Leading Health Organisations in New Zealand - Part 1

• Abstract
• Background
• Introduction
• The Relationship between Leadership and Change
• The Changing Nature and Attributes of Effective Leadership
• Distinguishing Between Leadership and Management
• The Potential for Leadership to Enhance the Workplace
  1. The business of nurturing leadership
  2. The importance of connectedness
  3. The importance of organisation wide learning
  4. The potential for the leadership development of followers

Click here for Part 2 of this paper

Abstract
This paper argues that:

• Clinical staff of all descriptions in the health system feel more satisfied at work if they see themselves as leaders contributing to positive changes within their organisation.
• Staff who feel connected to their organisation and the health system are more likely to be retained in employment.
• Workers who believe that leaders listen to their input and communicate with them regarding the continuously changing external environment feel valued.
• Satisfied, engaged and valued staff act as magnets for further recruitment into the health system.

Background
The work environment has the potential to provide part of the solution to New Zealand’s problem of retaining a skilled health workforce.^{[ 1 ]}

This paper has been written in response to an invitation from the Health Workforce Advisory Committee (HWAC) to discuss how leadership can positively support healthy workplace environments with particular reference to HWAC’s interest in improving retention and recruitment of a well-trained health workforce.

Introduction
The way to lead effective change within an organisation is to establish a sense of urgency, form a powerful coalition, create a vision, communicate the vision, empower others to act on the vision, plan for and create short-term wins, consolidate improvements and produce still more change and institutionalise new approaches.^{[ 2 ]}

If only it were this simple.

Problems arise when applying theories and normative models such as this in the state-funded health sector in a country like New Zealand. Leadership writers generally assume that workers at the operational level recognise as legitimate the goals and concerns of those in governance and top management. The operational level or operating core of the health sector is dominated by clinicians – doctors, nurses, allied health professionals and technologists – with professional, not ideological, concerns. Furthermore, health care professionals are strongly influenced by the ethics of duty.

This paper attempts to examine the elements that have been identified as components of successful leadership and management and place them in the context of a strategy to retain skilled staff in the New Zealand health service.

This paper therefore proposes to discuss:

1. The relationship between leadership and change.
2. The changing nature and attributes of effective leadership. 
3. Whether there is a difference between leadership and management. 
4. The potential for leadership to enhance the workplace including the:
• business of nurturing leadership
• importance of connectedness ^{[ a ]}
• importance of organisation-wide learning
• potential for the leadership development of followers.
5. The benefits of encouraging clinicians into leadership roles. 
6. The need for leadership development across all levels in the sector.
7. The critical role of trust in health care organisations.
8. The impact of leadership on retention and recruitment. 
9. The limited relationship between hierarchical leadership and staff retention. 
10. The likely impact of focused human resource management.

The Relationship Between Leadership and Change
Stace and Dunphy (1996) describe a relationship between leadership styles and the nature of change as shown in Figure 1.^{[ 3 ]} Their thesis is that different leadership roles are required depending on the scale of change being envisaged or undertaken and the style or approach to the change process.

Figure 1: Relating scale and style of change

They talk about major organisational change requiring charismatic leaders or commanders. Other leadership styles are shown in Figure 1. My observation over the past 15 years in the health sector in New Zealand is that the greater the scale of change (ie, the further to the right in Figure 1), the more it has been managed by decree, to the point where if corporate transformation has been required, the leadership style has been directive and coercive. The Government in the mid 1990s simply replaced CHE chairs if they failed to drive change programmes when this was required by the State to meet financial targets.

Critics of the Health Reforms of the 1990s would have difficulty with Stace and Dunphy’s model because it implies that coercive or at least directive measures are required to force transformational change. Health professionals respond positively to collaboration and consultation (and I would argue that a good deal of transformational change can be achieved through a good process). This theme will be discussed later in the paper.



The Changing Nature and Attributes of Effective Leadership
Peter Drucker identified four characteristics of leadership:

1. Leaders have followers – without followers there can be no leaders.
2. Followers do the right things and achieve results.
3. Leaders are highly visible and consequently set examples for others to follow.
4. Leadership is not about rank, privilege, title or money, rather it is about taking responsibility.^{[ 4 ]}

Leadership exists within an organisational context. Organisations are changing. The context in which health care systems operate is becoming more complex and, therefore, leadership is dynamic within a health care organisation. The contextual element is itself very dynamic with leadership ebbing and flowing between and through groups and individuals.

There is no Holy Grail of effective leadership. It is construed differently by people depending on their role within or external to an organisation. It also depends on the position or setting from which people observe leaders. Effective leadership is context dependent and its attributes change over time. An effective leader in one setting, may be ineffective in another. Furthermore, there is disagreement about what constitutes effective or good leadership. Health professionals have traditionally construed effective leaders as those who obtain additional resources to support clinical activity. Ministers of Health, on the other hand, construe effectiveness on the part of District Health Board (DHB^{[ b ]} ) Chairs as living within allocated resources and avoiding political conflict.

In 2002, a group of senior managers and clinicians in DHBs and non-governmental organisations (NGOs) undertook a repertory grid exercise^{[ c ]} in which they identified constructs of effective leadership in the New Zealand health sector. The major constructs could be grouped under the following headings:

1. Listening and communicating.
2. Encouraging and facilitating.
3. Having a vision that they shared.
4. Being goal oriented and getting things done.

I will discuss these points using a model of health care that identifies governance and political leadership in the sector as being in a fundamentally different locale from those operating at the core of the clinical delivery system. This model, shown in Figure 2, depicts the system as a hierarchy with an apex and operating core. The focus of those at the top is strategic direction and their value drivers are ideological. This is often described in utilitarian terms – the greatest good for the greatest number. At the operating core, where the clinical activity of the organisation is centred, the focus is on best practice and the value drivers are professional.

It is noteworthy that if leaders at the apex balance an ideological and strategic approach with a strong values approach, they can demonstrate a commitment to a professional’s duty of care in their everyday actions. This can be seen by those at the operational level as supportive of their professional values and strengthens the potential for a partnership between managerial leaders and clinicians.

Figure 2: Value drivers in publicly-owned health organisations

This way of conceiving of healthcare organisations provides a context for discussion of the challenge of the four points above.

1. Listening and communicating
Leaders in health settings are located at all points at and between the Apex and the Operating Core. Irrespective of where they are located, they need to be able to gather information and intelligence from both the top and the bottom. This means leaders must be able to listen to people at all levels.

Using the organisational model depicted in Figure 2, some leaders work at or close to the apex of the organisation while others work at or close to the operating core. Irrespective of where the leader is to be found, the job of leadership in contemporary health organisations is to manage a variety of agendas which are subject to continuous change. Irrespective of the setting, the role is to balance innovation and change (which is usually being advocated from the apex) with maintenance of service delivery and ongoing activity (from the operating core). Those at the apex in health organisations seldom really understand the business of the operating core. Therefore, the job becomes one of creating conditions in which innovation and improvement can emerge from teams operating on the ground. The critical leadership competency here is communication. Constructs expressed by participants included the following:

• Listened, understood, implemented, reviewed.
• Communicated vision and direction.
• Communicated ideas and made it happen.
• They developed a listening understanding.

2. Encouraging and facilitating
Teams exist throughout health organisations. The job of health care (be it policy work, planning, managing or delivering) is no longer a job for individuals, it is a job for teams. Furthermore, professionals have cultural characteristics which make them different from one another and from managers. They operate from different value and belief systems. For example, nurses as a group find clinical pathways enhance their autonomy while doctors consider pathways to be systems which reduce their autonomy.^{[ 5 ]} People in different disciplines have different frameworks of meaning and consequently contest the goals and missions of their employing organisations. Facilitating groups, encouraging individuals and teams along with mediating differences between them is central to the leadership role in the health setting. Constructs from participants that voice the above include:

• Gave the clinicians a voice. 
• Consulted widely. 
• Used silence appropriately and spoke only when able to be constructive.
• Shepherded. 
• Interpersonal skills - the ability to bring people along with the changes. 
• Empowered people to take responsibility for their actions and gave them feedback on their actions

3. Having a vision that they shared
Leaders have visions, purposes, goals and objectives for followers to identify with and work toward. Creating a vision requires recognising what is possible for the group being led, which in turn requires intelligence to assess the skills of the group. In addition, leaders in the health sector need to know where the group wants to be led. Failure to recognise and take this into account results in leadership failure. For example, if a group of clinicians believes that it is being led in a direction that will involve members in rationing choices that they believe are unacceptable, members will abandon the leader. Leaders have to be able to get their followers to co-operate with one another as well as with them in order to achieve the vision. Achieving co-operation requires a range of interpersonal skills. Constructs from participants included:

• Inspired people with vision by articulating complex things into simple things.
• Clear sense of purpose and direction. 
• Clear goals/explanations. 
• Thought about the big picture. 
• Created clear visions/strategies. 
• Articulated sense of direction/clarity. 
• Vision for health outcomes. 
• Inspired and used creative processes to achieve a commonly shared vision.

This repertory grid exercise has limitations with respect to the issue of vision. On reflection, it is notable that none of the participants referred to consumers, clients or patients, or the role of leadership in giving these groups a voice. If the exercise was repeated today, I can imagine that leaders who related to consumers would be identified as being particularly effective.

4. Being goal oriented and getting things done
Leadership requires a vision, purposes and goals that cannot be obtained without a leader’s assistance. These ideas were articulated by participants in these terms:

• Got things done. 
• Would deal with purpose at all levels. 
• Set goals and targets and met them. 
• Met his and others expectations. 
• Did what was required when it was required.

Effective leaders have the skills to know how to sell a concept to their colleagues and, in turn, how to gain collegial support. They have a sense of timing and know when to stop short of advocating for an integrated concept or plan, instead seeking support and permission to take the next step.

 

Distinguishing Between Leadership and Management
Leadership and management writers address the question as to whether management and leadership are the same in a variety of ways. One approach is to distinguish between transactional and transformational leadership and then define management in the light of the former.

Transactional leadership focuses on the accomplishment of tasks and good worker relationships in exchange for desirable rewards. However, it may encourage the leader to adapt their style and behaviour to meet the perceived expectations of the followers. The key point is that managers like transactional leaders focus on tasks and processes.

In contrast, transformational leadership occurs when leaders "broaden and elevate the interests of their employees, when they generate awareness and acceptance of the purposes and the missions of the group and when they stir their employees to look beyond their own self-interest for the good of the group".^{[ 6 ]} In contrast with transactional leadership or managers, transformational leaders focus on people.

Another approach to distinguishing between leadership and management is to identify what leaders and managers do. Following Drucker’s classic line "Effectiveness is doing the right thing; efficiency is doing the right thing right",^{[ 7 ]}  it has been asserted that leaders do the right things and managers do things right. Put another way, processes and things can be managed but it is people who are led. Management works with processes, models, systems and structures. Leadership on the other hand is totally focused on people, their potential, their impact and what makes them function optimally.


The Potential for Leadership to Enhance the Workplace

1. The business of nurturing leadership
Four contextual influences that have the potential to encourage or nurture people into leadership roles have been identified in a seminal article in the Academy of Management Review ^{[ 8 ]} written by Pawar and Eastman. Providing the appropriate context in the health system is challenging but we should not ignore these influences:

• Organisations should be continuously seeking to adapt to change rather than seek to become more efficient. An "adaption" orientation rather than an "efficiency" orientation is more nurturing for those developing leadership roles. Throughout the 1990s, the public health sector in New Zealand was characterised by a drive to save money, spend less, contain costs and improve efficiency. These strategies impact negatively on an organisation’s ability to nurture leadership. Research suggests that leaders will emerge if the organisation is continuously orientated towards changes in its external environment and seeking to adapt to them.
• Organisations should have straightforward, easily understood organisational design structures. Uncomplicated structures with clear lines of responsibility and accountability have the greatest potential to nurture leadership. Simple structures are preferred over intricate arrangements with a mixture of complex dotted-line accountability provisions. While large health systems such as DHBs do not lend themselves to the simple organisational designs possible in a primary care setting, those with decentralised structures and identified decision points will be more nurturing of leaders than their complex counterparts.
• The primary focus of leadership should not be on the activities taking place at the workface or operational level. Rather, effort and energy should be directed to activities that continually impact on the organisation from outside. Organisations that emphasise the role and opportunity of taskforces, planning groups, working parties, project teams will be more empowering to members of the organisation than organisations focused entirely on activities that take place at the workface. This raises particular challenges for health organisations that employ many of their most talented people at the workface – a place where work of immense technical and human importance takes place. This raises questions for leaders because some of the most important work done by health care organisations is done at the operational level. What is important is that the work of planning groups, task forces and others in staff functions be seen to be adding value to the community.
• The form of governance should reflect the interests and concerns of the key groups working in the organisation. Pawar and Eastman refer to "market", "bureaucratic" and "clan" modes of governance.^{[ 8 ]} The latter have been found to be the most effective when it comes to nurturing leadership within organisations. While challenging, there are a variety of ways these different systems of governance can be incorporated into publicly funded health systems. The appointment of at least one clinician to the boards of Crown Health Enterprises in the 1990s was one response in recognition of the desirability of those in governance to relate directly to those at the operating core.

2. The importance of connectedness
In a qualitative study of the relationship between pairs of mental health clinical directors and managers working in the New Zealand system, Dr Lyndy Mathews found that the notion of connectedness was a unifying theme.^{[ 9 ]} In her words:

Staying connected is the central concept from this research. It is about achieving and retaining connection. . . . it (connectedness) embraces the apparent contradiction of trying to provide effective leadership in a system characterised by chaos and change, disconnected accountabilities and responsibilities across the wider system.

She notes that providing strong leadership and direction is central to the role of mental health managers and clinical directors and they need to be connected to a range of stakeholders including:

• those they manage 
• the government and purchasers 
• the community 
• other leaders.

The need for connectedness is challenging because leadership in the health sector requires reference to a policy context which has roots in politics and the agencies of central government. Clinicians who take leadership roles do so at some personal risk – there is the likelihood of their losing connectedness with their clinical colleagues. Employees generally want to feel a connectedness with the system in which they work and to be travelling on a journey that makes sense to them, with people they respect. Because of constant change coming from central or regional agencies, leaders are critical to ensuring connectedness. Without leaders people disconnect.



3. The importance of organisation wide learning
The learning organisation has been defined as an organisation skilled in creating, acquiring and transferring knowledge, and at modifying its behaviour to reflect new knowledge and insights.^{[ 10 ]} Within this context, organisational learning is concerned with understanding organisational processes and systems and, importantly, how the organisation can improve its performance. Health sector agendas in 2004 are new and challenging, yet the New Zealand tradition is one of focusing on individual learning. Medical staff in particular have financial provision for continuing medical education (CME) in their contracts with DHBs. (Notwithstanding that often the content of professional conferences is changing to reflect changing imperatives of knowledge management.) The pharmaceutical companies have traditionally supported CME for primary and secondary care doctors.

Leadership can be a by-product of organisational learning, however, there is no tradition of education, training and development in respect to organisational learning (a prerequisite to becoming a learning organisation). The opportunities for employees to develop into leaders have previously been limited. There is a consensus that leadership can be developed, it is not something that we are born with.



4. The potential for the leadership development of followers
Quality improvement initiatives are engaging clinicians and managers in countless ways. People other than those in designated leadership or management roles are being developed as leaders through the development of new ways of doing work. For example, a member of a surgical team may be delegated (or through their own initiative may take on) the job of developing a clinical pathway. The leadership role here will last as long as the job takes. It may be quite transient. However, followers such as the member of the surgical team identified in this example can develop the attributes of leadership in the context of projects taking place as organisations grow, develop and adapt.

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Footnote

a.	The word connectedness is used to refer to the way individuals engage with real, practical or hypothetical issues in their workplace, which are linked to their prior knowledge and congruent with their beliefs and values.
b.	Under the New Zealand Health & Disability Act 2000, 21 District Health Boards (DHBs) were created throughout the country. Each DHB is responsible for both the funding and provision of services within a defined geographical area. Typically, public hospitals form a substantial portion of the provider operations of a DHB.
c.	As part of a class exercise, participants were asked to identify 6–8 people they knew who either were or had been in leadership roles in the health sector. They were then asked to write the names of these people on a piece of paper as follows: in the first of three columns, they were to write the names of the effective leaders; in the middle column, they were to write the names of people they thought were neither particularly effective or ineffective; and in the third column, they were to write the name of those people they thought were ineffective leaders. They were then asked to think about the first effective leader (ie, the person whose name appears at the top of the first column) and write down what it was that made them a more effective leader than the people whose names were at the top of columns two and three. When they finished writing propositions in response to this question, they were asked to answer the same question with respect to the second person in the first column compared with other people whose names were in columns two and three. The strength of the methodology is that when applied correctly it avoids researcher bias, the researcher never knowing the names of people considered effective or ineffective, and avoids informer embarrassment.

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