title: 'New' and distributed leadership in quality and safety in health care, or 'old' and hierarchical? An interview study with strategic stakeholders.
abstract: OBJECTIVE
  We aimed to explore the views of strategic level stakeholders on leadership for quality and safety in the UK National 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 the academic literature, participants distinguished between traditional hierarchical 'concentrated' leadership associated with particular positions, and distributed leadership involving those with particular skills and abilities across multiple institutional levels. They clearly and explicitly saw a role for distributed leadership, emphasizing that all staff had responsibility for leading on patient safety and quality. They described the particular value of leadership coalitions between managers and clinicians. However, concern was expressed that distributed leadership could mean confusion about who was in charge, and that at national level it risked creating a vacuum of authority, mixed messages, and conflicting expectations and demands. Participants also argued that hierarchically based leadership was needed to complement distributed leadership, 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 that blends distributed and concentrated leadership. Policy and academic prescriptions about leadership may benefit from the sophisticated and pragmatic know-how of insiders who work in organizations that remain permeated by traditional structures, cleavages and power relationships.
authors.affiliation: Professor of Management, Health Services Research Unit, University of Aberdeen, UK.
authors.forename: Lorna
authors.initials: L
authors.lastname: McKee
authors.forename: Kathryn
authors.initials: K
authors.lastname: Charles
authors.forename: Mary
authors.initials: M
authors.lastname: Dixon-Woods
authors.forename: Janet
authors.initials: J
authors.lastname: Willars
authors.forename: Graham
authors.initials: G
authors.lastname: Martin
mesh_terms: D000288:Administrative Personnel; D000328:Adult; D004739:England; D005260:Female; D006291:Health Policy; D006801:Humans; D007407:Interviews as Topic; D007857:Leadership; D008297:Male; D015279:Organizational Culture; D061214:Patient Safety; D011785:Quality Assurance, Health Care; D058996:Quality Improvement; D013222:State Medicine / Q000592:standards*
keywords: leadership; quality; safety