‘New’ and distributed leadership in quality and safety in health care, or ‘old’ and hierarchical? An interview study with strategic stakeholders.

Objectives:We aimed to explore the views of strategic level stakeholders on leadership for quality and safety in the UKNational Health Service.Methods: We interviewed 107 stakeholders with close involvement in quality and safety as professionals, managers,policy makers or commentators. Analysis was based on the constant comparative method.Results: Participants identified the crucial role of leadership in ensuring safe, high quality care. Consistent with theacademic literature, participants distinguished between traditional hierarchical 'concentrated' leadership associated withparticular positions, and distributed leadership involving those with particular skills and abilities across multiple institutionallevels. They clearly and explicitly saw a role for distributed leadership, emphasizing that all staff had responsibilityfor leading on patient safety and quality. They described the particular value of leadership coalitions between managersand clinicians. However, concern was expressed that distributed leadership could mean confusion about who was incharge, and that at national level it risked creating a vacuum of authority, mixed messages, and conflicting expectationsand demands. Participants also argued that hierarchically based leadership was needed to complement distributedleadership, not least to provide focus, practical support and expertise, and managerial clout.Conclusions: Strategic level stakeholders see the most effective form of leadership for quality and safety as one thatblends distributed and concentrated leadership. Policy and academic prescriptions about leadership may benefit from thesophisticated and pragmatic know-how of insiders who work in organizations that remain permeated by traditionalstructures, cleavages and power relationships. [ABSTRACT FROM AUTHOR]