Leadership and Learning: A Review of Leadership Themes in Health Informatics

Leadership in Context
In most discussions on leadership in business, success is equated with commercial success, often narrowly defined by financial measures such as increased shareholder value or profit. It could be argued that this model is not an appropriate one to apply to health care, in particular, to a national health care system that is largely publicly funded, as is the case in New Zealand. However, successful commercial organisations do also define their success in other terms, at least internally. The perception of many in public service that commercial organisations are relentlessly focused on financial measures does not bear scrutiny in practice. Certainly, commercial drivers are imperative at the lower end of the food chain; if one does not have enough money to provide the necessities of life, obtaining it becomes the first priority. However, in most successful commercial companies in New Zealand, the organisation provides for a much wider set of social needs than simply income. An often-cited example is Hubbards Foods. A sign outside the offices of this company in Auckland reads:

WARNING
This is a "no nonsense" management zone. No management excesses, corporate ego trips, committee decisions, inter-company memos, buck passing, back stabbing, or any other dubious management decisions allowed on these premises.

Dick Hubbard, the founder of Hubbards Foods, was recently elected Mayor of Auckland City. During the campaign, it was apparent that some thought Hubbard’s approach and views naïve in the extreme. Nevertheless, Hubbard won a convincing victory over his opponent, who had based his campaign largely on a conservative fiscal responsibility platform.^[9-11]

Rod Perkins^{[ 12 ]} has outlined four characteristics of effective leadership in health care, and argues that quality of leadership depends on the context, thus a different style of leadership is required by clinicians. The leadership characteristics described: listening and communicating; encouraging and facilitating; having a shared vision; being goal oriented and getting things done; appear to a non-clinical observer to be consistent with the established literature on the subject of leadership in general. Perkins goes on to outline a difference between leadership and management which appears completely consistent with the views of Adair and others, thus undermining his own argument that a different model is required. ^{[ 13 ]}

Works have also been produced arguing that different styles of leadership are required for technology staff. For example, Glen has explained in simple and compelling terms why "geeks", as he calls them, are unresponsive to traditional techniques of leadership, however, little evidence is offered that the requirements of this group are significantly different from other professions where a high degree of technical knowledge is required, such as engineering.

Advocates of the view that any particular group requires a "special" form of leadership will quickly run up against the pragmatic experience of CEOs and other seasoned, professional leaders who are capable of and accustomed to providing differing leadership styles to meet the needs of whatever circumstances they find themselves in.

Market Forces
There are many areas where the public health care "market" does not operate in the same ways as other markets. Theoretically, free market forces create incentives that would mean, for example, that nurses’ salaries would be at a premium due to the worldwide shortage of trained nurses. The campaign for increased nursing wages which was directed at the New Zealand government during 2004^{[ a ]} indicates that these forces have not always been in effect or, at least, that there are other forces also at work.

Another identifiable characteristic of the good leader is the highly capable follower. Leaders are often heard to give credit to their staff when their organisations are successful. Collins addresses the old adage that "our people are important" and argues that it is not people per se that are important, but the right people. The definition of "right people" has more to do with character traits and innate capabilities than with specific knowledge, background or skills. Obtaining the right people is relatively simple in a large, well-functioning market, where there is much choice, but more difficult in the artificially controlled publicly funded health care market. One of the primary foundations of good leadership is thus undermined. Leaders may be forced to compromise on the personnel they hire and thus end up with inferior results in terms of choosing the right people. This may ultimately reflect poorly on the leader themselves.

These differences notwithstanding, there is sufficient evidence to suggest that the fundamental characteristics of leadership are not strongly influenced by environment and that good leaders will adjust their approach to suit a wide variety of circumstances. Collins considers that many people have the potential to evolve into level 5 leaders, reinforcing the views of Adair that leadership is a set of transferable skills that can be learned.

Leadership in Health Care and Health Informatics
What is meant by leadership in health informatics? In most cases, the answer to this in the minds of technologists seems to be the best technology or the best deployment of technology. In the world-view of the technocrat, leadership is demonstrated by conceiving and creating a clever system. This view ignores the very considerable practical problems associated with the end-users of such a system that may not share the technocratic perspective. This problem is reinforced by the technology provider industry:Awards are made for "best use of technology in health care"; Technology leaders in health care as in most other sectors are still chosen primarily for their understanding of technical detail. However, it is becoming apparent that obtaining good results in technology areas is increasingly a matter of mastering what the technology people call "people skills" or "soft skills".^{[ 14 ]} Leadership in the deployment of advanced information systems in hospitals and – more importantly – obtaining the organisational benefit from such deployment has been shown to be a significant factor in the success of these initiatives.^{[ 15 ]}

Peters encourages leaders to "lead with questions, not answers, engage in dialogues and debate, not in coercion" and to "conduct autopsies without blame." The latter seems particularly relevant for health care, but does imply some risks.

When Waitemata Health conducted its investigation into the tragic Lachlan Jones case under the Medical Practitioners Act 1995 which allows for the names of individual practitioners involved to be kept confidential instead of the more traditional public enquiry, the organisation was accused from all directions of attempting to cover up incompetent behaviour. It was apparently the intention of Waitemata Health to genuinely understand the root causes of the tragedy, an intent that W. Edwards Deming, the great quality guru^{[ 16 ]} would no doubt have approved of. Deming urged managers to dig deep into causes of poor quality, which necessitates that they "drive out fear" in the workforce There was a belief within the clinical and business leaders involved that inquisitorial enquiries rarely uncovered the truth, due to the highly threatening nature of the enquiry process for those providing evidence. Unfortunately, what was in all probability intended as a brave effort to challenge the traditional process and thereby move to a new reality foundered for lack of public support for the concept.^[17-18]

Innovation, by its very nature, usually requires that mistakes will be made. Thomas Edison is attributed with the comment, "I failed my way to success". The idea that we learn better from failures than successes is well established in management circles; where it has been said that if you’re not making 10 mistakes a day you’re not trying hard enough. It is hard to imagine how public support for this concept in health care could be obtained, and yet the evidence shows that this level of error is in fact common anyway.^{[ 19 ]} Without significant challenging of traditional processes, we, as a society, are in the situation of having the worst of both worlds: mistakes constantly being made, from which no one learns anything.

At least one hospital in New Zealand has embraced the challenge of embedding improved quality into leadership practices in its redevelopment programme. Waitakere Hospital in West Auckland has achieved a remarkable turnaround in quality in recent years by embracing alternative ways of dealing with traditional problems. Under the leadership of Robin Youngson, who describes himself simply as "clinical leader", professional conflicts between obstetricians and midwives is being replaced by multiprofessional teamwork. Although it is probably too early to judge the results, early indications show great promise. ^{[ 20 ]}

The Perils of Failing to Lead
Information systems developed by clinicians are increasingly becoming a feature of the health informatics landscape. It is not unusual for clinicians (or other staff that work closely with clinicians) who have an enthusiasm for computer systems to invest significant time in the development of systems of their own to support research and audit activities. These "databases" are commonly built using end-user development tools such as Microsoft Access. It is the nature of these systems to be developed incrementally and, thus, finely tuned to the needs of the individual. This is an entirely appropriate use of standard IT components, which is generally referred to as "end-user computing". Such an approach can overcome some of the more common issues with health care information systems that have been identified by researchers in the informatics field^{[ 21 ]} and, as a result, such clinician-driven innovations can come to be perceived by clinicians to be highly valuable tools. Since such systems are closely attuned to the needs of the individual lay developer, these systems are perceived as superior, in both cost and quality, to the corporate information systems provided on a formal basis by professional health informaticists. Over time, the locally developed systems can grow organically beyond their original individual scope, to become an integral part of the clinical process on a multi-user level. At this point, risks may be incurred that are not immediately apparent at the outset.

Multi-user systems involve a greater level of technological complexity and thus require a greater level of technological support capability. Providing this is typically far beyond the resources of the individual operating the system on a "part-time" basis. Even where this is not the case, the amount of effort required to manage the technology risks may result in the individual diverting more and more of their time to the technology issues, to the detriment of their regular responsibilities. In simple terms, the amount of time invested by clinicians in developing and maintaining databases may not return a improved quality of care or more efficient delivery of care commensurate with the effort involved in establishing and maintaining the databases in the first place.

These matters are extraordinarily difficult to evaluate objectively. A firm belief by clinicians in the value of databases may not be reinforced by IT providers, who will tend to consider systems that have been developed by end users to be ipso facto not mission-critical. End-user developed systems will in general be accorded the same service support level as any other file on the organisational network, such as word-processing files. This does not necessarily entail a poor level of service, but it does mean that the support level may be less that that required to ensure risk management appropriate to a 24-hour, seven-day-a-week clinical service. Simply because such a database can be made to work in a given environment for a period of time does not mean that it is always guaranteed to do so in all future environments. Periods of organisational change are particularly risky in this regard. On the other hand, clinicians are likely to take the view that their database must have the highest level of support under all circumstances, and the mere fact that the IT provider has been advised of its existence is all that is necessary to guarantee that this will happen.

There is a risk that incrementalism of this nature, without proper training and skills facilitated by appropriate leadership, will lead to adverse patient outcomes due to lack of accurate and timely information. This risk must be balanced against the situation which is unfortunately still all too common where clinicians do not have access to effective information systems of any kind.

All of this is one indication of the stage of evolution of the use of information technology in health care. Health care has been referred to as "still a rather immature user of information technology compared to other parts of society".^{[ 22 ]} The implementation of information technology is generally associated with innovation, and it has been observed that innovation in health care proceeds more slowly than in other areas of human activity.^{[ 23 ]}

To avoid the risk of harming patients as a by-product of such situations, it is essential that health informatics leaders firmly establish their credibility alongside the clinical groups that they work with. It is not enough to serve the needs of clinicians without question. It is also necessary to challenge, model and implement appropriate processes such that the risks that may only be apparent to the informaticist are mitigated. This cannot be achieved by people working only at the information technology level, it also requires knowledge and leadership from both side, informaticists and clinicians.

Technology experts are legendary for an idiosyncratic view of the world where everything is perceived through the lens of the technology that they work with, and inter-personal skills are low. These traits are unlikely to interact well with clinical groups unless there is some form of external facilitation of the process. In most organisations in health care as in other areas of society, technology skills are likely to continue to be in short supply. It is in the interests of everyone to find ways in which these scarce resources can be deployed to maximum effect.

Conclusion
Leadership is much more than setting a visionary strategy and bidding for funding to implement it. As well as the visionary strategy, leaders must have what Collins calls a "ferocious resolve" and "an almost stoic determination to do whatever needs to be done" to implement the vision.^{[ 5 ]} Further, leaders must exhibit traits that encourage their followers during tough times, while removing any obstacles to action. Above all, leaders must have humility and integrity and must lead by example. These characteristics are consistent with the generic principles of ethics and good behaviour in society, and are transferable across many areas of human endeavour.

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