System Leaders Research Articles

Leading without position power: preliminary validation of the multiparty collaborative leadership scale (MCLS)

Purpose This paper aims to report the development of the multiparty collaborative leadership scale (MCLS) that assesses four dimensions of collaborative leadership that have been defined in the literature regarding the functions of collaborative leadership in intra- and interorganizational settings. Design/methodology/approach The authors have tested the validity and reliability of the MCLS in a sample of 110 managers and professionals who participated in five multiparty collaboration workshops, each lasting for two days. The authors used multilevel analyses to test the construct, discriminant and predictive validity of the MCLS. Findings The results generally supported the reliability and validity of the MCLS. The scale has good internal consistency and in terms of validation, the authors show that MCLS negatively predicts the conflictuality and positively predicts the collaborativeness of the leading party as well as trust in the multiparty system and its entitativity. Research limitations/implications The MCLS can be used to extend literature on collaborative leadership and generate insights on the antecedents and consequences of effective collaborative leadership in multiparty systems. Social implications Multiparty systems are set to deal with important societal challenges and mediators involved in multiparty issues are asked to settle important international disputes and conflicts. Understanding collaborative leadership in such systems and its role in establishing effective multiparty collaboration is key. The MCLS can be used as a research instrument and as a development tool toward realizing much-needed collaboration. Originality/value The authors present a first attempt to develop a short scale to assess collaborative leadership in complex systems in which participating stakeholders lack position power.

Design, delivery and effectiveness of health practitioner regulation systems: an integrative review

BackgroundHealth practitioner regulation (HPR) systems are increasingly recognized as playing an important role in supporting health workforce availability, accessibility, quality, and sustainability, while promoting patient safety. This review aimed to identify evidence on the design, delivery and effectiveness of HPR to inform policy decisions.MethodsWe conducted an integrative analysis of literature published between 2010 and 2021. Fourteen databases were systematically searched, with data extracted and synthesized based on a modified Donabedian framework.FindingsThis large-scale review synthesized evidence from a range of academic (n = 410) and grey literature (n = 426) relevant to HPR. We identified key themes and findings for a series of HPR topics organized according to our structures–processes–outcomes conceptual framework. Governance reforms in HPR are shifting towards multi-profession regulators, enhanced accountability, and risk-based approaches; however, comparisons between HPR models were complicated by a lack of a standardized HPR typology. HPR can support government workforce strategies, despite persisting challenges in cross-border recognition of qualifications and portability of registration. Scope of practice reform adapted to modern health systems can improve access and quality. Alternatives to statutory registration for lower-risk health occupations can improve services and protect the public, while standardized evaluation frameworks can aid regulatory strengthening. Knowledge gaps remain around the outcomes and effectiveness of HPR processes, including continuing professional development models, national licensing examinations, accreditation of health practitioner education programs, mandatory reporting obligations, remediation programs, and statutory registration of traditional and complementary medicine practitioners.ConclusionWe identified key themes, issues, and evidence gaps valuable for governments, regulators, and health system leaders. We also identified evidence base limitations that warrant caution when interpreting and generalizing the results across jurisdictions and professions. Themes and findings reflect interests and concerns in high-income Anglophone countries where most literature originated. Most studies were descriptive, resulting in a low certainty of evidence. To inform regulatory design and reform, research funders and governments should prioritize evidence on regulatory outcomes, including innovative approaches we identified in our review. Additionally, a systematic approach is needed to track and evaluate the impact of regulatory interventions and innovations on achieving health workforce and health systems goals.

What Value-Based Care Means for Physician Leaders

Value-based contracts have spread unevenly across the country but are becoming increasingly common. Although they require chief medical officers and other physician leaders in health systems to adopt new thinking and master skills well beyond clinical expertise, value-based contracts offer a strategy for improving healthcare overall.

Study protocol of an economic evaluation embedded in the Midwives and Obstetricians Helping Mothers to Quit Smoking (MOHMQuit) trial

BackgroundTobacco smoking during pregnancy is the most important preventable risk factor for pregnancy complications and adverse birth outcomes and can have lifelong consequences for infants. Smoking during pregnancy is associated with higher healthcare costs related to birth complications and during childhood. Psychosocial interventions to support pregnant women to quit are effective, yet provision of smoking cessation support has been inconsistent. The Midwives and Obstetricians Helping Mothers to Quit Smoking (MOHMQuit) intervention provides systems change, and leadership and clinician elements, to support clinicians to help women stop smoking in pregnancy. There have been few long-term analyses conducted of the cost-effectiveness of smoking cessation interventions for pregnant women that target healthcare providers. This protocol describes the economic evaluation of the MOHMQuit trial, a pragmatic stepped-wedge cluster-randomised controlled implementation trial in nine public maternity services in New South Wales (NSW), Australia, to ascertain whether MOHMQuit is cost-effective in supporting clinicians to help women quit smoking in pregnancy compared to usual care.MethodsTwo primary analyses will be carried out comparing MOHMQuit with usual care from an Australian health care system perspective: i) a within-trial cost-effectiveness analysis with results presented as the incremental cost per additional quitter; and ii) a lifetime cost-utility analysis using a published probabilistic decision analytic Markov model with results presented as incremental cost per quality-adjusted life-year (QALY) gained for mother and child. Patient-level data on resource use and outcomes will be used in the within-trial analysis and extrapolated and supplemented with national population statistics and published data from the literature for the lifetime analysis.DiscussionThere is increasing demand for information on the cost-effectiveness of implementing healthcare interventions to provide policy makers with critical information for the best value for money within finite budgets. Economic evaluation of the MOHMQuit trial will provide essential, policy-relevant information for decision makers on the value of evidence-based implementation of support for healthcare providers delivering services for pregnant women.Trial registrationsACTRN12622000167763, registered 2 February 2022.

Accelerating systemness through shared vision and culture

As health systems across the United States consolidate, tremendous potential exists to expand and optimise their breadth and depth by integrating services so that patient care is coordinated, supportive and equitable. The financial pressures and workforce crisis resulting from the COVID-19 pandemic have further exacerbated the need for fiscal discipline and operational efficiencies that can come from effective, system-wide integration. Yet many health systems continue to fall short of achieving the promise of post-merger integration and the value it can create for the diverse communities they serve. This paper explores one health system’s journey from ‘operational synergies’ to full ‘systemness’ enabled by a shared vision laser focused on a commitment to frictionless, patient-centred care through enabling care teams to do their best work, accelerating integrated operations and building an inclusive culture. It will explore the journey of a system in name only (Wellforce) to a unified team with a single brand (Tufts Medicine) and a shared commitment to the future with a mission to empower people to live their best lives. This case study will describe how the system evolved, starting from the development of a transformational Strategic Vision, through the shared trials of the COVID-19 pandemic and its effect on patients and providers. Having a shared vision is an essential first step to building systemness. Bringing that vision to life requires significant discipline and culture change. It requires a systemic approach and unwavering leadership, rooted in a shared philosophy, deep commitment and aligned behaviour. The case study will continue with an exploration of the path system and entity leaders took to identify shared priorities, adapt organisational and governance structures, and engage more than 14,000 clinical and administrative staff and physicians in building an inclusive culture with a clear and actionable commitment to anti-racism. It is a story about moving from words and ideas to action and removing the barriers that impeded progress.

Challenges and Opportunities for Clinician Implicit Bias Training: Insights from Perinatal Care Stakeholders.

In an attempt to address health inequities, many U.S. states have considered or enacted legislation requiring antibias or implicit bias training (IBT) for health care providers. California's "Dignity in Pregnancy and Childbirth Act" requires that hospitals and alternative birthing centers provide IBT to perinatal clinicians with the goal of improving clinical outcomes for Black women and birthing people. However, there is as yet insufficient evidence to identify what IBT approaches, if any, achieve this goal. Engaging the experiences and insights of IBT stakeholders is a foundational step in informing nascent IBT policy, curricula, and implementation. We conducted a multimethod community-based participatory research study with key stakeholders of California's IBT policy to identify key challenges and recommendations for effective clinician IBT. We used focus groups, in-depth interviews, combined inductive/deductive thematic analysis, and multiple techniques to promote rigor and validity. Participants were San Francisco Bay Area-based individuals who identified as Black or African American women with a recent hospital birth (n=20), and hospital-based perinatal clinicians (n=20). We identified numerous actionable challenges and recommendations regarding aspects of (1) state law; (2) IBT content and format; (3) health care facility IBT implementation; (4) health care facility environment; and (5) provider commitment and behaviors. Patient and clinician insights overlapped substantially. Many respondents felt IBT would improve outcomes only in combination with other antiracism interventions. These stakeholder insights offer policy-makers, health system leaders, and curriculum developers crucial guidance for the future development and implementation of clinician antibias interventions.

International cooperation for nursing human resource development in Lao PDR: Investing in nursing leadership.

Strengthening nursing leadership in health systems has been identified as a priority for achieving Universal Health Coverage (UHC). We aimed to analyse the characteristics of Japanese technical assistance projects for nursing human resource development in Lao People's Democratic Republic (Lao PDR) and suggest directions for future assistance. An upgrading program, as part of human resource development, was initiated in the 1990s; it has contributed to the development of nursing leaders. Moreover, technical assistance from development partners has had synergistic effects by consistently promoting the involvement of nursing leaders in administration, education, and clinical practice to establish a functional regulatory system. In resource-limited settings, the application of both edge-pulling (leadership development) and bottom-up (quality improvement of the mass population) strategies are required. From a long-term perspective, development partners should continue to invest in increasing the number and quality of nursing leaders by upgrading the courses and leadership training programs, starting from the younger generation.

Scaling Family Voices and Engagement to Measure and Improve Systems Performance and Whole Child Health: Progress and Lessons from the Child and Adolescent Health Measurement Initiative.

The 1997 legislation authorizing the United States Child Health Insurance Program sparked progress to measure and publicly report on children's healthcare services quality and system performance. To meet the moment, the national Child and Adolescent Health Measurement Initiative (CAHMI) public-private collaboration was launched to put families at the center of defining, measuring and using healthcare performance information to drive improved services quality and outcomes. Since 1996 the CAHMI followed an intentional path of collaborative action to (1) articulate shared goals for child health and advance a comprehensive, life-course and outcomes-based healthcare performance measurement and reporting framework; (2) collaborate with families, providers, payers and government agencies to specify, validate and support national, state and local use of dozens of framework aligned measures; (3) create novel public-facing digital data query, collection and reporting tools that liberate data findings for use by families, providers, advocates, policymakers, the media and researchers (Data Resource Center, Well Visit Planner); and (4) generate field building research and systems change agendas and frameworks (Prioritizing Possibilities, Engagement In Action) to catalyze prevention, flourishing and healing centered, trauma-informed, whole child and family engaged approaches, integrated systems and supportive financing and policies. Lessons call for a restored, sustainable family and community engaged measurement infrastructure, public activation campaigns, and undeterred federal, state and systems leadership that implement policies to incentivize, resource, measure and remove barriers to integrated systems of care that scale family engagement to equitably promote whole child, youth and family well-being. Population health requires effective family engagement.

Driving systemic reform and enhancing professional capital: the transformative roles of excellent retired principals

PurposeThis study examines the deployment of excellent retired principals (ERPs) as system leaders to facilitate systemic professional capital building in Taipei City, Taiwan. It explores the unique approach of the Taipei City government and contributions of ERPs in driving educational reforms.Design/methodology/approachThis study combines the perspectives of system leadership and professional capital, and analyzes the roles and practices of ERPs in promoting professional capital in Taipei's local education system. It draws on qualitative data gathered through interviews and document analyses.FindingsThe findings reveal that the Taipei City government adopted a systemic approach by appointing designated retired principals as system leaders. The findings are categorized into three themes. ERPs serve as systemic capacity-builders, enhancing leadership across the local education system; ERPs act as collaborators and bridge-builders, fostering joint work and a collective sense of professional responsibility; and ERPs function as facilitators and advisors, cultivating decisional capital by providing informed decision-making support based on their experiences and wisdom. These roles challenge the notion of late-career decline, highlight the ongoing contributions of ERPs to the education system, and extend professional capital beyond teacher development, influencing system-wide collective capacity-building, collective responsibility, and policy enactments.Originality/valueThis study contributes to understanding how exceptional retired principals can drive systemic reform and build systemic professional capital. It expands previous research by highlighting the unique Chinese cultural context in Taipei City and continued contributions of retired principals to the education system.

Economic performance of rural collective‐owned cooperatives: Determinants and influence mechanism

AbstractRural collective‐owned cooperatives (RCOCs) have received significant attention for rural development, alleviating rural poverty, and achieving common welfare in China. Using the Social‐ecological system (SES) framework as a conceptual and analytical lens, this paper clarifies the determinants and the influence mechanism for the economic performance of RCOCs. A mixed method, PLS‐SEM combined NCA approach is applied to 420 smallholder farmers in rural China. The results reveal that rural collective property‐rights system reform (RCPRSR), leadership, social capital, and collective action positively affect the economic performance of RCOCs. Moreover, leadership and social capital also operate through their mediating effect on collective action amongst collective members. Our results further show that RCPRSR, leadership, and social capital are necessary conditions for the high economic performance of RCOCs.

Applying the consolidated framework for implementation research to evaluate the community rapid intervention service

BackgroundDeveloped in 2019, the Community Rapid Intervention Service (CRIS) is a community intervention service aiming to prevent hospital admissions. CRIS provides a response within two hours to patients with sub-acute medical needs in their usual place of residence. This evaluation aimed to identify challenges and facilitators to implementation of the service, with a view to informing future service development, optimising patient care and disseminating learning to other areas looking to implement similar services.MethodsThis study used the Consolidated Framework for Implementation Research (CFIR) as an evaluation framework. We conducted semi-structured interviews with local healthcare system leaders, clinicians that worked within the CRIS, and clinicians who interfaced with the CRIS. The CFIR was used to guide data collection and analysis. Two Community of Practice (CoP) meetings were held to gather stakeholders’ perspectives of the evaluation.ResultsThree key themes were identified from the analysis of 13 interviews: contextual factors influencing implementation, service identity and navigating complexity. Contextual factors such the influence of the Covid 19 pandemic upon health services and the expansion of the CRIS were discussed by participants. The adaptability of the service was deemed both a facilitator and challenge of implementation. Ways to build-on and improve the existing CRIS model were suggested.ConclusionThis evaluation has shown that the CRIS may need to be redefined with clarity provided as to how the service interfaces with other urgent and planned care offered in acute, primary, community and social services. Structuring the evaluation around the CFIR was helpful in identifying facilitators and challenges that influenced the implementation of the CRIS.

Comparing three observation instruments of the coach's behaviour in grassroots football

Coach behaviour has long been known to influence the sporting experience of grassroots players; however, it is currently unclear how the instruments used to assess their behaviour are related. Therefore, the aim of this study is to evaluate the relationships between three observational coaching behaviour tools. Sixteen matches with teams led by four female football coaches were recorded and analysed using three observational instruments: (a) Coaching Behaviour Assessment System (CBAS); (b) Multidimensional Motivational Climate Observation System (MMCOS) and (c) Coach Leadership Assessment System (CLAS). The dimensions measured by each instrument are theorised as being adaptive or maladaptive. The specific objectives of this study are targeted to assess: (a) the commonalities between the three instruments and (b) what differentiated aspects each instrument provides. The results show that both the adaptive and the maladaptive dimensions of the three instruments are positively related among themselves but negatively related to the others. The results also show that the MMCOS is sensitive to behavioural changes during the matches, while the CBAS and the CLAS do not reflect these changes but assess the stability of the behaviour. In conclusion, this research provides empirical evidence supporting the conceptual relationship between the three instruments and of the specific information that each instrument offers. Furthermore, it highlights the need to observe the sport environment more closely in a more diversified way.

Implementation Challenges for a Multisite Advance Care Planning Pragmatic Trial: Lessons Learned.

Advance care planning (ACP) pragmatic trials are needed. We determined key system-level activities to implement ACP interventions for a cluster-randomized pragmatic trial. We identified patients with serious illness from 50 primary care clinics across three University of California health systems using a validated algorithm. If patients lacked documented ACP within the last 3 years, they were eligible for an intervention: (Arm 1) an advance directive (AD); (Arm 2) AD+PREPAREforYourCare.org; (Arm 3) AD+PREPARE+lay health navigator outreach. Triggered by an appointment, we mailed and sent interventions through automated electronic health record (EHR) messaging. We collaborated with patients/caregivers, clinicians, payors, and national/health system leader advisors. We are currently finalizing 24 months follow-up data. We used the Consolidated Framework for Implementation Research (CFIR) and Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) frameworks to track secular trends and implementation efforts. Required multisite, system-level activities: 1) obtaining leadership, legal/privacy, and EHR approvals; 2) standardizing ACP documentation; 3) providing clinician education; 3) validating an automated serious illness identification algorithm; 4) standardizing ACP messaging with input from over 100 key advisors; 5) monitoring secular trends (e.g., COVID); and 6) standardizing ACP workflows (e.g., scanned ADs). Of 8707 patients with serious illness, 6883 were eligible for an intervention. Across all arms, 99% received the mailed intervention, 78.3% had an active patient portal (64.2% opened intervention), and 90.5% of arm three patients (n=2243) received navigator outreach. Implementing a multisite health system-wide ACP program and pragmatic trial, with automated EHR-based cohort identification and intervention delivery, requires a high level of multidisciplinary key advisor engagement, standardization, and monitoring. These activities provide guidance for the implementation of other large-scale, population-based ACP efforts.

Adoption and use of various health information exchange methods for sending inside health information in US hospitals

BackgroundHospitals may adopt various information transmission methods to participate in health information exchange (HIE) programs. However, even if they adopt multiple mechanisms, they may not actively use all of them to send inside information. This study analyzes the frequently used methods for sending data and the common barriers blocking sending practices in hospital settings. MethodsOur sample included 3,015 community hospitals that reported their methods of sending patient health information in the 2019 American Hospital Association Information Technology Supplement Survey. The relationship between obstacles hospitals experienced and their use of the information-sending method was analyzed by using robust Poisson regression models. ResultsMany-to-many exchanges that involve intermediaries such as a health information service provider (HISP), electronic health record (EHR) vendor-based network, and national network, once adopted, were more often used by hospitals than one-to-one exchange methods such as provider portals and direct access to EHR by login credentials. Hospitals that lacked the technical capability to electronically send patient health information were less likely to use any of the methods (p <.01), while hospitals located in a more concentrated market were more likely to send information to outside providers by using provider portal, interface connection and national network (p <.01). DiscussionThere is still a notable gap between hospitals' adoption and the actual use of different HIE methods to send inside information to outside organizations. Results argue that even if hospitals adopted an HIE method, they might not necessarily participate in the actual sharing of information, and the method may remain unused due to several usage barriers. ConclusionHospital and market-level barriers associated with using one-to-one and many-to-many HIE methods for sharing information may affect progress in interoperability. Examining the barriers to using multiple HIE methods and their impact on interoperability could offer implications for health information technology (IT) policy and inform health system leaders.

Despicable ‘other’ and innocent ‘us’: emotion politics in the time of the pandemic

This study investigates the emotional management strategies employed by the Chinese maintream media Huanqiu Shibao (HQSB), through the use of nationalistic rhetoric during the Covid-19 pandemic. By conducting a discourse analysis of the coverage of Covid-19 on HQSB’s WeChat account, this research reveals two primary emotional management strategies: defensive nationalism and aggressive nationalism. Defensive nationalism utilizes fear and positive emotions to uphold and defend Chinese politics, while aggressive nationalism employs disgust to counter external criticisms and delegitimize the US democratic system and international leadership. By examining how HQSB emotionally differentiates the world, the study unveils that tactics Chinese mainstream media use to construct national identity, drawing a divisive line between a despised ‘them’ and an innocent ‘us’. The Covid-19 pandemic presents a unique opportunity to reflect on the emotionalisation of Chinese digital propaganda and the evolution of state-led nationalism during a public health crisis. The research concludes that the use of emotion in HQSB’s Covid-19 coverage aligns with China’s broader strategy of nation-building and global influence promotion. It underscores the need for greater awareness of the emotional mobilization used in political communication, particularly during times of crisis.

Paradoxes of Multi-Level Leadership: Insights from an Integrated Care System

ABSTRACTIn this paper, we draw on systems leadership, complexity and paradox theory to elucidate the tensions that organizational actors experience when practising multi-level leadership. We explore these issues through a study of the perceptions and experiences of stakeholders within an Integrated Care System (ICS) in England. Employing a collaborative inquiry approach, data were collected via 19 narrative interviews with participants in key leadership roles across ICS partners and nine co-creation workshops with a total of 86 participants from different parts of the ICS. Findings highlight that in developing multi-level leadership practice, leaders experience contradictory expectations and outcomes, including paradoxes of identity, place, purpose and change. We conclude by suggesting that leadership in multi-level contexts requires oscillating between competing polarities in a dynamic equilibrium with attention to localized interactions.MAD statementIntegrated Care Systems were enacted across England in July 2022 to enhance the capacity for statutory, voluntary and community organizations to work in partnership to improve health outcomes across diverse populations. Multi-level systems leadership, however, poses significant challenges around navigating the inevitable tensions that arise when working with complexity. Through qualitative research in a vanguard ICS, this paper highlights a range of paradoxes faced by leaders and organizations and proposes implications for policy and practice in enabling dynamic equilibrium and working in contexts of uncertainty and change.

Applying a systems oriented ethical decision making framework to mitigating social and structural determinants of health.

Clinical ethical decision-making models are largely geared toward individual clinician choices and individual patient outcomes, not necessarily accounting for larger systemic issues that affect optimal patient outcomes. The purpose of this paper is to provide an ethical decision-making model, drawing upon systems orientation and ethical theory, specifically incorporating and aiding in the mitigation of social and structural determinants of health. This paper presents a systems-oriented ethical decision-making framework derived from the analysis and critique of the Four-Box Method for Ethical Decision-Making by Jonsen, Siegler, and Winslade. Drawing upon both deontological and utilitarian ethical theory, the developed framework will assist providers, organizations, and health system leaders in navigating the increasingly complex ethical dimensions of care delivery for underserved patient populations, who are largely impacted by social and structural determinants of health. The needs of underserved patients are inextricably linked to various social and structural determinants of health that, if left unaddressed, result in even poorer health outcomes, exacerbating existing health disparities. A systems-oriented ethical decision-making framework, centered on obligation, duty, and a utilitarian view of the optimal good, will aid providers, organizations, health system leaders, and community stakeholders in navigating the increasingly complex ethical dimensions of care delivery for underserved patient populations. Socioeconomic and political contexts have a significant impact on the way society is organized, how people are positioned in society, and how they will fare in terms of their health. Healthcare providers, including dentists, are largely unaware of and insensitive to the social issues that underlie the biological or psychological concerns that patients from socially disadvantaged backgrounds face. A systems-oriented ethical decision-making model will aid in mitigating social and structural determinants of health and the dental profession's obligations to the underserved.

Care coordination in primary care: mapping the territory.

To document the current approaches to care coordination among different types of care systems in Minnesota. Observational survey of leaders of most of the care systems in Minnesota that have implemented care coordination. Survey questions about organizational structure, size, and approach to care coordination were sent to the leaders of 42 care systems with a total of 327 primary care clinics. Surveys were completed by leaders at every care system participating in this study (100% response rate); 16 small care systems (each with 1-2 clinics) had a total of 26 primary care clinics, 15 medium care systems (3-9 clinics) had 57 clinics, and 11 large care systems (> 9 clinics) had 244 clinics. The large care systems had larger clinics (clinicians per clinic, 8.6 in large vs 4.3 in small and 5.2 in medium; P = .03) and more clinicians per care coordinator (5.7 vs 3.3 and 4.0; P = .04). They also more frequently included a social worker in their care coordination team: 82% vs 25% of small and 40% of medium care systems (P = .01). However, the services provided and complexity tools used were similar. Nearly all reported addressing both medical and social needs for their complex patients with multiple chronic conditions. Although there are large differences in resources and capabilities between large and small care systems, they were not associated with much difference in the approach taken to care coordination. This map of the care coordination territory in Minnesota has the potential to be valuable to researchers and care system leaders for understanding current implementation trends and directing further evaluations.

Leadership in times of crisis: Ontario teachers’ perspectives of system leaders during the COVID-19 pandemic

ABSTRACT Systemic disruptions and uncertainties resulting from the prolonged COVID-19 pandemic have put extraordinary pressure on system-level educational leadership worldwide. Despite often being seen as drivers of thinking and change, system leaders had few, if any, precedents to draw from on how to lead effectively through such crises. This paper examines Ontario secondary school teachers’ (N = 17) perspectives on system-level educational leadership during the initial weeks of the COVID-19 pandemic and considers how these perspectives can inform future approaches to leading school systems through such uncertainty and disruption. Drawing on prolonged semi-structured interviews, six leverage points for systemic change are discussed: actors and elements, feedback, relationships and power, structures and roles, goals, and the overarching paradigm for teaching and learning.

Promises and challenges for effective school and system leadership

Promises and challenges for effective school and system leadership