Elsevier

Health Policy

Volume 91, Issue 3, August 2009, Pages 306-313
Health Policy

Consensus on the leadership of hospital CEOs and its impact on the participation of physicians in improvement projects

https://doi.org/10.1016/j.healthpol.2009.01.003Get rights and content

Abstract

Objectives

The success of a Dutch program to disseminate quality improvement projects depends on the participation of physicians working in program hospitals. The leadership of hospital executives (CEOs) is considered an important explanation. This study aims to determine whether the relation, between the extent to which physicians notice their CEOs stimulate improvement initiatives and the number of projects joined by physicians, is moderated by the consensus among physicians working in the same hospital.

Methods

Multilevel analyses are applied on data of 286 physicians from eight hospitals to: (1) estimate whether participation depends on noticing if CEOs stimulate improvement, (2) test if an individual's participation differs when more colleagues have the same opinion (effect modification).

Results

Significant moderator effects are found. The participation of physicians, noticing that CEOs stimulate improvement is higher when more colleagues share this opinion. For physicians not knowing whether improvement is encouraged, higher consensus coincides with lower participation.

Conclusion

Project involvement of physicians depends on their consensus about encouragement by CEOs. This confirms the importance of strategic leaders in dissemination programs. Further research is recommended into causes of CEO leadership visibility and methods to strengthen leadership climate.

Introduction

Since the 1970s increasing attention is given to the effects of leadership in organizations. The current scientific debate is often centred at the nature, causes and effects of leadership in general or particular leadership styles. It is common to express the effects of leadership in terms of productivity, job satisfaction, self efficacy, learning behaviour, organizational culture or team performance [1], [2], [3]. The leadership effect we focus on in the current study is the participation of physicians in a variety of improvement projects. It is one of the outcome measures of a change program for hospitals in the Netherlands. Better Faster pillar 3 (BFp3) aims at organizational learning and the spread of innovations. The program is based on the simultaneous implementation of several improvement projects by multidisciplinary teams, combined with a strategic leadership program for chief executive officers (CEOs) (Box 1 contains information on BFp3) [4], [5].

In the Netherlands hospital CEOs are responsible for formulating, preparing and executing the hospital's policy. Within the national change program, executives of participating hospitals have the explicit task to stimulate internal improvement processes and the active participation of hospital staff, and physicians in particular. Executives have a key role to fulfil in setting out the strategic course of their organization to match the program targets of sustainability and spread [6]. They are expected to communicate a vision favouring the hospital-wide spread of BFp3 improvement projects [8]. Program success requires motivation among physicians and nursing staff to implement promising techniques to improve the quality, safety and efficiency of the care delivery. The focus of this article is on the relation between the number of projects joined by physicians in eight BFp3 hospitals and a specific aspect of CEO leadership: the extent to which physicians perceive that their CEOs stimulate improvement. Secondly – because it is likely that physicians working in different hospitals perceive and experience the leadership of executives differently – we will examine whether the degree of consensus among physicians influences this relation. In the literature this degree of consensus on leadership among staff is defined as the strength of the leadership climate; an organizational characteristic with a known moderator effect [7]. By testing two hypotheses we want to answer the question whether consensus on perceived CEO change support among physicians of the same hospital influences the relation between physician's perception and participation.

Section snippets

CEO leadership in a dissemination program

The planned implementation and internal spread can only take place when projects are sufficiently supported by external change agents and internal hospital actors at all organizational levels [8], [9]. When it comes to the highest level, strategic management, we know from the literature that executives play an important role in change processes [10], [11], [12], [13], [14]. Strategic managers determine the organization's focus and direction. Based on a review of the conditions for successful

Respondents and data collection

Physicians were sampled from eight hospitals that participated in BFp3 from the end of 2004 until the end of 2006. All hospitals started their program participation in October 2004. Seven of the hospitals are general hospitals, one of them is a university hospital. After comparing medical specialties or departments per hospital, we found twelve departments that were present in each hospital: anaesthetics, cardiology, ear, nose and throat (ENT), general surgery, gynaecology, internal medicine,

Degree of participation by physicians

The total response to the questionnaires was 36% (n = 313), ranging from 17% to 49% across the hospitals (Table 2). On average, physicians in the eight BFp3 hospitals participated in 1 project (SD = .91, range: 0–5); 29% did not join any project, 50% participated in 1 project, 16% in 2 projects, 4% in 3 projects, 0% in 4 projects and 1% in 5 projects. In Table 2 we can see how the average participation differs between hospitals from .41 to 1.32. Physicians were asked if CEOs stimulate improvement

Main findings

In this study the concept of leadership climate was used to explain the participation of physicians in improvement projects within a national change and dissemination program. We tested how the relation between physician participation and the extent to which CEOs stimulate improvement initiatives is moderated by the degree of consensus among physicians of the same hospital. On average, the participation of physicians, noticing that executives stimulate improvement, does not differ significantly

Conclusions

In this study we analyzed the moderating effect of leadership climate within hospitals on the relation between perceived leadership of CEOs by physicians and the participation of physicians in improvement projects. The hypothesized moderator effect was confirmed. Participation reaches an optimum when a physician, who perceives that CEOs stimulate improvement, works in a hospital with more colleagues with the same perception. Participation decreases when a physician, who has no idea about

Acknowledgements

The authors wish to thank the medical specialists who participated in this study.

References (29)

  • A.S. Tsui et al.

    Unpacking the relationship between CEO leadership behavior and organizational culture

    Leadership Quarterly

    (2006)
  • A. Mehra et al.

    Distributed leadership in teams: the network of leadership perceptions and team performance

    Leadership Quarterly

    (2006)
  • M.S. Joshi et al.

    Getting the board on board: engaging hospital boards in quality and patient safety

    Joint Commission Journal on Quality and Patient Safety

    (2006)
  • A. Carmeli et al.

    The influence of leaders’ and other referents’ normative expectations on individual involvement in creative work

    Leadership Quarterly

    (2008)
  • W. Schellekens et al.

    A stone in the pond: stimulating hospitals to implement proven improvements (in Dutch)

    Medisch Contact

    (2003)
  • Consortium Better Faster pillar 3. National strategy Better Faster pillar 3 (April 2004–September 2008)....
  • M. Dückers et al.

    Evaluating the implementation and effects of a multilevel quality collaborative in hospital care

  • G. Chen et al.

    The role of different levels of leadership in predicting self- and collective efficacy: evidence for discontinuity

    Journal of Applied Psychology

    (2002)
  • M. Dückers et al.

    Determinants of a knowledge based sector wide improvement program in Dutch hospital care (in Dutch)

    Acta Hospitalia

    (2005)
  • D.A. Buchanan et al.

    The sustainability and spread of organizational change: modernizing healthcare

    (2007)
  • S.L. Walston et al.

    Does reengineering really work? An examination of the context and outcomes of hospital reengineering initiatives

    Health Services Research

    (2000)
  • P.L. Green

    Improving clinical effectiveness in an integrated care delivery system

    Journal for Healthcare Quality

    (1998)
  • D.H. Gustafson et al.

    Developing and testing a model to predict outcomes of organizational change

    Health Services Research

    (2003)
  • J. Øvretveit

    The leaders role in quality and safety improvement: a review of research and guidance

    (2005)
  • Cited by (18)

    View all citing articles on Scopus

    This study was funded by ZonMw, the Netherlands organization for health research and development.

    View full text