Practicing physicians' leadership and management skills play a central role in their ability to deliver high-quality, cost-effective care.1 Now more than ever, patient safety, health care quality, and cost containment depend significantly on practicing physicians' abilities not only to decide what care services to deliver but also to manage the delivery of these services.1 For most of these “frontline” physicians, these leadership responsibilities are new and unexpected, in large part because medical school and residency training do not emphasize them.
Simultaneously, emerging evidence suggests that improving the leadership skills of practicing clinicians yields superior outcomes for patients and health care delivery organizations.2 – 12 Effective clinician leadership improves patient care by encouraging teamwork, facilitating the design and close monitoring of care processes, promoting a clinical culture that supports safe practices, and enabling innovation and continuous development of skills and outcomes. Additionally, the clinical and systems-level innovations sought by the Patient Protection and Affordable Care Act (PPACA) presuppose that clinicians possess the leadership and managerial competencies necessary to carry out a practicing physician's daily responsibilities.13 To achieve the best outcomes in today's health care system, all clinicians should be equipped with clinical leadership skills.
Thankfully, leadership can be both taught and learned in a systematic way.14,15 Although many residency programs now offer leadership and management training to residents interested in hospital administration and executive leadership, few clinical training programs provide formally structured, evidence-based leadership and management training for all residents.16 Yet, in a system that desperately needs sound physician leadership at all levels, and which relies so heavily on the educational process to produce sound outcomes, it is no longer acceptable for residency programs to ignore the importance of structured leadership development.
The purpose of this article is twofold. First, we make the case for making formal leadership development an explicit goal of residency training. Second, we propose an evidence-based framework for addressing the barriers to leadership development in health care and for designing formal leadership development training interventions for residents.
Defining Leadership and Management
Leadership and management are closely interrelated processes, and both are essential for organizations to accomplish strategic objectives. Classical teaching holds that “Management is about coping with complexity,” whereas “Leadership is about coping with change.”17 Although no universal definition of leadership currently exists, effective leaders across diverse settings demonstrate the abilities to articulate a vision or goal, communicate this vision to others, build willing support for this vision, and empower others through passion and teamwork to be leaders in return.18,19 Furthermore, leadership can be distributed across many levels of an organization, and people without named leadership positions can take on leadership roles that significantly and positively affect organizational performance.20,21 Similarly, although there is no universal definition of management, a number of responsibilities are often ascribed to managers, including setting work goals and targets, creating work plans and budgets, hiring qualified people, communicating work targets and plans for achieving them, delegating work appropriately, monitoring work performance, and responding to problems in real time.17
In practice, the distinctions between leadership and management are rarely clear-cut. Indeed, leaders often find themselves moving quickly between management and leadership tasks. Many leaders are adept at performing managerial functions, and vice versa. Thus, leading and managing fall on a broad spectrum of complementary, and mutually dependent, behaviors.22
For physicians in the modern practice environment, leadership and management skills are vitally important to health care quality and organizational performance because individual physicians can no longer achieve optimal patient outcomes on their own. Indeed, delivering high-quality care requires that physicians work within and oversee large, diverse teams; navigate increasingly complex technological and human systems; and simultaneously manage the care of large numbers of patients, for each of whom there are multiple goals of care.
Defining Clinical Leadership
Effective teamwork improves clinical outcomes and is a hallmark of good clinical leadership.23 – 25 Good clinical leaders thus possess team leadership skills, including understanding how to harness a team's collective skills and resources to produce clinical care that is superior to what each team member could provide individually, encouraging communication and collaboration between team members and across teams to maximize team performance, setting team direction, delegating responsibilities, encouraging purposeful action, and following others' leadership as necessary to accomplish team goals.21
Thus, in our view, the term “clinical leadership” refers to a physician's ability to serve as both a manager and a leader of diverse teams in pursuit of maximally effective patient care.26 We believe that clinical leaders must take responsibility not only for improving tomorrow's care but also for effectively delivering today's care. Efforts to improve clinical leadership should be focused on developing institutional structures and environments as well as individual skills that enable hospital staff to work together efficiently and effectively.
Importantly, efforts to develop physicians' clinical leadership abilities are not intended to foster a culture of “physician exceptionalism” (i.e., the physician as the authoritarian leader); rather, they must be directed toward instilling in clinicians a set of skills and attitudes that promote seamless collaboration within and between patient care teams for the benefit of patients. To cultivate this collaboration, clinical leadership training should ideally include all health care professionals who participate in clinical care, not just physicians.
At least three different types of clinical leaders have been identified: institutional leaders (e.g., CEOs), service leaders (e.g., department chairs or research directors), and frontline leaders (e.g., those who work at the interface of patient care).27 Although institutional and service leaders play significant roles in creating and managing the structure and strategy of health care delivery organizations, frontline leaders largely drive clinical outcomes and organizational performance.28 The need for, and importance of, outstanding institutional leaders in health care has been widely recognized and well described.16,29 Yet, despite their importance in achieving optimal outcomes, frontline clinical leaders remain underrecognized and underdeveloped. For this reason, we focus primarily on the need for frontline clinical leadership development during residency training. However, we also believe that leadership development should ideally begin during medical school, and we think that our findings and suggestions also apply to efforts to incorporate leadership development into medical school curricula.
The Relationship Between Leadership and Clinical Outcomes
Frontline physician and nurse leaders have been shown to positively influence patient outcomes, patient satisfaction, and provider satisfaction across a broad range of clinical settings.2,3,24,25,30,31 For example, pediatric intensive care unit (ICU) teams' ability to complete their daily work goals has been positively associated with the leadership and management skills of team leaders,32 and patient outcomes in community health centers have been found to be positively correlated with frontline clinical leadership.33
Effective frontline clinical leadership also has been shown to facilitate open discussion of patient safety issues, implementation of quality improvement and patient safety initiatives, staff retention, and efforts to redesign health care delivery systems.3,7,10,27,34 – 40 Nembhard and Edmondson10 provide empirical evidence that neonatal ICU team leaders' level of inclusiveness—defined as the “words and deeds by a leader or leaders that indicate an invitation and appreciation for others' contributions”—predicts the degree of psychological safety that team members experience, as well as their willingness to engage in quality improvement efforts.
Multiple studies from the nursing literature demonstrate that effective clinical nursing leadership increases nursing job satisfaction and retention, reduces rates of staff burnout, and is associated with lower rates of patient falls, medication errors, and hospital-acquired pneumonias and urinary tract infections.4,41 – 45 Recent qualitative research by Curry et al7 identifies significant positive associations between the quality of care that hospitals provide for acute myocardial infarction (AMI) and (1) staff support for “a shared vision of excellence in clinical care, ” (2) organizational emphasis on learning from failure and experience, (3) the quality of staff communications, (4) organizational attention to care coordination, (5) the presence of “physician champions” for quality improvement practices and “empowered nursing staff,” and (6) senior leadership support for quality improvement efforts. Importantly, Curry et al7 found no significant differences between the protocols and processes that top-performing and poorly performing hospitals used to guide the management of AMI. Finally, in an assessment of preventable mortality in 16 academic medical centers, frontline clinical leadership was identified as a central driver of the success of efforts to reduce mortality.38
In sum, clinical outcomes are increasingly a function of organizational performance in general and team performance in particular. The “team” on which patient outcomes depend is the small group of frontline clinicians who are in direct contact with the patient. The way this team is led—how it is configured, inspired, motivated, and managed—is a powerful determinant of clinical outcomes. This leadership task falls not to institutional leaders but, rather, to doctors and nurses, including charge nurses, attending physicians, and residents, who lead clinical teams in the course of their day-to-day work. Thus, leadership is first and foremost about improving the quality and efficiency of the core work of medicine.
A Leadership Gap
Gaps in frontline physician leadership have been identified across a broad range of organizational and geographic settings. A study of primary health care teams identified deficiencies in the following competencies: communication, team building, planning and priority setting, assessing performance, problem solving, and leading.46 A survey of 177 medical residents revealed that 85% reported a need for management training in negotiation, practice partnerships, knowledge of the health care system, and career planning.47 Similarly, a survey of 23 Baylor University surgical residents found that more than 50% believed that they had, at best, an average ability to inspire others, to help others improve performance, and to challenge the status quo.47
The U.S. health care system also suffers from a dearth of institutional physician–leaders. In 1935, 35% of U.S. hospital CEOs were doctors; as of 2008, only 4% of America's roughly 6,500 hospitals were run by physicians—a decline of 90% since 1935.29 A more systematic approach to leadership development for young trainees would prepare physicians for, and hopefully foster their interest in, midlevel and senior-level hospital management.29
Moreover, the passage of the PPACA and the accompanying establishment of accountable care organizations (ACOs) further heighten the need for improved clinical leadership. To achieve cost and quality benchmarks set by the Centers for Medicare and Medicaid Services, ACOs will have to overcome traditional fragmented models of care for Medicare beneficiaries and build care systems that enable teamwork and coordination across the spectrum of care.48 Shortell and Casalino49 argue that both clinical and managerial leadership will be needed to guide physicians and health care delivery organizations through this transition; the challenge, they contend, will be to develop a sizeable-enough cohort of such leaders. Thus, despite evidence supporting the link between leadership and improved clinical outcomes, a significant frontline “leadership gap” exists in health care.40,46,47,50 – 54 This gap exacerbates health care disparities, inequalities in access to care,53,55 and patient safety failures56 and hinders the implementation of reforms aimed at improving health care quality and curbing spending.40
Residency programs' and health care systems' historical lack of emphasis on leadership development and acknowledgment of effective leaders have contributed to this gap. Unfortunately, most medical schools and residency programs provide trainees with little or no structured leadership and management training.1,52,53 Instead, health care providers are left to learn these critical skills while leading care teams or through ad hoc leadership experiences. Not surprisingly, many clinicians consider themselves to be “accidental leaders.”53,57 One potential explanation for this paucity of formal leadership training is that the “creativity, innovation, and strategic insight required for successful leadership and management” are often seen as being at odds with the analytical thinking skills that medical training emphasizes.26 Also, health care organizations rarely identify or reward frontline leaders who can serve as role models for younger clinicians, missing critical opportunities to publicly acknowledge their importance and making it difficult for formal leadership training to take place.26 Furthermore, medicine's performance-oriented culture has traditionally rewarded and recognized individual accomplishments with a particular focus on academic pursuits, rather than team-based successes, leadership abilities, or quality outcomes.52 Although academic success is largely gauged by publications, leaders have few outlets to publish articles about leadership successes.
Additionally, individual physicians' skepticism about the need to develop leadership abilities contributes to the gap in leadership training. Most physicians value autonomy and often view practice interventions—including efforts to increase collaboration across providers—as a threat to their independence. Moreover, many providers perceive an inherent tension between managing care and providing it. This wariness of managerial work is deeply rooted in the culture of medicine and medical education. It is fueled, at least in part, by a belief that managerial functions—including the promotion of standardization-of-care processes and decision-making protocols—will undermine clinicians' independence, flexibility, and ability to treat patients as individuals.58 Today, a physician–leader may worry that his or her responsibilities to patients will conflict with commitments to prudently manage his or her organization's limited financial and medical resources. Clinicians also worry that leadership development will be overly time-consuming and will detract from opportunities to improve clinical proficiency, rather than enabling them to achieve better clinical outcomes.27 In addition, providers may be skeptical of the validity of leadership studies that yield qualitative outcomes, however robust their findings; for many clinicians, this wariness of “soft” outcomes becomes deeply rooted during medical school and is perpetuated through residency and beyond.27
Finally, finding time for leadership education in residents' already-overbooked schedules poses yet another challenge to delivering this training to residents. We realize that our call to action has significant implications for residency directors, and we acknowledge that scheduling leadership development training may prove difficult.
Leadership Can Be Taught
Leadership scholars have long debated whether leaders are born or made. However, a vast body of literature supports the notion that leadership can be learned. The U.S. Army relies on this very notion. The United States Military Academy at West Point is built on the foundation that leadership can be taught:
The [Military] Academy has never believed that only a few human beings are endowed from birth with leadership's requisite traits.… The often-heard phrase “leaders are born, not made ” neglects the potent possibility that leaders are both.14
Mumford et al59 identified statistically significant and positive correlations between the strength and depth of U.S. Army officers' leadership skills—including their leadership expertise, ability to solve complex problems, creative thinking, and social judgment—and their degree of formal leadership training and leadership experiences. The study cohort included 1,790 officers between the ages of 21 and 58. Leadership skills, training, and experience of junior-level, midlevel, and senior-level Army officers were evaluated using previously validated assessment techniques. Sensitivity analyses performed by the authors revealed no evidence of confounding due to selection bias from changes in Army recruiting policy over time or the Army's “up or out” promotion policy, or due to changes in the structure of skill measures across these three groups. To our knowledge, no study has demonstrated that these findings can be generalized to health care providers. Nonetheless, Mumford et al59 provide convincing empirical evidence that people of varying ages, and from different backgrounds, can learn to become better leaders.
Similar findings have been reported in the business literature. Goldsmith and Morgan60 evaluated the medium-term changes in leadership effectiveness of 11,480 leaders participating in leadership development training programs at eight multinational corporations. They found that leaders can improve over time and that trainees' commitment to improvement and the engagement of coworkers in improvement efforts may facilitate leadership development. These findings were consistent across all eight corporations studied.
Many organizations both within and outside of health care—including Kaiser Permanente, the United Kingdom's National Health Service, Denmark's National Board of Health, General Electric, IBM, Boeing, and Proctor and Gamble—devote significant time, energy, and resources to leadership development.61 – 63 Although these organizations appear to use leadership development training to accomplish similar goals, their different approaches to achieving these goals can be sources for informing the development of formal leadership training for residents (Table 1).
Best Practices of Leadership Development Programs
Medical educators face an important challenge to providing residents with leadership development training: how to effectively teach leadership in the context of graduate medical education. Fortunately, educators can look to a number of resources—including existing leadership development courses in medicine and other disciplines, leadership development consultants, and published reports of leadership development best practices—for guidance on how to develop and implement leadership development training programs.64 – 68 We highlight below two useful frameworks for structuring leadership development interventions.
The first framework comes from Authentic Leadership Development, a popular leadership course taught at Harvard Business School. MBA students explore their leadership motivations and capabilities through an iterative process that includes three critical parts: experience, reflection, and feedback.64 In this framework, experiences—including students' experiences prior to enrolling in business school, as well as in-class and small-group exercises—provide content for reflection on a number of important subjects, including how students' prior experiences have shaped their values, beliefs, priorities, and motivations; students' personality traits and preferred leadership styles; and their strengths, weaknesses, and potential blind spots as friends, professionals, team members, and leaders. Students discuss their reflections in small groups and provide structured feedback about each of these topics to other group members. To participate, students must agree not to discuss the content of group meetings with others outside the group.
The second framework originates from the Center for Creative Leadership (CCL), a nonprofit educational institute that offers leadership development consulting services to public and private organizations and that is broadly acclaimed for training leaders across many professional domains. The Financial Times and Business Week have ranked CCL's courses among the top 10 leadership programs offered by any institution worldwide.69 CCL's programs (both open enrollment and customized) are designed to develop leaders at all levels of an organization. CCL asserts that successful leadership development programs include three components: Assessments of trainees' leadership skills and development over time; content that Challenges participants to operate outside of their comfort zones—which is critical for skill development—and to take personal responsibility for their leadership development; and Support for learners through high-quality teaching, constructive feedback, and postcourse coaching (the “ACS Model”).66 CCL also offers a health care leadership training program for health care delivery organizations which addresses delivery organizations' seven essential needs, including “Patient Care, Quality and Safety,” “Resource Stewardship,” and increasing “Capacity for Complexity and Change”70 (Table 2).
Finally, any leadership training program for residents should be based in established best practices. A recent review of leadership theory and development, which was largely focused on organizations outside of health care, identified nine best practices of leadership training programs, including (1) reinforcing and building a supportive culture, (2) ensuring high-level sponsorship and involvement, (3) tailoring the goals and approach of the program to the context, (4) targeting the program toward a specific audience, (5) integrating all features of the program, (6) using a variety of learning methods, (7) offering extended learning periods with sustained support, (8) encouraging ownership of self-development, and (9) commitment to continuous improvement of the program (Table 3).65
Making Clinical Leadership an Explicit Focus of Residency Training
Bridging the leadership gap will require that health care providers think differently about the goals of medical training. Until now, the single most important goal of medical training has been to develop outstanding clinicians. However, we believe that residency programs must strive to produce not just outstanding clinicians but outstanding clinician–leaders.
To realize this vision, residency training programs must teach physicians many nontraditional skills, such as how to engage in self-reflection, cultivate self-awareness and the capacity for self-regulation, lead teams, practice “followership” (which, at West Point, is a prerequisite for learning how to work in and lead teams), lead change, negotiate with patients and colleagues, and develop and manage professional networks.25,26,47 – 49 These competencies are some of the critical skills in the management of large and complex organizations that are lacking in physician training.71
At least two steps must be taken to catalyze the systematic adoption of frontline leadership training for residents. First, leadership development must become an explicit goal of residency training. Second, physicians, residency directors, and educators must tackle the barriers to developing health care leaders.
Residents need leadership development training for a number of reasons. For one thing, residents compose a significant portion of the “professional base” that drives care delivery in most teaching hospitals. Although residents may not routinely hold formal administrative or leadership positions, they take on clinical leadership responsibilities in the course of their day-to-day clinical work that have a tremendous impact on patient care. These responsibilities include leading teams, managing relationships with nurses and other health care providers, overseeing the training and development of younger physicians, leading meetings and negotiating with colleagues and patients, managing conflict, and making resource allocation decisions. And, because residents work consistently at the point of care, they are well positioned to identify quality failures and to initiate and lead efforts to mitigate them. Furthermore, today's residents are tomorrow's clinic, department, hospital, and national leaders. Finally, residents must cope with new personal and professional stresses—including managing professional conflicts and relationships and integrating their personal and professional lives—and make significant decisions that will influence their careers and personal relationships.64
In our view, clinical leadership training is consistent with the Accreditation Council for Graduate Medical Education (ACGME)'s goals for resident education and provides an alternative set of approaches for developing ACGME core competencies.72 For example, the ACGME's Practice-based Learning and Improvement competency (which includes engaging in “constant self-evaluation”; participating in patient, family, student, and health care professional education; and leading quality improvement efforts) is addressed in leadership training through efforts to build self-understanding, the capacity for self-reflection, negotiation skills, and the abilities to learn from experience, create personal development goals, and manage interpersonal relationships.72,73 In addition, education about team leadership, followership—the development of self-awareness, self-regulation, and the capacity for reflection—and how to manage relationships and negotiate with colleagues and patients will address proficiencies included in the Interpersonal and Communication Skills14 core competency. Similarly, learning about one's own leadership styles, how to influence others, appropriate uses of power, and how to lead change in health care delivery organizations will facilitate the development of “an awareness of and responsiveness to the large context and system of health care” that lies at the heart of the Systems-based Practice core competency.72
Because residency programs already make significant efforts to meet the minimum clinical training standards for accreditation, however, it would be unrealistic to expect them to adopt training methods or to teach any additional skills that are not part of national training standards.1 Thus, this paradigm shift must occur from the top down. First, the ACGME should make comprehensive frontline clinical leadership development an explicit goal of residency training. Doing so would send a strong signal to all residency training programs that clinical leadership skills are integral to the provision of high-quality care—that they are in fact foundational skills for the competent doctor—and it would push residency programs to incorporate clinical leadership development into their postgraduate training. Moreover, making leadership development an explicit goal of medical training may help trainees to realize and accept that the dual roles of clinician and leader are both necessary and complementary, a shift in mindset that is an important marker of trainees' readiness to become clinician–leaders.15
Second, residency programs, hospitals, and health systems must address the array of barriers to developing clinical leaders, including the perception that clinical and administrative responsibilities are in conflict with each other, and the paucity of formal mechanisms for recognizing and rewarding outstanding physician–leaders. Providers, educators, and administrators need to dispel the myth that clinical and managerial responsibilities are inherently at odds with one another.9,74 Kaiser Permanente has accomplished this, at least in part, through a joint commitment by physicians and senior managers to build a culture that acknowledges the critical role that clinicians play in the daily management of their organization. The resulting organizational culture “transcends the traditional conflicts between ‘medicine’ and ‘management.’”71
Furthermore, health care organizations must demonstrate with clear action that they value frontline leaders by publicly acknowledging and rewarding outstanding clinical leaders in the same way that they have traditionally praised and rewarded outstanding clinicians and researchers.27,75 To this end, hospitals should offer larger leadership or management opportunities to promising young physician and nurse leaders.14 In addition, medical schools should consider creating academic positions for outstanding frontline clinical leaders, and residency programs should create opportunities for clinical leaders to teach and mentor trainees.27,71,75 Rather than focusing narrowly on traditional clinical topics, aspiring researchers should be encouraged to pursue investigations of the relationships between effective frontline leadership and patient outcomes.27,75
As providers, educators, and administrators begin to build leadership development interventions, they should seek to learn from the experiences of organizations—both within and outside of health care—that have successfully institutionalized leadership development training (Table 1). Studying these organizations' leadership development programs will likely yield additional insights into the critical determinants of a program's success, barriers to implementing training programs and how to mitigate them, the advantages and disadvantages of specific training techniques, and methods for evaluating outcomes of leadership development training. Of course, further experimentation will be required to identify best practices for teaching leadership to clinicians. Careful assessment of new and ongoing leadership training programs in health care will hopefully facilitate the identification of training techniques that do and do not yield demonstrable improvements in residents' leadership abilities as well as health care outcomes.
Designing a System to Close the Leadership Gap
A common tenet shared by health care quality improvement experts is that “every system is perfectly designed to achieve the results it gets.”56 The U.S. health care system currently suffers from a dearth of frontline clinical leaders precisely because our educational system does not consistently and explicitly prioritize leadership development. With mounting evidence that effective frontline clinical leadership improves clinical outcomes, we owe it to our patients and to our colleagues to work expeditiously toward bridging this leadership gap. The U.S. health care system needs a first generation of frontline clinical leaders who are equipped not only with traditional medical knowledge but also with the necessary skills to lead, manage, and continuously improve on how care is delivered. Preparing tomorrow's providers for the complementary roles of “clinician” and “leader” will require deliberate, systematic, and interdisciplinary efforts to develop these critical skills.
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