How can leadership influence the quality of care in a health-care organization?

Abstract Objective This study focuses on how leadership could influence the quality of care in a health-care organization. Methods The concept of leadership and quality are analyzed. In addition, issues concerning how leadership can influence quality of care through the effect on the organizational culture and the engagement of both nurses and patients are discussed. Results Leadership is the pivotal factor in the improvement of quality through the effect on the organizational culture and the engagement of both nurses and patients. Conclusions Leadership can influence the quality of care directly and indirectly. The organization and the leaders should know the importance of effective leadership to a better work environment, facilitate the implementation of the new mode of nursing, and provide best services to the patients.


Introduction
It is generally believed that the quality of health-care services needs to be improved significantly, due to improved quality of life and high demand of patients. In the face of how to improve the quality effectively, the quality should be identified first. Harteloh defined quality as "an optimal balance between possibilities realized and a framework of norms and values." 1 In the framework for improving quality in Ireland, leadership is considered as the foundation stone which is recognized for improving quality. 2 Leadership, as an integral part of nursing practice, plays an essential role in our daily work. How can leadership influence the quality of care in a health-care organization will be analyzed by discussing the concept of leadership and the influences of the culture cultivated by leadership on the health-care quality, as well as the engagement of staff and patient in this article.

What is leadership?
Although leadership has been conceptualized in many ways, Northouse reports that there are four central components about leadership: leadership is a process, enhance their professional knowledge and skills. There is no doubt that nurses' skills have a key role to play in the quality of nursing care. A study by McKenna proposes that employing a large number of qualified staff helps to effectively deliver health care. 7 Simultaneously, it is an effective way to strengthen learning and improve services through sharing adverse events in an open and fair culture. 8 For example, leaders with collective leadership see mistakes as a good opportunity for learning, through the analysis of mistakes, adverse events, complaints, and problems, while the key point is making the process transparent. 9

The role of leadership in staff engagement
In addition, there are many findings indicating that the quality of service can be improved by work engagement. The King's Fund leadership review reports that the more engaged staff involved in the organization, the patient can experience improved outcomes. 10 Nurse managers play a vital role in creating a culture of empowerment that has a positive impact on employee involvement. A study conducted by Cziraki and Laschinger demonstrates that nurse managers create empowering environments where staff are engaged and given access to pertinent opportunities, information, supports, and resources. 11 Another study shows that accessing to organizational resources not only helps staff eliminate barriers, but also lets them feel engaged, which contributes to the establishment of positive work atmosphere. 12 That means if employees do not feel engaged, they may have obstacles in their work or in their minds that may lead them feel listless and burned-out, which can lead to mistakes or deliver low quality care. This will increase the turnover rate of nurses, which can negatively influence the health-care quality and may threaten the basic service. Moreover, the more staff feel engaged, the less turnover takes place in this organization. 13 The retention of nurses is a basic guarantee of quality. A leader plays a significant role in influencing staff engagement. Every staff should be aware of the vision of the organization clearly and feel empowered and supported by the organization. They know what to do, and the leader will give them positive feedback and helpful advice afterward. It is crucial that every member of staff receives recognition and is confident about their work because they know that the leader trusts them and believes that their work is meaningful. Finally, and most importantly, employees must feel valued by their direct supervisor and by their organization and this feeling of value should come directly from the nursing leadership.
involves different forms of influence, occurs in groups, involves clear vision and common goal. 3 According to this statement, it can be said that leadership plays a vital role in nursing profession because nursing involves teamwork and all nurses need to cooperate with each other to accomplish the same goal, delivering a quality service to their clients.

The role of leadership in shaping culture
In the challenge to achieve high quality of service, there are some critical factors related to leadership that should be involved: the framework for improving quality in our health service states that nurturing a culture in which the primary objective is pursuing secure, efficient, patient-centered care. 2 The process of providing services is crucial to guarantee long-term improved quality of care. Only an organization where the culture is based on dignity, mutual respect, and equality can achieve every aspect of good care, improving quality, productivity, and patient satisfaction; fostering compassion; ensuring effectiveness; and inspiring innovation. 4 Thus, it can be seen that culture plays a key role in improving quality. Therefore, what is the role of leadership in shaping culture? Leadership has a critical part to play in nurturing a culture that maintains highquality care ceaselessly. There is evidence to suggest that leadership behavior has positively impacted on organizational culture. 5 The process of the generation of organizational culture is the process in which the value of leader and staff tends to be consistent. In this process, the leader can form a culture by his own behavior of handling some specific events such as the allocation of resources, the assessment of staff performance, and rewarding results. It thus gradually forms a consensus of belief, system, and value which can lead employees' behavior. Subsequently, Kane-Urrabazo notes that trustworthiness and empowerment should be paid attention to by leaders, as well as consistency and mentorship, and these four aspects are considered as foundation in nurturing a culture. 6 First, a leader who is trustworthy would have lots of followers who are always supportive of each other. In addition, feeling empowered makes staff attain a sense of being trusted and can also improve staff engagement. Furthermore, consistency not only represents the congruence of behavior and goal but also the same values. Finally, leadership should lead employees in the right direction and mentor them at the critical moment. An effective leadership can also encourage the staff to learn continually and keep improving that can

The role of leadership in patient engagement
Patients', as care receivers, engagement is also closely related to the quality of service. Patient engagement is a relatively new concept. The concept of patient engagement was defined as "the empowerment of patients through collaboration with nurses and other health care practitioners to provide health information and promote patient activation." 14 Patient engagement not only contributes to improve the quality of care and better health outcomes but also has a possibility of reducing healthcare costs, which can improve patient satisfaction effectively. 15 Making decisions with staff not only enables patients to exercise control of their overall health and well-being but also enables staff to see services through patients' eyes, which in turn can help leaders mold culture and practice to attain an increasingly responsive and empathetic care. 10 Patient engagement has a key role to play in a patient-centered service, and patientcentered care is considered to be an essential aspect of high-quality health care so that the culture created by leaders should involve this. The Institute of Medicine has defined patient-centered care as "care that is respectful of and responsive to individual patient preferences, needs, and values." 16 As mentioned earlier, patient-centered care is one of the four domains of the quality. However, it does not mean that health-care practitioners make every decision only according to patients' wishes. An exploratory study about patient engagement in clinical communication suggests that it is advisable to adopt a tailored approach to achieve such engagement because patient engages in the organization in different ways. 17 Therefore, leaders should strengthen the awareness of patient-centered service to staff and at the same time educate nurses to deal with the problem flexibly.

Conclusions
This study focuses on how can leadership influence the quality of care in a health-care organization. Improving and sustaining the quality of care is a long-term goal for all the nurses. There are many factors that affect the quality of care in the context of health care. However, it is found that leadership is the pivotal factor in the improvement of quality when the relationship between the quality of care and leadership has been analyzed. Nevertheless, in China, studies on how leadership influence the quality of care are rare. Therefore, to continuously improve the quality of care, leadership as the most basic foundation must be taken into account.

Ethical approval
Ethical issues are not involved in this article.

Conflicts of interest
All contributing authors declare no conflicts of interest.