Insights April 2015

We Have A Glimpse Of The Future...Leadership Capacity Is Crucial

Graham Dickson and Hugh MacLeod

Graham Dickson joins me once again on the "balcony of personal reflection." We begin our conversation with this hypothesis...something happens to a number of formal and informal leaders when they join healthcare. It’s as if the “Emergency Room” syndrome infects them all. Rather than see a system, plan for patient care in a broad context, or invest in long term strategic thinking, they get caught up in crisis management. If they acted in their social family network as they do at work, they would have no pension, no vacations, no education plan—but they would solve all the immediate family crises that came their way. And maybe create some to be relevant, too.

We ask you to pause and remind yourselves that, within your context, within your organizations you have all the people gifts you need to move forward. Every individual has the capacity to contribute to healthcare transformation. But to do so means being able to put that change in a large system, long term context. Every individual that is part of the system carries the seeds of success: skills, talents, potentialities and enthusiasm. Unfortunately for many front line care providers and patients the same seeds also contain too many intellectual, emotional and systemic barriers in day-to-day operational challenges. Leaders – all of us – need to take action and nurture the growth of those seeds that will allow for change to a patient-centred, connected system over time.

The Ghost of Healthcare Hope arrives...

"Hugh, in a recent essay titled “World Cup and Posing The Wrong Questions” you made this comment...'Soccer, like healthcare, involves a lot of running around often without clear outcomes. Games are usually low scoring. Recent global studies suggest Canada scores low on multiple indicators. Fans, the customers take the game of soccer seriously. To the point there are riots in the stands by those backing one team. Our healthcare customers are passive but becoming restless. Our healthcare players have become experts at passive aggressive behaviour to protect the status quo. Healthcare has various interest groups calling for either the saving of Medicare or the scrapping of it. Redesigning a healthcare system with its complex organic properties, powerful interest groups, political game playing, is more challenging than the transformation of the auto sector, housing sector and the financial sector combined."

You have challenges and you have a glimpse of what the future holds: an aging population and workforce combined with a significant change in the ethnic and linguistic character of society. In addition, the pace of change combined with the introduction of new drugs and new technologies will continually test our human capacity to deliver safe quality care...enough talking, reading and studying - it is time for a sense of urgency.

My hope is aggressive and committed leadership action from care providers, management, executive and board leadership in healthcare organizations; and from government, but sustained over time. Like seeing soccer not just from an individual game perspective, but from a long term world cup perspective. Committed leadership action anchored by prudent and future focused policy to drive expectations, with leadership action from above and below.

You are at a social, economic, emotional and philosophical, healthcare crossroad. In this emerging scenario of accelerating healthcare change, complexity and uncertainty, an effective healthcare leader needs to understand and act with self-confidence and a sense of personal mission, purpose and direction, both operationally and strategically.

Health System Redesign Research Project

A recent Leadership and Health System Redesign Research Project that involved Graham as Principal Investigator and I as Co-Chair of Canadian Health Leadership Network (CHLNet) confirmed the need for immediate “action to build leadership capacity, particularly strategic leadership capacity". The project was stewarded by a network comprised of senior decision makers under the auspices of the Canadian Health Leaders Network (CHLNet) and representatives of the health leadership research community from nine universities across Canada.

The purpose of the project was to help develop leadership capacity in the Canadian health system through applied research and knowledge translation. The intention was to build a bridge between researchers and leaders in the field of leadership, and in so doing, inform leadership practice through knowledge generated through a rigorous research design. A participatory action research method was used to generate that knowledge over a four-year, longitudinal case study approach. What follows are excerpts from the final report which can be found on the CHLNet website.


Specific objectives were to:

  1. Create an evidence-base of the qualities that leaders use to address critical health challenges successfully;
  2. Translate existing knowledge of what comprises effective leadership in different organizational contexts into improved leadership development approaches;

  3. Explore effective means to develop and sustain leaders at all stages of their career; and

  4. Develop a set of national standards for leadership.

Research Questions

Three research questions guided the study:

  1. What is the current state of health leadership capacity in Canada? What is working, or not working, in terms of stimulating and supporting health system transformation, and what contextual factors influence effective leadership action?
  2. Where are the gaps between current practices, the evidential base in the literature, and the expectations for leadership outlined in the emerging health leadership capability/competency frameworks (e.g., LEADS capabilities framework), and how might a set of national standards for leadership be structured?

  3. How can knowledge of effective leadership be translated and mobilized by the network into approaches, programs, tools and techniques to develop a culture of effective leadership in Canada, and enhance the development of quality health leaders?

Methods & Measures

To answer the research questions, a longitudinal participatory action research (PAR) approach was employed (three cycles over two years: overall project, four years in duration). The research was exploratory and interpretive, aimed at helping leaders and health researchers to understand the deeper meaning and challenges associated with leading health reform. The longitudinal method recognized the ongoing, iterative development of understanding leadership of change and its dynamic manifestation through time, circumstance and situation.

Leadership Capacity

Data suggests that Canada does not have the leadership capacity that is required to lead health reform. Capacity challenges are not due to a single factor, but to a confluence of factors. They are:

  • Creating large-scale change requires levels of systems thinking, strategic thinking, relationship development, and self-leadership that supersede the current capacity of many formal leaders. Day-to-day crisis management and operational demands, coupled with little opportunity to develop these skills, mitigates coordinated strategic action.
  • Quality physician leadership—at all levels—is required for reform to be successful. Physician leadership is sporadic and variable. Physician leadership capacity can be engendered through exemplary practices of physician engagement throughout the system.

  • Political dynamics and regular turnover among ministerial, senior policy, public service, executive and organizational leaders impede achievement of large-scale change over time. The short term imperatives of a democratic political process and the diminutive time span of many senior leaders in a particular role makes long term change difficult.

  • Collective leadership capacity requires alignment of thinking and action amongst formal leaders that challenges conventional notions of autonomy, accountability, and collaboration. Change demands that leaders who don’t usually work together must do so over long time periods. Sustained coalitions require interdependence that is contrary to conventional practice.

  • The ongoing need to expend energy to overcome factors that impede change—structural, cultural, and political—are draining the capacity of Canada’s leaders faster than that capacity is being rejuvenated. The fragmentation of the system drains energy because of the immense effort required to bring the parts together for change.

Reinforcement of Leadership Literature and National Standards

  • The research reinforced some basic leadership concepts found in the literature. Trait leadership, distributed leadership, substitutes for leadership, and complexity leadership were strong themes. Some support for the constructs of authentic and transformational leadership (closely related) and servant leadership arose.
  • Results showed a continued reliance in many parts of the health system on hierarchical, heroic leadership models. However, formal leaders no longer have the same power or privilege as before. Informal leadership is also emerging.

  • Patient-centred health reform is increasingly complex and interconnected yet the forces of fragmentation—political dynamics, turnover of leaders, constitutional and organizational structure, and the diverse interests of organized professional organizations—prevent alignment of effort.

  • Leadership of health reform requires striking the right balance between centralization and decentralization, formal and informal leadership, individual and collective accountabilities and authorities, organization and system performance; and alignment of effort across boundaries.
  • Our current individualistic leadership cannot sustain large scale health reform. Shared, distributed models with an understanding of associated authorities and accountabilities need to emerge. As a consequence, there would be value on a more strategic focus being brought to bear on systematic succession planning and leadership development.

  • The LEADS in a Caring Environment framework was referenced in many cases as having potential as a foundation for the above-mentioned succession planning and leadership development needs.

Knowledge Mobilization

  • Individual and organizational effort to translate and mobilize knowledge and best practices of effective leadership in Canada is ad hoc and peripatetic. This is a contributing obstacle to sustained, positive health system reform.
  • Both collective and individual approaches to creating a better bridge from the research world to the policy world are required. The research literature suggests, for instance, that systematic leadership talent management (e.g., succession planning and leadership development) are sound organizational investments in this regard.

  • Informants suggest there should be increased focus on succession planning and leadership development. There is a need to develop and support new innovation pathways to affect a coordinated national approach to leadership development, although local efforts must continue. Canada appears to under-invest in knowledge translation. Post-secondary institutions should play an integral part in this function.

Six Key Findings

This study has several key contributions to make to guide future efforts at health system renewal. Six key findings are highlighted here for further consideration.

  • First, all change initiatives studied were severely compromised by the constant churn of leaders at the political and senior administrative levels.
  • Second, engagement at middle and front line manager level was much weaker than what political and senior administrative leaders assumed.

  • Third, sustaining focus was very difficult in all cases studied and in large part was due to the churn of senior leadership bringing along new priorities and directions. But in addition the fragmented Canadian system makes it difficult to sustain change efforts when different messages and priorities are generated by different provinces and national agencies.

  • Fourth, while there is general recognition that the health system needs to be viewed and function as a complex adaptive system, a lack of systems thinking and hierarchical approaches are still the dominant tendencies.

  • Fifth, there is a significant lack of attention on leadership and leadership development. Generally even those persons who saw themselves as key leaders spent little time in self-reflection on their leadership approach.
  • Sixth, and related to the above is the need for a particular focus on physician leadership.”

The Ghost returns...

"I hope for the following:

  • Demand more strategic leadership from governance, and senior leadership. For example, a long term vision for healthcare into the future; efforts to address a lack of real attention and action to local, regional, provincial and national variations in practice through serious evaluation from a behavioural perspective and organized system-wide, will cross-fertilize change and become a recipe for above-standard care.

  • A need to stop convincing yourselves that the remedy is more money, more technology, more staff and look within ourselves and our organizations for the courage to change over time through prolonged, sustained effort.

  • You all use the term “continuum of healthcare,” what about a reframing to “continuum of leadership interaction and connection” involving those we rely on to deliver the service to patients / residents?

  • Give people reasons to follow. A vision with clear long term measurable results. After all, healthcare organizations are organic structures, patterns of energy, webs of relationships, conversations and decisions between people. What keeps the patterns alive is the valuing of people – the spirit and oxygen of healthcare organizations. But those people—like sailors on the ocean—need navigational tools to achieve their desired goals.

  • Embracement of values and ethics to guide the development of relationship patterns."

Daniel Goleman author of Emotional Intelligence, puts it this way: “The single most important factor in maximizing the excellence of a group’s product was the degree to which the members were able to create a state of harmony…as knowledge based services and intellectual capital become more central to corporations improving the way people work together will be a major way to leverage intellectual capital, making a critical competitive difference.”

Healthcare reform requires “a state of harmony” over time: the true challenge of strategic leadership. My guest next week is Professor Alan Best in a conversation about leadership, white space and mindsets.

See essays in this series.

See essays from series 2

See essays from series 1

About the Author(s)

Graham Dickson (PhD) is Senior Policy Advisor to the Canadian Health Leadership Network, Research Advisor to the Canadian Society of Physician Executives, and a member of the Health LEADS Collaborative in Canada. Dr. Dickson, with Bill Tholl, authored a book entitled LEADS: Bringing Leadership to Life in Health Care, published by Springer Publishing in the UK, in January 2014.

Hugh MacLeod, is founder of Global Healthcare Knowledge Exchange. Concerned and engaged citizen.


MacLeod, H. (2014). World Cup and Posing the Wrong Questions. Longwoods Essays

Dickson, G., Tholl (Ed.), and B., Baker, G. R., Blais, R., Clavel, N., Fletcher, A., Gorley, C., Grimes, K., LeBlanc, D., Lindstrom, R., Marchildon, G., McPhee, M., Mills, S., Philippon, D., Power, C., and Solberg, S. (2014).  Partnerships for Health System Improvement (PHSI) Leadership and Health System Redesign Cross-Case Analysis Final Report. Retrieved from Canadian Health Leadership Network ( ).

Kernaghan, G. & Grimes, K. (2014). Health Leadership Action Plan. Retrieved from the Canadian Health Leadership Network ( ).

Lazar, H. Lavis, J., Forest, P-G., Church, J. (2014). Paradigm Freeze: Why it is so hard to reform health-care policy in Canada. McGill-Queen’s University Press: Montreal.

Macleod, H. (2014). Back to the Future - What Have We Learned About Ourselves. Longwoods Essays.

Goleman, D. (1995).  Emotional Intelligence .Bantam Books.


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