Volume 6 no 2

Physician engagement, leadership, and wellness

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Physician engagement, leadership, and wellness

Johny Van Aerde, MD, PhD, and Graham Dickson, PhD

 

Physician wellness is a pre-requisite for engaging physicians in shaping health systems of the future. Before reform can occur, physician leaders must address issues of wellness. In this article, we outline steps leaders can take to reduce physician burnout, to grow and sustain physician engagement, and to move to a place of wellness where other physicians can and will take on both formal and informal leadership roles. We also describe how use of the LEADS framework can generate leadership practices that increase wellness and reduce burnout at all levels of the health care system.

 

KEY WORDS: physician engagement, LEADS framework, health system change, physician leadership, burnout, wellness, psychological safety

 

Health care systems world-wide and in Canada are facing significant reform, and physician leadership is key in that reform.1 Yet evidence shows that a critical proportion of physicians are suffering from low engagement and burnout, factors that limit their ability to be healthy receptors of change or to engage as partners in that change.2-4 Indeed, the collective state of physician health has become a significant threat to the viability of the Canadian health care system.3 Physician wellness is a prerequisite for any efforts to engage physicians in shaping health care systems of the future. Physician leadership must address issues of wellness before reform can happen.

 

The challenge is simple: the same physician leaders who would champion change must first address and mitigate conditions and circumstances that forestall physician wellness. To do so, they must recognize that, for many physicians, the path to wellness goes through three stages: diminishing and eliminating burnout, participating in activities and opportunities that enhance engagement, and taking the opportunity to become a physician leader in the cause of reform. This paper deals with how physician leaders, in partnership with other health system leaders, can introduce and take steps to address these concerns. The focus is on wellness, because the presence or absence of mental and social well-being of health care workers either enhances or limits health system performance.  Top

 

In the first part of the paper, we outline steps leaders can take to reduce physician burnout, to grow and sustain physician engagement, and move to a place of wellness where other physicians can and will take on both formal and informal leadership roles. In the second part of the paper, we describe how use of the Canadian LEADS framework (Table 1) can generate leadership practices that increase wellness and reduce burnout at all levels of the health care system.

 

Steps in addressing physician burnout

 

To generate wellness, we must first define it. The World Health Organization (WHO) describes wellness as a state of complete physical, mental, and social well-being.5 In its recent survey on physician health, the Canadian Medical Association defined mental health as a combination of emotional, psychological, and social well-being. In that survey, overall state of mental health was good in 58% of respondents, while 30% were experiencing burnout.3 WHO describes burnout in ICD-11 as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.”5 It is characterized by different ratios of Maslach’s three dimensions: emotional exhaustion, increased distance from one’s job with negativism or cynicism and depersonalization, and perceived or real reduction in professional efficacy.5,6

 

According to the Utrecht Work Engagement Scale,6 vigour, dedication, and absorption result from engagement and are the assumed opposite poles of the three Maslach burnout characteristics: exhaustion, cynicism, and inefficacy.7 Leadership and engagement are at the upper end of the engagement scale, burnout is at the opposite pole (Figure 1). The absence of trust and psychological safety — the belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns or mistakes16 — can lead to apathy and disengagement, further descending to emotional fatigue, moral distress, and finally burnout. When trust and psychological safety are absent, leadership, engagement, and even simple participation are difficult if not impossible. Top

 

Wellness, engagement, and burnout are multi-level issues

 

There is debate about whether the lowest level of engagement is the same as burnout.8 In a meta-analytic study, Goering et al.9 found that “burnout and engagement predict a variety of behavioral and attitudinal outcomes differentially from one another,” a sentiment shared by Sonnetag10 and Prins et al.11 In this context, it is likely better for leaders who wish to address both issues to see them as related but distinct; different strategies and tactics are required to ameliorate both. Whereas individual characteristics, such as perfectionism, used to be viewed as the main reason for burnout, organizational and systemic factors have come to the forefront more recently.12 To generate wellness, offering only resilience programs to individual physicians is no longer sufficient, and leaders must address burnout prevention and wellness using a multi-level approach.

Shanafelt and Noseworthy12 identified drivers that determine interconnections between individual and systemic factors and that leadership can affect to improve wellness: workload and job demands, resources, meaning in work, organizational culture and values, control and flexibility, social support and community at work, and work–life integration. In other words, the main causes of burnout or the factors that could enable and maintain wellness are embedded in the structure and culture of organizations. In addition, there is a demoralizing misalignment between professional values and physicians’ ability to meet each patient’s needs for reasons that appear to be beyond a physician’s control.12

 

Recently, new resources intended to improve health care, such as electronic health records (EHR), have actually reduced the quality of physician–patient interactions, resulting in even more fatigue and feelings of inefficacy, further decreasing the level of wellness and increasing the risk for burnout.13,14 Stress caused by EHR design and use can be aggravated by chaotic clinical environments and lack of workload control.15 Top

 

In short, increasing wellness requires formal and informal leadership at all levels — personal, interpersonal, organizational, and systemic — with nuanced strategies and tactics dependent on whether one is addressing burnout, as opposed to improving wellness or engagement.

 

Whereas Figure 1 illustrates the degrees of engagement for an individual physician, Table 2 reflects the range of organizational cultures of engagement and leadership with their various leadership types, mental models and cultures, relationships, and levels of engagement. The bottom three cultures — toxic at the bottom, moving up through dysfunctional to compliant — emerge from a hierarchical and mechanistic structure, where leadership resides only in formal authority. The top two cultures progress from sustainable, where leadership is distributed and embedded in organizational structures, to generative, an ideal state in which formal and informal leaders co-create the future. The organizational culture chasm implies a gap between compliant cultures (with formal leadership only and limited to no participation by physicians) to those where leadership, formal and informal, is shared by many, leading to trust, wellness, and engagement. Below the culture chasm, one cannot expect people to have the energy and mental fitness to become engaged and creatively participate in transformational changes. Top

 

Psychological safety and well-being

 

Based on two decades of research in organizations in the United States, Amy Edmondson16 has developed frameworks and leadership toolkits that can be used to create psychological safety in the workplace surrounding learning, innovation, and growth. Without psychological safety and wellness the organizational culture chasm cannot be crossed (Table 2), and people will not be able to become engaged.

 

In Canada, the LEADS framework17 has been mapped against the National Standard for Psychological Health and Safety in the Workplace,18 demonstrating that LEADS can be used as a guide to improve psychological safety for all who work in the health care system. Research shows that compassionate leadership is one of the primary factors needed to create a caring environment in healthy workplaces.18 Health care leaders who employ the practices of LEADS will model behaviours that support the desired psychosocial factors of the national standard. In this respect, there is evidence that the leadership quality of immediate supervisors and executives can reduce burnout, improve satisfaction, and indirectly improve patient outcomes.19,20 In one study,19 every one-point increase in leadership score was associated with a 9% improvement in professional satisfaction and a 4% decrease in burnout among frontline doctors.

 

Evidence and return on investment in wellness programs for physicians

 

There are no longitudinal studies on the impact of interventions to prevent burnout or increase physician well-being, and studies on the effect of combinations of interventions at the individual, community, and system level are scarce. However, two articles provide evidence-based reviews and meta-analyses of both approaches.21,22

 

West et al.21 looked at studies of interventions to prevent and reduce physician burnout, including single-arm, pre–post comparisons. Outcomes were changes in overall burnout rate, emotional exhaustion score, and depersonalization score. Of 15 randomized controlled trials, three involved structural intervention in the work environment and 12 were based on individual-focused interventions consisting of facilitated small group curricula, stress management and self-care training, communication skills, and community building. This review also looked at 37 cohort studies, 17 with structural and 20 with individual-focused interventions. Overall, the interventions decreased burnout rate (from 54% to 44%) and significantly reduced emotional exhaustion and depersonalization scores. Although both structural and individual-focused strategies resulted in clinically meaningful reductions in physician burnout, there was no information on a combination of these approaches and no long-term studies.   Top

 

Panagioti et al.22 also looked at individual- and organization-directed interventions in 19 studies with 1550 physicians. Overall, interventions were associated with small, significant reductions in burnout and emotional exhaustion. Subgroup analysis showed “significantly improved effects for organization-directed interventions compared with physician-directed interventions,” suggesting that burnout is more an organizational and systemic problem than individual. The organization-directed interventions that combined several elements, such as structural changes, fostering communication, cultivating a sense of control, and teamwork, tended to be the most effective in reducing burnout. Individual physician-directed interventions led to small but significant improvement, without evidence that content or intensity of the interventions further increased Top

the benefits.

 

Based on these two reviews, Shanafelt at al.23 made a business case for organizational interventions to invest in physician well-being. The authors demonstrated a positive economic effect, improved quality of care, and increased patient safety and satisfaction after changes were introduced to promote physician well-being. Many of these changes comprised elements of leadership and leadership development, as described in the five LEADS domains,17 i.e., Lead self, Engage others, Achieve results, Develop coalitions, and Systems transformation.

 

In “Physician–organization collaboration reduces physician burnout and promotes engagement,” Swensen24 uses three principles to support the Mayo strategy against burnout: addressing people’s psychological needs, developing constructive organization–physician relationships, and sponsoring physician leadership development. He writes, “The effectiveness of frontline physician leadership is one of the most critical ingredients for success. Medical centres need to develop physician leaders who can foster excellence, choice and camaraderie. Leadership development programs send a message that organization–physician partnerships are valued... they build social capital... accrued from trust, cooperation and connectedness of individuals and groups.” These statements indicate that physician leadership development underlies the essence of Swensen’s principles. Shanafelt et al.23 further add that “Commitment from executive leadership is the prerequisite, assessment the first step, and frontline leadership a force multiplier.” From the work of these frontrunners in the field of burnout, physician leadership and wellness seem to be going hand in hand.   Top

 

In short, burnout reduction has been associated with organization-directed wellness initiatives, with weaker evidence for programs geared toward individual physicians.

 

Embedding physician engagement, leadership, and wellness in organizations

 

The articles discussed above focus primarily on addressing the challenges of burnout rather than generating higher levels of engagement, the next step in creating wellness. For this step, the Spurgeon model for engagement is helpful.

 

Spurgeon et al.25,26 studied what engages physicians in leadership and later also reflected on the fourth of the Institute for Healthcare Improvement’s quadruple aims (provider well-being)27 and its effect on quality of care.25,26 The Spurgeon model includes two dimensions: individual capacity, which reflects skills leading to increased self-efficacy and personal empowerment to tackle new challenges; and organizational opportunities reflecting structure and the cultural conditions that help physicians become more actively engaged in leadership activities (Figure 2). Top

 

While improving individuals’ ability or capacity increases “can do,” organizational opportunities increase personal motivation and “want to do.” When some conditions are missing, physicians can feel powerless, frustrated, or challenged. Spurgeon showed that medical engagement is positively associated with organizational quality,25,26,28 which has resulted in better outcomes, such as lower mortality rates and fewer patient safety incidents.25,26 Once doctors become systematically engaged and take on leadership roles, the scores for patient experience also improve, as was seen at the Cleveland Clinic.29 Top

 

Although the Spurgeon model25,26 has been shown to improve physician engagement and leadership, organizational outcomes, quality of care, and patient satisfaction, it not yet been used for physician well-being. However, as leadership, engagement, disengagement, and burnout are all part of one continuum (see Figure 1), the Spurgeon model could also be used to improve physician wellness for those who are not in the burnout space.

 

To operationalize the Spurgeon model, the Influencer model can also be applied to enable and maintain engagement at individual, interpersonal or social, and organizational levels.30,31 The Influencer model has been suggested as a way to embed physician leadership development in the structure and culture of organizations,31 but, so far, it has not been linked with physician wellness.

 

The Influencer framework encompasses six sources of influence, i.e., sources of motivation and ability in the personal, social, and structural spheres within organizations. Combining four or more sources of influence increases the chance of maintaining behavioural change tenfold.30 When using this model, behavioural changes linked to the nine strategies delineated by Shanafelt and Noseworthy12 have to be defined, and the six sources of influence have to be used to optimize the chance of improving wellness of physicians and other health care workers.30,31 Top

 

Leadership and LEADS for physician wellness

 

Long-term solutions to improve the wellness of physicians must be implemented and maintained at all levels of health care delivery: individual, interpersonal, organizational, and systemic. A major premise of this paper is that leaders have both the responsibility and the skill set to create the conditions that will minimize burnout, improve engagement, and increase physician leadership. But, like our definition of wellness and our efforts to delineate what comprises burnout and engagement, leadership practice must also be defined. Earlier, the LEADS framework was introduced as a delineation of leadership practices with application at the individual, organizational, and systemic levels of the health care system. It also embraces leadership practices consistent with the Spurgeon25 and the Influencer models.30

 

The LEADS framework provides a set of expectations and standards that can be used both to guide development of leadership skills for the individual physician’s wellness (horizontal axis of Figure 2) and for organizational culture and structure (vertical axis) by embedding the framework systemically. Using practices guided by LEADS will enhance organizational opportunities for professionals to engage in quality for wellness, hopefully contributing to future health system transformation. Top

 

LEADS is a framework for leadership and leadership development, and its 20 capabilities can be integrated with actions to be taken for improving and maintaining physician wellness. In Table3, the nine evidence-based strategies to improve physician wellness and reduce burnout described by Shanafelt and Noseworthy12 and implemented at the Mayo Clinic are aligned with the corresponding domains and capabilities of the LEADS leadership model.17 Each strategy can be implemented using two to eight LEADS capabilities, and the capabilities together can fulfill the needs of the nine strategies. The term capability refers to the ability to work in a complex, multi-level, ever-changing environment, such as in the health care system, in the context of lifelong learning; the term competency refers to the skills and knowledge required to work in a predictable environment.

 

The LEADS framework can be used in three ways to embed physician well-being systemically. The first is for physicians, their peers, and coworkers to actually practise the behaviours implicit in the LEADS domains and capabilities. In doing so, they can model behaviours that support the workplace factors that lead to a culture of well-being and psychological safety. To that end, physicians, physician leaders, and their peers must truly concentrate on learning and demonstrating those capabilities, formally and informally. Top

 

Second, the LEADS framework can be used as a disciplined approach to change for creating psychologically healthy workplaces. Although the first use (above) benefits individual physicians and their teams, this second use is a change management process to support physician and non-physician leaders and help their organizations and the health care system cross the culture chasm into wellness, sustainability, and generative transformation. Although the theory behind each capability will show commonalities for each individual and organization, the practical behavioural implementation is likely to be different.

 

The third use is at the system level and consists in continuing to advance the use of LEADS as a common vocabulary of leadership throughout the health care system, such that practices, initiatives, and solutions based on LEADS can be understood and shared as they are refined for individual system contexts, including physicians.32,33 LEADS can also be seen as a change approach that embraces the “caring” goal inherent in psychological health and safety.34 Top

 

Conclusion

 

Leaders have the responsibility to create change within an environment of psychological health and safety. Physicians must provide the leadership required to generate psychological health and safe environments for their colleagues before such change can happen. For many physicians, the path to wellness goes through three stages: diminishing and eliminating burnout, participating in activities and opportunities that enhance engagement, and taking the opportunity to become a physician leader, formally and informally, in their own right. Top

 

If an organization is already experiencing psychological risks, any change process layered on top of day-to-day tasks can put additional stress on already strained staff, and individuals cannot contribute much if they live below the culture chasm. Achieving organizational wellness requires a sophisticated approach to the process of change management and distributed leadership. In organizations, leaders and physician leaders have the responsibility to steward the change.

 

LEADS can be used as a leadership development framework and as a change management tool to champion the practices that address burnout, as at the Mayo Clinic,12,24 and improve engagement by using the sustainability model based on the Spurgeon25 and Influencer30 models. In doing so, physician leaders can generate wellness for physicians and all workers in the health care system. It behooves all physician leaders to acquaint themselves with the expectations of LEADS and embrace them in practice to create the healthy workplaces that our physicians need to be meaningful partners in health care reform.  Top

 

References

1.Van Aerde J, Dickson G. Accepting our responsibility: a blueprint for physician leadership in transforming Canada’s health care system. White paper. Ottawa: Canadian Society of Physician Leaders; 2017. Available: https://bit.ly/2OfUIj0

2.Shanafelt T, Boone S, Tan L, Dyrbye L, Sotile W, Satele D, West C, Sloan J, Oreskovich M. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012;172(18):1377-85. DOI: 10.1001/archinternmed.2012.3199

3.CMA national physician health survey. Ottawa: Canadian Medical Association; 2018. Available: https://tinyurl.com/ubtd4s3

4.Boudreau R, Grieco R, Cahoon S, Robertson R, Wedel RJ. The pandemic from within: two surveys of physician burnout in Canada. Can J Commun Mental Health 2006;25(2):71-88. DOI: 10.7870/cjcmh-2006-0014

5.Burn-out an “occupational phenomenon”: International Classification of Diseases. Geneva: World Health Organization; 2019. Available: https://tinyurl.com/y3mr2gq9

6.Schaufeli W, Bakker. UWES: Utrecht Work Engagement Scale. Version 1.1. Utrecht: Occupational Health Psychology Unit, Utrecht University; 2004. Available:

https://tinyurl.com/thby5nx

7.Leiter M, Maslach C. Latent burnout profiles: a new approach to understanding the burnout profile. Burn Res 2016:3(4):89-100. DOI: 10.1016/j.burn.2016.09.001

8.Taris T, Ybema JF, Beek I. Burnout and engagement: identical twins or just close relatives? Burn Res 2017;5:3-11. DOI: 10.1016/j.burn.2017.05.002

9.Goering DD, Shimazu A, Zhou F, Wada T, Sakai R. Not if, but how they differ: a meta-analytic test of the nomological networks of burnout and engagement. Burn Res 2017;5:21-34. DOI: 10.1016/j.burn.2017.05.003

10.Sonnetag S. A task-level perspective on work engagement: a new approach that helps to differentiate the concepts of engagement and burnout. Burn Res 2017;5:12-20. DOI: 10.1016/j.burn.2017.04.001

11.Prins JT, Hoekstra-Weebers JE, Gazendam-Donofrio SM, Dillingh GS, Bakker AB, Huisman M, et al. Burnout and engagement among resident doctors in the Netherlands: a national study. Med Educ 2010;44(3);236-47. DOI: 10.1111/j.1365-2923.2009.03590.x

12.Shanafelt T, Noseworthy J. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc 2017;92(1):129-46. DOI: 10.1016/j.mayocp.2016.10.004

13.Shanafelt T, Dyrbye L, Sinsky C, Hasan O, Satele D, Sloan J, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc 2016; 91(7):836-48. DOI: 10.1016/j.mayocp.2016.05.007

14. Gardner RL, Cooper E, Haskell J, Harris DA, Poplau S, Kroth PJ, et al. Physician stress and burnout: impact of health information technology. J Am Med Inform Assoc 2019;26(2):106-14. DOI: 10.1093/jamia/ocy145

15.Kroth PJ, Moriaka-Douglas N, Veres S, Bobbott S, Poplau S, Qeadan F, et al. Association of electronic health record design and use factors with clinician stress and burnout. JAMA Netw Open 2019;2(8):e1999609. DOI: 10.1001/jamanetworkopen.2019.9609

16.Edmondson A. The fearless organization: creating psychological safety in the workplace for learning, innovation, and growth. Hoboken, NJ: John Wiley & Sons; 2019.

17.Dickson G, Tholl B. Bringing leadership to life in health: LEADS in a caring environment: a new perspective. London: Springer; 2014.

18.Dickson G. Transforming healthcare organizations. Healthier workers. Healthier leaders. Healthier organizations. Ottawa: Mental Health Commission of Canada; 2018.

19.Shanafelt T, Gorringe G, Menaker R, Storz K, Reeves D, Buskirk S, et al. Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc 2015;90(4):432-40. DOI: 10.1016/j.mayocp.2015.01.012

20.Shanafelt T, Lightner D, Conley C, Petrou S, Richardson J, Schroeder P, et al. An organization model to assist individual physicians, scientists, and senior health care administrators with personal and professional needs. Mayo Clin Proc 2017;92(11):1688-96. DOI: 10.1016/j.mayocp.2017.08.020

21.West C, Dyrbye L, Erwin P, Shanafelt T. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet 2016;388:2272-80. DOI: 10.1016/S0140-6736(16)31279-X

22.Panagioti M, Panagopoulou E, Bower P, Lewith G, Kontopantelis E, Chew-Graham C, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med 2017;177(2):195-205. DOI: 10.1001/jamainternmed.2016.7674

23.Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med 2017;177(12):1826-32. DOI: 10.1001/jamainternmed.2017.4340

24.Swensen S, Kabcenell A, Shanafelt T. Physician–organization collaboration reduces physician burnout and promotes engagement: the Mayo experience. J Healthc Manag 2016;61(2):105-27.

25.Spurgeon P, Barwell F, Mazelan P. Developing a medical engagement scale (MES). Int J Clin Leadersh 2008;16:213-23.

26.Spurgeon P, Mazelan PM, 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

27.Feeley D. The triple aim or the quadruple aim? Four points to help set your strategy. Boston: Institute for Healthcare Improvement; 2017. Available: https://tinyurl.com/sv2a267

28.Spurgeon P, Clark J. Medical leadership: the key to medical engagement and effective organisations. London: CRC Press; 2018.

29.Merlino J, Raman A. Health care’s fanatics. Harv Bus Rev 2013;91(5):108-16.

30.Grenny J, Patterson K, Maxfield D, McMillan R, Switzler A. Influencer: the new science of leading change. New York; McGraw Hill; 2013.

31.Snell AJ, Eagle C, Van Aerde JE. Embedding physician leadership development within health organizations. Leadersh Health Serv 2014;27(4):330-42. DOI: 10.1108/LHS-04-2014-0033

32.Van Aerde, J. Putting LEADS to work in the health professions. In Dickson G, Tholl B. (editors). Bringing leadership to life in health: LEADS in a caring environment (2nd ed.). London: Springer; 2020. In press.

33.Dickson G, Van Aerde J. Enabling physicians to lead: Canada’s LEADS framework. Leadersh Health Serv 2018;31(2):183-94. DOI: 10.1108/LHS-12-2017-0077

34.Dickson G, Tholl B. (editors). Bringing leadership to life in health: LEADS in a caring environment (2nd ed.). London: Springer; 2020. In press.

 

Authors

Johny Van Aerde, MD, PhD, FRCPC

Graham Dickson, PhD, is senior research advisor to the Canadian Society of Physician Leaders.

 

Correspondence to:

johny.vanaerde@gmail.com

 

 

This article has been peer reviewed.

Top

Health care systems world-wide and in Canada are facing significant reform, and physician leadership is key in that reform.1 Yet evidence shows that a critical proportion of physicians are suffering from low engagement and burnout, factors that limit their ability to be healthy receptors of change or to engage as partners in that change.2-4 Indeed, the collective state of physician health has become a significant threat to the viability of the Canadian health care system.3 Physician wellness is a prerequisite for any efforts to engage physicians in shaping health care systems of the future. Physician leadership must address issues of wellness before reform can happen.

Wellness, engagement, and burnout are multi-level issues

Based on two decades of research in organizations in the United States, Amy Edmondson16 has developed frameworks and leadership toolkits that can be used to create psychological safety in the workplace surrounding learning, innovation, and growth. Without psychological safety and wellness the organizational culture chasm cannot be crossed (Table 2), and people will not be able to become engaged.

The articles discussed above focus primarily on addressing the challenges of burnout rather than generating higher levels of engagement, the next step in creating wellness. For this step, the Spurgeon model for engagement is helpful.

Long-term solutions to improve the wellness of physicians must be implemented and maintained at all levels of health care delivery: individual, interpersonal, organizational, and systemic. A major premise of this paper is that leaders have both the responsibility and the skill set to create the conditions that will minimize burnout, improve engagement, and increase physician leadership. But, like our definition of wellness and our efforts to delineate what comprises burnout and engagement, leadership practice must also be defined. Earlier, the LEADS framework was introduced as a delineation of leadership practices with application at the individual, organizational, and systemic levels of the health care system. It also embraces leadership practices consistent with the Spurgeon25 and the Influencer models.30