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This paper draws on a case study of a large public hospital to examine the processes of leadership and strategic change in organizations where goals are unclear and authority is fluid and ambiguous. The case history describes the evolution of leadership roles during a period of radical change in which a general hospital acquires a university affiliation while moving towards a more integrated form of management. The study traces the tactics used by members of the leadership group to stimulate change, and the corresponding impact of these tactics on both the progress of change and on leadership roles themselves. It is suggested that strategic change in these organizations requires collaborat ive leadership involving constellations of actors playing distinct but tightly-knit roles. Yet, collaborative leadership is fragile and can easily disintegrate due to intemal conflict or to discreditation associated with more unpopular (although potentially effective) change tactics. Thus, under ambiguity, radical trans formations may tend to occur in a cyclical non-linear pattern with periods of substantive change alternating with periods of political realignment. The paper concludes with a series of five propositions concerning the collaborative, cyc lical, interpretative, and entropic nature of leadership and strategic change pro cesses under ambiguity.

The food environment surrounding schools can constitute a target for interventions to improve food choices among secondary-school children living in the province of Quebec. Transforming environments around schools to promote healthy eating includes modifying zoning regulations that restrict access to fast-food outlets around schools.

BackgroundTeamwork is a key component of the health care renewal strategy emphasized in Quebec, elsewhere in Canada and in other countries to enhance the quality of oncology services. While this innovation would appear beneficial in theory, empirical evidences of its impact are limited. Current efforts in Quebec to encourage the development of local interdisciplinary teams in all hospitals offer a unique opportunity to assess the anticipated benefits. These teams working in hospital outpatient clinics are responsible for treatment, follow-up and patient support. The study objective is to assess the impact of interdisciplinarity on cancer patients and health professionals.Methods/DesignThis is a quasi-experimental study with three comparison groups distinguished by intensity of interdisciplinarity: strong, moderate and weak. The study will use a random sample of 12 local teams in Quebec, stratified by intensity of interdisciplinarity. The instrument to measure the intensity of the interdisciplinarity, developed in collaboration with experts, encompasses five dimensions referring to aspects of team structure and process. Self-administered questionnaires will be used to measure the impact of interdisciplinarity on patients (health care utilization, continuity of care and cancer services responsiveness) and on professionals (professional well-being, assessment of teamwork and perception of teamwork climate). Approximately 100 health professionals working on the selected teams and 2000 patients will be recruited. Statistical analyses will include descriptive statistics and comparative analysis of the impact observed according to the strata of interdisciplinarity. Fixed and random multivariate statistical models (multilevel analyses) will also be used.DiscussionThis study will pinpoint to what extent interdisciplinarity is linked to quality of care and meets the complex and varied needs of cancer patients. It will ascertain to what extent interdisciplinary teamwork facilitated the work of professionals. Such findings are important given the growing prevalence of cancer and the importance of attracting and retaining health professionals to work with cancer patients.

Based on lessons learned from the evaluation of the implementation of an integrated oncological services network in Québec, this paper discusses the following question: to what extent is strong clinical leadership a propitious means of transforming health-care systems, especially when the change leads to significant evolution in inter-professional and inter-organizational relations? Through a qualitative case study, we analysed the exercising of leadership by studying over time the clinical leaders' initiatives while trying to understand the sources of influence, the nature of the tactics adopted and their consequences for the degree of integration of health services. This study seems to show that clinical leadership is effective but limited. We conclude that a constellation of clinical, administrative and political leaders found at different levels of the health-care system offers more promise of positive change for the health-care system.