In their article in this issue of BMJ Quality and Safety, ‘We listened and depended on and supported each other’, Ginsburg et al examine how leaders shaped the site-level experience in a quality improvement collaborative aimed at improving safety in long-term elder care.1 They performed a secondary thematic analysis of an existing mixed-methods data set generated from over 150 leaders and staff at 31 sites, where the qualitative data describing leadership processes included written materials, observations, survey responses and focus groups. The research team had previously reported that participants’ perceptions of leader support correlated with success to an even greater extent than their perceptions of the intervention itself.2 In the additional analysis presented in this issue, the actions of effective leaders are described in three thematic areas: developing commitment, creating learning capacity and nurturing relationships.

The authors assert that relatively little is known about the how of quality improvement (QI) leadership. Why, in light of our field’s longstanding interest in facilitators, barriers, contexts and key ingredients of successful QI,3 4 has this same curiosity not been extended to how leaders as individuals and leadership as a concept support and create lasting change? At the heart of high-quality healthcare are relationships between patients and clinicians, healthcare workers and teams and systems and leaders. So, it is puzzling that leadership is infrequently explored as a relational construct in healthcare improvement.

Healthcare is organised as a sociotechnical system. We often call it complex and adaptive, but the main reason why it is complex is people, and it is adaptive because its structures are constantly changing.5 6 Traditionally, practitioners of QI learn, apply and teach the use of tools with a more technical than social orientation, such as the model for Improvement and statistical process control.7 8 In our effort to be systematic, we compose aim statements, identify measures, construct driver diagrams, deconstruct work into process maps and perform linear series of Plan-Do-Study-Act (PDSA) cycles (or, sometimes, ‘fake PDSA’).9 10 This approach is certainly justified and can be highly effective. However, as a community, we may be overly rigid in our adherence to these tools and methods, perhaps stemming from a need to compete for credibility in an arena historically driven by the biomedical research paradigm or from wishing to create a distinct discipline and identity. Whatever the cause, our rigid adherence to these QI tools and our drive to conform to dichotomous variables for counting may be limiting our capacity to examine and fully realise the critical roles that leadership plays in bringing about improvement.

Like healthcare, QI is a humanistic response to solving problems. It is personal in both processes that we follow to engage humans in change and the outcomes that matter to us enough to make these efforts. The article by Ginsburg et al subtly reminds us of this fact. The findings force us, sometimes uncomfortably, to think critically about our own roles in leading quality and to reflect on the question of how? How do we lead? How do we both empower and inspire? How do we lead and follow? As Ginsburg et al note, for QI to be successful, leaders must be strong but humble, curious yet compassionate, inspiring and predictable: leaders that are human and humane.1 Change is hard. Leading change is hard. It cannot be distilled to a number or code; it is thousands of imperceptible moments over time that culminate in the impossible. Given this, how do we find, develop and support QI leaders?

There is an urgency to examine and optimise the role of the leader in QI, as this role is becoming increasingly complex and challenging. As the practice of QI has grown and spread, it is shared by people with an increasing diversity of professional backgrounds. Improvement teams might include physicians, nurses, allied health professionals, informaticians, public health experts, project managers, strategy and communications professionals, engineers, designers, researchers, organisational psychologists, administrators and advocates. Increasingly, they may include patients and community members to assist with, or even co-design solutions.11 Each brings different ways of seeing the world and different tools and methods for approaching improvement. In our personal experiences leading in quality, we increasingly encounter teams using alternative methods to the classic approaches listed above that might lend themselves to an ideal relationship between the leader and the front-line enactors of change, such as those described in Ginsberg et al. These might include examples such as user-centred design, strengths-based thinking, simulation, human factors analysis or ‘proactive safety’ tools. In these situations, the traditional QI practitioner might become impatient wondering when the aim and measures will be articulated, while others are busy engaging and motivating people, generating ideas and making the improvement real.

While this expansion towards greater inclusivity in QI is likely a positive for the healthcare field, a leadership challenge brought about by this democratisation of improvement work is that it makes the work even harder to plan, coordinate and evaluate across multiple initiatives and in the face of ever-changing and competing priorities. This is further exacerbated by the traditional QI training model in which participants are encouraged to take on individual QI projects, resulting in ‘a thousand flowers blooming’.12 All of this is superimposed on global acute-on-chronic funding and healthcare human resource challenges, in which we must also navigate the rising complexities of managing the human–technology interface and contend with the fervour over emerging technologies such as artificial intelligence.13

Healthcare delivery relies on tacit versus explicit knowledge transfer, and tacit knowledge transfer relies on relationships and the strength of social networks.14 This is centred around ‘influencers,’ or informal leaders at the sharp end of care who are knowledge keepers. There is a robust literature focused on ‘local champions’ who tend to be these local knowledge keepers and influencers. These individuals may or may not hold traditional leadership roles but are the people who get stuff done—through relationships and knowledge of how to navigate the social and technical aspects of the system. The importance of these individuals is highlighted in Ginsburg et al’s paper, further supporting the body of literature on the influence of knowledge keepers on the success of QI. However one frames it—influential, relational, charismatic, transformative—a leader’s ability to connect with people on a human level is central to their ability to drive sustainable healthcare change.

Despite the focus on leadership and teams throughout Ginsburg et al’s article, it does miss the opportunity to lean in on the role of patients as leaders in QI. There is increasing attention on the role of patients in research and QI. Patients and family members have unique insights on the care experience and are often the only members of the healthcare team present throughout a given care journey. Thus, as QI leaders with a collective goal of bringing together teams of experts to address intractable challenges of healthcare, we are remiss to undervalue or ignore the role the patient and their care partners might play in achieving our improvement goals. Our research and others’15–18 consistently demonstrate that engaging patients and family members in QI produces transformative results by connecting the ‘head with the heart’ and somewhat effortlessly and intuitively keeping us focused on what really matters—high-quality, patient-centred care. Given the prevalence of patient-engaged improvement, learning more about the leadership roles of patients within improvement teams is an opportunity for future exploration.

The context of Ginsburg et al’s paper is a multisite improvement collaborative. As this becomes an increasingly prevalent approach to healthcare QI,19 20 the role of leaders and the imperatives of leadership will continue to evolve. There is a paucity of literature or discussion on how the site leader drives successful QI in this model, but our lived experiences in multisite improvement efforts have revealed tremendous variation in how senior leaders, clinical team leaders and QI leaders operate despite the seemingly high-fidelity replication of technical artefacts such as ‘bundles’ that characterise these efforts.21 While the authors have furthered our understanding of how leaders influence QI teams, connecting their findings to what we already know, both theoretically and practically in a purposive way, could generate a roadmap for identifying, selecting and developing future leaders to tackle the intractable challenges of today’s healthcare environment. These individuals, who are probably all-around ‘good leaders’, attend to, nurture and navigate relationships and inspire commitment, learning and growth in their followers. What the authors have achieved is that by clearly articulating and exemplifying the intangible characteristics of QI leaders, they have created an archetype of improvement leadership for us to ponder. However, we caution the zealous counters among us from simply using these attributes as boxes on a checklist for replicating good QI leadership. Much like QI leadership, the development and support of great QI leaders is a humanistic art.

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