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The British Columbia Ministry of Health’s Clinical Care Management initiative was used as a case study to better understand large-scale change (LSC) within BC’s health system. Using a complex system framework, the purpose of this paper is to examine mechanisms that enable and constrain the implementation of clinical guidelines across various clinical settings.

Researchers applied a general model of complex adaptive systems plus two specific conceptual frameworks (realist evaluation and system dynamics mapping) to define and study enablers and constraints. Focus group sessions and interviews with clinicians, executives, managers and board members were validated through an online survey.

The functional themes for managing large-scale clinical change included: creating a context to prepare clinicians for health system transformation initiatives; promoting shared clinical leadership; strengthening knowledge management, strategic communications and opportunities for networking; and clearing pathways through the complexity of a multilevel, dynamic system.

The action research methodology was designed to guide continuing improvement of implementation. A sample of initiatives was selected; it was not intended to compare and contrast facilitators and barriers across all initiatives and regions. Similarly, evaluating the results or process of guideline implementation was outside the scope; the methods were designed to enable conversations at multiple levels – policy, management and practice – about how to improve implementation. The study is best seen as a case study of LSC, offering a possible model for replication by others and a tool to shape further dialogue.

Recommended action-oriented strategies included engaging local champions; supporting local adaptation for implementation of clinical guidelines; strengthening local teams to guide implementation; reducing change fatigue; ensuring adequate resources; providing consistent communication especially for front-line care providers; and supporting local teams to demonstrate the clinical value of the guidelines to their colleagues.

Bringing a complex systems perspective to clinical guideline implementation resulted in a clear understanding of the challenges involved in LSC.

HRM is supposed to increase job satisfaction. But does it also increase client satisfaction? Sets out to discuss this issue.

The unit of analysis is the home. Using data from a benchmark study among Dutch homes for elderly care, 154 homes were scored on three groups of indicators: HRM activities as experienced by employees, employee satisfaction, and client satisfaction. Scores were based on interviews with 3,542 patients and surveys of 12,193 employees.

HRM does affect job and client satisfaction. Correlations between HRM and client satisfaction were generally rather low. Employees’ satisfaction with their organisation is a better predictor of client satisfaction than job satisfaction. Job‐related training showed no relation with job satisfaction, but a clear relation with client satisfaction, while leadership style of their manager had a significant relation with job satisfaction, and a more limited one with client satisfaction. Regular performance reviews are important for job satisfaction and client satisfaction. Employee and client satisfaction can also conflict: more regular schedules increase employee satisfaction, but decrease client satisfaction.

To decide on best practices the correlations found need to be explained. For instance, why do performance reviews correlate with employee satisfaction and with client satisfaction about employee expertise?

These results confirm the importance of the leadership style of line managers. Helping middle management to develop a supportive and transparent leadership style can improve employee satisfaction. The HRM activity most relevant for client satisfaction seems to be job‐related training.

The paper is unique in combining data on employee and client satisfaction. It is of interest both to HRM researchers and to health‐care management.