cover crop biomass inputs are fueling soil microbe conversion of organic residues into mineral-accessible nutrients, such as nitrate and ammonium, faster than in the controlled plots. Higher aggregate stability measurements confirmed that the soil under cover crops was much better aggregated compared to the non-cover cropped, more compacted, soil (Table 1, Figure 3). Living roots, their associated mycorrhizal fungi (AMF), and increased organic matter all help build and maintain stable aggregates, which in turn support greater water infiltration and reduced topsoil erosion. This is evident in a comparison of respiration and aggregate stability values and soil health scores for the Betts Farms treatments compared to pastures and perennial fruit (orchards and vineyards) on silt loam soils in New York (Figure 3). No significant differences were observed in soil organic matter and active carbon, which may be due to high initial levels of soil organic matter and inherent site variability. There is an indication that cover crops make phosphorous (P) and potassium (K) more available, which could help increase vine productivity.

table with data on cover crop versus non-cover crop soil compositions and chemistries

Table 1: Cover crop (CC) vs. non-cover crop control (NCC) treatment effect for the Betts Farms vineyard in 2021. These values reflect the mean of two composite soil samples per treatment. The abbreviations in the table are as follows: Treatment (Trt), Soil Organic Matter (SOM), Respiration (Resp), Aggregate Stability (Agg Stab), Phosphorus (P), Potassium (K), Magnesium (Mg), Iron (Fe), Soil Health score (SH score), Cover Crop Treatment (CC), Non-Cover Crop Treatment (NCC).

charts with markings and standard deviation bars to show CO2 respiration (left) and percent aggregate stability (right)

Figure 3: Soil health benchmarking of Betts Farms soil respiration (a) and aggregate stability (b) compared to other pastures and perennial fruit systems on silt loam soils in NYS.

Vine Productivity Benefits

The ultimate test of any management system is its effect on productivity, and farmers dream of finding a win-win solution that both improves soil health and increases crop yield. Through pruning weight measurements taken between 2019-2021, vines in cover cropped plots where shown to have consistently higher pruning weights than control plots (Table 2). Pruning weights measure the annual growth removed from dormant vines as an indicator of larger vine size and potential crop yield, so higher pruning weights demonstrate that cover crops have improved soil health and nutrient availability, in turn supporting better vine growth. Conversely, loss in vine size would have indicated that cover crops competed with vines for water and nutrients. To verify this effect, crop yield data will be analyzed over the coming years to assess pruning weight trends.

table with data on pruning weights for 3 years in cover cropped vs. non-cover cropped areas

Table 2: Pruning weights for cover cropped and non-cover cropped areas between 2019-2021.

Bob Betts began his farm’s cover cropping trial in an attempt to reduce soil compaction, but found that it also led to improved soil health and vine productivity. This case study was instrumental in securing additional funding for Betts Farms, working with the Cornell Lake Erie Research and Extension Laboratory, NRCS, New York Soil Health Initiative at Cornell, and the New York Farm Viability Institute, to explore further research efforts designed to improve vineyard soil health and achieve farm goals. Stay tuned for more exciting vineyard cover crop innovations!

Jennifer Phillips Russo is an extension associate and viticulture specialist for Cornell Cooperative Extension. She is part of the Cornell Lake Erie Research Extension Laboratory (CLEREL) and serves as team leader for the Lake Erie Regional Grape Program . Bob Betts is the fourth-generation farmer and owner of Betts Farm in Westfield, NY. He is passionate about multi-species cover cropping research. Joseph Amsili is an extension associate and program coordinator with the Cornell Soil Health Program and New York Soil Health Initiative.

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Program Profile: Front-End Diversion Initiative

Evidence Rating: Promising | One study

Program Summary

This is a preadjudication diversion program designed to divert juveniles with mental health needs away from the juvenile justice system through specialized supervision and case management. The program is rated Promising. Participants were statistically significantly less likely to face adjudication compared to those who only received traditional supervision while on probation.

A Promising rating implies that implementing the program may result in the intended outcome(s).

Program Description

Program goals.

The Front-End Diversion Initiative (FEDI) seeks to divert juveniles with mental health needs from adjudication in the juvenile justice system by using specialized supervision and case management. FEDI was originally implemented in four Texas probation departments: in Bexar, Dallas, Lubbock, and Travis Counties. In Texas, probation intake is the gatekeeper to the juvenile court and therefore was an ideal point to implement a preadjudicatory diversion strategy. The primary diversion strategy was the use of specialized juvenile probation officers. The efforts of the initiative supported the development, implementation, and evaluation of the use of specialized juvenile probation officers.

Program Theory

A central aspect of FEDI is diversion, which is “an attempt to divert, or channel out, youths from the juvenile justice system” (Bynum and Thompson 1996). Diversion is based on the labeling theory, which suggests that processing certain youths through the juvenile justice system may do more harm than good because of the potential for stigmatization (Bynum and Thompson 1996).

In addition, youths with mental health disorders (such as anxiety disorders, depression, attention deficit/hyperactivity disorder) may be at greater risk of experiencing the negative consequences of juvenile justice system involvement. Anywhere from 50 percent to 70 percent of adolescents in the juvenile justice system suffer from a mental health disorder, compared with only 9 percent to 20 percent of adolescents in the general population (Colwell, Villarreal, and Espinosa 2012). Research suggests that those with mental health disorders are less capable of understanding the juvenile justice system, treated more harshly than those without a mental illness, and more vulnerable to delve further into the system as a result of their disorder (Colwell, Villarreal, and Espinosa 2012).

Target Population/Eligibility

As a result of the Texas Family Code, probation officers, the juvenile, and a caregiver have the ability to enter into an informal agreement of deferred prosecution for up to 6 months. To be eligible to participate in the FEDI program, juveniles had to qualify for deferred prosecution; receive MAYSI–2 scores that indicated additional mental health screening may be needed, such as four or more cautions or two or more warnings; have a current mental health diagnosis; and have a parent or guardian who is willing to participate in the program.

Program Components

The FEDI program used several specialized supervision and case management strategies that were considered best practices, such as small caseloads, specialized trained officers, internal and external service coordination, and active problem solving (Colwell Villarreal, and Espinosa 2012). In following this model, FEDI included specialized juvenile probation officers whose caseload did not have more than 15 juveniles with mental health needs, which is smaller than a traditional caseload for juvenile probation officers in Texas. These officers were trained in motivational interviewing, family engagement, crisis intervention, and behavioral health management.

Although all the various FEDI program sites implemented a similar framework, each site varied on specific program components. For example, in Dallas referrals to the FEDI program can be made by intake officers, psychological staff, deferred prosecution officers, field assessment officers, and the detention referee. Once a youth is determined eligible–following the same core criteria–a face sheet, MAYSI scores, a case history, a social history, and a psychological evaluation/screen (if available) must be submitted to the FEDI supervisor. Next, the FEDI supervisor assigns a probation officer to the case, who decides whether the FEDI program is appropriate for the youth based on the documentation provided, as well as on information gained through the Family Suitability Interview (Spriggs 2009).

If a child is accepted into the FEDI program, the initial case plan is completed within the first 72 hours. This plan includes the goals for the child and family to work toward, as well as services in the community. The plan also identifies the educational needs of a child and the child’s overall strengths and values. This plan is reviewed monthly during the youth’s participation in the FEDI program. Once a goal is obtained, the officer determines new goals for the child and family to work toward completing. Finally, once the program is completed the officer develops a discharge plan that links the child and family with services in the community (Spriggs 2009).

Evaluation Outcomes

Adjudication.

Colwell, Villarreal, and Espinosa (2012) found that juveniles who participated in the Front End Diversion Initiative (FEDI) program were less likely to face adjudication compared with those who only received traditional supervision while on probation. Only 7.7 percent of the FEDI treatment group were adjudicated, compared with 22.0 percent of the comparison group. This difference was statistically significant. .

Evaluation Methodology

In an effort to analyze the ability of the Front End Diversion Initiative (FEDI) program to divert juveniles from the juvenile justice system, Colwell, Villarreal, and Espinosa (2012) used a quasi-experimental design, with a treatment group consisting of 65 juveniles who received specialized supervision through FEDI and a comparison group consisting of 64 juveniles who received traditional supervision. The majority of participants in the study (64.3 percent) were male, and more than 80 percent of participants were minorities. Specifically, the comparison group was 80.5 percent Hispanic, 9.8 percent African American, 4.9 percent Anglo, 2.4 percent Asian, and 2.4 percent unknown or not reported. By contrast, the treatment group was 36.9 percent Hispanic, 36.9 percent African American, 15.4 percent Anglo, 1.5 percent Asian, 1.5 percent Native American, 4.6 percent other, and 3.1 percent unknown or not reported. Although youths in the treatment group had a mean age of 14, the mean age of youths in the comparison group was not provided. Participants were assigned to the two groups based on the availability of the specialized officer, as well as on the juvenile and his or her guardian’s willingness to participate. Juveniles in the comparison group were matched to juveniles in the treatment group on ethnicity, sex, age, MAYSI–2 scores, and offense.

Data were collected for the following items: demographics, information regarding deferment date, contacts made by the probation officers, links and referrals to community resources, active problem solving, and probation outcomes. A logistic regression was also used to predict adjudication based on four variables: 1) number of referrals to services, 2) number of contacts between the juvenile probation officers and others involved in the case, 3) active problem solving, and 4) caseload. Finally, although data was also collected on the Global Assessment of Functioning and the Ohio Scale, this information was collected only for the treatment group, not the comparison group, and therefore excluded from the outcome evaluation.

Implementation Information

To become specialized juvenile probation officers, the Front End Diversion Initiative (FEDI) required probation officers to receive training. The Specialized Officer Certificate Program included training in motivational interviewing, family engagement, crisis intervention, and mental health (Spriggs 2009). Download a copy of the FEDI Program Policy and Procedure Manual .

Evidence-Base (Studies Reviewed)

These sources were used in the development of the program profile:

Colwell, Brian, Soila F. Villarreal, and Erin M. Espinosa. 2012. “Preliminary Outcomes of a Preadjudication Diversion Initiative for Juvenile Justice Involved Youth With Mental Needs in Texas.” Criminal Justice and Behavior 39(4):447–60.

Additional References

Bynum, Jack E., and William E. Thompson. 1996. Juvenile Delinquency: A Sociological Approach (Third Edition) . Needham Heights, Mass: Allyson and Bacon.

Spriggs, Vicki. 2009. Front-End Diversion Initiative Program: Policy and Procedure Manual Overview . Austin, Texas: Texas Juvenile Probation Commission.

Related Practices

Following are CrimeSolutions-rated programs that are related to this practice:

An intervention strategy that redirects youths away from formal processing in the juvenile justice system, while still holding them accountable for their actions. The practice is rated Promising for reducing recidivism rates of juveniles who participated in diversion programming compared with juveniles who were formally processed in the justice system.

Evidence Ratings for Outcomes

Crime & Delinquency - Multiple crime/offense types

Why might a practice's outcome ratings differ from the ratings of specific programs encompassed by that practice?

Age: 12 - 16

Gender: Male, Female

Race/Ethnicity: Black, American Indians/Alaska Native, Asian/Pacific Islander, Hispanic, White, Other

Geography: Suburban Urban

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Program Type: Crisis Intervention/Response, Diversion, Family Therapy, Motivational Interviewing, Probation/Parole Services

Targeted Population: Mentally Ill Offenders, Young Offenders

Current Program Status: Active

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Ai-powered virtual assistants: beyond siri and alexa.

Posted on July 31, 2024 by Sapna Naga in R bloggers | 0 Comments

“We can only see a short distance ahead, but we can see plenty there that needs to be done.” ― Alan Turing

AI virtual assistants have become indispensable tools for both personal and professional settings. While Siri and Alexa are household names, the latest advancements in AI-powered virtual assistants offer capabilities that far surpass these early pioneers.

Remix Institute ’s founder, Douglas Davila-Pestana , had a good point when he posted on X: “ Even though Amazon sold millions of Alexa devices, I’ve never seen anyone actually use an Alexa. ”

Alexa used to be so popular that it became a go-to Christmas gift, often chosen when people had no idea what else to give. Now it’s an obsolete virtual assistant in the age of smarter AI assistants like ChatGPT and LegalMente AI’s Para .

So, let’s explore a few innovative AI virtual assistants on the market today that make Siri and Alexa look like children’s toys.

The New Wave of Virtual Assistants

Virtual assistants today are not just about setting reminders or playing music. They are integrated into sophisticated workflows, assisting in complex tasks and providing specialized support across various industries.

Healthcare: Personalized Patient Care

Financial Management: Streamlining Expense Management

Digital Management: Pioneering Personalized AI

Case Study: Para – LegalMente AI’s AI Paralegal Assistant

Features of Para:

Legal question answering:.

Para can provide accurate and timely answers to legal questions so you don’t have to spend hundreds of dollars to ask a lawyer.

Business Insights:

Para offers valuable insights to support informed business decisions.

Document Analysis:

Para efficiently analyses contracts, data files, and various legal documents, regardless of file format.

Business Formation Assistance:

Para helps guide users through the process of forming a business in the US such as an LLC or Corporation.

Impact of Para:

Para is fine-tuned with specialized expertise in the legal domain and guardrailed to prevent hallucinations. It’s more reliable to ask legal questions to Para compared to Google Gemini or ChatGPT . Para also maintains political neutrality and will politely decline to answer any questions related to politics, ensuring focused and unbiased legal assistance. Para assists small businesses, startups, healthcare providers, and individuals with their legal work without the burden of huge legal bills.

Meet Para, your free AI Paralegal assistant.

AI-powered virtual assistants have moved beyond basic functionalities, such as playing music or telling the weather, to become critical tools in various domains. Whether it’s healthcare, digital clones, customer service, or legal assistance, these advancements are making tasks easier, more efficient, and more personalized. As AI technology continues to evolve, we can anticipate even more innovative applications that will reshape how we interact with our digital environments.

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