Professionalizing physician leadership
Johny Van Aerde, MD, PhD
There is a need to professionalize leadership development in Canada; for physicians, that need has increased with the inclusion of the new role of Leader in CanMEDS 2015. For the health care system, LEADS provides a set of standards for guiding leadership development for each individual health care worker and for all organizations. This paper addresses how to engage physicians in leadership roles and explores what professionalized leadership might look like.
KEY WORDS: physician leadership development, professionalism, physician engagement, certification, LEADS
Optimizing physician engagement
According to Spurgeon et al.,1 physician engagement is a two-directional social process: the organization must reciprocate for the engagement of individual physicians in high-quality care by incorporating opportunities and processes in which they can participate (Figure 1). The model of professional engagement contains two dimensions: individual capacity, which reflects skills leading to increased self-efficacy and personal empowerment to tackle new challenges (horizontal axis of Figure 1), and organizational opportunities reflecting structure and cultural conditions that prompt doctors to become more actively engaged in leadership activities (vertical axis of Figure 1). Depending on what conditions are missing, professionals can feel powerless, frustrated, or challenged. Spurgeon showed that medical engagement is positively associated with organizational quality, including lower mortality.1,2 Once doctors become engaged systemically, the scores for patient experience improve as well, as was seen at the Cleveland Clinic.3 Top
The LEADS framework4 and the Spurgeon model1 can be integrated to engage physicians and other health care professionals. When everyone who works in an organization possesses the necessary skills and is offered opportunities, transformation happens. LEADS provides a set of expectations and standards that can be used to guide both leadership development for the individual physician and the organizational culture and structure by embedding the framework systemically. That embeddedness, e.g., including physicians in governance and offering purposeful committee work and projects, motivates physicians to take on organizational opportunities when they come along because they have the skills to do so. As a result, physician engagement increases and more doctors move into the upper right quadrant of the model. Evidence indicates that increasing the percentage of doctors on boards has a positive impact on organizational performance and patient experience.5 Examples of organizational opportunities include quality improvement initiatives6,7 and incorporation of physicians in the provincial health care governance structure, as in Saskatchewan.8 Top
St. Joseph’s Health Care in London, Ontario, used the LEADS framework when it embedded leadership development programs into its structure and culture for all leaders. For physicians, LEADS capabilities were integrated with CanMEDS competencies, in collaboration with the London Health Sciences Centre and the Schulich School of Medicine & Dentistry. As a result, the organization’s culture is one of ongoing learning and evaluation: LEADS-based self-assessment and 360 evaluations are used to review goals, strengths, and areas for growth, in alignment with templates for role descriptions for all leaders. The evaluations are also used to optimize talent management as part of the organization’s succession planning, all integrated as part of the leadership development culture of the organization. For physicians, the 360 evaluation is aligned with both LEADS and CanMEDS.
To improve physician engagement, the LEADS framework can be integrated into organizations in a way that fulfills Spurgeon’s1 medical engagement model for both dimensions (Figure 1). How could this model be used to professionalize leadership? Top
Professionalized leadership development for physicians and other health professionals
Unlike the professions of medicine and law, leadership has no standardized body of knowledge, core curriculum, or skill set, and there are no generally accepted metrics or qualification criteria. By and large, different individuals and institutions pursue and design their own education paths in a leadership “industry” that consists largely of countless different programs in many different contexts, each claiming to teach how to lead.9
According to Barbara Kellerman,9 markers associated with professional status in medicine and law are:
Education, training, development: knowing, doing, being
There are three different but intertwined elements in leadership learning: education, training, and development. Although these three words have been used interchangeably, they have different meanings. According to the 70/20/10 concept of blended learning, 10% of learning takes place through education in the classroom by knowledge transfer and formal learning.10,11 This is the knowing or expertise component of leadership learning.9 Twenty per cent of learning is acquired through training, by doing, what Kellerman calls experience.9-11 It comprises the practice and acquisition of skills derived from the classroom knowledge, sometimes in simulation situations.12 Those two elements, education and training, reflect learning about what leadership is and are represented by the horizontal axis of the Spurgeon diagram.
The Holland Bloorview Kids Rehabilitation Hospital in Toronto, Ontario, which employs about 1000 people, has developed a 90-minute session for each of the 20 LEADS capabilities. Given that resources, particularly time, are limited, people have welcomed the 90-minute session inside the hospital. Knowledge, relevance, and potential application are explored for each capability in an integrated and real-life fashion, thereby facilitating transition into the workplace. This is where leadership learning programs often stop as learners return to their work environment where the culture is not conducive for ongoing learning to develop leadership skills. Top
If education and training are about what leadership is, then the remaining 70% is about how to lead. This part, the being, should take place in the organization through such action learning as day-to-day activities and problem-solving.10,11 Kellerman uses the term “leadership development” for the individual and “leadership embeddedness” for the learning organization within which the learner works.9 The Holland Bloorview Hospital provides real-time coaching and 360 evaluations for leadership learners to develop each capability in their work environment. St. Joseph’s Health Care also exemplifies an organization that has embedded leadership development into its entire structure and culture, as described above.
It is clear that embedded leadership development and the related organizational opportunities require life-long learning for the individual; for the organization, it means integrated talent management and succession.7 Professionalizing leadership around LEADS capabilities would make talent management consistent across organizations and indeed the entire health system.
The leadership system: leader, follower, and context
Leadership, as a system, is complex and has three components: leader, follower, and context. Although the leadership industry has focused on leaders and leadership, no attention has been given to the learning and development of followers. Yet, we are all followers at certain times and in particular circumstances. Kellerman argues that, besides leadership programs, there should also be learning for followers, both what it is and how to follow.9 Top
The fashion is to talk about shared and distributed or team leadership, while the follower is often portrayed as submissive.9 The word “follower” must be redefined, as it allocates a value and a stereotype of submission — as the word “leader” portrays dominance. Leadership and followership are about relationships. Followership is not a person but a role within a relationship. What distinguishes followers from leaders is not intelligence or character, but the role they play in the relationships they develop. Effective followers and effective leaders are often the same people playing different parts for the same project simultaneously or at different times or in separate spaces. The qualities that make effective followers are pretty much the same qualities found in effective leaders.9,13,14 Meanwhile, most organizations assume that leadership skills have to be taught but that everyone knows how to follow.9
The third part of the leadership system, context, is a function of many elements, including culture, goals, diversity and social context, process, structure (functional and physical), task, systems perspective (stable, complex, or crisis), and time.15,16 Some situations can make leadership difficult. For example, geographic separation makes true distributed leadership difficult, while today’s pressure on time can also influence outcomes.9 As embeddedness or context is a major part of leadership development, it has to become integrated into leadership professionalization across the health care system.
LEADS for professionalizing physician and health care leadership
With the release of To Err is Human17 by the Institute in Medicine in 1999, the medical profession had no choice but to become engaged systemically in quality control and leadership. In response to changing demands in the field, medical leadership has been undergoing a paradigm shift from the traditional autocratic role physicians played to more collaborative clinical and administrative leadership. Until a few decades ago, physicians did not receive any dedicated leadership or management development because they were considered leaders automatically by virtue of their profession. As a result, without evidence-based best practices showing what effective leadership is, anything goes. Doctors often conceptualize and practise management and leadership skills by observing others and learning on the job.1 Top
In 2015, the Royal College of Physicians and Surgeons of Canada (RCPSC) changed the CanMEDS Manager role into Leader.19,20 The LEADS framework has been adopted by the RCPSC and the College of Family Physicians of Canada (CFPC). The CFPC has embarked on the development of a curriculum to align the competencies of the CanMEDS 2015 role of Leader with the LEADS framework. Joule’s Physician Leadership Institute, under the umbrella of the Canadian Medical Association and with the support of the Canadian Society of Physician Leaders, aligns its professional development leadership courses with the LEADS domains. The Canadian Certified Physician Executive designation is awarded by the CSPL, based on certain educational requirements and senior leadership experience aligned with all LEADS capabilities.21 Renewal of the certificate after five years requires the same rigorous process.
A professionalized certificate as described by Kellerman9 should further be developed throughout the Canadian health care system. The two-year fellowship program from the Royal Australasian College of Medical Administrators is one of the best examples of a professionalized leadership degree for physicians. Progress toward professionalization is also being made in the United Kingdom where the Medical Leadership Competency Framework (MLCF) was jointly developed by the Academy of Medical Royal Colleges and the National Health Service’s Institute for Innovation and Improvement in conjunction with a wide range of stakeholders. The MLCF describes the leadership competencies doctors need to become actively engaged in the planning, delivery, and transformation of health care services. Learners can then enter 12-month Clinical Fellow Schemes for emerging clinical leaders outside clinical practice, offering them the opportunity to develop skills in leadership, management, strategy, project management, and health policy.22 Clinical fellows have the opportunity to work with senior leaders to fast track their leadership skills and experience in a diverse range of organizations. The Faculty of Medical Leadership and Management hopes that introduction of the fellowship will be the beginning of a professionalized leadership learning program. As for leadership competencies, it is interesting to see international consistencies between England, Australia, and Canada. Top
The need for leadership development and professionalization has also created a need for changes in medical education. For example, the Association of the Faculties of Medical Education in Canada states that:
Medical leadership is essential to both patient care and the broader health system. Faculties of Medicine must foster medical leadership in faculty and students, including how to manage, navigate, and help transform medical practice and the health care system in collaboration with others.23 Top
A great example of how LEADS can be integrated in resident education is Sanokondu, a non-profit, international collaboration of health leadership educators and organizations with an interest in health leadership development. A set of modules portraying real clinical scenarios was developed for residents and preceptors, based on the five domains of LEADS and several roles of CanMEDS 2015, mainly the role of Leader. Sanokondu has made those modules available free of charge online (https://sites.google.com/site/sanokondu/).
In conclusion, there is a need to professionalize leadership development in Canada. For the health care system, LEADS provides a set of standards for guiding leadership development for the individual and for organizations. Just as CanMEDS provides a framework to standardize professional competencies for medicine, LEADS can serve as a similar model to standardize leadership capabilities for professionalizing leadership.
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Johny Van Aerde, MD, PhD, FRCPC, is editor-in-chief of the Canadian Journal of Physician Leadership and executive medical director of the Canadian Society of Physician Leaders.
This article has been peer reviewed.