Physician leadership and leading across boundaries
Anurag Saxena, MD, MBA
Health care involves cooperation, coordination, and collaboration across multiple intra- and interorganizational stakeholder boundaries. Five domains of boundaries — vertical, horizontal, stakeholder, demographic, and geographic — are present in health care and in academic health centres. These highlight differences in mission, vision, mandates, and the organizational culture, structures, and processes of different groups. Groups have both negative and positive attitudes toward each other, which exist simultaneously and independently of each other. The boundaries can be viewed as constraints or as frontiers that can be explored for innovations and entrepreneurship. Physician leaders have an integral role to play in the ongoing evolution of health care toward an integrated model, which requires leading across multiple boundaries. The ultimate aim of cross-boundary work is to achieve shared goals, such as patient-centred care. In intergroup collaboration, physician leaders must be perceived as representing all groups; they must simultaneously mitigate group differences and enhance positive intergroup relations; and, when in dyad relationships, they must establish a joint front with the partner through mutually valued relationships and role clarity.
KEY WORDS: physician leadership, boundaries, identity, intergroup leadership, integrated health care
When working with people from different units, departments, professions, and organizations, we often wonder why their perspectives, positions, interests, ways of working, and proposed solutions are different from ours. Enter the concept of “boundaries.”
According to the Merriam-Webster Dictionary, a boundary is “a limit that indicates where two things become different” or “that shows where an area ends and another area begins.” Health care, with its many interdependent variables, is a complex adaptive system1 because of its emergent, dynamic, entangled, and robust nature2 and its numerous intra- and interorganizational boundaries. At the same time, the word “frontier,” a synonym of boundary, refers to the limit of the most advanced achievement or knowledge and suggests opportunities for further development.
This dual interpretation of boundaries is attributed to Ernst and Chrobot-Mason’s work.3 The former definition conveys limiting possibilities, e.g., mere cooperation and coordination of efforts across borders, while the latter encourages exploration and expanding possibilities to create an inclusive future for all entities with a new identity. The difference lies in how leaders approach, collaborate, and innovate across the borders and divides. Top
Why should physician leaders care about this concept?
Physician leaders have an integral role to play in the ongoing evolution of health care toward an integrated model,4,5 which requires leading across multiple boundaries. The Develop coalitions domain of the LEADS framework recognizes and addresses this need for collaboration.6
Even in leading apparently homogeneous groups, such as physicians in a unit, there are boundaries related to functions and demographics. Most health care work also requires cooperation and coordination across intergroup boundaries, between stakeholders with different backgrounds and mandates, e.g., professions, administration, organizations, social workers, communities, and government. In some cases, physicians share leadership with those from other, usually administrative, backgrounds (dyad leadership),7,8 which adds a layer of complexity because leadership work itself must be coordinated for joint accountability. Academic physician leaders have an added dimension of working within universities and with other health profession education institutions.
The ability to lead across groups is not the same as that required to lead a single group.9 Physician leaders must be adept at cross-boundary leadership to meet the expectations surrounding health care transformation.
Health care integration is cross-boundary work
The ongoing evolution from provider-centric to patient-centric care is a classic example of intra- and interorganizational cross-boundary work. Driven by the necessity for better access, higher quality of care, improved outcomes, and enhanced efficiency, health care systems are moving toward such an integrated model in Canada.10,11 One Canadian definition —“integration is a coherent set of methods and models on the funding, administrative, organizational, service delivery and clinical levels designed to create connectivity, alignment and collaboration within and between the cure and care sectors”12 — highlights the landscape of boundaries we face.
Ernst and Chrobot-Mason3 delineate boundaries across five domains: vertical (rank, authority), horizontal (units, functions), stakeholders (alliances, networks, communities), demographic (race, gender, ideology), and geographic (regions, cultures). All five are present in health care and a few examples are listed in Table 1. Establishing the proposed foundations of integrated health care in Canada — patient access; patient-centred care; and informational, management, and relational continuity of care11 — requires collaboration and synergy across these boundaries along with addressing the divides.13 Top
Although regionalization of health care in Canada has brought together some pieces of fragmented care under unifying umbrellas,10 this is considered to have had a somewhat limited impact14-16 and its role in achieving integrated health care is unclear.10 It appears, then, that the creation of a single health authority in Alberta in 200817 and in Saskatchewan in 2017 is based on the premise that this model (as opposed to multiple regional authorities) is better suited to achieve integrated health care.
In partnerships between medical schools and health care organizations (HCOs), despite mission overlap (clinical care, education, and research), priorities are usually different. Most professional education of physicians is in clinical settings and involves delivery of care by residents. Physician leaders on both sides are involved in ongoing medical education reform, including implementing the recent competency-based medical education initiative, which affects the nature of work for both residents and faculty across this boundary. In addition, academic physician leaders lead across multiple intra- and interorganizational boundaries, e.g., expanding distributed medical education involves working with governments, HCOs, advocacy groups, and communities.
What underlies boundaries?
Organizational boundaries are reflected in differences in mission, vision, specific mandates, and territories related to group functions, organizational culture, and organizational structures and processes, e.g., around decision-making and accountability. These differences are ultimately linked to the notion of identity. A robust body of research on social psychology of leadership,18 intergroup relations in organizations,19 and social identity/identity theories20 highlights the importance of social cognition and social identity and their implications for collaboration, a concept essential for health care integration.
Identity serves two somewhat opposing purposes: creating a sense of belonging and, at the same time, highlighting uniqueness.21 Rooted in their social identity (based on who one is and to which group one belongs) and identity (based on what one does),20 individuals and groups think and behave in ways commensurate with their own identity and organizational mandate, separating them from the efforts of others. By delineating roles and purpose, intergroup boundaries are helpful in making people feel safe; but these also create challenges to working together. Top
Negative aspects of intergroup behaviour refer to a spectrum of interactions between group members and others when the perspectives of non-group members may not be considered leading to in-group favouritism and out-group derogation.22 These may lead to power struggles and relationship problems22,23 and can manifest in many ways, such as pulling apart of groups and a clash of values with no give and take.3 This potentially breeds disruptive energy and negatively impacts collaborative work.
However, between-group attitudes are not necessarily negative. According to Pittinsky,24 allophilia, “a term for positive feelings of kinship, comfort, affection, engagement and enthusiasm concerning members of a group different from one’s own” has received considerably less attention. Groups with positive attitudes toward each other have a stronger propensity to work together and act on behalf of the other group compared with those who merely have an absence of negative intergroup attitudes.
The two attitudes — negative (prejudice) and positive (allophilia) — exist simultaneously and independent of each other and affect intergroup relations.25 Reducing tensions between groups is simply not enough; enhancing positive attitudes is just as neccessary26 to achieve the highest degree of collaboration.
Challenges in cross-boundary leadership
Leadership work across boundaries is challenging, and the limited progress toward integration highlights difficulties in achieving success. A few challenges are common across all boundaries, although their relative importance varies. Achieving cooperation and collaboration among those who have developed a strong sense of identity with a group/profession/organization through narratives and values is difficult.
Further, the capacity for collaboration and cross-boundary work among individuals and organizations may not be similar. For example, at the individual or group level, certain mental models, competitiveness, and a short-term focus hinder cross-boundary work. At the organizational level, operational leaders may not have bought into the common vision or there may be competition for scarce resources, unwillingness to share power, ineffective intergroup relations, and poor communication and misunderstandings, the latter especially in teams composed of members with different cultural backgrounds.27 At the interorganizational level, differences in purpose, priorities, and agendas may hamper progress despite a common vision. Top
Some challenges are more applicable to certain boundaries. A few examples are listed in Table 1. The theme weaving through these challenges is the requirement for effective leadership across groups.
So how can cross-boundary work be accomplished?
Ernst and Yip28 define boundary-spanning leadership as, “the ability to create direction, alignment, and commitment across boundaries in service of a higher vision or goal” (p. 89). The Develop Coalitions domain of the LEADS framework addresses collaboration among various stakeholders and articulates four required capabilities: building partnerships and networks; facilitating collaboration and coalitions to improve service; mobilizing knowledge; and navigating sociopolitical environments.6
In this paper, I offer strategies and specific actions for leading successfully across organizational boundaries and pitfalls to be avoided. Given the dominant nature of the physician profession in health care, physician leaders must be aware of sensitivities when leading coalitions of multistakeholder groups. Three considerations must be kept in mind (Figure 1): how the leaders are perceived by the groups; how to achieve intergroup collaboration; and exercising joint leadership in the dyad model.
When leading multiple groups, physician leaders must be perceived as leaders of all of them and as “one of us,” not promoting physicians’ interests only. Leaders who do not meet the expectations of their groups run the risk of being ineffective.26 An awareness of this requirement is the first step.
Staying authentic and caring for all groups, especially those with less power, coupled with political savvy when addressing different stakeholder groups is helpful. Framing issues toward emergent future physician leaders conveys commitment to the success of intergroup collaboration.
Most leaders know that what they say and what they do must match in the eyes of their followers. For intergroup leadership, this requires even more attention, as multiple groups are watching. The ability to practise transformational leadership is essential to cross-boundary work as this helps achieve group cohesiveness by motivating followers to achieve a higher goal and promoting values, such as equality and strong commitment.29 However, caution must be exercised so as not to “mislead toward the truth” in pursuit of collective goals, because once discovered, the loss of credibility would be irreparable.
Achieving intergroup collaboration requires effort to bring groups together. As prejudice and allophilia between groups exist simultaneously and independently of each other,24 working with groups involves deliberate mitigation of differences3 coupled with emphasis and building on positive attitudes, including respect for each other.26 Both approaches aim to arrive at the same destination of synergy of efforts to achieve desired outcomes and continue the journey toward limitless possibilities through innovations and entrepreneurship.
The strategies and examples of specific actions given below reflect a distillation of the two approaches: Ernst and Chrobot-Mason’s six boundary-spanning strategies3 and Pitinsky’s five pathways to promote positive intergroup relations.26 Top
Finally, in the dyad model, the exercise of leadership itself is to integrate administrative and clinical governance for joint accountability. At least four aspects of this require attention (Figure1). Leaders need a clear understanding of roles and responsibilities in the individual and shared domains.7,8 The groups they lead must perceive the dyad as a “united front,” and this becomes authentic if the dyad partners develop a strong mutually valued professional relationship.8 Finally, having good relations with at least some members of the other group (e.g., physician leaders with the administrative team) helps build intergroup cohesiveness.
It can be done but does it work?
A number of examples of successful cross-boundary work exist, although they have required adjusting strategies to the local context, as is almost always the case. In Alberta Health Services, three projects related to patient access (central access and triage, clinically coherent tools for prioritization, and access and efficiency collaboratives) involved connecting people, creating communities for action, balancing common good with self-interest, and minority versus majority opinion. This led to improvements in patient access to services.34
In another setting, successful collaboration between health and social services and housing professionals and between central and local health authorities led to improved integration of primary care services for vulnerable populations.35 Specifically, development of local networks required addressing trust, mutual respect, diverse operations, funding arrangements, and professional and cultural fragmentation. The role of the central authorities focused on creating the legal and financial framework to facilitate local work. Improvements in interprofessional education and care across the health care–academic boundary required changes to policies, integration of top-down and bottom-up authority in joint working groups, sharing costs, and developing a culture of interprofessionalism.36
In summary, collaborations across boundaries in health care involve diverse people with different backgrounds in multiple groups. Physician leaders must be cognizant of the underlying social identity dynamics. Three aspects are relevant: perception of leaders as representing all groups; a combined approach that includes mitigating differences and building on and enhancing positive attitudes for intergroup collaboration; and the importance of role clarity, mutually valued relations, and a joint front in dyad leadership. These strategies will help provide leadership across health care boundaries, work with which physicians are increasingly being entrusted. Top
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No sponsorship or funding was received for this work. I declare no conflicts of interest. Top
Anurag Saxena, MD, MEd, MBA, FRCPC, CHE, CCPE, is the associate dean postgraduate medical education and professor of pathology at the University of Saskatchewan.
This article has been peer reviewed.