Leading top-down implementation processes: A qualitative study on the role of managers

Abstract

Background: Leadership has been identified as an influential factor in implementation processes in healthcare organizations. However, the processes through which leaders affect implementation outcomes are largely unknown. The purpose of this study is to analyse how managers interpret and make sense of a large scale top-down implementation initiative and what implications this has for the implementation process. This was studied at the implementation of an academic primary healthcare initiative covering 210 primary healthcare centres in central Sweden. The aim of the initiative was to integrate research and education into regular primary healthcare services. Methods: The study builds on 16 in-depth individual semi-structured interviews with all managers (n = 8) who had operative responsibility for the implementation. Each manager was interviewed twice during the initial phase of the implementation. Data were analysed using a thematic approach guided by theory on managerial role taking based on the Transforming Experience Framework. Results: How the managers interpreted and made sense of the implementation task built on three factors: how they perceived the different parts of the initiative, how they perceived themselves in relation to these parts, and the resources available for the initiative. Based on how they combined these three factors the managers chose to integrate or separate the different parts of the initiative in their management of the implementation process. Conclusions: This research emphasizes that managers in healthcare seem to have a substantial impact on how and to what extent different tasks are addressed and prioritized in top-down implementation processes. This has policy implications. To achieve intended implementation outcomes, the authors recognize the necessity of an early and on-going dialogue about how the implementation is perceived by the managers responsible for the implementation.