Journal of Health Organization and Management

Exploring the nature and impact of leadership on the local implementation of The
Productive Ward Releasing Time to Care™
Elizabeth Morrow Glenn Robert Jill Maben
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Elizabeth Morrow Glenn Robert Jill Maben , (2014),"Exploring the nature and impact of leadership on the
local implementation of The Productive Ward Releasing Time to Care™", Journal of Health Organization
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and Management, Vol. 28 Iss 2 pp. 154 - 176

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JHOM
28,2
Exploring the nature and impact
of leadership on the local
implementation of
154 The Productive Ward Releasing
Time to Caret
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Elizabeth Morrow, Glenn Robert and Jill Maben

National Nursing Research Unit, Florence Nightingale School of Nursing and
Midwifery, King’s College London, London, UK
Abstract
Purpose – The purpose of this paper is to explore the nature and impact of leadership in relation to
the local implementation of quality improvement interventions in health care organisations.
Design/methodology/approach – Using empirical data from two studies of the implementation of
The Productive Ward: Releasing Time to Caret in English hospitals, the paper explores leadership in
relation to local implementation. Data were attained from in-depth interviews with senior managers,
middle managers and frontline staff (n ¼ 79) in 13 NHS hospital case study sites. Framework
Approach was used to explore staff views and to identify themes about leadership.
Findings – Four overall themes were identified: different leadership roles at multiple levels of
the organisation, experiences of “good and bad” leadership styles, frontline staff having a sense
of permission to lead change, leader’s actions to spread learning and sustain improvements.
Originality/value – This paper offers useful perspectives in understanding informal, emergent,
developmental or shared “new” leadership because it emphasises that health care structures,
systems and processes influence and shape interactions between the people who work within
them. The framework of leadership processes developed could guide implementing organisations
to achieve leadership at multiple levels, use appropriate leadership roles, styles and behaviours
at different levels and stages of implementation, value and provide support for meaningful
staff empowerment, and enable leader’s boundary spanning activities to spread learning and
sustain improvements.
Keywords Leadership, Productivity, Quality improvement
Paper type Research paper

Introduction
Health care organisations all over the world face challenges of improving safety,
quality and efficiency. Initiatives based on Lean thinking (Lean) have shown promise
for achieving these goals in a range of health care contexts (see e.g. Savary and
Crawford-Mason, 2006; Bem-Tovim et al., 2007; Jones and Mitchell, 2006; Fillingham,

Journal of Health Organization and
Management
Vol. 28 No. 2, 2014
pp. 154-176
r Emerald Group Publishing Limited
1477-7266
DOI 10.1108/JHOM-01-2013-0001
The studies which inform this work were commissioned and supported by Helen Bevan and
Lynn Callard and Kristy Parnell at the National Health Service Institute for Innovation
and Improvement (NHS Institute) in England. Diane Ketley provided helpful comments and
suggestions on an earlier version of this paper. Professor Peter Griffiths, University of
Southampton contributed to the design and conduct of the studies. The views expressed here are
those of the authors, not of the NHS Institute. The authors thank all those who participated in the
studies whether by participating in interviews, facilitating access to organisations or providing
other information. Thank you to the two anonymous reviewers of this paper who provided
helpful suggestions and comments.
 2007). Lean has a long history of development and use in the commercial sector Impact of
and manufacturing industry where it is a well-established improvement approach leadership
(Young and McClean, 2008; Radnor and Boaden, 2008). It provides organisations with
principles and tools to focus on the values which drive systems (Rooney and Rooney,
2005) and realign or refine processes or practices to cut out “waste” (e.g. interruptions,
delays, mistakes or replication) and achieve the desired values (e.g. effective treatment,
safe high quality care) (Womack et al., 1990; Crump, 2008). Now, to maximise on these 155
benefits, there is a need to build evidence and strategies to support implementation in
health care (Eccles et al., 2009). One important factor for driving improvement work is
leadership (Ferlie and Shortell, 2001; Miller, 2006; Øvretveit, 2009; Barr and Dowding
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2012) sometimes called “improvement leadership”, however little is known about the
most effective forms of leadership in this context (Øvretveit, 2009; Buchanan et al.,
2007b; Denis et al., 2012).
The aim of this paper is to explore issues about leadership in relation to
implementation of improvement initiatives in health care. The paper draws upon
perspectives of Lean thinking and leadership from the health care literature to explore
the issues from the perspectives of staff in implementing organisations. Specifically,
the paper explores the following research questions:

RQ1. What type of leadership roles do organisations need to successfully

implement interventions like The Productive Ward?

RQ2. What type of leadership styles and behaviours should leaders use?

RQ3. How can leaders engage and energise frontline staff?

RQ4. How can leaders act to ensure implementation is spread and sustained?

The paper explores these questions in a real case of Lean implementation

by drawing upon empirical data from two studies of the implementation of
The Productive Ward: Releasing Time to Caret (The Productive Ward) in English
hospitals. The aim of The Productive Ward programme is to increase the proportion of
time nurses spend on direct patient care, to improve experiences for staff and patients,
and to make structural changes to the use of ward spaces to improve efficiency. It is a
useful test ground to explore issues of leadership as the programme has been widely
and rapidly adopted by many health care organisations in England (Robert et al., 2011)
as well as in hospitals across the UK and Republic of Ireland, Canada, the USA, the
Netherlands and Denmark. Internationally the programme is sometimes referred
to as Releasing Time to Care or RTC; variations in national/regional strategies for
implementation of The Productive Ward are themselves interesting but outside of the
scope of this paper.
The structure of the paper is as follows. The background section presents current
knowledge on Lean thinking and leadership in health care from the research literature.
The methods section provides information about the empirical studies that inform the
paper and the methods of analysis used in this paper. The findings are presented
according to themes and the discussion examines these findings in relation to the four
research questions above to develop a framework of leadership processes. Conclusions
for research and practice are presented.
 JHOM Background
28,2 Different approaches to Lean in health care have been classified (Brandao de Souza,
2009) as “manufacturing like” approaches which usually involve streamlining
departments within a hospital that typically deal with the physical flow of materials
(such as pharmacy, radiology or pathology). “Managerial and support service”
approaches to Lean concern the flow of information within the organisation (such as
156 finance, medical secretaries, or other managerial departments and divisions). “Patient
flow” approaches attempt to improve the patient journey within the hospital (or system)
by streamlining the patient pathway. While “organisational” approaches emphasise the
importance of designing a strategic and cultural plan from an organisational perspective
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in order to successfully implement Lean. Differences in approaches to Lean have been

described by Emiliani (2008) as “fake” or “real” Lean. Fake Lean is where an organisation
uses just the tools with an emphasis on rapid improvement rather than long-term change.
Real Lean means showing a “commitment to continuous improvement” using tools
and methods to improve productivity, as well as “showing respect for people through
leadership behaviours and business practices” (Radnor and Boaden, 2008). Thus a key
perspective that informs our exploration is that leadership shapes and influences
approaches to Lean implementation.
Leadership of change, improvement and innovation in health care is not always a
smooth process and “improvement leaders” (Øvretveit, 2009) face at least four types of
challenges in relation to implementing Lean initiatives. First, staff perception is known
to play an important role in receptivity to Lean and staff may be resistant to what they
perceive to be commercial ideas based on productivity values (Young and McClean,
2009). There are associated challenges of how leaders can engage staff in meaningful
ways (Mumford et al., 2000) and build workforce capacity for implementation (Eccles
et al., 2009). Second is the complexity of decisions about implementation of any
particular initiative or innovation (McNulty and Ferlie, 2002): in organisations made
up of different health-care providers, local strategies, structures and professional
groupings, the “innovation journey” may be a fuzzy or contentious process (Van de Ven
et al., 1999) characterised by ambiguity about roles and responsibilities (Ham et al.,
2003). Third, generating evidence about any particular innovation faces challenges
of attributing, documenting and interpreting the implementation costs and benefits in
a way that is meaningful to different audiences (Berwick, 2003). Many organisations
may decide to hold-off implementation until there is convincing evidence from other
organisations about such investment (Rogers, 1995). Fourth, challenges of spreading
and embedding change within organisations include replacing old ways of working
and developing appropriate policy, practice and research to embed and sustain
improvements (Buchanan et al., 2007b; Ham et al., 2003). A key perspective that
underpins these challenges is the role of leaders in creating organisational conditions
for effective implementation.
The Productive Ward was devised and developed in this wider context of multiple
approaches to Lean and challenges to implementation in health care. The National
Health Service Institute for Innovation and Improvement (NHS Institute) (now part of
NHS Improving Quality) worked with industrial partners from Toyota to look at how
care delivered in hospital ward settings could be streamlined and create a clear set of
tools, resources and support for health care organisations. The programme was
developed at four hospital test sites in 2006, before being rolled-out to ten Learning
Partners in 2007. The programme frames Lean in language and examples that are
intended to appeal to health care staff and enable them to bring about changes at ward
 level (Morrow et al., 2012). It comprises 13 modules and tools designed for self-directed Impact of
learning at ward level, beginning with three foundation modules called Knowing leadership
How We are Doing, Well-Organised Ward and Patient Status at a Glance; and
further modules which focus on a range of ward processes including admissions,
discharge and shift handovers. The design and development of the programme itself
are important factors in implementation (NNRU&NHSI, 2010) but our focus here is
on leadership. 157
In the case of The Productive Ward “involved leadership” of senior executive
leaders and ward leaders has been identified as being an important facilitating
factor in implementation (White et al., 2013). This assertion corresponds with
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well-established findings in the literature on leadership that show senior

organisational/executive leaders of health care organisations can help to “challenge
the process, inspire a shared vision, enable others to act, model the way, and encourage
the heart” (Kouzes and Posner, 1988). Formal organisational hierarchies can provide
coordinated and strategic leadership of organisations and organisational change
(Dickson, 2009). It is also known that appointed senior leaders can drive organisational
change by initiating the adoption and implementation of innovation (Rogers, 1995),
including applying improvement principles and replicating actions that other
senior organisational leaders have found to be successful (Øvretveit, 2009). A key
perspective that informs our exploration is that leadership from the “top down” (Sabatier,
1986) directed towards sharing knowledge can support a receptive organisational
context for implementation and routinisation of innovation (Greenhalgh et al., 2005; May
et al., 2009).
At the same time it is known that leaders do not only operate at the “top” of
organisations. Leaders may operate at different macro (health-care system), meso
(organisation) and micro (frontline clinical team) levels to carry out different leadership
functions (House et al., 1995). Similarly, leadership can be perceived according to
individual, team and organisational perspectives (Barr and Dowding, 2012). The notion
of “leadership in the plural” (Denis et al., 2012) suggests that leadership can take on
different forms, including being shared in teams, pooled at the top of organisations,
spread (or distributed) across boundaries over time, or produced through interaction.
Thus a key perspective is that implementation of any Lean initiative in health care
takes place in the context of different perceptions and understandings of who leaders
are and what leadership means (Hartley and Benington, 2010).
Individuals in clearly defined leadership roles can help to work across boundaries
between professional groups, departments, divisions, teams and localities to convey
goals, share information or learning (Pearce, 2004; Goodwin, 2000). Boundary spanning
leadership has been defined as “the capability to establish direction, alignment, and
commitment across boundaries (vertical, horizontal, stakeholder, demographic and
geographic) in service of a higher vision or goal” (Ernst and Chrobot-Mason, 2010).
In relation to implementation of innovation leader’s boundary spanning activities
(Fleming and Waguespack, 2007) are known to be an important factor in the spread of
initiatives across disciplinary fields and sectors (Greenhalgh et al., 2005). Another key
perspective that we explore in this paper is how staff in recognised leadership positions
can support spread and sustained implementation across an organisation.
Engaging influential individuals (who may or may not perceive themselves to be
leaders) across an organisation can help to secure credibility for an innovation
( Jacobson and Goering, 2006), and strategies to develop “role models” and “opinion
leaders” have shown to be effective in implementing changes at the clinical level
 JHOM (MA, 2005). Hence implementation strategies in health care now recognise and seek
28,2 to engage with staff groups who have not traditionally been perceived as leaders
(Doumit et al., 2011) and from different communities of practice (Kislov et al., 2011).
Spreading leadership roles through organisations can support implementation by
attracting followers from different disciplinary backgrounds and service localities
(Grimshaw et al., 2006). However, the notion of leadership as something to be
158 distributed across complex systems and boundaries (Benington and Hartley, 2010;
Hartley, 2012) can be problematic in health care organisations with established
institutional structures and norms (Martin and Waring, 2013). Staff may also question
whether the underlying intention of initiatives to distribute leadership is to support
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“democratic organization” or to gain greater control through “instrumental delegation”

(Mayrowetz, 2008). Changing existing patterns of leadership in health care is challenging
because of contextual issues such as interprofessional barriers and patterns of knowledge
exchange or “brokering” (Currie, 2012). Attempts to promote distributed leadership
in health care, for example through public service networks, have faced challenges of
organisational bureaucracy, power differentials, and a strong centralised performance
management policy regime (Currie and Lockett, 2011).
As Edmonstone (2011) argues, perhaps a rebalancing is needed – from an
over-concentration on individual leaders to an emphasis on the contexts and
relationships in health care organisations that enable leadership to happen. Such
perspectives consider leadership and its outcomes to extend beyond the actions of
individuals to include the multiple roles and dynamics between different “leaders” and
“followers” in different decision-making contexts (Pedersen and Hartley, 2008). As such
“post-heroic” (Dickson, 2009) perspectives of leadership suggest that leadership is not
only attributable to the actions and behaviours of senior leaders but is “a social process
that occurs in and through human interactions” (Fletcher, 2004).
Insights from leadership of change in health care suggest that leaders need to
cultivate a strong culture of engagement for patients and staff and to deploy a range
of leadership styles and behaviours (The King’s Fund, 2012). Leadership that enables
perspectives and needs of different staff groups to be shared helps to generate knowledge
of problems or issues from the “bottom-up” (Sabatier, 1986), co-produce viable solutions
(Gough and Masterson, 2009), and support wider organisational learning and
improvement (Brown and Duguid, 1991). Accordingly the notion of a transformational
leadership approach (Burns, 1978) has become popular in health care organisations
(Bass and Riggio, 2006) as it emphasises leadership behaviours that engage and
motivate frontline staff to bring about change for themselves (Govier and Nash, 2009).
A further key perspective which can be taken from the literature is the notion of
leadership being generated through engagement and interaction.
Drawing on these perspectives, in this paper we suggest the process of
implementing Lean can help to critically examine different forms of leadership and
create conditions for leadership to emerge. In particular Lean offers useful perspectives
in understanding “new” leadership (i.e. informal, emergent, developmental or shared)
because it emphasises that health care structures, systems and processes influence and
shape interactions between the people who work within them (Radnor et al., 2012).
By examining the processes of health care Lean highlights the presence of organisational
rhetoric, ritual and resistance in the discourse of leadership (Waring and Bishop, 2010).
In this respect Lean can perhaps help to understand the values which drive systems and
prompt questions about how “old” (i.e. formal, autocratic, directive) leadership can help to
orientate the organisation towards achieving such values.
 Method Impact of
The focus of this paper is to explore the nature and impact of leadership from leadership
the perspective of health service leaders, managers and frontline staff working
to implement an improvement initiative (The Productive Ward programme).
We chose to use Framework Approach (Richie and Spencer, 1994) to explore
staff experiences because it is particularly suited to analysing descriptive data
from multiple sources, thereby enabling different aspects of the phenomena under 159
investigation to be captured (Ritchie and Lewis, 2003). Using this approach the
context of participant’s experiences can be retained, while also exploring
associations and explanations in the data and drawing on existing theories and
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established literature (Richie and Spencer, 1994). Data were drawn from two studies
of The Productive Ward described below.
Study 1: undertaken in 2009 using mixed methods (NNRU&NHSI, 2010) and an
evidence-based diffusion of innovations framework (Greenhalgh et al., 2005) the study
aimed to examine key factors which had helped to promote rapid programme adoption
(Robert et al., 2011). Data were collected from three different “stakeholder” groups
(Golden-Biddell and Locke, 1997), these were: policymakers (15 in-depth interviews not
used in this paper), hospital managers and health care practitioners who had personal
experience of implementing the programme (web-based survey of 150 self selecting
staff from 96 different NHS acute hospitals, this data has previously been published in
Robert et al., 2011); and frontline staff working on the programme (58 in-depth
interviews) within five hospital case study sites (see Table I). The interview schedule
covered questions about professional role, involvement in implementation, views
about the work/progress, factors helping/hindering implementation and perceptions of
types of impact.
Study 2: undertaken a year later (in 2010) the study focused on examining
theorised circumstances of “non-spread” (NNRU&NHSI, 2011) these were:
discontinuation when people (or organisations) decide to reject an innovation after
adopting it, islands of improvement where pockets of excellence remain isolated and
unknown to others, improvement evaporation when change is not sustained leading
to the decay of organisational change (Ferlie et al., 2005). Eight hospitals were
selected for case study (using Yin’s, 2008 method) on the basis that they were known
to have purchased a Productive Ward package from the NHS Institute and to have
initiated implementation (see Table I). In-depth interviews were undertaken with 21
hospital staff who held a formal leadership role in programme implementation (staff
were senior organisational leads or programme leads/coordinators). Semi-structured
interviews covered questions on the person’s involvement in the work, current
activity, future plans, where things are going well/not so well, staff engagement,
“energy levels” like behind the work, factors that have helped/hindered the work,
fit with other initiatives, monitoring.
This paper focuses on the in-depth interviews conducted with hospital staff during
study 1 (n ¼ 58) and study 2 (n ¼ 21). In both study 1 and study 2, leadership was a
recurrent issue for staff at all levels and we recognised the need to develop more
informed understanding of leadership in this context by exploring “what works and
why” (Walshe, 2007). Drawing on Framework Approach we used qualitative analytic
techniques (Denzin and Lincoln, 2000) to explore staff views. The analysis aimed to be
context sensitive, iterative and flexible (Holloway and Todres, 2003) but it involved a
number of stages. These were: re-familiarisation: reading case study summaries and
interview transcripts; immersion: to explore the data in relation to the focus of the
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28,2

160

Table I.
JHOM

case study sites

Summary of hospital
Support
Adoption package Approach to implementation Resourcing Study participants

Study 1 (2009)
S1H1 Aug 2007 Learning Whole hospital implementation Executive/board member (1); the
As an original learning partner
partner rolled out in stages; wards received support from NHS Productive Ward team, e.g.
undergo selection process to Institute. Have dedicated programme lead/facilitator (5);
join Productive Ward team skilled clinical team (6), non-clinical/support
in change management staff (1) total ¼ 13 participants
S1H2 Jun 2007 Accelerated Whole-organisation Dedicated service development Executive/board member (2); the
implementation (one of first two team with extensive clinical Productive Ward team, e.g.
whole-hospital pilots) experience programme lead/facilitator (2);
clinical team (7), non-clinical/support
staff (1) total ¼ 12 participants
S1H3 Oct 2007 None Phased whole hospital Key executives and staff Executive/board member (2); the
implementation; initially experienced in improvement Productive Ward team e.g.
launched using previous methodologies; in-house service programme lead/facilitator (3);
service improvement improvement team, but no clinical team (4), non-clinical/support
experience rather than NHSI dedicated PW facilitators at staff (1) total ¼ 10 participants
package; subsequent phases launch; June 08 two dedicated
using package facilitators appointed
S1H4 Mar 2008 Accelerated Focused implementation with Project lead and facilitator, both Executive/board member (3); the
selected wards supported by clinically qualified Productive Ward team e.g.
dedicated Productive Ward programme lead/facilitator (2);
facilitator clinical team (4), non-clinical/support
staff (2) total ¼ 11 participants
S1H5 Feb 2008 Accelerated Planned and organised strategy Dedicated PW implementation Executive/board member (-); the
for implementation at stages team including service Productive Ward team, e.g.
across organisation improvement and clinical programme lead/facilitator (3);
specialists clinical team (6), non-clinical/support
staff (3) total ¼ 12 participants

(continued )
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Support
Adoption package Approach to implementation Resourcing Study participants

Study 2 (2010)
S2H1 Oct 2008 Standard Originally implemented on six Seconded PW lead nurse for Service improvement facilitator/PW
wards but work lapsed due to first year. A year later a service lead (1), service improvement
move to new building. Roll-out improvement facilitator facilitator/PW facilitator (1) total ¼ 2
initiated in April 2010 identified to lead the work. Two participants
full-time facilitators appointed
for 18 months
S2H2 Jan 2009 Accelerated Lean work running two years PW programme lead and PW PW coordinator surgery (1), former
before PW was replaced by PW. Support Officer appointed in PW facilitator (1) total ¼ 2
Initially implemented on 7 early 2009. A support nurse participants
wards then roll-out over was appointed to provide ward
hospital cover for nurses to participate
in training
S2H3 Jun 2008 Accelerated Initial implementation on two PW programme lead was PW lead (1), service improvement
surgical wards. Officially identified from an existing facilitator (1), sister surgery (1),
launched on both hospital sites organisation and development matron surgery (1) total ¼ 4
in April 2009 team. PW coordinator participants
communicated plans to all of
the ward areas and PW
programme lead supported
training
S2H4 May 2008 Accelerated Planned to implement PW Two senior nurses were Associate head of nursing/PW
Foundation modules on 20 seconded to lead lead (1), PW facilitator (1) total ¼ 2
wards (of 30) across the implementation. Part of the participants
hospital remit was to work with the PW
facilitator in delivering
Productive Ward. A PW
facilitator was employed for
three days a week until
March 2009

(continued )
leadership

161

Table I.
Impact of
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28,2

162

Table I.
JHOM

Support
Adoption package Approach to implementation Resourcing Study participants

S2H5 Feb 2008 Accelerated Three pilot wards started the A full-time practice Service improvement facilitator/PW
programme in April 2008. Plan development nurse for 18 lead (1), practice development nurse/
months, and administrative
for whole hospital (24 wards) to PW facilitator (1), ward manager
have some support and support from within the Service general medical ward (1), sister for
engagement with the Improvement Department. PW in trauma (1) total ¼ 4
programme Another member of staff from participants
the Service Improvement
Department working as PW
facilitator almost full-time
S2H6 Jun 2008 Accelerated 13 wards were selected to work Appoint a full-time lead to 1 (former PW lead) total ¼ 1
on PW foundation modules implement the programme over participant
a two-year period. A ward sister
was appointed for six months.
Two matrons since provide
support
S2H7 Oct 2008 Accelerated Two showcase wards followed PW facilitator and a PW lead Director of nursing (1), PW lead (1),
by staged roll-out to whole appointed in 2009 PW facilitator (1) total ¼ 3
hospital participants
S2H8 Oct 2008 Accelerated Implementation of PW Team of five nurses (four PW lead (1), department manager (1),
foundation modules on all seconded) worked full-time on clinical nurse manager (1) total ¼ 3
wards, then process modules the programme for 12 months. participants
Senior nurse continued to
support implementation as part
of their quality improvement
role

Note: PW, The Productive Ward programme

 issues (e.g. leadership, control, decision-making power), the types of language or ways Impact of
of talking about issues, and the types of information used to substantiate claims/views leadership
(e.g. direct experience, policy, research evidence); coding and extraction: selection
of passages of text and coding according to themes (Braun and Clarke, 2006);
and refinement of themes: members of the research team examined the coherency
of the meaning of each theme (Holloway and Todres, 2003) (supporting validity of the
analysis), the assumptions underpinning it (Walshe, 2007), the possible implications 163
and the overall story the different themes reveal about leadership and staff
perspectives of the issues. Using a staged approach enables researchers to track
decisions, which ensures links between the original data and findings are maintained
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and transparent. This adds to the rigour of the research process and enhances the
validity of the findings, described below (Ritchie and Lewis, 2003).

Findings
The findings are presented according to four interrelated themes about leadership that
we identified across study 1 and study 2 data. Quotes from interviews with staff
working to implement the programme are used to illustrate each of these themes.

Different leadership roles at multiple levels of the organisation

The first theme we identified was that to implement and spread The Productive Ward
organisations needed to have leadership in place at multiple levels. This “multi-level
leadership” was consistently described as involving staff within four distinct types of
leadership roles, described below and illustrated by Table II.
The first distinct leadership role was senior executive and senior clinical leaders.
In study 1 we found that senior clinical leaders were perceived by both senior executives
and frontline staff to play an important role in aligning programme implementation with
clinical goals and priorities (all five case study hospitals in study 1). This work included
alignment of The Productive Ward with ongoing patient safety initiatives, infection
control and falls prevention strategies (see final report for further information
NNRU&NHSI, 2010). In study 2 the importance of visible executive/senior leadership
was again held by staff at all levels as being important for continuing to engage staff as
the programme was rolled-out to new wards:
The Deputy Director of Nursing attends steering group meetings and there have been
walkabouts from the Chairman and the Chief Executive. This support helps the areas that are
being visited to see that PW is important and that the work they are doing is being recognised
(Productive Ward (PW) programme lead, study 2, hospital 3).
The second leadership role was programme lead (also called PW facilitators in some
organisations). In study 1 all five case study hospitals had appointed one or more
programme leads for the organisation or funded secondments for senior nurses
or members of existing improvement teams (see Table I, study 1 hospitals 1-5). The
programme lead role was characterised by planning implementation at an organisational
level and facilitating ward teams to move forward with implementation and encourage
progress: which included: maintaining connections with external change agents to learn
about the programme and plan implementation; linking with staff in other implementing
hospitals to share learning; securing support from executive/senior managers by linking
the programme with broader organisational goals and; linking with ward staff to
provide training and to facilitate implementation. Study 2 revealed how in later stages
of implementation securing funding for this role proved critical as to whether
 Downloaded by LULEA UNIVERSITY OF TECHNOLOGY At 23:03 30 January 2016 (PT)
Table II.
Multiple leadership roles
Role Formal/informal
Executive/senior manager Senior staff formally
lead appointed to a position of
authority within the
organisation
Programme lead Formally appointed,
nominated or seconded
(often time-limited) lead for
organisational
implementation
Middle manager Formally appointed middle
manager/ward manager
Local Productive Ward lead Selected or self-nominated
individual who leads on
implementation at ward/
unit level
28,2
164
JHOM
Leadership styles and behaviours
Championing the programme
Strategic alignment of the programme with organisational goals or priorities
Securing resources/allocating funds
Visioning and conveying potential gains to staff
Designating overall targets for programme implementation
Engaging with staff who are actively involved in implementing the programme
Planning implementation across the whole organisation with senior leaders
Linking work with external networks and internal quality improvement teams
Facilitating training or learning of staff at unit/team level
Monitoring implementation and outcomes at organisational level
Managing decisions about whether/when/how to engage in the programme
Informing ward staff about the programme
Enabling and encouraging staff to work on the programme (releasing staff to training)
Linking the programme to quality improvement work at ward/unit level
Participating in the work, arranging ward-level meetings and sharing learning
Encouraging frontline staff to monitor the improvements and record their achievements
Explaining to frontline staff how to use tools and modules
Discussing plans and progress at ward/unit level
Documenting work at a local (ward/unit) level
 implementation was sustained and spread through organisations (hospitals 2, 4 and 7), or Impact of
whether only a few enthusiastic wards participated in the programme (hospitals 3, 6, 8): leadership
The energy and the motivation in the first instance was tremendously high, particularly on
the showcase wards. Staff were very keen and welcomed the initiative. Some staff came in to
the ward on their days off to do the activity follow in their own time. But now, staff motivation
has disappeared because of the lack of facilitator support (PW facilitator (programme lead),
study 2, hospital 4). 165
The third leadership role, that of middle managers/ward managers, involved showing
“commitment to the vision” of The Productive Ward and “being prepared to empower
staff” by releasing their time, delegate or share decision making and encouraging staff
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to learn about the programme (see Table II). Understandably some ward managers felt
they needed to direct the work and ensure the programme was implemented swiftly
and efficiently. We found that in hospitals where middle managers and ward managers
focused on creating opportunities for staff engagement rather than trying to direct staff
in an authoritarian way, this instilled a sense of team ownership and changes were
more likely to be sustained (study 1, hospitals 1, 2 and 4).
The fourth type of leadership role was local Productive Ward leads at ward level.
Successful local leads used a participative style to engaging themselves and others,
to bring a sense of credibility to the project and share knowledge and experiences
of implementation (study 1, hospitals 1-5). Although local “informal” leaders did not
generally describe themselves as leaders they did talk about leading the work in terms
of ensuring frontline staff were aware of the programme and changes colleagues were
making to their working practices e.g. facilitating staff from “showcase” wards to
present their work to other staff working on other hospital wards (hospitals 2-5). In this
respect local leaders did recognise their leadership role in championing the programme
or changes initiated through the work. For example:
One healthcare assistant had a huge involvement in the programme and she was able to say
what a difference it had made to her working day [y] she’s getting all these accolades
and suddenly the other healthcare assistants who weren’t interested at all were all on board
(PW trainer, study 1, hospital 4)
Some senior/formal leaders described the importance of recognising the work of local
leads as leadership “so that we can help to develop and encourage these types of skills
in nurses and other frontline staff” (Matron, study 1, hospital 5). In all organisations
(study 1 hospitals 1-5) there was evidence of the potential for skills development as
staff across the organisation took on implementation work:
[y] they don’t realise that in fact, by implementing this in their clinical areas, they in fact go
on a leadership programme – and I don’t think they realise it until they’ve finished
implementing the Releasing Time To Caret for their area (Senior nurse, study 1, hospital 2).
In relation to the numbers of staff filling these four leadership roles, these varied across
the five hospitals in study 1 according to the size of an organisation, the approach and
stage of implementation. For example, in hospitals 1 and 2 where the programme was
being implemented across the whole-organisational, local leads had been identified for
every ward, whereas there were far fewer identifiable ward-level and local leaders
where the programme was being piloted on a few wards (study 1, hospitals 4 and 5).
In some hospitals ward managers were the staff group that were given/took on the
role of local Productive Ward lead (study 1, hospitals 3 and 5), and this “duality” of
leadership roles was sometimes a point of tension, as discussed in the next section.
 JHOM Experiences of “good and bad” leadership styles
28,2 The second theme related to how leaders enacted their role through different styles
and behaviours. In study 1 there was agreement across all sources of data about
the necessity of strategic leadership. Senior leaders expressed strong views about the
importance of strategic leadership – suggesting this was necessary to “create vision”,
“champion the programme”, “align the initiative with strategic goals” and to “connect
166 the work with other initiatives, targets and local priorities”. Interviews with frontline
staff showed that for many staff working to implement the programme at ward level
encouragement and support for their own participation was a direct indication of
whether there was strong leadership behind the programme. Frontline staff expressed
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their positive experiences in terms of being “involved”, “encouraged” and “enabled” by

senior leaders. Programme leads described the need for “keen” wards and staff groups
to participate in ways and at a pace that suited them. The realisation for many
programme leads was that successful implementation required them to use a degree of
free-reign to their approach to leading implementation whilst also facilitating local leads
and frontline staff to adapt Productive Ward work to their own contexts and needs:
With a project of this size, it’s probably something – you have to make your mistakes, learn
from them and move on (PW programme lead, study 1, hospital 4).
For many frontline staff the best way of understanding The Productive Ward was
“learning by experience”, which included making mistakes and learning how to
resolve issues and avoid problems in the future. In three case study sites (study 1,
hospitals 1, 2 and 5) frontline staff were encouraged by programme leaders to interpret
and develop modules in the way they considered most appropriate for them and
encouraging sharing of learning between wards (study 1, hospitals 3 and 6). At some
sites they were even encouraged to take the principles of the modules and toolkit and
apply them to projects or issues not covered in the modules, if appropriate for their
needs. However not all organisations or leaders were confident to delegate leadership
or control. Some senior managers noted that because of the high profile of Productive
Ward, ward managers often rushed to take up the role of local lead without fully
understanding the implications of this particular leadership role. The reality of
facilitating rather than directing staff proved challenging for some ward leaders:
I went to the first event, so we were told we were on cohort two, and we went to the initiation
event and I sat there and I thought, ‘Oh my God, what have I come to? I should have done a bit
more research into this. I was like leafing through the toolkit and all of that, thinking, ‘Okay,
lots of work here (Ward sister, study 1, hospital 3).
Managerial staff often needed to develop skills and knowledge for implementation that
differed from the leadership style and behaviours associated with their managerial role.
Within all five case study sites (study 1) this led to recognition of the need for
leadership training and development for programme leads, managers and local leads;
and in one hospital the initiation of a custom designed leadership training course to
help prepare staff to lead:
Traditionally in nursing we’ve not been fantastic at giving all managers leadership training
before they go in to post. And this is giving them a real clear focus about how to lead (PW
facilitator, study 1, hospital 2).
This head-start was important, because programme leads and others had realised that
in order to lead change at ward level, local leads needed to gain knowledge about the
programme and how best to engage rather than direct frontline staff.
 Frontline staff having a sense of permission to lead change Impact of
The third theme related to issues of frontline staff feeling a sense of permission to leadership
change established practices and routines at ward level. In general interviews with senior
organisational leaders (executives and clinical directors) indicated that they recognised
that they are not necessarily the best people to address ward-level problems and that ward
staff have a better understanding of the day-to-day problems they encounter. An important
factor in enabling senior leaders to delegate control about implementation decisions was 167
confidence in the programme itself and understanding of how Lean principles can help
frontline staff to bring their observations and ideas for change to the fore:
It’s enabled them to use an established structure and process to harvest the good ideas many
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staff have had on their minds for years, and we’ve never actually been able to harvest them
(Chief executive, NHS hospital, study 1, hospital 1).
Case study data from study 1 shows that staff in non-traditional leadership roles
(such as lower grade nurses and health care assistants) can have several advantages
when influencing frontline staff to engage with the programme, based on their
credibility amongst colleagues. However, in some cases individual ward managers
admitted initially feeling concerned about handing over decision-making power to
their staff (study 1, hospitals 3 and 5), fearing a resulting lack of consistency that could
make it difficult to enforce standards. As previously mentioned, it was often this sense
of freedom to adapt the programme to local needs (expressed by staff in study 1,
hospitals 1 and 2) that engaged frontline staff interest and drove progress:
I think it’s that free-rein and people being able to develop the modules as they want [y] that’s
helped people to move on as far as they have done [y] because they’re the people that really
know (PW facilitator (programme lead), study 1, hospital 1).
Indeed, for some ward managers who had taken on the role of local Productive
Ward lead (study 1, hospitals 3 and 5) there was a sense that responsibility remained
with them personally to lead implementation rather than supporting the process of
implementation to be led by the potential insights, drive and enthusiasm of frontline staff:
I’m still leading it and I haven’t been able to completely pull away. And if, for example,
I wasn’t here for a long period of time, they would sustain everything that I do. They would
make some small changes, but they wouldn’t make dramatic changes without coming to me
almost to seek permission to do so (Ward sister, study 1, hospital 3).
At these two hospitals frontline staff had not become as involved in leading
implementation as they had done at other sites. The reasons why seemed to be related
to how resources for implementation had been allocated, in particular having sufficient
resources to free up staff time (“backfill” for nurses’ time away from the ward), access
to training and support provided by the NHS Institute, and allocated budgets for
changes to ward storage areas or layouts. In study 2, differences were noted in whether
ward teams were receptive to change and wanted to take ownership of implementation:
Wards with staff that express a ‘can do attitude’ take on the programme with interest. Wards
where the general attitude is less positive are harder to motivate. Some wards require a lot
more support and encouragement than others before they perceive benefits and become
committed to the programme (PW programme lead, study 2, hospital 6).
Interviews with frontline staff showed that they were often very aware and irritated by
having to work around problems and cope with disorganisation (all hospitals study 1).
What generally held them back from initiating change is that they did not see it as part
of their job or something that they will be encouraged to do, or rewarded for. Or, as one
 JHOM senior leader explained, frontline staff were sometimes unwilling to challenge existing
28,2 ways of working because of a fear of repercussions:
Part of what you ask your staff to do in Productive Ward programme – is take some risk – the
staff feel that if they take a risk and it goes wrong, they’re going to be punished. And they
won’t want to do it (Chief executive, study 1, hospital 2).
At this hospital (study 1, hospital 2) it had been found that rather than anarchy, giving
168 frontline staff guidance and support to tackle issues themselves resulted in similar
solutions from different wards, which could then be combined and developed into a
hospital-wide standard.
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Leader’s actions to spread learning and sustain improvements

The fourth theme was the importance of leader’s actions to spread learning and sustain
improvements. Across the data it was possible to identify seven ways in which leaders
connected, these were: leader’s connections with each other; with different staff and
professional groups across the organisation; with existing organisational structures/
systems; with other/external organisations; with information and knowledge resources;
with skills development/training, and support networks; and with systems to evaluate
impact/improvement and share learning. In organisations where the programme had
spread well (in particular study 1, hospitals 1 and 2) programme leads had sought to
connect with different staff, professional and cultural groups by actively linking
implementation with staff interests, goals and priorities. Findings from study 2 (all eight
hospitals) also showed that leaders’ activities were important for spreading
implementation through organisations but many executive and programme leaders did
not prioritise/invest time in creating opportunities to spread learning to other staff
groups. Consequently in six of the eight case study sites (study 2, hospitals 1-5 and 7)
islands of improvement occurred where improvement was isolated and failed to spread:
Generally the energy is present in the organisation but improvement has taken longer on some
wards than others because of communication issues (Programme lead, study 2, hospital 3).
In contrast, leaders in organisations where the programme had spread well had taken
steps to use existing organisational structures, such as staff orientation and induction
programmes to spread knowledge and learning about the programme to new employees.
Another factor was that leaders sustained connections within other leaders in
implementing organisations to gain emergent knowledge and learning (study 1,
hospitals 1-5), rather than disconnecting from intra-organisational networks once
implementation had begun (study 2, hospitals 1, 5, 6, 8). In study 2 dwindling senior
leadership engagement at three case study sites (study 2, hospitals 1, 3 and 6) had led
to the breakdown of vertical connections between senior leadership and leaders
working to implement the programme at lower levels. Local leaders reported feeling
disappointed that the organisation had “lost interest” or had moved on to new
priorities. At hospital 6 there had been limited executive buy-in for the first three
months at which point the organisation’s steering group was disbanded leading to
implementation being discontinued. In one hospital (study 2, hospital 5), reluctance
to share information or learning between wards contributed to discontinuation
of the programme’s implementation. For these respondents, there was a general sense
of failure and missed opportunity to encourage and support leadership development
in others (contrasting with positive examples of mentorship, clinical supervision
and peer-education described by staff in study 1). Another reason for leadership
connections breaking down in three hospital sites (study 2, hospitals 2, 3 and 6) was
 that a lack of continuation funding for the programme lead had contributed to Impact of
discontinuation of implementation across the organisation. leadership
Discussion
Our findings add to the growing body of evidence that suggest improvement programmes
based on Lean thinking can assist with the challenges health care organisations face in
both improving quality and developing effective leadership. The scope of the study – 169
nationally representative of NHS hospitals in England – and depth of the study data
means our findings are likely to be transferable to cases of implementation of Lean
initiatives in other hospital settings and internationally. Overall the findings illustrate
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the dynamic nature of leadership in organisations that are implementing Lean and
development of leadership through undertaking Lean improvement work. We found
evidence that the Productive Ward is helping to develop leadership skills within the health
care workforce in England; which has been shown elsewhere (BHSCT, 2009; NHSL, 2009;
NHSS, 2008) by acting as a learning system to try out new skills and approaches on real
projects within health care environments (Balle and Regnier, 2007).

What type of leadership roles do organisations need to successfully implement

interventions like The Productive Ward?
Senior organisational leaders need to give consideration to leadership at multiple levels
and how interactions between these levels shape outcomes. Such consideration could help
to overcome ambiguity about responsibility for implementation (Ham et al., 2003) and
spread leadership functions vertically through the organisation (Bathurst and Morin,
2010). A proposition for future research is that multi-level leadership enables outcomes by
aligning “top-down” and “bottom-up” leadership of Lean. We suggest that considering
“leadership processes” (rather than just looking at leadership roles) is a useful approach.
Taking this broader view, leadership processes involve not only leaders, but also
followers, interactions (e.g. communication, information, decision making), contexts (e.g.
situations, events, environments, resources, timescales) and outcomes (e.g. results, impact,
organisational learning, and staff morale). Our findings and perspectives from the
literature enable us to put forward a framework of “leadership processes”, illustrated by
Figure 1. This framework could inform strategic and cultural development from an
organisational perspective in order to successfully implement Lean (Brandao de Souza,
2009); as well as offering directions for future research about the challenges of leading
change, innovation and improvement in health care (Hartley and Benington, 2010).

What type of leadership styles and behaviours should leaders use?

Part of strong leadership is understanding the need for different and contextually
appropriate leadership roles, styles and behaviours at different levels and stages of
implementation. Leaders’ contributions to each leadership process are summarised
in Table III. In the early stages of implementation executive/senior organisational
leaders are often best equipped to gain support, information or resources from external
stakeholders and involve other formal leaders (e.g. board members, clinical directors,
service managers, appointed programme leads) in creating a vision and allocating or
securing resources for implementation. In the later stages of implementation programme
leadership and managerial level leadership can help to create the conditions for informal
leadership to emerge (Mumford et al., 2000). This might involve providing information
and support to those who do not necessarily recognise themselves as leaders – typically
health care assistants and junior/student nurses (Cummings et al., 2008). For example,
 JHOM Formal leader
National
(macro)
28,2 Project/programme leader context
Informal leader

170

a Organisational
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(meso)
context

Frontline
(micro)
context
c

Notes: (a), Multi-level leadership: senior leaders plan and are committed to multi-level
leadership; project/programme leaders are appointed; managers are aware and supportive;
local (informal) leaders are identified; (b), leadership styles and behaviours: all leaders
understand what type of style to use for their role and types of skills and knowledge they
need; (c), staff empowerment: formal leaders know when and how to relinquish control
through encouraging and supporting informal leaders; informal leaders use their credibility
to engage andinform colleagues; all leaders have access to necessary resources, information,
guidance and support; (d), boundary spanning: leaders communicate well with each other,
reach different staff and professional groups, use existing organisational structures/systems,
Figure 1. link and learn from other organisations, share information and knowledge resources, use
Framework of leadership
processes skills development/training, and support networks, evaluate impact/improvement and share
learning

providing information about transformational and relational approaches to leadership

required at a local level of implementation ( Davis and Adams, 2011).

How can leaders engage and energise frontline staff?

Valuing and providing support for meaningful staff empowerment is a key leadership
process. In the case of The Productive Ward, for executive/senior leads valuing the
contributions of frontline staff and providing support for staff to engage in meaningful
ways were felt to be crucial factors to sustained implementation (Table III). The main
contribution of programme leads was providing information and improvement resources
 Downloaded by LULEA UNIVERSITY OF TECHNOLOGY At 23:03 30 January 2016 (PT)
Leadership processes (a) Multi-level leadership
Executive/senior manager Valuing multi-level
lead leadership, securing
funding and constructing
formal leadership posts at
lower levels
Programme lead Planning and monitoring
implementation, developing
local strategies to engage
staff groups
Middle manager Management of frontline
staff participation and
engagement
Local lead Identifying areas for change
at local level, leading
change with staff in teams
Leaders’ contributions to
leadership processes
Table III.
(b) Leadership styles and
behaviours
Communicating vision/
strategic goals from
organisational perspective
(strategic)
Facilitating access to
training and skills
development at lower levels
(facilitative/planning)
Allowing frontline staff to
lead change (free-reign/
delegation)
Developing personal skills
and knowledge in
leadership
(transformational/
facilitative)
(c) Staff empowerment (d) Boundary spanning
Allocating resources to Communication beyond the
cover staff time to organisation (stakeholders)
participate and at board/executive level
Acknowledging staff to gain support and
achievements and successes resources
Providing information and Planning, collating and
improvement resources sharing information across
across organisations, localities/sites, evaluation of
providing feedback about impact with other leaders,
achievements creating opportunities to
spread learning to other
staff groups
Freeing up staff time and Communicating and
encouraging staff to sharing information,
participate explaining goals of the
work at ward level
Communication, Sharing experiences of
coordination of work and implementation and local
monitoring team learning
achievements
leadership
171
Impact of
 JHOM across organisations and providing feedback about achievements. While frontline
28,2 staff expressed their commitment to the programme according to personal and emotive
aspects of belonging to a “team” or “professional group”; which corresponds with a
mutual understanding of leadership ( Denis et al., 2012). It would therefore seem
appropriate to place these types of values at the centre of organisational strategies
for implementation. Future research could explore interactions between leaders and
172 followers that lead to a sense of empowerment and the impact on outcomes.

How can leaders act to ensure implementation is spread and sustained?

Connecting vertical and horizontal boundary spanning leadership activities helps to
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spread learning and sustain improvements. The term the “nexus effect” has been
used to describe the collaborative, transformational outcomes that can be achieved
when leaders span boundaries that are above and beyond what different groups could
achieve on their own (Yip et al., 2008). Adding to this notion, in the present study
leaders’ boundary spanning activities were found to be an indicator of the impact of
leadership on outcomes, and this is an interesting area for future research on long-term
impact. Leaders therefore need to understand the different types of boundaries
and possible meeting places across boundaries (the nexus) that might exist in the
organisations that they work within. Otherwise, as our findings clearly show, even in
organisations where leaders are fully committed to implementation “islands of
improvement”, “discontinuation” or “improvement evaporation” occur when leaders
underestimate the importance of their boundary spanning activities.

Conclusion
This study aimed to explore the nature and impact of leadership in relation to the local
implementation of quality improvement interventions in health care organisations.
By drawing on staff experiences of implementing The Productive Ward in English
hospitals insights were gained into leadership processes as related to lean health care.
A framework for leadership processes is presented which could be applied, tested and
developed in other contexts. The framework includes: consideration of leadership at
multiple levels and how interactions between these levels shape outcomes; reflection on
the need for different and contextually appropriate leadership roles, styles and
behaviours at different levels and stages of implementation; valuing and providing
support for meaningful staff empowerment; and connecting vertical and horizontal
boundary spanning leadership activities to spread learning and sustain improvements.
Further research is needed to explore potential differences in leadership within late
adopting or non-adopting health care organisations; to better define and understand
the longer term impact of spread and sustainability (beyond three years post-
implementation); and to examine the influence of external driving factors such as health
service policy and resourcing, external change agencies and patient groups.
Authors’ contributions: All of the authors made substantial contributions to conception
and design of the reported studies and to the perspectives put forward in this paper. E.M.
led study 1 and study 2 and led the secondary analysis and writing of the paper. G.R.
provided advice and insights into the literature on quality improvement in health care,
implementation research and supported the secondary analysis. J.M. provided guidance
on study design and analysis and contributed thoughts on the nature and potential for
development of leadership in this context. All authors have given final approval of the
version to be published.
Competing interests: The authors declare that they have no competing interests.
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Further reading
Buchanan, D., Addicott, R., Fitzgerald, L., Ferlie, E. and Baeza, J. (2007a), “Nobody in charge:
distributed change agency in healthcare”, Human Relations, Vol. 60 No. 7, pp. 1065-1090.
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spanning and role conflict in the workplace”, British Journal of Management, Vol. 19,
pp. 138-144.

Corresponding author
Dr Elizabeth Morrow can be contacted at: elizabethmmorrow@hotmail.co.uk

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