Introduction: Physician leadership is required for transformation and improvement of health care organizations and systems. However, although development of physician leadership is presumably helpful, there is no clear evidence base for such development. Thus, our study aimed to answer the questions: What evidence-based interventions are used to develop physician leadership for health care transformation and improvement? What are the outcomes of these interventions? What are the enablers of and barriers to these interventions and their outcomes?
Methods: We conducted a systematic scoping review of scientific and grey literature, using key words to search databases and other sources. Two raters reviewed the literature and resolved any disagreement by discussion.
Results: No randomized controlled trials were found. Other studies were clustered into five themes: Physician leadership development programs (developing programs and creating new positions); Physician “leadership inclusiveness” (leaders’ behaviours, quality traits, collaborative relationships); Training in physician leadership skills and competencies; Evaluation of physician leadership development programs; and Barriers/challenges to and enablers of physician leadership development.
Conclusion: There is no rigorous research on physician leadership development, although various themes related to the topic have been described. More research is needed to address physician leadership development and related matters, such as physician leadership involvement.
KEY WORDS: physician leadership development, healthcare organizations and physicians leadership, effectiveness of leadership development program, leadership development program evaluation, health system reform/transformation, skills and competencies, physician inclusiveness Top
There is a need for programs that are focused on providing physicians with the requisite technical knowledge, skills, and competencies to build leadership capacity within organizations.1,2 Such development can promote organizational change, a culture of accountability, strategic alignment, and successful planning and help the organization reach its goals.1,2 The process of preparing clinicians to be administrative leaders is challenging, because physicians seldom receive training in the managerial and leadership skills needed to influence others and develop relationships.3,4 Indeed, physician leadership development may require clarification of first principles.5
The process also requires transformational change.6 McAlearney et al.7 note that the “transformational change required for physicians to develop and appreciate business and leadership skills can be supported and encouraged in a leadership development program that includes the components of careful curriculum design, program monitoring, and opportunities to apply new skills in practice” (p. 18). Transformational leadership also suggests organizational change to promote a culture that recognizes and supports physicians’ contributions to hospital leadership and one in which medical staff and hospital administrators work collaboratively and share accountability.8
The purpose of this scoping review — a systematic review of literature where not much, if any, rigorous research may exist9 — was to try to identify research and related evidence addressing interventional programs that support physician leadership development. Specifically, we asked: What evidence-based interventions are used to develop physician leadership for health care transformation and improvement? What are the outcomes of these interventions? What are the enablers of and barriers to these interventions and their outcomes? Top
We searched a wide range of electronic databases (PubMed, MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, CINAHL) and a variety of health management and leadership journals (Health Care Management Review, Journal of Organizational Behavior, Canadian Journal of Physician Leadership, Journal of Healthcare Management, Journal of Health Services and Research Policy, Healthcare Management Forum, and Journal of Healthcare Organizational Management) that address this topic. Key words were: “physician leadership development,” healthcare organizations and physicians leadership,” “effectiveness of leadership development program,” leadership development program evaluation,” health system reform/transformation,” “skills and competencies,” and “physician inclusiveness.”
The search was conducted to identify articles published from earliest until June 2016 (inclusive) in relation to physician leadership inclusion in health care transformation and improvement, training in leadership skills and competencies, and physicians’ leadership development programs. In addition, we manually searched such sources as the reference lists of relevant articles and Google Scholar, as well as grey literature (reports, white papers, conference proceedings, websites, and policy documents) to find additional information on networks, coalitions, and policies existing in the area of health care organizations and systems as related to the development of physician leadership for health care transformation and improvement.
Identified articles were independently reviewed and rated for relevancy by two reviewers. Any disagreement between the reviewers was resolved by discussion between them. Synthesis of the studies was conducted using a realist review. A realist review is an approach used for review and synthesis of evidence, focusing on understanding the mechanisms by which an intervention works or not.10 A key principle of realist reviews is the assumption that a specific intervention produces specific change, which can be more or less effective in producing intended outcomes, depending on interactions with various factors in particular settings.11 This type of literature review is particularly useful when assessing the complexity of implementing health services interventions, as the social context of service delivery is complex, diverse, and dynamic; thus, the same intervention seldom works in the same way in different social contexts.12-14
Extracted data were summarized and organized into categories and question-related topics. These data were then themed, the themes were challenged, and contrary evidence was sought. In relation to the characteristics of change or outcomes, a number of themes emerged. To confirm themes, connections were looked for across data to establish the existence of interventions, outcomes, and their barriers and enablers. Top
No randomized controlled trials (RCTs) were found in relation to physician leadership development. Hence, we post hoc reviewed case studies, qualitative studies, pre- and post-study design and systematic reviews (n = 94).
During the synthesis of the selected articles, five themes emerged: Physician leadership development programming (developing in-house leadership programs and creating new physician leadership positions); Physician “leadership inclusiveness” (leaders’ behaviours, quality traits, collaborative relationships); Training in physician leadership skills and competencies; Evaluation of physician leadership development programs; and Barriers/challenges to and enablers of physician leadership development. The latter domain is also interwoven throughout the other themes. Key examples from each theme are provided below.
Physician leadership development programming
Most existing physician development programs are based on traditional managerial training and focus mostly on improving managerial skills and on-the job performance rather than quality and efficiency improvement,15,16 which might substantially affect organizational dynamics, climate, and culture.17
Physician leadership development programs should be designed to enhance effectiveness and/or improve the organizational culture.18 They should include developing the individual leader, socializing company vision and values, strategic leadership initiatives, and action learning.1 Examples of such interventions are developing in-house leadership programs8,19-22 and creating physician leadership positions.23,24
Evidence indicates that an in-house leadership program that uses in-house instructors and intends to promote a culture that recognizes and supports physicians’ contribution to hospital leadership and in which medical staff and hospital administrators work collaboratively and share accountability has the largest impact on organizations and the highest level of physician engagement.7,25 The greatest challenges in implementing an in-house leadership program are the need for resources, the capacity to deliver such programs, and the difficulty of promoting them, particularly when physicians do not have formal continuing education programs and are not compensated for their time for this.
To address the low level of physician engagement in quality improvement, several hospitals have established formal physician leadership positions, such as the physician quality officer (PQO).23,24,26 The key to the success of such programs is that physician leaders are involved in all important corporate initiatives, can set objectives, and are given protected time and remuneration. Top
However, implementation of this program highlighted three main challenges that had to be overcome. First, the quality improvement structure of the medical system had to be changed from the financial, reporting, and project selection perspectives and buy-in of the chairs had to be gained. Second, as a new enterprise, details of the PQO system had to be worked out. The PQOs grew into their roles as they gained knowledge and experience. Third, the program had to be presented in a way that engaged the medical staff in quality improvement.
Physician “leadership inclusiveness”
Behaviour of a team leader can substantially influence the climate and dynamics of the team.27-31 Nemeth27 stated that “people are reluctant to voice novel or deviant views for fear they will be ridiculed. Thus, the diversity of viewpoints is unexpressed in most groups, and therefore there is a reduced likelihood of finding creative solutions” (p. 29). Research has shown that such feelings of threat or risk hinder professionals’ willingness to voice their concerns or ideas.32,33
In the same context, team members tend to speak up less often if a team leader displays authoritarian, unresponsive, or defensive behaviours, but they tend to be interactive and feel involved if the leader is open-minded, supportive, and proactive, has the ability to share and encourage new ideas, and is open to constructive criticism or voiced challenges. These behaviours and qualitative traits constitute what has been termed leadership inclusiveness, which facilitates team processes and provides elucidation and positive responsiveness.29 According to Nembhard and Edmondson,34 leadership inclusiveness refers to “words and deeds by a leader or leaders that indicate an invitation and appreciation for others’ contributions. Leadership inclusiveness captures attempts by leaders to include others in discussions and decisions in which their voices and perspectives might otherwise be absent” (p. 947). Top
Leadership inclusiveness is necessary in health care settings not only because it provides an opportunity for low-social-status professionals to be proactive through their contributions, but it also creates a psychological safe environment that allows people to speak up and overcome communication boundaries.34 In contrast, deference to power status substantially influences the process of quality improvement and, as result, can lead to poor decision-making and be detrimental to achieving the organization’s goals.27,35-37
Training in physician leadership skills and competencies
Physicians may have high academic achievements, clinical expertise, and some traits of leadership, e.g., compassion, caring, integrity, passion, judgement, and critical thinking. However, they may not have the knowledge, skills, and competencies — in strategic planning, organizational management, finance, regulation, problem-solving, emotional intelligence, conflict resolution, effective communication, and network development — needed to lead organizations toward building strong alliances and partnerships, making strategic decisions, and ensuring effective and efficient high-quality care.3,38-41
Several core competencies for physician engagement and leadership have been proposed,42-44 and a variety of training courses, seminars, and workshops are offered for physician leadership development. Yet, an important question is often ignored, i.e., what are the skills/competencies and appropriate training that have been measured or otherwise evaluated and are deemed to be a good fit for a physician leader to have.
Pfeffer31 highlights two general ways to understand leadership failures: 1. organizations have done a poor job of selecting the right people for leadership roles, schools have failed to instill ethical leadership behaviours in their students, and some leaders have developed the wrong values; 2. systemic processes produce leaders who often behave differently from what most people may like or expect. In addition, there is little evidence that research-based recommendations have positive impacts, and there is scarcely any evidence that all the spending on leadership development is producing better leaders.31
Evaluation of physician leadership development programs
Evaluation of the effectiveness of initiatives to improve care is crucial for health care system transformation.45 Leadership development programs have used Kirkpatrick’s46 evaluation model and are mainly focused on individual learning outcomes (reaction and self-reported knowledge), neglecting organizational performance. In fact, this model is not designed for nor is it effective in measuring organizational performance or the effectiveness of an organization in achieving outcomes as identified by its strategic goals, and it does not focus on return on investments.47
Indeed, organizations largely ignore evaluation of leadership program outcomes and processes nor do they investigate whether the programs they offer have a positive effect on improving the organization’s performance.15,16,31,48-50 It is clear from several empirical studies15,16,49-52 that leadership program evaluation is of poor quality because of a high risk of bias.
It is imperative for organizations to evaluate the effectiveness of leadership development programs. Hence, before implementing one, developers should take into consideration the study design, define the target population and intervention, assess the outcomes blindly, use standardized and validated evaluation tools, and clearly define the competencies that are necessary for leaders to achieve organizational/system effectiveness. In addition, the experience of the trainer may be significant in influencing the effectiveness of the training program, and some management training methods may not lead to improved performance.16 Top
Barriers/challenges to and enablers of physician leadership development
The greatest challenges to health care organizations are their complexity, e.g., involving various professions2,53; physicians not having the right skills for management2,53,54; addressing existing gaps in quality of care; the complexity of caring for aging patient populations with chronic diseases; the uncertainty about the appropriate use of new devices and medications; the rapidly rising costs of care in a constrained economic time52; reluctance to change despite investments and high demands for innovations and quality improvement26,31,55; and professional cultures that may obstruct best decision-making and resource allocation.55
Several researchers have suggested a variety of enablers that may enhance the integration of physician leadership and physician leaders’ engagement as facilitators of health care system improvement.2,3,7,36,44,45,56-58 However, such factors and interventions should undergo rigorous evaluation.
Although physician leadership development is needed, this systematic review demonstrates the lack of rigorous research in this area and the paucity of other literature directly related to it. Only about half of the references we identified are from the last decade, further suggesting the need for more research.
There is a need to develop and rigorously evaluate standardized physician leadership development programs that are responsive to organizations’ and systems’ priorities. Admittedly, standard RCTs may not be adequate to study such complex interventions; hence, other forms of rigorous research may be needed, such as well-matched quasi-experimental, case–control or cohort studies and long-term evaluation of well-controlled quality-improvement initiatives. In summary, empirical research is needed on the processes and practices that can help involve physician leadership in transformation change and improvement. Top
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We thank Lueda Alia and Hui Ying Zhao for their assistance in the literature search and reviewing process.
Luljeta Pallaveshi, RN, LLB, BA, is a research associate in the Psychosis Program at the Parkwood Institute Mental Health, London, Ontario.
Abraham Rudnick, MD, PhD, is a professor in the Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario.
This article was not sponsored nor did either author receive any financial payment for the work. The authors certify that they accept responsibility for the content of this article. Both authors helped write this manuscript and agree with the decisions about it. Both meet the definition of an author as stated by the International Committee of Medical Journal Editors, and they have seen and approved the final manuscript. The authors declare no conflict of interest.
This article has been reviewed by a panel of physician leaders.