Leading in Health Care Organizations: Improving Safety, Satisfaction and Financial Performance: Volume 14

The purpose of the study was to explore in literature what different leadership styles and behaviors of head nurses have a positive influence on the outcomes of patient safety or quality of care.

We reviewed the literature from January 2000 until September 2011. We searched Pubmed, Embase, Cinahl, Psychlit, and Econlit.

We found 10 studies addressing the relationship between head nurse leadership and safety and quality. A wide array of styles and practices were associated with different patient outcomes. Transformational leadership was the most used concept in the studies. A trend can be observed over these studies suggesting that a trustful relationship between the head nurse and subordinates is an important driving force for the achievement of positive patient outcomes. Furthermore, the effects of these trustful relationships seem to be amplified by supporting mechanisms, often objective conditions like clinical pathways and, especially, staffing level.

This study offers an up-to-date review of the limited number of studies on the relationship between nurse leadership and patient outcomes. Although mostly transformational leadership was found to be responsible for positive associations with outcomes, also contingent reward had positive influence on outcomes. We formulated some comments on the predominance of the transformational leadership concept and suggested the application of complexity theory and political leadership for the current context of care. We formulated some implications for practice and further research, mainly the need for more systematic empirical and cross cultural studies and the urgent need for the development of a validated set of nurse-sensitive patient outcome indicators.

This chapter seeks to increase our understanding of health care employees' perceptions of effective and ineffective leadership behavior within their organization.

Interviews were conducted with 59 employees working in a diversity of positions within the case study hospital. Interviewees were asked to cite behaviors of both an effective and an ineffective leader in their organization. They were also asked to clarify whether their example described the behavior of a formal or informal leader. Grounded theory data analysis techniques were used and findings were interpreting using existing leadership behavior theories.

(1) There was a consistent link between effective leadership and relationally oriented behaviors. (2) Employees identified both formal and informal leadership within their hospital. (3) There were both similarities and differences with respect to the types of behaviors attributed to informal versus formal leaders. (4) Informants cited a number of leadership behaviors not yet accounted for in the leadership behavior literature (e.g., ‘hands on’, ‘professional’, ‘knows organization’). (5) Ineffective leadership behavior is not simply the opposite of effective leadership.

Findings support the following ideas: (1) there may be a relationship between the type of job held by employees in health care organizations and their perceptions of leader behavior, and (2) leadership behavior theories are not yet comprehensive enough to account for the varieties of leadership behavior in a health care organization. This study is limited by the fact that it focused on only those leadership theories that considered leader behavior.

There are two practical implications for health care organizations: (1) leaders should recognize that the type of behavior an employee prefers from a leader may vary by follower job group (e.g., nurses may prefer relational behavior more than managerial staff do), and (2) organizations could improve leader development programs and evaluation tools by identifying ineffective leadership behaviors that they want to see reduced within their workplace.

Health care organizations could use these findings to identify informal leaders in their organization and invest in training and development for them in hopes that these individuals will have positive direct or indirect impacts on patient, staff, and organizational outcomes through their informal leadership role.

This study contributes to research and practice on leadership behavior in health care organizations by explicitly considering effective and ineffective leader behavior preferences across multiple job types in a health care organization. Such a study has not previously been done despite the multi-professional nature of health care organizations.

Despite hospitals’ efforts to reduce health care-associated infections (HAIs), success rates vary. We studied how leadership practices might impact these efforts.

We conducted eight case studies at hospitals pursuing central line-associated blood stream infection (CLABSI)-prevention initiatives. At each hospital, we interviewed senior leaders, clinical leaders, and line clinicians (n=194) using a semi-structured interview protocol. All interviews were transcribed and iteratively analyzed.

We found that the presence of local clinical champions was perceived across organizations and interviewees as a key factor contributing to HAI-prevention efforts, with champions playing important roles as coordinators, cheerleaders, and advocates for the initiatives. Top-level support was also critical, with elements such as visibility, commitment, and clear expectations valued across interviewees.

Results suggest that leadership plays an important role in the successful implementation of HAI-prevention interventions. Improving our understanding of nonclinical differences across health systems may contribute to efforts to eliminate HAIs.

The main goal of the current research was to investigate whether and how leaders in health care organizations can stimulate incident reporting and error management by “walking the safety talk” (enacted priority of safety).

Open interviews (N=26) and a cross-sectional questionnaire (N=183) were conducted at the Rotterdam Eye Hospital (REH) in The Netherlands.

As hypothesized, leaders’ enacted priority of safety was positively related to incident reporting and error management, and the relation between leaders’ enacted priority of safety and error management was mediated by incident reporting. The interviews yielded rich data on (near) incidents, the leaders’ role in (non)reporting, and error management, grounding quantitative findings in concrete case descriptions.

We support previous theorizing by providing empirical evidence showing that (1) enacted priority of safety has a stronger relationship with incident reporting than espoused priority of safety and (2) the previously implied positive link between incident reporting and error management indeed exists. Moreover, our findings extend our understanding of behavioral integrity for safety and the mechanisms through which it operates in medical settings.

Our findings indicate that for the promotion of incident reporting and error management, active reinforcement of priority of safety by leaders is crucial.

Social sciences researchers, health care researchers and health care practitioners can utilize the findings of the current paper in order to help leaders create health care systems characterized by higher incident reporting and more constructive error handling.

We examine how interpersonal behavior and social interaction influence team sensemaking and subsequent team actions during a hospital-based health information technology (HIT) implementation project.

Over the course of 18 months, we directly observed the interpersonal interactions of HIT implementation teams using a sensemaking lens.

We identified three voice-promoting strategies enacted by team leaders that fostered team member voice and sensemaking; communicating a vision; connecting goals to team member values; and seeking team member input. However, infrequent leader expressions of anger quickly undermined team sensemaking, halting dialog essential to problem solving. By seeking team member opinions, team leaders overcame the negative effects of anger.

Leaders must enact voice-promoting behaviors and use them throughout a team’s engagement. Further, training teams in how to use conflict to achieve greater innovation may improve sensemaking essential to project risk mitigation.

Health care work processes are complex; teams involved in implementing improvements must be prepared to deal with conflicting, contentious issues, which will arise during change. Therefore, team conflict training may be essential to sustaining sensemaking.

Future research should seek to identify team interactions that foster sensemaking, especially when topics are difficult or unwelcome, then determine the association between staff sensemaking and the impact on HIT implementation outcomes.

We are among the first to focus on project teams tasked with HIT implementation. This research extends our understanding of how leaders’ behaviors might facilitate or impeded speaking up among project teams in health care settings.

This paper explores the relationship between entrepreneurial orientation (EO) (i.e., their innovativeness, proactiveness and risk-taking) and financial performance in nursing homes. We hypothesize that nursing homes that are more proactive will report better short-term financial performance, while when firms with higher propensities for innovativeness and risk-taking will experience poorer financial performance in the short period due to the high costs associated with the initial adoption of innovation and with pursuing high-risks ventures.

In 2004, a survey was developed and mailed to a population of 670 nursing homes in the state of Florida who were listed in the Florida Nursing Home Guide of the Agency for Health Care Administration. The final sample for this study included 104 respondents. The data from these surveys were merged with additional variables gathered from the 2004 Online Survey Certification and Reporting (OSCAR) system and the 2004/2005 Medicare Cost Reports (MCR). EO was operationalized using a nine-item scale adapted from Covin and Slevin (1989), and financial performance was assessed using total profit margin.

The overall findings suggest partial support for the hypotheses. Support was found for the negative relationship between innovativeness and short-term financial performance, but only partial support was found for the relationship between performance and risk-taking. Our results demonstrated that the various aspects of entrepreneurial behaviors have a differential effect on firm performance.

From a managerial perspective, nursing home administrators may continue to seek ways to be entrepreneurial while understanding that some activities may only lead to short-term profitability. These findings should not dissuade administrators from innovative behaviors. They do suggest, however, that innovative administrators should prepare for some initial decrease in profitability following new service implementation.

Findings suggest that to varying degrees, nursing home administrators may view themselves as being entrepreneurial despite the intense pressures from governments, poor public perceptions, decreasing reimbursement, more impaired residents, and increasing competition from substitute providers. Further administrators may need to manage the expectations of key stakeholders when they undertake innovative programs that will support social outcomes but which may not enhance short term financial performance.

This paper demonstrates the complex relationship between entrepreneurial activities and firm performance in nursing homes and has implications for the broader health care setting.

Personnel costs typically account for 60% or more of total operating expenses in health systems, and as such beome a necessary focus in most if not all substantive health reform adaptations. This study sought to assess whether strategic alignment of the human resource (HR) and learning functions was associated with greater adaptive capacity in U.S. health systems.

Data were gathered using a survey that was distributed electronically to chief human resource officers from two U.S.-based associations. The survey included questions about organizational structure, strategic human resource management, strategic learning, and organizational response to health reform.

Significant correlations were found between strategic alignment of HR and HR’s involvement in responses related to cost control (r=0.46, p<0.01); quality improvement (r=0.45, p<0.01), and patient access (r=0.39, p<0.01). However, no significant relationships were found between strategic alignment of organizational learning and HR involvement with these responses.

Results suggest that HR structure may affect an organization’s capacity for adaptive response. Top-management teams in health systems should consider positioning HR as part of the core leadership team, with a reporting relationship that allows HR to maximally participate in formulating and implementing organizational adaptation.

Hospitals within the United States consistently have injury rates that are over twice the national employee injury rate. Hospital safety studies typically investigate care providers rather than support service employees. Compounding the lack of evidence for this understudied population is the scant evidence that is available to examine the relationship of support service employees’ perceptions of safety and work-related injuries. To examine this phenomenon, the purpose of this study was to investigate support service employees’ perceptions of safety leadership and social support as well as the relationship of safety perception to levels of reported injuries.

A nonexperimental survey was conducted with the data collected from hospital support service employees (n=1,272) and examined: (1) relationships between safety leadership (supervisor and organization) and individual and unit safety perceptions; (2) the moderating effect of social support (supervisor and coworker) on individual and unit safety perceptions; and (3) the relationship of safety perception to reported injury rates. The survey items in this study were based on the items from the AHRQ Patient Safety Culture Survey and the U.S. National Health Care Surveys.

Safety leadership (supervisor and organization) was found to be positively related to individual safety perceptions and unit safety grade as was supervisor and coworker support. Coworker support was found to positively moderate the following relationships: supervisor safety leadership and safety perceptions, supervisor safety leadership and unit safety grade, and senior management safety leadership and safety perceptions. Positive employee safety perceptions were found to have a significant relationship with lower reported injury rates.

These findings suggest that safety leadership from supervisors and senior management as well as coworker support has positive implications for support service employees’ perceptions of safety, which, in turn, are negatively related to lower odds of reporting injuries.

We provide a review of the research in this volume and suggest avenues for future research.

Review of the research in this volume and unstructured interviews with health care executives.

We identified the three central themes: (1) trust in leadership, (2) leading by example, and (3) multi-level leadership. For each of these themes, we highlight the shared concerns and findings, and provide commentary about the contribution to the literature on leadership.

While relation-oriented leadership is important in health care, there is a danger of too much emphasis on relations in an already caring profession. Moreover, in most health care organizations, leadership is distributed and scholars need to adopt the appropriate methods to investigate these multi-level phenomena.

In health care organizations, hands-on leadership, through role modeling, may be necessary to promote change. However, practicing what you preach is not as easy as it may seem.

We provide a framework for understanding current research on leadership in health care organizations.