David A. Buchanan

This article explores the problems of implementing change in hospital operating theatres, following a series of patient safety incidents known as ‘never events’ due to their serious nature. Such incidents open a ‘window on the system’, exposing gaps in an organization's procedures and practices, and highlighting the need for change. However, as documented in other sectors, the recommendations from investigations into the causes of such events are not always implemented. What are the problems? Information was gathered from interviews, from hospital documentation and external reports, and from a theatres team workshop. Analysis of these incidents and the sequence of events that followed demonstrates how post-incident changes were impeded by the mandatory reporting and investigation procedures that were designed to identify and encourage those changes. Institutional regulations and expectations generated a path dependent process, which locked the organization into a narrow range of actions which could be addressed quickly, but which overlooked the wider systemic changes that had been identified as desirable. Post-incident change was caught in an ‘investigation trap’, sprung by the combination of external demands and internal procedures. Path creation measures for escaping from this trap are suggested, in the interests of effective post-incident change, and improved patient safety.

Purpose: – The purpose of this paper is to explore the incidence of “extreme jobs” among middle managers in acute hospitals, and to identify individual and organizational implications. Design/methodology/approach: – The paper is based on interviews and focus groups with managers at six hospitals, a “proof of concept” pilot with an operations management team, and a survey administered at five hospitals. Findings: – Six of the original dimensions of extreme jobs, identified in commercial settings, apply to hospital management: long hours, unpredictable work patterns, tight deadlines with fast pace, broad responsibility, “24/7 availability”, mentoring and coaching. Six healthcare-specific dimensions were identified: making life or death decisions, conflicting priorities, being required to do more with fewer resources, responding to regulatory bodies, the need to involve many people before introducing improvements, fighting a negative climate. Around 75 per cent of hospital middle managers have extreme jobs. Research limitations/implications: – This extreme healthcare management job model was derived inductively from a qualitative study involving a small number of respondents. While the evidence suggests that extreme jobs are common, further research is required to assess the antecedents, incidence, and implications of these working practices. Practical implications: – A varied, intense, fast-paced role with responsibility and long hours can be rewarding, for some. However, multi-tasking across complex roles can lead to fatigue, burnout, and mistakes, patient care may be compromised, and family life may be adversely affected. Originality/value: – As far as the authors can ascertain, there are no other studies exploring acute sector management roles through an extreme jobs lens.

Objectives: To identify the management populations of acute hospitals, and to consider how the composition of this critical but criticized group affects managerial capacity. Methods: A multi-method study of six acute trusts, involving 1200 managers in setup interviews, focus groups and a survey. Interviews with senior managers identified the key middle management groups in their trusts. The workforce information offices at two trusts estimated the management numbers from their databases. The findings were compared with the NHS Information Centre data on the number of ‘managers and senior managers’ across the service. Results: The management population of an acute trust includes ‘pure plays’, whose roles are mainly managerial, and ‘hybrids’, whose roles combine managerial and clinical duties. Together, pure plays and hybrids comprise around 30% of staff in an acute trust, and even this may be an underestimate. Hybrid managers typically outnumber pure plays by four to one. NHS Information Centre data indicate that only 3% of all NHS employees are ‘managers and senior managers’. Conclusions: In a climate of cost reductions and radical change, acute trusts have challenging management agendas. Policy to ‘cut management’, if focused on pure plays, increases the managerial burden on hybrids, diluting their clinical focus, and potentially jeopardizing the change agenda along with quality and safety of patient care. To strengthen management capacity, acute trust leadership and management development programmes must target the full ‘hybrids and pure plays’ population, and particularly hybrids who comprise the majority.

Solving small, annoying problems may appear to be unimportant in a political, demographic, and economic climate that focuses attention on radical long-term changes to the organization, delivery, funding, and regulation of the healthcare system. Most contemporary commentary emphasizes the need for large-scale, major, strategic, transformational change. Deliberately designed to focus on minor issues, however, the intervention reported here, in a hospital gastroenterology department, demonstrates how small changes generate major benefits for patients, staff, and hospital performance. This approach can also strengthen clinical–managerial relationships, which are key to larger scale changes and which suffer when ‘the small stuff’ is not fixed. The success of this intervention is explained with reference to a model of change combining context, content, process, and individual dispositions. The intervention, however, is easily modified to suit different contexts and was subsequently used successfully in other service areas in the same hospital. These outcomes present a challenge to the contemporary preoccupation with transformational change. Healthcare managers are thus advised, on the basis of this experience, to be alert to what appear to be minor unresolved issues, and to address these rapidly, in addition to larger scale, longer term projects.

The incidence and impact of crises, disasters and other extreme events appears to be increasing, thus heightening the significance of crisis research. The nature of such events – sudden, inconceivable, damaging, sensitive, unique – has encouraged unconventional methodological perspectives and practices. A review of these developments is timely. This article presents a bounded, temporally bracketed overview of the literatures exploring extreme events, structured around an ‘ideal type’ event sequence with six phases: incubation period, incident, crisis management, investigation, organizational learning and implementation of ‘lessons learned’. While not a traditional review, this approach serves to overcome problems associated with phenomena resistant to precise definition, and maps the structure of a field characterized by fragmentation, insular traditions and epistemological pluralism, generating a template against which crises can be explored. Crisis research appears to have overcome the problems associated with relying on retrospective research designs, accessing sensitive data, addressing novel ethical concerns, developing multi‐level explanations and using single case studies to develop generalizable theory. The wider adoption of these approaches in ‘mainstream’ organization and management studies may prompt innovation and fresh insights in other areas, particularly where the temporal structure of events, the role of slow‐moving causes, and conjunctural reasoning, play significant roles.

It is exciting to have a real crisis on your hands, when you have spent half your political life dealing with humdrum issues like the environment. Margaret Thatcher (on the Falklands campaign, 1982) The aim of this reflection is to identify a set of puzzles which have not been explored by change management researchers, have not been resolved by other approaches and where a change management perspective may be particularly valuable. These puzzles derive from the observation that, following an accident, crisis, disaster or other extreme event, the recommendations from investigations and inquiries are often not implemented. The failure to change can then lead to a repeat of that event. It cannot be presumed that receptivity to change in such circumstances is invariably high, or that change will be automatic and straightforward. The currently dominant perspective in this field views these problems in terms of organizational learning difficulties. In arguing the need for a complementary change management perspective, this article first illustrates the nature and consequences of these change failures, using public domain sources. The features that distinguish extreme from routine change contexts are then outlined, and the potential barriers to change in extreme contexts are explored. Finally, the value of a change management perspective is explored, suggesting new modes of researcher–organization collaboration to strengthen the contribution of research findings to practice in an area where effective change can literally save lives.

Purpose: This paper aims to explore the theoretical and practical management implications of a case involving the falsification of hospital patient waiting lists for elective orthopaedic surgery.Design/methodology/approach: This case study is based on qualitative schedule‐structured interviews with 20 senior hospital staff (managerial and clinical), including the head of the investigation team, downloads from the hospital website, and internal hospital documentation. Those data were used to construct an event narrative exploring the underlying causes and implications of the incident.Findings: The blame for misconduct pointed at three surgeons, a senior manager, a general manager, an assistant general manager, one administrative staff member, and several organizational factors. In addition to censuring some of those involved, an investigation recommended changes to training and working practices, policies and procedures, governance arrangements, and organization culture, and led to an external evaluation of the hospital board. However, one year later, another similar incident occurred.Research limitations/implications: This is a single case, and events are viewed through a management lens, the individuals concerned being protected by research ethics considerations.Practical implications: By detailing the sequence of events, surrounding conditions, and the reactions of multiple players, this analysis reveals typified responses to incidents of this kind, and the limitations inherent in post‐event investigations. If the benefits derived from national targets are to be realized in a manner which commands support from staff at all levels, then greater attention should be paid by managers and regulators to issues of transparency, responsiveness, and honesty. As core dimensions of good governance, managers must be accountable for helping to meet targets, and also for tracking how targets are met, ensuring that resources are made available, and that problematic issues raised are promptly and effectively addressed.Originality/value: Studies of organizational misbehaviour are rare in healthcare where the focus often lies with patient deaths and injuries arising from system failures and gross individual misconduct. The analysis in this case explores the organizational conditions that contribute to such incidents.

Purpose – The purpose of this paper is to examine critically the concept of “leadership transmission”, considering what theoretical and practical value this metaphor brings to the healthcare modernization agenda. Design/methodology/approach – The paper develops understanding of the transmission metaphor, whilst theoretical perspectives on leadership are reviewed, including debates, which shed light on the concept by focusing on the phenomenon of distributed or dispersed leadership. Findings – The transmission metaphor is perhaps misleading, by implying that “leadership can be caught” like a disease. However, defining leadership in terms of influence, a novel typology of transmission processes is introduced; top down (one-way), inter-organizational (bi-lateral), and dispersed (multi-directional). Recent research suggests that organizational changes are often led by the spontaneous concertive action of staff at all levels, not just by senior élite groups. The way in which dispersed influence processes arise, unfold, and are transmitted into organizational outcomes can be understood through theoretical narratives, which capture event sequences and combinations of factors unfolding over time in a given context. Given the scale and pace of the change agenda, healthcare modernization may indeed depend on widely dispersed leadership. Practical implications – It is therefore necessary to establish the conditions in which leadership transmission is encouraged, to recognize, support, and develop the “unsung heroes” who assume change leadership positions, and to widen the agenda and coverage of NHS leadership development programmes. Originality/value – There is currently no other commentary, empirical or theoretical, academic or professional, which examines critically the concept of leadership transmission, while exploring the nature of this perspective, and its theoretical and practical value.

This paper reports the findings of a survey of 250 British managers, exploring their experience and perceptions of organization politics. Political behaviour appeared to be common. Most managers viewed political behaviour as ethical and necessary, and aspects of organizational effectiveness, change, resourcing and reputation were attributed to political tactics, although 80% had no training in this area. Tactics experienced frequently included networking, using ‘key players’ to support initiatives, making friends with power brokers, bending the rules, and self‐promotion. Tactics experienced as rare, but not unknown, included misinformation, spreading rumours, and keeping ‘dirt files’ for blackmail. A consistent pattern of responses concerning willingness to engage in politics, the need to act ruthlessly and the appropriateness of reciprocity when faced with political behaviour implies an attitude of ‘you stab my back, I'll stab yours’. Findings are discussed using an ‘antecedents–behaviours–consequences’ framework of perceived organization politics to guide research.