A review of the business and philosophy of leadership development leads to a framework for developing the entire basket of skills needed to lead in today’s health care environment. To improve our current state, health care requires an invigorated leadership paradigm, rather than yet another organizational redesign, one that better reflects basic business and philosophy principles. Leadership development must focus less on standardization and more on skill development, judgement, and cultural appreciation, given the variability of inputs and the desired customization of outputs underpinning health care environments. Effective operational leaders maximize sense-making, innovation, relationship building, visioning, and interpersonal communication, attributes represented by the mnemonic and spirit of SERVANTS leadership. Effective change leaders add the softer skills — motivation, teams, and communication — that can be captured in the mnemonic MASTERS. Although the latter implies mastery, it is at one’s peril to forget that, to be a master, one must first, and always, be a servant.
“Science is organized knowledge. Wisdom is organized life.” — Immanuel Kant
Health care delivery is fragmented and chaotic. Systems continue to reorganize — looking for better answers, pushing for more science, promoting best business practices, searching for the next big breakthrough — all under the flag of promoting evidence-based medicine.1 In spite of valiant efforts, it is estimated that only 55% of care in the United States currently meets generally accepted standards.2Top
Interminable organizational redesign cannot continue to be touted as the answer. Instead, it is time to redesign health care leaders. What is needed are leaders who measure performance by patient outcome, apply both financial and behavioural incentives, optimize processes, and re-engineer current dysfunctional cultures — leaders who organize care delivery around the needs of patients rather than providers.3
The current leadership paradigm places heavy emphasis on standardized business management principles, such as process redesign and elimination of waste. However, the business literature suggests that, when inputs are variable (as each patient is variable) and when customers value variation in outputs (individualized medicine), leadership must be less about standardization and more about investing in employee skill development, judgement, and cultural appreciation.4 Input/output variability is the reality of health care environments; unfortunately, such leadership investments are not. Top
Leadership skill development must consider both “leader as manager” and “leader as leader.”5 Managers are the operational stalwarts who deal with the status quo and promote stability; leaders manage and promote change. Managers remove ambiguity; leaders not only tolerate but also at times relish and create ambiguity. Current leadership development is skewed toward development of the skills required to be an excellent manager. To promote a new paradigm, we need skill development focused on change management, judgement, and cultural appreciation
The following is an agenda for developing change leaders. I outline a framework for developing skills needed to be a change leader based on the business and philosophy literature (including suggested resources) and paying special attention to my perspective on top leadership articles from the last 15 years from the pre-eminent business magazine, Harvard Business Review. Top
Skills for leaders as managers — SERVANTS
For operational managers, key skills are focusing, business plans, tactical plans, and process improvement methodologies such as LEAN or Six Sigma. Managers use skills flowing from the Drucker tradition.6 They rely on acquisition and management of content knowledge within extensive networks. They develop and promote habits (repeatable ways of doing things) through practice, in keeping with the dictum that if one does the same thing the same way 10 000 times it will become a habit.
The four most important skills of a leader as manager are sense-making, innovation, relationship building, and vision, in that order.7 Attention must also be directed toward interpersonal communication. These include the “surgeon creed” taught to me by a mentor during residency: the skills required of a good surgeon are availability, affability, accountability, and ability (in that order). There is also great value in transparently considering all perspectives by suspending judgement until one can truly understand the issues and perspectives. This leads to the SERVANTS mnemonic (Figure 1). It also represents servant leadership as advanced by Robert Greenleaf.8 We are ultimately all in service to each other. Although servant leadership has a significant presence in the spiritual world, it has not had significant traction in secular health care environments, even though it applies equally well to the caring professions that make up the health care system. Top
Skills for leaders as leaders — MASTERS
Growth into strategic leadership involves not only acquisition of SERVANTS skills, but also the softer skills of motivation, teamwork, and communication that can be captured in the mnemonic MASTERS (Figure 2). These skills are different and focus on change management, judgement, and cultural appreciation; they are not merely continued enhancement of manager skills. Top
•Macro — Kaplan and Porter9-11 propose that the cost crisis in health care arises from providers’ almost complete lack of understanding of how much it costs to deliver patient care. They suggest that the remedy is neither further medical science breakthroughs nor more governmental regulations, but rather a new way to measure costs and outcomes. Look and understand associations before quickly assuming a cause-and-effect relationship. Some decisions are simple (categorize), some complicated (determinable and repeatable), some complex (deciding changes the landscape), and some chaotic (where to start?). Understand and act accordingly.12
Resources: Kahneman,13 Hume,14 other 17th- and 18th-century philosophers
•Micro — Understand yourself, your preferences, and your decision style. Different leaders lead differently, but can transform.15-17 One can’t purposely change what one does not understand; the only change possible without understanding is destabilization.
Resources: Robbins,18 a Meyers-Briggs, colour profile or similar Top
•Meso — Consider all four drivers of human behaviour: acquisition, bonding, comprehension, and defence.19 The acquire driver, especially financial, often receives preeminence, to the exclusion of others. Consider other acquire drivers, such as prestige and sense of worth. The drive to be part of a high-functioning team (bonding) and the drive to learn and understand (comprehension) are very powerful, often ignored, drivers in health care. The defensive driver of command and control provides short-term success but seldom demonstrates lasting effects. Recent research from social scientists and evolutionary biologists suggests that people behave far less selfishly than most assume, perhaps related to a genetic predisposition to cooperate.
Resources: Social science courses/readings in psychology, behavioural economics, or sociology
•Words you say — Stories are more powerful than statistics in health care. However, for stories to move and captivate, they must be true to you, your audience, the moment, and the mission.21 Harness the science of persuasion.22
Resources: Patterson et al.,23 courses in communicationTop
•Things you do — Not everyone will like you; that is a reality outside your control. However, whether people respect you is within your control as it will depend on how you treat those around you more than what you say. As only one in three change programs succeed, how you treat failure will be more noticed than how you respond to success.24 Treat others as you would like to be treated. Relativism is significant, especially for physicians; it is not just what an individual receives but just as important what other “like” individuals receive.
Resources: Conduct a 360-degree review, through something like the Pulse 360 Program25
Consider becoming the “quiet moral leader” who follows four rules in meeting ethical challenges and making decisions: put things off until tomorrow; pick your battles; bend but do not break the rules; and find a compromise.26 All perspectives should be heard, transparently considered, and balanced. Principles will invariably collide as the urge to “do good” (beneficence: the Golden Rule), not “do bad” (non-maleficence: the Silver Rule), be just, and respect autonomy cannot all be maximized for every situation. Promote justice as fairness to encourage long-term buy in. Walk a mile in someone else’s shoes. Consider that a virtue is the golden mean between two vices (one of excess and one of deficiency) to better understand that some people are just working to get to virtue with a bit more experimentation than you might be comfortable with today; there will be a tomorrow. Very few people wake up in the morning intending to “do bad,” but sometimes it takes a bit of work to discover the intended good.
Resources: Beauchamp and Childress,27 Rawls,28 Aristotle and Sachs,29 any book by Daniels30 Top
Surowicki31 promotes the wisdom of crowds, where in a respectful, non-hierarchical environment, an informed group will outperform the best experts in the group (known in math as Condorcet’s jury theorem). High-functioning teams can be nurtured by carefully managing information signals and reputational pressures.32-34 Such teams commit to and become mutually responsible for a common purpose and performance goals.35 When they make decisions, greater emphasis is placed on the dynamics and motivation of the team while they amass sufficient, rather than maximal, content knowledge.36 Skills include seeing the bigger picture, working within a scope, asking good questions, and treating each other with respect. Physicians and others, who are classically trained as experts rather than team players, struggle at times in such environments.3,37-39
Resources: Surowicki,31 books/articles on generative governance
Everyone — our patients and our providers — has and lives a life narrative. Respect and try to understand others’ narratives. Try different lenses when looking at problems. Be curious. Ask why five times. Think in metaphors on occasion. Think outside the box. Read around rather than about. Medicine is about human beings and the human condition; don’t devote all your time to learning about the science. Forsake the art at your peril!
Resources: Homer,40 Augustine,41 take a language courseTop
The best way to care for patients is to care for and listen to providers. We need to respect and support those who provide front-line care with more than just a pay cheque. Rather than imposing top-down change programs, try “positive deviance,” which is bottom-up and inside-out and encourages change from within by identifying and leveraging innovators.42 Develop emotionally and physically safe, respectful environments for optimal patient outcomes and provider performance.
Resources: Lee,43 religious/spiritual books of choice and one more that you have not read before (the Bible, the Quran, the Book of Mormon, etc.), check out the Greenleaf Foundation website8
When thinking about organizational structures and forming groups, remember that groups of over 150–200 people tend to split into smaller groups. Plan group sizes to accommodate the realities of social networks and social contacts. Individuals will be in multiple groups at the same time. Identify and respect the informal leader of a group; the formal leader will not always be your best ally. Segmentation is a robust tool for understanding and reflecting on how different people require different incentives. Generations — Gen X, Gen Y, or Baby Boomers — are among the most powerful forces in history; although they seem unique, even they follow a pattern.44 Learn about the four Ps and three Cs of marketing. Marketers do this consciously every day. Learn these skills, not to exploit those we manage, but rather to provide contextually appropriate support for those providing and receiving care; we succeed when they succeed.
Resources: Fisher and Ury,45 Lax and Sebenius,46 Logan et al.,47 any of the original writers on social contract (Hobbes,48 Locke,49 Rousseau50), take a course in marketing or advertising Top
Operational managers are essential to any organization. However, they are not change leaders. The skills required for leaders of change — the few who move to the top and provide direction to an organization — are not continued development and enhancement of manager skills. Their skills are different. Change leaders, described by Collins51 as level 5 leaders, have genuine personal humility blended with intense professional will.
Growth of such leaders requires a different kind of training. It involves broadening rather than focusing; respect; valuing and seeking out diversity; pattern recognition; bringing something unique to the table; doing 10 000 different things — not to create habits, but rather to identify and break habits and paradigms blocking needed change. Top
SERVANTS and MASTERS leadership are complementary. Metaphorically they remind us that one must first be and continue to be a servant if one is to take on mastery and leadership. Both reflect the value of strong teams built around respectful diversity channeling all talents for the common good.
Centuries ago, Aristotle maintained that it was not only possible but essential to train leaders to do the right thing, focusing on the cardinal virtues of prudence, justice, temperance, and courage. When talking about the level 5 leader, Collins51 promotes the same qualities, suggesting while some may have the “seed within,” leaders need development based on life experiences. This is virtue ethics.29,52,53 This is servant leadership.8 This is the way forward out of our current paradigm to a better system through better prepared leaders — adventurous, creative, and courageous. Top
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