TABLE 2.

How Simple Rules and Mid-Range Theories Were Derived from the Data (Using “Leadership” as the Worked Example)

Stage in Analysis	Output of Stage
Read and reread primary studies to gain familiarity with the data.	All primary studies broadly defined “leadership” as essential to success of large-system change. Most studies emphasized importance of “strategic leadership” and “top management buy-in.” Several also talked of “distributed,” “collective,” “collateral,” and “emergent” leadership.
Systematically extract statements of high-level principles and theoretical orientations made by authors of primary studies.	Examples of distributed leadership:
	•“Top-down” leadership alone cannot achieve whole-system change because (a) health systems are complex; (b) power is distributed among professional groups; (c) care is necessarily multidisciplinary; and (d) professions have their own norms and hierarchies (Chreim et al. 2010).
	• Processual theory (a “grand theory” about organizational change): we need to go beyond studying traits (e.g., qualities of “successful leaders”) and use richly described longitudinal case studies to explore the context and process through which distributed leadership emerges and evolves dynamically in a way that cannot be planned in advance (Chreim et al. 2010).
	• Neoinstitutional theory (a “grand theory” about how institutions operate): the behavior of health care systems is strongly influenced by macro-level social forces, including professional norms, regulatory frameworks, and accepted ways of working (Harrison and Kimani 2009).
Systematically extract empirical findings from primary studies.	Examples of empirical findings on distributed leadership:
	•“In mobilizing and sustaining internal and external commitment to the redesign, the leaders of the transformation derived influence from their preexisting personal resources and network ties, as well as their formal authority. Their informal sources of influence included personal ties, status, knowledge, and past experience in improvement efforts” (Harrison and Kimani 2009, 46).
	•“The leaders we identified typically did not identify themselves as leaders. When asked about their leadership, they invariably took a modest approach and downplayed the importance of their roles”; “No single agent (individual or group) had full authority, resources, or expertise to lead the change. These elements were distributed across a number of actors who pooled their resources and abilities to bring about change” (Chreim et al. 2010, 197, 198).
	•“ … by themselves, improvement teams ran up against the limits of traditional intra-organizational boundaries. Often teams could not obtain the commitment of resources or the cooperation from other departments needed to effect change” (Lukas et al. 2007, 317).
Extract mid-range theories of leadership explicitly described or implicit in authors’ accounts in primary studies.	Examples of mid-range theories invoked for distributed leadership:
	• Social capital theory (explicit, Chreim et al. 2010).
	• Freidson's theory of professions (explicit, Chreim et al. 2010).
	• Social influence theory, especially homophily: “The ability to influence is associated with the credibility and legitimacy that is attributed to those in leadership positions” (implicit, Chreim et al. 2010, 195).
	• Activity theory and distributed cognition—i.e., the notion that in order to achieve a complex task, members of a team work interactively and in an ongoing way that accommodates their separate inputs (Diamond 2007).
Pursue further relevant literature (e.g., papers cited by authors of primary studies) for new theories and/or additional detail.	Examples:
	•Buchanan et al. 2007; Carroll and Edmondson 2002; Ferlie et al. 2005 (all cited in Harrison and Kimani 2009).
Summarize findings in “simple rule.”	Leadership must be both designated (i.e., someone is formally in charge of the program) and distributed (i.e., responsibility for mobilizing effort and delivering program components is shared among professionals and across partner organizations and teams).