Jennifer Bowerman (Department of Commerce, Grant MacEwan University, Edmonton, Canada.)

Leadership in Health Services

ISSN: 1751-1879

Article publication date: 6 July 2015



Bowerman, J. (2015), "Editorial", Leadership in Health Services, Vol. 28 No. 3. https://doi.org/10.1108/LHS-05-2015-0013



Emerald Group Publishing Limited


Article Type: Editorial From: Leadership in Health Services, Volume 28, Issue 3

Because I teach Organizational Behaviour, I take a keen interest in how organizations are structured and their style of leadership. One of my favourite articles of all time was written about Dee Hock’s role in Visa by M Mitchell Waldrop (Fast Company, 1996). The story goes that when first introduced, Visa credit cards reflected total disorganization, with banks competing with banks and trying to eat each other up, no rules, and everyone and their dogs receiving Visa cards in the mail or on the street corner. It was a chaos. Dee Hock is known as the savior of Visa. He knew that the heavily bureaucratized, structured, rule-bound organization type, which is so hard wired into our brains, had had its day. As he saw it, “the command and control structure in organizations is causing us to be on the brink of institutional failure.” He initiated a largely self-organizing movement where leaders came together, and worked out for themselves the absolute rules necessary for survival, but beyond that they were free to compete and innovate as much as possible. It was a harmonious blend of cooperation and competition. The organic and lateral structure they developed was not centralized, it was developed by the participants, and it was run by the participants. Today Visa is one of the most successful financial organizations in the world.

These ideas are energizing for students. Students tend to be enthusiastic about the idea of lateral, fluid and organic organizations. I too have learned a lot from Hock’s ideas. Every time, I feel as though I am in the midst of chaos and change, and everyone is looking to the centre for a strong leadership initiative to save them, I start looking at others and wonder how we can start working together to resolve the situation. I wonder what rules we would absolutely have to have to maintain the core vision but at the same time allow for maximum freedom. What are the key relationships? How can we make the system work – together – and not have a solution imposed from above – which we know from experience – never works!

As part of a class project to find out how work and organizations are changing over the generations, one of my student groups, after the Hock/Visa discussion, prepared a presentation and written paper on “the Changing Nature of Work”. The students interviewed some of their relatives, from different generations each of whom had a background in medicine and health. They gathered their information from three physicians, a nurse, and a paramedic about how each had experienced changes in their various professions over the course of their working lives. Recognizing that this was not scientific research, their presentation turned out to be rich in narrative and insight.

Much to their surprise, the group’s main finding was that instead of their medical relatives working in flatter organizations with blurred boundaries and increasing flexibility, they were in fact experiencing the opposite, much more bureaucratization, and many more control structures which affected and impeded their respective practices. They described the bureaucracy that people were encountering as “an intricate web”, which had come about as a result of increasing specialization and institutional structures. They spoke of “practice protocols, treatment guidelines and numerous requirements for authorizations.” Added to this were the demands of patients for immediate treatment, plus fear on the part of medical professionals of always being potentially challenged by law suits, resulting in “defensive” medicine, and a generally defensive approach to overall health care.

I was surprised by these students’ findings. Sure they mentioned the wonders of modern medicine, but overall they did not find the stories that the literature had told them to expect. It is ironic that as business teachers, we teach the need for flexibility and empowerment, where self-managed teams operate without the hierarchy, where the rules are few allowing for maximum flexibility and efficiency, where people come before profits and individuals can feel empowered, yet this is clearly not the reality people are encountering, particularly in health services.

How can we change things for the better? How can we make better sense of the complexity? It clearly takes time, and it often takes the courage to do things differently, to let go of the need to be in control. As well as waiting for the leadership to emerge, we must actively live our own personal leadership whatever the bureaucracy says to us! Goodness knows health services require leadership at all levels and in all places. Even our role with this journal is to be part of the movement that encourages this. We see the need to be a vehicle that shares leadership practices and successes amidst the chaos and complexity that we know to be out there.

For this issue, we have 6 articles some of which reflect the theme above. In particular, Peter Spurgeon asks whether we need medical leadership or medical engagement. He argues that what we need for overall system improvement is for medical leaders to go beyond the immediate concerns of their individual professional practice and explore ways of improving medical (and health outcomes) for entire communities. It is difficult to change an operating paradigm or mode of thought, to some extent we are all victims of tunnel vision. But like Spurgeon, I believe that with skill development, enhanced undergraduate and graduate curriculum and ongoing practice and reflection, it can be done.

Adding to the complexity of health care and service is that of dentistry. This particular journal has not received papers about this topic before, but given the increased importance being placed on oral hygiene and care as vital supports to overall health, perhaps this is a timely contribution. Author Dr Paul Brocklehurst describes the new initiative that allows General Dental Practitioners (GDPs) to participate in programs so that they can influence the way that services are delivered at a local level. Developing dental leadership for involvement in these types of programs is difficult, and Dr Brocklehurst highlights a Leadership Exploration and Discovery program (LEAD) that has been helpful at a clinical and strategic level in “enabling GDPs to better influence the world that sits outside their practice bubble”.

Kjeld Aij has contributed an article about US hospitals and the advantages of lean management in terms of improving quality of care outcomes. As the author notes, the journey to lean is a long one. Transformation does not occur over night. But the research suggests that lean manager traits are more prevalent in better performing hospitals, thus encouraging a lean management approach to health outcome improvement.

Kristina Westerberg‘s longitudinal study examines changes in commitment to organizational change among leaders in home help services in Sweden. Home help services have undergone a great many changes over the past few years, particularly as they affect the elderly, and the changes have greatly increased the stress experienced by working staff in this field. Westerberg’s study demonstrates the conflicting roles that leaders experience in a change environment over time having to juggle different expectations from different groups. Over reliance on training and development at the start of a change initiative leads to a lack of commitment over time. The initiative needs support throughout so that those people leading it are involved continuously. As Westerberg notes, change in behaviour takes time, often more than expected!

Mai-Stina Lambinen’s paper from Finland discusses a somewhat similar theme, but this time it discusses about job satisfaction among social and health-care managers. Much of the organizational development literature emphasises the need for job satisfaction – satisfied and happy workers make for better organizations. This particular study reinforces this philosophy – but relates job satisfaction to the sense of community that develops in a workplace. She notes that along with job meaningfulness, open, transparent and appreciative communication and trusting relationships all help to enhance job satisfaction, particularly on the part of managers. Presumably, we can extrapolate from the data and apply the concepts not just to managers but to all health care and social workers who need to cope in stressful work environments.

Finally, we have an article based on a research project in Bogor, Indonesia, on patient loyalty. Author Sik Sumaedi describes why patient loyalty is a key construct in developing health care service institutions in what is now a competitive health environment. His theory and research speaks to the need for “subjective norm” and trust as necessary concepts in influencing patient loyalty to health institutions.

We have increased the number of articles as we go forward with Leadership in Health Services. This reflects increasing contributions from authors, an increased awareness of the concept of leadership in health service and a desire to publish your contributions with less delay. Less time delay between peer review completion and actual publication results in happier authors. Thanks to all of you for your ongoing support of our journal.

Jennifer Bowerman

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