The Scenario: You have just become the Chief Operating Officer of a hospital site where you were the former CEO. The senior team met for the first time last week and includes former leaders and several new faces. A new CEO was selected by a steering committee of the new board and hails from the private sector. The hospital has become one of six sites consolidated into a regional health system, which also includes home care, long-term care, public-health, ambulance and other services. There is only one governance, management and medical staff structure where there had been eight (including non-institutional providers) previously. A seventh site, owned and operated by a religious order, has made a contractual arrangement for its continued autonomy and funding. Several of the sites had deficits in the preceding fiscal year and a financial recovery plan has been requested within 90 days. Three years ago, a consultant's report noted numerous efficiency opportunities but the focus of its implementation became the new regional model.

The new board comprises a mix of local representatives from the former facilities and new trustees with strong ties to community groups. Several trustees have noted that their role is to ensure that their former site "doesn't lose anything," while others have publicly stated a need to focus on the needs of the community and the future. The newly appointed Chair was the popular choice of a steering committee and the Minister of Health.

The middle-management ranks have been downsized and reorganized along program lines. The model has centralized corporate portfolios of human resources, environmental, finance, information systems and a host of other corporate services. Sites remain responsible for managing resources earmarked for patient-care programs and services according to a new strategic plan which focused on the broader determinants of health. A recent planning framework document emphasized a population-based approach and created high expectations among community groups within the region.

The medical staffs of the various facilities have had variable participation in the restructuring process to date. Staff physicians have been frustrated by and vocal about deficits, lack of clinical technology and their role in the new system. Increased waiting times, long lengths of stay and crowded ERs have exacerbated a highly political medical-staff environment which is also going through a consolidation. Primary-care physicians are concerned about continuity of care as the former sites change roles or emphasis within the new model. Fee disputes with the government and highly visible vacancies in several clinical sub-specialties are ongoing. Most physicians blame long hospital stays on a shortage of long-term-care beds and have not accepted any responsibility for community-based solutions.

The last study completed by a regional planning body identified increased performance and capacity of the system, more long-term-care beds and decreased wait times for service as being the top priorities for the newly created system. Every union has, in turn, presented its list of concerns and expectations. Utilization and other clinical indicators would suggest that untapped performance and economic opportunities exist. Hearing about the benefits of integrated care and possible cost-saving opportunities, the government's Speech from the Throne hailed the new regional structure as a panacea to the ills which have plagued the healthcare system.

The Ministers of Health and Finance announced a three-year financial plan indicating flat funding and, with a stable population, reinvestments in non-institutional sectors and elder care. With a majority in the House, the next election is at least four years hence. Both the Minister and Deputy Minister have been in place for less than a year. Both have indicated a willingness to have a greater number and variety of private ventures responding to the needs of the system, especially venture capital for infrastructure and ongoing system needs. As well, the Minister confirmed that hospital closures were not expected at this time, although the new authority could relocate and/or consolidate programs as required. Many community agencies have announced plans for expanded programs through reallocations from institutional providers. Private-sector providers for laboratory, rehabilitative and other services have expressed an interest in entering the market.

The former hospitals had colourful leaders and the sparring over the years was legendary. The unions, advocacy and professional groups, and the media have been vocal about the viability of the regional model created by the Ministry of Health and formalized in legislation. Well-connected former trustees have been eloquent in their non-support of the substance and style of the reform. Many residents in the community have resisted the new model and have promised to withdraw their site-specific philanthropy in protest. Some foundations and auxiliaries have similarly declared their allegiance to the former sites, although the two largest have publicly embraced the new structure and encouraged others to follow suit.

Sound Familiar?

The above scenario is fictional. However, the issues are real and operating throughout the Canadian healthcare system in a wide variety of settings and communities. What the scenario demonstrates is the degree of change that has swept through the healthcare system and the expectations that have been placed upon its leaders. Its sponsors, the Canadian public and the governments they have elected, have come to the conclusion that our system is under siege and that its transformation is more than a funding issue. For many, it has become a debate on system performance, leadership and accountability. The healthcare landscape is being bulldozed by change and new models of healthcare delivery, and their leaders, are arising from the duststorm.

Leaders in the system have been faced with these crises for some time. Crises are excellent promoters of change management, and some would argue that the crises facing the healthcare system exist on three fronts: crisis of vision (Where is the system going and how will we know when we get there?); crisis of quality (What are the standards and indices for healthcare?); and crisis of resources (What is the appropriate amount we should spend to maintain the "health" of Canadians?). Many would agree that crises can spawn new leaders and champions, those unafraid to challenge, those willing to question the status quo. Others had become so frustrated with the situation presenting itself that they just "did it" and asked questions later.

The purpose of this article is to reflect on leadership and to take inventory of the skills and attributes (some might argue competencies) needed to not only survive but thrive amidst the tidal wave of change occurring in our industry. Using a natural-disaster metaphor might be a little premature for the healthcare system but it helps in examining three key leadership attributes: early warning; preparedness; and skilled and practised response.

Leaders are successful when they make decisions while engaging and exciting people (and the organization) around a common or shared vision of the future. They select from amidst competing interests those options which best satisfy a set of values common to the greatest number of stakeholders and to the environment within which the organization finds itself. They give meaning to personal contributions and permission to celebrate accomplishments. In short, they create an environment conducive to change. They empower, teach, retool and give permission to challenge the status quo. They get power by giving it away.

However, rarely do we get a chance to "practise" leadership. When was the last time you saw a healthcare CEO, board Chair or Minister of Health (not that they are the only leaders in the system) get into a "simulator" and spend an hour grappling with the issues in today's healthcare headline? We won't and never will. The issues of the day in the healthcare system are more enduring than one reporter's run at the Pulitzer or today's anecdote during Question Period. Let's take a quick look at some of the healthcare issues surfacing as we try to reform the system. Here are a few I think our case study contains.

Responding to the Issues in Healthcare

1. Patient-Focused/Centred Care
   
2. Funding
   
3. Restructuring Organizations and Multifacility Arrangements
   
4. Regionalization
   
5. Medical Staff and Other Professional Relations
   
6. Information Technology
   
7. Labour Relations and Human Resources
   
8. Total Quality Management/Continuous Quality Improvement (TQM/CQI)
   
9. Strategic Alliances
   
10. Governance and Management
    
11. Process Redesign and Re-engineering
    
12. Health Services Integration
    
13. Venture (Private-Sector) Capital
    
14. Legislation, Public Policy and Advocacy
    
15. Leadership and Managing Change
    
16. Paradigm Shifts in Healthcare
    
17. Teaching, Education and Research
    
18. Health Services Planning
    
19. Organizational Culture and Design
    
20. Resource Management and Operational Performance

The list above is by no means comprehensive but illustrates that the system is changing and will continue to change with issues and a pace not of our choosing. Whatever the issues, all have common threads: a knowledge base, a process skill and personal style. But whether active or passive, with direction or in a vacuum, leadership is not a spectator sport. Leadership in action is about involvement and the risk of participation. I often refer to an axiom I once heard about leadership: A successful leader takes a group of people to a destination that they would not have imagined possible and once there, they cannot imagine ever returning to their departure point.

Getting There from Here: How Do You Measure Up?

I believe that leadership results from opportunity: most people have the capacity to be a leader if the right conditions exist. Finding the "winning" combination of conditions for our leadership to surface becomes the challenge. It is not an intellectual exercise, although leadership is assisted by knowledge and experience. However, I do believe that we can become better leaders with practice and the ability to recognize and incorporate leadership characteristics when we run into them. We can also immerse ourselves in "target rich" environments and learn from leadership mentors.

Let's assume our list is representative of the agenda ahead. What will successful leaders bring to the table? In their book The Leadership Challenge (1987), Kouzes and Posner outline five key attributes of leadership: challenging the status quo, inspiring a shared vision, enabling others to act, modeling the way, and, encouraging the heart. The attributes they link to successful leadership are similarly characterized by Nadler and Nadler in their work, Champions of Change (1998). These and other popular management treatises contain variations on a consistent theme: successful leadership is linked to successful change management.

The leadership checklist was developed for those fortunate enough to have a role in the design, management and celebration of our new healthcare system. (For actual competencies, readers might want to refer to the CHE Competencies Document published by the Canadian College of Health Service Executives.) Not intended as a recipe for success, this list should be a source of reflection, like the opening scenario, to assess personal strengths and weakness for incorporation into a plan for lifelong professional learning. There is no "silver bullet" in leadership development; rather, it is the consequence of a variety of variables interacting with a compendium of skills, grounded by experience. But I believe that leadership proficiency is linked to three broad categories of attributes: knowledge, skill and personal style. I also believe that no one style is durable: styles must be both balanced and responsive to the needs of the situation.

Conclusion

All organizations have formal and informal leadership roles within them. In the traditional sense, most management positions contain leadership activities and responsibilities relating to the departmental employees, colleagues or teams for which they are responsible and accountable. But leadership has far more opportunities to manifest itself: teams, steering groups, work teams, task forces, projects and studies. The current list of issues facing these incumbents is well beyond "standard operating procedure" and the situation is not "business as usual." This fertile reality has placed unprecedented demands upon leaders and opportunities for leadership at all levels within organizations and the system as a whole. These demands are more than process and content: they include real-time leadership under the stress of fundamental change. The issues are many; the solutions elusive.

The imagery and anecdotes about a system under siege are commonplace. However, there is nothing common about the leadership skill sets and behaviours needed for success. I believe one attribute of leadership is to periodically take stock of both the environment within which we are expected to function and the skills and experience we can bring to bear. I hope that the scenario, quick inventory of issues, and skills checklist I've presented here will assist readers in assessing their leadership skills and educational plans and, perhaps, in opening dialogue with their colleagues.

The success of the reforms shaping the Canadian healthcare system will not be measured by the dollars saved, efficiencies gained and people displaced for those are transient measures. It will be gauged by the sustainability of the new steady state (if there will be one). In either case, there is no better opportunity for leadership, both in what we do and how we do it. For, from amidst the noise and chaos, there will be those who will rise to the occasion and will be successful. Leadership is about change and change is about leadership. Are you ready?

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