PERSPECTIVE: Breaking health care leadership silos
Colonel Marc Bilodeau, MD, and Lieutenant Colonel John Crook, MPH
Leadership is a critical factor for successful health care reform. Leadership development is, therefore, vital to ensure that future leaders have the right competencies to succeed. Building on the journey of two military health care leaders, this article argues that current leadership development frameworks and the sponsoring health care leadership organizations lack integration, considering that physicians and non-physicians are trained separately and belong to different networks. The Canadian Armed Forces experience is used to demonstrate a more integrated professional development framework. Based on shared leadership principles, such a model could improve the likelihood of success of the health care transformation currently underway in Canada. The Canadian College of Health Leaders and the Canadian Society of Physician Leaders share a common purpose and should be collaborating more to enable partnerships at the local and regional level, thus contributing to the Develop coalitions domain of the LEADS framework. Such enhanced cooperation will ultimately ensure better patient care today and improve population health tomorrow.
KEY WORDS: shared leadership, professional development, Canadian Armed Forces, integration, partnership, collaboration
The importance of leadership in health care organizations has gained attention in the last few decades. Leadership competencies, like those espoused in Bringing Leadership to Life in Health: LEADS in a Caring Environment,1 have become vital components of clinicians’ training programs in addition to health care management programs. Leadership is also likely to remain a critical factor in the success of health care reforms currently underway in Canada.
Canadian membership-based health care leadership organizations have put much effort into leadership development in support of such transformation. In this article, we argue for a more integrated leadership development framework and network to position us better to transform more efficiently our health care organizations and systems through the expansion of coalitions, as proposed by LEADS.2Top
CCHL and CSPL: a historical background
The Canadian College of Health Leaders (CCHL), formerly known as the Canadian College of Health Service Executives (CCHSE), was founded in 1970 (www.cchl-ccls.ca/). Almost 30 years later, the Canadian Society of Physician Leaders, formerly known as the Canadian Society of Physician Executives, was brought to life (www.physicianleaders.ca). These two organizations bring together approximately 3000 and 700 members, respectively. They both create a home for health care leaders and give legitimacy to such leaders being professionals in their fields.
CSPL came into being at a time in the Canadian health care journey when physician leadership was recognized as bringing value to the system and physicians were given more responsibility in leading health care organizations. Although we can find CSPL as a partner organization on the CCHL website, the opposite is not true: there is no mention of CCHL on the CSPL website. It is fair to say, based on our recent experience, that despite sharing common ground and principles, the two organizations are operating in silos.
Our experience in the Canadian Armed Forces
Health care leadership in the military, as in any other organization, is a critical aspect of how we deliver health care to our military members. Although the Canadian military organization at large offers many leadership development opportunities very early on in a military career, they relate more to the command aspect of the role and not so much to the leadership component. However, the uniqueness of health care in the military organization requires a different approach. This approach is familiar within the Department of National Defence, making it unique among federal departments: the chief of the defence staff and the defence deputy minister share the leadership of the department as mandated by the minister. Top
In the last 15 years, the Canadian Forces Health Services Group, the organization responsible for the delivery of health care to Canadian Armed Forces members, has also adopted a model of shared leadership between physician and non-physician leaders. Our leadership stories are provided here for readers who want to learn more about where we are coming from and what prompted us to write this article.
There were some growing pains with this new model, as shared decision-making is challenging. For this to work and be fully optimized, we had to start exposing more of the two leader groups to each other. We did that by hosting an annual Clinic Leadership Proficiency Training, a week-long event where military health care leaders are brought together to discuss key leadership challenges and share best practices. The 10th such event took place last October.
In addition, a few years ago, we started a “boot camp,” just-in-time preparation for those about to start their new role in a shared leadership team. This training is intended to expose them to the challenges they can expect in their new professional relationship, to provide them with a tool kit, but also expose them to their physician or non-physician counterpart before they assume their new role. As the rotation of the physician and non-physician leaders is seldom fully synchronized, we rarely have the dyad trained together, but at least each group is exposed to the other. The next step will be to create a training syllabus, whereby the two-person “command team” will participate in joint training. These two activities have, without a doubt, demonstrated their value over the years as evidenced not only by the positive feedback received from participants, but also by the success our organization has had in executing its mission in support of the CAF, here and abroad, year after year. Top
The existing literature contains a fair amount of evidence that shows the benefit of a shared, collaborative leadership model in health care organizations.4 Some authors claim that the collaboration between medical and administrative leaders has a positive impact on quality of care.5 Others indicate that shared leadership results in less variance in decision-making and helps improve communication and clarify responsibilities.6,7 There is also evidence that such models promote clinical effectiveness as a subcomponent of overall quality of care.8 Finally, others argue that “a shared, distributed, or collective approach to leadership is necessary to address complex problems.”9
This approach requires the development of a collective leadership identity, shifting from “I” to “we.” This has been our personal experience: the more we expose health care leaders to each other, the more we improve collaboration and understanding of each other and their respective groups. In the end, these efforts to enable collaboration have made us more efficient in executing our health care mission.
As a physician in the Canadian Armed Forces (CAF), I have been fortunate to be exposed to leadership roles very early on in my career and for the last 15 years of my work within the organization. I learned about CSPL in 2010 by attending Physician Leadership Institute workshops. I decided to join the CSPL a few years later and became a Canadian Certified Physician Executive in 2014. This was a means for me to connect with a network of like-minded physician leaders who were experiencing similar challenges. Top
I was always intrigued by my non-physician military health care leader colleagues who belonged to what I perceived to be a closed circle of CCHL members. I say closed circle because, as a non-member of CCHL, and not being a Certified Health Executive (CHE), my organization did not fund my participation in the CCHL’s annual National Health Leadership Conference (NHLC). Therefore, I decided to join the CCHL in 2016 and started the process to obtain the CHE designation, which I was awarded in 2017. During the same period, I also joined my local CCHL chapter (Northern Alberta) as many of my non-physician military colleagues were actively involved in this organization. In June 2018, I finally attended the NHLC for the first time.
These recent experiences were a revelation for me. Being in contact with this group of accomplished and professional leaders allowed me to realize that the challenges they were facing, and the resulting discussions, were the same ones that my Canadian Certified Physician Executive colleagues were having, as witnessed by my readings in this journal and my participation at the Canadian Conference on Physician Leadership (CCPL). Top
I also noticed something quite telling: the near absence of physicians at CCHL events and of non-physicians at the CCPL conference. Well-established silos are separating physician and non-physician health care leader groups and this, I believe, prevents us from realizing the full potential of our health care systems. This has motivated me to write this article.
As a health care administration officer in the CAF, I, too, was exposed to leaders in health care at a very early stage in my career, which began almost 25 years ago. With formal internal training, professional development opportunities, and observational learning, leadership lessons and experiences were readily available. Furthermore, as a non-clinician health care leader, I was strongly encouraged to become a member of the CCHL. Alignment with that organization was of strategic importance, so that we could professionalize the non-clinician leadership core, a recommendation of a 1999 internal report.3Top
From my point of view, joining the CCHL was an opportunity to broaden my understanding of leadership in health care and to become a member of a group of professionals committed to excellence in health care leadership. Furthermore, college membership was recognized with credits toward advancement in the CAF. One was recognized for demonstrating a willingness to take on the challenge of life-long learning, personal professional development, and dedication to honing one’s craft. As members of the college, we were also encouraged to become actively involved in our local chapters. Since becoming a member of the college, I have been actively engaged in Executive Committee work for seven of the last nine years. I have found it to be professionally and personally rewarding, and have made several contacts with like-minded people across the country.
Similar to Marc’s experience, I found that physicians who were CCHL members were a rarity. In fact, hearing that a physician had pursued a CHE seemed out of the ordinary. Until meeting Marc, I was oblivious to the existence of the CSPL. Clearly, there was a common need that both these organizations were trying to fill, each approaching it from its own point of view. When Marc invited me to co-author this paper, I took it as an excellent opportunity to offer the perspective of a non-clinician health care leader who has worked closely and successfully with a physician leader. I believe our example can be used as a model for others to emulate. Each of us has benefited from the “cross-contamination” of each other’s point of view and experience. The leadership skills required to be an effective and transformative health care leader are not the inherent purview of any one professional group. By working together, we can successfully address the complex challenges that face our health care systems. Top
A case for collaboration
Collectively, our personal experience, our organization’s experience, and a growing body of research suggest that there is potential for significant benefit for the health care organizations we lead if our two groups increase their collaboration, by Developing coalitions, as described in LEADS, a framework familiar to both groups.1 Ultimately, we all share the same purpose: to achieve the best results possible for the patients and populations under our care by using appropriately the limited resources made available to our organizations. We must do this by continually improving and transforming our health care systems to adapt to the ever-changing environment. We firmly believe that our organizations might have reached a level of maturity that now position them well to engage in a deliberate process aimed at expanding their scope of influence, thus improving overall health care governance. Browning et al.10 describe this as “boundary spanning,” a concept that encourages health care leaders to “draw on networks and relationships as they work system-wide to meet the mission of healthcare.” Top
Many other factors are predisposing us to work more closely with each other. First, we all come from very different backgrounds: physician, non-physician clinicians, health care administrators, and non-health care administrators. Our diversity is a strength, but only if we expose our expertise and uniqueness to the others. We all bring different talents to the table, and this mix of talent makes us better as a team by a multiplicative versus an additive factor.
Second, we speak a common language, and that language is LEADS. This framework is the building block of both the Canadian Certified Physician Executive and Certified Health Executive credentials. The importance of sharing such a model for capability development in health care has been emphasized in the United States, some authors arguing that this is a driver for the performance and quality of health care systems.11
Third, there are numerous fora where members from both groups are meeting and sharing their thoughts regularly. However, the Canadian Health Leadership Network is the only one listing the organizations as partners on its website.12Top
Finally, we need to build on the trend of growing interprofessional collaboration in health care leadership development programs.13 Such integrated programs have proven to create a better understanding between professional groups and to break down barriers.14
This alignment predisposes our two national health care leadership organizations to integrate better and leverage opportunities for collaboration that could have a synergistic effect on our efforts to transform our health care systems. This is, in our opinion, the perfect illustration of the Develop coalitions domain of the LEADS framework, that is “the practice of collaboration between organizations and organizational leaders as they work together.”1
Although a lot has been written regarding why shared leadership development and practices bring value, the literature is not as strong on how to operationalize it. Our intent here is to propose a few ideas, based on our experience, that we believe could be implemented to strengthen our partnership (Table 1).
First, although increased collaboration at the national level is desirable, an even more significant benefit would be realized where the common values are much more tangible and concrete, i.e., at the local or regional level. Current local health care leadership networks are mostly disjointed, with health care administrators, family physicians, medical and surgical specialists, nurses, academics, trainees, and others each with their own forum for sharing their experiences and challenges. Most CCHL chapters are almost exclusively composed of non-physician members. Similarly, most physician leader groups exclude non-physicians.
The health care leadership world is not large enough to allow us to divide ourselves into smaller groups, thus reinforcing the already existing silos. Through better local and regional collaboration, in the form of coalitions, we could increase diversity and, ultimately, improve the quality of health care governance, considering the common challenges to which we are all exposed. Such enhanced integration will allow us to know each other better; foster trust, mutual respect and understanding of roles and expertise; and lead to increased collaboration and synergy at the organization and, eventually, system level. This would also allow, as suggested in the literature, for a stronger emphasis on context and relationships.15 Top
Through this article, we are calling for the deliberate formation of a coalition and a broadening of the local and regional networks of health care leaders to improve our chances of success with the health care transformation in which our two groups are equally invested. These local and regional partnerships could be facilitated and enabled by agreements between national organizations and local (academic, professional, institutional) ones. Initially, this will require willing representatives of various organizations to come together in a deliberate partnership, guided by a “clear and compelling vision” to achieve a specific result.1 This vision could be something as simple as “best patient outcome” or “optimizing health.” It may also include having representation on each other’s board, jointly hosting local events, as well as attendance at national-level webinars or other similar fora. The recent Ontario Hospital Association Health Care Leadership Summit is one good example.16 Another option is the so-called “study tour” or “field trip” that can be organized to include members of the other organization. A task-based, ad hoc coalition is another way of enhancing the collaboration between the two groups and could be considered for any health care project whatever the scope. Top
In a recent lecture attended by one of the authors, a senior physician leader commented that while trying to improve quality in a large health care organization, she and her counterpart would meet monthly to share a meal. The only ground rule: do not talk about work. The idea was that they would get to know each other on a personal level, and then they could trust each other better and support each other when it was time to take risks.17 An easy first step might, therefore, be as simple as extending a personal invitation to a health care leader colleague from another group to a networking or training opportunity, or even out for a cup of coffee. To support this ideal, health care leaders can participate together in these no-risk but potentially high-payoff activities.
Unfortunately, coalitions do not happen by themselves. They are at risk of failing because of lack of sustained focus or prioritization, lack of continuity in key leadership positions, lack of trust between the parties, lack of a clear governance structure, a disconnect between the strategic desire, the local realities, and needs of both/all parties. All these potential obstacles must be anticipated and mitigated to achieve success, meaning that such coalition-building requires a deliberate approach with appropriate planning to be successful.1Top
Still, health care leadership is about us, the individual leaders who are making health care delivery happen daily. We, therefore, all have an individual responsibility to optimize our shared leadership with our colleagues. Our front-line clinicians and staff discovered decades ago that working together is the only way to effectively care for our patients: perhaps it is time for their leaders to follow their example.
We would like to recognize Dr. Marcie Lorenzen and Colonel Steve Plourde for their generous contributions in reviewing and providing meaningful comments on this manuscript. Top
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Colonel Marc Bilodeau, CD, MD, CCFP(EM), FCFP, CCPE, CHE, is a military family physician and executive leader for the Canadian Forces Health Services Group. He is currently undertaking the National Security Programme at Canadian Forces College, Toronto, and a master of public administration degree with the Royal Military College of Canada.
Lieutenant-Colonel John Crook, CD, MPH, CHE, is chief of staff of 1 Health Services Group, Canadian Forces, responsible for coordinating delivery of health care to 15,000 personnel across western Canada. He is also an adjunct professor in the School of Public Health, University of Alberta and a mentor in the school’s Fellowship in Health System Improvement program.