Leadership defined for our generation and the next
Jaason M. Geerts, PhD
The evolving nature of how health care is delivered in Canada requires effective complex adaptive systems, which depend on capable leaders, including physicians. Understanding the core concepts of “leadership,” “leaders,” and “team members” is the foundation for the “great task of our generation,” which is creating and leading the kinds of systems needed to meet the opportunities, challenges, and uncertain future of modern health care. Based on a literature review and consideration of theoretical and practical implications, three definitions are provided, along with discussion of their composite terms. Leadership is a process that involves leaders and team members collaborating meaningfully to realize a shared vision. Leaders are individuals who take responsibility and accountability for this process, and team members contribute to it intentionally. These definitions support models of shared and distributed leadership and informal leadership, as well as recognizing the importance of diversity. Management and power are also addressed, as are the implications for organizations, leaders, and team members.
KEY WORDS: leadership, leader, team member, follower, system transformation, management, power
The evolving nature of how health care is delivered in Canada presents unprecedented opportunities and challenges, as well as an urgent need for effective leadership.1-5 The many examples of centralization at the provincial, regional, and multi-site health network levels have led to shifts in governance and organizational structures, which require enhanced coordination of personnel, services, and resources. Similarly, health care environments and organizations are increasingly being understood as complex adaptive systems, in which advanced capabilities and processes are needed to lead effectively.6-9 Recent technological innovations provide unique opportunities for quality improvement; however, they can be expensive and challenging to implement department- or system-wide.10 Tightening budgets and an unsustainable rising cost of care confound efforts to achieve the “triple aim” of health care provision.8,11 The triple aim began as a quality improvement framework that simultaneously involves striving to improve population health, the quality of patient care and patient experience, and access to and affordability of care.12,13 Top
To maximize opportunities in modern health care in the face of these tensions and challenges, system transformation, evidence-based change management strategies, and — most important — effective leadership are essential.8,14,15 Effective leadership is a significant determinant of improved clinical outcomes in health care organizations,16-18 as well as financial performance.19-21 It is important that this leadership is demonstrated by all health care professionals,22 including physicians, as effective physician leadership has been associated with improved patient care and hospital performance.3,4,23-29 Physicians hold many formal and informal leadership roles in health care organizations, they influence how a substantial portion of organizational resources is allocated, including through prescribing treatment and medication, and they play a crucial role in driving improvement initiatives.15,30 These are some of the reasons that physician engagement and leadership are vital to system transformation in health care organizations.19,28,31
Harvard surgeon and author Atul Gawande summarizes our point in health care history, from a physician’s perspective:
We have now found treatments for nearly all of the tens of thousands of conditions humans can have and we’ve reached the point where we’ve realized, as doctors, that we can’t know it all. We can’t do it by ourselves… [consequently], making systems work is the great task for my generation.32
“Making systems work” is only possible with competent physician leaders as champions, who collaborate with other health care leaders and team members.1-3,11 Understanding the core concepts of “leadership,” “leaders,” and “team members” is the foundation of the noble and challenging work that our generation is tasked to undertake. These concepts are also important to define amid discussions of distributed leadership and flatter organizational structures, informal leadership, followership, and the prospect of facing uncertain and “alternative futures” in a health care context.33 Top
The following definitions are the result of a literature review, including grey literature, and consideration of the theoretical and practical implications of each component of the definitions. The three definitions are presented together initially, followed by elaborations on, and implications of, the composite elements of each.
Leadership is the process of leaders and team members collaborating meaningfully to realize a shared vision.34
A leader is anyone who takes responsibility or is ultimately accountable for the process of realizing a shared vision in a given situation.34
A team member is anyone who collaborates intentionally in the process of realizing a shared vision. 34 Top
Leadership is the process of leaders and team members collaborating meaningfully to realize a shared vision.34
Leadership is understood as a process that is broader than a person or position and implies activity, whereas “relationship” (with followers) and “capacity” do not necessarily. For example, a situation in which a positional leader (person and role) and a follower (in a professional relationship) do nothing for a prolonged period does not appear to characterize leadership adequately, even if the pair have the capacity to act.
There are two essential roles in leadership: leaders and team members, both of which contribute to the leadership process intentionally. This implies that team members are not blind followers, ignorant to the overall purpose and direction, nor are they coerced to participate. Including both leaders and team members in the definition also avoids a common mistake of defining leadership by simply describing what a leader does,35 which is similar to restricting a definition of “education” to the actions of a teacher. Top
The term “collaborating meaningfully” suggests that each person’s contribution to the process is important and valued. This concept is similar to a theatre production: even if actors only have two lines, when it is their turn to speak, the entire momentum of the play rests on them. This is especially pertinent given the team nature of much of current health care delivery.
Finally, the collaboration of leaders and team members is directed toward creating a future reality that resonates with each of them. This is supported by an organization’s mission, which is its day-to-day mandate that is intended to lead to the vision. In health care, a vision ideally has care for patients, families, and communities at its heart.36 For example, the vision of St. Joseph’s Health Care, London, is: “We earn complete confidence in the care we provide, and make a lasting difference in the quest to live fully.”37 Top
The vision of the future aspect of leadership distinguishes it from management, which, at its core, strives to make current operations more coordinated, effective, and efficient.38
A leader is anyone who takes responsibility or is ultimately accountable for the process of realizing a shared vision in a given situation.34
This definition reinforces the notion that being a leader does not depend on holding an official title or position and supports the concept of informal leadership. This is not, however, to negate the importance of formal positions. The efficient and effective operation of organizations depends, at least in part, on established roles and accountabilities. Consider an orchestra without a conductor, for instance. Top
It is also important to differentiate between formal and informal leadership, as there are distinct advantages and challenges associated with each. For example, informal leaders tend to take the lead only when the opportunity suits them, whereas formal leaders are inevitably responsible for all problems facing the organization, whether they prefer to handle them or not. Informal leaders tend not to have an abundance of resources at their disposal and must establish their own social capital to influence others, whereas formal leaders normally have more substantial resources and positional authority, often with the ability to impose consequences for non-compliance.39
Consequences for non-compliance are characteristic of management, rather than the inspiration aspect of leadership described above. Power, as the opposite extreme of leadership, often used synonymously with “authority,” is understood as the ability to force others against their will to achieve one’s ends, whether that force is exercised or not.39- 41 To illustrate the distinction, management is like a contract: one enters into it freely, but once agreed upon, one is subject to its conditions, an example of “voluntary coercion.” Prison and military dictatorships are examples of power where authority figures impose conditions and mandates on others without giving them the option of refusing, which can involve total coercion. Although in practice, the distinctions among the concepts of leadership, management, and power are not always clear and, in many ways, they can overlap, one differentiating factor among the three is the degree of inspiration versus coercion leaders or authority figures use to achieve their goals. Top
The definition of team member above also means that as the leadership process advances, people can alternate between leader and team member at different times. This flexibility enables the most suitable people to lead in a given situation and affords those with diverse skills and backgrounds opportunities to lead, which they might not have in a rigid hierarchical structure. Recent work on the importance of diversity and its effect on team and organizational performance reinforces this fluid approach to leadership roles.42
The factors that determine who is assuming leadership roles are taking responsibility and being accountable for the process in a given situation. Responsibility and accountability can generally be assumed by the same person or they can be shared. For example, speakers at a conference function as leaders by virtue of leading their sessions; however, the conference chair is also a leader by being ultimately accountable for the quality of the event and content presented. Understanding leadership this way, versus simply as what a leader does, is conducive to models of shared and distributed leadership. Top
Five fundamental leadership capabilities are implicit in our definition (note: this is not an exhaustive list of key leadership capabilities):
A team member is anyone who collaborates intentionally in the process of realizing a shared vision.34
“Team member” is preferable to alternatives, as it values the person in a way that “subordinate” does not, for example,41 nor does omitting them from the definition of leadership. This term also values the contribution of each person by implying that each plays an important role, as every member of a sports team does. The definition also states that team members are aware that they are contributing to the leadership process and do so willingly, rather than passively or blindly, which “follower” could suggest. Finally, this understanding implies that all team members identify with, and share in, the vision. Top
It is not necessary to select a term for members of an organization who are not inspired to identify with the vision and simply come to work each day and tacitly comply, nor for others who may disagree with the organization’s vision or strategy but decide not to object explicitly and instead reluctantly comply. The implication of the definitions presented here is that leaders and team members should endeavour to creatively engage others and encourage them to collaborate meaningfully to realize the shared vision, without oversimplifying the issue of how to prioritize one’s time and energy among colleagues according to their degree of engagement.
In summary, these three definitions suggest that although there are differences in the roles of leaders and team members, mainly concerning accountability, instead of focusing on dividing people dichotomously into two groups, what is most important is appreciating that leadership is an ongoing collective effort to realize the vision. Leadership is rarely a simple process and is often laden with challenges that exceed the scope of this article to address. This is intended to be the philosophical foundation for understanding leadership. Nuances, limitations, and best practice examples of the real-world application of these definitions, particularly in the context of health care organizations, can be discussed in a subsequent article. Top
Implications for organizations
The first implication of these definitions for organizations is that leadership is a continuous process that ideally involves the active collaboration of everyone in the organization,43,44 not a behaviour exhibited by the few who hold official positions. Total engagement of all staff is not presented as the expectation or norm, but rather the goal to which organizations aspire on an ongoing basis.
A second implication is the importance of striving to ensure that the organization has a vision that is shared among all stakeholders. Within the larger vision, departments or teams can create customized visions to reflect their unique role. Inspiring others to contribute meaningfully to realizing the vision is a key leadership function. The leadership process is enhanced when a clear organizational strategy is in place, especially one that is informed by input from multiple stakeholders. This strategy can be reinforced by an organizational culture that expects individuals and teams to take the initiative to realize the shared vision and that supports and celebrates them when they do. This includes encouraging them to experiment with innovative ways to achieve their goals in a safe and supportive environment. Top
Large-scale innovation can be expensive and time-consuming, and advocating it does not ignore the value of alignment of effective system-wide protocols and processes. Innovation can simply refer to creatively finding ways to realize the shared vision, including in individual instances at point-of-care, within the organizational structure. Furthermore, in a complex adaptive system, the ability to innovate is vital.45,46 The more people in an organization who develop effective leadership skills and experience and are prepared and encouraged to use them, the greater the overall organizational capacity and adaptability. When these organizations also promote and support innovation, they become more resilient and able to implement change and system transformation more effectively, as the culture facilitates these processes. This understanding of leadership also demonstrates a recognition that diversity (of people and leaders) leads to better overall performance.
Finally, organizations can demonstrate the value they place on leadership by incorporating it explicitly into regular staff performance evaluations, recruiting, development opportunities, promotions, and succession planning. Although beneficial, this degree of alignment takes time to generate, particularly in larger organizations or in those that have deeply entrenched existing structures. The concept of learning organizations suggests that investing in increasing organizational capacity and system-wide cultural alignment is worthwhile and leads to improved engagement, adaptability, and performance.47-49
In summary, regardless of their role(s), when people genuinely believe in the importance of an organization’s vision, can see themselves in it, feel that they contribute meaningfully to realizing it, and feel supported, then performance, engagement, morale, and job satisfaction increase. Top
Implications for individuals in formal positions
Those in formal positions must remember that leadership does not happen automatically by virtue of one’s title or position; it requires inspiring others and other capabilities. Leaders are responsible for engaging team members to share in the vision, partly by involving them in its creation when possible. They also focus on motivating others to contribute meaningfully, as well as explicitly celebrating these contributions, especially in direct reference to how those efforts advance progress toward realizing the shared vision.
These definitions also prompt leaders to consider the extent to which they are inspiring others to collaborate, versus relying on managerial consequences to orchestrate alignment. Leaders are additionally charged with setting the strategy and consulting multiple stakeholders to design or refine it. Finally, leaders should champion and promote an organizational culture that encourages everyone to experiment with innovative ways to realize the vision and that endorses leadership at all levels.35,43 This involves not only enabling others to take responsibility as leaders, but trusting and supporting them to do so, which builds their capacity and adaptability. This understanding also distributes leadership; respects and encourages diversity of people, ideas, and approaches; and flattens the hierarchy, while still maintaining the accountabilities of positional leaders. Top
Implications for individuals not in formal positions
Those who are not in formal positions find uncommon advocacy in this understanding of leadership, and they and their organizations stand to benefit significantly as a result. There is a recognition that team members and informal leaders are typically the ones who, often at the point of care, make their organization’s vision a reality for patients and other stakeholders. The implication of the definitions is that anyone can be a leader by taking responsibility in a given situation for an aspect of the leadership process. From this perspective, every team member and leader is valued and their roles are affirmed as being necessary to realizing the vision. Top
Team members should consider how they see themselves in the vision and how they can most meaningfully contribute to realizing it. They are responsible for collaborating with leaders, providing input into the strategy, and offering or experimenting with new ideas and innovations.50 These tasks are also associated with “followers,” who are defined as “individuals who adopt the leader’s goals temporally (e.g., following someone’s directions to a place) or structurally (e.g., accepting someone’s positional authority) and freely accept the influence of leaders.”51,52 The definitions allow for situations where team members can immediately transition to a leadership role by taking responsibility for an initiative and, in fact, imply that they are expected to lead in this way whenever appropriate. A final implication for team members is that they are key players in creating and sustaining the desired organizational culture by encouraging colleagues to contribute meaningfully and innovate and by celebrating and supporting these efforts. Top
In summary, for organizations, positional leaders, informal leaders, and team members, the essentials of leadership are individually and collectively making meaningful contributions to realizing the shared vision, which is aligned with the strategy and supported by a culture that encourages experimentation, innovation, and taking responsibility for the leadership process.
Despite the exciting nature of leadership in terms of future possibilities, leadership cannot exist without management and the follow through that management can provide. Leadership, in its purest form, involves leaders and team members who are so inspired that they self-manage. Although this is the ideal to which organizations can strive, it is important not to be impatient with instances when progress is dubious or team members are not meeting expectations. Leaders and team members can best serve their organizations by leading by example,53 encouraging their colleagues to lead, celebrating instances of success, and continuing to promote a supportive culture with an unwavering commitment to the vision with the confidence that results will come. In addition to results, these efforts have the potential to lead to the kind of increased organizational capacity and adaptability needed to face the future opportunities, challenges, and “alternative futures” in health care, as well as “making systems work.” Top
If it is true that, in health care, the great work of our generation is to make systems work, then certainly effective leadership, including by physicians, is essential. It is important to begin with a clear understanding of leadership, as well as the roles of leaders and team members, in the process of realizing a shared vision. In health care, this vision must be patient- and people-centred to achieve the triple aim. It should also be understood that realizing this vision requires the active collaboration of leaders and team members, a strategy informed by multiple stakeholders and a culture that encourages and supports efforts to make the vision a reality. This is the task, challenge, and opportunity for our generation and the next, which the philosophical foundation presented here is intended to enhance.
1. Murdock J, Brammer C. A successful model of leadership development for community practice physicians. Physician Exec 2011;37(2):52-6.
2. Rose S. Better leadership for tomorrow: NHS leadership review. London: Department of Health; 2015. https://tinyurl.com/y3596e6u
3. Tasi MC, Keswani A, Bozic KJ. Does physician leadership affect hospital quality, operational efficiency, and financial performance? Health Care Manage Rev 2017;11 Jul. DOI: 10.1097/HMR.0000000000000173 Top
4. Goodall AH. Physician-leaders and hospital performance: is there an association? Soc Sci Med 2011;73(4):535-9. DOI: 10.1016/j.socscimed.2011.06.025
5. Naylor D, Girard F, Mintz J, Fraser N, Jenkins T, Power C. Unleashing innovation: excellent healthcare for Canada. Report of the Advisory Panel on Healthcare Innovation. Ottawa: Health Canada; 2015. https://tinyurl.com/y357e2es
6. Devlin R. Hallway health care: a system under strain. First interim report from the Premier’s Council on Improving Healthcare and Ending Hallway Medicine. Toronto: Ministry of Health and Long-Term Care; 2019. https://tinyurl.com/yyhr7w6f
7. Pype P, Mertens F, Helewaut F, Krystallidou D. Healthcare teams as complex adaptive systems: understanding team behaviour through team members’ perception of interpersonal interaction. BMC Health Serv Res 2018;18(1):570. DOI: 10.1016/j.pec.2017.06.029
8. Stoller JK. Developing physician leaders: does it work? BMJ Leader 2019;in press.
9. Hannah ST, Uhl-Bien M, Avolio BJ, Cavarretta FL. A framework for examining leadership in extreme contexts. Leadersh Q 2009;20(6):897-919. DOI:10.1016/j.leaqua.2009.09.006
10. Lee TH, Hall KW. Turning doctors into leaders. Harv Bus Rev 2010;88(4):50-8.
11. Stoller JK. Developing physician leaders: a perspective on rationale, current experience, and needs. Chest 2018;154(1):16-20. DOI: 10.1016/j.chest.2017.12.014
12. Farmanova E, Kirvan C, Verma J, Mukerji G, Akunov N, Phillips K, et al. Triple Aim in Canada: developing capacity to lead to better health, care and cost. Int J Qual Health Care 2016;28(6):830-7. https://doi.org/10.1093/intqhc/mzw118
13. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood) 2008;27(3):759-69. DOI: 10.1377/hlthaff.27.3.759
14. The IHI triple aim. Ottawa: Institute for Healthcare Improvement; 2019. https://tinyurl.com/kjckxv6 (accessed 15 Mar. 2019).
15. Denis JL, van Gestel N. Medical doctors in healthcare leadership: theoretical and practical challenges. BMC Health Serv Res 2016;16:158. https://doi.org/10.1186/s12913-016-1392-8
16. Mountford J, Webb C. When clinicians lead. McKinsey Q 2009;(February):1-8. https://tinyurl.com/y7msgpr4
17. McAlearney AS. Executive leadership development in U.S. health systems. J Healthc Manag 2010;55(3):206-24.
18. Husebø SE, Akerjordet K. Quantitative systematic review of multi professional teamwork and leadership training to optimize patient outcomes in acute hospital settings. J Adv Nurs 2016;72(12):2980-3000. DOI: 10.1111/jan.13035
19. Spurgeon P, Mazelan P, Barwell F. Medical engagement: a crucial underpinning to organizational performance. Health Serv Manage Res 2011;24(3):114-20. DOI: 10.1258/hsmr.2011.011006 Top
20. Bloom N, Sadun R, Reenen JV. Does management matter in healthcare? Working paper. London: London School of Economics; 2014:1-30. https://tinyurl.com/y25c2ms2
21. Sarto F, Veronesi G. Clinical leadership and hospital performance: assessing the evidence base. BMC Health Serv Res 2016;16(suppl 2):169. https://doi.org/10.1186/s12913-016-1395-5
22. MacPhail A, Young C, Ibrahim JE. Workplace-based clinical leadership training increases willingness to lead. Leadersh Health Serv 2015;28(2):100-18.
23. Castro PJ, Dorgan SJ, Richardson B. A healthier health care system for the United Kingdom. New York: McKinsey & Co.; 2008. https://tinyurl.com/ycoraznf
24. Candace I, Giordano RW. Doctors as leaders. BMJ 2009;338:b1555. doi: https://doi.org/10.1136/bmj.b1555
25. Dwyer AJ. Medical managers in contemporary healthcare organisations: a consideration of the literature. Aust Health Rev 2010;34(4):514-22. DOI: 10.1071/AH09736
26. Falcone RE, Santiani B. Physician as hospital chief executive officer. Vasc Endovascular Surg 2008;42(1):88-94. DOI: 10.1177/1538574407309320
27. Stoller JK. Developing physician-leaders: a call to action. J Gen Intern Med 2009;24(7):876-8. doi: 10.1007/s11606-009-1007-8
28. Bohmer R. The instrumental value of medical leadership: engaging doctors in improving services. London: King’s Fund; 2012. https://tinyurl.com/y4tzl66l
29. Baker GR. The roles of leaders in high-performing healthcare systems. London: King’s Fund; 2016. https://tinyurl.com/y4flonku
30. Daly J, Jackson D, Mannix J, Davidson PM, Hutchinson M. The importance of clinical leadership in the hospital setting. J Healthc Leadersh 2014;6. https://tinyurl.com/y2dj89xm
31. Spurgeon P, Long P, Clark J, Daly F. Do we need medical leadership or medical engagement? Leadersh Health Serv 2015;28(3):173-84.
32. Gawande A. How do we heal medicine? Long Beach, Calif.: TED Talks 2012;28 Feb. https://tinyurl.com/y62jmg7y
33. Waddell K, Moat KA, Lavis JN. Preparing emerging leaders for alternative features in health systems across Canada. Evidence brief. Hamilton: McMaster Health Forum, McMaster University; 2019. https://tinyurl.com/y6jrwjcm
34. Geerts JM. Optimal leadership development for professionals. PhD thesis. Cambridge: University of Cambridge; 2018. https://doi.org/10.17863/CAM.23159
35. Van Aerde J. Physician leadership development. Edmonton: Alberta Health Services; 2013. https://tinyurl.com/y6krft7y
36. Jones S, McCay L, Keogh SB. The importance of clinical leadership. In: Swanwick T, McKimm J, editors. ABC of clinical leadership. Chichester, UK: BMJ Publishing Group; 2011:1-3.
37. Vision, mission, and values. London: St. Joseph’s Health Care; 2018. https://www.sjhc.london.on.ca/missionvisionvalues
38. Northouse PG. Leadership: theory and practice. London: Sage; 2006. Top
39. Heifetz RA. Leadership without easy answers. Boston: Harvard University Press; 1994.
40. Bass BM. Bass and Stogdill’s handbook of leadership: theory, research, and managerial applications. New York: Free Press; 1990.
41. Kellerman B. The end of leadership. New York: Harper Collins; 2012.
42. Tekleab AG, Karaca A, Quigley NR, Tsang EWK. Re-examining the functional diversity–performance relationship: the roles of behavioral integration, team cohesion, and team learning. J Bus Res 2016;69(9):3500-7. https://doi.org/10.1016/j.jbusres.2016.01.036
43. Dalakoura A. Differentiating leader and leadership development: a collective framework for leadership development. J Manag Dev 2010;29(5):432-41. DOI: 10.1108/02621711011039204
44. Peters L, Baum J, Stephens G. Creating ROI in leadership development. Organ Dynamics 2011;40(2):104-9. DOI: 10.1016/j.orgdyn.2011.01.004
45. Heifetz RA, Grashow A, Linsky M. The practice of adaptive leadership: tools and tactics for changing your organization and the world. Brighton, Mass.: Harvard Business Press; 2009.
46. Uhl-Bien M, Marion R. Complexity leadership in bureaucratic forms of organizing: a meso model. Leadersh Q 2009;20(4):631-50. https://doi.org/10.1016/j.leaqua.2009.04.007
47. Vassalou L. The learning organization in health-care services: theory and practice. J Euro Ind Train 2001;25(7):354-65. https://tinyurl.com/y5a36hjd
48. Ravichandran N, Mishra R. Toward building HR competencies: a shift from the non-learning toward the learning organization. Int J Healthc Manag 2018;11(3):233-8. https://doi.org/10.1080/20479700.2017.1336835
49. Senge PM. The fifth discipline. Measur Bus Excellence 1997;1(3):46-51. https://doi.org/10.1108/eb025496
50. Yukl GA. Leadership in organizations. New Jersey: Prentice Hall; 2010.
51. Bastardoz N, Van Vugt M. The nature of followership: evolutionary analysis and review. Leadersh Q 2019;30(1):81-95. https://doi.org/10.1016/j.leaqua.2018.09.004
52. Antonakis J, Bastardoz N, Jacquart P, Shamir B. Charisma: an ill-defined and ill-measured gift. In: Morgeson FP, editor. Annual review of organizational psychology and organizational behavior (vol. 3). Palo Alto: Annual Reviews; 2016: 293-319.
53. Qiu H, Zhang Y, Hou G, Wang Z. The integrative effects of leading by example and follower traits in public goods game: a multilevel study. Front Psychol 2018;9:1687. doi: 10.3389/fpsyg.2018.01687 Top
The work reported here was carried out as part of the requirements for a PhD degree from the Faculty of Education, University of Cambridge.
Jaason M. Geerts, MTS, MPhil, PhD, is currently the manager of leadership and partnerships development, Canadian College of Health Leaders and the project manager for CHLNet of a nation-wide survey on leadership and leadership development in Canadian health care organizations. He is also a visiting fellow at the Cass Business School, City, University of London.
This article has been peer reviewed.