Amanda Smith
Discussion: Skills Versus Traits and the Systems Perspective
Skills Approach differs from Trait Theory because it focuses on an individuals skills and abilities versus an individuals traits. Although traits may be important for a leader in health care administration, skills also determine leadership effectiveness. Contemporary research has noted that an individual may garner skills and competencies from professional experiences. For example, a leaders skills derived from nonprofit experience securing funds for multiple low-funded health clinics may assist in developing valuable competencies in matters of negotiation and organization. From developed skills and competencies, an individual may gain a leadership position or emerge as an effective leader.
For this Discussion, review the Learning Resources, paying specific attention to the journal article by Morrow, Glenn, and Maben (2014) (attached). Reflect on skills and traits that might be necessary for leadership within a health care administration setting. Also, think about how traits and skills may relate to your personal health care administration leadership philosophy.
By Day 3
Post a brief explanation that contrasts the Skills Approach and Trait Theory of leadership. Then, explain whether a skill represents a trait or if a trait represents a skill for informing leadership. Justify your response and provide an example. Finally, explain how each might relate to your personal health care administration leadership philosophy. Be specific and provide examples. Exploring the nature and impact
of leadership on the local
implementation of
The Productive Ward Releasing
Time to Caret
Elizabeth Morrow, Glenn Robert and Jill Maben
National Nursing Research Unit, Florence Nightingale School of Nursing and
Midwifery, Kings 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 (n79) 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, leaders 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 leaders 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,
The current issue and full text archive of this journal is available at
www.emeraldinsight.com/1477-7266.htm
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.
154
JHOM
28,2
2007). Lean has a long history of development and use in the commercial sector
and manufacturing industry where it is a well-established improvement approach
(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
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; vretveit, 2009; Barr and Dowding
2012) sometimes called improvement leadership, however little is known about the
most effective forms of leadership in this context (vretveit, 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.
155
Impact of
leadership
Background
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
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
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 (vretveit, 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
156
JHOM
28,2
level (Morrow et al., 2012). It comprises 13 modules and tools designed for self-directed
learning at ward level, beginning with three foundation modules called Knowing
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.
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
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 (vretveit, 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 leaders 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
157
Impact of
leadership
(MA, 2005). Hence implementation strategies in health care now recognise and seek
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
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
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 Kings 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.
158
JHOM
28,2
Method
The focus of this paper is to explore the nature and impact of leadership from
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
investigation to be captured (Ritchie and Lewis, 2003). Using this approach the
context of participants experiences can be retained, while also exploring
associations and explanations in the data and drawing on existing theories and
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 Yins, 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 persons 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 (n58) and study 2 (n21). 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
159
Impact of
leadership
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ra
m
m
e
le
a
d
/f
a
ci
li
ta
to
r
(2
);
cl
in
ic
a
l
te
a
m
(4
),
n
o
n
-c
li
n
ic
a
l/
su
p
p
o
rt
st
a
ff
(2
)
to
ta
l
1
1
p
a
rt
ic
ip
a
n
ts
S
1
H
5
F
eb
2
0
0
8
A
cc
el
er
a
te
d
P
la
n
n
ed
a
n
d
o
rg
a
n
is
ed
st
ra
te
g
y
fo
r
im
p
le
m
en
ta
ti
o
n
a
t
st
a
g
es
a
cr
o
ss
o
rg
a
n
is
a
ti
o
n
D
ed
ic
a
te
d
P
W
im
p
le
m
en
ta
ti
o
n
te
a
m
in
cl
u
d
in
g
se
rv
ic
e
im
p
ro
v
em
en
t
a
n
d
cl
in
ic
a
l
sp
ec
ia
li
st
s
E
x
ec
u
ti
v
e/
b
o
a
rd
m
em
b
er
(-
);
th
e
P
ro
d
u
ct
iv
e
W
a
rd
te
a
m
,
e.
g
.
p
ro
g
ra
m
m
e
le
a
d
/f
a
ci
li
ta
to
r
(3
);
cl
in
ic
a
l
te
a
m
(6
),
n
o
n
-c
li
n
ic
a
l/
su
p
p
o
rt
st
a
ff
(3
)
to
ta
l
1
2
p
a
rt
ic
ip
a
n
ts
(c
o
n
ti
n
u
ed
)
Table I.
Summary of hospital
case study sites
160
JHOM
28,2
A
d
o
p
ti
o
n
S
u
p
p
o
rt
p
a
ck
a
g
e
A
p
p
ro
a
ch
to
im
p
le
m
en
ta
ti
o
n
R
es
o
u
rc
in
g
S
tu
d
y
p
a
rt
ic
ip
a
n
ts
S
tu
d
y
2
(2
0
1
0
)
S
2
H
1
O
ct
2
0
0
8
S
ta
n
d
a
rd
O
ri
g
in
a
ll
y
im
p
le
m
en
te
d
o
n
si
x
w
a
rd
s
b
u
t
w
o
rk
la
p
se
d
d
u
e
to
m
o
v
e
to
n
ew
b
u
il
d
in
g
.
R
o
ll
-o
u
t
in
it
ia
te
d
in
A
p
ri
l
2
0
1
0
S
ec
o
n
d
ed
P
W
le
a
d
n
u
rs
e
fo
r
fi
rs
t
y
ea
r.
A
y
ea
r
la
te
r
a
se
rv
ic
e
im
p
ro
v
em
en
t
fa
ci
li
ta
to
r
id
en
ti
fi
ed
to
le
a
d
th
e
w
o
rk
.T
w
o
fu
ll
-t
im
e
fa
ci
li
ta
to
rs
a
p
p
o
in
te
d
fo
r
1
8
m
o
n
th
s
S
er
v
ic
e
im
p
ro
v
em
en
t
fa
ci
li
ta
to
r/
P
W
le
a
d
(1
),
se
rv
ic
e
im
p
ro
v
em
en
t
fa
ci
li
ta
to
r/
P
W
fa
ci
li
ta
to
r
(1
)
to
ta
l
2
p
a
rt
ic
ip
a
n
ts
S
2
H
2
Ja
n
2
0
0
9
A
cc
el
er
a
te
d
L
ea
n
w
o
rk
ru
n
n
in
g
tw
o
y
ea
rs
b
ef
o
re
P
W
w
a
s
re
p
la
ce
d
b
y
P
W
.
In
it
ia
ll
y
im
p
le
m
en
te
d
o
n
7
w
a
rd
s
th
en
ro
ll
-o
u
t
o
v
er
h
o
sp
it
a
l
P
W
p
ro
g
ra
m
m
e
le
a
d
a
n
d
P
W
S
u
p
p
o
rt
O
ff
ic
er
a
p
p
o
in
te
d
in
ea
rl
y
2
0
0
9
.
A
su
p
p
o
rt
n
u
rs
e
w
a
s
a
p
p
o
in
te
d
to
p
ro
v
id
e
w
a
rd
co
v
er
fo
r
n
u
rs
es
to
p
a
rt
ic
ip
a
te
in
tr
a
in
in
g
P
W
co
o
rd
in
a
to
r
su
rg
er
y
(1
),
fo
rm
er
P
W
fa
ci
li
ta
to
r
(1
)
to
ta
l
2
p
a
rt
ic
ip
a
n
ts
S
2
H
3
Ju
n
2
0
0
8
A
cc
el
er
a
te
d
In
it
ia
l
im
p
le
m
en
ta
ti
o
n
o
n
tw
o
su
rg
ic
a
l
w
a
rd
s.
O
ff
ic
ia
ll
y
la
u
n
ch
ed
o
n
b
o
th
h
o
sp
it
a
l
si
te
s
in
A
p
ri
l
2
0
0
9
P
W
p
ro
g
ra
m
m
e
le
a
d
w
a
s
id
en
ti
fi
ed
fr
o
m
a
n
ex
is
ti
n
g
o
rg
a
n
is
a
ti
o
n
a
n
d
d
ev
el
o
p
m
en
t
te
a
m
.
P
W
co
o
rd
in
a
to
r
co
m
m
u
n
ic
a
te
d
p
la
n
s
to
a
ll
o
f
th
e
w
a
rd
a
re
a
s
a
n
d
P
W
p
ro
g
ra
m
m
e
le
a
d
su
p
p
o
rt
ed
tr
a
in
in
g
P
W
le
a
d
(1
),
se
rv
ic
e
im
p
ro
v
em
en
t
fa
ci
li
ta
to
r
(1
),
si
st
er
su
rg
er
y
(1
),
m
a
tr
o
n
su
rg
er
y
(1
)
to
ta
l
4
p
a
rt
ic
ip
a
n
ts
S
2
H
4
M
a
y
2
0
0
8
A
cc
el
er
a
te
d
P
la
n
n
ed
to
im
p
le
m
en
t
P
W
F
o
u
n
d
a
ti
o
n
m
o
d
u
le
s
o
n
2
0
w
a
rd
s
(o
f
3
0
)
a
cr
o
ss
th
e
h
o
sp
it
a
l
T
w
o
se
n
io
r
n
u
rs
es
w
er
e
se
co
n
d
ed
to
le
a
d
im
p
le
m
en
ta
ti
o
n
.
P
a
rt
o
f
th
e
re
m
it
w
a
s
to
w
o
rk
w
it
h
th
e
P
W
fa
ci
li
ta
to
r
in
d
el
iv
er
in
g
P
ro
d
u
ct
iv
e
W
a
rd
.
A
P
W
fa
ci
li
ta
to
r
w
a
s
em
p
lo
y
ed
fo
r
th
re
e
d
a
y
s
a
w
ee
k
u
n
ti
l
M
a
rc
h
2
0
0
9
A
ss
o
ci
a
te
h
ea
d
o
f
n
u
rs
in
g
/P
W
le
a
d
(1
),
P
W
fa
ci
li
ta
to
r
(1
)
to
ta
l
2
p
a
rt
ic
ip
a
n
ts
(c
o
n
ti
n
u
ed
)
Table I.
161
Impact of
leadership
A
d
o
p
ti
o
n
S
u
p
p
o
rt
p
a
ck
a
g
e
A
p
p
ro
a
ch
to
im
p
le
m
en
ta
ti
o
n
R
es
o
u
rc
in
g
S
tu
d
y
p
a
rt
ic
ip
a
n
ts
S
2
H
5
F
eb
2
0
0
8
A
cc
el
er
a
te
d
T
h
re
e
p
il
o
t
w
a
rd
s
st
a
rt
ed
th
e
p
ro
g
ra
m
m
e
in
A
p
ri
l
2
0
0
8
.
P
la
n
fo
r
w
h
o
le
h
o
sp
it
a
l
(2
4
w
a
rd
s)
to
h
av
e
so
m
e
su
p
p
o
rt
a
n
d
en
g
a
g
em
en
t
w
it
h
th
e
p
ro
g
ra
m
m
e
A
fu
ll
-t
im
e
p
ra
ct
ic
e
d
ev
el
o
p
m
en
t
n
u
rs
e
fo
r
1
8
m
o
n
th
s,
a
n
d
a
d
m
in
is
tr
a
ti
v
e
su
p
p
o
rt
fr
o
m
w
it
h
in
th
e
S
er
v
ic
e
Im
p
ro
v
em
en
t
D
ep
a
rt
m
en
t.
A
n
o
th
er
m
em
b
er
o
f
st
a
ff
fr
o
m
th
e
S
er
v
ic
e
Im
p
ro
v
em
en
t
D
ep
a
rt
m
en
t
w
o
rk
in
g
a
s
P
W
fa
ci
li
ta
to
r
a
lm
o
st
fu
ll
-t
im
e
S
er
v
ic
e
im
p
ro
v
em
en
t
fa
ci
li
ta
to
r/
P
W
le
a
d
(1
),
p
ra
ct
ic
e
d
ev
el
o
p
m
en
t
n
u
rs
e/
P
W
fa
ci
li
ta
to
r
(1
),
w
a
rd
m
a
n
a
g
er
g
en
er
a
l
m
ed
ic
a
l
w
a
rd
(1
),
si
st
er
fo
r
P
W
in
tr
a
u
m
a
(1
)
to
ta
l
4
p
a
rt
ic
ip
a
n
ts
S
2
H
6
Ju
n
2
0
0
8
A
cc
el
er
a
te
d
1
3
w
a
rd
s
w
er
e
se
le
ct
ed
to
w
o
rk
o
n
P
W
fo
u
n
d
a
ti
o
n
m
o
d
u
le
s
A
p
p
o
in
t
a
fu
ll
-t
im
e
le
a
d
to
im
p
le
m
en
t
th
e
p
ro
g
ra
m
m
e
o
v
er
a
tw
o
-y
ea
r
p
er
io
d
.A
w
a
rd
si
st
er
w
a
s
a
p
p
o
in
te
d
fo
r
si
x
m
o
n
th
s.
T
w
o
m
a
tr
o
n
s
si
n
ce
p
ro
v
id
e
su
p
p
o
rt
1
(f
o
rm
er
P
W
le
a
d
)
to
ta
l
1
p
a
rt
ic
ip
a
n
t
S
2
H
7
O
ct
2
0
0
8
A
cc
el
er
a
te
d
T
w
o
sh
o
w
ca
se
w
a
rd
s
fo
ll
o
w
ed
b
y
st
a
g
ed
ro
ll
-o
u
t
to
w
h
o
le
h
o
sp
it
a
l
P
W
fa
ci
li
ta
to
r
a
n
d
a
P
W
le
a
d
a
p
p
o
in
te
d
in
2
0
0
9
D
ir
ec
to
r
o
f
n
u
rs
in
g
(1
),
P
W
le
a
d
(1
),
P
W
fa
ci
li
ta
to
r
(1
)
to
ta
l
3
p
a
rt
ic
ip
a
n
ts
S
2
H
8
O
ct
2
0
0
8
A
cc
el
