Prelims

Half Title Page

Developing and Engaging Clinical Leaders in the “New Normal” of Hospitals

Series Title Page

European Health Management in Transition

Series Editors:

Federico Lega, Full Professor of Health Management and Policy, Director of the Research and Executive Education Center in Health Administration, University of Milan.

Usman Khan, Visiting Professor, KU Leuven Healthcare, is currently undergoing an unprecedented period of change, which is presenting a challenge to the fundamental tenants of health management and policy established over the last decades. The differentiated nature of the change agenda and the pace of change has been such that there has been limited space or time to provide a structured or comprehensive response, or to consider at a strategic level how health management teaching and practice should evolve and develop. This then is the focus for the European Health Management in Transition series, published in alliance with the European Health Management Association (EHMA).

Books in the series investigate how changes to the health and social care environment are leading to innovative and different practices in health management, health services delivery design, roles and professions, architecture and governance of health systems, patients' engagement and all other paradigmatic shifts taking place in the health context.

The books provide a roadmap for managers, educators, researchers and policymakers to better understand this rapidly developing environment.

Books in the Series:

Federico Lega and Usman Khan: Health Management 2.0: Meeting the Challenge of 21st Century Health

Axel Kaehne and Henk Nies (eds): How to Deliver Integrated Care: A Guidebook for Managers

Federico Lega and Giada Carola Castellini: Resilient Health Systems: What We Know; What We Should Do

Title Page

Developing and Engaging Clinical Leaders in the “New Normal” of Hospitals

Why It Matters, How to Do It

By

Federico Lega

Milan University, Italy

And

Angela Pirino

Bocconi University, Italy

United Kingdom – North America – Japan – India – Malaysia – China

Copyright Page

Emerald Publishing Limited

Howard House, Wagon Lane, Bingley BD16 1WA, UK

First edition 2022

Copyright © 2022 Federico Lega and Angela Pirino.

Published under exclusive licence by Emerald Publishing Limited.

Reprints and permissions service

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No part of this book may be reproduced, stored in a retrieval system, transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise without either the prior written permission of the publisher or a licence permitting restricted copying issued in the UK by The Copyright Licensing Agency and in the USA by The Copyright Clearance Center. Any opinions expressed in the chapters are those of the authors. Whilst Emerald makes every effort to ensure the quality and accuracy of its content, Emerald makes no representation implied or otherwise, as to the chapters' suitability and application and disclaims any warranties, express or implied, to their use.

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

ISBN: 978-1-80382-934-0 (Print)

ISBN: 978-1-80382-931-9 (Online)

ISBN: 978-1-80382-933-3 (Epub)

List of Figures and Tables

Foreword

Foreword. Why Clinical Leadership Is no Longer Optional

Here we will explain why clinical leadership is not a passing issue but rather the key to the future of health systems, their sustainability, performance, quality, and other dimensions of success.

Leadership is a buzzword for health policymakers. The development of clinical leadership and managerial skills is a priority in healthcare reforms across the globe.^1,2 Framework programmes for teaching physicians management skills have attracted increasing interest through the initiatives of health departments, medical societies and medical schools. While clinical leadership is clearly a global policy priority worldwide, it is less evident whether it has real substance. Based on in-depth analysis of the recent literature and an empirical survey, we argue that clinical leadership is the (necessary, inevitable) response to challenges and trends ahead.

Clinical needs are changing. Today's patients have multiple comorbidities and the average age of the population is steadily rising. Patients struggle to find adequate answers from healthcare organisations, where service is fragmented along medical specialty boundaries. Integrated care pathways and multidisciplinary treatment approaches are now needed. This means that the current healthcare organisation, with its professional clans, autonomous hierarchies and guarded areas of practice and working rules, is no longer adequate.

Reforms in most Western countries have called for cost containment in response to spiraling healthcare expenditure for the ageing population and for new technologies. Efficiency and efficacy were introduced to provide physicians in charge of medical staff with performance parameters. Similarly, evidence-based medicine and accountability for treatment outcomes have replaced informal, peer-based non-standardised performance appraisal. Hospitals now measure performance, collect data and report it. Organisations are compared according to the results they achieve, as are individuals and groups working within an organisation. This shift has generated new managerial needs and calls for new competences such as performance management, value-based approaches and operations management.⁵ Finally, patient expectations (e.g. quality of nonclinical services, hospitality, waiting times, flexibility, customer support) have all changed. Healthcare services are subject to societal pressures that demand more streamlined and patient-centred organisations.⁶

Hybrid doctor–manager roles are often seen as the solution to these challenges, to ‘bridge the gap’ between the old and new. While clinical leadership is not a panacea for all of healthcare's problems, it is much needed, as clinical leaders will have to be better equipped to improve clinical governance, develop multidisciplinary and interprofessional collaboration, and achieve cost savings without compromising the quality of care.⁷

There is recent international evidence that good management and clinical leadership have an impact on healthcare performance.^2,8,9 Despite political enthusiasm for medical managerial roles in healthcare organisations, the actual practice of medical management varies. International comparative research on the involvement of doctors in management shows a rather diversified picture of the timing of healthcare managerial reforms. Denmark, the United Kingdom and the Netherlands were among the pioneers of such reforms back in the 1980s and early 1990s, whereas Italy, Germany and France only more recently implemented similar processes, which is why they lag behind the others.¹

Comparative research has identified a number of factors at the system and the organisational level that may explain the degree of development of managerial roles and the engagement of doctors in such roles, for instance, the extent to which these roles are endowed with authority and autonomy for decision-making (e.g. budgeting and investment planning). National policies supporting clinical management are in place the United Kingdom and Italy in contrast to Germany, where the healthcare sector is fragmented into numerous local and private providers and where hospital owners critical toward the development of clinical leadership have sought to limit physician empowerment.¹⁰

Another important factor is the availability of financial and career incentives for doctors to get involved in management, e.g. whether the doctor is a hospital employee or works on a contractual fee-for-service basis. In the Netherlands, for example, there is wide variability in the development of clinical leaders in large university hospitals and smaller local hospitals, also because the latter employ staff on a contractual basis.

But there also exists the paradox and the risk of wasting capacity and capability. If we have an extraordinary medical doctor, he/she should be allowed to practice as a physician or surgeon as much as possible. Anything less would mean denying patients access to the best care. According to evidence from the last 20 years, great doctors often (if not always) place medical practice above their managerial duties. A possible solution might be to identify a second tier of physicians and, after evaluation of their potential, train them as managers so that doctors could focus solely on clinical practice. In healthcare organisations (as in other professional contexts) there is an unwritten rule by which top management and clinical leadership are one and the same. Doctors are legitimised (and accepted) by their peers if they are recognised as clinical leaders. Consequently, clinical leaders have to be great doctors.

It's up to us to support top clinicians in their managerial roles so they can reserve as much of their time as possible for clinical practice. This involves training them in various fields, making them charismatic leaders that provide vision, sense-making and problem-solving, while coaching and supporting them in operational functions. Most likely we will need to develop leaders that act as organisational designers and operations managers. Operations managers do not necessarily have a medical degree, since their job is to serve as project managers, change agents and administrators.

For the past 100 years, organisational studies have reported that organisations change when someone pursues their vision to bring about improvement. This is what makes the difference between good and great (healthcare) organisations, between those stuck in their “comfort bunker” and those who innovate and evolve. In this light, co-management by two types of leaders might benefit healthcare organisations. Leadership training should be developed within this framework. These are the “big” items on the clinical leadership agenda.

Complex issues are ambiguous as evidence. For instance, strong non-clinical managerial roles in a system have been found to hamper the development of hybrid leadership. In the United Kingdom, many decisions are taken by general managers, who are numerous and hold a strong position in Britain's National Health Service (NHS), whereas in Italy doctors employed with the public health system have historically been in charge of hospitals; therefore, developing clinical leadership to its full potential was seen as less urgent.^1,11 The influence of professional bodies in policymaking is also relevant. In France, for example, hospital management models were implemented under the guidance of powerful medical associations.^12,13

Many contextual factors can influence medical involvement in management.¹⁴ Research has shown that choices can be made to foster clinical leadership. Policymakers and executive managers should show courage and allow medical managers ample autonomy and space to work within. Clinical leadership is an exercise in problem-solving management through administrative and budgetary accountability. It has much more to do with doing the right things rather than just doing things right. Without the genuine engagement of clinical leaders, decisions about which services should be delivered, to whom, when, where and how, will be difficult to deliver when they contend with the challenges posed by new technologies and drugs, therapeutic alternatives, turf wars, defensive medicine and inappropriate use of diagnostics to name just a few. Executives should not shy away from the risks inherent to such decisions and should be ready to support clinical leaders effectively by delegating power, ensuring adequate staffing and training and giving individuals the opportunity to best perform in their role.

Clinical leadership is not only about clinical leaders; it is also about how clinical leaders are led.¹¹ The specifics of healthcare must be taken into account when selecting, training and evaluating clinical leaders. Healthcare organisations are complex professional bureaucracies, especially those in the public or not-for-profit sector. Healthcare organisations are also tightly interconnected with external stakeholders and politics. As a consequence, healthcare leaders face highly complex problems that cannot be solved with linear, analytical approaches.¹⁵

Moreover, leaders rely on their capability for network management: not only to steer their organisation but also to connect, build consensus, balance and compromise in their effort to overcome conflicting objectives.¹⁶ Clinical leadership applies a structured method to address problems, as well as sensitivity to cope with complex dynamics through a strategic management approach. Finally, professionals and professional associations should understand that clinical leadership is not about dismantling professionalism but rather about reconfiguring it, incorporating new values and logic into medical culture to make it more responsive to societal changes and expectations from patients and citizens.¹⁷

Summarising, medicine and management are not incompatible. Management entails taking clinical problems to a higher level, not focusing exclusively on specialty-based treatment of individual cases. Accordingly, healthcare can become more interconnected and organised, more responsive to the demands of the external environment. If this is what we know, what is it then that we don't yet appreciate and need to understand? There are few comparative studies on the challenges, impact and effect of clinical leadership. The time has come to do serious research and assemble evidence. If the next decade is about taking a value-based approach to working inside the black box, then clinical leadership is no longer optional. The correlations between effective clinical leadership, professional background, training schemes, organisational design, decision-making and governance models, skills mix and leadership strategies are just some of the areas that need to be fully investigated. This needs to be done now, quickly and in depth. Our patients are waiting.

Acknowledgements

I would like to dedicate this book to those people who, with their infinite support, have attended me in this wonderful and indelible path. In particular, a special thank goes to Professor Federico Lega, the co-author, to my Family, to my fiancé, Federico, and to my dearest friend, Mirko.

Thank you all, I could not have done it without you.