ARTICLE

Physician leadership and leading across boundaries

 

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

 

  1. Creating safety: Recognize and define reality by clarifying groups’ roles and contributions. Reducing real or perceived external threats to the groups lays the foundation for future collaboration.
  2. Fostering intergroup respect: Ask meaningful questions that bring out deep differences (i.e., assumptions and emotions) and positive opinions (like/admire) about the other group’s work. One cannot fast track this work as the groups need time to reflect.
  3. Fostering trust: There are many ways to develop trust, e.g., meetings in neutral physical space, where members of different groups interact rather than mingle within their own group, and shared community spaces (physical or online environments). Intergroup work requires mutual trust and trust lays the foundation for relationship-building.
  4. Developing community and creating a superordinate identity: A galvanizing common vision (e.g., patient care improvement) builds a community with a shared identity, where everyone can feel that they belong. Reducing intergroup bias by changing perceptions of group members from “them” and “us” to “we,” e.g., through cooperative interaction,30 or by emphasizing similarities has value, but is also fraught with risks. Bringing people under the umbrella of an overarching collective identity may not be successful when the subgroups perceive this as loss of their identity, e.g., when one dominant group, such as physicians, has a lot of say or when group conflict has not been addressed. This means that creation of a superordinate identity must include preservation and protection of group identities so that the collective work does not subsume groups and individuals.31 A recent report from the King’s Fund32 highlighted that valuing identities helps develop trust and recognition that fosters cross-boundary work.
  5. Increasing positive intergroup attitudes and developing strong intergroup relations: When people have mutually valued relations, they can solve almost any problem, as the trust between them and support for each other are high. This can be achieved by highlighting the mutual benefits of collaboration and the increased value it brings and making sense and meaning of the intergroup work.9 Once established, these strong relations and intergroup relational identity can be leveraged for ongoing work.
  6. Achieving collaborative intergroup performance: The role of leaders does not stop at managing conflict, promoting liking/kinship and respect, building a community around a compelling goal, identity management, and strengthening intergroup relationships. Leaders must also achieve results by ensuring “collaborative intergroup performance,” as their success will be measured by this criterion.9
  7. Being a resource steward and advancing interdependence: Often, groups compete with each other for limited resources, which may lead to conflict.33 Leaders must ensure that groups work together to achieve interdependent goals that individual groups can not achieve on their own. This draws on the power of the unique expertise different groups bring.
  8. Enabling reinvention: Long-term collaboration is enhanced by providing opportunities for all groups to contribute to newer ways of working and using diverse perspectives to develop the future state. This leads to reinvention, innovation, and new possibilities and identities. 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

 

References

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4.Van Aerde J, Dickson G. Accepting our responsibility: a blueprint for physician leadership in transforming Canada’s health care system. Ottawa: Canadian Society of Physician Leaders; 2017.

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8.Saxena A, Davies M, Philippon D. Structure of health-care dyad leadership: an organization’s experience. Leadersh Health Serv 2018;31(2):238-53. https://doi.org/10.1108/LHS-12-2017-0076

9.Hogg MA, van Knippenberg D, Rast III DE. Intergroup leadership in organizations: leading across group and organizational boundaries. Acad Manage Rev 2012;37(2):232-255.

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11.Integration: a new direction for Canadian health care : a report on the health provider summit process. Ottawa: Canadian Nurses’ Association, Canadian Medical Association, Health Action Lobby; 2013.

12.Kodner DL, Spreeuwenberg C. Integrated care: meaning, logic, applications, and implications — a discussion paper. Int J Integr Care 2002;2:e12.

13.Braithwaite J. Between-group behaviour in health care: gaps, edges, boundaries, disconnections, weak ties, spaces and holes. A systematic review. BMC Health Serv Res 2010;10:330.

14.Lewis S, Kouri D. Regionalization: making sense of the Canadian experience. Healthc Pap 2004;5(1):12-31.

15.Collier R. Is regionalization working? CMAJ 2010;182(4):331-2.

16.Van Aerde J. Has regionalization of the Canadian health system contributed to better health? Can J Physician Leadersh 2016;2(3):65-70.

17.Collier R. All eyes on Alberta. CMAJ 2010;182(4):329.

18.Hogg MA. Social psychology of leadership. In: Kruglanski AW, Higgins ET, editors. Social psychology: handbook of basic principles. New York: Guilford Press; 2007.

19.Moreland RL, Hogg MA, Hains SC. Back to the future: social psychological research on groups. J Exp Soc Psychol 1994;30:527-55.

20.Stets JE, Burke PJ. Identity theory and social identity theory. Soc Psychol Q 2000;63(3):224-37.

21.Brewer MB. The social self: on being the same and different at the same time. Pers Soc Psychol Bull 1991;17(5):475-82.

22.Chrobot-Mason D, Ruderman MN, Weber TJ, Ernst C. The challenge of leading on unstable ground: triggers that activate social identity faultlines. Hum Relat 2009;62(11):1763-94.

23.Duck JM, Fielding KS. Leaders and their treatment of subgroups: implications for evaluations of the leader and the superordinate group. Eur J Soc Psychol 2003;33(3):387-401.

24.Pittinsky T. Introduction: intergroup leadership, what it is, why it matters, and how it is done. In: Pittinsky T, editor. Crossing the divide: intergroup leadership in a world of difference. Boston: Harvard Business Press; 2009.

25.Pittinsky TL, Rosenthal SA, Montoya MR. Measuring positive attitudes toward outgroups: development and validation of the allophilia scale. In: Tropp LR, Mallett RK, editors. Moving beyond prejudice reduction: pathways to positive intergroup relations. Washington, DC: American Psychology Association; 2011.

26.Pittinsky TL, Simon S. Intergroup leadership. Leadersh Q 2007;18(5):586-605.

27.Thomas DC. Cross-cultural management: essential concepts. Thousand Oaks, Calif.: Sage; 2008.

28.Ernst C, Yip J. Boundary-spanning leadership: tactics to bridge social identity groups in organizations. In: Pittinsky TL, editor. Crossing the divide: intergroup leadership in a world of difference. Boston: Harvard Business Press; 2009:87-99.

29.Bass BM. Leadership and performance beyond expectations. New York: Free Press; 1985.

30.Gaertner SL, Dovidio JF, Rust MC, Nier JA, Banker BS, Ward CM, et al. Reducing intergroup bias: elements of intergroup cooperation. J Pers Soc Psychol 1999;76(3):388-402.

31.Hewstone M, Brown R. Contact is not enough: an intergroup perspective. In: Hewstone M, Brown R, editors. Contact and conflict in intergroup encounters. Oxford, UK: Blackwell; 1986:1-44.

32.Gilburt H. Supporting integration through new roles and working across boundaries. London, UK: The King’s Fund; 2016.

33.Mills ME. Conflict in health care organizations. J Health Care Law Policy 2002;5(2):502-23.

34.Bichel A, Erfle S, Wiebe V, Axelrod D, Conly J. Improving patient access to medical services: preventing the patient from being lost in translation. Healthc Q 2009;13 spec no.:61-8.

35.Hudson B, Hardy B, Henwood M, Wistow G. Strategic alliances: working across professional boundaries: primary health care and social care. Publ Money Manage 1997;17(4):25-30.

36.Mitchell PH, Belza B, Schaad DC, Robins LS, Gianola FJ, Odegard PS, et al. Working across the boundaries of health professions disciplines in education, research, and service: the University of Washington experience. Acad Med 2006;81(10):891-6.

37.Steihaug S, Johannessen AK, Adnanes M, Paulsen B, Mannion R. Challenges in achieving collaboration in clinical practice: the case of Norwegian health care. Int J Integr Care 2016;16(3):3.

38.Lingard L, Vanstone M, Durrant M, Fleming-Carroll B, Lowe M, Rashotte J, et al. Conflicting messages: examining the dynamics of leadership on interprofessional teams. Acad Med 2012;87(12):1762-7.

39.Cameron A, Lart R, Bostock L, Coomber C. Factors that promote and hinder joint and integrated working beween health and social care services. London, UK: Social Care Institute for Excellence; 2015.

40.Bhardwaj A. Alignment between physicians and hospital administrators: historical perspective and future directions. Hosp Pract 2017;45(3):81-7.

41.Nicholson C, Jackson C, Marley J. A governance model for integrated primary/secondary care for the health-reforming first world – results of a systematic review. BMC Health Serv Res 2013;13:528.

42.Ramanujam R, Rousseau Denise M. The challenges are organizational not just clinical. J Organ Behav 2006;27(7):811-27.

43.Struijs JN, Drewes HW, Stein KV. Beyond integrated care: challenges on the way towards population health management. Int J Integr Care 2015;15:e043.

44.Lavoie JG, Boulton AF, Gervais L. Regionalization as an opportunity for meaningful indigenous participation in healthcare: comparing Canada and New Zealand. Int Indig Policy J 2012;3(1):1-14.

45.Cohen JJ, Gabriel BA, Terrell C. The case for diversity in the health care workforce. Health Aff (Millwood) 2002;21(5):90-102.

46.Gannon MJ, Newman KL, editors. The Blackwell handbook of cross-cultural management. Oxford, UK: Blackwell; 2002.

47.Malat J. The appeal and problems of a cultural competence approach to reducing racial disparities. J Gen Intern Med 2013;28(5):605-7.

48.Beach MC, Saha S, Cooper LA. The role and relationship cultural competence and patient-centeredness in health care quality. New York: Commonwealth Fund; October 2006.

49.Oosterveer TM, Kue Young T. Primary health care accessibility challenges in remote indigenous communities in Canada’s North. Int J Circumpolar Health 2015;74:29576. DOI:10.3402/ijch.v3474.29576.

50.O’Meara P. Would a prehospital practitioner model improve patient care in rural Australia? Emerg Med J 2003;20(2):199-203.

 

Author statement

No sponsorship or funding was received for this work. I declare no conflicts of interest. Top

 

Author

Anurag Saxena, MD, MEd, MBA, FRCPC, CHE, CCPE, is the associate dean postgraduate medical education and professor of pathology at the University of Saskatchewan.

 

Correspondence to:

anurag.saxena@usask.ca

 

This article has been peer reviewed.

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

 

  1. Creating safety: Recognize and define reality by clarifying groups’ roles and contributions. Reducing real or perceived external threats to the groups lays the foundation for future collaboration.
  2. Fostering intergroup respect: Ask meaningful questions that bring out deep differences (i.e., assumptions and emotions) and positive opinions (like/admire) about the other group’s work. One cannot fast track this work as the groups need time to reflect.
  3. Fostering trust: There are many ways to develop trust, e.g., meetings in neutral physical space, where members of different groups interact rather than mingle within their own group, and shared community spaces (physical or online environments). Intergroup work requires mutual trust and trust lays the foundation for relationship-building.
  4. Developing community and creating a superordinate identity: A galvanizing common vision (e.g., patient care improvement) builds a community with a shared identity, where everyone can feel that they belong. Reducing intergroup bias by changing perceptions of group members from “them” and “us” to “we,” e.g., through cooperative interaction,30 or by emphasizing similarities has value, but is also fraught with risks. Bringing people under the umbrella of an overarching collective identity may not be successful when the subgroups perceive this as loss of their identity, e.g., when one dominant group, such as physicians, has a lot of say or when group conflict has not been addressed. This means that creation of a superordinate identity must include preservation and protection of group identities so that the collective work does not subsume groups and individuals.31 A recent report from the King’s Fund32 highlighted that valuing identities helps develop trust and recognition that fosters cross-boundary work.
  5. Increasing positive intergroup attitudes and developing strong intergroup relations: When people have mutually valued relations, they can solve almost any problem, as the trust between them and support for each other are high. This can be achieved by highlighting the mutual benefits of collaboration and the increased value it brings and making sense and meaning of the intergroup work.9 Once established, these strong relations and intergroup relational identity can be leveraged for ongoing work.
  6. Achieving collaborative intergroup performance: The role of leaders does not stop at managing conflict, promoting liking/kinship and respect, building a community around a compelling goal, identity management, and strengthening intergroup relationships. Leaders must also achieve results by ensuring “collaborative intergroup performance,” as their success will be measured by this criterion.9
  7. Being a resource steward and advancing interdependence: Often, groups compete with each other for limited resources, which may lead to conflict.33 Leaders must ensure that groups work together to achieve interdependent goals that individual groups can not achieve on their own. This draws on the power of the unique expertise different groups bring.
  8. Enabling reinvention: Long-term collaboration is enhanced by providing opportunities for all groups to contribute to newer ways of working and using diverse perspectives to develop the future state. This leads to reinvention, innovation, and new possibilities and identities. 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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Author statement

No sponsorship or funding was received for this work. I declare no conflicts of interest. Top

 

Author

Anurag Saxena, MD, MEd, MBA, FRCPC, CHE, CCPE, is the associate dean postgraduate medical education and professor of pathology at the University of Saskatchewan.

 

Correspondence to:

anurag.saxena@usask.ca

 

This article has been peer reviewed.