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Graham Dickson and Bill Tholl
Principal Investigator and Lead Decision Maker
and
G. Ross Baker, Régis Blais, Nathalie Clavel, Charlotte Gorley, Kelly Grimes, Diane LeBlanc, Ron
Lindstrom, Greg Marchildon, Sue Mills, Don Philippon, Chris Power, and Shirley Solberg—with
special assistance re NVivo analysis from Amber Fletcher, Maura MacPhee and Kim Taylor.
May 2014 (Rev. November 2014)
Partnerships for Health System Improvement (PHSI)
Leadership and Health System Redesign
Cross-Case Analysis Final Report
(Revised November 2014)
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Key Messages
Current Capacity:
The challenge of creating large-scale change requires levels of systems thinking, strategic thinking, relationship development, and self-leadership that supersede the current capacity of many formal leaders. Quality physician leadership—at all levels—is required for reform to be successful; yet that capacity is only engendered through exemplary practices of ongoing, meaningful physician engagement. Political dynamics and regular turnover among ministerial, senior policy, public service leaders, executive, and organizational leaders impede leadership of large-scale change over time. Collective leadership capacity^1 requires alignment of thinking and action amongst formal leaders that challenges traditional conventional notions of autonomy, accountability, and collaboration that they currently bring to their role. The ongoing need to expend energy to overcome factors that impede change— structural, cultural, and political—are draining the capacity of Canada’s leaders faster than that capacity is being rejuvenated.
Gaps Between Current and Leading Practices Described in the Literature
The findings support many of the leading edge practices, models, and theories of leadership found in the literature. However, they do not suggest “validation” of one theory over another—in fact theory validation is not the point of the study. Understanding leadership better is; and there is some illumination related to existing leadership theories inherent in the data. Four key ideas emerging in the leadership literature were highly relevant to interpreting findings from the case studies: trait theory of leadership; shared or distributed leadership; substitutes for leadership; and complexity leadership. In addition, some strong support for the construct of authentic leadership and servant leadership emerged. Four out of the six case studies (with the exception of Quebec and BC which did not address the use of LEADS) showed that the LEADS in a Caring Environment (Dickson,
- capabilities framework, adopted by many jurisdictions and agencies across Canada is increasingly being accepted as a “common language” of leadership across
(^1) Collective leadership capacity refers to the overall capacity to lead as exhibited by all formal and informal leaders in
the system. This term is not to be confused with the construct of distributed leadership, shared leadership, or collaborative leadership, terms with unique definitions within the literature.
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Table of Contents
Key Messages ................................................................................................................................... ii
Executive Summary ......................................................................................................................... vi
Background.................................................................................................................................. vi Research Design .......................................................................................................................... vi Findings....................................................................................................................................... vii Conclusion ................................................................................................................................... ix
Acknowledgments ............................................................................................................................ x
Acronyms ....................................................................................................................................... xiii
Cross-Case Analysis Final Report ..................................................................................................... 1
Introduction ................................................................................................................................. 1
Research Methodology ................................................................................................................... 3
Decentralized Approach .............................................................................................................. 3 Participatory Action Research ..................................................................................................... 4 Multiple Case Comparative Approach......................................................................................... 5 Data Collection Method .............................................................................................................. 5 Data Analysis ............................................................................................................................... 6 Thematic Analysis ...................................................................................................................... 13 Limitations ................................................................................................................................. 13 Findings...................................................................................................................................... 14 Question One: Current State of Leadership Capacity in Canada........................................... 14 Question Two: Gaps between Current Practice and Evidential Base.................................... 24 Question Three: Knowledge Translation and Mobilization ................................................... 37
Discussion ...................................................................................................................................... 38
Alignment .................................................................................................................................. 39 A Complex Systems Thinking Perspective ................................................................................. 40 Two Way Communication and Engagement ............................................................................. 40 Importance of Context .............................................................................................................. 42 Reinforcement of Leadership Theory ........................................................................................ 42 Shared or Distributed Leadership.......................................................................................... 42
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- Substitutes for Leadership..................................................................................................... - Authentic and Transformational Leadership......................................................................... - Complexity Leadership - Servant Leadership
- Individual Behaviour Change
- Politics
- Contradictions and Conflicting Dynamics of Leadership
- Systemic Contradictions
- Practical Contradictions.............................................................................................................
- Personal Contradictions
- Knowledge Translation and Mobilization
- Summary........................................................................................................................................
- Goal 1: Exploring the dynamics of leadership of health reform
- Goal 2: Building an integrated regional and national KT/KM strategy
- Goal 3: Developing a Sustainable Network of Networks in Health Leadership Research.........
- Conclusion
- References
- Table 1. Research Methodology Overview by Node List of Tables
- Table 2. Common Leadership Capabilities Needed for Reform Across Cases................................ - Challenges ......................................................................................................................... Table 3. Synthesis of Findings Regarding Leadership Capacity, Capabilities, Enablers, and
- Figure 1. Six Node Health Leadership Case Study Projects List of Figures
- Figure 2. Three Cycles of Participatory Action Research and Cross-Case Analysis
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challenges associated with leading health reform. The study was conducted in two stages. In the first stage each of the six case studies utilized mixed qualitative methods to gather data over three cycles. They described, in rich, thick case reports, the practice of leadership in real life reform situations. In stage two a cross-case analysis was conducted. Common themes relating to the three questions guiding the study were identified. The longitudinal method recognized the ongoing, iterative development of understanding leadership of change and its dynamic manifestation through time, circumstance and situation. This document reports on the second stage (i.e. cross-case analysis) of this study.
Findings Leadership Capacity
Each of the case study reports analyzed respective data to determine the leadership capacity required to create change in their specific context. Common themes that occurred were identified.
With respect to the first research question, cross-case data suggests that Canada does not have the leadership capacity that is required to lead significant health reform. Findings included:
The challenge of creating large-scale change requires levels of systems thinking, strategic thinking, relationship development, and self-leadership that supersede the current capacity of many formal leaders. Quality physician leadership—at all levels—is required for reform to be successful, yet that capacity is only engendered through exemplary practices of ongoing, meaningful physician engagement. Political dynamics and regular turnover among ministerial, senior policy, public service leaders, executives, and organizational leaders impede leadership of large-scale change over time. Collective leadership capacity requires alignment of thinking and action among formal leaders that challenges conventional notions of autonomy, accountability, and collaboration that they currently bring to their role. The ongoing need to expend energy to overcome factors that impede change—structural, cultural, and political—is draining the capacity of Canada’s leaders faster than that capacity is being rejuvenated.
Reinforcement of Leadership Literature and National Standards
Our collective research reinforced some basic leadership concepts found in the literature regarding the practice of leadership in health reform. Trait leadership, distributed leadership, substitutes for leadership, and complexity leadership were strong themes. In addition, some support for the constructs of authentic and transformational leadership (closely related) and servant leadership arose.
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Cross-case results show a continued reliance in some parts of the health system on hierarchical, heroic leadership models. However, formal leaders no longer have the same power or privilege as before. Informal leadership is also emerging. Health service delivery is increasingly complex and interconnected, yet the forces of fragmentation—perceived negative politicization, turnover of leaders, constitutional and organizational structure, and the plethora of organized professional organizations that each have a stake in the process—prevent alignment of effort. Leadership for large-system health reform requires striking the right balance between centralization and decentralization forces, formal and informal leadership, individual and organizational accountabilities and authorities, organization and system performance, and alignment of effort across boundaries. Our current individualistic leadership cannot sustain large-scale health reform. Shared, distributed models with an understanding of associated authorities and accountabilities need to emerge. As a consequence, there would be value on a more strategic focus being brought to bear on systematic succession planning and leadership development (see the knowledge mobilization points below). In this study, the LEADS in a Caring Environment (Dickson, 2010) framework was referenced in many cases as having potential as a foundation for the above-mentioned succession planning and leadership development needs within the Canadian health system. It has many similarities to Health LEADS Australia and the National Health Service Leadership Framework in England (currently under revision) that are being used to underpin system- wide strategic approaches to creating reform.
Knowledge Mobilization
Individual and organizational effort to translate and mobilize knowledge and best practices of effective leadership in Canada continues to be ad hoc and sporadic. This is a contributing obstacle to sustained, positive health system reform. Both collective and individual approaches to creating a better bridge from the research world to the policy world are required. The research literature suggests, for instance, that systematic leadership talent management (e.g., succession planning and leadership development) are sound organizational investments in this regard. Informants across nodes suggest there should be increased focus on succession planning and leadership development (including mentoring and coaching). Leaders reported the need to develop and support new innovation pathways to effect a stronger national approach to leadership development, although local efforts must continue. Canada appears to under-invest in knowledge translation. Post-secondary institutions should play an integral part in this function.
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Acknowledgments
The Leadership and Health System Redesign project research conducted in five geographical locations (nodes) across the country was comprised of the following researchers and decision- makers.
National
Dr. Graham Dickson (Principal Investigator) Royal Roads University Victoria, British Columbia
Bill Tholl Canadian Health Leadership Network Ottawa, Ontario
Dr. Maura MacPhee University of British Columbia Vancouver, British Columbia
Gavin Brown Health Canada Ottawa, Ontario
British Columbia
Dr. Ronald R. Lindstrom Royal Roads University Victoria, British Columbia
Dr. Charlyn Black University of British Columbia Vancouver, British Columbia
Dr. Sue Mills University of British Columbia Vancouver, British Columbia
Dr. Charlotte Gorley Royal Roads University Victoria, British Columbia
Dr. Nigel Murray Fraser Health Surrey, British Columbia
Prairies
Dr. Greg Marchildon University of Regina Regina, Saskatchewan
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Dr. Don Philippon University of Alberta Edmonton, Alberta
Maura Davies Saskatoon Health Region Saskatoon, Saskatchewan
Andrew Will 3S Health Regina, Saskatchewan
Dr. Amber Fletcher University of Regina Regina, Saskatchewan
Dan Florizone Former Deputy Minister of Health Saskatchewan Ministry of Health Regina, Saskatchewan
Ontario
Dr. Ross Baker University of Toronto Toronto, Ontario
Dr. John Lavis McMaster University Hamilton, Ontario
Dr. Joshua Tepper Sunnybrook Health Sciences Centre Toronto, Ontario
Dr. Monica Aggarwal Toronto, Ontario Québec
Dr. Jean-Louis Denis École nationale d’administration publique Montréal, Québec
Dr. Régis Blais Université de Montréal Montréal, Québec
Dr. Julie Lajeunesse GMFs Notre-Dame Montréal, Québec
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Acronyms
AQA Access, Quality and Appropriateness
CH Capital Health
CHLNet Canadian Health Leadership Network
CCM Comprehensive Care Models
FATT Fully at the Table
FHG Family Health Groups
FHN Family Health Networks
FHO Family Health Organizations
FHT Family Health Teams
FMG Family Medicine Group – Group de médicine de famille
IPCC Integrated Primary and Community Care
IWK IWK Health Centre
KT Knowledge Translation
KM Knowledge Mobilization
LEADS L ead Self, E ngage Others, A chieve Results, D evelop Coalitions, S ystem Transformation in a Caring Environment
LHIN Local Health Integration Network
NPLC Nurse Practitioner Led Clinics
PAR Participatory Action Research
PCN Primary Care Networks
PHSI Partnerships for Health System Improvement
RHA Regional Health Authority
RNPGA Rural and Northern Physician Group Agreement
Cross-case Analysis Final Report
Introduction
The purpose of the Leadership and Health System Redesign project was to help develop leadership capacity in the Canadian health system through applied research and knowledge translation. The project was stewarded by a network comprised of senior decision-makers (under the auspices of the Canadian Health Leadership Network [CHLNet representing over 40 health organizations]) and representatives of the health leadership research community from nine universities across Canada (with Royal Roads University [RRU] as institution of record) in a unique collaborative partnership – a network of networks.
The intention was to build a bridge between researchers and leaders in the field of leadership. The Canadian Institutes for Health Research under the Partnerships for Health System Improvement (PHSI) grants and the Michael Smith Foundation for Health Research provided the funding for this four-year project ($450,000 over four years, with $400,000 in kind from project partners). Ethics approval for the overall study was granted by Royal Roads University, and each node received ethics approval or ethics certificates from their respective universities.
Six case study projects undertook to explore and understand the leadership dynamics at play across Canada in redesigning the health system:
- National Node Project on Access, Quality and Appropriateness
- British Columbia Project on Integrated Primary and Community Care
- Prairies Project on Shared Services in Saskatchewan
- Ontario Project on New Models of Primary Care Delivery
- Quebec Project on New Models of Primary Care Delivery
- Atlantic Project on Employee/Physician Engagement (two case studies)
This report provides a cross-case analysis of these six case studies based on the following three research questions that guided the study:
- What is the current state of health leadership capacity in Canada? What is working, or not working, in terms of stimulating and supporting health system transformation, and what contextual factors influence effective leadership action?
- Where are the gaps between current practices, the evidential base in the literature, and the expectations for leadership outlined in the emerging health leadership capability/competency frameworks (e.g., LEADS capabilities framework), and how might a set of national standards for leadership be structured?
- How can knowledge of effective leadership be translated and mobilized by the network into approaches, programs, tools and techniques to develop a culture of effective leadership in Canada, and enhance the development of quality health leaders?
organizations across Canada had initiated collaborative strategies to build evidence-informed leadership capability within the health system.
This challenge grows larger as comparative country analyses, such as those prepared by the Commonwealth Fund (www. commonwealthfund .org ), show Canada’s continued downward slide. The Health Council of Canada has recommended more "supportive leadership"; the Premiers' report From Innovation to Action (Health Care Innovation Working Group, 2012) identified "present leadership" as one of four critical factors for better system performance; and the Health Council of Canada’s November 2013 report Better Health, Better Care, Better Value for All: Refocusing Health Care Reform in Canada calls for strong leadership as the first of five key enablers of high performing systems.”^3 Leadership is now on the policy agenda of most provincial governments in Canada. However, there is a lack of research on, and understanding of, the ways in which different forms of leadership – especially highly distributed and networked forms of leadership – affect health system reforms and improve overall performance (Currie and Lockett 2011; Dickson 2009; Fitzgerald et al., 2013).
Consequently, the purpose of the Leadership and Health System Redesign research study was to explore the leadership dynamics at play in Canadian health reform and to develop leadership capacity in the Canadian health system through applied research and knowledge translation. The findings from this project advance this body of evidence and are outlined in the next sections, following an initial overview of the research methodology.
Research Methodology
Each case study employed the same foundational methodology for research. A decentralized approach to participatory action research (PAR) was used (Reason & Bradbury, 2008; Smith et al., 2010; Swantz, 2008). Each node research team was free to use PAR methods that suited their context. A multiple-case comparative approach (Yin, 2009) was then employed for interpretive purposes. Given the decentralized method to this project, modifications were made for each node and these are summarized in Table 1.
Decentralized Approach
The methodology employed to answer the questions was chosen to reflect the unique context of distributed or shared responsibility for service delivery in the Canadian health system. Canada is a Westminster-style federation with a Canada-wide set of interlocking provincial/territorial universal health insurance programs, guided by the spirit and intent of national standards as set out in the Canada Health Act (1985). This decentralized approach is due to the fact that constitutional responsibility for health service delivery resides primarily at the provincial and territorial level (except for specific services delivered by the federal government to first nations
(^3) Health Council of Canada. (September, 2013). Better Health, Better Care, Better Value for All: Refocusing
Health Care Reform in Canada.
and aboriginal peoples and to employees of national agencies, such as the Department of National Defence).
Participatory Action Research To understand the leadership dynamics of health system delivery in Canada, all six nodes conducted up to three rounds of participatory action research into the practice of leadership during ongoing health system redesign initiatives (Reason & Bradbury, 2008; Smith et al., 2010; Swantz, 2008). “PAR is a process of systematic inquiry in which those who are experiencing a work-related problem participate with trained researchers in deciding the focus of knowledge generation, in collecting and analyzing information, and in taking action to improve the conditions or to resolve the problem entirely” (Rosskam, 2008, p.3). This approach was operationalized by seeking cases at different levels of the system and in diverse regions across the country, including one national case to explore change on a Canadian scale, and adapting the PAR method to each individual context. The method reflects a need to adapt to the decentralized or ‘loose’ governmental stewardship and approach to leadership of health care in Canada (Currie & Lockett, 2011; Tholl & Bujold, 2011).
The longitudinal PAR approach (i.e., three cycles of participatory action research over two years—see Figure 2) utilized a mixed qualitative methodology to gather data (Brydon-Miller et al., 2011; Lincoln & Guba, 1985; Stringer, 2007) and a case study method to explain and interpret it (Creswell, 1998; Flick, 2007; Stake, 1995; Yin, 2009).
In PAR, participants are seen not only as participants but also as research collaborators or partners who are actively involved in research activities (Rosskam, 2008). There is a desire to create reflexivity, which emphasizes “mutual dependence of researcher and the researched, their influence on actions taken, and that sensemaking emerges from the dynamics of process.” (Tedmanson & Banerjee, 2010, p.3). The goal of PAR is to produce change-oriented research through dialogue and interaction, and to produce results that participants can use in their own organizations (Brydon-Miller et al., 2011). The specific approaches employed in each case are outlined in Table 1. The PAR approach recognized the ongoing, iterative development of understanding phenomena such as leadership of change, distributed leadership and its dynamic manifestation through time, circumstance and situation. Approaches across cases differed in the extent to which PAR was employed and in the degree of the researcher in the process.
The research project was both exploratory and interpretive, aimed at helping readers to understand the deeper meaning and challenges associated with leading health reform (Dickson & Tholl 2014; Greenfield, 1979 cited in Gronn, 2002; Krauss 2005; Nicklin 2012; Varney 2009). Each of the six cases explored, documented, interpreted and described, in rich, thick case reports, the exercise of the practice of leadership in real life situations demanding or requiring its skills in creating change (Lincoln, 2010; Lincoln & Guba, 1985). For brevity’s sake, these data can be found in the separate case reports.
Figure 2: Three Cycles of Participatory Action Research and Cross-case Analysis
Data Analysis
Thematic analysis, a qualitative method, was used to code data from within and across the cases. NVivo 9 software was used to organize the data to create parsimonious themes within the node data, and to better make comparisons across the cases (Boyatzis, 1998; Fereday & Muir-Cochrane, 2006).
In qualitative research, a code is a summative word or phrase that captures the character of a particular piece of data (Saldaña 2009). Two main approaches to coding, inductive and deductive, were used in this analysis process. Inductive coding is exemplified by the “open coding” used in grounded theory research (Auerbach & Silverstein, 2003). In this “bottom-up” approach, the researcher does not begin with any pre-existing codes and instead looks for repeating ideas, which are gathered to eventually become codes. In contrast, deductive coding begins with a preliminary set of codes, which are usually drawn from existing research.
engaged^ Issue engaged^ Issue
Data collection and analysis
Data collection and analysis^ Data collection and analysis
Reflections on Leadership in context
Reflections on Leadership in context
Reflections on Leadership in context
Critical defined & issue engaged
Critical issue engaged
Critical issue engaged
Final case report for each of six cases
Cross-case analysis
Cross-case Report
However, these codes are used flexibly and new codes are added as necessary to account for unanticipated ideas that emerge as coding proceeds (Gilgun, 2011).
Cross-case coding was done in two rounds by at least two people out of a team of three research team members (each was skilled in NVivo analysis) to ensure consistency. In both rounds, all three researchers inductively coded one case report as a trial or pilot case. Key codes from each report that were likely to be found in other reports were compiled into a preliminary list to be used deductively on the subsequent reports. However, the list was treated flexibly and new codes were added to account for new ideas and contextual factors in each study. The second round of coding employed the themes from round one deductively but flexibly, allowing for comparison between the two rounds and capturing changes over time.
After the second round of coding was complete, codes were consolidated into broader themes and sub-themes that addressed the main research questions that guided the study. The resulting Excel matrix with themes, sub-themes and representative leader quotes, was presented to the cross-case panel in November 2013. The coding confirmed some of the panel members’ preliminary observations and also revealed themes that had not previously been noted (e.g., the importance of alignment).
Table 1 outlines the differences in research methodology among the six node projects. Each regional node operated within its own situational context and unique circumstances. The unit of analysis varied from micro, meso and macro levels of the health system. As well, modifications to the application of PAR did occur and are highlighted.
