Four Leadership Cornerstones for Health Care

For the past twenty years the Center for the Health Professions here at UCSF, and the precursor programs at Duke University and the University of North Carolina at Chapel Hill, have divided emphasis more or less equally between research and policy work on where the health professional communities of the U.S. should be to create a better system of care and how they could get there. This second theme has generally been carried out under the theme of leadership development or, at times, organizational change. Today the Center for the Health Professions sponsors four high profile national or statewide leadership initiatives for the Robert Wood Johnson Foundation, the Pew Charitable Trusts, the California HealthCare Foundation, the California Endowment and the Gordon and Betty Moore Foundation. In addition, we sponsor half a dozen other initiatives to advance the practice of leadership among health care clinicians. Increasingly we are working directly with hospitals, professional practices, state associations, and care systems to bring what we have learned from two decades of practice in developing leaders.

The argument for a leadership investment in health care has changed much over the past two decades. For many years health care was an insulated, cost-plus reimbursed business. The task was: Do your best delivering the services and pass along the bill. We took more care to maintain the professional and institutional silos then we did in focusing on what was the most effective way to delivering an outcome. The regulatory infrastructure, lack of a market, professional jealousies and few viable alternatives kept the system pretty much intact. Increasingly, but still at a glacial pace, the organizations and emergent systems that structure and deliver care are turning a responsive eye to quality improvement, cost effectiveness and consumer satisfaction. I realize that there is much agreement on this; what remains is the development of the leadership and management disciplines to deliver such a transition over the next decade. This will require clinical leaders to project competency in four broad domains of leadership: purpose, people, process and personal.

Increasingly, the leadership programs and services at the Center for the Health Professions are being built around these four themes. For the most part our existing programs project these competencies, but often under different names and categories. As we move to realign our work to encompass these competencies, it may be useful to give a general introduction to each.

Purpose - Proverbs 29:18 warns us that without a vision "the people will perish". Direction has always been one of the defining marks of an effective leader and that is what purpose is all about. How to take where we have been, the challenges we face today, and the desired future state and translate what we have learned into a vision which appeals to both the heart and the head, motivating others to move forward. Beyond crafting a vision, the competency of purpose also includes understanding and responding to organizational mandates, developing and projecting organizational mission, clarifying and using core values, understanding the changing environment both internal and external to the organization, embracing a capacity for creativity in the development of responses, translating these challenges and creative responses into medium-term strategies, pushing these strategies into short-term objectives and plans and developing and sustaining new partnerships and collaborations. A long list, but there is one more essential trait for the competent leader to project around purpose: adaptability and responsiveness. While there will always be some things that one cannot anticipate, purpose prepares the leader to respond to the inevitable with grace and courage.

People - The essential difference between doing a good job and doing a good leadership job is the ability to accomplish work through others. Many people have the technical skills and many of these even have a vision of what needs to be done. Fewer have the ability to create relationships that bring others to the work in a unified manner. The elements of this competency domain are many and varied but include the following: building effective teams, creating environments for giving and receiving feedback, managing relationships up, down and to the side, motivating and developing others, building consensus, gaining and using power, developing interpersonal communication skills including listening, having difficult conversations, working with diverse populations and needs, and building positive work environments. All of these competencies combined have the power to align and inspire the contributions of those we seek to lead.

Process - Work still needs to be accomplished and it will fall to the competent leader to possess an array of technical process skills to accomplish these tasks. In all leadership work there is a need to understand the core activity that one is leading. It is not necessary to have learned it from the bottom up, even though most leaders have come to their roles in this fashion, but one must know the business first before leadership can happen. Beyond this basic knowledge there are a number of more generic process skills that need to be a part of every leader's toolkit. These include: designing operation plans to enact strategies, using project management structures for control and evaluation, using budgeting and financial management principles and techniques, making a relevant business case for an undertaking, managing a change process, managing conflict within the organization, using decision making, and developing and using process improvement projects. These competencies must be linked back to the purpose. Much mischief occurs in health care because these core process competencies are not present, which can cause the implementation of any strategy to fail.

Personal - This domain is about the individual as a leader and their personal attributes. Few in leadership roles will have success without adequate attention to this competency. In many ways it is key to the successful deployment of the other three domains. The skills in this area vary from the most philosophical to the most practical and include: developing self-knowledge, particularly of strengths and areas needed for development, managing time and energy, using communication skills interpersonally and publicly, developing a capacity for self-regulation, maintaining integrity and developing trusting relationships, demonstrating courage, valuing leadership style and presence, balancing professional and personal life and maintaining resilience. The personal is about using self as an instrument of leadership. While some excel at this competency naturally, others bring a practiced cultivation of self, much like the Greeks who once encouraged the conscious development of all virtues.

After twenty years of doing work in this area, these four broad domains stand out as the paramount touchstones for leadership in health care. Mastery of these will be essential as leaders address the enormous tasks ahead of remaking our health care system. These are not competencies that one develops in a single training session or even an extended program; better that they are thought of as a life's work in which refinement of established skills and responding to new challenges is a continual process of growth and development.

The Center for the Health Professions is proud of its work in this area to date and grateful for the support and encouragement from the institutions listed above and others who have recognized the value of such work. In the coming months we will begin a more aggressive effort to take the lessons learned from the last 20 years and roll out new ways to transfer the leadership knowledge in the four competency domains to small professional practices, health systems, professional organizations; any part of the health care system which sees that making it through the challenges of the next decade will require new and better leadership and management skills throughout the organization.

If this challenge speaks to you, I encourage you to email me with your ideas as to how our work in these four leadership domains could help address your needs.