Introduction
Health systems in the 21st century face increasing
complexity. Technological advances, changing patient demographics and
expectations, fiscal pressures, accelerated information flow, and health
human resource challenges, among others, are increasing system
complexity.1 Complex health systems require leaders
who are agile and adaptive to dynamic environments. This paper explores
the nuanced roles and career paths of health systems leaders within
academic health centres (AHCs, clinical units that are affiliated with
academic institutions/universities), where leaders typically have
multiple identities. These may include professional identities as a
clinician, administrator, researcher, educator, opinion leader, among
many other professional (and personal) identities. Regardless of their
professional identity, each person must engage in both leadership and
followership (i.e. a phenomenon in which individuals support the leader
through assuming responsibility for given objectives, serving the
requests made of them, challenging the leader when appropriate,
participating in organizational transformation, and taking moral action
as needed2,3) in ever increasing complexity as they
develop professionally. The LEADS in a Caring Environment
framework (LEADS) was developed in 2006 to articulate and promote core
leadership capabilities in healthcare.4,5 Today, the
LEADS framework (or adapted versions) is one of the most popular
leadership frameworks for health systems in Canada6,7with adoption in Australia8,
Belgium9, India10,
Israel5,11 and has strongly influenced the United
Kingdom’s Faculty of Medical Leadership and Management’s certification
standards.
In the complexities of AHCs, leaders who inhabit multiple roles may
grapple with how to apply the LEADS capabilities across multiple roles.
For example, an individual may have an executive role in hospital
administration, serve as a clinical supervisor, and be a junior faculty
member in an academic department. The LEADS framework helps leaders to
understand the capabilities of leadership required within a defined
system. It does not guide leaders navigating multiple roles, where
seniority and complexity vary.
In matrix organizations,12 such as AHCs, there are at
least two entities at play: a hospital and a university. Matrix
organizations are interdependent organizations with separate cultures
and systems that are connected by individuals who cross between groups,
seeking to enact common outcomes across an organization. Based on its
strategic and operational realities, each entity within an AHC has
unique goals, values and priorities. Each enterprise also brings about
different challenges and stakeholders. The interconnectedness of
hospital systems and academic institutions within AHCs results in
individuals holding multiple roles and, across these, multiple
identities. Leaders working within each entity are often left to
navigate competing needs, goals, values and
perspectives.13 This is exemplified in different
exhibited behaviors, leadership and management styles, trade-offs, and
ways of thinking based on context. As individuals advance in their
career, they are often challenged to develop both personally and
professionally within leadership roles. The capacity to do so is
variable between individuals. Prior work by Kegan and colleagues has
described various ways in which individuals develop and assume various
orders of consciousness, engage in constructive-development (despite an
innate resistance to change), and create cultures that support all
members of an organization.14–16 As such, academic
health system leaders require flexible leadership models that address
multiple identities across varying levels of seniority. This paper
addresses this need by integrating LEADS with Kegan’s five levels of
development.
The LEADS+ Development Model articulates leadership and followership
practice when occupying multiple leadership roles. We highlight both the
dynamics of leadership and followership. Afterall, without followership,
leadership cannot exist.17,18 Four styles of
engagement within an AHC are described: two followership styles
(essential, strategic) and two leadership styles (role- and
complexity-based). We propose that advanced leadership requires fluid
shifts among leadership styles as appropriate for the given role,
organization, time, and context.
Methods
A conceptual review19 was conducted to explore how a
leader’s development interfaces with a leading healthcare leadership
framework, the LEADS in a Caring Environment framework. Similar to the
process used by Gottlieb and colleagues, sequential iterative cycles of
divergent and convergent thinking were employed, exploring various
vantage points and theories within the literature.20Ultimately, the perspectives of the authors coalesced into a singular
conceptual framework.
The Team
Our study team was composed of two clinicians (JS, TMC, both with
decanal positions in education leadership), one healthcare
administrative leader (SR), one leadership and health entrepreneurship
educator (SL), and a PhD scientist, who is one of the originators of theLEADS framework (GD).4,5 Throughout the process
we empowered members of the team to challenge each other’s personal
assumptions and interrogated our selections of theories to ensure that
we remained reflexive about the literature reviewed.
Discussions Within the Analysis
Team
A pilot review of various leadership frameworks and theories was
conducted (by SR, SL, TMC). This formed the basis of initial
discussions. The two most prominent frameworks were felt to be Kegan’s
model of human development14 and the LEADS
framework.4,5 These frameworks continued to inform our
discussions, similar to how sensitizing concepts are incorporated in
other qualitative methods.21
<Box 1 about here>
<Box 2 about here>
We engaged in multiple rounds of discussions via videoconferencing with
memo-generation and collaborative conceptual development using
cloud-based, real-time interactive documents, each session lasting
approximately one-hour in length.
Literature Review &
Synthesis
After refining our initial model, we conducted a focused literature
review. We drew from literature within health systems leadership,
followership and organizational development, contrasting our own newly
formulated conceptualization with other existing models. We engaged in
iterative rounds of revisions. Ultimately, we coalesced our thinking
into one conceptual model (see results section), which we refined
through persona-driven testing (i.e. cognitive simulations with various
types of simulated characters that were used to elucidate each role in
various scenarios) and stakeholder consultation.22,23
Prototype and Persona-based testing of the
model
Next, we simulated personas and stories to test and prototype our
model.22–24 The resulting model with associated
persona-driven vignettes were submitted to a representative sampling of
health system stakeholders (clinicians, administrators, educators and
researchers in healthcare leadership) for review. Feedback from
stakeholder consultation was used to refine the model.
Stakeholder consultations
Similar to stakeholder consultations endorsed by scoping
reviews25 and the Canadian Institutes of Health
Research Knowledge Exchange process26, we sought
formative feedback on our provisional concepts from a range of
educators, experts, and frontline practitioners. This process has been
used previously20. Our inclusion criteria were that
the individual would meet one of the following criteria:
- Personal experience in blended leadership roles across two or more
organizations/units;
- Supervised/led others who bridge across more than one role; or
- Actively engaged in teaching or scholarship about leadership training
and development.
We excluded those who met the above criteria but had no experience
within the North American leadership context. We constructed a simple
survey tool with an embedded video
(https://bit.ly/BridgeLEADsurvey)
and requested that each stakeholder help us to identify the strengths,
weaknesses, and relevance of the conceptual model to their own
leadership-related practice. We subsequently met with each of the
leaders for a one-on-one interview led by our senior author (TC) to
gather feedback from those who volunteered to engage with us to provide
further feedback. A thirty-minute, one-on-one Zoom interview (Zoom
communications, Inc., San Jose, CA) was completed within a one-month
span with any stakeholder who sought to provide verbal feedback about
our model in addition to their survey responses.