The emergence of a value transformation strategic initiative in the healthcare context.

How do strategic initiatives emerge? Despite rich tradition in the emergent strategy literature-focused on significant organizational change-surprisingly little insight exists on the dynamics of a new initiative's emergence. This is particularly relevant in healthcare because of the increasing pressure to implement value transformation models focused on maximizing value at the point of care. The value transformation model prioritizes the decisions of the frontline providers and thus requires their expertise and commitment for the model's implementation and success. In our case study of a dental organization, "OptiPlex," we trace the emergence of a value transformation strategic initiative from its origination at the point of care to its formalization into the organization's strategic plan. Using qualitative methods, we identify three phases in the emergence of the value transformation strategic initiative, each embodying different championing behaviors necessary for the initiative's emergence. In doing so, we explicate the nature of these behaviors and how they link up across the organizational hierarchy to drive the value transformation strategic initiative's emergence and implementation.

Shared accountability in distributed leadership for improved healthcare access: a study of a US dental institution.

PURPOSE: Accountability within distributed leadership (DL) is critical for DL to drive positive outcomes in health services organizations. Despite this, how accountability emerges in DL is less clear. This study aims to understand how accountability emerges in DL so that distributed leaders can drive improvements in healthcare access - an increasingly important outcome in today's health services environment. DESIGN/METHODOLOGY/APPROACH: The authors use an instrumental case study of a dental institution in the USA, "Environ," as it underwent a strategic change to improve healthcare access to rural populations. The authors focused on DL occurring within the strategic change and collected interview, observation and archival data. FINDINGS: The findings demonstrate accountability in DL emerged as shared accountability and has three elements: personal ownership, agentic actions and a shared belief system. Each of these was necessary for DL to advance the strategic change for improved healthcare access. PRACTICAL IMPLICATIONS: Top managers should be cognizant of the emergence processes driven by DL. This includes enabling pockets of employees to connect, align and link up so that ideas, processes and practices can emerge and allow for shared accountability in DL. ORIGINALITY/VALUE: The overarching contribution of this research is identifying shared accountability in DL and its three elements: personal ownership, agentic actions and a shared belief system. These elements serve as a platform to demonstrate "how DL works" in a healthcare organization.

Complexity Leadership in the Nursing Context.

Consolidation through mergers and acquisitions is occurring across health care as a strategic move to address the disruptive forces of complexity. While consolidation is improving the overall fitness and viability of health care organizations, it is having the opposite effect on the professionals working within them who are reporting increasing rates of burnout from ongoing complexity in the health care environment. This happens in all organizations that try to respond to complexity with traditional bureaucratic leadership approaches. What is needed is to replace bureaucratic leadership with the networked approach of complexity leadership. The idea is not to "do more with less" but to "do things better." In this article, we show how to do this by applying complexity leadership to the nursing context. Complexity leadership is a framework for enabling people and organizations for adaptability. It views leaders not as managerial implementers of top-down directives but as collaborators who work together to enhance the overall adaptability and fitness of the system. From a complexity leadership perspective, the role of nurse leaders should be not only to help the system run but also to help it run better by increasing organizational adaptability.

Embracing uncertainty, managing complexity: applying complexity thinking principles to transformation efforts in healthcare systems.

BACKGROUND: Complexity thinking is increasingly being embraced in healthcare, which is often described as a complex adaptive system (CAS). Applying CAS to healthcare as an explanatory model for understanding the nature of the system, and to stimulate changes and transformations within the system, is valuable. MAIN TEXT: A seminar series on systems and complexity thinking hosted at the University of Toronto in 2016 offered a number of insights on applications of CAS perspectives to healthcare that we explore here. We synthesized topics from this series into a set of six insights on how complexity thinking fosters a deeper understanding of accepted ideas in healthcare, applications of CAS to actors within the system, and paradoxes in applications of complexity thinking that may require further debate: 1) a complexity lens helps us better understand the nebulous term "context"; 2) concepts of CAS may be applied differently when actors are cognizant of the system in which they operate; 3) actor responses to uncertainty within a CAS is a mechanism for emergent and intentional adaptation; 4) acknowledging complexity supports patient-centred intersectional approaches to patient care; 5) complexity perspectives can support ways that leaders manage change (and transformation) in healthcare; and 6) complexity demands different ways of implementing ideas and assessing the system. To enhance our exploration of key insights, we augmented the knowledge gleaned from the series with key articles on complexity in the literature. CONCLUSIONS: Ultimately, complexity thinking acknowledges the "messiness" that we seek to control in healthcare and encourages us to embrace it. This means seeing challenges as opportunities for adaptation, stimulating innovative solutions to ensure positive adaptation, leveraging the social system to enable ideas to emerge and spread across the system, and even more important, acknowledging that these adaptive actions are part of system behaviour just as much as periods of stability are. By embracing uncertainty and adapting innovatively, complexity thinking enables system actors to engage meaningfully and comfortably in healthcare system transformation.