Frontline Teams Research Articles

Nurse Managers' Experiences in Organisational Adaptation During Public Health Emergencies: A Qualitative Study.

To elucidate strategies for improving organisational adaptation during public health emergencies from the perspectives of nurse managers. This study utilised a qualitative approach, incorporating complex adaptive system theory within a phenomenological tradition. Semi-structured interviews were conducted from May 2022 to June 2022. Participants included core members of the Shanghai Public Health Emergency Teams-Nursing from 12 tertiary hospitals in Shanghai, all of whom had substantial experience as nurse leaders impacting health systems. Data obtained were coded and analysed using interpretative phenomenological analysis. Seventeen frontline nurse managers participated, leading to the emergence of three key themes related to complex organisational adaptation: seeking institutional support for environmental adaptation, building intrateam support for structural adaptation and activating individual support for behavioural adaptation. A conceptual framework of organisational adaptation was proposed, displaying the interconnections among these themes. The study provides valuable insights into managing nursing teams involved in public health emergency preparedness and response as an adaptive system. Identified managerial strategies offer guidance to ensure effective organisational assembly and optimal utilisation of the nursing workforce within the healthcare system. Recognising the crucial role of nurses in managerial positions, who leverage leadership, adaptability and decision-making skills to coordinate frontline teams, is vital for effective public health emergency response. Their involvement in administrative roles underscores the importance of nursing perspectives in strategic planning, organisational adaptation and enhancing health system resilience during crises. The organisational adaptation strategies effectively adopted by nurse managers provide a reference for international scholars seeking to enhance the function and performance of nursing staff in healthcare system during public health emergencies. Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. No Patient or Public Contributions.

A facilitator's reflection on the democratizing potential of emancipatory practice development.

Emancipatory practice development (ePD) is a practitioner-led research methodology which enables workplace transformation. Underpinned by the critical paradigm, ePD works through facilitation and workplace learning, with people in their local context on practice issues that are significant to them. Its purpose is to embed safe, person-centred learning cultures which transform individuals and workplaces. In this article, we critically reflect on a year-long ePD study in an acute care hospital ward. We explore the challenges of practice change within systems, building collective strength with frontline collaborations and leadership to sustain new learning cultures. Our work advances practice development dialogue through working closely with the underpinning theories. Our critique analyses how ePD can enact and sustain change within a complex system. We argue that ePD works to strengthen safety cultures by challenging antidemocratic practices through communicative action. By opening communicative spaces, ePD enables staff to collectively deliberate and reach consensus. Their raised awareness supports staff to resist ways of working which conspire against safe patient care. Sustainability of practice change is fostered by the co-operative democracies created within the frontline team and meso level enablement. We conclude that the democratising potential of ePDt generates staff agency at the frontline.

Conversion of an outpatient pharmacy to a mail-order pharmacy within a health system.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. The establishment of a new outpatient pharmacy provided a strategic opportunity to repurpose and convert an existing outpatient pharmacy into a closed-door mail-order pharmacy within a health system. This article describes the steps taken to successfully make this change and evaluates the impact. The mail-order pharmacy conversion project was divided into 3 phases: phase 1 (before conversion) from July through August 2022, phase 2 (conversion) from October through November 2022, and phase 3 (after conversion) from December 2022 through February 2023. Phase 1 included standardizing workflows with standard operating procedure (SOP) development, improving automation, determining staffing ratios, gathering baseline staff engagement data, and identifying primary and secondary outcomes of interest. Phase 2 encompassed SOP implementation and training of mail-order team members. Phase 3 involved evaluating available pharmacy floorspace, marketing mail-order services, and the second distribution of the staff engagement survey. The measured outcomes of this project were total prescription volumes, increase in total revenue, and staff engagement. Data collection was completed in phase 3. The existing outpatient pharmacy was successfully converted to a closed-door pharmacy, and the associated prescription volume increased. Developing a strategic action plan to establish SOPs, calculate staffing performance metrics, and identify opportunities for growth and engaging frontline team members were essential to the success of this project.

Advancing Implementation Practice: Supplemental Tools to Aid in Selection of Implementation Strategies and Outcomes for Healthcare Practitioners

The field of implementation science has grown exponentially within healthcare and human service delivery settings. Scientists in the field have made tremendous strides in generating new knowledge aimed at increasing uptake of evidence into practice settings, including development of numerous theories, models, and frameworks to guide the process of implementation, strategies to operationalize optimal methods of implementing an evidence-based practice change, and designated outcomes to evaluate the progress of a change initiative. Despite these gains in scientific discovery surrounding implementation, routine use and application of this knowledge among healthcare practitioners seeking to implement a practice change in real world settings remains fragmented, risking development of a “secondary gap” between what we know from the science of implementation and what is actually done by frontline teams when implementing evidence-based practice changes. To address this gap, we developed two supplemental tools to bridge the language between implementation science and implementation practice: the Implementation Strategies Supplemental Tool (ISST), and the Implementation Outcomes Supplemental Tool (IOST). The purpose of this paper is to describe the development and intended use of these tools for healthcare practitioners seeking to use a science-informed approach when implementing an evidence-based practice change. We include a case example of how healthcare practitioners may apply these tools to improve implementation of evidence-based practices in real-world settings.

Creating public value in frontline teams: an empirical exploration of shared leadership behaviour by frontline officials

ABSTRACT In this study, we aim to provide insight into the way in which frontline officials in teams employ leadership behaviour aimed at creating public value. We conducted 29 in-depth semi-structured narrative interviews with frontline officials and their direct supervisors from three teams in Dutch public organizations, to identify shared leadership behaviours used to stimulate decision-making based on a shared meaning of public value and to facilitate work processes that enable public value creation. Based on these findings, we formulate propositions to further study shared leadership mechanisms by frontline officials, and we point out recommendations to stimulate leadership within frontline teams.

How to Sustain Healthcare Process Improvement in Heterogenous Teams? Evidence from a Systems Dynamic Model

This research investigates how to sustain process improvement (PI) initiatives in healthcare. Despite the abundant knowledge on PI, we know very little on why and how PI sustains over time. This is particularly true in the context of heterogeneous frontline teams of physicians and nurses with different operational characteristics such as attrition rates, skill sets, training, and goals. Our study builds a model that simulates the mutual, dynamic interaction of these stakeholders with each other and with processes with different characteristics in the presence of endogenous management prioritization. We build confidence in the model by calibrating it to data from PI teams at several family medicine clinics at a large US Midwestern healthcare system. The computational experiments performed using data from these teams yield several important insights for theory and practice. First, we find that process metrics, which are leading metrics related to the day-to-day functioning of the units, and outcome metrics, which are lagging metrics often tied to the unit's bottom line, are both critical for the functioning of the PI teams. Emphasizing one over the other can reduce sustainability while a mixed case in which one group of employees is incentivized to leading and another group to lagging can create a regime that is more effective in many scenarios. Second, we find that management interventions that improve short-term PI gains generally also reduce the likelihood of long-run sustainment. Third, we find that attrition and turnover among the team members affect sustainability of PI initiatives and reducing turnover for one class of employee, which attends lagging metrics, facilitates sustainment while reducing it for the other class, which attends leading metrics, can hinder sustainment. We conclude by discussing these implications to the practice of PI among healthcare teams.

Exploring the influence of work-life balance on employee engagement in Mumbai’s real estate industry

The real estate industry, particularly in Mumbai, is a thriving domain in India and globally. The success of this industry heavily relies on the dedication and enthusiasm of its front-line sales team. This study investigates the interconnection between work-life balance and employee engagement, seeking to identify aspects of work-life equilibrium that significantly impact employee engagement. The real estate sector’s sustained prosperity hinges upon the engaged and motivated sales teams responsible for revenue generation. Amidst the evolution of technology and organizational dynamics, individuals grappling with personal-professional equilibrium face amplified challenges. These challenges, propelled by peer pressure, organizational culture, and technological advancements like artificial intelligence and machine learning, have cast shadows on employee contentment and capabilities at work. The primary objective is to discern the potential correlation between work-life balance and employee engagement within the real estate sector, outlining how specific facets of balancing professional commitments with personal life significantly influence engagement levels. The findings indicated a compelling relationship between work-life equilibrium and employee engagement. Maintaining a balanced approach positively impacts employee dedication, motivation, work efficiency, and overall productivity. Striking this equilibrium bears a direct correlation with enhanced organizational output and performance. Fostering a conducive work-life balance retains a motivated workforce and elevates organizational effectiveness. Recognizing and addressing the nuanced aspects of balancing professional and personal spheres are pivotal in optimizing employee engagement, thereby contributing significantly to the real estate sector’s sustained success

Quality improvement in public–private partnerships in low- and middle-income countries: a systematic review

BackgroundPublic–private partnerships (PPP) are often how health improvement programs are implemented in low-and-middle-income countries (LMICs). We therefore aimed to systematically review the literature about the aim and impacts of quality improvement (QI) approaches in PPP in LMICs.MethodsWe searched SCOPUS and grey literature for studies published before March 2022. One reviewer screened abstracts and full-text studies for inclusion. The study characteristics, setting, design, outcomes, and lessons learned were abstracted using a standard tool and reviewed in detail by a second author.ResultsWe identified 9,457 citations, of which 144 met the inclusion criteria and underwent full-text abstraction. We identified five key themes for successful QI projects in LMICs: 1) leadership support and alignment with overarching priorities, 2) local ownership and engagement of frontline teams, 3) shared authentic learning across teams, 4) resilience in managing external challenges, and 5) robust data and data visualization to track progress. We found great heterogeneity in QI tools, study designs, participants, and outcome measures. Most studies had diffuse aims and poor descriptions of the intervention components and their follow-up. Few papers formally reported on actual deployment of private-sector capital, and either provided insufficient information or did not follow the formal PPP model, which involves capital investment for a explicit return on investment. Few studies discussed the response to their findings and the organizational willingness to change.ConclusionsMany of the same factors that impact the success of QI in healthcare in high-income countries are relevant for PPP in LMICs. Vague descriptions of the structure and financial arrangements of the PPPs, and the roles of public and private entities made it difficult to draw meaningful conclusions about the impacts of the organizational governance on the outcomes of QI programs in LMICs. While we found many articles in the published literature on PPP-funded QI partnerships in LMICs, there is a dire need for research that more clearly describes the intervention details, implementation challenges, contextual factors, leadership and organizational structures. These details are needed to better align incentives to support the kinds of collaboration needed for guiding accountability in advancing global health. More ownership and power needs to be shifted to local leaders and researchers to improve research equity and sustainability.

Transforming nursing assessment in acute hospitals: A cluster randomised controlled trial of an evidence-based nursing core assessment (the ENCORE trial)

BackgroundPatient safety is threatened when early signs of clinical deterioration are missed or not acted upon. This research began as a clinical-academic partnership established around a shared concern of nursing physical assessment practices on general wards and delayed recognition of clinical deterioration. The outcome was the development of a complex intervention facilitated at the ward level for proactive nursing surveillance. MethodsThe evidence-based nursing core assessment (ENCORE) trial was a pragmatic cluster-randomised controlled trial. We hypothesised that ward intervention would reduce the incidence of patient rescue events (medical emergency team activations) and serious adverse events. We randomised 29 general wards in a 1:2 allocation, across 5 Australian hospitals to intervention (n = 10) and usual care wards (n = 19). Skilled facilitation over 12 months enabled practitioner-led, ward-level practice change for proactive nursing surveillance. The primary outcome was the rate of medical emergency team activations and secondary outcomes were unplanned intensive care unit admissions, on-ward resuscitations, and unexpected deaths. Outcomes were prospectively collected for 6 months following the initial 6 months of implementation. Analysis was at the patient level using generalised linear mixed models to account for clustering by ward. ResultsWe analysed 29,385 patient admissions to intervention (n = 11,792) and control (n = 17,593) wards. Adjusted models for overall effects suggested the intervention increased the rate of medical emergency team activations (adjusted incidence rate ratio 1.314; 95 % confidence interval 0.975, 1.773), although the confidence interval was compatible with a marginal decrease to a substantial increase in rate. Confidence intervals for secondary outcomes included a range of plausible effects from benefit to harm. However, considerable heterogeneity was observed in intervention effects by patient comorbidity. Among patients with few comorbid conditions in the intervention arm there was a lower medical emergency team activation rate and decreased odds of unexpected death. Among patients with multimorbidity in the intervention arm there were higher rates of medical emergency team activation and intensive care unit admissions. ConclusionTrial outcomes have refined our assumptions about the impact of the ENCORE intervention. The intervention appears to have protective effects for patients with low complexity where frontline teams can respond locally. It also appears to have redistributed medical emergency team activations and unplanned intensive care unit admissions, mobilising higher rates of rescue for patients with multimorbidity. Trial registration numberACTRN12618001903279 (Date of registration: 22/11/2018; First participant recruited: 01/02/2019).

Improving safety and preventing falls using an evidence-based, front-line staff huddling practice: protocol for a pragmatic trial to increase quality of care in State Veterans Homes

IntroductionFalls in nursing homes are a major cause for decreases in residents’ quality of life and overall health. This study aims to reduce resident falls by implementing the LOCK Falls...

Uncertainties and opportunities in delivering environmentally sustainable surgery: the surgeons' view.

Surgery is a carbon-heavy activity and creates a high volume of waste. Surgical teams around the world want to deliver more environmentally sustainable surgery but are unsure what to do and how to create change. There are many interventions available, but resources and time are limited. Capital investment into healthcare and engagement of senior management are challenging. However, frontline teams can change behaviours and drive wider change. Patients have a voice here too, as they would like to ensure their surgery does not harm their local community but are concerned about the effects on them when changes are made. Environmentally sustainable surgery is at the start of its journey. Surgeons need to rapidly upskill their generic knowledge base, identify which measures they can implement locally and take part in national research programmes. Surgical teams in the NHS have the chance to create a world-leading programme that can bring change to hospitals around the world. This article provides an overview of how surgeons see the surgical team being involved in environmentally sustainable surgery.

Determinants of Disaster Competencies Among Jordanian Nurses in Public Hospitals.

In the last decade, disasters increased by 60% worldwide. These occurrences have resulted in approximately two million deaths and 4.2 million injuries and left 33 million people homeless. Nurses are part of the front-line response team and should be critical during disasters. For nurses to respond competently, they must have the knowledge and skills to provide comprehensive and holistic care to the populations affected by disasters. This study aims to assess the level of competencies among nurses providing disaster care and identify their predictors. A descriptive correlation design was utilized to measure and predict nursing competencies in providing care to individuals amid disasters. An electronic form of disaster response competencies assessment survey was distributed to 400 nurses working at three public hospitals in the central region of Jordan. Jordanian nurses reported a moderate level of competencies in providing care for individuals. Furthermore, multiple regression analysis revealed that disaster training, disaster education, sex, and real disaster experience significantly predict nurses' competencies. With the increasing frequency of disasters, nurses should be adequately prepared to respond to disasters competently to relieve the negative consequences of these events on the affected individuals.

Centralizing Telehealth Test-to-Treat Through a Regional Clinical Contact Center: A Veterans Health Administration Pilot.

Background: This project describes a Veterans Health Administration telehealth pilot to facilitate COVID-19 oral antiviral treatment as part of the national test-to-treat (T2T) strategy. The pilot was operationalized for two pilot VA medical centers by the regional clinical contact center (CCC) for a Veteran Integrated Service Network, which offers multiple services through several virtual modalities. Methods: Nurse triage and medical provider evaluation templates were developed for the CCC to standardize clinical interventions with veteran callers reporting positive home COVID-19 test results. When veterans were determined eligible and consented to treatment with an emergency use authorization (EUA) antiviral medication, CCC providers used secure direct messaging for synchronous communication with local pharmacy services to facilitate adjudication and dispensing. Templates for pharmacy documentation and primary care follow-up monitoring were also developed and disseminated. Results: In total, 198 veterans (mean age 65 years, 89% male, 88% non-Hispanic White) were evaluated through telehealth by regional CCC providers using the T2T process and 96% were prescribed an antiviral medication. Primary care follow-up occurred in 86% of cases, a median of 3 days after the telehealth evaluation. The 30-day all-cause hospitalization rate was 1.5% and there were no deaths within 30 days of treatment initiation. Conclusions: Veterans Integrated Service Network's CCC telehealth triage and evaluation processes enabled safe EUA-compliant care delivery, improved evaluator experience and efficiency, and augmented existing EUA processes in place by front-line pharmacy and primary care teams.

Leadership Coaching to Improve Nursing Unit Practice Councils Effectiveness

Nursing shared governance (SG) provides an opportunity for alignment between frontline team members and nursing leadership. A department of nursing had a mature SG program with many thriving departmental-based SG groups. However, structural processes and guidance for unit-based SG groups were lacking and demonstrated a need for improvement. The General Theory of Effective Multilevel Shared Governance framework provided an opportunity to refocus and improve unit practice councils (UPC). Results demonstrated that UPC leadership competencies can be improved through focused 1:1 leadership coaching by identifying a UPC area of opportunity and utilizing evidence-based tools and resources.

Do employees dare to improvise under authoritarian leadership? A conditional indirect effect depending on relationship and task environment

Abstract To understand the extent to which employees choose to improvise under authoritarian leadership, we applied social information processing theory to examine the mechanisms and boundary conditions of such leadership’s influence on subordinates’ perceptions of managerial intolerance of errors and their improvisation from the perspective of negative leadership. Data from a multi-wave questionnaire survey of 319 frontline teams analysed using SPSS and Mplus revealed that authoritarian leadership can have an inhibitory effect on subordinates’ improvisation due to perceiving managerial intolerance of errors. Even so, the negative mediating effect is significantly weakened by the moderating effect of a leader–member exchange (LMX) relationship and task complexity. That is, when the level of the LMX relationship or task complexity is high, it mitigates authoritarian leadership’s indirect inhibitory effect on subordinates’ improvisation via their perceptions of management’s intolerance of errors.

Reducing physical restraints in pediatrics: A quality improvement mixed-methods analysis of implementing a clinical debriefing process after behavioural health emergencies in a Children's Hospital

IntroductionAn increasing number of pediatric patients with mental and behavioral health (MBH) conditions present to Emergency Department (ED) and inpatient settings with behavioral events that require physical restraint (PR). PR usage is associated with adverse outcomes. Clinical debriefing (CD) programs have been associated with improved performance but have not been studied in this population. After implementing an MBH-CD program in our Children's Hospital, we aimed to decrease the baseline (7/2018-3/2021) rate of a second PR episode (2PR) by 50 % in the ED and inpatient settings over two years. MethodsA multidisciplinary team implemented an MBH-CD process in April 2021 for hospital teams to use immediately after behavioral events. We included patients ≤18 years old, with an ED or inpatient discharge MBH diagnosis, between July 2018 and June 2023. Pre- and post-implementation secondary outcomes included the ED median duration of PR and the ED PR time per 1000 h of ED care. ED and inpatient mean length of stay (LOS) and mean monthly visits (MMV) in pre- and post-implementation were also compared. Qualitative analysis identified major themes. ResultsPost-implementation, the ED significantly decreased 2PR rate by 67 %; in inpatients, no significant change was demonstrated. Median duration of ED PR decreased from 112 to 71 min (p = 0.006) and ED PR time significantly decreased by 82 % (14.8 to 2.7 h per 1000 h). In the post-implementation period, mean LOS (ED and inpatient) and MMV (ED only) were significantly higher. Fifty-one percent of 494 behavioral alerts were debriefed. Median debriefing duration was 6 min (IQR 4,10). Common themes included cooperation and coordination (23 %) and clinical standards (14 %). DiscussionClinical debriefing implementation was associated with significant improvement in ED patient outcomes. Inpatient outcomes were unchanged, but debriefings in both settings should enable frontline teams to continuously identify opportunities to improve future outcomes.

Interdisciplinary frontline teams in home-based healthcare services—paradoxes between organisational work structures and the trust model: a qualitative study

BackgroundAchieving access to quality healthcare services to ensure healthy lives and promote well-being for all at all ages is one of the United Nation’s Sustainable Developments Goals. In view of this goal, sustainable community healthcare services in Norway need to be urgently restructured in light of demographic changes, including an increase in the percentage of older adults in the country. National healthcare policies recommend finding new ways to organise and perform services using new technology, new methods and new solutions. The goal is to ensure greater continuity in the provision of services and softer transitions that enable service users to deal with a smaller number of people. The trust model is one such suggested organisational approach. The goal of the trust model is to involve service users and their next of kin in decisions that concern them while also trusting frontline workers’ professional judgement in assessing the need for services and adjusting them to address changes in the health of the users, thus making the services individually tailored and more flexible. This study aims to explore how organisational work structures influence the delivery of interdisciplinary home-based healthcare services.MethodsObservations, individual-, and focus groups interviews were conducted within community home-based healthcare services in a large Norwegian city with managers at different levels, nurses, occupational therapists, physiotherapists, purchaser-unit employees and other healthcare workers. Data was analysed thematically.ResultsThe results are presented in terms of themes— “Balancing on the margins: Negotiations between the time available, users’ needs, unforeseen events and administrative tasks” and “One gathered unit, but with different work structures”. The results identify organisational work structures that influence the performance of the trust model with regard to its intention of making flexible and individually tailored services available. However, these structures are different for the members of the interdisciplinary team, thus creating several paradoxes that need to be negotiated while fulfilling their daily responsibilities.ConclusionThis study suggests that it is crucial to pay attention to paradoxes and structures experienced by interdisciplinary frontline workers in home-based healthcare services, since they are unavoidable factors that need to be acknowledged when designing approaches for addressing the changes expected in community healthcare services.

2020: what COVID taught us about women in medicine.

As Vice Chair of Clinical Services of Psychiatry at the University of Colorado, I choose to work where clinical services need most attention. As a woman, I want to show up where we can be seen and show up in the best possible way. Just as COVID began, I found myself doing clinical shifts in the newly created psychiatry emergency room. I became part of a front-line team, where "I" became "We," facing an unknown enemy. Not only was my work life upended, but my personal life was too, as I rushed to help my daughter, a medical student, care for her son when his day-care closed. My commentary highlights the increased burden experienced by women during this time, an example of systemic bias in medicine.

Advancing Staff Safety: Assessment of Quality Improvement Interventions in Reducing Needlestick Injuries Among Staff at Nyaho Medical Centre.

Needlestick injury, which occurs when the skin is accidentally punctured, is linked to infection transmission of HIV, hepatitis B, and hepatitis C. Because of the associated risks, hospitals are keen to do everything necessary to prevent needlestick injuries to their staff. This is a quality improvement project aimed at reducing needlestick injuries among staff at Nyaho Medical Centre (NMC). A facility-based assessment of the incidence of needlestick injury recorded and quality intervention employed was conducted between 2018 and 2021. Quality improvement tools such as the fishbone (cause and effect analysis) and the run chart were used to analyze and evaluate improvements made over time. NMC staff have greatly reduced the incidence of needlestick injuries from 2018 to 2021 (from 11 needlestick injuries in 2018 to 3 recorded needlestick injuries in 2021). Using root cause analysis to investigate the possible cause of needlestick injury and use of the run chart to monitor the implemented improvement strategies (interventions) helped reduce the incidence of needlestick injuries among staff and thereby improved staff safety. The introduction of the incident reporting management systems saw an increase in the culture of incident reporting in general. Other incidents, such as medical errors and patient falls, were being reported using the incident reporting system. The inclusion of infection prevention and control training as part of NMC's onboarding for new employees helped in the knowledge and awareness creation of needlestick injuries and safety measures to prevent injury from needles and sharps. Policy changes and audit with feedback sharing key performance indicators with frontline team members were identified to have had the most effect.

Harnessing our greatest asset: Solving margin issues by investing in frontline leaders

The rate of change in combination with the scope and magnitude and the need for increased efficacy in healthcare operations are on the rise, especially with the advent of a plethora of patient needs in the post-COVID-19 world. Senior leaders in the field are faced with various operational and financial challenges on account of the new and rapidly rising patient requirements in the healthcare sector, and, instead of optimising existing resources to meet current challenges, they are often persuaded to just add on new programmes, leaving the existing programmes to languish. Thus, to circumvent some of the major issues in healthcare operations, a more effective strategy has to be pursued than the usual one of simply buying and implementing a new productivity system with updated targets or performance benchmarks. The solution is to assess the efficacy and profitability of existing improvement programmes and resources in the advent of a new set of requirements: deploying burst versus incremental improvement; engaging middle managers to enable their solutions; and achieving organisation speed, spread and scalability across the organisation [Caldwell, C., Cook, K., (2020), ‘Achieving speed, spread, scalability, and sustainability in health systems’, American College of Healthcare Executives-Cluster Session, Clearwater, FL, 17–20th January]. This paper describes how Dignity Health East Valley was able to optimise the use of existing performance improvement resources and deploy an accelerated improvement structure to achieve rapid gains, followed by incremental improvement to both sustain and further the gains made. The approach included mentoring middle managers to become adaptive change agents and achieve 5 per cent improvement in margins in six months. The burst method described in this paper is based on the findings from the research undertaken by top-performing hospitals that identified five essential characteristics that healthcare’s frontline leaders are expected to possess and which are a clear mark of their leadership skills and competence [Caldwell, C., Cook, K., (2020), ‘Achieving speed, spread, scalability, and sustainability in health systems’, American College of Healthcare Executives-Cluster Session, Clearwater, FL, 17–20th January]. The paper presents the background to this research as well as the structure that builds these top-performer capabilities in the front-line team in order for them to lead change and drive its implementation. The positive results that emerged from the leadership training provided to frontline leaders are substantial, including improved margin, higher patient experience and higher employee engagement.