Distributed versus centralized leadership in the implementation of a Canadian integrated care initiative

摘要

Introduction : Traditional notions of leadership involve more centralized power at the senior levels, with the expectation that vision and strategy will trickle down to operational levels. This type of leadership may work well in smaller organizations, but the complexity of integrated health models involving large inter-organizational networks may challenge this notion of leadership. To date, the evidence on how traditional centralized leadership impacts the implementation and functioning of integrated care networks is unclear. There is a need to understand different forms of leadership within and across organizations that are involved in integrated care networks. Theory/Methods : We conducted multiple case studies evaluating the implementation of Health Links (HL), a “low-rules”/bottom-up integrated care model in Ontario, Canada. Through an analysis of the qualitative data via semi-structured interviews, this study provides a practical exploration of leadership in the HL context. Our analysis draws on process- or action-oriented theories of leadership that look beyond senior leadership (e.g., distributed and shared leadership, complexity leadership theory). These theories posit that non-formal leaders are critical to the functioning of complex organizations and systems, and consider leadership as an interactive adaptive process, often emergent in nature. Results : Preliminary results show that leadership was highly centralized in implementing HL and concentrated almost exclusively at the senior level, which entailed governance committees involving CEOs and upper management. This centralized leadership seemed to result from a failure to develop capacity for distributed leadership throughout partner organizations, which further impeded front-line workers from understanding the goals of HLs to provide integrated care. That is, due to factors such as insufficient education/communication regarding HLs, lack of delegation of more operational tasks, and failure to meaningfully seek out front-line support, there was limited ability within the organizations to sustain the integrated care effort without an ‘overreliance’ on senior leadership to drive HLs forward. Conclusions : Though senior leadership is critical in setting a vision for integrated care networks, our findings indicate that a centralized leadership approach may not be optimally effective at the stage of implementation and ongoing functioning of these networks. Discussion : In light of these findings, efforts to implement ‘low rules’ integrated care initiatives may require a more proactive approach to leadership, which clearly delineates the possible shared leadership roles throughout organizations. However, in order to develop distributed leadership, senior leadership must facilitate a context (e.g., via knowledge sharing) for informal leaders to take ownership of the implementation project and champion it to those delivering integrated care on the front lines. Lessons Learned : Through the establishment of ‘shared’ or complementary leadership roles across all levels of the organization, distributed leadership may allow for more meaningful clinician buy-in and subsequent spread of the integrated care initiative. Limitations : At this stage, results are still preliminary and limited by the fact that case studies are not generalizable beyond the Ontario, Canada context. Nevertheless, these results help set a foundational groundwork from which to further explore distributed leadership in integrated care. Suggestions for future research : Future research should continue to explore the value of distributed leadership in integrated care, and would particularly benefit by studying contrasting models of leadership and comparing their impact on implementation outcomes.