The importance of physician–hospital relations in the Canadian health care system

Atefeh Samadi-niya, MD, DHA(PhD), CCRP

Facilitative leaders ask questions, collaborate, share, consult, and focus on the process of decision-making. This style is replacing the earlier directive or autocratic approach, and physician leaders are eager to acquire the skills needed to be a facilitative leader. In this first of a series of articles, we describe the facilitative approach and how it relates to quality improvement, leads to healthy dialogue, and transforms the culture of organizations.


Why facilitation and why now?

More than ever before, physicians (and other health care professionals) are yearning for transparent and meaningful engagement with their work that genuinely and safely explores their knowledge, opinions, feelings, and talents. Recently, we were contracted by a group of hospital physicians who are in the midst of transforming their mortality and morbidity rounds into a model that is consistent with quality improvement assumptions and practices. Specifically, the role of “meeting facilitator” has been created for this reconstituted quality improvement exercise, and the physicians were looking for support to help them


  • lead the transition from a culture that focuses on errors, fear, and blame to one of learning
  • create a safe, productive, and comfortable “learning space”
  • be empathic and approachable, less directive and less authoritarian
  • foster team problem-solving and decision-making


We piloted a 1-day facilitation skills program with this physician group, and participant feedback strongly demonstrated the value of this kind of development, at both a fundamental and advanced level. Further design work is underway to help meet these emerging needs.


In addition, we are both certified trainers in Crucial Conversations® and we provide a 2-day program on how to master high-stakes interactions for a provincial medical association. Over the last two years, physician participants at these workshops have emphasized the pervasive lack of healthy dialogue in their organizations and have exhibited a strong desire to change their culture to solve problems and achieve innovative solutions. It has been encouraging to see the majority of participants committed to implementing a new approach to facilitating healthier conversations. In another variation of this same program, which was run as a four-part series, many physicians were able to apply their learning immediately between sessions and reported on significant positive shifts in relationships as well as outcomes. Top


Given the widespread adoption of LEADS in a Caring Environment, a framework of leadership capabilities, across Canada, it seems reasonable that facilitation skills would greatly strengthen the type of leadership that Dickson and Tholl1 define as “the capacity of an individual or group to influence people to work together to achieve a constructive purpose.” The significance of “distributed leadership” or “shared leadership” is also increasingly noted in the literature.


Facilitative leadership is replacing top-down, directive, or autocratic styles. Zimmerman et al2 also noted how important front-line ownership is in fostering resilient safety cultures in health care. This requires a departure from the traditional health care culture where leaders attempt to get buy in from front-line workers and, ultimately, may only succeed in obtaining short-term compliance.


“Facilitation is a way of providing leadership without taking the reins.” Ingrid Bens3 Top












Making it easy

A facilitator is an objective, neutral third party who can guide team members in sharing information, solving problems, and making decisions. Facilitation comes from the word “facile” which is French for easy. The role of the facilitator is to help make information-sharing, problem-solving, and decision-making processes easy or at least easier than if the facilitator is not present.


The facilitator has little or no investment in the outcome of the meeting; rather his or her focus is on helping the team members clarify the meeting’s outcome and then help them manage processes so that they can achieve this agreed upon outcome. The facilitative style of leadership is to ask questions rather than provide answers. Because the facilitator is not there to provide subject matter expertise, the focus is on helping team members contribute to the dialogue in a meaningful and authentic way. Top


Beliefs that underlie the practice of facilitation

The practice of facilitation is grounded in the belief that the members of the problem-solving team are capable of solving problems that affect their work. The role of the facilitator is to help the team members access this expertise. The practice of facilitation is also predicated on the belief that when team members feel respected and safe (to share what is important to them), the team is more likely to achieve its outcome.


Traditional versus facilitative leadership

The traditional leadership style is characterized by providing answers; in contrast, the facilitative leader asks questions. The traditional leader believes the correct answer lies within the person with the most subject matter expertise; the facilitative leader believes the correct answer lies in the collective intelligence of the team members. The traditional leader uses his or her expertise to inform the group’s problem-solving and decision-making and will often focus on convincing team members that he or she is right; the facilitative leader has acquired expertise in helping groups share information, solve problems, and make decisions (Table 1).


It is important to note that a facilitative style of leadership it not always preferred. In the event of a crisis, for instance, a traditional style of leadership may be more appropriate. Top


Content and process

All human interaction consists of two components: content and process. Content refers to the “what”: the tasks that need to be accomplished and what is being said. Content is typically reflected in the agenda and includes the meeting goal, the topic that will be discussed, the problem that must be solved, and the decisions that have to be made. Process refers to “how” the task gets completed and includes a focus on how things are being said and on the relations among team members as they go about solving problems and making decisions.


Process includes how constructive relations among team members are built and maintained, including unspoken beliefs, acknowledging group norms, creating meeting guidelines, and the psychological climate of the team meeting. Although these dynamics are rarely referred to in agendas, they have an enormous impact on the way the team does its work and achieves its goals. When people come together to solve problems, facilitators need to pay attention to both of these aspects of human interaction. Top


Because problem-solving and decision-making are the work of the team, the facilitator must create the necessary conditions for team members to share the information that is important to them. This information includes facts and data, but these rarely fully inform decision-making. Also part of team decision-making are the biases, values, assumptions, and beliefs of the team members. The role of the facilitator includes making it safe for people to share these as well, so that the team can make a decision to which everyone is committed.


The practice of facilitation does not require the use of a sophisticated set of skills. Rather, facilitators can be tremendously useful in helping the team achieve its goal by paying attention to, and enabling mechanisms for, three important meeting processes: time keeping, gate keeping, and recording the team’s dialogue.


Time keeping helps to ensure that the dialogue stays on track and gets the task completed. Gate keeping refers to interventions the facilitator undertakes to help balance participation, ensuring that all team members have an opportunity to contribute both their expertise and other perspectives that are important to them. Finally, the facilitator must ensure that a process is in place for capturing the team’s dialogue as it goes about its work of accomplishing its goal. Top


Basic and developmental facilitation

An important distinction in the practice of facilitation is between basic and developmental facilitation. A person who is engaged in basic facilitation is helping a team for a limited period; the facilitator takes a lead role in managing the group process so that the team’s goal is achieved. Developmental facilitation has a different purpose: to help team members manage themselves and their meeting processes with the goal of eventually becoming unneeded.


Key facilitation skills

  • Effective facilitators require knowledge and skills in
  • designing engaging and productive meetings
  • keeping the discussion on track
  • types of decision-making and discerning best fit
  • managing the behaviour of challenging team member


This is the first in a series of five articles on facilitation. In upcoming issues of the CJPL, we will focus on each of these key facilitation skills. Top



1.Dickson G, Tholl W. Bringing leadership to life in health: LEADS in a caring environment. London: Springer; 2014.

2.Zimmerman B, Reason P, Rykert L, Gitterman l, Christian J, Gardam M. Front-line ownership: generating a cure mindset for patient safety. Healthcare Papers 2013;13(1): 6-22.

3.Bens I. Facilitating with ease! Core skills for facilitators, team leaders and members, managers, consultants, and trainers. San Francisco: John Wiley and Sons; 2005.



Monica Olsen is an independent organization development consultant (Olsen and Associates Consulting Inc., Richmond Hill, Ontario). Her current focus is on leadership development in the health care sector through customized education programs, facilitation, and coaching.


Mary Yates is director of the Physician Workplace Support Program, a unique service offered through the Physician Health Program of the Ontario Medical Association. Her expertise is in the area of leadership development, team effectiveness, performance management, meeting and retreat facilitation, human resources management, curriculum design and quality improvement.


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This article has been reviewed by a panel of physician leaders.