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Leadership with a small “l”

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

    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 …

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