Insights

In 2012 Hugh MacLeod, CEO of the Canadian Patient Safety Institute, published a series of 24 Ghost busting essays (“Ghost busting – Series 1”) on healthcare leadership which sparked interest from a broad readership. The series provided a rich pool of powerful ideas for what is needed to implement and sustain transformative leadership, and offered a unique resource to guide development of an implementation framework for system improvement leadership. To capitalize on the call to action implicit throughout the series, we have conducted a thematic analysis to identify key implementation principles for transformational leadership. The synthesis was not designed to map emerging themes onto the LEADS Leadership Framework, nor was the Ghost busting series of essays designed to extract or expand upon items from LEADS, yet the overlap between the two was striking.

The purpose of health policy, funding and services is to improve health outcomes. Focusing on leadership is consistent with this purpose, for according to a recent Health Council of Canada report, leadership is the primary enabler of organizational and system performance (Health Council of Canada 2013). Leadership “supports and provides momentum to move actions toward attaining health system goals” (Health Council of Canada 2013, p. 24). Leaders are accountable for system performance, but true system performance is achieved only through collective accountability for outcomes. Leadership not only needs to be implemented in ways that focus on improving health outcomes, but also to change what the health system is held accountable for.

From the Ghost busting series a clear message emerges that the future of Canadian healthcare is in the hands of leaders throughout the system to shape.  The health system is complex, not merely complicated. As such, it requires an approach to implementing leadership consistent with complex systems: one size does not fit all, there are no simple cause and effect relationships, and a focus on the whole is necessary to achieve our intended outcomes. Viewing the series with a complex systems lens, five guiding principles emerge for implementing leadership to achieve sustainable health system reform. 

1. CLARITY OF PURPOSE

Canada has hundreds of healthcare networks, regions, institutes, councils, agencies, foundations, etc., and thousands of independent health service delivery agents – all operating relatively independently. Rather than a “system,” there is a set of publicly financed interlocking federal, provincial and territorial insurance plans. 

Under the current system, when faced with high-level macro design ideas, individuals look for safety within traditional silos. Risk avoidance or protectionist behaviour rules the day. Enormous resources are at our disposal. There must surely be a vast number of leaders within the health system who believe we can provide Canadians with a much better system of healthcare. What is holding us back? 

What is needed is a clear, compelling purpose that reflects our nation’s core health values. This purpose should reflect a functionally integrated system across the continuum of care and be built to achieve its intended outcomes for the people of Canada.

2. ALIGNMENT OF EFFORT

Leaders communicate and listen effectively, and set clear direction for their organizations. These capabilities enable leaders to create structures with clear roles for every person and group within an organization. The result is an effective and functionally efficient organization or system with clear lines of accountability and authority.

If this is our model, ministers, deputy ministers, boards and CEOs, clinicians, and other front line leaders need to work together to develop a shared vision for the future, and to define the roles each must play toward achieving that vision.  

Policy Leaders

As the payer for 70% of all health services, effective governments set the goals for the system and allow managers and providers to implement strategies for achieving those goals at the local level, within a local context. Roles, accountabilities and authorities for action must be clear at every level. Governments that micromanage undermine local authority and accountability for transformation.

Executive Leaders

Senior leaders must let people within their organizations know that they have the freedom to carry out agreed-upon plans in ways that are consistent and resonant with their local context and take on measured risks. Without some risk there is no innovation. Change is the currency of leaders and leadership. Innovation involves adaptations and adjustments that happen at the local level, by people working within those unique contexts. Authentic leaders understand that context matters and allow for the operationalization of goals and culture at the local level. Active engagement combined with leadership tasks (communicate opportunities and risks, encourage broad participation, foster collaboration and give people the freedom to carry out agreed-upon plans) comprise a platform upon which any change process can be built. But executive leaders need to allow these principles to be applied as appropriate within the unique contexts where people work. 

Front Line Individuals

Clinicians and people working on the front lines are in the best position to identify new ideas and understand how goals can be achieved within their local context. Empowering individuals, including patients, to take action is critical for implementing transformative leadership. The implementation of Lean management strategies in Saskatchewan is an example of how individuals in the workplace can be empowered thus enabling efficient, effective and sustainable innovations. 

3. CREDIBILITY OF LEADERSHIP

Transformative leadership requires courage and risk-taking, as well as leading by example. Authentic, credible leaders champion and orchestrate change by taking action and “walking the talk.” Leaders must model the behaviours and values they wish others to emulate (e.g., building relationships, establishing partnerships and building teams, walking the halls, showing empathy).

Leaders have an obligation to identify and nurture people with the capacity and discipline required for driving improvement and sustaining change. Initial efforts and resources should be focused on enabling these individuals – the ones most willing to change – usually representing about 30% of an organization. Others will follow once they see the results. 

Courageous leadership involves sharing control. Leaders set the direction for an organization and communicate its purpose. But actualizing that purpose requires the engagement of everyone. 

Relationships are key. Leadership involves creating opportunities for trusted relationships to develop, making it necessary for people from all levels of the organization to interact to get their work done. Relationships foster increased collaboration, understanding, mutual accountability and trust. Executive leaders must model relationship-fostering behaviour with their peers in other organizations, with individuals throughout their own organization, and with patients and families. 

Senior and middle managers handle issues coming from two directions: executive leaders and the front lines. They can serve as bridges between these different levels, and help facilitate relationship building. Listen to them. Respect their experience. If leaders are self-aware they can demonstrate empathy. Empathy provides a foundation for integrity, trust and quality relationships. Relationships foster better communication that fosters better interconnectedness that fosters networks that foster the emergence of ideas, practices and systems. Thus the “soft” side of healthcare (relationships, organizational culture) mitigates the costs of the “hard” side (crisis management, employee turnover, error rates).  

4. INTEGRITY IN THE ORGANIZATION

Authentic leaders are moral leaders, imbued with an internal ethical compass. Effective leaders align their values with their professional actions, and model their personal and organizational values constantly and explicitly. Failure to do so erodes the credibility of the organization and the leader. Values of high performing organizations align with their goals and incentive structures. Coherence in the system creates space and energy for creativity, innovation and transformation. 

Personal and organizational values are particularly important in contexts that are continually changing, which is the new norm of healthcare. In complex systems, politics, resources, relationships and structures flow in a complicated dance that is rarely predictable. In such an environment strong core values are essential. So too is the need for flexibility and adaptability. For example, a commitment to customer service and/or employee development allow organizations to remain consistently rooted in their core values while continually evolving to meet the needs of a changing environment. 

Successful leaders value and encourage diversity and different points of view. People need to know that their voice counts and feel free to state opinions that may not be shared by everyone. In well-led organizations, everyone feels free to state her or his views. This can be difficult for a leader to accommodate (How much diversity is too much? Where is the line between keeping things moving in the right direction and respecting competing points of view?), but it is fundamental to courageous and effective leadership. The challenge is demonstrating leadership in a way that supports healthy and creative tension between engagement and the need to make tough decisions and set clear direction. When engagement occurs without direction, groups flounder because both purpose and boundaries are unclear. And when direction occurs without engagement, the result is a superficial consensus that saps energy and blocks creativity. 

Embracing diversity also extends to patients. If health systems are viewed as pyramids, patient expectations must be at the top. They are the consumers of healthcare and provide the reason for the system to exist. The purpose of the system is to improve health outcomes. Patients today are better educated and informed. Patients and their families expect greater autonomy and empowerment in managing their healthcare. The only constant factor in all transitions of care is the patient and the power of the patient’s voice is only beginning to emerge. It is time to bring to life what is meant by “family- and patient-centred care.”

5. ACCOUNTABILITY FOR PERFORMANCE

Leaders are accountable for organizational and system performance, but true system performance is achieved only through collective accountability for outcomes. In high performing systems, all stations are involved in the system (clinicians cannot operate outside the networks/accountability structures created by government), and all stakeholders (physicians, other care providers, professional associations, regulatory bodies, government, regional networks, the public – i.e., patients and their families) are allowed a say in all aspects of planning, implementation and decision-making. Everyone feels part of the process and is able to participate in a meaningful way.  

Engagement is also critical for teambuilding and employee satisfaction. People who feel engaged, and see how they contribute to the purpose of the organization, tend to work harder and are more productive. For employees who are not engaged in this way, the research shows that productivity suffers. Achieving a caring culture, one that embraces employee commitment (as opposed to culture of compliance), also reduces employee cynicism.

Transformation involves aligning micro-level adjustments or adaptations with macro-level mandates and policies. Transformational change most readily occurs when individuals can see how they contribute to achieving the organization’s purpose, and when that purpose is reinforced every day throughout the organization. Meaningful participation of employees requires dedicated time and financial resources. Yet “meaningful” participation will look different from one location to another due to context (i.e., history, relationships, power distribution, etc.). Meaningful participation also requires valuing diverse viewpoints.

Accountable leaders require both assessment and evaluation to measure meaningful results. However, it is critical to measure that which is meant to be achieved and not just results. Successful leaders help people understand the linkage between what they do and the measures of progress on organizational goals. 

Accountable leaders also align measures with the organization’s values. In her 2012 report “Measuring What Matters” Ann Snowdon found that Canadian values (what consumers of healthcare value in their healthcare system, such as patient engagement and partnership with healthcare providers) do not match the standard dashboard of organizational metrics (e.g., costs, medication errors, mortality rates) (Snowdon et al. 2012). That which is measured gets done. Yet “there is no link between costs and outcomes of health care, such as quality of life, collaborative partnerships with providers, or community empowerment. Thus, there are no direct incentive models or performance measures to account for health system outcomes that align with the values of health, wellness, or quality of life for Canadians” (Snowdon et al. 2012).

Short-term feedback loops maximize opportunities to learn, change and improve from experience. However, a note of caution is prudent here as well: creating new measures/metrics without giving emerging system dynamics a chance to grow and mature may promote unintended conflicts, gaming of the system or changes in priorities without initial priorities being given a chance to be achieved. Balancing the need for meaningful measurement tied to values, with the acknowledgement that measures must be appropriately developed, timed and interpreted, is a challenging yet critical task for today’s leaders in health.

Leader accountability involves sustaining a caring culture, moving from the current culture of blame and finding scapegoats to one of mutual support and learning. For many people, scapegoating helps compensate for feelings of inadequacy and fear. Overcoming the temptation of scapegoating takes self-confidence, wisdom and effort.

It is critical to acknowledge that failures happen to everyone and that they provide learning opportunities. But failures must be analyzed in order to capture the lessons they illustrate. This involves collecting enough information that root causes can be assessed and changes made. The “black boxes” used by the aviation industry record all actions, discussions and decisions to aid in the assessment of what happened when things go wrong. They offer a good model for healthcare, but only if the use of this information is limited to assessing what happened and why, and not for use by prosecutors for litigation.

A CALL TO ACTION FOR LEADERSHIP IMPLEMENTATION

Ultimately, effective and transformative leadership is about sharing control and dispersing both accountability and authority throughout organizations and systems, thus creating the enabling conditions for leadership to be transformative. The power of relationships cannot be overestimated. By engaging others in developing the system’s purpose, and enabling others to see the part they play in achieving that purpose, leaders provide self-perpetuating guidance for the organization (or system). A clear purpose or vision for the health system is currently lacking. This is the first order of business for today’s health leaders.

Part of the process of developing a clear purpose for the health system may involve following a recommendation of the Snowdon report: “Align health system values with Canadians’ values” (Snowdon et al. 2012). This offers the opportunity for having Canadians see themselves in the larger vision for the Canadian health system. 

In addition to providing a clear purpose or vision, transformational leaders encourage, model and create opportunities for relationships to form and be maintained. A clear purpose with agreed-upon goals reduces the emergence of sub-agendas that can lead to siloing and turf wars. Strong relationships help foster communication that leads to the creation of networks and emergence of new ideas, practices and systems. But strong relationships can only thrive in an environment/culture of trust and respect. Authentic leaders value diversity of perspective and opinions.

Credible leaders model the values and purpose of the organization. High performing organizations reflect these values and its purpose at all levels. People in such organizations feel free to speak up and identify conflict/disconnects/inconsistencies. Everyone shares accountability for achieving the organizational purpose and is imbued with the personal authority to take action. It is up to today’s health system leaders to lead with integrity, to model the values and purpose of the system in every aspect of their work, and to encourage such behaviour at all levels of the organization.

The series also highlights five guiding principles for implementing leadership to achieve sustainable health system reform. These principles articulated above are all interconnected. Successful leaders cannot focus on one or two at the expense of the others – implementing effective leadership requires the development and practice of all of them. They become self-perpetuating and self-sustaining. 

Along with adhering to these principles, the leadership path for healthcare system transformation requires a self-awareness of one’s current mindset, a readiness to change and, finally, a change of mindset in the following areas: 

1. Relationships. I don’t have to know everything if I trust the others. This is important because: If I am committed to being trustworthy myself and take responsibility for building relationships that model this behaviour, others will deliver for me.
2. Identity. I understand and am committed to what is in this for us … not just for me. This is important because: I must see myself in the vision. Without a feeling of personal connection, I will feel a need for control based on fear.
3. Information. I openly share information as a tool for relationship building. This is important because: Accurate information must be the air that we breathe, and the more open the flow the more easily we can convert data into meaningful knowledge.
4. Realizing Our Collective Potential. We cannot do it alone. This is important because: To maximize our effectiveness we must take advantage of the unused skills, talents and potentialities of everyone in the organization, and overcome the intellectual, emotional and systemic barriers in the way of creating a truly healthy learning organization.

Today’s health system leaders must not only lead well but also lead differently. That means accepting a shift in the drivers of the health system from care providers to consumers, from hospitals to primary/home and community care, and from an emphasis on downstream/acute care to upstream/preventive and wellness factors.

Can these changes be made? Clearly the transformation that the Ghost busting series #1 discusses represents a challenge. However, the integrity, intelligence, commitment and courage of Canada’s leaders in health are evident, at least amongst those working to create sustainable change within the system. The reflections of front line practitioners and patients in the Ghost busting series #2 may present a different but equally important perspective on leadership in the health system. We would be advised to consider carefully their words of wisdom, experience and advice as we move forward.

Canada’s health system CEOs have an opportunity to provide the strategic thinking that political leaders can’t or won’t provide, and work together to create a new collective vision for health in Canada. If today’s leaders don’t do it, it won’t be done. There is an opportunity before us to reform the Canadian health system to achieve its purpose of improving health outcomes, and to do it better than any other system in the world. The skills, power and passion required to meet this challenge today are present in abundance … so let us begin.

Ghostbusting Essay Series Titles

About the Author

References

Snowdon, A., K. Schnarr, A. Hussein and C. Alessi. Measuring What Matters: The Cost vs. Values of Health Care. International Centre for Health Innovation, Richard Ivey School of Business, The University of Western Ontario. London, Ontario. November 2012