Insights January 2015

Healthcare Leadership Contradictions

Dr. Graham Dickson and Hugh MacLeod

Dr. Graham Dickson joins me on the “balcony of personal reflection.” There is a growing appetite in healthcare today for a more decisive and action-oriented form of leadership, a leadership that demonstrates a deep commitment to justice, equality and citizen engagement. In order to survive and thrive in this new environment, leaders must respond to this prevailing public sentiment while focusing unwaveringly on the purpose and reasons for them to be leading in the first place.

The Ghost of Healthcare Hope emerges…

“The key question that healthcare leaders need to address is… what do healthcare consumers need and how can the system respond? But while the question is simple, the issues that need to be addressed are complex. Executives, managers, professionals and front-line staff developed their careers in a silo-centered, bureaucratic model of healthcare delivery, driven by the provider’s control of health services, not the consumer's perception of value and need.

In command and control hierarchies, behaviour is honed to operationalize one’s formal authority. In order to actualize future-focused sustainability within healthcare, leaders will need to model, exercise, emphasize, develop and promote new collaboration skills.

Significant change cannot occur unless leaders, both formal and informal, empty out the models, assumptions and directives that no longer have merit or meaning. When leaders remove the debris they will be rewarded with the necessary space that allows for new vision and ideas. This form of purging requires discipline and courage. Leaders must be disciplined enough to resist knee-jerk reactions and bring courage to separate old patterns, structures and processes which have become obsolete.”

Organizations and health systems are a web of relationships, conversations and decisions between people. Transformational leaders recognize that the healthcare organization is not its organizational chart. Organization charts are frozen photos in time with rigid turf boundaries. Organizational structures are as dynamic as the external environment around them. The key is tapping into the white spaces, the webs of relationships not seen on the organizational chart.

Before leaders can see the future state, they come to understand the underlying values, beliefs, attitudes and power dynamics held by interest groups, professional bodies, community agencies and citizen groups including patients. With this understanding, the old expression “you cannot see the forest for the trees” takes on a new meaning. Transformational leaders see the trees and the spaces between the trees and the surrounding flora and fauna. Successful leaders admit to themselves that they do not have all the “answers”: they are motivated to ask the right “questions.”

Questions asked focus on accountability, self-reflection, honesty and purpose. Examples include: What results do you want to create to make the healthcare system realize its purpose, as a patient, an individual, a team and as an organization? What will that future look like, its vision for achievement? What relationships will you have to build to do it? How is what you are doing right now helping you get there? What is hampering you in achieving this now? What are you afraid of losing? What might you gain by doing something differently? How will you work with others to adopt the changes in practice that are necessary?

Asking the right questions also breaks the ritual conversations that take place. Leaders ask the right questions at the right time. The key is in framing of the question: the timing of its asking, in a manner that creates commitment to continuously learn and improve. At a fundamental level, every individual across our complex healthcare system has the potential to undermine or create successful system dynamics at any point in time and at every transition of patient care.

The following contains a number of contradictions (different perspectives or ways of seeing the healthcare world). For simplicity, we have divided contradictions into three categories:

1. Systemic Contradictions

The dynamics of technology, the rapidity of changes in the external environment and burgeoning medical challenges associated with a society of abundance versus scarcity has changed the game of leadership. Social media, just-in-time decision-making, the explosion of knowledge and a media-dominated public discourse has altered the balance of power between formal leaders, the consumer public, and governments. Collective decision-making is in a context whereby dialogue and discourse is conducted in an open marketplace and fuelled by ever-changing information that is both enhanced by those circumstances and impeded by them.

Leaders appear to be caught up in a society that is going through a tectonic shift of distribution of leadership responsibilities between formal and informal leaders. Barbara Kellerman called this, “the end of leadership,” referring, of course, to the diminution of trust and acceptance of formal leadership in society. We live in a time where large-scale reform is possible, yet due to the same factors, difficult to achieve. It is almost as if the abundance of the system impels the parts of that system to bolster their independence, while at the same time, the nature of the problems that need to be solved require the exact opposite: interdependence.

Constantly “shifting sands” of policy environments create a number of contradictions that leaders must deal with. Indeed, change itself is the ultimate contradiction: between our aspirations for the future, and the gap between those and our current state. Social media, news media, the internet, and medical technology have sped up the ability to acquaint people with the problems that need fixing (hence the demand for change in healthcare) and some of the technological solutions have not yet been systematically harnessed by the health system to solve them (except in isolated cases).

Efforts to regionalize service delivery across vast geographical regions are possible due to the virtues of modern communication and information technology. Without a commensurate knowledge of how to use that technology for its promise, and without the funds to buy it, a disconnect emerges. We understand the virtues of regionalization, but are contradicted by our inability to create it.

Another contradiction that emerges in the socio-economic context is the contradiction that is created between the formal leader in the health system and the informal consumer leader. In modern society, the informal leader can marshal knowledge and information and share it like a virus, sometimes creating mass movements galvanizing public support for specific health issues. While not supported by the authority and resources of a formal leader, they are also not constrained by policy and procedure.

Just watch the news to see the multitude of disease-specific or case-specific advocates gaining access to the public. Formal leaders may in fact wish to do similar things, but are hamstrung by policies, procedures, ethical guidelines and privacy laws that are artifacts of an age where knowledge was scarce. They don’t have the luxury of singular focus: they need to maintain a focus on all aspects of the system on a day-to-day basis and resist being whipsawed by the variations of public opinion. Informal leaders often are spurred by passion and common sense; they are not hamstrung in their vision by policy, procedure, rule of law, et cetera, and due to that very same freedom to act, can access the media when their case is compelling (and controversial). They also bear no responsibility for overall system performance, advocating solely for their area of personal interest. Contradictions arise when the two remain separate and isolated and don’t find ways to work together to create innovation in the system.

2. Practical Contradictions

Practical contradictions are also legion. First there is the operational versus strategic contradiction. As service delivery entities get larger, senior leaders need to act more strategically, and pay less attention to operational demands: the very demands in which they excelled prior to be being promoted into those senior positions.

A second contradiction is that large-scale change takes time whereas the current turnover of leaders and the realities of the existing political process do not provide that time. It is little wonder that clinicians and mid-managers who are committed to an organization or community for the long term feel that they can “wait out” the demands for change that come from the top.

A third is the tension between the collective accountability required of distributed leadership and the individual accountability of designated leadership. We are all well aware of our individual accountabilities relative to our designated role, but are we willing to be accountable for our collective results that are a consequence of our ability to work as a member of a team?

A fourth is the contradiction inherent in dealing with the ever-increasing number of individuals who need care (e.g., co-morbid conditions) because the system has been so successful in treating them, and the reluctance of the taxpayer to fund the requisite expansion of services.

And finally, there is the professionalism contradiction: professionals who want to retain their independent professional status, and who have professional organizations to protect it, while at the same time having to be partners in the health reform process, a partnership that requires flexibility in terms of changing those professional practices. Current patterns of structure, culture and politics within the Canadian health system reinforce an operational focus, short time frames for decision making, and designated accountability. Countervailing structures, cultural values and political actions need to be found to redress the balance.

3. Personal Contradictions

The third set of contradictions is personal contradictions. Change demands that leaders and followers change their behaviour. The sheer number of contradictions that we have described suggest myriad behaviour changes for leaders: being better systems thinkers, strategists, communicators, coalition builders, information experts, team-builders and servant leaders, and the list goes on and on. But each behaviour change is a discrete act of both will and corresponding action.

Behaviour change illuminates the first human contradiction: how does one find the reflection and practice time in a very demanding environment in which demands are insatiable, and that mitigates against these very actions? And given this circumstance, how much behaviour change can any individual take on?

Leaders seem to find themselves in a place where their intellect tells them that they have to create significant reform to be relevant, and that they also have to master a whole new array of skills to be successful at doing so. Yet their emotions may tell them that to take the time to learn new skills, or unlearn behaviours that are no longer desirable, but which got them to a pre-eminent position, leaves them vulnerable. Is it surprising that letting go of what one knows and does well to grab onto something that takes will and effort to develop and may never be done well gives such leaders pause?

Another personal contradiction is the ego altruism paradox. Serving the patient, having a common vision dedicated to quality patient care, motivates many a health leader. However, when to do so means giving up something in their self-interest, e.g., remuneration, independence, clarity of role and/or status, then the demands of the ego can come into conflict with the demands of public service.

We wonder if it is consistently easier to go with the ego as opposed to altruism, because if structural and cultural factors reinforce self-gratification, then to deliberately deny oneself those benefits for altruistic purposes can ultimately wear any leader down over the length of a career.

The tension between independence of leaders and interdependence of leaders, represented by individualistic versus distributed references to leadership also creates contradiction. Almost by definition, a leader requires a follower. But in a distributed leadership approach, who is the follower? Or does the term not make sense in that context? Is follower another term for anyone who is not in a formal leadership position, or someone who, regardless of role, simply does what he or she is told?

Distributed leadership is a euphemism for the sharing of a leadership role amongst formal leaders, informal leaders, doctors, clinicians and consumers that assigns to each a temporary responsibility in that constantly shifting locus of control, depending on situation and circumstance, and whose influence is required to maintain momentum for that change. But what does that look like in practice, and how does it affect learned notions of responsibility and accountability? Will formal leaders “give up power and control” to informal leaders (e.g., employees, clinicians, consumers) in the best interests of the change process? Distributed leadership is an admirable concept but a difficult one to operationalize.

The Ghost of Healthcare Hope returns…

I imagine a future photo album of healthcare leadership that includes these snapshots:

  • Leaders are always a work in progress. They know their strengths and limitations and commit to self-reflection and improvement. They understand and display self-awareness, self-regulation, motivation, empathy, and social skills. They demonstrate integrity in their role and context, and show resilience in challenging situations.
  • Leaders enable people to engage with a vision or goal through stories and explanations that make sense of complexity. Leaders encourage others to see and accept opportunities to contribute, learn and grow.
  • Leaders are people who work to make a difference. They set a direction that is inspiring and motivating, they enable energy and effort to succeed, and they keep their eye on the goal. They work with compassion to influence the quality and safety of care and the sustainability of the system.
  • Leaders see innovation in health is not just for a new product. It includes fundamental changes to business and models of care to achieve people-centred quality services. They are passionate that there is no STATUS in the QUO.
  • Leaders are continually asking how can we together meaningfully tap into a culture that encourages the expression of the intellect, passion, commitment and experience of front-line staff and patients to make real changes that satisfy healthcare consumer needs and expectations.
  • Leaders recognize the importance of the connection between patients, care providers and the organization and that failure to connect leads to passive-aggressive behaviour which creates and consumes negative energy, creating a sense of hopelessness, squandering funds through inefficiencies and above all defeating any vision of creating a patient-centred system.
  • Leaders embrace healthcare as a complex, evolving system where all the parts, including services, legislation and funding, are interconnected. A change in one part has implications for the whole. Leaders who recognize patterns of interdependency are able to explain trends and facilitate strategies that achieve maximum benefits and minimize unintended harm or negative consequences.

Born in an environment rife with those contradictions, and with the express purpose of helping leaders to tackle them, the LEADS in a Caring Environment capabilities framework was created. It provides a customized By Health, For Health framework for responding to a growing need for a concerted, coherent, and sustainable strategy for strengthening healthcare leadership capacity in a complex system. The LEADS capabilities framework features five domains: Lead Self, Engage Others, Achieve Results, Develop Coalitions, and Systems Transformation. Each of these five domains consists of four core, measurable capabilities.

Deep down, leaders know, no matter what position they occupy in a group, a team or organization, that sooner or later they are going to be put to the test. To handle this circumstance, which is simply the test of one’s past complacency, one’s current certainties, and one’s ambitions (conscious and unconscious), leadership fortitude may need tempering. Begin with the question: “What do healthcare consumers need and how can the system leaders respond?”

Join my next guest Dr. Ron Lindstrom in a conversation about getting a grip on complexity.

See essays in this series.

See essays from series 2

See essays from series 1

About the Author(s)

Dr. Graham Dickson, Professor Emeritus, Royal Roads University.

Hugh Macleod, Concerned Citizen.


MacLeod, H. and M. Davies. 2013. “Conditions Leaders Influence”, Longwoods Ghost Busting Essays.
LEADS Collaborative, “LEADS in a Caring Environment Capabilities Framework.” Available at Brochure.
Kellerman, B. 2010. Lecture, Harvard University, John F Kennedy School of Government.
MacLeod, H. 2014. “Are We Prepared To See and Leverage The Grey Zone”, Longwoods Ghost Busting Essays. 


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