appendices · suggests that the new world demands that leaders be visionaries, change agents,...
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CHAPTER ONE - STUDY BACKGROUND 2 THE OPPORTUNITY 3 THE ORGANIZATION 6
CHAPTER TWO - LITERATURE REVIEW 10 REVIEW OF ORGANIZATIONAL DOCUMENTS 10 REVlEW OF SUPPORTING LITERATURE 13
1. Leadership 13 2. Physician Leadership 21 3. Cornpetence 25 4. Leadership Cornpetencies for Physicians 30
CHAPTER THREE - CONDUCT OF RESEARCH STUDY 38 RESEARCH METHODS 39 DATA GATHERING TOOLS AND STUDY CONDUCT 40
INTERVIEWS 41 QUESTIONNAIRES 46
CHAPTER FOUR - RESEARCH STUDY RESULTS 50 RESEARCH FlNDlNGS 51
INTERVIEWS 51 QUESTIONNAIRES 67
CHAPTER FlVE - STUDY INTERPRETATION, 81 CONCLUSIONS AND RECOMMENDATIONS 81
INTERPRETATION AND CONCLUSIONS 81 RECOMMENDATIONS 93
CHAPTER SIX - RESEARCH IMPLICATIONS 1 03 ORGANlZATlON IMPLEMENTATION 1 03 FUTURE RESEARCH 1 07
CHAPTER SEVEN - LESSONS LEARNED 110 RESEARCH PROGRAM LESSONS LEARNED 111 PROGRAM LESSONS LEARNED 120
REFERENCES 124 APPENDICES
APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX
CHAPTER ONE - STUDY BACKGROUND
Health care organizations today are complex systems, continually seeking to
adapt to ever-changing, unpredictable environments. Many factors contribute to
this instability. Some of these include: rapid developments in technology,
increased access to vast amounts of information, evolving demograph ics, major
shifts in consumer demand for services, and the need for accountability. AI1 this
at a time when resources, both financial and human, are limited.
Leadership and leadership competencies have become topics of great relevance
to organizations because of the need to navigate through the "murkiness" toward
a vision. Leadership is no longer taken for granted. Widespread agreement exists
that a proactive approach is essential if the best people are to be selected to lead
organizations through these turbulent times.
Like other health care organizations, the Capital Health Region (CHR) is in a
state of continua1 transition. The CHR is committed to involving physicians in
decision-making throughout the organization. Because of this cornmitment, the
Departmental structure within which the medical staff operate is gaining
increased attention. There is agreement that formal (paid) leadership positions
for physicians (Clinical ChiefdDivision Heads) are critical and make a difference.
There is also consensus in the literature that leadership cccompetencies," or skills,
knowledge and abilities, can be identified and learned and are a must for
effective leadership.
In the past, physicians in formal leadership roles (Clinical Chiefs and Division
Heads) have volunteered, been appointed or selected through a variety of other
mechanisms. The goal of this research project was to engage key stakeholders,
such as physicians and administrators, in a process of identifying the key
competencies required of physician leaders. To develop a shared understanding
Of leadership and to help clarify the roles and expectations for physicians
occupying these positions, I chose to involve people in this research project who
could provide information and insight into the depth and breadth of the issue.
This chapter will review the opportunity for this research project.
THE OPPORTUNIN
The opportunity for my research project involves the identification of the
leadership cornpetencies required of physician leaders in the Capital Health
Region (CHR). The inquiry will focus on the perspectives of physicians in both
forma1 and informa1 leadership positions as well as administrators in the
organization. The goal is to create a framework that will enable the organization
to select the most appropriate physicians for formal leadership positions. In
addition, the framework could be utilized for the purposes of evaluation as well as
assisting physicians to identify their own developmental needs as leaders.
Currently, a description of the roles and responsibilities of the Clinical Chiefs is
outlined in the CHR Medical Staff RuIes (Interna1 Document, May, 2000). While
the roles and responsibilities for these positions are clearly described, the
qualifications in terms of skills, experience, and education have not been forrnally
identified. The opportunity is to obtain this information through a process of
systematic inquiry to gain the perspectives of physicians in both formal and
informal leadership positions as well as the health care administrators with whom
they work closely.
Research Questions
What are the leadership cornpetencies required of physicians in forma1
leadership roles in the Capital Health Region?
How is leadership defined in the Capital Health Region?
From their perspective, what skills, knowledge, and abilities required of
physician leaders? From the perspective of their peers, what skills,
knowledge, and abilities are required of physician leaders? Frorn the
perspective of non-physician leaders, what skills, knowledge, and abilities are
required of physician leaders?
How do each of these groups rank these competencies in terms of
importance?
How can al1 stakeholders be involved in a process to identify core
cornpetencies for physicians?
How can the CHR support its Clinical Chiefs/Division Heads in the
development of these competencies?
The identification of the leadership cornpetencies required of physicians will
increase the CHR's ability to identify and select the most appropriate physicians
for formal leadership positions. The information gained through this process
could also help current leaders identify their own developrnental needs. ln
addition, the organization could use this information to develop an evaluation
framework and to support current or potential physician leaders.
An increased awareness of the competencies required of physicians in
leadership positions is one way an organization can move toward being what
Senge (1 990) calls a learning organization - "an organization that is continually
expanding its capacity to create its future" (p. 14). In a world of rapid change,
health care organizations and physicians need to be continually adapting to their
environments in order to be able to work together. One way to adapt is to clarify
roles and expeclations.
The need for physician leadership has been acknowledged by the Capital Health
Region. This cornmitment is dernonstrated by the presence of formal, paid
leadership positions for physicians. Physicians are now included in decision-
making throughout the organization. This is supported by one of the CHR's
guiding principles which is to "encourage leadership at al1 levels by supporting
everyone in working towards achieving the vision [CHR Annual Report, 2000, p.
8)."
Historically, a transactional leadership approach was used with physicians where
there was an exchange of rewards for compliance (Zaher, 1999). Physicians,
according to Zaher, were often appointed to formai leadership positions and paid
to act as liaisons between the organization and other physicians rather than to be
true members of the leadership team.
Bass (1 985) argues that, while transactional leadership is one way to maintain
quality, for the most part this approach leads to mediocrity. WhiIe an exchange
takes place, nothing unites the leader with followers in a commitment towards a
common goal. Today, several factors support the need for leadership that goes
beyond the traditional transactional approach. First, a more informed public is
demanding increased accountability from health care organizations and from
physicians. Second, the shrinking pool of physicians in Canada is making it more
difficult for organizations to compete when trying to recruit the best people. Bass
suggests that the new world demands that leaders be visionaries, change
agents, catalysts and "architects" of the future. Zaher (1 996) agrees that the
physician leader of the future will need to be "a process connector who sees
illness as a whole, a knowledge builder who liberaies information, a visualizer
who sees the future, a strategist who formulates the path to the vision, a project
manager, a team builder, a value creator who optimizes the relation between
cost and quality, a generalist, a change master, and a market shaper who keeps
an eye on customers and cornpetitors (p.2)."
There is growing recognition in the literature across North America that the role
of physicians working within health care organizations is becoming increasingly
complex (Larson, 2000; Sotile and Sotile, 1999; Lok and Crawford, 1 999;
McKegney, 1989; Pasternak, 1999; Bujak, 1999). For this reason, it is
increasingly important to identify the leadership competencies necessary for
physicians. lnvolving stakeholders in my research project such as physicians
currently in forrnal leadership positions, physicians who are not format leaders
and health care administrators, will increase the understanding of al1 about this
important issue. An inclusive process will also allow current leaders to reflect on
their own beliefs about leadership competencieç and how they are developed.
THE ORGANIZATION
The Capital Health Region (CHR) was formed in 1997 as part of a provincial
initiative to increase public participation in decision making by dividing the
province into a series of geographic regions. Each region is now responsible for
organizing its own hospital and community-based health care services. The CHR
provides hospital, community, home, environmental and public health services
including education and prevention to the peopIe living in the capital region.
Approximately 2,300 square kilometers, the region serves over 340,000 local
residents in an area that stretches from the southern Gulf Islands to Port
Renfrew. The CHR also provides referral services for al1 of Vancouver Island.
Within the CHR, there are four acute care hospitals. Two of these are considered
community hospitals (Saanich Peninsula Hospital and Lady Minto Hospital) and
two are considered tertiary care hospitals (Royal Jubilee Hospital and Victoria
General Hospital). Tertiary care is defined as care that requires highly
specialized skills, technology and support services -- such as heart surgery and
renal dialysis. Tertiary care is usually provided in facilities serving large regions
or the province as a whole. The Royal Jubilee and Victoria General hospitals are
considered te rtiary care referrals centers for Vancouver Island.
Approximately 870 members of the CHR rnedical staff provide care for patients,
residents and clients. The medical staff includes physicians, dentists and
midwives, the majority of which are physicians. The CHR hospitals are not
academic health science centers. An academic health science center is
considered to be a hospital with a forrnal university affiliation that has major
research initiatives and provides substantial training for medical students.
Physicians practicing in the CHR are organized in two different ways, depending
on the purpose. The first is by a Program Management mode1 of care; the
second is by a Departmental structure. Both structures employ physicians in
forma1 (paid) leadership positions . The Program Management model of care is
an operational way of delivering services based on the needs of separate patient
populations. The mandate of the Medical Departmental structure relates to
professional practice and quality of medical care detivered in the region. The
Department structure is organized according to the clinical specialty areas of
physicians. The purpose of this research project relates only to the Medical
Departmental structure in the CHR.
In the Program Management model of care, services are organized according to
the needs of the people who use them. The nine programs are: Cancer Care,
ChilWouth and Maternai Health, Community Health, Digestive Health, Health
Restoration, Heart Health, Lung Health, Mental Health and Seniors' Health. In
addition to the nine programs, there are a number of designated "core services"
which include: Medical Imaging, Laboratory Services, Emergency Care, lntensive
Care and Palliative Care. Each program is CO-directed by a Medical Director (a
physician) and a Regional Director (a non-physician).
The Medical Department structure is organized into fifteen Departments based
on area of clinical specialization. These are: Family Practice, Medical Services,
Surgical Services, Pediatrics, Cardiac Services, Psychiatry, Medical Imaging,
Laboratory Medicine, Obstetrics/Gynecology, Neurosciences, Geriatric Services,
Emergency Medicine, Intensive Care, Anesthesia and Midwifery. Each
Department has a Clinical Chief who reports to the Corporate Medical Director
who is himself a physician. Depending on the size of the Department, several
Division Heads may report to the Clinical Chief. The responsibilities of the
Division Heads are similar but subordinate to those of the Clinical Chief and are
focused on the specific activities within the Division. The Clinical Chief of each
Department is a member of the Regional Medical Advisory Comrnittee (RMAC)
whose role is to provide advice and direction on the provision of medical care as
well as the overall quality of care in the region. The Chair of RMAC reports
directly to the CE0 who ultirnately reports to the Board of Directors for the CHR.
For the purposes of this research project, it is important to clarify the distinction
between the position of Medical Director and that of Clinical Chief of a
Department. The table in Appendix A outlines the key differences between these
positions. The main difference is that the Medical Program Director is an
administrative position responsible for program ope rations while the role of
Clinical Chief is one concerned with professional standards and the quality of
medical care provided by the rnedical staff (Le. physicians, dentists and
midwives). The focus of this research project will be on the role of Clinicai Chief
or Division Head. In this report, any reference to "physician leaders" or
"physicians in formal leadership roles" is rneant to refer to either the position of
Clinical Chief or Division Head. In addition, any reference to "ChieP' or "Chiefs" in
this report is intended to refer to either Clinical Chief (s) andor Division Head (s)
within the organization within which the research project is being conducted.
This research project exists to engage people in a process to deveIop a shared
understanding of leadership and the competencies required of physicians in
formal leadership positions in the CHR. The work of this research project is
based on two main underlying assumptions. The first is that the role of the
Clinical Chief/Division Head is important and makes a difference. The second is
that there are specific leadership competencies required of physicians who
occupy these roles. The goal of the research project is to develop a framework
based on the input of key stakeholders in the organization - which includes the
physicians themselves. The hope is that the development of such a framework
will be used to help in the overall functioning of the organization by providing a
foundation for the selection and evaluation of Clinical Chiefs and Division Heads.
Summary
Change in health care is occurring at an unprecedented pace. Leadership, and
the appropriate selection of leaders, is critical now more han ever if
organizations are to adapt during these times of change and instability. The CHR
is committed to involving physicians in decision making and to promoting
leadership at al1 levels of the organization. One way to accornplish this is by
clarifying expectations and developing shared understandings. The purpose of
this chapter was to begin to outline the research project and to show how 1
worked to involve key stakeholders in a process to begin a dialogue about
leadership and "what it takes" to be a physician leader in the CHR.
The next chapter will describe a review of the literature related to this topic in
order to provide a context for the research project.
CHAPTER TWO - LITERATURE REVIEW
This chapter is divided into two parts. The first part reviews the organizational
documents relevant to my project and provides a setting for the research. The
second part of the chapter reviews the supporting literature related to four key
areas: leadership, physician leadership, competency and the leadership
com pet encies required of p hysicians. The review of literature provides a broader
context for the research project and gives the reader a sense that this is a topic
of interest and importance beyond the confines of the Capital Health Region.
REVIEW OF ORGANIZATIONAL DOCUMENTS
The Capital Health Region is rich in organizational documentation. It is an
organization in a state of transition. Since the regionalization process began in
1997, a number of documents have been published which attempt to bring
together a large number of diverse facilities and programs. The following is a
brief summary of some of the documentation that has relevance to this research
project.
Capital Health Region - Annual Report (2000)
This document describes the organization including the vision, mission, facilities
and services, financial statements, regional priorities, operational priorities, how
services are organized, how decisions are made, guiding principles, partnerships
and the function of the client relations office. lncluded in the report is the
structure of the Regional Medical Advisory Cornmittee and its role in the
organization.
One of the CHR's regional priorities is "improved labor relations environment and
availability of staff including physicians with required specialty skills." This priority
directly relates to the research question because the information gained from the
inquiry could ultimately improve the work environment, thereby enhancing
recruitment and retention initiatives for physicians with specialty skills. In other
words, if it is a good place to work, it will be easier to get good people
The operational priorities of the CHR include "responding to information from
clients, community and staff" and "quality of work life." These operational
priorities directly relate to the research question in two ways. First, the
organization will gain information from staff which will enable it to be responsive.
Second, the quality of work Iife of al1 health care professionals would be
enhanced if the most appropriate people held formal leadership positions.
The CHR uses five principtes to guide the way decisions are made in every area
of the organization. One principle encourages "leadership at al1 levels by
supporting everyone in working towards our vision." This principle directly relates
to the research topic because increased knowledge of the leadership
cornpetencies required of physicians is one way to ensure that the most
appropriate people are selected for forma1 leadership positions.
The CHR's Annual Report includes a brief description outlining the role of the
Regional Medical Advisory Cornmittee (RMAC) in relation to the medical staff.
The role of RMAC is to provide advice and direction on the provision of medical,
dental and midwifery care, as well as the overall quality of care in the region. In
addition, the document specifically outlines membership of the various Medical
Departments.
This document is relevant to rny research question because it dernonstrates that
this the Capital Health Reg ion is a hig hly-structured organization that supports
the role of physicians in decision-making.
Capital Health Region - Approved Board of Directors' Policies (Internai
Document, May, 1999)
This set of policies includes the CHRs policy governance process, executive
limitations and "endsn. The CHR is govemed by a Board of Directors who are
responsible for ends rather than means. This method of governance was chosen
to empower patient care providers to determine the "meansn while the Board
determines the "endsn. The role of the CE0 is to ensure the organizations'
accomplishment of "endsn and operation within the boundaries of prudence and
ethics.
Capital Health Region - Role Description of Medical ChiefIDivision Heads
(Interna1 Document, January, 2000)
Draft #2 (April 1999) describes the role summary and typicai duties and
responsibilities of the MedicaI Chief. This document directly relates to the
research question because the qualifications, skills, experience and education
have yet to be defined.
Capital Health Region - Medical Staff Rules (Interna1 Document, Draft, May,
2000)
The Medical Staff Rules (May 2000) include a description of the organization of
the medical staff, a description of the role of the Clinical Chief, Vice Chief,
Division Heads, Section Heads and the process for appointment of a Medical
Department Chief. Also included is a brief description of the process for review of
a Medical Department Chief and a brief description of the medical staff
commîttees. This lengthy document (44 pages) clearly delineates roles and
responsibilities of the medical staff practicing within the CHR facilities. The
document also clearly outlines the consequences to the medical staff if the niles
and regulations are not followed. Although the processes for appointment to the
medicat staff are clear, there is no indication of how decisions are made.
A review of the organizational documents of the CHR highlights three main things
about the organization. First, the CHR is a "top-down," highly structured and
hierarchical organization . Volumes of policy and procedures manuals describe
processes to follow for almost everything. Second, much of the information
available both in written form and on the internet depicts an organization that
values leadership and the developrnent of partnerships. Third, the organization is
still in its relative infancy since the regionalization process in 1997. As such,
many organizational documents have been recently revised in an attempt to
integrate a variety of policies and procedures from a diverse group of facilities
and services. When reviewing the organizational documents, one gets a sense
that this is a new organization coming together and struggling to develop an
identity.
REVIEW OF SUPPORTING LITERATURE
The review of the literature will focus on the foIlowing four areas:
1. Leadership
2. Physician Leadership
3. Competence
4. Leadership Competencies for P hysicians
1. LEADERSHIP
Leadership has fascinated humans for centuries. Despite the vast amount written
and researched on the topic, leadership remains an elusive concept that is
difficult to define. Stogdill (1 974) noted that there are practically as many different
definitions of leadership as there are perçons who have attempted to define the
concept over the years. And, each definition brings with it its own limitations.
During the industrial age, the rote of the leader was primarily to ensure work
efficiency. Leaders were relied upon to break processes into manageable parts.
These "specialn people set the direction, made the key decisions and energized
the troops (Senge, 1990). Leaders were portrayed as directing, comrnanding and
controlling. Providing leadership was viewed as an individualistic, non-systemic
activity .
Lambert, Walker, Zirnmennan, Cooper, Lambert, Gardner and Slack (1 995)
provide a history of six leadership theories. The traditional approach is autocratic
in nature, ernphasizing efficiency and quality control. The behavioral approach
focuses on a transactional relationship where there is an exchange between
leader and follower. The contingency/situational approach is based on the work
style of the employee where the leader is either more or less directional,
depending on the situation and need. The instructional leadershiphrait theory
insists that everyone can learn leadership skills. The community of leaders
approach is viewed as a shared process which promotes continuous
improvernent and assessment. Finally, the premise of the constructivist leader is
that knowledge is formed in the learner and brought out by a skilled teacher. This
approach emphasizes the reciprocal nature of the process which enables both
parties to develop a cornmon purpose.
Yukl's (1 998) review of research on leadership describes leadership in terrns of
the researchers' perspectives and area of interest based on skills, traits,
influence or role. In addition, many theories of leadership have emphasized
elements such as traits, behaviors, styles and situations.
The following is a brief review of various theories put forward by a variety of
authors on the subject of leadership. These include: trait theories, behavior
theories, leadership styles, situational theories, values-based leadership,
transformational leadership, servant leadership, transactional leadership,
leadership and management, and emerging perspectives.
Trait Theories
Trait theories such as the "great man or woman" idea highlight the person, who
he or she is, and what made hirn or her that way. Much of this research attempts
to identify characteristics that differentiate leaders from non-leaders. The
suggestion is that great leaders are born and not made. The characteristics
thought to contribute to great leadership include physical traits such as weight,
height, appearance and age; other capacities such as intelligence, scholarship
and fluency; and personality traits such as aggression, motivation, self-esteem
and extroversion (Bryman, in Gibson, Maclver and Picard, 1999). The main
limitation of trait theories of leadership is that they have no consistent predictive
value and are therefore of little practical use.
Behavior Theories
Behavior theories of leadership suggest that it is what leaders do that makes
them effective. Yukl (1 998) listed fourteen categories of leader behavior
including: planning and organizing, problem-solving, clarifying, informing,
monitoring, motivating, consulting, recognizing, supporting, rnanaging conflict,
team-building, networking, delegating, developing, mentoring and rewarding. The
emphasis of behaviorist theories is on trying to quantify the actions of leaders as
well as the resultant effects on followers. Much of the research in this area has
focused on rneasuring leadership be havior in terms of "task-oriented" and
"person-oriented activities and their resultant effects. There are several
limitations to this approach to leadership, not the least of which is the inability of
the researcher to infer any causal influence (Yukl, 1998). Behaviorist theories
also seem to discount a number of subjective variables which may also have
significant impacts on outcornes.
Leadership Styles
Leadership styles has been a popular approach to the study of leadership. Lewin,
Lippet and White in Gibson et al. (1 999) suggested that there are three basic
leadership styles: autocratic, democratic and laissez-faire. A style is defined as "a
manner of behavior rather than identified with any definite set of behaviors"
(Gibson et al., 1999, p.9). The main thrust of research on leadership style was
that people and groups will behave differently under leaders who behave
differently. The main limitation of the behaviorists' approach is that different
styles seem to be effective under different circumstances (Stogdill, 1974).
Situational Theories
Situational or contingency theory remains a popular framework for the study of
leadership. G iven the relative effectiveness of trait, be havior or style theories of
leadership, contingency theory simply states that appropriate leadership depends
on the situation and calls for a variety of approaches depending on the
circumstances. Proponents of contingency theory support the idea that there is
no "one best way" to lead under al1 circurnstances. This prevalent approach to
leadership suggests that effective styles and behaviors Vary depending on the
situation. The main criticism of contingency theory cornes from the supporters of
"values-based leadership." Gauthier (2000) rejects the moral relativism of
contingency theory and argues that universal ethical principles must always
underlie sound and sustainable leadership. Advocates for values-based
leadership rnaintain that "the moral error inherent in 'it al1 depends' is that there is
no limit to if' (OYToole, 1996, p. 105).
Values-Based Leadership
Values-based leaders beiieve that leadership should be based on principles.
Principles are "natural laws that are woven into the fabric of every civilized
society throughout history and form the roots of every family and institution that
has endured and prospered" (Covey, 1990, p. 33). Values-based leadership has,
as its foundation, the concepts of character, principles, values, ethics and morals.
In addition, values-based leadership also suggests that leaders are servants and
stewards who share a "covenant" with those they iead. Values-based leadership
adds a spiritual dimension and focuses on the leader as a person.
Covey (1 990) discusses the need for leadership to be centered on principles.
Effective leaders, according to Covey, are continually learning, are service-
oriented, radiate positive energy, believe in other people, lead balanced lives,
see life as an adventure, are synergistic, and exercise self-renewal. O'Toole
(1 996) suggests that values-based leadership is the only way to pull and not
push change.
Transformational Leadership
DePree (1 989) describes the role of the leader as one of servant and debtor.
Relationships between leaders and followers are described as covenants which,
according to DePree, "fil1 deep needs, enable work to have meaning and to be
fulfilling. They make possible relationships that can manage conflict and change"
(p. 38). He argues that leadership begins with a belief in the potential of people.
DePree describes the "art" of leadership as the ability to polish, liberate, and
enable these gifts. He argues that the best people working in organizations are
like volunteers - they have chosen to work there for reasons less tangible than
salary or power. DePreels emphasis is on a "covenantal relationship" based on
the inherent rights of the individual. These right include: the right to be needed, to
be involved, to a covenantal relationship, to understand, to affect one's own
destiny, to be accountable, to appeal, and to make a commitment. Relationships,
according to Depree, are more important than structure.
Kouzes and Posner (1 997) define leadership as "the art of mobilizing others to
want to struggle for shared aspirationsn(p. 30). To them, successful leadership
practices include challenging the process, inspiring a shared vision, enabling
others to act, modeling the way, and encouraging the heart. They suggest that al1
people look for four characteristics when selecting a leader: honest, fonvard-
looking, inspiring, and competent Yukl (1 998) describes leader characteristics
as: self-confidence, interna1 locus of control, emotional maturity, integrity,
socialized power motivation, achievement orientation and the need for affiliation.
Kouzes and Posner (1997) Say leaders are flexible, take initiative, and are able to
learn and to conceptualize. They found that "leaders.. .cornmitteci to their lives,
felt a sense of control over things that happened and experienced change as a
positive challenge" (p. 71 ). Covey (1 990) describes leaders as pro-active, willing
to take initiative, and able to make and keep commitrnents.
Implicit in the values-based definitions of leadership is the concept of "followers"
and the recognition that leaders are not leaders unless they have followers.
OSToole (1 996) and Kouzes and Posner (1 997) emphasize the notion that "a
person with no constituents is not a leader (p.1 l)."
Transformational leadership is defined in terms of the leader's effect on followers.
They feel trust, admiration, loyaity and respect toward the leader and are
motivated to do more than they originally expected to do (Yukl, 1998). At the
heart of transformational leadership are the concepts of inspiration, vision and
empowerment. Transformational leaders elevate the interests of their followers to
go beyond self-interest and generate an awareness and acceptance of a vision,
mission and common pu rpose (Gibson et al., 1 999). Transformational leadership
integrates ideas from trait, behavior, style and situational theories while
incorporating the concepts of culture, charisma, and visionary leadership. Recent
literature regarding leadership stresses the importance of developing shared
visions (Sennis, 1989; Senge, 1990; Covey, 1990, Depree, 1 989; Farrell and
Robbins, 1993).
Senge (1 990) emphasizes the need for leaders to develop shared visions. His
transformational approach to leadership includes five disciplines, not the least of
which is a shared vision that is created together. The second discipline is to
challenge our mental models - those deep persona1 beliefs we al1 hold. Third is
the discipline of personal mastery - the ability of individuals to realize persona1
capacities and dreams. The fourth is team learning - peoples' ability to
collaborate and share knowledge in groups. Finally, the concept of systems
thinking - a way of seeing one's own place in the big picture and recognize its
inter-connectedness with everyone and everything else.
Servant Leadership
Greenleaf states that the primary role of the leader is to serve others. Spears
(1 995) cites Greenleaf's notion of servant leadership in terms that it "emphasizes
increased service to others, a holistic approach to work and a sense of
community, and shared decision-making power (p.4). Greenleaf's main premise
is that able leaders empower others to do the work for themselves. At the heart
of servant-leadership is devoted serious attention to doing things in the service of
others (Spears, 1995). Although not rneant to be an exhaustive Iist, Spears
(1 995) has identified the following ten characteristics of the servant-leader:
Iistening, empathy, healing, awareness, persuasion, conceptualization, foresight,
stewardship, commitment to the growth of people and building community .
Wilson (1 998) further supports the concept of servant leadership as being a
necessity in today's complex, global environment where it is necessary to satisfy
multiple stakeholders.
Transactional Leadership
One of the most significant ways of classifying leadership has been to separate
transformational and transactional leadership approaches. Bass (1 985) describes
transactional leadership as an exchange process whereby the needs of followers
are met if performance measures up to the expectations of the leader. This
ciassic "carrot and stick" approach to leadership suggests that an exchange
takes place between followers and leaders where followers are rewarded for
cornpliance, either directly with a reward or indirectly by the avoidance of a
penalty or punishment. The biggest criticism of the transactional approach to
leadership is that it does not appeal to higher order needs and therefore has
Iimited effectiveness.
Bass (1 985) suggests that, although transactional and transformational
leadership are separate dimensions, a leader can be both transactional and
transformational at once. The transactional style of leadership emphasizes
manage rial skills such as establishing expectations, monitoring progress and
rewarding performance while the transformational style of leadership provides
the inspiration and motivation to manage change-
Leadership and Management
Bennis and Nanus (1 985) have discussed the difference between management
and leadership and suggest that leaders do the right thing while managers do the
thing right. Maccoby (2000) suggest that while both management and leadership
skills are important, it is not necessarily important for the same person in a group
to demonstrate both of these competencies. While leadership and management
are distinct concepts, there is some agreement in the Iiterature that the ideal
leader is one who also possesses some management skills (Yukl, 1998).
The term management is often a position linked with administrative functions.
While managers seek stability and predictability, leaders innovate and inspire.
Managers have their eyes on the bottom Iine, while leaders keep their eyes on
the horizon (Kouzes and Posner, 1997; Depree, 1989; Covey, 1990). Leaders
provide vision and motivation whereas managers faithfully and efficiently
executive the plans of the organization (Kouzes and Posner, 1 995, DePree,
1989, Covey, 1990). In this way, leaders provide the "ends" while managers
provide the "means." Covey (1 991) relates leadership to right brain thinking and
management to left brain thinking. The right brain deals with emotions, pictures,
wholes, relationships, synthesis, simultaneous and holistic thinking and is free of
time. The left brain deals with logic, words, parts and specifics, analysis,
sequential thinking and is bound by time.
Emerging Perspectives
Wheatley (1 994) describes organizations in terms of chaos where the leader's
role is to "bring us back to the importance of simple governing principles: guiding
visions, strong values, organizational beliefs" (p. 133). And, the leader's task is to
keep these principles clear while allowing individuals in the system their
seemingly random, chaotic meanderings. Wheatley stresses that leaders and
organizations can actually use chaos to create a natural order. One of her rnost
provocative suggestions is the concept of a "leaderlessn organization and cites
the building of termite towers as an example of a self-organizing system. She
sees organizations as complex adaptive systems where leaders emerge and
retreat as needed
Helgeson (1 995) studied leadership among fernale executives and identified
unique characteristics among female leaders. Women leaders, according to her
work, characteristically value people, relationships, cooperation, and
communication. The words used by the women Helgeson studied to describe
their work included: flow, interaction, access, conduit, involvement, network, and
reach. These words that above al1 emphasize relationships with people; they are
also process words that reveal a focus on the doing of various tasks rather than
on the compIetion
Several authors have provided different frameworks for thinking about
leadership. What they seem to al1 have in common is the recognition that
leadership is not mereIy a role or a position but a way of being. It is a process by
which one person influences another. Although considered relatively easy to
recognize, leadership remains hard to define. There does, however, seem to be
widespread recognition that leadership involves persuading others to temporarily
set aside personal goals to pursue common goals. Leaders cause the whole to
exceed the sum of the parts.
2. PHYSlClAN LEADERSHIP
In the past, physicians have operated as sole practitioners who wanted to be left
alone to practice medicine (Pugno, 1999; Lyons, 1999). It used to be simple - physicians cared for patients, business managers ran physician's offices, and
business executives ran hospitals (Zaher, 1996). Historically, physicians became
forrnal leaders only when they were either burned out, easing into retirement,
filling a perfunctory role no one else wanted, when they were dissatisfied with the
practice of medicine or disappointed due to failed job expectations (Zaher, 1996).
Today, the most common reason physicians cite for entering forma1 leadership
rofes is a passion for leadership and a desire for new challenges (Zaher, 1996).
A survey of chief medical officers in 1996 showed that the single most important
reason stated by physicians for entering into leadership roies was the perceived
opportunity for leadership. This reason was followed by the desire to affect
organizational policies and the enjoyment of the management aspects of clinical
practice (Kimmey and Haddock, in Zaher, 1 996).
Health care organizations today are cornplex, adaptive systems. Increasing focus
is being placed on the need for leadership by physicians as they are being drawn
closer and closer to the corporate setting (Bujak, 1999). Physicians throughout
the world are playing a greater role in the management of health care facilities
and services (Battistella and Weil, 1996). In addition, drarnatic evolutionary
changes in health care are blurring the divisions between medical and
administrative leadership (Zaher, 1996). Many of the forces that transform health
care challenge the traditional roles held by physicians. "Changes in the delivery
of health care are throwing physicians into new and unsettling roles" (Triester
and Schultz, 1997, p. 4).
There are rnany reasons physicians are natural leaders. First, they are trained to
use acumen and analytic ability to assess complex, interdependent conditions
and must often consider multiple problems concurrently. Medical schools foster
lateral thin king processes which help to integrate seve ral pieces of information
simultaneously. In addition, lateral thinkers tend to be creative and resourceful
(Zaher, 1996).
Magill (1 999) integrates the five fundamental practices of exemplary leadership
suggested by Kouzes and Posner (1997) to show why physicians are natural
leaders. He suggests that physicians already possess, exemplary, and use
leadership skills in their daily practice. For example, physicians routinely utilize
the skill of imagining possibilities as they imagine better futures for people with
chronic problems such as depression or addiction and give their patients
confidence and hope for a better future. The second is good communication skills
- a skill possessed by physicians who develop excellent interpersonal skills for
the purposes of taking histories, looking after children, etc. Finally, physicians
usually have the leadership skill of helping others realize their potential -the
primary goal of al1 leaders. Magill (1 999) encourages physicians to think of
themselves as natural leaders and urges them to take their rightful place in the
leadership of medicine for the 21st century.
Physicians have historically been leaders - guardians for the public good and
servants of the wider human community (deVau1 and Knight, 1994). Much
charismatic authority has been bestowed upon physicians with covenants and
oaths whereby the physician is a teacher, healer, leader, and guardian. Maccoby
(1 996) suggests that one reason physicians are natural leaders is because
people are motivated by either a belief in the leader's message or by fear of the
leader.
Physicians are in a pivotal ro[e to influence change. Cunningham 111 (1999)
suggests that physicians may be the only legitimate members of the health care
team that can make and irnplement clinical decisions in hospitals. Reinersten
(1 998) emphasizes that the presence of physicians in leadership roles provide
excellent leverage points for improvement of health care quality.
There are also many reasons why leadership within organizations is difficult for
physicians. By nature, physicians are not "company people." They are
accustomed to operating as the "captain of the ship" (Farrell and Robbins, 1993).
Their instincts lean toward being ferociously independent and individualistic
(Lyons, 1999). Zaher (1 996) suggests that physicians by nature distrust
management and have little respect for authority based on hierarchy. Instead,
they are impressed by accornplishment. Physicians are accustomed to a different
job culture (Cunningham 111, 1999). Several authors suggest the key is balancing
the heart of medicine with the business of medicine (LeTourneau and
Fleischauer, 1 999).
Physicians are used to functioning with autonomy and independence. They are
most comfortable working one-on-one in an authoritarian rather than participative
style. They are used to immediate gratification when managing patients instead
of having to adjust to the long-term outlook characteristic of leadership.
Physicians are accustomed to acquiring large amounts of data to be scientific
and objective about reaching conclusions rather than working with limited
information and relying on intuition and experience (Zaher, 1999).
Zaher (1 996) identified six areas of difficulty experienced by physicians who take
on forma1 leadership roles within organizations. These are:
1. psychological adjustment,
2. change from independent to dependent role,
3. change in focus from patient to organization,
4. naivete about organizational dynamics,
5. new skill requirements, and
6. change from a controlling role to one of persuasion - frorn a comfortable,
relationship with colleagues to one based on authority.
Several authors suggest that physicians need to take a leadership role in health
care simply because they understand the clinical aspects of providing patient
care (Reinersten, 1998; Cunningham 111, 1999; Schwartz, Pogge, Gillis and
Holsinger, 2000). It is also important to understand why most physicians chose
the profession - the desire to help others (Bujak and Annison, 1999).
Cunningham 111 (1 999), suggests that physicians may be the only legitimate
rnembers in health to make and implement clinical decisions.
Health care organizations and physicians have a mutually dependent
relationship. Conflicts can arise when physicians attempt to rnaintain professional
autonomy and hospitals attempt to maintain organizational stability (Longo,
1994). The time is right for physicians and organizations to work together to
respond to the complexities of the environment Physicians in leadership roles
are excellent leverage points and it is more crucial than ever that they work to
ensure quality health care (Reinersten, 1998; Schwartz, Pogge, Gillis and
Holsinger, 2000). Physicians need to recapture the essence of what it rneans to
heal and become architects of the future (Bujak and Annison, 1999). One
hallrnark of successful health care organizations is a positive physician culture
and meaningful physician involvement in governance (Lyons, 1999). There is
now widespread recognition of the importance of involving physicians in al1 levels
of decision making (Lumsdon, 1996).
Health care organizations of today are cornplex adaptive systerns, and
physicians throughout the world are playing a greater role in the decision-making
and problem solving within these organizations (Bujak, 1999; Battistella and Weil,
1996). Organizations have a responsibility to foster the development of physician
leaders by recognizing the extensive contribution they can make to the overall
outcornes of healthcare organizations (Guthrie, 1999).
3. COMPETENCE
The term competence, as it relates to physicians, is often defined as the capacity
or the qualifications to practice medicine appropriately. A competency is defined
as "the demonstrable behaviors, which combine skills, knowledge and attitudes
for a specific purpose" (Royal Roads University, MALT Learner Orientation Guide
99-1,2000). The terms competence and competencyare often used
interchangeably. For the purposes of this project, the term competency will be
used to mean a behavior that leads to competence.
Cornpetencies are directly reiated to leadership in that cornpetencies define the
skills, knowledge, and attitudes modeled by leaders. Since one of the CHR7s
guiding principles is "encouraging leadership at al1 levels by supporting everyone
in working towards our vision," the developrnent of a leadership competency
framework for physicians is one way to use the guiding principles of the
organization to work towards the vision.
A review of Iiterature on cornpetence and competencies reveals that the
development of competence is a process rather than a goal in and of itself. The
development of cornpetence is associated with practice as well as reflection. The
concept of competencies has existed for centuries. Medieval guilds had
apprentices learning skills by working with a master. Once the master was
satisfied with the apprentice's development, the apprentice would be deemed
competent at the craft. A more recent example is that of educators who have
created vast amounts of knowledge and skills to guide curriculum development.
For many years, frameworks of objectives have been built for the cognitive,
behavioral, and affective domains. These dornains can be compared to
knowledge, skills and attitudes (McLagan, 1 997).
Daniel Goleman (Goleman, 1998) writes about emotional intelligence as the
foundation for emotional cornpetence. He defines emotional intelligence as: "the
capacity for recognizing our own feelings and those of others, for motivating
ourselves, and for managing emotions well in ourselves and in our relationships
(p. 31 7). Goleman suggests that emotional intelligence, and therefore emotional
competence, is far more important for success than IQ. Goleman has developed
an Emotional Competence Framework that describes the core competencies he
believes al1 people require for success at work. The framework is built upon the
two domains of persona1 and social competence:
1. Personal Competence
Self-awareness, including ernotional awareness, accurate self-assessment, and self-confidence;
Self-regulation, including self-control, trust~orthiness~ conscientiousness, adaptability and innovation; and,
Motivation, including achievement drive, cornmitment initiative, and optimism.
2. Social Cornpetence
Empathy, including understanding others, developing others, service orientation, leveraging diversity and political awareness; and,
Social skills, including influence, communication, conflict management, leadership, change catalyst, building bonds, collaboration and cooperation, and team capabilities (Goleman, 1998, p.26).
McLagan (1 997) classifies competencies into six categories:
1. Task Competencies
The task view came as a result of many years of breaking work into manageable parts in order to lessen the amount of thinking required, eliminate performance variability, and spread best practices.
2. Results Competencies
Less common than task cornpetencies, this category adds the word ability to a result - for example, the ability to produce a profit.
3. Output Cornpetencies
An output competency is sornething that a person or team produces, provides or delivers.
4. Knowledge, Skills and Attitude Competencies
In this case, the subject matter, process abilities and attitudes, values, orientations and commitments (such as integrity or achievement) are called corn petencies.
5. Superior-Performer Differentiators
These competencies differentiate superior performers from others. They usually focus on the abilities of people in terms of intelligence and personality. Many companies use these types of competencies in selection and succession of employees.
6. Attribute Bundles
This is a collection of knowledge, skills and attitudes or tasks, outputs and results. Attribute Bundles are competencies typically used in terms of leadership, probfem solving and decision making.
McLagan (1 997) further describes three models of competency developrnent that
have been popular since World War II:
1. Differential Psychology
The focus of this model is on the elements of cornpetence related to human
differences, especially those that are hard to develop. The emphasis is on
intelligence, cognitive and physical abilities, values, personality traits, motives,
interests and emotional qualities. The focus is on inner drives rather than on
skills and knowledge.
2. Educational and Behavioral Psychology
This approach is driven by a desire to shape and develop people so they can be
successful and emphasizes the unique and innate abilities people bring to work.
The focus is on subject matter knowledge as well as the traits, values and beliefs
included in the differential psychology model. The underlying assumption is that
the performance environment is critical to the development of cornpetencies.
3. Management Sciences
The focus of this model is on the breakdown and analysis of work into parts so
that workers can be taught. The emphasis is on task lists, activity lists and
descriptions of tools and processes for effective performance. Although
knowledge, skills and attitudes are required, they are usually secondary.
Norcini and Shea (1 993) discuss why recertification processes should be based
on competency assessments. They claim that recertification programs should
have three goals. First, some aspect of the evaluation should assess the
competence of the individual as demonstrated in actual practice. This rnay be
achieved by an outcome assessment. Second, the evaluation should
demonstrate that the professional can respond appropriately to a wide variety of
problems. This might be seen as demonstrating an original knowledge base
while, at the same time, being knowledgeable of recent advances. Third, there
should be provision for the assessment of the interpersonal and moral
cornpetencies of the practitioner. In addition to skills, knowledge, and abilities,
qualities such as morals, ethics, and relationships with others must be included in
the assessment of professional competence . Professional competence is
thought to be important because the relationship between a physician and a
patient is one of unequal authority by virtue of the special knowledge possessed
by the physician. Patients are vulnerable to unscrupulous practitioners and a
simple assessment of outcome would not adequately evaluate competence
(Norcini and Shea, 1993, p. 99).
There is some criticism of the competency movement. Most seems to be related
to the concern that competence may be seen as an end rather than an ongoing,
lifelong, developmental learning process. Peter Vaill (1 989) cautions that the
competency movement does not capture the dynamic state of the work worfd. He
suggests that one core competency should be the ability to risk incompetence in
order for new learning to occur. "Competence should never be seen as a fixed or
static state (Vaill, 1989, p. 34).
The following general themes have been noted regarding competence:
Cornpetence should be seen as an ongoing learning process rather than an
end point.
Cornpetencies in the professional context cannot be assessed simply with
checklists.
Cornpetence is a multi-dimensional concept where attitude and self-
awareness is important besides skills and knowledge.
LEADERSHIP COMPETENCIES FOR PHYSlClANS
There is obvious interest in the topic of physician leadership in recent literature.
Both physicians and health care organizations have corne to acknowledge that
physician leadership is crucial as never before to ensure quality patient care
(Schwartz, Pogge, Gillis and Holsinger, 2000; McCorcle & Heet, 1997, Bujak,
1 998). The literature suggests two main reasons for this shift . First,
organizations are realizing that physicians in leadership roles can be excellent
leverage points for improving health care quality (Reinersten, 1998). Second,
there is recognition that physicians may be the only legitimate members in health
care to make and implement clinical decisions in hospitals (Cunningham III,
1 999).
What differentiates physician leadership from other leadership is the most
important competency of clinical expertise. Zaher (1 996) emphasizes that the
most important ski11 for physician leaders is clinical credibility. It is imperative that
physicians be well-respected, excellent practitioners with proven track records.
Kirschman (1999) supports the idea that, for physician leaders to be effective,
they must continue as clinicians. "Chief Medical Officers that do not provide
some patient care will be seen as just another 'suit' by the medical staff'
(Kirschman, 1999, p. 37). Pugno (1 999) agrees that those most likely to be
viewed as having a "reality perspective" are those with direct patient care
experience.
In 1996, the Royal College of Physicians and Surgeons of Canada
commissioned a project called CanMEDS 2000. The purpose of this project was
to examine the societai health care needs of Canadians and to assess their
implications for post-graduate specialty training programs for physicians. One
outcome of this project was the development of a framework of essential roles
and key competencies for specialist physicians. These key competencies are:
medical expert, communicator, collaborator, manager, health advocate, scholar
and professional (Royal College of Physicians and Surgeons of Canada
we bsite) .
A variety of leadership competencies are described in the literature. My initial
reading suggests that these might be organized under themes such as
management skills, leadership skills, communication and interpersonal skills,
organizational skills, and personal characteristics.
Management Skills
The ability to deal with technology is a theme that emerged in the literature. The
ability to manage large volumes of information was also seen as important by
many authors (KUSY, Essex and Marr, 1995; Finocchio, Bailiff, Grant and O'Neill
1995; Lister, 1998). On the other hand, a survey regarding essential leadership
competencies for physicians conducted by Hudak, Brooke, Finstuen and
Trounson (1 997) found that, although computer skills were important, these were
secondary compared to other competencies.
The list of leadership competencies that faIl under the theme of "management
skills" is long. For example, Kirschman (1 999) discusses the need for physicians
to be skilled at running meetings. Lister (1 998) feels physicians need to be
excellent public speakers. Pugno (1 999) suggests that the ability to do long-term
strategic planning is a core competency for physician leaders. Decision-making
and problem-solving are also suggested to be essential core competencies for
physician leaders (Lister, 1998; Finocchio, Bailiff, Grant and OINeil, 1995).
Conflict resolution, negotiation and mediation skills are discussed by Kirschman
(1 999), Kusy, Essex and Marr (1 995) and Lister (1 998).
Several authors discuss the importance of physicians entering into mentorship
roies with other prospective leaders in order to address the issue of succession
planning (Lister, 1998; Kirschman, 1999; Kusy, Essex and Marr, 1995). Although
not always explicitly identified as "mentoring," many authors indicate the
necessity of leaders to lead by example.
The ability to manage finances is a theme that has emerged from many
American sources of literature (Zaher 1 999; Cunningham 111 1 999; Guthrie 1 999;
Lister 1 998; Kirschman, 1 999). Most of these sources emphasize the that
physician leaders be able to balance the cost of care with the quaIity of care.
Because of the differences behveen the Canadian and the American health care
systems, the ability to manage finances is not a competency that will be
considered in the context of this research project.
Communication and Interpersonal Skills
Communication skills are the most frequently cited competency in the literature.
Many authors cite the need for physician leaders to be skilled comrnunicators as
the most crucial competency (Lister, 1 998; Magill, 1 999; Kirschman, 1 999;
Finnochio, Baiiiff, Grant and O'Neil, 1995; Gustafson and Schlosser, 1997;
Pugno, 1999). Zaher (1 996) sees physician leaders as "process connectors" and
"knowledge builders" who liberate information. Guthrie (1 999) suggests that
physician leaders need to minimize miscornmunication and, at the same time,
rnaximize agreement and understanding. Kirschman (1 999) interviewed several
CEOs who al1 agreed that communication skiils and the ability to develop
interpersonal relationships were the most important competencies required of
Chief Med ical Off icers.
Organizational S kills
A number of authors suggest that physician leaders need political sawy.
Gustafson and Schlosser (1 997) recommend knowledge in organizational
strategy, self-motivation and self-management as areas that can assist
physicians in leadership roles. Kusy, Essex and Marr (1 995) suggest that an
understanding of organizational politics and negotiation is essential for all
leaders, particularly physicians. Lister (1 998) describes the political skills needed
by physicians as influence, understanding of motivation, and alliance building.
Besides political skills, many authors describe the need for physicians to be able
to develop and work in teams. Kirschman's (1 999) research on leadership
competencies for physicians concluded that physicians need the ability to Iearn
as well as teach team building. Finnochio, Bailiff, Grant and O'Neil (1 995)
conducted a survey to examine the attitudes of three hundred physicians toward
specific corn pet encies deemed essential to effective practice. Of these, the ability
to work in teams was identified by at least half of the physicians as being a
competency for which they felt medical school had not prepared them for. Kusy,
Essex and Marr (1 995) conducted a "leadership practices inventory" survey. The
results of this suwey showed that physicians felt team-building and motivation
should have a stronger focus in their development as leaders.
Leadership Skills
Obviously, the literature cited above suggests that leadership is an extremely
broad concept that can be categorized in a multitude of ways. Two main themes
that emerge with respect to leadership are the concepts of vision and of change.
It is important to recognize that these are not necessarily distinct concepts and
there is a lot of overlap between the two. It is also difficult to separate activities
which are directly "leadership" as opposed to activities that support other
necessary competencies.
One of the professional development opportunities offered by the Canadian
Medical Association (CMA) is the Physician Manager Institute (PMI). The PMI is
a joint program between the CMA and the Canadian College of Health Service
Executives (CCHSE) that teaches leadership and management skills to
physicians. According to Wharry (1 997), the changes within health care are
prompting more and more physicians to seek this type of training. In total, the
PMI offers four levels of training as well as a refresher course through the use of
three-day workshops offered in locations throughout Canada. The courses and
their content are summarized below:
PMI 1 - Leadership Skilis for Shaping the Future
The focus of this course is on change in society as a whole, the qualities required
for leadership during times of change and the effect of change on organizations
and structures. Also included in this course is content related to health care
funding and structure, new approaches in health, the shift to regionalkation, the
future of Medicare, funding methods and basic financial management and
program costing.
PMI II - Leadership Skills Development - Mastering the Principles of Leadership
for Effective Performance
The focus of this course is on "people issues" such as performance
management.
PMI 111 - Conflict Management and Negotiation Skills for Effective Physician
Managers
The focus of this course is on how to deal with conflicts that can erupt without
warning within organizations. lncluded are topics such as negotiation in the
hospital, stages of negotiation and practical experience in negotiation.
PMI IV - Planning and Managing Change - The Medical Manager in a Shifiing
En vironment
The focus of this course is on change processes, theories, and experience.
lncluded are topics such as managing and influencing change, managing the
stress and uncertainty of change, the impacts of change on people and
organizations and how to implement a planned change.
PM Refresher
This refres her course revisits mate rial presented in previous levels while
exploring advanced management and leadership techniques. lncluded in the
session are updates on communications, advanced team building and problem
solving.
The fact that physicians in leadership positions need to be agents of change is
mentioned frequently in the literature (Kirschman, 1999; Cunningham 111, 1 999;
Gustafson and Schlosser, 1997; Pugno, 1999; Zaher, 1996). Cunningham III
(1 999) describes a certificate program at Johns Hopkins where physicians leam
to become change agents and develop leadership skills. Kirschman (1 999)
interviewed three CEOs to gain an understanding frorn their perspective on the
most important skills were for physician leaders. Among the responses, the
following cornpetencies are al1 either implicitly or expiicitly related to change:
managing growth, understanding cornpliance issues, leading shifts in
organizational behaviors, developing and implementing clinical practice
guidelines, and teaching colleagues how to make decisions using consensus
(Kirschman, 1 999).
The notion of leaders having visions of desired futures is a theme that surfaces
throughout the literature (Magill, 1999; OYDonohue, 1998; deVau1 and Knight,
1994; Zaher, 1996). Magill (1 999) suggests that "imagining possibilities" is a skill
physicians practice every day. deVau1 and Knight (1 994) suggest that medical
education should prepare leaders to develop visions, communicate possibilities
and believe in their attainment, and inspire others to contribute. Zaher (1996)
talks about physician leaders who assume the role of visualizers who see the
future and formulate a path to the vision. The transition for physicians in
leadership, according to Zaher, is from autocratic task master to empowering
visionary. Physicians require vision, courage, and a sense of purpose (deVau1
and Knight, 1994).
For some authors, skilled physician leaders are defined as those who can
manage the polarity between their roles as independent physicians and their
roles as mernbers of organizations (Pugno, 1999; Finocchio, Bailiff, Grant and
OyNeil, 1995; Kirschman, 1999; Zaher, 1996). Pugno suggests that physicians in
leadership roles need to have a high tolerance for ambiguity.
Kirschman (1 999) and Finocchio, Bailiff, Grant and O'Neil (1 995) note the impact
diverse cultures have on physicians in leadership roles. Being able to understand
the difference between what is important personally as opposed to what is
important organizationally is a competency that physicians need €0 develop
(Kirschman, 1999).
As well as knowing how to lead, physicians need to know how to follow (Pugno,
1999; Bujak, 1999). Magill (1 999) describes the ability to develop "synergy," to
achieve what no individual could do alone, as an important competency for
physicians in leadership.
Personal Characteristics
Besides the competencies identified above, severaf personal characteristics have
been described by various authors in the literature. OYDonohue (1 998) suggests
five necessary qualities of physician leaders: integrity, a gift for awakening
others, compassion, spontaneity and an ability to make use of failure. Creativity
and "imagining possibilities" is a skill mentioned by a number of authors (Pugno,
1999; Magill, 1999; Zaher, 1996). Courage and the ability to take risks are
described as essential leadership competencies by deVau1 and Knight (1 994)
and Kirschman (1999). In addition, Pugno (1 999) states that physician leaders
require "intellectual honesty" to know and to admit when they are uncornfortable.
Although psychologist Daniel Goleman (1 999) suggests that different situations
cal1 for different types of leadership, he claims that effective leaders are alike in
one crucial way: they al1 have a high degree of what has corne to be known as
"emotional intelligence." The components of emotional intelligence are: self-
awareness, self-regulation, motivation, empathy and social skill.
Besides an increased global interest in the topic of leadership, there is also an
increasing interest in leadership as it relates to specific groups. Leadership
specifically related to physicians is a topic health care organizations are now
taking very seriously. In the past, many physicians were "elevated" to leadership
positions sirnply because they were successful practitioners. There is now
widespread recognition that it takes more than clinical cornpetence to be a
leader. Many authors suggest leadership competency development programs for
physicians need to be local, long-terni and led by physicians (Schwartz, Pogge,
Gillis and Holsinger, 2000; Lane and Ross, 1998; Battistella and Weil, 1996).
Summary
In summary, the organizational documents reveal that the CHR is a relatively
new, complex organization in a state of transition. A review of these documents
suggests that leadership is prornoted at al[ levels of the organization and that
physicians are valued as leaders. A review of the supporting literature suggests
that the whole area of leadership, generally, and specificaIly as it relates to
physicians, is of great interest. While leadership remains difficult to define in any
strict sense, the volume of available Iiterature tells us that it is a significant topic.
Several authors have examined leadership as it relates specifically to physicians
through different "lenses" but some aspects seem almost universal throughout
the Iiterature.
The next chapter will desciibe the "lens" through which 1 conducted my research
project.
CHAPTER THREE - CONDUCT OF RESEARCH STUDY
Some aspects of action research were used in this research project. The
organization within which the research project took place is one driven primarily
by quantitative data. Given the organizational context, and the fact that the
research questions would be difficult, if not impossible, to answer using
quantitative methods alone, 1 chose to use a combination of qualitative and
quantitative approaches to answer the research questions. Data was collected
through the use of both individual interviews and questionnaires.
Ethical Considerations
Ethical conside rations for this project complied with Royal Roads University's
Ethics Policy and generally with well-accepted policies that meet ethical
considerations for research involving human subjects. The study respected the
principle of research participant autonomy. Participants were free to participate in
the research project. Participants were also advised that they were free to drop
out of the study at any time. The principles of beneficence (do good) and non-
maleficence (do no harm) were respected throughout, and al1 participants
received detailed explanations of the process as well as a summary of the
research project. (See Appendix B). lnformed consent was obtained from al1
participants. Each participant was advised of his or her rights as a research
participant.
Anonymity and confidentiality were maintained throughout the entire research
process. No names or identifying information are included in the final report.
Interview tapes were transcribed by a third party not employed by the Capital
Health Region. The transcriptionist signed a consent form agreeing to maintain
confidentiality and anonymity at al1 times in the handling of the data (Appendix
C). Identifiable information, tapes and transcripts were kept locked and secure in
the researcher's home. The names and identifying characteristics of participants
were removed from al1 reports generated from the raw data. Interview
participants also had the opportunity to review the final report before its release
to ensure their comfort with the level of confidentiality provided. Surveys did not
ask for specific identifying information beyond an indication that a respondent
belonged to one of the three general groups surveyed. Appendices Cl F, H and I
each relate in some way to the process of informed consent, confidentiality,
anonymity and of advising participants of their rights as research participants.
RESEARCH METHODS
As noted above, the methodology chosen for this research project contained
elements of action research. Action research is defined broadly as a "disciplined
inquiry which seeks focused efforts to improve the quality of peoples
organizational, community and family lives" (Cal houn in Stringer, 1996, p. 9).
More specifically, action research is a practical tool used by people to solve
problems or develop opportunities in their personal, professional, or cornmunity
Iives. Action research has, as one of its foundations, stakeholder participation.
Rather than the researcher being viewed as "objective," the researcher is
involved in the process and keeps participants apprised of the developments in
the process. Kirby and McKenna (1 989) suggest that action research "requires
intersubjectivity: an authentic dialogue between al1 participants in the research
process in which al1 are respected as equally knowing subjectsfl(p. 28). Instead of
the research being about a particular subject, research is for and with the people
involved in the subject.
Action research uses an inductive inquiry approach characterized by the belief
that research should begin with observation, since it is only on that basis that
grounded theory will emerge" (Palys, 1997, p. 415). An inductive approach
begins with specific concepts and uses the concepts to generate general
principles. Historically, action research has been often used by organizations to
implement change strategies, project development work, training programs and
human resource development. The approach begins with observation and then
moves to theory. In the context of my inquiry, the concept being studied is
leadership and leadership competencies. An inclusive, inductive approach to the
development of a leadership competency framework for physicians is in keeping
with many of the principles of action research design.
The process of involving others in my research began several months ago when I
had many informal discussions with key stakeholders regarding the possibility of
this project. Although not a formal part of the research, the questions that were
the genesis of this project developed based in discussions I had with others. I
needed to know if what I was asking was important and would make a difference
to people in the organization. Throughout this process, I became aware of the
fact that Ieadership, and specifically leadership as it relates to physicians, was a
topic of great interest and significance in the Capital Heaith Region. The
opportunity to engage people in a process to develop a shared understanding of
leadership and, more specifically, to work towards the development of leadership
competencies required of physicians in forma1 leadership positions, was the
result of these discussions.
DATA GATHERING TOOLS AND STUDY CONDUCT
1 chose two data collection methods for this research project - individual
interviews and surveys. To begin, I reviewed the literature and developed a
generic leadership competency framework based on this review . I then
conducted individual interviews to validate the generic framework. Based on the
input received during the interviews, I revised the generic framework and a
developed a questionnaire to establish trustworthiness through triangulation of
the findings from the interviews.
Research participants in this study belonged to one of three groups: 1)
physicians, 2) physicians in formal leadership positions and 3) administrators. I
sought equal representation from ali three groups throughout the entire research
process.
Preparation of the Generic Competency Framework
My initial work in the project involved reviewing existing literature regarding
leadership, physician leadership, competence, and leadership competencies for
physicians. A number of researchers and health care organizations throug hout
Canada and the United States have examined these topics from a variety of
lenses within the context of their own organizations. I used the information I
gathered as a foundation for the development of a leadership competency
f ramework.
The generic framework I created was, in essence, a composite of material
gathered from a variety of sources. As I proceeded with my research, I became
convinced that Iwo main sources, however, were most relevant both on a
national level as well as a local (CHR) level. First, I used the "Essential RoIes
and Key Competencies of Specialist Physicians" developed by the Royal Coflege
of Physicians and Surgeons of Canada's "CanMeds 2000" project (2000).
Second, I extracted information from the role description for the position of
Clinical Chief in the CHR's rules and regulations (May, 2000). The generic
framework was organized according to six main competencies (Appendix D).
INTERVIEWS
I conducted interviews for two purposes. First, 1 wanted to validate what I had
found in the literature. Second, I wanted to use the information from the
interviews to develop a questionnaire. Using elements of an action research
approach, 1 asked interview participants in advance to reflect on the
competencies required of Clinical ChiefdDivision Heads and to identify ways in
which the organization might better support these physicians in the development
of these competencies.
I had initially considered conducting focus groups, but decided that individual
interviews better suited rny needs as a researcher and the context of the
organization. There is a general sense within the organizational culture that
enough time is already "wastedn in meetings. I was concerned that a focus group
might be perceived as yet "another meeting" and, therefore, another waste of
time. Arranging for individual interviews reduced the complexity of scheduling
focus groups in a geographically diverse region. Many administrators are farniliar
with the use of focus groups but the prospect of getting a group of physicians
together to talk about leadership was daunting.
Another factor is that, while administrators are salaried ernployees, physicians do
not receive compensation for attending meetings. In my work as a Quality
lmprovernent Associate, I meet regularly with physicians and have first-hand
knowledge of the logistical challenges of arranging meeting times that do not
conflict with office hours, operating room time, or other direct patient care
activities. I am also conscious of the amount of time physicians in the
organization already commit to other activities not directly related to patient care.
I did not wish to be perceived as adding to this time. Instead, I relied on my
personal credibility to convince people to talk to me on a one-to-one basis
l solicited interview participants based on a number of factors. First, 1 knew al1 the
participants . Each had expressed an interest in leadership either directly
(through discussion) or indirectly (through action). I conducted a total of four
interviews. 1 interviewed two administrators, one physician, and one physician
with many years of experience as a Clinical Chief . Each participant expressed
an interest in my project and a sincere willingness to commit the tirne required for
an intewiew.
In preparation for the interviews, each participant was sent a copy of the generic
leadership competency framework that I had prepared based on a review of the
literature. (Appendix D) I also sent a letter to each participant to confim the date,
time, and location of the interview and some examples of the types of questions I
might ask during the interview. (Appendix E).
The interviews were semi-structured. I had pre-prepared questions but wanted to
ensure that the intewiew format was flexible enough to allow for the exploration
of other areas if it became apparent during the interview that other themes were
relevant and important to the research. The prepared interview questions were:
Tell me about your career/position.
How do you define leadership?
How are you impacted by the role of the Clinical Chief or Division Head?
What competencies do you feel are most important for the position of Clinicat
Chief/Division Head in the CHR?
As you look at the generic framework, are there additional competencies that
you feel need to be added or further emphasized?
Do you think these competencies can be learned? If so, how?
How do you feel the Capital Health Region could better support its Clinical
C hiefs/Division Heads?
I piloted the interview questions on one administrator and one physician to see
how well the questions worked to elicit responses and to test my own ability as
an interviewer. 1 taped the second test interviews with the idea that, if it went well,
I would include these as part of rny data. As no significant problems were
encountered this test interview has been included as part of the data for my
research.
Overall, the interviews went extremely smoothiy with few surprises. Part of the
reason for this is that I already had welI-established relationships with each
research participant. Therefore, 1 did not have to spend much time building
rapport. I had also spent considerable time in advance talking with people about
what 1 was doing and explaining the importance of their contributions not only to
me personally, but to the organization. This decreased the amount of time
required to introduce the topic at the time of the actual interviews. Everyone was
well prepared and we already knew each other.
My own preference for one-on-one interviews was also a factor. Because I was
cornfortable in the environment, it was easier for me to help others feel relaxed. A
few minutes were spent at the beginning of each interview to review the plan and
obtain inforrned consent. In each case, however, much more time was spent
debriefing after completion of the interview. After the tape recorder was stopped
and the formal part of the interview completed, I asked for feedback from each
interview participant about the general flow of the interview and how they felt.
Even though none of the participants seemed nervous, all (including me) seemed
more relaxed once the tape was turned off. The time spent debriefing with each
participant ranged from thirty minutes to an hour.
I began the interviews by asking participants about their own careers and then
led thern into a discussion of their perspective on leadership. This provided a
natural introduction into the topic of leadership competencies and the role of the
Clinical ChieWDivision Head. Each interview participant had reviewed the generic
framework prior to the interview and, it was apparent to me, had spent time
reflecting prier to the interview. In fact, one participant had obviously considered
the topic of such importance that I was handed a four-page typed document
during the actual interview which addressed many of the questions I had
prepared, complete with bibliography! Although this surprised me, we proceeded
with the interview and I used the information from the document to complement
the interview data.
Each interview was tape recorded then transcribed. Written consent was
obtained for each interview (Appendix F). Participants were informed of the
purpose of the recordings, that they would have an opportunity to review and
revise the transcripts, and that they were free to ask me to stop the tape at any
time. Ail of the interviews lasted approximately one hour although an additional
thirty to sixty minutes was spent debriefing with participants foilowing the
interviews. The questions seemed to work welt to engage participants in
discussion. Participants were given complete flexibility regarding time and
location for the interviews. Two interviews were conducted in my office, and two
were held in a location the research participant preferred.
After each interview, I recorded persona1 notes in a research journal. These
notes included specific thoughts, feelings, and observations about the interviews
and general thoughts about the project. I also used the journal to note key
phrases and words that struck me during the interviews to help prepare me for
the time when 1 would work to revise the generic competency framework. These
notes were used in conjunction with the tapes and transcripts of the interviews. 1
was consistently surprised by the degree of interest and enthusiasm
demonstrated in each of the interviews. Each participant arrived on time and
showed a genuine commitment to participate by turning off their pagers and cell
phones for the duration of the interview.
During the first interview, 1 asked the research participant to tell me a "story," to
give me an example that would help to illustrate exemplary leadership from their
perspective. This question 'tvorked" so well that 1 realized that these examples
would provide some of the richest information for my research. Asking for
anecdotes then became part of each subsequent interview.
My plan was to conduct interviews until 1 began to hear common, recurring
themes. In my original proposal, I predicted that 1 would need to conduct between
three to ten interviews. By the end of the third interview, it became evident to me
that 1 was already hearing recurrent themes. My fourth interview confirmed this
belief, and after this fourth interview, I stopped.
The tapes from each interview were transcribed verbatim. 1 kept notes during and
following each interview, then recorded my reflections in a research journal.
Thematic analysis was conducted by listening to the tapes and reading the
transcripts several times. I used a hi-lighter to note themes, key words, and
phrases in the transcripts. Through my notes and from my journal, 1 was able to
summarize themes and ideas in point form.
Each research participant was given the opportunity to review their own transcript
and to make revisions at their discretion. I then analyzed the transcripts, looking
for common themes. As 1 Iisted these fhemes, 1 tested each by looking for
qualitative data I could extract from the transcripts that would exernplify the
themes I had chosen. One way to enumerate these themes was through a
process of documenting words and phrases that the participants repeated. 1 also
listened to each interview tape at least five times. Finally, using this data, I
modified the generic leadership competency framework and developed the
questionnaire. (Appendix G ).
QUESTIONNAIRES
The interview data, in addition to the literature review, provided the foundation for
the development of a questionnaire. 1 chose to use questionnaires as a
secondary method of data collection for two reasons. First, they allowed me to
obtain data from a larger number of participants than would have been possible
with individual interviews. Second, questionnaires provided flexibility for
respondents who work in different geographic areas throughout the various sites
within the region.
I distributed sixty questionnaires to three groups: 1) physicians, 2) physicians in
formal leadership positions, and 3) administrators. A disproportional stratified
random sampling process was used to select participants. I sent twenty surveys
to each of the three groups. I chose this sampling method because I was
primarily interested in comparing results between strata rather than being able to
make general statements about any single group. The size of each of the three
groups surveyed was significantly different. For example, there are a total of 924
physicians with hospital privileges in the CHR and a total of 58 Clinical Chiefs
and Division Heads. I believed a proportionate sampling ratio would create a
sample size too small for adequate analysis in some groups (Palys, 1997).
1 designed the questionnaires based on data obtained from the literature and
through individual interviews. A cover letter attached to the surveys provided
background information about the project. Two slightly modified cover letters
were used to individualize the request for participation from the two main
populations: 1 ) physicians (Appendix H) and 2) administrators (Appendix 1). I also
included a summary of the research project (Appendix B) with each of the survey
packages. The summary included the purpose, research questions, and a brief
description of the research methodology. The cover letter assured participants of
confidentiality and anonymity. lnformed consent was implied by the fact that
survey respondents completed and returned the surveys.
The four page questionnaire was divided into three parts (Appendix G). The first
part listed eight competencies and asked respondents to rate the importance of
each competency with respect to the role of the Clinical ChiefIDivision Head on a
five point Likert-type scale. The second part asked respondents to rank order
each competency in terms of overall importance. The third part of the
questionnaire took the f o m of three short answer questions. Respondents were
asked to list any competencies that were not reflected in the table or required
additional emphasis. Respondents were then asked for suggestions about how
the Capital Health Region might better support its Clinical Chiefs and Division
Heads. Finally, 1 made a general request for any information that might me
develop the leadership competency frarnework.
The original draft of the questionnaire was circulated to the faculty supervisor and
project sponsor for feedback. I then revised the questionnaire based on feedback
I received. For example, 1 had originally asked respondents to rate the degree to
which they perceived each competency was currently being demonstrated by
leaders within the CHR. This question proved to be problematic in many ways
and was therefore deieted. I then piloted the questionnaire on three individuals
who had not been interviewed and who had not been selected through the
randomized process.
Although the questionnaire was anonyrnous, it did ask respondents to indicate
that they belonged to one of three groups: 1) physicians, 2) physicians in forma1
leadership positions, or 3) administrators. The survey cover letter, however,
indicated that if respondents were not cornfortable providing this information, they
could leave it blank. I considered collecting other dernographic information, but
decided not to because I decided that the size of some groups was too small to
ensure that confidentiality could be maintained.
A comprehensive mail-out of sixty questionnaires was made through the inter-
regional mail system. These survey packets included a self-addressed and a
return envelope with the researcher's name and business address. Participants
were asked to respond to the questionnaire within two weeks. After one week, I
sent out a reminder letter to every participant (Appendix J). In addition, I left
telephone messages for approximately thirty of the sixty respondents, reminding
thern to complete the questionnaire after one week. As most of the research
participants were known to me, 1 was able to remind many of them informally
throughout the course of my work.
The combination of qualitative (interviews) and quantitative (questionnaires) data
collection methods worked well for this research project. The interviews allowed
me to gather rich data and to probe more deeply when necessary. I was also
able to elicit stories from interview participants which helped me to better
understand what they were saying. The questionnaires allowed me to obtain data
from a broad sample of geographically-dispersed participants. The corn bination
of data collection rnethods also helped me establish the trustworthiness of the
findings. Given the organizational culture, the use of both methods will also help
to 'legitimize' the research findings in the final report.
Summary
The purpose of this chapter was to outline the steps in the research methodology
and provide an initial discussion of my findings. The conduct of this research
study took place during the months of August and September, 2000. First, a
generic leadership competency framework was developed based on a review of
the Iiterature. Individual interviews were then conducted with representatives
from three groups: 1) physicians in formal leadership positions, 2) physicians and
3) administrators.
The interviews validated that the same leadership cornpetencies that were seen
as important in the literature seemed to be important within my own organization.
What I had found in the literature suggested that there are definite, core
leadership cornpetencies that are critical for physicians to possess to be effective
leaders in any organization. I used some of the additional data gained data from
the interviews to revise the generic frarnework and then develop a questionnaire.
The questionnaire was sent to a stratified sarnple from the three groups
mentioned above. The purpose of the questionnaire was to triangulate my
research findings.
Chapter 4 will review the research study findings, conclusions and make
recommendations based on what I have found.
This chapter consists of the research study results. I have reported the findings
of my research in two parts. First, I have summarized the themes identified
during my interviews. Second, I have reported the data collected from my
questionnaire. The themes that emerged from both rnethodologies were the
same.
In my research project, I used interviews and questionnaires to ask two main
questions. First, I wanted to know "what it takes," in terms of competencies, to be
a Clinical Chief or Division Head in the CHR. Second, I wanted to know how the
CHR could better support its Clinical ChiefdDivision Heads. In the report of my
findings, I have quoted a number of the research participants. In some cases, I
have made minor editorial changes to convert oral quotes into written form.
These editorial changes have not, I believe, altered the substance of the
participants' words or meanings.
I have reported and organized the data from the interviews by themes that
related directly to the competencies I had found in my review of the research
literature. I have grouped the suggestions about how the CHR rnight better
support its Chiefs into four themes: education, role clarity, compensation, and
support.
Data from the questionnaires are reported by question, using the order in which
the questions appear on the actual questionnaire. The first section of the
questionnaire as ked respondents to state the overal l importance of each
individual competency. The second section asked respondents to rank order the
competencies in terms of their importance relative. The final section consisted of
three short answer questions. One question, as in the interviews, asked for ideas
about how the CHR might better support its Clinical Chiefs/Division Heads. The
responses to this question were grouped into the same four themes identified
during the interviews: education, role clarity, compensation, and support.
RESEARCH FlNDlNGS
The generic leadership competency framework that fomed the basis for the
interview questions was developed based on a review of the Iiterature. This
framework was then revised based on the information obtained from the
interviews and becarne the basis of the questionnaire. Each step of the process
was built logically on the step before.
INTERVIEWS
1 have reported the results of the intewiews in two parts. The first part relates to
the leadership competencies required for ChiefdDivision Heads. The second part
summarizes suggestions about how the CHR might better support its current
Clinical Chiefs/Division Heads.
Four interviews were conducted: two with administrators, one with a Clinical
Chief, and one with a practicing physician. Interview participants were selected
based on both their interest in the topic of leadership and their wiilingness to
participate in an in-depth interview. Al1 interview participants had over ten years
of experience in the Capital Health Region (formerly the Greater Victoria Hospital
Society).
The purpose of my questions was to engage participants in a dialogue about
leadership and the competencies required of Clinicat Chiefs/ Division Heads. 1
began each interview by asking participants to talk about their careers. Then, 1
asked them about their current role vis-à-vis the role of the Clinical Chief/Division
Head. The interviews were conducted more like conversations than interviews
and moved along in a cornfortable, natural Pace and direction. I asked people to
tell me "storiesn about leadership. Then, I asked for their ideas about how the
Capital Health Region might better support its current Clinical ChiefdDivision
Heads.
Each interview participant had received a copy of the generic leadership
competency framework prior to the interview. This framework provided a
foundation for our discussion and kept the interviews grounded in the
competencies. All intewiew participants had reviewed the frarnework in advance
and felt that, with minor revisions, it could be used as a leadership cornpetency
framework Clinical Chiefs in the CHR.
When I developed the generic framework, I grouped competencies into six
categories: medical expert, management, leadership, interpersonal skills,
communication skills, and personal characteristics. As I reviewed the tapes and
transcripts from the interviews, I was looking for themes to validate the
framework. I also looked and listened for any new themes that emerged.
Leadership Corn petencies
When 1 analyzed the tapes and transcripts from the interviews, 1 discovered two
new themes (or competencies) in addition to the six competencies that I had
identified from the literature review .These new thernes or competencies were
"education" and "organizational skills." I also changed the name of what I had
originally called "personal characteristics" to "self-awareness" in order to more
accurately reflect what I heard from interview participants. Table 1 illustrates the
difference between the themes (or competencies) 1 had identified in the literature
and the themes that emerged from my interviews.
Table 1
Generic Framework Cornpetencies (used for interviews)
7. Education 8. Organizational Skills
Revised Frarnework Corn petencies (used in questionnaire)
1. Medical Expert 2. Management Skills 3. Leadership 4. Interpersonal Skills 5. Communication Skills 6. Persona1 Characteristics
I have reported the results of the interviews according to eight themes (or
cornpetencies). These are: clinical expertise, education, communication skills,
interpersonal skills, organizationai skills, leadership, management, and self-
awareness. The themes "education" and "organizational skill" ernerged with such
frequency that they became part of the revised framework that would ultimately
forrn part of the questionnaire. The following is a summary of the themes from
the interviews.
1 . Clinical Expertise 2. Management Skills 3. Leadership 4. Interpersonal Skills 5. Communication Skills 6. Self-Awareness
1 . Clinical Expertise
The theme of clinical expertise was present throughout each of the interviews. All
interview participants agreed that it is critical for physicians in formal leadership
positions to maintain clinical expertise. The words, phrases, and ideas in the data
related to Clinical Expertise were, "credibility, practicing , direct patient care,
awareness of day to day problems, current, solid medical expertise, well
respected, "one foot in the camp of the working physician", "pulse on what was
happening." Exemplars of this theme can be found in the following quotes from
participants.
I don? know how you get around that because when you have a chief who is just an administrator, then they lose their clinical skills and knowledge and then they're not in a position to discuss clinical issues with members of the department (Interview participant, August 2000).
If they're willing to sacrifice patient care, they sacrifice the credibility with the members of their department and that's probably their number one competency, is credibility (Interview participant, August 2000).
The most important competency has got to be demonstrated competency in the clinical department that they're working in or representing. If not, it causes a great deal of difficulty with respect to credibility and being able to work with members of the department (Interview participant, August, 2000).
it is important for them to be practicing physicians who are up-to-date and know what they're talking about because physicians are very critical of hospital administrators who don't know anything about medicine (Interview participant, August, 2000).
You can't have somebody that is outdated working as a Chief or Division Head (Interview participant, AU~US~ , 2000).
There is no question that a person who practices, has a clinical practice and deals with patients and knows how the system works will be a more effective chief. It is the only way they will know what some of the problems are in relationship to day to day activities (Interview participant, August, 2000).
Chiefs are accountable for quality of care so from a risk management perspective, it is important for them to have a solid medical practice (Interview participant, August, 2000).
It is apparent, as these examples suggest, that clinical expertise is extrernely
valued and viewed as a key competency for the position of Clinical Chief/Division
Head. In fact, the theme of clinical expertise and the importance of this
competency in the role of Chief, was the most frequently noted theme throughout
ail the interviews.
Key Points
credibility
current practice
up-to-date
2. Education
Because l did not find this competency noted in the research Iiterature I read
prior to conducting the interviews, competency related to education had not
formed part of the original leadership framework. Hcwever, this theme emerged
with such frequency during the interviews that I added it to the revised
corn petency framework. Each interview participant referred to education either
directly, by saying that it was important, or indirectly, by referring to ongoing
learning as an integral part of the Clinical Chief/Division Head's role. While
reviewing the interview data, the following words, phrases and ideas reflected the
theme of education and leaming: "continuing learning, refresher courses,
educational experiences, teaching, mentoring, willing to learn sornething new,
contributing to new knowledge, stimulate."
Several references were made to the importance of both teaching and learning
with respect to the role of Clinical ChiefIDivision Head. Participants identified
ways for education to happen, both formally and informally. Formal settings
included Iiterature, journals, continuing medical education (CME), Physician
Manager lnstitute (PMI) training sessions, and executive management
workshops. It seemed, however, that more value and emphasis was placed on
the informal teaching and learning opportunities of "every day life," such as
mentoring and "learning from each other." Peer feedback was mentioned by
three of the interview participants as an educational oppoaunity they valued.
In addition to the theme of education and learning, concepts of motivation,
excitement, and the desire to "embrace challenge and change "also emerged.
Several references were made to the need for educational sessions to be
regular, ongoing activities, particularly for physicians in formal leadership
positions. The following participant statements reflected the theme of education
and learning:
You want to take advantage of the experience of others, of what they have done in the past and look at the literature. There is a ton of literature out there. That is number one (Interview participant, August, 2000).
Having individuals within your department bring fonnrard information that can be integrated and shared with other helps everyone learn (Interview participant, August, 2000).
Educational experiences. Thafs what i fs ail about. That's the fun part (1 nterview participant, August 2000).
The importance of education and learning, in its broadest sense, was evident
throughout al1 the interviews but was most frequently reflected in the interviews
with physicians.
Key Points
mentoring
ongoing learning
peer feedback
formal vs. informal education
3. Communication
As 1 read the research literature and listened to the words and meanings of those
who participated in my research project, the theme of communication came to
refer to two types of communication skilis. The first communication skill was the
ability to communicate informally with peers and colleagues internally (i.e., within
the organization). The second communication skill centered on those written,
verbal, and presentation skiils required to represent and advocate for a
Department externally. Within this research project, the words, phrases, and
ideas that described these communication skills included: "sharing information,
being a conduit, carrying the message, voice, public communication skills,
credibility, articulate, presentation skills, listening, seeking input, connecting
meaning to what you are hearing." Examples of statements that reflected
communication skills are:
For me, a lot of this is about credibility. 1 think people in leadership positions should be able to stand up and speak to others in a way that's articulate,
respectful and have good presentation skills (Interview participant, August, 2000).
I fs important to use good grammar and prose but ifs a difficult thing because physicians are so used to writing in a cryptic fashion (Interview participant, August, 2000).
If the chief is not hearing or listening, then the whole department misses the message (Interview participant, August, 2000).
I think the listening piece is huge .. . listening to understand where other people are coming from (Interview participant, August, 2000).
The ability to cornmunicate was seen by al1 interview participants as critical to the
role of the Clinical ChieWDivision Head. Listening, specificatly, was seen as an
essential part of the communication process. The ability to communicate in both
verbal and written foms was also felt to be important, especially when
representing Departments both internally and extemally. All interview participants
agreed that public speaking and presentation skills were important and that,
while many physicians did not possess these, these skills could be learned.
Key Points
conduit
presentation skills
listening
public speaking
articulate
4. Interpersonal Skills
Interpersonal skills were defined in the generic competency framework in terms
of the ability of leaders to develop and work in teams and to collaborate and build
supportive relationships. This compeiency included skills such as conflict
resolution, negotiation, and mediation. Two intewiew participants stated they
believed there was overlap between communication skills and interpersonal
skills. While I acknowledged this potential overlap, I attempted to clarify that, for
the purposes of the framework, interpersonal skills were "relationship oriented"
wh ile communication skills were "message oriented." The words, phrases, and
ideas that emerged as examples of this theme included: "relationship
development, team player, collaborator, trust, empathy, respect for others,
respect for diversity and attending to others." The following statements highlight
the participants' understanding of interpersonal skills:
We can have a Chief who has credibility and management skills but if you don't have good interpersonal skills, you canlt be effective (Interview participant, August, 2000).
Because they're often in a difficult position of giving negative messages to people, ifs essential to have good interpersonal skills (Interview participant, August, 2000).
They need to have highly developed interpersonal skills in order to deliver messages that are difficult or even to convey organizational decision s that other physicians may not want to hear (Interview participant, August, 2000).
Three of the four interview participants spoke of the necessity for well-developed
interpersonal skills today, more than ever before, due to the demands and
pressures on the health care system and, ultimately, health care professionais.
Clinical Chiefs/Division Heads were described as having the difficult task of
having to often convey unpopular messages at a time when the system seems to
be already "bursting at the seams."
Key Points:
negotiation
collaboration
teamwork
relationships, trust, respect, empathy
conflict resolution
5. Oraanizational Skills
Competency related to "organizational skillsn was not part of the genen'c
leadership framework; however, this theme emerged frequently and was
mentioned in every interview. As a result of this frequent mentioning, I added a
competency called "organizational skilln to the revised framework and, ultimately,
to the questionnaire. The words, phrases, and ideas that exemplified
organizational skills were: "knowledge of boundaries, scope of practice,
accountability, responsibility, systerns perspective, part of a whole, political
sa-, understanding the environment, politics, how decisions are made,
organ izational culture, unionized environment, organizational awareness,
operational standards, knowledge of the organization." The following participant
comments reflected this theme:
It's important (for ChiefdDivision Heads) to understand the administrative structure.. .what the corporate levels does, what the board does . . . because they're expected to follow that structure for approval (Interview participant, August, 2000).
Knowledge of how decisions are made and "Who's who" is important. It's important to understand the environment (Interview participant, August, 2000).
Organizational savvy is important . . . to know where to take things, how to lobby and the modus operandi (Interview participant, August, 2000).
Chiefs need the big picture of the system or the whole instead of just the medical perspective (Interview participant, August, 2000).
Boundaries are important . . . to know where one thing ends and another begins. And they need to be able to articulate that to the members of their Department (Interview participant, August, 2000).
One organization skill Clinical ChiefdDivision Heads need is the ability to see the
"big picturen and the "system." Participants described organizational skills in
relation to their Department and the Capital Health Region and the community as
a whole. Three interview participants noted the need for an awareness and
understanding of "organizational politics" as essential to the role of the Clinical
Chief/Division Head.
Key Points
understanding administrative structure
systems thinking
awareness of political environment
understanding organizational culture
6. leaders hi^
The therne of leadership emerged both directly and indirectly throughout al1 of the
interviews. The generic framework 1 used to begin the interviews included a
nurnber of behaviors that could be considered "leadership behaviors." These
included: creating a vision, inspiring others, demonstrating initiative, empowering
others, and advocating for patients and the Department. The concept of "vision"
came up often and was noted in every interview. One interview participant used
the metaphor of a leader as the "conductot' of an orchestra. During the data
analysis, sorne of the words, phrases and ideas that fit this leadership theme
included: "cornmitment, influence, stimulating capacity, develop others, guidance,
motivate, advocacy, voice, leading change, inspire others, future state, creating
excitement." Research participants used statements such as these to describe
leadership:
The leader provides a climate in which group members develop enthusiasm and motivation. It is the process of influencing people (Interview participant, August, 2000).
Leadership includes the idea of interaction and relationship in the pursuit of some objective al1 which to achieve (Interview participant, August, 2000).
Ifs important not only to have the ability to have a vision and inspire others but to also take action. So ifs the doing piece of leadership - no just thinking great thoughts. Ifs actually being part of making things happen, realizing the vision or at least moving towards it (Interview participant, A u ~ u s ~ , 2000).
"An had a vision of where to go and how to get there. Short and long terni goals were put forth and everyone knew how the vision would be operationalized (Interview participant, August, 2000).
The behavior cited most frequently under the theme of leadership by al1 interview
participants was the creation of a shared vision. Two participants spoke directly
of the importance of leadership being "shared." All interview participants
described the characteristics of effective leaders in terms of a transformational
approach to leadership.
Key Points:
vision
"conductor" of an orchestra
inspiring others
advocacy
empowerment
initiative
1 . Manaqement Skills
Management was a competency included in the generic leadership framework.
The literature I reviewed tended to describe management in terms of practical
activities such as running effective meetings, etc. As I analyzed the data from the
interviews, the following words, phrases, and ideas seemed to express this
sense of management as a competency: "decision-making, problem-solving,
growth and manpower management, negotiation skills, and the ability to use
technology and data. The following statements were examples of how
participants discussed the theme of management skills:
It's important to spend time in the office going through information, reading, being prepared, taking information back, being organized and being visible (Interview participant, August, 2000).
A combination of leadership and management skills is important. I f s not enough to be a good idea generator or visionary, you need to close the loop (Interview participant, August, 2000).
Effective leaders realize the effort that goes into strategizing and setting objectives for meetings so it is important (Interview participant, August, 2000).
All interview participants seemed to understand the difference between
leadership and management. Three participants emphasized that effective
leaders possessed both leadership and management competencies. Several
references were made to the necessity of setting aside time to attend to task
completion. AI1 research participants believed that management skills could be
learned.
Key Points
decision-making
problem-solving
technology and data
task completion
8. Self-Awareness
Self-awareness has been defined by Goleman (1 998) in terms of "personal
cornpetence." According to Goleman, self-awareness includes characteristics
such as emotional awareness, accurate self-assessment, and self-confidence.
As the interviews progressed, it became apparent to me that a number of the
competencies participants noted were related to the concept of "self-awareness."
When I developed the generic leadership competency framework, prior to the
interviews, I had grouped a number of items together under a general
competency I called "personal characteristics." However, as I conducted the
interviews, I heard many of these characteristics, as well as a number of new,
more explicit characteristics that seemed to group together under the idea of
"self-awareness." As a result of seeing these connections in participants' notes, I
created a cornpetency I called 'cself-awarenessn and added it to the revised
framework. Some of the words, phrases, and ideas I saw that seemed to identify
a leadership competency of self-awareness included: "making use of failure,
insight, self-discipline, initiative, judgment, awareness of others and emotional
stability." Examples of self-awareness as it relates to leadership are reflected in
the foltowing comments:
. . . important to recognize when you're losing credibility and enthusiasm and know when to pass along the baton (Interview participant, August, 2000).
It's important, when, for one reason or another, whether it's motivation or the wili to commit to the department, to pass along the responsibilities to someone who has enthusiasrn and a vision (Interview participant, August, 2000).
One interview participant believed that a tolerance for ambiguity was also an
extremely important leadership characte ristic. This participant defined tolerance
for ambiguity as the ability to work in "shades of gray" and to "tread through the
rnurkiness" (Interview participant, August, 2000). Although the term "self-
awareness" was never used specifically by any interview participant, it seemed to
fit as a way to describe this theme.
Key Points:
self-confide nce
insight
self-discipline
awareness of others
emotional stability
Support for Clinical Chiefdûivision Heads
During each interview, 1 asked participants for ideas about how the Capital
Health Region might better support its current Clinical Chiefs/Division Heads.
There was consensus that the role is both important and extremely difficult. A
number of creative ideas were suggested. I have reported these according to
four themes:
1 . education;
2. role clarity;
3. compensation; and,
4. support.
1. Education
One interview participant stated that the role of Clinical Chief/Division Head takes
a long time to develop and that it is unreaiistic to expect a new Chief/Division
Head to assume full responsibility immediately. It was suggested that at least 12-
18 months are needed for a new Chief to become fully functional. A suggestion
was made that the orientation of a new leader might include assuming the role of
"vice-Chief" for a period, with increasing responsibilities over time.
A formalized mentorship process was suggested as one way the organization
might support new Chiefs. The Corporate Medical Director was described as a
valuable resource and mentor for Chiefs by two interview participants. According
to these participants however, his current span of control is felt to limit the
amount of time he has available to mentor new Chiefs. lncreasing access to an
experienced physician leader (such as the Medical Director) was suggested as a
significant way to better support Chiefs.
One interview participant suggested a formalized orientation process for new
Chiefs (Interview participant, August, 2000) which would include topics such as
organizational culture, management structure, and the effect of external
influences (such as collective agreements, etc.) on the operations of the
organization. One interview participant suggested that physicians need to
become "part of" the organization and strengthen their relationships with the
Patient Care Managers who are often in a position to provide assistance and
support.
AI1 research participants reported that educational support for Clinical
Chiefs/Divisions Heads was extremely important. Throughout the course of the
interviews, three educational pnorities were identified. The first was the need for
physicians in formal leadership roles to have executive management skills. Three
interview participants described Physician Management lnstitute (PMI) courses
as valuable. Second, participants noted the need for education about conflict
resolution and negotiation skills. And, third, participants believed that physicians
required education and support about providing feedback and disciplining peers.
There was widespread agreement that this third competency was most critical to
the role of Clinical ChiefIDivision Head.
AII interview participants described the task of disciplining peers as being the
single most difficult responsibility of the Clinical Chief. Many participants
commented on the role conflict experienced by Chiefs when they were in
situations where they have to discipline their peers. One interview participant
commented that disciplining was particularly difficult when one's peers are
friends or colleagues. A metaphor of a leader as the conductor of an orchestra
was used earlier by one of the research participants. The metaphor was used a
second time in relation to the Chief's role in disciplining peers, this time to
emphasize the difficulty of being "part of the orchestra."
. . . when you're conducting an orchestra and someone isn't playing their instrument right, you don? have any problem telling them because you're not part of the orchestra, you're the conductor (Interview participant, August, 2000).
Another theme related to the education of physician leaders was the need for the
organization to provide the financial support necessary for interested physicians
to learn about leadership. Three intewiew participants viewed the provision of
educational resources to physician leaders as an organizational responsibility
and obligation. As one interview participant noted:
. . . they need the tools to do their jobs. Without it, it's like hiring someone and never giving them a desk or any money. It also recognizes their contribution (Interview participant, Auguçt, 2000).
2. Role Clarity
When asked how the CHR could better support itç Clinical Chiefs/Division
Heads, I heard recurrent themes about the lack of role ciarity. When 1 probed
further, I was told that a lack of clarity was experienced by both the Chiefs and
those who worked with them. A role definition, with clearly outlined expectations
for Chiefs was suggested by ail interview participants as a way to better support
the Chiefs. Three interview participants commented that CHR's move to a
Program Management mode1 of care had increased or created confusion and
arnbiguity with respect to the role of the Chief.
Another suggestion under the theme of "clarifying expectations" was that more
discretion could be used with respect to the Chiefs' role at meetings. lncreased
clarity about what their role is and whether or not their presence is really
necessary was seen as a way to help decrease the arnount of "wasted" time
spent in meetings. One interview participant commented: "sometimes (Chiefs)
are brought to the discussion yet their input is not needed or used (Interview
participant, August, 2000)."
3. Compensation
Although financial compensation was raised as an important issue, the theme of
compensation was much broader than financial compensation alone. A11
participants interviewed agreed that the role of Clinical Chief must be a paid
position. They also agreed that the role of Chief is important and must be
compensated accordingly. However, three interview participants felt that the
arnount of compensation was not adequate in proportion to the amount of time
and effort required to do the job. Two interview participants commented that it
was unacceptable that the Division Heads do not receive formalized financial
compensation.
4. Support
A number of suggestions were made about how resources could be better used
to support the Chiefs. Interview participants made several suggestions:
Office space should be allocated in one area, with integrated secretarial
support, where Chiefs would have more face-to-face contact. In this way,
Chiefs could better support each other.
If there were more computers, Chiefs might feel better supported because it
might decrease the number of meetings they were required to attend in
person.
The work of the Clinical Quality lmprovement Program supports the role of
the Chief. There is a need to increase the amount of this type of support.
Access to research assistants and data analysts, in coordination with the
Clinical Quality lmprovement Program, would assist the Chiefs in their
primary responsibility for quality of care
The current practice of involving external consultants to support Chiefs in
difficult disciplinary situations was valuable. (This note was more of a
validation than a suggestion.)
QUESTIONNAIRES
I have reported the results of the questionnaires in two parts. The first part deals
with the cornpetencies for ChiefdDivision Heads. The second part summarizes
the suggestions of how the CHR might better support its ChiefdDivision Heads.
A sarnple of twenty was drawn from each of three groups for a total of sixty
people who would be asked to answer a questionnaire. These groups were: 1)
physicians currentty in the position of Clinical Chief or Division Head, 2)
physicians, and 3) administrators. Each physician had hospital privileges in the
CHR and was actively practicing at the time of the study.
The questionnaire was comprised of three parts (Appendix G). The first part
asked respondents to rate each of the competencies in ternis of its importance in
relation to the role of the Clinical Chief/Division Head. Descriptors of the types of
activities that might be used to describe each of the competencies were listed to
help respondents answer this question. My goal was to discover what importance
respondents attached to each competency.
The second part of the questionnaire asked respondents to rank order the
competencies in relation to each other. 1 asked participants to number each
competency in order of priority by entering a "1" in the box beside the most
important, a "2" in the box beside the next important, etc. My goal was to
discover which competencies were seen as having most (and least) importance
relative to each other-
The third part of the questionnaire was comprised of three short answer
questions:
1. Please Iist any leadership cornpetencies that you feel are either not
reflected in the above table or require additional emphasis.
2. From your perspective, how can the Capital Health Region better support
its Clinical Chiefs and Division Heads?
3. Is there anything else you would like to add to this survey that might help
in the development of a leadership competency framework for the role of
Clinical C hief/Division Head?
The findings are reported in the order in which they appear on the questionnaire.
A total of fifty-one surveys were received for an overall response rate of 85%.
Respondents were asked to identify themselves as belonging to one of the three
groups mentioned above. Al1 respondents answered this section. Within each of
the three groups surveyed, 95% (nineteen of twenty) of Clinical Chiefs/Division
Heads responded, 80% (sixteen of twenty) of physicians responded, and 80%
(sixteen of twenty) of administrators responded to the survey.
Of the total number of fifty-one responses received, 38% of these were from
Clinical ChiefdDivision Heads, 31 % were from physicians, and 31 % were from
administrators. As shown in figure 1, the number of responses received from
each of the different groups surveyed were distributed relatively evenly.
Figure 1
% Response by Category n = 51
Bi Clinical Chiefs/Division 8% Heads
I Physicians
Administrators
Leadership Cornpetencies
Respondents were then asked to rate each cornpetency in terms of its overall
importance in relation to the role of Clinical ChiefIDivision Head. A Likert type
scale was used where: 1 = not important, 2 = somewhat important, 3 = important,
4 = very important and 5 = critical. All respondents completed this part of the
questionnaire. None of the respondents rated any of the competencies as "not
importanr (Le., an importance rating of 1 ). The range of means was between 3.6
and 4.3. The overall rnean response rate for each competency is shown in figure
2.
Figure 2
Overall Mean Importance Rating
I corn petencies
Figure 3 illustrates the mean importance ratings by respondent group:
Figure 3
Mean importance Rating by Respondent Group
in Heads
corn pet encie s
As figure 3 illustrates, the competencies rated as most important by the three
groups surveyed varied. The three competencies rated as most important to
Clinical Chiefs and Division Heads were: clinical expertise, leadership and
communication skills. The three competencies rated as most important by
physicians were: clinical expertise, communication skills and interpersonal skills.
The three competencies rated as most important to administrators were:
leadership, interpersonal skills and communication skills.
It is also worth describing the differences between the three groups surveyed
with respect to the ratings of each competency. 1 will described the mean
importance rating of each competency by group surveyed in ternis of "high,
medium or low" based on overall mean by group in table 2.
Table 2.
Clinical Chiefs and
Division Heads CIinical Expertise Education
Physicians Administrators
high medium
Communication Skills medium
Management Self-Awareness
low Interpersonal Skills Organizational Skills Leadership
medium low
1 medium
low
medium low
medium medium medium
low hig h
high high high
low low
high high
Question # 3 asked respondents to rank each competency in order of relative
priority. Respondents were asked to rate each of the eight competencies from
most important to least important by putting a "#ln by the most important, then "#
2' by the next most important, etc. Four questionnaire respondents noted the
difficulty they experienced when responding to this question. They each stated
that al1 the competencies were important and that it was difficult, if not
impossible, to rate one as more important than another. Table 2 demonstrates
the number of times each competency was rated in terrns of importance in
relation to others. For the purposes of simplification and clarity, I have chosen to
report this information in groups of two. For example, I have grouped the number
of times respondents rated a competency as either "#1 or #2," "#3 or #4," etc.
The rationale is that there is likely not much difference behnreen two subsequent
categories. I was more interested in trends and the overall "most important" and
"least important" competencies. Forty-nine of the fifty-one questionnaire
participants responded to this question. The results to this question are listed in
Table 3.
Table 3
Cornpetencies
I have reported the cornpetencies deerned to be "most important" and "least
important according to the number of times each was ranked as #1 or #2 (most
important - Figure 4) or #7 or #8 (least important - Figure 5).
Figure 4
Competencies Selected as Most Important
Competencies
Figure 5
Competencies Selected as Least Important
Corn pet encies
Question #4 asked respondents to list any additional leadership cornpetencies
they felt were either not reflected in the framework, or required additional
emphasis. A total of eighteen (36%) of research participants responded to this
question. I have categorized their responses into the following themes:
Personal Attributes
honesty, straighfforwardness, trustworthiness, patience, diplomacy;
common sense, even temper, ethical behavior, professionalism;
Leadership Skilts
the ability to motivate, support, and encourage others;
openness regarding decision-making processes would make unpopular
decisions easier to accept;
innovation and creativity;
SystemslOrgan izational Skil ls
the ability to promote group cohesiveness and teamwork;
understanding of human and fiscal management (i.e., budgets and union
contracts) ;
a global perspective; and,
ability to initiate and adjust to change, particularly when not initiated by or for
the Department.
Support for Clinical ChiefslDivision Heads
Question #5 asked respondents to suggest ways in which the Capital Health
Region might better support its Clinical Chiefs/Division Heads. A total of thirty-
seven participants (73%) responded to this question. I have categorized the
responses according to the following four themes:
1. education;
2. role clarity;
3. compensation; and,
4. support.
1. Education
The provision of education as a way to provide support to Chiefs surfaced at
least eighteen times in response to this question. Suggestions for topics
included: management skills, running effective meetings, consensus-building,
teamwork, communication skills, conflict resolution skills, systems, collaboration,
"win-win" skills, leadership, and quality assurance. Four participants suggested
that the Physician Management Institute (PMI) courses be mandatory for al1
Chiefs and Division Heads. Questionnaire respondents also suggested that
leadership programs for Chiefs be conducted in conjunction with Program
Directors. Three respondents ernphasized the need for formal, regular education
sessions to support the Chiefs. Eight respondents suggested that it was the
organization's responsibility to pay for education sessions for Chiefs.
2. Role Clarity
Thirteen respondents (28%) made suggestions that I have grouped together
under the theme of Vole clarity." Three main ideas emerged under this theme.
First, the role of the ChiefIDivision Head needs to be more clearly articulated. A
suggestion was made that the job description be further defined to include the
resources available to the Chief. Six participants suggested that increased role
clarity would enable everyone, including the Chiefs themselves, to have more
realistic expectations. Comments were made by two respondents that the current
roles and responsibilities for Chiefs are too "generic." Two respondents
suggested that the length of term for Chiefs be clarified and adhered to. Four
respondents noted that the move to Program Management has created
increased role confusion for Chiefs, particuiarly when the Program Director is the
same person as the Clinical Chief. One respondent commented that "wearing
both hats is difficult, causes confusion and this can be counter-productive
(Questionnaire respondent, September, 2000).
The second suggestion related to role clarity was to have an evaluation process
in place for Chiefs. Twelve (25%) respondents suggested that a review process
be developed and used on a regular basis to provide a feedback mechanism for
the Chiefs. Such feedback would assist and support Chiefs by providing
information on strengths and as a way to identify opportunities for improvement,
motivate, and provide encouragement and support. Three respondents
suggested that the review process involve both rnembers of the Department and
rnembers of the CHR administration. As one respondent noted:
... ongoing review would benefit both the Chiefs and the organization. The job is very complex and too important to be delegated and then not supported or reviewed (Questionnaire respondent, September, 2000).
Third, three questionnaire respondents suggested that a more formalized
selection process would help clarify the role and the cornpetencies required of
Chiefs. Respondents suggested that, if the job description were fu rther clarif ied, it
would assist in both the selection and review process. One respondent
suggested that it was difficult to select from "within" the organization due to
personal bias. A suggestion was to objectify the cornpetencies required for the
position and develop the selection process based on the cornpetencies. Two
respondents noted the dilernma of a Chief being "internaIn versus "external" to
the organization. Both respondents agreed that the Chief needed to be a
currently practicing physician, yet this means increased difficulty in maintaining
objectivity during the selection process.
3. Compensation
Suggestions related to compensation were made fourteen times. Eleven
respondents stated that they did not feel that Chiefs were adequately
compensated financially for the time they spend in their role. Four respondents
stated that Division Heads should be compensated financially for their work. A
suggestion was made to pay ChiefdDivision Heads to attend meetings. Providing
free parking was also suggested as a way to compensate Chiefs. Although rnany
comments related directly to financial compensation, this theme was very closely
Iinked with recognition for tirne and effort.
4. Support
Support, in a very broad sense, was a theme that emerged at ieast fifteen (32%)
times. I also grouped responses related to "mentoring" under this theme,
although mentoring might also have fit well under the theme of "education."
Three reçpondents suggested mentorship, or role-modeling, as a way to support
Chiefs. One person suggested a mentorship program with an external
management consultant as a way to support Chiefs.
As I read the participants' comments, it became obvious to me that one of the
biggest ways the CHR could better support its Chiefs is by valuing and
acknowledging their contributions. As 1 read responses, 1 came to believe that
Iittle recognition is given to the time and effort put into the extremely difficult and
complex leadership roles Chiefs are asked to undertake. Although no specific
reference was made to "recognition" per se, many suggestions for supporting the
Chiefs could directly be related to valuing, recognizing, and acknowledging their
efforts. One respondent commented that simply iistening to Chiefs would help
them to feel supported. As one participant noted:
Rather than more formal training, one needs to support Chiefs with evidence that the organization believes they can make a difference. Chiefs, like the rest of the troops, need encouragement and support. This can be done only by devoting more resources to Medical Administration, QA and QI (Questionnaire respondent, September, 2000).
The need to acknowledge, recognize and compensate the work, time, and effort
of Division Heads was stated explicitly on eight occasions. As one respondent
commented: "not only do they need to get paid, but they need to be recognized
for what they do (Questionnaire respondent, September, 2000)."
Four respondents suggested that Chiefs need increased secretarial support and
that this should be centralized and integrated. Two comments were made that
the current secretarial support was sporadic and insufficient. Three respondents
commented on the need for increased support through the Clinical Quality
lmprovement Program.
Four respondents commented on the need for Chiefs/Division Heads to be able
to mutually support each other. A suggestion was made that office space in a
cornmon area would assist the Chiefs to brainstorm and problem-solve informally
among themselves. The monthly "Chief's luncheonsn were seen as helpful
venues, but not frequent enough to promote an adequate amount of "support
from within." Increased access to one another was suggested as a way to
provide Chiefs with the opportunity to engage in joint problem-solving and
capitalize on each other's strengths. As one respondent commented, "we do a lot
of our stuff in secrecy ..... it's always helpful to see how others deal with tough
problems" (Questionnaire respondent, September, 2000)".
Finally, the need for increased support from the CHR's senior administration was
suggested as a way to support the Chiefs. This included support from the
Corporate Medical Director as well as the Vice-Presidents and Chief Executive
Officer (CEO). A suggestion was made that Chiefs should meet regularfy with
senior executives including the CEO. Three respondents suggested that one of
the Vice-Presidents of the CHR shouId be a physician. Two questionnaire
respondents commented that the CHR's Iobbying the Provincial Governrnent
more forcefully for resources would be seen as a way to support its Chiefs and
Division Heads. As one respondent commented:
By marshalling more resources from the Provincial Government so that care quality can be improved.. .continued efforts within our organization are essential but there is a limit to what can be achieved when resources allocated are inadequate (Questionnaire respondent, September, 2000).
The last, very general question asked respondents to add anything they thought
might help in the development of a leadership competency framework for Clinical
Chiefs/Division Heads. Three responses (5%) were received. Two comments
were made related the need for ongoing review of the position of Chief. One
comment was made about the necessity of physician representation at the senior
executive level. I was surprised by the low number of responses to this question,
however, it may mean that respondents that this question was answered
elsewhere.
Summary
In this chapter, I have reported the resuIts of the research study. I used two
different methodologies (interviews and questionnaires) to ask the following
questions :
1. What are the competencies required of Clinical ChiefslDivision Heads in
the CHR?
2. How can the CHR support its ChiefdDivision Heads?
The information gathered to answer the first question from both the interviews
and the questionnaires was virtually the same. The information 1 obtained from
the interviews validated what I had found in the literature. Four themes emerged
in response to the second question both during the interviews and from the
ir?forrnation gathered in the questionnaires. The themes regarding how the CHR
could support its Chiefs were: education, role clarity, compensation and support.
Although I used two very different methodologies to ask the questions, the
answers were virtually the same. During the initial planning stages, it seemed
that my process of inquiry was rather linear. As I conducted the research,
however, I realized that my approach was in fact circular. l began with a review of
the literature to build a frarnework. Next, I validated the framework with the
interviews. Then, I validated what I had found in the interviews with the
questionnaire. The final (completing the circle) stage will be to return to my
original framework, make revisions according to the information f have collected,
and return to the literature by making a contribution to my organization.
In the next chapter, I will interpret the research study results and make
recommendations based on my findings.
CHAPTER FlVE - STUDY INTERPRETATION, CONCLUSIONS AND RECOMMENDATIONS
In this chapter, I have interpreted the meaning of the data collected in this
research project. I have drawn six conclusions based on themes that emerged
from my research.
The original questions for this research project were:
1. What are the competencies required of Clinical ChiefdDivision Heads in
the CHR?
2. How can the CHR support it Clinical Chiefs/Division Heads?
Underlying these questions were two assumptions. First, that the role of Clinical
Chief/Division Head is important and rnakes a difference. Second, that the CHR
values and supports leadership at ail Ievels of the organization.
Research participants answered both these questions. They told me what "it
takes," in terms of competencies, to be a Clinical chief in the CHR. They also
provided me with a number of suggestions as to how this role could be better
supported. The information obtained from the interviews and questionnaires was
virtually the same. I have, therefore, interpreted them together.
INTERPRETATION AND CONCLUSIONS
Based on the research questions, the assumptions noted above, my
interpretation of the findings, and the research process itself, I have drawn the
following six conclusions:
1. Leadership is important-
My research findings suggest that leadership is important to people in the CHR.
The overwhelming response and support 1 have received throughout this
research project is testimony to the fact that people care about leadership.
Although 1 am aware that the high response rate was, in part, related to me as a
researcher and the relationships I have with people in the organization, I believe
that is only part of the story. Even prior to beginning this research, 1 was struck
by the enthusiasm and interest people demonstrated when 1 spoke with them
about my proposai. 1 had no difficulty finding willing interview participants.
Although I delimited my research project to four interviews as part of the data
collection for my research, I have spent hours over the past few months talking
with people throughout the organization about leadership. Leadership is relevant
and interesting but we rarely take the time to talk about it. It is so integrated with
our everyday lives, both persona1 and professionai, that it is hard to discuss
leadership without a context. This research study seemed to provide a forum for
people to talk about leadership, and they embraced the opportunity with
enthusiasm.
The high response rate to my questionnaire also showed that people care about
the topic of leadership. Although the actual numben were never intended to be
statistically significant, the fact that the overall response rate was 85% tells me
that people care. More importantly to me is the fact that 95% of the Clinical
ChiefdDivision Heads surveyed responded to the questionnaire. This tells me
that they are both interested in leadership and want their voices to be heard. In
addition, my research proposa1 was reviewed by the CHR's Research Review
and Ethical Approval Committee and was supported as a "valuable quality
improvement initiative."
The following examples from the interviews and questionnaires suggest that
people care deeply about leadership:
One interview participant took the tirne to prepare a thoughfful, written
response to the interview questions prior to the interview.
Each interview participant spent time reflecting prior to the interviews and
came prepared to give thoughtful responses to the questions.
I received five phone calls and two emaiIs from participants who had received
my questionnaire and were concerned about missing the return deadline. This
demonstrates that people not only care about this topic, but that they want to
ensure they are heard.
One interview participant surnmarized the themes from the interview
transcript before returning it to me.
Prior to, and throughout, the research project f received very strong support
for this work from the Manager of the Clinical Quality lmprovement Program,
the Corporate Medical Director, and the Director of Continuing Medical
Education.
One research participant actually took the time to dictate (and have
transcribed) the responses to the questionnaire as there was insufficient
space allotted.
Throughout the course of this research, 1 had, and continue to have, frequent
"hallway conversations" with people throughout the organization about my
research and about leadership.
As stated earlier, some of these examples are undoubtedly related to the
relationships that 1, as a working colleague, have with people in the organization
in addition to my research role. But, I am assurning that the busy people in my
organization would not have engaged rny project in this way if it were not
important to them. Based on the findings, I believe that underlying the
enthusiasm is the deep desire people have to want to do a good job. It is
because they care. If they did not care, they would be apathetic. People care
about leadership. People want to talk about leadership. People think leadership
is important.
2. Leadership corn petencies can be developed.
My study findings told suggest that there are specific leadership competencies
and that these can be developed. My own research validated what I had found in
the Iiterature with respect to competencies for physician leaders. Through their
responses, research participants consistently supported the notion that the skills,
knowledge, and abilities required of physician leaders could be learned.
My study findings also reinforced the need for a type of framework to begin a
dialogue about leadership and the development of leadership competencies.
People need Ianguage and an opportunity to taIk about leadership as a first step
in developing shared understanding. 1 believe my research project was that first
opportunity for some participants.
All of the competencies in the framework were considered essential. Four
questionnaire respondents noted the difficulty they experienced when asked to
rate the competencies in order of relative importance. They felt al1 the
competencies were so important and that it was impossible to name one more
important than another. This validated what I had found in the literature.
The single most frequent suggestion made by research participants, when asked
how the CHR could better support its Chiefs, was to provide support and
education related to the development of leadership competencies. I heard from
participants repeatedly that leadership competencies not only can - but must - be learned. My findings suggested that leadership was too important to be left to
chance and that a proactive approach is critical not only in the selection process
for new leaders, but in the development of current leaders. My findings support
my growing befief that it is no longer acceptable to allow leadership to follow
tradition or to be left to volunteers.
Several responses, including many from physicians thernselves, suggested that
physicians typically do not feel prepared when they first assume forma1
leadership positions. They lack the forma1 training and education in leadership,
and organizational skills. The data from my study suggest that physician leaders
both need and want opportunities to learn about leadership. The themes of
mentoring and role-modeling emerged throughout my findings as a way to
support physician leaders. One research participant stated that Chiefs feel they
are 'Yhrown to the wolves" (Questionnaire participant, September, 2000) when
they begin formal leadership positions without adequate preparation.
In summary, leadership cornpetencies can be developed and my findings
suggest that physicians want - and need - the opportunities to develop them.
3. Leaders need recognition and support.
Although not always stated explicitly, the fact that leaders need support and
recognition for their work was obvious not only by what was said but by what was
not said. Underlying many of the respondents' comments was sense that the
Chiefs' work is not acknowledged. As 1 read responses from the interview
transcripts and questionnaires, 1 got the sense that little recognition is given to
the time and effort put into the extremely difficult and complex leadership roles
Chiefs are asked to undertake.
The issue of financial compensation came up repeatedly. While this must not be
overlooked, I believe that financial compensation is closely linked with the need
for recognition and support. Money is just one way an organization can recognize
the time and effort required for this difficult role. Money is tangible, unlike
"recognition" or "acknowledgernent." But it is oniy part of the story.
It does not make good financial sense for a physician to assume the role
Chief/Division Head. The money that Chiefs are paid is, not in and of itself, an
incentive to do the job. There are other, "higher-leveln reasons physicians spend
the time and energy assuming formal leadership positions. The money itsetf is
not enticing; everyone knows that it is more lucrative and makes much more
practical financial sense to practice medicine. In a sense, Clinical Chiefs/Division
Heads actually "lose" money whenever they spend time in their role as
Chief/Division Head. Besides, medicine is what physicians are trained to do. So,
while Chiefs need to be compensated appropriately for the work they do, I
believe the CHR needs to focus on other, higher-Ievel needs such as recognition
and support.
The fact that many research participants feel the Chiefs are not adequately
compensated for their work creates a barrier. Research participants have stated
explicitly that Division Heads should be paid - and that it is not acceptable for
such an important role to be filled by volunteers. The dilemma is that it is difficult
to attend to "higher-level" needs (like acknowledgement and support) when
"lower level" needs (like money) are not met. I believe the underlying issue is
beyond money; it is the need to feel acknowledged for the tirne and effort spent
doing a difficult job. However, as long as money is an issue, it will remain the
focus and interfere with the organization's ability to address the higher leveI
needs for acknowledgernent and support.
The study findings suggest that the role of the Chief is complex and can lead to
feelings of isolation. My findings suggest that many physicians in leadership
positions do not feel heard. Issues related to financial compensation can distract
people from getting to the "real" issues which, I believe, are partly related to
feelings of isolation. The elimination of a senior executive position in 1999 (Vice-
President), formerly occupied by a physician, has increased the sense of
isolation and aiienation among physicians in the CHR. My findings suggest that
physicians do not feel adequately represented at the senior executive level of the
organization. Four questionnaire respondents suggested that physicians need
better representation at the senior executive level. As one questionnaire
respondent stated:
Senior management needs to hear the concerns of Clinical Chiefs directly, not through the Regional Directors . .. we need one M.D. as Vice-President who could then relate to the Clinical Chiefs" (Questionnaire respondent, September, 2000).
Three research participants commented on the span of control of the Corporate
Medical Director being too wide to enable him to support the Chiefs to the extent
that they require. As one questionnaire respondent commented:
It is rernarkable that there is only one full-tirne Medical Administrator in the whole of the CHR. In contrast, there are dozens, if not one hundred, other types of full-time administrators. This sends a message that medical administration is not highly valued ... and this message is not missed by the medical staff (Questionnaire respondent, September, 2000).
The logical question is: How can anyone feel acknowledged and supported if
they do not feel heard?
Leaders, in any democratic organization need to be recognized and supported.
My study findings reinforced this by the large number of suggestions made for
ways the CHR could provide better support for Chiefs. My participants told me,
both in the interviews and in questionnaires, that leadership is important.
Leadership cornpetencies can be developed. Leaders want to do a good job - they do not do it for the money. They need to be acknowledged and feel
supported.
4. The role of Clinical Chiefmivision Head is not clearly defined.
Ironically, the lack of role definition is the conclusion that was most clear from my
study findings. Research participants told me that the role of the Chief is vague,
ambiguous and that there seems to be a lot of overlap between the role of
Clinical Chief and Medical Prograrn Director. During interviews, participants told
me that the lack of clarity with respect to the role of Chief/Division Head is the
cause of much angst and frustration on the parts of both the Chiefs themselves,
and the people with whom they work. The CHR's move to a Program
Management mode1 of care has further increased this confusion. Many Chiefs
have dual roles - they are both Clinical Chief and Medical Program Director.
Balancing these disparate functions can be extremely confusing not only for
them, but also for those with whom they work.
My findings suggest that physician leaders find themselves in a "catch-22
situation. They want to do a good job but, because their role is not clear, it is
difficult for them to know what to do. Furthermore, it is almost impossible for them
to know if they are doing their leadership jobs well. One respondent Iikened the
role of C hief to "herding catsn or "squeezing Jell-O" (Questionnaire respondent,
September, 2000). These analogies express the frustration of trying to do the
impossible. This sense of frustration was supported throughout the research
findings. People want to do a good job, but they don? know specifically what their
job is. The role of the Chief is not clear and the move to Program Management
had made it less clear.
5. Feedback mechaaisms are needed.
My study findings indicate that the leadership role needs to be taken seriously
within my organization. This is of particular importance now, when physicians are
more involved than ever, in decision-making throughout the CHR. My findings
stressed the importance of selecting the most appropriate leaders in a systematic
way. While the a selection process is outlined for Chiefs in the Rules and
Regulations, as one questionnaire participant described the current selection
process, particularly for Division Heads, is descri bed as:
... it's thrust upon them - i.e., it's your turn to do it - with no formai training in management, quality assurance, etc. (Ifs) not always the best person - sometimes ifs the only person who will do if' (Questionnaire respondent, Septem ber, 2000).
My findings suggest that it is no longer acceptable to rely upon the goodwill of
volunteers.
Research participants told me that formalized mechanisms are needed for al1
aspects related to physician leadership. These same participants suggested the
following examples of forrnalized processes: a structured orientation prograrn for
new Chiefs, mentorship programs, regular performance evaluations, and a
competency frarnework to be used in the selection process for new Chiefs.
6. Physician leadership has unique characteristics.
Although leadership is difficult to define in any strict sense, we know it when we
see it. I have heard people Say that "Leadership is leadership." But, in reference
to my particular research project and my organization, the question that must be
asked is: Is leadership different for physicians than other leaders? My research
tells me that, although the cornpetencies required of physician leaders are the
same as for any leader, the contextual differences cannot be ignored when it
cornes to physicians. A number of factors are responsible for these differences.
So, the answer to the question, "is leadership different for physicians than other
leaders?" is both yes and no. And, there are a number of factors responsible for
this confounding answer.
One obvious factor is the unique environment within which physicians work. In
the CHR, as in the rest of Canada, physicians could be considered private
entrepreneurs working in a publicly funded systern. This means that, while they
work within organizations, they are not ernployees, nor are they accountable
directly to the organization. A type of symbiotic relationship exists between
physicians and health care organizations where neither can exist without the
other and both depend on their ability to work together. Because this
environment is unique, physicians - and physician leaders - cannot be expected
to behave like ernployees in an organization (Longo, 1994; Meyer, 1992). They
simply are not.
An important factor that emerged as a finding from my research is that
physicians, particularly physician leaders, value competency related to clinical
expertise above al1 else. This fact is supported in the Iiterature (Zaher, 1996;
Longo, 1994) and was clearly reinforced by my findings. 60th the groups of
Clinical ChiefdDivision Heads surveyed as well as the physicians surveyed rated
clinical expertise as more important than other competencies although the
Clinical ChiefdDivision Heads rated this as the most important cornpetency
overall. The overall importance rating of physicians to the cornpetency of clinical
expertise was more cIosely related to the response of administrators who also
valued clinical expertise as important yet the Chiefs themselves saw is as the
most important overall. P hysicians rated leadership and communication skills
most important beyond other competencies and administrators rated leadership,
communication skills and interpersonal skills most important (Figure 3, Table 3).
One may speculate that the reason for this is a perception among Chiefs that
clinical expertise is what is valued most of all. And, does it matter? fi seems that
what is most important is to elicit from the various groups what their perceptions
are in order to increase our shared understanding. The point is to begin a
dialogue about what "it takes" in order to understand what Senge (1 990) calls our
"mental models" so that we can better comrnunicate and interface with each
other in working toward the mission and vision of the organization. It is also
important to note that there are differences in perception as to what is important
to various groups of stakeholders. It is not surprising, therefore, that a physician's
perspective might differ from an administrator's, for example, who may value
leadership, communication skills, and interpersonal skills more highly (Figure 3
and Table 3).
Another factor to consider is that the practice of medicine is based on autonomy,
independence, and a focus on individuals rather than groups. Because this is
true, physicians in leadership positions need to learn many of competencies
related to teamwork. A significant shift is required to go from making quick,
independent decisions to working with limited information in a system that
responds slowly to change. When physicians assume positions of leadership,
their focus must change from individual needs to the needs of a group.
Physicians must then switch from a position of control to one of persuasion. The
physician leader, accustomed to operating as "captain of the ship," must develop
the group leadership skills to inspire a shared vision, develop consensus and
facilitate change. (Farrell & Robbins, 1993; Kaiser, 1999). Although this may
seem simple, the shift for many physicians is monumental.
One of the most significant differences with respect to physician leadership is the
difficult position Clinical ChiefdDivision Heads find thernselveç in when they have
to provide negative feedback or discipline to one of their peers. This is not easy
for anyone, at best, but it is exceedingly difficult for physicians. There are two
main reasons physicians have trouble with giving negative feedback. First,
physicians are trained to strive for perfection. The predominant culture in
medicine is, unfortunately, an irnpediment to accepting anything less than
perfection (McKegney, 1989; Larson, 2000). Second, physicians value their
relationships with other physicians. A study by Kirschman (1 999) found that the
number one activity most enjoyed by physician leaders was working with other
physicians as leader, mentor, and educator. The value placed on their
interpersonal relationships with other physicians makes the task of discipline and
feedback extremely difficult for physicians. Add to this the fact that physicians in
forma! leadership positions who are expected to provide negative feedback or
discipline to their peers risk being alienated by their colleagues. Aside from the
difficult personal implications, this can have very real financial implications for
physicians in leadership positions. For example, when a physician leader is
required to provide negative feedback or discipline to colleague, this colleague
may be reluctant to refer patients to this physician in the future because of
potential hard feelings. This dilemma was mentioned at least twice during my
research.
Physician leaders must rnarch to the beat of many different interna1 and external
drummers. First, to their own drum as independent practitioners; second, to the
drums of their colleagues whose relationships are highly regarded; third, to the
drum of the organization with its own agenda and set of expectations; and fourth,
they are held accountable by case law, to the Royal College of Physicians and
Surgeons of Canada and to the British Columbian Medical Association. Still,
many physicians assume the role of Clinical ChiefIDivision Head without any
formal education or training in management or leadership. Add to this the fact
that many physician leaders do not feel adequately compensated for their work
and the fact that Division Heads are not paid, and it is not surprising that we do
not have a shared understanding of physician leadership within the organization.
The bottom line is that, while the leadership competencies required of physicians
are not unique to physicians, what is different is the complex environment and
culture within which they work. Information gathered from rny research suggests
that, while many of these factors are not within the control of the organization,
any solid research study of physician leadership must be sensitive to the very
real environmental and cultural, and legal circumstances unique to physicians.
In this section, I have described six conclusions that I have drawn from my
interpretation of the research study findings. These are:
1. Ieadership is important;
2. leadership competencies can be developed;
3. leaders need recognition and support;
4. the role is not clearly defined;
5. feedback mechanisms are needed; and,
6. physicîan leadership has unique characteristîcs.
RECOMMENDATIONS
The process I foliowed to develop my research recommendations could be
described as circular in nature. My conclusions were drawn from the data I
obtained from my research as well as on the entire research process itself. My
recommendations are based on these conclusions. My recommendations are,
therefore, indirectly based on and supported by my research data.
My research began with a review of the literature regarding leadership
competencies for physicians in forma1 leadership roles. Using the information
from the literature, I drafted a leadership cornpetency framework which was really
a hybrid of a number of other leadership cornpetency frameworks. I validated this
framework by conducting interviews, and revised it according to what I heard
from interview participants. 1 then included the framework in a questionnaire to
further validate what I had heard in the interviews.
Each of my study recommendations is based on conclusions I drew from my
interpretation of the research data. For example, the ovenvhelming response
rate, the fact that each of the competencies was rated as either important, very
important, or critical, led me to the conclusion that leadership is important and
that it is possible to articulate leadership competencies in a framework. This
conclusion formed the basis for two of the eight recommendations. First, that a
leadership competency framework be adopted by the CHR. Second, that the
selection process for new ChiefdDivision Heads reflect these competencies.
A similar process was used to develop each of the following eight
recommendations:
1. A leadership competency framework for the position of Clinicat ChiefdDivision Heads should be adopted by the CHR.
The CHR should adopt a leadership cornpetency framework based on input from
key stakeholdersl. This framework should be used as the basis for the selection
process of new Chiefs and for the evaluation of existing Chiefs. An example of
this framework can be found in Appendix K.
The competency framework should be evaluated on a regular basis to ensure it
continues to reflect the needs both of the stakeholders and the needs of the
organization.
The leadership competency framework should be reviewed and endorsed by
members of the Regional Medical Advisory Cornmittee as well as the Corporate
Medical Director prior to being adopted by the CHR.
2. The selection process for Chiefs/Division Heads should reflect the competencies identified in the leadership competency framework.
The competencies identified in the framework shoula be the focus for the
selection process of new Chiefs. A supportive infrastructure is necessary to
maximize the contributions of medical administrators. As one participant
commented:
The temi "leadership competency framework" well describes the context of this approach. Part-time medical leaders with vision will certainly appear randomly and unpredictably but it is hardly a system designed to produce good outcomes (Questionnaire respondent, September, 2000).
The framework could form the basis for the development of the job description
and be used to develop interview questions for the sefection process of new
1 Key çtakeholders are: senior executives including the Corporate Medical Director, Clinical Chiefs, Division Heads, Medical Program Directors, practicing ph ysicians, and adm inistrators including Regional Directors and Patient Care Managers.
Chief/Division Heads. A rating system could be developed when interviewing
potential candidates where a weighting system could be assigned to the various
cornpetencies deerned most important by key stakeholders involved in this
research. Interview questions could be stnictured to elicit descriptions of how
these competencies have been demonstrated in the past or might be
demonstrated in the future. Key stakeholders should be involved in the
development of interview questions based on the competencies.
The leadership competency framework should becorne part of the role
description and should be shared with any physician expressing interest in the
position of Clinical Chief or Division Head.
3. A selection and review process for ChiefdDivision Heads should be implemented and involve key stakeholders.
The selection and review process for Clinical Chiefs and Division Heads should
be based on the leadership cornpetency frarnework.
The current practice of including stakeholders on "search and selection
cornmittees" should be continued.
A systernatic, regular review process involving key stakeholders should be
established and followed. The review should be based on the leadership
competency framework like the one outlined in this project.
The review process should be an open process that involves the Clinical Chief
/Division Head at every step. A self-assessment should form part of the review
and be based on the Ieadership competency framework.
A "provisional" period should be established for new Chiefs that would provide an
opportunity for the Chiefs to obtain feedback before they commit to the role for
the full term.
4. Leadership training and developrnent opportunities for ChiefsIDivision Heads should be supported by the CHR.
The current practice of supporting ChiefdDivision Heads participation in
Physician Management Institute (PMI) courses should continue and be strongly
encouraged for al1 Chiefs and Division Heads.
Additional opportunities for Chiefs to participate in executive leadership and
management education and training should be supported and funded by the
CHR.
The CHR should support joint leadership prograrns that include both physicians
and administrators in programs that focus on the development of interpersonal,
management, and organizational skills. These should be strongly encouraged
and funded by the CHR.
Existing frameworks could be used to for leadership development activities. For
example, one questionnaire respondent suggested that the "Chief's luncheon"
forum may be an appropriate venue to provide more structured opportunities for
learning. Interactive sessions with planned speakers might be one way this could
be done without increased financial resources.
Regular education sessions related to communication skills, providing feedback,
quality assurance, quality improvement and conflict resolution should be
mandatory for al1 Chiefs/Division Heads. These should be funded by the CHR.
The suggestion of regular education sessions be was made by al1 interview
participants and by at least twenty survey respondents. At least thirteen research
participants stated that these sessions shouid be funded by the CHR.
5. A formalized orientation process should be developed for new Ch ief S.
The CHR should develop a forma1 systematic orientation process for new Chiefs
to ensure that key elements are addressed during the orientation period.
A mentorship process should be established whereby physicians are given the
opportunity to act in the capacity of vice-chief for a defined period of time prior to
assuming full responsibility for a Department.
Responsibility for the orientation of new Chiefs should be centralized to ensure
consistency. Key stakeholders should be involved in the orientation of al1 new
ChiefdDivision Heads.
6. The role of the Clinical ChiefIDivision Head should be clarified.
The current roles and responsibilities outlined in the Medical Staff RuIes (April,
2000), should be further clarified. Key stakeholderç should be involved in this
process and the Medical Staff Rules should contain examples of typical duties.
A clear definition of how the role of the Chiefs differs from the role of the Medical
Program Directors should be provided, acknowledging areas of overlap and
interdependence. As one respondent noted:
There is still a tension and uncertainty about the importance of the Chief's role. Quality of care is a big responsibility but the Chief's ability to influence it is modest. There are just so rnany variables which influence outcornes of medical care (Questionnaire respondent, Septernber, 2000).
Research participants agreed that both leadership and management skills were
important in the role of Chief. Wherever possible, the distinction should be made
in the role description to define the differences between the leadership roles of
the Chiefs and the Management roles of the Program Directors. Ernphasis
should be placed on the role of the Chief in relation to quality of care - doing the
"right thing;" whereas the Program Director's role is to ensure that this "right
thing" is "done right" (Covey 1990).
The importance of vision, and of developing a shared vision with goals and
objectives, was a recurrent theme throughout my research. The deveiopment
and articulation of a Department vision should become part of the role of the
Chief. Each Department should have the support required to develop a vision
and this should be shared with rnembers of the Department.
Responsibilities of the Chief regarding discipline should be outlined in the role
description. Formal processes should be developed for issues related to
discipline.
The resources available to Chiefs should be included as part of the role
description.
7. A review of the remuneration system for CIinical Chiefs and Division Heads should be seriously considered, along with other forms of recognition.
Based on the findings of rny research project, it seems timely to review the
current payment system for Clinical Chiefs and to consider paying Division
Heads. My findings suggest that physician leaders do not feel adequately
compensated for their work. The current infrastructure for payrnent seems to rely
on volunteerisrn on the part of the Division Heads, many of whom without which
the Clinical Chiefs could not manage. It therefore seems logical that a review of
the current arrangements for compensating physician leaders is in order. A
different payment structure may be a way the CHR could better support and
recognize its Clinical Chiefs/Division Heads. Remuneration does not need to be
limited to financial compensation alone. There are other mechanisms by which
Chiefs/Division Heads could be compensated including free parking, dedicated
office space, cornputers, educational opportunities related to leadership,
cornputers, etc. The primary role of Chiefs/Division Heads is to be responsible
and accountable for the overalI quality of medical care. This may be the most
important role in the entire organization and yet, it seems difficult to imagine
sustaining the current leadership structure unless changes are made to the
system of remuneration for both Chiefs and Division Heads. Division Heads
require remuneration.
Research respondents have told me that physicians are not "chomping at the bit"
to become ChiefslDivisions Heads. A review of the system of remuneration may
be one way to aid in the recruitment and retention of Clinical ChiefdDiviçion
Heads.
As one questionnaire respondent suggested, there are also other forms of
recognition. One may be to provide free parking for Chiefs/ Division Heads as
this is not only expensive, but a very contentious issue, particularly at the Royal
Jubilee Hospital site.
8. Clinical ChiefdDivision Heads should be recognized and supported.
The CHR should increase the medical administrative resources available to
support its ChiefdDivision Heads. Physician leaders in my research told me they
need the support of an experienced physician leader to act as a mentor and role
model. The position of Vice-President Programs, previously occupied by a
physician, was valued by physicians but was replaced by a non-physician in
1 999. At least three research participants indicated that the CHR should consider
having one physician in the position of Vice-President. As one respondent noted:
Clinical development and innovation would be supported by a VP (Medicine). Programs . .. would be more likely to be initiated and developed if a senior medical administrator dedicated to medical TQM was present on the 3rd floor of Begbie (Questionnaire respondent, Septernber, 2000).
My findings indicate that the current span of control of the Corporate Medical
Director is seen as too wide. The CHR should consider having site specific that
would act to support the Clinical Chiefs/Division Heads on a daily basis.
Research participants told me that the current practice of involving external
medical consultants, when appropriate, should be continued. lnvolving external
physician consultants in situations where the Chief/Division Head rnay be
perceived as having a "conflict of interest" is one way the organization can
support its current ChiefdDivision Heads and this practice is seen as valuable
and should be continued.
The CHR should provide physical space where Chiefs/Division Heads could
interact with each other on a daily basis. This may help to decrease the isolation
felt by Chiefs, enable them to provide each other with support, and promote
informa1 learning opportunities identified in my research as most valuable.
The Clinical Quality lmprovement Program (CQIP) should be expanded to
increase the amount of support available to Chiefs. This would help the Chiefs
fulfill their mandate related to the quality of medical care by providing assistance
and support in the development of clinical practice guidelines and in monitoring
compliance. According to my findings, the current resources available through
the Clinical Quality lmprovement Program were seen as valuable, but were
Iimited and fragmented. As one interview participant stated: " . . . each Division
needs a dedicated Quality lmprovement Associate to monitor overall patient care
(Interview Participant, August, 2000)." A suggestion was made that a medical
presence (physician) working in the CQIP office would assist in supporting the
Chiefs/Division Heads in their commitment and support for medical quality
improvement (Questionnaire respondent, September, 2000). Another comment
by a research respondent stated :
. . . the frarnework would involve an increased number of full-tirne medical administrators, an office where innovative programs could be nurtured, and a medical consultant in the Quality lmprovement Office. AI1 of this would require a re-evaluation of the role of the medical leadership in the organization(Questionnaire respondent, September, 2000).
My findings suggest that consideration should also be given to increasing the
resources in the Ciinical Quality lmprovement Program to include data analysts
and research assistants.
The CHR should provide adequate, integrated secretarial support to its Chiefs.
My findings suggest that the current resource is viewed as insufficient and
fragmented.
The CHR should provide the Chiefs with access to computers to facilitate
electronic communication. My findings indicate that access to computers is
currently limited and inadequate. Chiefs need access to computers and other
means of electronic communication. This could help decrease the amount of time
spent in meetings and potentially reduce time spent on correspondence. It would
also provide an additional, alternative way for Chiefs to communicate with each
other.
Summary
In this chapter, I have interpreted the rneaning of my research findings and drawn
six conclusions. My conclusions are:
1. leadership is important;
2. leadership cornpetencies can be developed;
3. leaders need recognition and support;
4. the role of Clinicai ChieflDivision Head is not clearly defined;
5. feedback mechanisms are needed; and,
6. physician leadership has unique characteristics.
Based on these conclusions, and the themes that emerged from my research, 1
have made eight recommendations. My recommendations are:
1. a Ieadership competency framework for the position of Clinical Chief/Division
Head should be adopted by the CHR;
the selection process for ChiefsfDivision Heads should reflect the
corn pet encies identified in the leadership competency f ramework;
a selection and review process for Chiefs/Division Heads should be
implemented and involve key çtakehoiders;
leadership training and development opportunities for ChiefdDivision Heads
should be supported by the CHR;
a formalized orientation process should be developed for new Chiefs;
the role of the Clinical ChieffDivision Head should be ctarified;
a review of the remuneration system for Clinicat Chiefs and Division Heads
should be seriously considered, along with other forms of recognition; and,
Clinical ChiefdDivision Heads should be recognized and supported.
In the next chapter, I will describe the organizational implications of my research
findings and recommendations and make suggestions for future research.
In this chapter, I have described the initial steps required to implement the
recommendations of my research project. Along with some of the organizational
implications, I have predicted what might happen if changes are not undertaken.
In addition, I have suggested some areas for future research.
As a result of this research project, I have provided the Capital Health Region
with eight recommendations. The findings of this study have answered the
original research questions regarding the competencies required of Clinical
Chiefs and Division Heads and have helped suggest ways in which the CHR can
support its physician leaders.
The findings related to leadership competencies were not surprising considering
the volume of Iiterature available about leadership and leadership competencies.
This study validated what I found in the literature. In some ways, the leadership
competencies required of physicians are no different from the competencies
required of other leaders. What is different is the context, the environment, and
the culture within which physicians work. What is unique about my research are
those findings that suggest practica! ways physician leaders might better be
supported - right now - in the CHR. Although my recommendations may be
applicable elsewhere, the findings are unique to the culture, climate, and
organizational structure of the CHR today.
The main benefit for the CHR is that this research project provided an opportunity
for people to be involved in a process of building a leadership competency
framework with the potential to be used where they work. I hope that the
framework can and will be used in practical ways and that, because people were
involved in the process they will feel committed to its implernentation and
accountable for the outcomes. This framework may also be of value to other
regions.
Considering the number of changes the Capital Health Region has undergone in
recent years, it is not surprising that physicians in the region feel isolated and
alienated. The CHR is a relatively new organization, still feeling the aftershocks
of the regionalization process. The move to a Program Management mode1 of
care, combined with the fact that there have been four CEOs in three years, a
number of changes of Vice-Presidents, have al1 resulted in re-structuring
processes that have been difficuft for everyone to manage.
Despite the chaos in the organization, the energy and enthusiasm I have enjoyed
throughout the course of my research provide me with optimism for the future.
People are interested in talking about leadership, and they want their voices to
be heard. Participants have expressed excitement about the process and are
anticipating that action will be taken to change things for the better. The mere
"doing" of this research has provided an opportunity for people to begin a
dialogue about something that had previously been left to managers, executives,
and tradition.
In addition to those changes noted above, a number of ChiefdDivision Heads
have both resigned or retired recently. The time is right to talk about leadership
within the CHR. There is an immediate and practical need to develop processes
to find new leaders. I hope my research findings can be used in practical ways to
capitalize on the changes happening now within the region.
Many recornmendations from my research require additional resources. The lack
of resources will be a very real limitation to the CHR's ability to implement a
nurnber of my recommendations. The creation of common office space for
Chiefs, the purchase of cornputers, the expansion of the Clinical Quality
lmprovement Program, increased funding for education and remuneration for
Division Heads al1 require additional money. But, many recommendations do not
require direct funding and could begin immediately without additional funds.
The main recommendation from my research iç that the CHR adopt the
leadership competency framework for the position of Clinical Chief/Division Head
that I have developed through this process of inquiry. The final draft of the
leadership competency framework was reviewed by the four interview
participants to ensure their feedback had been accurately reflected.
This step is required before many other recornmendations can be implemented.
For example, once adopted, the framework could fom the basis for developing
interview questions and could be used to develop an evaluation tool.
The first step to adopting the framework will be to obtain the endorse of the
Regional Medical Advisory Committee (RMAC). This Committee is comprised of
all the Chiefs of Departments and a number of administrators. This Cornmittee's
role is to make recommendations to the CHR Board of Directors. The support
and approval of RMAC is essential if the framework is to be used.
While many of the Chiefs have participated in the development of the framework
as research participants, its acceptance is not guaranteed. As a large
organization that employs over 10,000 people, the CHR is extremely
bureaucratic. Physicians, in general, have a low tolerance for bureaucracy. As a
result, this framework could potentially be viewed as yet another bureaucratic
process without any tangible benefit. The way in which the framework is
presented to members of RMAC will have a significant impact on whether or not
it is accepted.
Physician participation and acceptance will be critical at every step of
implementation. Despite the fact that physicians were involved to a large extent
in the development of the framework, unless they believe it to be useful it will be
of little value. The fact that the researcher was not a physician was not a barrier
during the research; however, it will be essential to have physician "champions"
take the process further.
It will be important for this framework be viewed as helpful rather than as another
"hoop" for physician~ to "jump through." Physicians are already inundated with
rules, regulations, and requirements to participate in peer reviews, provisional
reviews, and quality assurance reviews. If the competency framework is
perceived as more work, it will not be supported.
Once the leadership competency framework is accepted, the next step will be to
integrate it into the selection process for hiring new chiefs and to develop
evaluation tools and processes based on the competencies. Again, physician
support and involvement will be absolutely essential every step of the way.
The major implication of integrating the leadership competency framework is that
it requires time, work, and commitment. A consistent, coordinated effort will be
required to ensure people are involved in every step if the framework is to be
successfully used. Without "buy-in" from al1 stakeholders, the CHR will never truly
adopt and use a cornpetency-based mode1 of leadership. Processes need to be
developed, and these can be Iaborious and time-consuming - at a time when
people already feel overburdened and under-resourced. The importance of
support for the framework cannot be overstated. Once support is obtained, most
of the work wilI be "up front." This means that, once the processes are
developed, time would actually be saved because the framework, interview
questions, and evaluation tools would be ready for use and would require
minimal effort to keep updated.
The ultimate long-term goal, of course, is that the processes developed actually
work - and help. My hope is that an open, participatory process for the selection
and evaluation of physician leaders makes a difference. lmplicit in this entire
process of building a competency framework is the need to build in some type of
evaluation. Without systematic evaluation, it is impossible to know if the
leadership cornpetency framework has made any difference. Will it help in the
selection process for new Chiefs?
If the CHR does not adopt the leadership competency framework, the status quo
will continue. With the current trend toward competency-based performance
models, however, it is hard to imagine that nothing will happen. The potential
exists that, if this framework is not used, another will be adopted (or irnported)
that may or rnay not reflect the needs of the region and, specifically, the needs of
the physicians in the region. The most valuable part of this framework, I believe,
is that it was developed with the input of the very people who would benefit from
its implementation. Perhaps, even if this frarnework is not adopted, nothing
drastic will happen. However, I believe that some competency framework will
eventually be employed to "hefp" Chiefs. The data from my research project
suggests a strong need for some sort of competency-based leadership mode1 for
the organization; and, it would be difficult not to believe that eventually something
will eventually be imported to fiIl this need.
FUTURE RESEARCH
The focus of this study was to develop a leadership competency framework for
the positions of Clinical Chief/Division Head by using a process that involved
current ChiefdDivision Heads, physicians, and administrators. The study also
Iooked at ways the CHR could support it current ChiefdDivision Heads. The
goals of this project have been met. However, other questions related to this
study remain that require further research.
This study concentrated its efforts on the formal role of Clinical Chief and
Division Head. More work is needed to look at those "informal" leaders
throughout the organization.
Since the CHR moved to a Program Management model of care delivery,
Medical Program Directors (physicians) and Regional Directors
(administrators) have come together to "CO-leadn Programs. The area of
"shared leadershipn and what this idea means need to be explored.
The results of the study were based on a broad group of respondents. It
would be interesting to see if there are differences within specific
Departments with respect to competencies and needs for support. For
example, are the leadership competencies required of surgeons different from
those of famiiy physicians?
The participants in my research were predominantly white, Anglo-saxon
males. It would be interesting to explore whether gender differences exist
when it cornes to leadership competencies and the support needs of
physician leaders. An inquiry into how different cultures define leadership and
the type of support that is vaIued would also be of interest.
The CHR's Organizational Developrnent/Human Resources Department has
recently piloted a Performance Management tool for al1 employees based on
%ore competencies." Further exploration into how this tool might be used in
conjunction with the leadership competency framework would be of benefit.
These are but some suggestions for future research. This research project could
be viewed as a starting point in the dialogue about leadership. The possibilities
for future research related to leadership are endless.
Summary
This chapter reviewed some of the organizational implications of implementing
my recornmendations. In addition to these, I have outlined some areas for future
researc h.
in the next chapter, I will review some of the lessons I have learned from doing
this research study and identify the cornpetencies 1 have dernonstrated and
developed throughout this process.
This chapter reviews some of my key learnings from the conduct and
management of this applied research project. In this chapter, I have also
suggested some examples of what I might do differently if 1 were to do this
research again. My hope is that others might learn from the insights I have
gained from the process of doing this research project. 1 have also described how
I have mastered the MALT program competencies through the process of
compteting this project.
Summary of Research
In conducting this research project, I was guided by two questions:
What are the competencies required of Clinical Chiefs/ Division Heads in the
Capital Health Region?
How can the CHR better support its Clinical Chiefs/Division Heads?
My goal in the project was to develop a generic leadership competency
framework based on a review of literature in the areas of leadership and my own
research with those people who were employed within such positions within the
organization. In the end, 1 hoped to develop a competency framework that would
prove functional in the recruitment and development of leaders within my own
organization. In this project, I have worked to outline, in the most rigorous way I
could, the leadership competencies required of physician leaders.
This generic framework was validated through individual interviews with
participants from three key groups: 1) physicians in formal leadership positions,
2) physicians and 3) administrators. As 1 inteMewed participants, 1 also asked
them to suggest ways in which the CHR might better support its Clinical
ChiefdDivision Heads. The generic framework that emerged was revised based
on themes identified during the interviews and a questionnaire was developed.
This questionnaire was then distributed to sixty respondents - twenty from each
of the groups Iisted above. Respondents were asked to validate the competency
framework and for suggestions of how the CHR could support its Chiefs/Division
Heads.
RESEARCH PROGRAM LESSONS LEARNED
My research project proceeded with few administrative difficulties. Participants
were enthusiastic, candid, and provided me with rich data. Undoubtedly, my long-
terrn professional and persona! relationships with many of the research
participants, along with the general interest in the topic of leadership, contributed
to the success of this project. The following is a summary of "key learnings" that
have occurred during the course of my research process.
Timing
I believe the timing of my research was good and positively affected my results.
Most of my interviews were conducted at the end of August and my
questionnaire was sent out on September 8, 2000. The "timing" coincided with
people returning to work following summer vacations and avoided major
holidays. Although my timing was not intentional, 1 believe it made it easier for
me to plan my interviews and increased the response rate to my questionnaire.
The timing was incidental, but it facilitated and helped expedite the data
collection process.
Executive Summary
With the cover letters to the interviews and questionnaires, I included a brief, one
page executive summary outlining the proposed research questions, the
methodology, and some information about the overall research process. This
provided participants with a quick overview of the project, and, 1 believe it
influenced their decision whether or not to participate in the research. Because 1
believe the sumrnary helped to positively influence my response by providing
clarity, 1 will always include a type of sumrnary in any of my future research.
Major Project Sponsor
The selection of rny Major Project Sponsor, I believe, had a positive impact on
my research. Dr. Donen is extremely well respected in the CHR and I have no
doubt that his association with rny project helped lend credibility to my research.
The fact that 1 was a "non-physician" conducting research on the competencies
required of physicians might have been otherwise problematic. Dr. Donen's
support, as a highly-esteemed physician in the medical community, helped me to
a great extent in the successful completion of this project. His interest in my
topic, along with his insights as a physician, an educator, and a researcher, were
extremely valuable. Given the cultural context in which the research was
conducted, it might have been difficult for me to complete this type of research
without the support of a physician leader. In addition, I had the support of Dr.
Higgs, the Corporate Medical Director. Although not a formal part of my
supervisory cornmittee, Dr. Higgs's approval and support for my project were
invaluable in terms of credibility and contributed to the overall success of my
project.
l nterviews
The individual interview format was well-suited for this type of research and for
my own personal style as a researcher. I had originally considered focus groups,
and, although I believe they would have provided a rich source of data, the
logistics of trying to conduct focus groups would have been extremely cornplex.
lndividual interviews enabled me to proceed with my research in an expedient
manner. This methodology suited me best as a researcher and worked well for
my research participants. I also found it beneficial to conduct at least one pilot
interview to refine the interview questions.
The interviews were taped and transcribed verbatim. The interview participants
were each given a copy of their transcripts to review. Although the interviews
were transcribed by a h ighly-skilled professional, the word-for-word format was
cumbersome, lengthy, and difficult for al1 to navigate. Each interview participant
commented about how awkward it was to review his or her own transcript. In
retrospect, I would not have had the tapes transcribed. Through my notes and
frorn my journal, I was able to adequately summarize themes and ideas.
Summaries in point form would have been both easier for me to work with and
easier for interview participants to review. I also made double tapes of al1 the
interviews. This process proved to be very practical. Because I had dubbed the
tapes, 1 was able to begin my analysis by Iistening to my copies of the tapes
before the transcripts were completed. Overall, the transcription was an
unnecessary expense and did not provide any additional benefit to me, rny
participants, or to the quality of my data. In the future, i would not have my tapes
transcribed.
Questionnaires
The response to my questionnaire was very high at 85%. Most surveys were
received well within the established time frame of two weeks. I received five
phone calls from participants who were concerned about missing the deadline. 1
was not concerned about a fixed date. Instead, I urged participants to complete
and return the questionnaires, regardless of the deadline. As noted in Chapter 5,
1 believe the high return rate was partially a consequence of my relationships with
the research participants. In my work, 1 interact with many people throughout the
organization on a daily basis. Both prior to and during my research, I had many
informal "hallway conversations" with participants. One week after the survey
was mailed out, I made several "reminder phone caIls" in addition to sending out
a "reminder letter" to al1 participants. I already knew most of the research
participants and took every opportunity to remind them to complete and return
their questionnaires.
I used the inter-hospitai mail system to distribute the questionnaires. A self-
addressed envelope was inciuded with the questionnaire, and I used multi-use
envelopes to distribute the questionnaires and retum envelopes. A number of
surveys were returned to me not only sealed in the envelope provided, but also
taped. In retrospect, I would have used sealed, single-use envelopes to distribute
the blank questionnaires and return envelopes. Although I do not think this
affected my response rate, it suggests that privacy is extremely important
throughout al1 phases of research.
Part of my high response rate, I believe, was due to the fact that my
questionnaire was simple. Although I had originally hoped to keep my survey to
one or two pages, the final version was four pages long. I could have
compressed the questions onto two pages, but I chose to make it four pages to
keep the information on each page to a minimum and not ovetwhelrn participants
with text. The fact that my questionnaire was visually simple made it easier for
respondents to complete and, I believe, increased rny response rate. It also
helped that 1 pilot tested my questionnaire on at least three people prior to
sending it out.
The first part of my questionnaire asked respondents to rate each competency in
terms of importance on a Likert type scale. On the first draft of my questionnaire,
I had also asked respondents to indicate the degree to which they felt each
competency was currently being demonstrated by the Clinicat Chiefs/Division
Heads in the CHR. Thanks to feedback from both my Faculty Supervisor and
Project Sponsor, I eliminated this question. In retrospect, this question would
have changed the entire tone of my research project, been extremely difficult to
report, and likely decreased rny response rate. My intent was never to conduct
an evaluation of the Chiefs. The most important research lesson that I have
learned is that if I do not wish to deal with the data, I should not ask the question.
One question in my survey asked participants to rank order each competency
according to its relative importance. A number of respondents commented that
this was extremely difficult for thern to do. I also struggled when it came time to
report the response to this question. In retrospect, I would have asked this
question differently. In the future, for example, I might ask respondents to list the
three "most important" competencies rather than asking them to rank order
competencies from most important to least important. Essentially, asking for the
tnree most important competencies would have given me virtually the same data
and would have been easier for respondents to answer and for me to report.
Closure
in order to provide closure to this research project for both myself and my
research participants, 1 plan to follow up with a letter thanking al1 participants for
their participation. Along with the letter, I will attach an executive summary of the
research and a copy of the leadership competency framework. Participants will
also be rerninded of when and how to access the final report.
Researcher Bias
Because I was both the researcher on this project and a Quality lmprovement
Associate in the Clinical Quality lmprovement Program (CQIP), I have a
considerable vested interest the appropriate selection and development of
physician leaders. The mandate of the CQIP is to support the Clinical Chiefs and
Division Heads in their role with respect to the quality of medical care delivered in
the region. Because of my work in the CQIP Program, throughout this study 1
attempted to remain as objective as possible. Specifically, I tried to remain
rnindful of my own bias as a researcher. I believe my persona1 and professional
relationships with many of the research participants were not a deterrent.
Instead, I befieve they enhanced the process by providing me with genuine
support and authenticity.
Another consideration for me, as a researcher, was the responsibility 1 had to
report the research findings honestly and to base my recommendations on the
findings. 1 had not fully considered the potential that my findings might suggest
recornmendations directly related to my role as a Quality lmprovement Associate
or program within which I work. My research has helped reinforce the statement 1
have often heard that ali research is subjective and that the researcher can never
be fully or objectively "removedn from any research. The mere fact that I chose to
study this topic is directly related to my own interests and worldview. While the
topic may be of interest and benefit to others, I chose it because it directly related
to my daily work. It is not surprising, then, that some of the recommendations
also related both directly and indirectly to my work in the Quality lmprovement
Program. While 1 acknowledge rny own bias as a researcher, my
recomrnendations were based on, and supported by, my research findings.
Ethics
Prior to commencing this research, my proposa1 was approved by the Royal
Roads University Research and Ethics Board. I also submitted my proposal to
the Capital Health Reg ion's Research Review and Ethical Approval Committee. It
was my understanding that al1 research initiatives in the CHR must obtain the
approval of this Committee. My research project was deemed to meet ethical
guidelines by academic staff at both Royal Roads and the University of Alberta.
As a result, I did not have any ethicaI concerns about my research. 1 also believe
1 had assessed the organizational impact, in terms of resources required, as
minimal. Nevertheless, 1 submitted my proposa1 for approval because 1 viewed it
as an opportunity to obtain feedback and to 'Validate" my research by letting
people within my organization know what I was doing.
My research project was considered by Royal Roads University to be "minimal
risk." This phrase was defined as meaning that "potential subjects can
reasonably be expected to regard the probability and magnitude of possible harm
implied by participation in the research to be no greater than those encountered
in those aspects of his or her everyday lifen (RRU, Ethics template, August,
2000). 1 worked hard to ensure that the participants in my research were not
exposed to any risks. Confidentiality and anonymity were maintained at al1 times.
I intewiewed and sunreyed physicians and administrators, neither of whom would
be considered "vulnerable" populations. Participation was completely voluntary
and, because I am not a "manager," there were no concerns directly related to
power. As a nurse, I was intimately familiar with the concept of "informed
consent" and accustomed to practicing within a Code of Ethics. I was also
acutely aware of issues reIated to confidentiality, pBvacy and freedom of
information legislation. 1 had absolutely no questions or concerns about the
ethics of my research project.
Folfowing my initial submission to the CHR's Research Review and Ethical
Approval Cornmittee, 1 was asked to clarify a number issues regarding the
proposed methodology, rny method of analysis, and to provide additional detail
on the "action research" elements contained in my proposal. The committee also
suggested that my proposa1 be reviewed, and a Ietter of support provided, by the
CHR's Planning and Priorities Council. I responded to the Committee and saw it
as an opportunity to learn more about how to write clearly and provide sufficient
detail when submitting proposals for approval. My proposai was reviewed a
second time by the Committee, this time including an "external" review. In the
end, the "committee felt that my proposal more closely resembled a QI (Quality
Improvement) project rather than a research protocol" (V. Morris, personal
communication, September 28, 2000). I appreciated their statement that my work
was an opportunity to improve the quality of the organization in which I worked - my job title within the organization exactly.
1 learnod many lessons from this process. I learned fhat:
It is important to write clearly and provide sufficient detail when seeking
approval for research proposals.
It is helpfuI to have an understanding of the ternis of reference and mandate
of a Cornmittee prior to submitting a research proposa1 for review.
The terni "research" is extremely broad both in definition and interpretation.
There is not always a "shared understanding" of this concept.
Action research is not well understood, nor is it "black and white." It is more
related to a phiIosophy or an approach to research than to any specific
methodology. I learned that research may include aspects of action research
and that action research might be best described on a continuum.
It is difficult to obtain approval for qualitative research in an organization
driven primarily by quantitative research and data.
Although questionnaires are typically used in quantitative research, my
questionnaire was intended to provide descriptive information only. I had
never intended to prove, justify, compare, or apply any of the research
findings based on the survey results alone. I chose a sunrey as a way to
validate the findings from my interviews. In the future, I would provide more
clarity about the intended use of questionnaires in any submissions for
approvat.
My experience with the CHR Research Review and Ethical Approval
Committee is not unique. Opportunities abound to impact change within the
organization. There is potential to increase ouf shared understanding of
research in its broadest sense. Collaborative relationships could be
developed between Royal Roads University and the CHR. There may be, for
example, a way to develop a streamlined process for research that is
considered to be "minimal risk."
It is critical to have the support of key people in the organization when doing
this type of research. A letter of support for my research from the Manager of
the Clinical Quality lmprovernent Program, the Corporate Medical Director,
and the Director of Continuing Medicai Education enabled me to proceed with
my research while 1 waited for the final response from the CHR's Research
Review and Ethical Approval Committee (Appendix L).
It is an onerous task for any cornmittee to review proposals with respect to
research methods and organizational impact in addition to ethics. While al1
three are critical, each component requires separate consideration. I
submitted my proposal to the Committee for ethical review, never expecting a
review of my research methodology. I have learned to use discretion in the
future.
It is important to question feedback and to understand the difference between
a "suggestion" and a "requirement. " Had I waited for the Priorities and
Planning Council to review my proposal and provide a letter of support, I
would Iikely not have been able to begin my data collection until December.
This was a suggestion, not a requirement.
While the process of seeking approval of the Research Review and Ethical
Approval Committee seemed, at times, frustrating, I have learned many lessons
through this process. In the future, I would consider submitting this type of
proposa1 for information only, rather than seeking fornlal approval.
Manageability
My research project was manageable. At first, I was concerned that I would have
insufficient data to draw any conclusions. I was wrong - I had more than enough
data. As mentioned earlier, 1 had originally planned to include an evaluative
component in my research project. Fortunately, with the feedback of my Faculty
Supervisor and Project Sponsor, I realized the cornplexities of this idea and
aborted it. Although an evaluation would be both interesting and useful, this could
be a research project in and of itself. I believe the key to the success of my
research project was its simplicity and manageability.
PROGRAM LESSONS LEARNED
This research project provided me with a number of learning opportunities, both
professional and personal. Many of these opportunities were directly related to
the MALT competencies. The research project has enabled me to begin a
dialogue about leadership with my colleagues and within my organization. As a
result of this project, 1 will be considered a "leader" with respect to the
implementation of many of the recommendations made in this project.
I believe that competencies can never be "mastered," that they can only be
practiced and honed over time through a process of Iifelong learning. However,
within the context of the completion of this MALT project, the following table
demonstrates how I have mastered the ten MALT competencies:
1 c Provide leadership
demonstrated persona1 commitment to successfully complete the major project provided an example to members of the organization by my commitment to learning identified an opportunity in the organization adjusted leadership style during project interaction with participants managed project, including planning, organizing, managing resources, gathering and analyzing data and making recommendations coordinated interviews and suweys kept participants, Faculty Supervisor and Project Sponsor informed about the progress of my project
2b Apply systems thinking
used a systems approach to the Major Project through the development of the research questions, potentiat impacts, and implications provided oral and written submissions to Faculty Supervisor applied effective problem solving techniques during the conduct of the research promoted the development of a leadership competency framework
applied the study findings to develop a competency framework recognized the interde pendencies of cornpetencies acknowledged the broad context in which the research took place collected information from a variety of sources included stakeholders in the research who would be most affected by the implementation of the recommendations recognized some of the organizational implications of implementing the recommendations identified the impact of the tremendous changes occurring in the organization included the CHR "guiding principles" document which supports the recommendations
5a Identify, locate and evaluate research findings
completed a comprehensive review of relevant literature selected appropriate research methodologies accessed research in the field of leadership, systems, organization and learning validated research findings by referring back to the Iiterature used university Iibraries as well as the WWW to access and evaluate information related to my project
-
5b Use research methods to solve problems
identified, adapted and used appropriate research methodologies articulated specific research methodologies in Major Project Proposal used appropriate research skills during the conduct of the Major Project used triangulation to validate research results used thematic analysis to interpret data demonstrated the spirit of inquiry and reflection in the preparation for the design and conduct of the research activities selected participants who would be most impacted by the implementation of the recommendations documented reflection in a research journal
7b Communicate with others through writing
completed and had Major Project Proposal signed off created consent forms, covering letters and a leadership competency f ramework
provided a written report of the Major Project which was clear and unarnbiguous ensured leadership competency framework was understandable submissions to ethics comrnittees were clear and concise summarized appropriate literature sources to support the project maintained correspondence with Faculty Supervisor and Project Sponsor used RRU style guide to format Major Project
1 b Demonstrate leadership characteristics
conducted and completed the Major Project contributed to a positive group ethos during the course of the research showed initiative by seeking additional learning opportunities as they arose demonstrated cornmitment to the project by being flexible with research participants prioritized own workload in order to minimize impact of research in the workplace
4f Manage own learning to achieve maximum added value
responded to the demands of completing a Major Project completed Major Project including comprehensive, relevant literature review collected and analyzed data documented reflections in a research journal took advantage of external opportunities to develop leadership (i.e., RNABC leadership activities)
4c Create learning opportunities in the workplace
Major Project report identified and recommended a leadership competency f ramework stimulated dialogue about leadership within the workplace through the conduct of the research applied learnings to other contexts within nursing conducted sessions with staff regarding leadership cornpetencies for nurses
7a lnterpret oral communication
accurately interpreted verbal and non-verbal communication of research participants
confirmed interpretation of information with participants respected and valued differing opinions dernonstrated collaborationy authenticity and candor during interviews stimulated dialogue about leadership within the workplace through study data collection clarified meaning of interview participants and responded to questions about the surveys
1 e Recognize ethical considerations
recognized and integrated ethicai principles throughout the research informed consent was obtained for al1 interviews protected the confidentiality and anonymity of al! research participants acknowledged the persona1 values of others while maintaining my own ensured research proposa1 was approved by the Royal Roads Research and Ethics Board acknowledged ethical considerations in al1 cover letter and invitations for participation
Summary
In this chapter, I have reviewed key aspects of the conduct and management of
my research project along with some of the lessons 1 have learned as I
completed the study. 1 hope others might benefit from these Iessons. 1 have also
provided a list of the MALT competencies along with a description of how 1 have
demonstrated "mastery" of them.
Beginning the Dialogue
This research project helped me gain insight into how people in my organization
view leadership. The research project provided a forum and acted as a catalyst
for people to talk about leadership. The "doing" of my research project has
stirnulated discussion among people who were involved both directly and
indirectly in my research. The fact that people are talking about leadership and
about leadership competencies has begun a conversation within my own
organization. 1 believe my research provided an "excuse" for people to talk about
leadership and the dialogue has really only just begun.
REFERENCES
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APPENDIX A
ROLES & RESPONSIBILITIES OF MEDICAL PROGRAM DIRECTOR AND CLlNlCAL CHlEF
IN THE CAPITAL HEALTH REGION
Organued according to:
Responsibilities include:
Works closely with:
Span of control:
Main Focus: - -
Other duties include:
Medical Program Director Vice-President of Prograrn Proarams:
Heart HeaIth Lung Health Mental Health Senior's Health Community Health Digestive Health ChildNouth and Maternal Health Cancer Care Health Restoration
Core Services: Medical Imaging Laboratory Services Emergency Care Palliative Care development and management of program or core service support and promotion of clinical and academic activities within prograrn to achieve outcomes
Regional Directors
inter-disciplinary tearn throughout the CHR including the community operations (budget, utilization) strategic planning
promote inter-disciplinary collaboration and decision- making within program provide comm unity lin kage resource planning - human and financial resources
-
Clinical Chief Corporate Medical Director Clinical De~artments:
Farn ily P ractice Medical Services Surgical Services Pediatrics Cardiac Services Psychiatry Medical lmaging Laboratory Medicine Obstetrics/Gynecology Neurosciences Geriatric Semices Emergency Medicine Intensive Care Anesthesia Midwifery
responsible for quality of medical care establish standards of medical care review, evaluate and analyze quality of medical care continuous quality improvement
Division Heads
physicians with hospital privileges only
professional standards quality of medical care member of the Regional Medical Advisory Comm ittee manages medical manpower and staff ing monitors corn pliance with professional standards manages process for recommendation of privileges and credentials establishes continuing medical education program
LEADERSHIP COMPETENCIES IN THE CAPITAL HEALTH REGION Creating a Framework for the position of Clinical Chief/Division Head
SUMMARY
A competency is a demonstrated behavior which combines skills, knowledge and attitudes for a specific purpose.
The Opportunity The roles and responsibilities for the positions of Clinical ChiefIDivision Head in the Capital Health Region are clearly articulated in the Medical Staff Rules (May, 2000). However, the qualifications (competencies) in terrns of skills, knowledge and abilities have not been formalized. The opportunity is to obtain this information through a process of inquiry that will involve physicians as well as health care administrators.
Research Questions What are the cornpetencies required of Clinical ChiefsIDivision Heads in the Capital Health Reg ion? What are the skills, knowledge and abilities required from the perspective of physicians currently in these roles? From the perspective of their peers? From the perspective of administrators? How are these cornpetencies ranked in terms of importance? How can al1 stakeholders be involved in a process to identify the core cornpetencies for this position? How can the Capital t-iealth Region support its Clinical ChiefsIDivision Heads?
Methodology A generic leadership competency framework will be developed based on a review of the literature. The generic leadership competency framework will be validated through interviews with individuals from the following three groups: 1) physicians currently in the position of Cfinical Chief or Division Head, 2) physicians and 3) administrators. The number of interviews will depend upon the emergence of themes. Once recurrent thernes are identified, the interviews will be stopped. The generic leadership competency framework will be revised based upon the feedback obtained during the interviews. A questionnaire will be developed using the revised competency framework. Respondents will be asked to validate the framework and to prioritize the competencies in terms of importance. Approximately 60 surveys wilI be distributed to participants from the three groups identified above. Analysis: Interview transcripts will be analyzed through an inductive process of coding and categorizing of themes that emerge through careful rnultiple readings. Suwey results will be analyzed through a process of coding and counting of survey responses. Trustworthiness will be established through triangulation of the findings of the survey and interview results. Themes will be validated with interview participants. A final report with research results and recommendations will be shared with Dr. E. Higgs (Corporate Medical Director) and Dr. N. Donen (Director of Continuing Medical Education and Project Sponsor). The final report will also be made available to research participants at their request,
CONFlDENTlALlTY AGREEMENT
This is to confirm that 1, Renate Wellman of e-Scribe Transcription Services, will treat as confidential al1 information gained while providing services to Margaret Gauthier, and will not permit its disclosure, except as where applicable by law.
I will also ensure that any sub-contractors employed tu provide services to e- Scribe for Margaret Gauthier will also meet the intent of this agreement.
Renate T. Wellman e-Scribe Transcription Services
Dated:
Margaret Gauthier
Dated :
APPENDIX D
GENERIC COMPETENCY FRAMEWORK FOR THE POSITION OF: CLlNlCAL CHIEF/DIVISION HEAD
COMPETENCY
Medical Expert
Leaders hi p
Demonstrated by:
diagnostic and therapeutic skills for ethical and effective patient care application of relevant information to clinical practice effective consultation with respect to patient care and education well respected clinically with proven track record continued medicai practice with direct patient care informed of current practice and trends develop, implement and monitor a personal continuing education strategy critically appraise sources of medical information facilitate learning of others contribute to development of new knowledge ability to deal with technology and data ability to run effective meetings decision rnaking problern solving negotiation skills manages growth and manpower within Department makes decisions using consensus meets regularly with Department copes with strict deadlines or demands follows through on commitrnents attentive to detail manages multiple projects at once mentoring and leading by example communicates a vision is creative inspires others provides feedback to peers shares information follows through on commitments dernonstrates initiative identifies long term Departmental goals empowers others accountable for own actions values diversity establishes a QA structure to carry out review, evaluation and analysis of the quality of medical care Ieads QI projects
Interpersonal Skills
Communication Skills
Personal Characteristics
ensures Department members are familiar with professional standards in Medical Staff by-laws, Rules and Regulations and Policies abiIity to advocate for improved patient care ability to advocate for Department members provides a voice for Department members at RMAC understanding com pliance issues leading shifts in behavior developing and implementing clinical practice guidelines ability to implement disciplinary action organizationai awareness conflict resolution negotiation mediation develops and work in teams builds personal relationships shows support by building trust within DepartmentlDivision makes time to attend to others demonstrates understanding, trust, respect, empathy and confidentiality contributes effectively to teams including respecting opinions and roles of team members public speakingfpresentation skills clear written and verbal communication skills ability to develop interpersonal relationships seeks input from Department members effectivelistening ability to work through communication challenges such as anger and confusion manages the polarity between role of independent practitioner and that of mernber of an organization tolerance for ambiguity understanding difference between what is important personally versus organizationally integrity compassion ability to make use of failure spontaneity creativity courage and risk taking self-awareness motivation em pathy social ski11 sense of humor accountable open mind
Interview Cover Letter
Dear Research Participant,
Thank you for agreeing to participate in an in-depth interview regarding leadership competencies for physicians in forma1 leadership roles. As I mentioned during our discussion, this research project fulfills part of the requirements of rny Master of Arts in leadership thesis at Royal Roads University.
Please find attached a brief summary of the proposed research including the opportunity, research questions and proposed methodology. Also attached is a copy of the interview consent form for your perusal, I will have copies available at the time of the interview.
As we discussed, I have also attached a copy of the generic leadership competency framework that has been developed based on a review of literature. The purpose of the interview will be to validate what I have found and to determine its relevance to the CHR from your perspective. Some of the types of questions I might ask are:
How do you define leadership? What competencies do you feel are most important for the position of Clinical Chief in the CXR? What parts of this framework are relevant in the CHR? What is missing?
There is no preparation required for the interview. This information is sirnply for your consideration. I anticipate that the interview will last a maximum of 60 minutes.
Our interview is scheduled for:
Date: Time: Location :
Once again, thank you for agreeing to participate. If you have any questions, please do not hesitate to cal1 me at 370-81 1 1 local 2850 or e-mail mgauthiera caphealth.org
Sincerely,
Margaret Gauthier
Interview Consent Form Research Project Title: Leadership cornpetencies for physicians in the Capital
Health Region - Creating a framework.
Investigator: Margaret Gauthier, MA Candidate
Please read the following carefully. Your signature below indicates that you consent to participate in the study which will follow the methods described betow:
You will be interviewed in an initial interview of approximately 60 minutes in duration. The interview will be recorded with a tape recorder and through written notes. AI! tapes will later be transcribed and the tapes erased. You will have the right to turn off the tape recorder at any time during the interview or to request that the tape not be transcribed. Al! interview data and conversations will be kept strictly confidential. Your participation is completely anonymous. The researcher and the Project Faculty Supervisor are the only individuals who will know of your participation. You will be identified throughout the research notes and transcripts through a pseudonym. You will be given a copy of the transcript created from the tape to review, verify and revise at your discretion. Following your approval, the tape will be erased. The data ftom your interview rnay be used in other forms such as submissions to professional journals, maintaining the same standards of confidentiality and anonymity. There will be no monetary compensation to you for participating in this study. A summary of the study results will be made available to you at the end. The final report and recommendations will be shared with Dr. E. Higgs (Corporate Medical Director) and Dr. N. Donen (Director of Continuing Medical Education and Project Sponsor), In addition, Royal Roads University will also possess a copy of the final report. Your participation in this study is voluntary and you may withdraw at any time.
Your signature indicates that you have understood to your satisfaction the information regarding participation in the research project and agree to participate. You should feel free to ask for clarification or new information throughout your participation in this study. If you have further questions concerning matters reIated to this research, please contact Margaret Gauthier at (250) 370-81 11, local 2850 or e-mail mgauthierQcaphealth.org If you have any questions regarding your rights as a research participant, please feel free to contact Dr. Ernie Higgs at 727-41 10.
Participant Date
Researcher Date
LEADERSHIP COMPETENCIES FOR THE POSITIONS OF CLINICAL CHIEF AND DIVISION HEAD IN THE CAPITAL HEALTH REGION
1. Please check one of the following:
17 Physician - Clinical Chief or Division Head Physician Administrator
2. Leadership Cornpetencies
Following a review of the literature and a number of individual interviews, the list of competencies in the table below has been developed with respect to the role of the Clinical ChiefIDivision Head.
k competency is a demonstrated behavior which combines skills, knowledge and attitudes for a specific purpose.
In the following table, please circle the number that reflects most accurately the degree to which you feel each of the competencies is important for the role of Clinical ChiefIDivision Head.
COMPETENCY
Clinical Expertise > maintains clinical credibility and respect by
remaining in clinical practice and providing direct patient care
2 contributes to the development of new knowledge/participates in research
3 keeps inforrned of cuvent practices and trends 3 participates in the developrnent of clinical
practice guidelines
Education
3 willing and motivated to learn 3 mentors others F desires challenge and embraces change E participates in CM€ > involves others in the provision of peer feedback
- -
How important is this competency in the role of Clinical Chief or Division
Head?
1 Not important
2 Somewhat lmportant
3 lmportant
4 Very lmportant
5 Critical
-
1 Not important
2 Somewhat lmportant
3 lmportant
4 Very lmportant
5 Criticai
Communication Skills
ability to speak publicly/deliver presentations communicates cleariy both verbally and in written form fistens effectively elicits input from Department mem bers deals tactfully with anger and hostility articulates a vision for the Department shares information/acts as conduit between Department and the organization maintains pertinent documentation conflict resolution/mediation skills provides constructive1objective feedback based on standards conveys information objectively advocates for Department at RMAC maintains focus on quality of carelstandards
Interpersonal Skills
exhibits professionalism demonstrates empathy expects the best from others appreciates relationships/people-oriented maintains collegial relationships with peers meets regularly with Department mern bers individually and as a group provides encouragement and support delivers feedback in a professional and supportive manner
Organizational Skills
lobbies for Department understands organizational and administrative structure aware of organizational culture able to work as a team player values contributions of others understands implications of large organization/com plex systems aware of own scope of practice within the context of the organization possesses political sawy collaborates with other Departments
--
How important is this competency in the role of Clinical Chief
or Division Head?
1 Not important
2 Somewhat Important
3 lmportant
4 Very lmportant
5 Critical
1 Not important
2 Somewhat Important
3 lmportant
4 Very lmportant
5 Critical
1 Not important
2 Sornewhat lmportant
3 lmportant
4 Very lmportant
5 Critical
- COMPETENCY
Leadership regards quality of care as top priority articulates a personal vision and creates a shared vision for the Department coordinates goals of Department with the needs of the community demonstrates creativity/takes risks and makes use of failure mentorsAeads by exam ple understands and Ieads change demonstrates initiativekelf-starter delegates responsibility/shares leadership accountable for quality of care inspires others toward the vision develops/organizes a plan to reach vision stimulates the capacity of others able to make difficult/unpopular decisions empowers others rernains objective and offers criticism when required creates excitement within Department strives for a unified Department
Management
sets aside time to plan, strategize and review information follows through on commitments/completes tasks develops both short term and long term goals for the Department skilled in decision making/problem solving manages datafdeals with new technology plans, organizes and conducts effective meetings makes decisions using consensus when appropriate applies learning about management from a variety of sources attends to manpower needs of Department
Self-Awareness 3 recognizes personal strengths and limitations > plans for own succession 3 knows when to engage an extemal consultant "r uses a range of assistance as available and
appropriate > recognizes personal bumout and takes action
-How important is this competency in the role of Clinid Chief
or Division Head?
1 Not important
2 Somewhat lmportant
3 lmportant
4 Very lmportant
5 Critical
1 Not important
2 Somewhat Important
3 lmportant
4 Very lmportant
5 Critical
- -
1 Not important
2 Somewhat lmportant
3 1 mportant
4 Very lmportant
5 Critical
3. From your perspective, please rank the 8 competencies in order of priority by entering a "1" in the box beside the most important, a"2" in the box beside the next important etc.
Clinical Expertise [7 Communication Skillç
interpersonal Skills Leadership
[7 Management [7 Education
Organizational Skills [7 Self-Awareness
4. Please k t any leadership competencies that you feel are either not reflected in the above table or require additional emphasis:
5. From your perspective, how can the Capital Health Region better support its Clinical Chiefs and Division Heads?
6. Is there anything else you would like to add to this survey that might help in the development of a leadership competency framework for the role of Clinical ChieWDivision Head?
Thank you for taking the time to complete this suwey. Your contribution is valued. Please return the survey to me via the inter-hospital mail system in the envelope provided by Se~tember 22, 2000.
September 8,2000 Dear Dr.
I am conducting research on the topic of leadership. This study w*ll be taking place during the fall of 2000 and will form part of my final project for rny Master of Arts thesis. The information collected will be used to develop a leadership competency framework for the positions of Clinicat Chief/Division Head in the Capital Health Region.
The idea for this research project was developed in response to a need to define the leadership skills required of physicians in formal leadership positions in the CHR. There are two main underlying assurnptions. The first is that the role of the Clinical Chief is important and makes a difference. The second is that there are specific leadership competencies required of physicians who occupy these roles. Within the current Departmental structure, each physician reports to a Clinical Chief. Physicians are therefore clearly the most appropriate group to define these competencies. Your participation as a physician practicing in the CHR is critical to this research project. I hope you will look upon this as an opportunity to contribute to the development of a iramework that has the potential to help in the overall functioning of your Department.
Attached please find a brief summary of the proposed research project including the purpose and methodology. A combination of quantitative and qualitative approaches will be used in an attempt to answer the research questions.
The attached survey was developed following interviews of a nurnber with individuais from the following groups: 1) physicians, 2) physicians in formal leadership roles (Clinical Chiefs/ Division Heads) and 3) administrators (Patient Care Managers, Regional Directors, etc.).
Your name has been chosen through a disproportional stratified random selection process. Your participation in this survey is completely voluntas, and should take approxirnately 10-1 5 minutes. All responses will be kept strictly confidential. Only I will have access to the information in order to analyze the data and prepare the final report. You are not asked to identify yourself on this survey. You are, however, asked to indicate whether you are a physician, a physician in a formal leadership role or an administrator. This information will assist me in analyzing any trends in responses. If you would rather not complete this section, please leave it blank.
The final report will be available to you upon request by April30, 2001. The report will be shared with Dr. E. Higgs (Corporate Medical Director) and Dr. N. Donen (Director of Continuing Medical Education and Project Sponsor)- A copy of the report will also be held at Royal Roads University.
PIease complete the suwey and return it to me via the inter-hospital mail system in the self-addressed envelope provided by September 22,2000. If you have any questions, please do not hesitate to cal1 me at 370-81 11 local 2850 or email [email protected] If you have any questions as a research participant, please feel free to contact Dr. E. Higgs ât 727-41 10.
Thank you for participating in this survey. Your fime and input is very much appreciated!
Sincerely,
Margaret Gauthier
Septernber 8,2000
Dear
I am conducting research on the topic of leadership. This study will be taking place during the faIl of 2000 and wiIl form part of my final project for rny Master of Arts thesis. The information collected will be used to develop a leadership competency framework for the positions of Clinical Chief/Division Head in the Capital Health Region.
The idea for this research project was developed in response to a need to define the leadership skills required of physicians in forma1 leadership positions in the CHR. There are two main underlying assumptions. The first is that the role of the Clinicat Chief is important and makes a difference. The second is that there are specific leadership cornpetencies required of physicians who occupy these roles. Your participation as an administrator who works directly with physicians in formal leadership positions is critical to this research project. 1 hope you will look upon this as an opportunity to contribute to the development of a frarnework that has the potential to help in the overall functioning of the organization.
Attached please find a brief summary of the proposed research project including the purpose and methodology. A combination of quantitative and qualitative approaches wilf be used in an attempt to answer the research questions.
The attached survey was developed following interviews with a number of individuals from the following groups: 1) physicians, 2) physicians in forma1 leadership roles (Clinical Chiefs/ Division Heads) and 3) administrators (Patient Care Managers, Regional Directors, etc.).
Your narne has been chosen through a disproportional stratified random selection process. Your participation in this survey is comptetely voluntary and should take approximately 10-15 minutes. AI1 responses will be kept strictly confidential. Only 1 will have access to the information in order to analyze the data and prepare the final report- You are not asked to identify yourself on this suwey. You are, however, asked to indicate whether you are a physician, a physician in a formal leadership role or an adrninistrator. This information will assist me in analyzing any trends in responses. If you would rather not complete this section, please leave it blank.
The final report will be available to you upon request by April30,2001. The report will be shared with Dr. E. Higgs (Corporate Medical Director) and Dr. N. Donen (Director of Continuing Medical Education and Project Sponsor). A copy of the report will also be held at Royal Roads University.
Please complete the survey and return it to me via the inter-hospital mail system in the self-addressed envetope provided by September 22,2000. If you have any questions, please do not hesitate to cal1 me at 370-81 11 local 2850 or email [email protected] If you have any questions as a research participant, please feel free to contact Dr. E. Higgs at 727-41 10.
Thank you for participating in this suwey. Your time and input is very much appreciated!
Sincerely,
Margaret Gauthier
September 15,2000
Dear
The purpose of this [etter is to remind you of the "Leadership Cornpetencies" survey you received recently. If you have already completed the survey, thank you. If not, the purpose of this letter is to gently remind you that your participation is critical.
If you have any questions or require any additional information, please do not hesitate to cal1 me at 370-81 11 local 2850 or email mgauthier8caphealth.org
Once again, thank you for your participation. It is only through obtaining your feedback that we will truly end up with a meaningful and useable framework.
Sincerely,
Margaret Gauthier
LEADERSHIP COMPETENCY FRAMEWORK FOR CLlNlCAL CHIEFS/DIVISION HEADS IN THE
CAPITAL HEALTH REGION
LEADERSHIP
regards quality of care as top priority articulates a persona1 vision and creates a shared vision for the Department coordinates goals of Department with the needs of the community demonstrates creativityltakes risks and makes use of failure mentorsAeads by example understands and leads change demonstrates initiative/self-starter delegates responsibility/shares leadership accountable for quality of care inspires others toward the vision develops/organizes a plan to reach vision stimulates the capacity of others able to make diff icuIt/unpopular decisions motivates, leads and empowers others remains objective and offers criticism when required creates excitement within Department demonstrates innovation and creativity take risks strives for a unified Department
CLlNlCAL EXPERTISE
3 maintains clinical credibility and respect by remaining in clinical practice and providing direct patient care
> contributes to the development of new knowledgelparticipates in research 3 keeps informed of current practices and trends
participates in the development of clinicat practice guidelines
COMMUNICATION SK1LLS
ability to speak publiclyldeliver presentations communicates clearly both verbally and in written fonn Iistens effectively elicits input from Department members deals tactfully with anger and hostility articulates a vision for the Department shares information/acts as conduit between Department and the organization maintains pertinent documentation conflict resolution/mediation skills
exhibits professionalism demonstrates empathy expects the best from others appreciates relationships/people-oriented maintains collegial relationships with peers meets regularly with Department members individually and as a group provides encouragement and support delivers feedback in a professional and supportive manner
4 provides constructive/objective feedback based on standards i- conveys information objectively i- advocates for Department at RMAC "r maintains focus on quality of care/standards
INTERPERSONAL SKILLS
ORGANIZATIONAL SKILLS
lobbies for Department understands organizational and administrative structure aware of organizational culture able to work as a team player promotes cohesiveness and teamwork understands global perspective able to initiate and adjust to change, particularly when not initiated by or for the Department values contributions of others understands implications of large organization/complex systems possesses an understanding of human and fiscal management (i.e., budgets and unions) aware of own scope of practice within the context of the organization able to separate persona1 needs from professional goals possesses political sawy collaborates with other Departments
MANAGEMENT SKILLS
sets aside time to plan, strategize and review information follows through on commitments/completes tasks develops both short term and long terni goals for the Department skilled in decision making/problem solving manages dataldeals with new technology plans, organizes and conducts effective meetings makes decisions using consensus when appropriate applies learning about management from a variety of sources attends to manpower needs of Department
O willing and motivated to learn 3 mentors others O desires challenge and embraces change > participates in CME P involves others in the provision of peer feedback 3 plans for own succession
SELF-AWARENESS
recognizes personal strengths and limitations plans for own succession knows when to engage an external consultant uses a range of assistance as available and appropriate recognizes personal burnout and takes action common sense, even temper trustworthiness, patience, diplomacy honestly, straighfforwardness ethical behavior professionalism
APPENDIX L
August 1,2000
Ms. Veronica Morris Co-Chair, Research Review and Ethical Approval Cornmittee Suite 430 - 1900 Richmond Avenue Victoria, BC V8R 4R2
Dear Ms. Morris;
Re: To create a leadership competency framework based on the input of stakeholders - Le., physicians, physicians in leadership roles and administra tors. (CnR File 00-39)
The intent of this letter is to advise members of the Research Review and Ethical Approval Cornmittee of our support for the above research project that wili be undertaken by Ms. Margaret Gauthier. We are familiar with the research questions and proposed methodology.
Ms. L. Birdsall Date
Dr. N. Donen Date
Dr. E. Higgs Date
If you have any questions, please do not hesitate to contact any of us or Margaret Gauthier at local 2850.