Marchal et al. BMC Public Health 2010, 10:787 http://www.biomedcentral.com/1471-2458/10/787 organisation by management practices, procedures and rewards. In other words, it reflects how the staff feel about their relations with their managers and their per- ceptions regarding the interventions of the management team. Four particular themes emerged during the analy- sis: the perceptions about changed leadership, the inter- vention of the CMT as perceived by the operational staff, perceptions of positive change and perceptions of sup- port for the workforce as well the revamped institution. The perception of changed leadership The changes in leadership were perceived as an impor- tant event by most interviewees. They describe their relations with the CMT members, their approach to communication and their accessibility and note the effects on staff morale. In those days, the relationship was not cordial. That time, the way the former management handled staff was not the best. So, some of the staff were discour- aged from rendering their services because of the way things were happening, but now, everybody is trying to do his best because of the way they handle us, because there is a change. (HMH GO 1-4) The interviewees noted especially the new vision on leadership and management and specifically the empha- sis on participation. For instance, interviewees appre- ciated the efforts to ensure a participative process that would define the hospital’s mission and the core values, or to the problem analysis exercise in which they were also involved. They note how this participative approach was applied at the management level of the hospital and at the interface with the operational staff. For the for- mer, the interviews show that the strategy was to create a critical mass of staff supporting the changes. Indeed, the M/Supt. delegated responsibilities to take initiatives and to implement the change agenda to a group of staff members committed to change. The ward conferences reconnected the CMT to the mid-level cadre and the operational staff. Later, these ward conferences and the quality assurance workshops were used to maintain the drive of the plan and the organisational vision. We want to communicate with the staff, we want to build their confidence, we want them to take and participate in whatever that is happening. And one way to do this is the ward conference. Above all, we want to teach them methods of arriving at certain things with that method. How do you arrive at pro- blem solving? This is a problem, so in the ward let’s sit down, what do you do in other to do this and that. (HMH IM 1-4) Page 9 of 16 Many interviewees recognise the role of the M/Supt. in making this a truly shared vision on leadership and management, and his emphasis on teamwork and infor- mation sharing. In fact, the medical superintendent is a key player in the team. He inspires us. He works with us as a team. Even if he is having the idea, he calls us, dis- cusses it with us and we also make our contributions and whatever is agreed on, then we start implement- ing. So, it is like, all the time, we are all together in the work. Even if he has taken a decision which needed to be taken instantly he calls us and tell us this is why he has done this and that. So, we are not left out of the game. (HMH IM 1-5) But for the key ones who understand, we will even come to you and tell you: “We are doing this and that, why can’t we do this other thing”. Sometimes you may not necessarily go to them but they may come to you with what they’re thinking. [...] So, that is how we discovered them and that is how we try to include them in whatever, so that they don’t get fru- strated and they keep on thinking about what is at stake. (HMH IM 1-6) This inclusive approach, however, met with some resistance, both from operational staff (for instance the theatre staff) as well as from management team mem- bers, who objected when the M/Supt. wanted junior staff members to join the CMT. The director finally gave in to the CMT, but kept the junior staff in the loop by delegating key tasks to them, which served to keep them committed to improving the hospital. How the management intervention is perceived by operational staff When asked about the key interventions of the CMT, the interviewees refer commonly to 4 main elements: delega- tion to the units, improved flow of information through the committee system, team work and shared values. First, the interviewees recognise that the CMT facili- tates the delegation of problem analysis and - solving to the departments, a main aim of the 5-year strategic plan. You know, [the CMT] doesn’t want to impose things on us. [...] What I mean is that there are things that we ourselves can do. There are some problems, which everyone among us can solve. Do we wait for man- agement to come and solve those problems? So, they want to draw our attention to those things. It is not everything that you sit down for management to come and do it for you. No, we must try as much as possible to do it ourselves. (HMH GO 1-2)