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Leadership Forum (July 2004)

Author: Stephen Shortell, Dean, UC Berkeley School of Public Health

Countries throughout the globe are challenged to increase the value of their investments in health. This is as true for the developing countries faced with the challenges of AIDS, malaria, tuberculosis, and malnutrition as it is for the developed countries facing the challenges of cancer, heart disease, diabetes, asthma, depression and obesity. The challenge is not only one of more effective policy development in the allocation of resources but also the need for more effective managerial and leadership development in the effective use of those resources. For example, there is growing worldwide evidence of significant variation in the quality and efficiency with which health services are delivered (WHO, 2000, Institute of Medicine, 2001).

A useful starting point for evaluating the performance of health systems is provided by the Institute of Medicine's Crossing the Quality Chasm Report (National Academy of Sciences, 2001). The Report identifies six aims of any health system—safety, effectiveness, efficiency, patient-centered, timely and equitable. Safe care assures that citizens will not be harmed by the care provided and that the environment in which they receive that care will not cause undo injury. Safe care also requires full and open disclosure and communication between health care professionals and patients to assure that unintended consequences that result in unsafe care are corrected. Care should also be effective based on the best available scientific knowledge that avoids both under-use of effective care and overuse of ineffective care. Evidence-based care combines the best research evidence with clinical expertise and patient values. Care should also be efficient by eliminating waste and ensuring that resources are used to maximize value. Care should be patient-centered by respecting individual patient preferences, needs, and values and ensuring that these are incorporated into the decision-making process. Care should also be timely by reducing waiting times and harmful delays. Finally, care should be equitable . It should not vary in quality or efficiency because of where a person lives, their gender, ethnicity, or socioeconomic status. These are tall aims for any health system to achieve. But, the failure to aspire to them is a concession to our lack of vision and courage and the failure to achieve them is a concession to our inability or unwillingness to exert the necessary leadership.

Leadership has many definitions but from a practical perspective we might define leaders as people with the “…ability to get things done.” There is also a corollary–wise leaders are people who get the right things done. Most frequently we think of leadership as individual acts performed by individual people. But the real effectiveness of individual leaders is the ability to martial collective efforts to achieve shared goals. This broad view of leadership encompasses not only the level of individual motivation and capabilities but also the level of groups and teams, organizations at large, and the larger society in which organizations and institutions are embedded. Effective leaders are able to mobilize action on all four of these fronts—individual, group/team, organization, and society—as needed. The importance of multilevel leadership is seen everyday in Africa, India, and other developing countries in the struggle to get drugs, vaccines, and related treatments to those in need. The importance of multilevel leadership is also seen everyday in the challenges faced by the developed countries to provide better coordinated prevention and treatment programs for increasingly chronically ill populations.

The need for multi-level leadership requires a greater integration of leadership programs focused on individual development with programs designed to advance the effectiveness of managerial and health care teams and the performance of the organization at large. As we have stated elsewhere: “leadership development programs based on the individual alone may well assist these people in their own career development but will leave the organizations with which they are affiliated fundamentally unchanged” (Shortell, 2002).

For communities and countries without the resources to send people to formal leadership training programs, such training can be embedded within the daily technical and educational training provided by funding agencies. This has the advantage of immediate on going application in the daily work of health care provision. For example, people can be trained in the Plan Do Study Act (PDSA) approach to rapid cycle quality improvement as a part of ongoing immunization, health education, and follow-up treatment programs. In developed countries with organizations that have the resources for targeted leadership efforts more emphasis should be given to sending teams of individuals from single organizations for leadership development training. Since most care for patients with chronic illness is delivered by teams, leadership programs aimed at the health care team are likely to have the biggest impact. This is one of the cornerstones of quality improvement collaboratives (Kilo, 1998; Overeit et all, 2002). Recent research suggests the importance of team effectiveness in making changes to improve the quality of chronic illness care (Shortell, 2004). Among the distinguishing characteristics of more effective teams is the ability to be highly patient focused, the presence of a team champion or leader, and the ability to balance cultural values such as people's needs for affiliation along with their need for achievement. Team based leadership development approaches are also needed for non-clinical leaders. The U.S. based National Center for Health Care Leadership (NCHL) has pioneered the development of such approaches, but a major challenge has been persuading organizations to invest the necessary resources in such efforts.

We recommend that leadership development institutes work with both developing and developed countries in fostering more team based approaches to leadership directly linked to improving the performance of organizations to achieve the six aims of safety, effectiveness, efficiency, timeliness, patient-centered care, and equity. There exists a growing number of such institutes and programs worldwide. Examples include the Leadership Centre in the U.K., the Joint Health Leaders Network in Australia and New Zealand, Leadership Development Programs at INSEAD (France), initiatives sponsored by the World Bank, programs at Cambridge and Harvard, programs sponsored by the Governance Institute, the newly developed Berkeley-Barcelona Advanced Health Leadership Development Program, and the earlier mentioned initiatives of the NCHL in the U.S. There is a growing demand worldwide for greater accountability as citizens of all countries are beginning to recognize that their health care delivery systems are falling far short of their potential exhibiting unwarranted variance in quality, outcomes, and costs of care that are difficult to explain. Efforts to address these “shortfalls” will fail to achieve their potential without expanded leadership efforts that focus on the development of effective teams that can improve the overall performance of the organizations that society has entrusted with their care.

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Feature Reference

  • Institute of Medicine, (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C., National Academy Press.

  • Kilo, C.M. (1998). “A Framework for Collaborative Improvement: Lessons from IHI’s Breakthrough Series.” Quality Management in Health Care 6(4):1-13

  • Ovretveit, J., P. Bate, et al. (2002). "Quality Collaboratives: Lessons from Research." Quality and Safety in Healthcare 11(4): 345-351.

  • Shortell, S.M. (2002). “Developing Individual Leaders Is Not Enough.” Journal Health Services Research Policy, 7(4):193-194.

  • Shortell, S.M., J.A. Marsteller, M. Lin, M.L. Pearson, S. Wu, P. Mendel, S. Cretin, and M. Rosen. “The Role of Team Effectiveness in Improving Chronic Illness Care.”  Medical Care forthcoming, November, 2004.

  • WHO (2000).  World Health Report 2000.  Health Systems: Improving performance, Geneva: WHO.




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