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The central role played by governance and leadership in the actions (and inactions) relating to quality of care and patient safety has been repeatedly identified by inquiries and investigations into major organisational failures. They show that governance and leadership - through their influence on priorities, oversight, management and culture – are often part of both problem and solution.

The challenges of leadership are complex. Whether leading at the board level or within a clinical team, effective leadership relies in part on assessing and responding to present and oncoming shifts in context. Making sense of these complex and dynamic changes in context is likely to play an important part in effective leadership for quality. Much of the thinking on leadership has traditionally drawn on what are now fairly outdated understandings of how leadership works. For instance, the focus on heroic models contrasts with the reality that achieving high-quality care is likely to rely on more collective efforts.  

Governance and leadership of healthcare operate at several levels. The authors of this comprehensive examination of governance and leadership distinguish between macro (national), meso (organisational), and micro (team or individual) levels:

• In some systems, macro-level governance sets overarching direction and priorities for quality and safety (e.g. national recommendations) and may feature a variety of bodies serving different functions (including regulatory roles)
• At the meso level, organisations develop and implement strategies aimed at delivering high-quality, safe care to the populations they serve
• At the micro level, frontline staff deliver this care

The paper lists key components of both governance and leadership for creating quality care. Key governance actions are identified as:

• Setting strategy
• Ensuring accountability
• Fostering culture

From the governance perspective, boards that address quality effectively prioritise learning and development. They learn from external examples of good practice to drive initial improvement, then analyse local problem-solving to develop tailored improvement strategies. Members of these boards are also more likely to have undergone formal QI training – for example, on what quality means and relevant improvement techniques, including investigation (e.g. root cause analysis) and improvement approaches (e.g. plan-do-study-act cycles). Board-level improvement tools can support the development of effective organisational QI strategies at a relatively low cost. However, support from senior board members is necessary for such interventions to have optimal impact.

Effective leadership plays an important role in delivering major system change, addressing both the challenges of complex change and associated resistance. Bottom-up clinical leadership can help to ensure suitably designed systems that are supported by the people who will deliver them; top-down, region-wide leadership can encourage relevant stakeholders not to withdraw from discussions in the change process. 

This is a comprehensive exploration of governance and leadership for care quality. It will be useful for boards and executives seeking to evolve their role clarity. It will also reference clinicians, managers and quality teams about what governance and leadership approaches are effective for supporting quality care within the complex human services environment.

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All accessed: 21/11/23

Fulop, N., & Ramsay, A. (2023). Governance and Leadership (Elements of Improving Quality and Safety in Healthcare). Cambridge: Cambridge University Press. 08 November 2023  doi:10.1017/9781009309578