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Leadership with a small “l”

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c483 (Published 27 January 2010) Cite this as: BMJ 2010;340:c483
  1. Richard Bohmer, senior lecturer, Harvard Business School
  1. rbohmer{at}hbs.edu

    What exactly do we mean by leadership in health care? Does it mean to take formal positions in senior leadership teams in hospitals, trusts, health boards, ministries of health, and professional societies—what might be termed leadership with a big “L?” Or does it mean something fine grained and local—leadership with a small “l”?

    It is tempting to frame the discussion in terms of the first, if only because the big issues dealt with at higher levels in delivery organisations and government—such as licensure, reimbursement, malpractice, technology licensing, and working hours—profoundly affect the working lives of so many doctors. But mounting evidence of the impact of organisations on clinical outcomes is making the second model of physician leadership increasingly important.

    As the growing complexity of clinical problems is paralleled by increasing organisational and technical complexity of health care, medical outcomes have become as much a function of organisational performance as of individual doctors’ skill. Quality and safety failures are driven by system failures as well as failures of individual physicians’ skill and decision making; and higher performing hospitals are differentiated by their greater use of organisational interventions, cultures that support innovation, structures such as multidisciplinary teams and computerisation, and highly specified care processes.

    Thus for doctors to assure optimal health outcomes for their patients they now need to concern themselves with the performance of the organisation in which these patients receive their care. From the perspective of an individual doctor it is the small scale operating system that is most important in determining health outcomes. This microsystem is the small group whose members collaborate to create a clinical outcome—their information, technology, and physical environments and the management policies and clinical processes they follow. Small “l” leadership is exercised at the level of a ward, clinic, or practice. Its goal is to create and oversee the local operating system in which each doctor’s patients receive their care. A consultant and a senior nurse on a ward have such a leadership role. So does a registrar training a house officer, trainee intern, and a medical student; or a nurse leading a multidisciplinary chronic care team.

    Optimising the performance of a small scale operating system requires both leadership (articulating a vision and setting direction) and management (assigning accountabilities and monitoring performance). An essential leadership task is to frame the clinical team’s work: elevating the staff’s perspective from the immediate activities that consume their day, such as tests, referrals, and paperwork, to the goals that these activities are intended to achieve. Clinical care can be framed as “production” (execution of highly specified protocols), “problem solving” (the search for a unique solution to the patient’s problem), or learning (creating new knowledge from current experience).

    Not only is each frame appropriate to a different setting—a disease management programme or an academic medical centre—but each also requires a different operating system. An emergency doctor who frames the department’s work as “stabilise and ship” will create a very different operating system from one who frames the work as “diagnose and initiate definitive treatment.” They will select different policies, technologies, clinical protocols, and performance measures and will establish different relations with the inpatient wards and even different physical layouts. Hence a clinical leader’s second important task is to help design the operating system in which their patients are treated, including the mechanisms by which performance is managed: measurement, monitoring, and accountability systems. A third task is to shape the culture that surrounds these structures and processes. For example, quality and safety improvement require an environment in which people feel comfortable sharing unpopular information, expressing dissent, and admitting mistakes.

    Small “l” leaders perform these tasks by being and doing. Although much is made of leadership as “being,” a leader’s actions are also important: something as simple as a doctor’s tone of voice has an important effect on how others will evaluate him or her. Simple deliberate actions—for instance, inviting the input of lower status staff and publicly admitting your own mistakes—can help create a culture that promotes patient safety.

    A number of barriers prevent doctors from taking a greater leadership role: the “siloed” structure of delivery organisations, the demands of clinical practice, and the challenge of managing autonomous professionals. Moreover, small “l” leaders often lack formal authority and control over resources in their working environments and must lead by creating consensus, modelling behaviour, articulating vision, and asking questions. And they are usually not paid for this work.

    But perhaps the biggest impediment is that practising doctors simply do not think of themselves as leaders, nor do they see leadership as vital for the care of patients. Medical training, in fact, emphasises exactly the opposite: individual action and accountability. For most doctors the small “l” leadership skills needed to improve the performance of individual practices, clinics, and wards must be learnt. Doctors’ daily work is defined by a collection of individual activities and transactions; little in medical and postgraduate training emphasises the interdependencies between these often fragmented events, nor the way in which they are part of a larger system designed to realise a specific patient outcome. Although some schools offer joint medical and management training, most doctors learn little about how complex organisations work and how they can be made to work better.

    As we call for medical leadership in healthcare reform, we should not focus solely on big “L” leadership and overlook the importance of leading the micro-systems that have such an effect on care outcomes. We need for medical and postgraduate training to prepare doctors to lead at this level. Any call for leadership should include a call to doctors to think of their daily work as not only treating individual patients but also helping create and manage the small scale operating systems that support their medical work.

    Notes

    Cite this as: BMJ 2010;340:c483

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