The case for medical leadership – part two
Effective frontline clinical leadership has been shown to facilitate open discussion of patient safety issues, implementation of quality improvement and patient safety initiatives, staff retention, and efforts to redesign health care delivery systems1.
Not surprisingly, there is a growing body of evidence that medical leadership plays an important role in improving organisational performance, including the quality of care, patent safety and cost efficient care2. Furthermore, medical leadership is necessary for overcoming the divide between medical and managerial logics in hospitals that hampers improvement in healthcare. Medical leadership differs from general leadership, as it includes a balancing between clinical and organisational objectives to safeguard both the quality and efficiency of care2. A medical background therefore appears crucial for optimally conducting these boundary-spanning roles.
The requirement for expert leadership is perhaps best filled by doctors. Expert leaders combine knowledge, experience and technical competence with innate ability and leadership training. Such doctor leaders in psychiatry, where this concept has been defined, are viewed as being more credible by their peers3. Following on from a dispute in the South Australian Industrial Relations Tribunal which reinforced clinical directors as being responsible for the total management of regional mental health services there has been improved patient care in South Australia e.g. halving of emergency waiting times3.
Good medical leadership is vital in delivering high-quality healthcare, and yet medical career progression has traditionally seen leadership lack credence in comparison with technical and academic ability. Individual standards have varied, leading to variations in the quality of medical leadership between different organisations and, on occasions, catastrophic lapses in the standard of care provided to patients4. The Goodall report was one of the first to show that there was a strong positive association between ranked quality of a hospital and whether the CEO was a physician (p<0.001)5.
Furthermore, there is evidence at the hospital unit level that medical leadership improves efficiency and patient outcomes e.g. in intensive care. In one study, length of stay decreased and efficiency/cost improved along with the relative risk of death by ensuring an intensivist led care, as opposed to any alternate model involving use of guidelines alone 6.
A survey of 19 OECD countries (not Australia) published in 2016 showed doctors were increasingly involved in hospital management and fulfilled a broad scope of managerial roles, but only partly accompanied by formal decision-making responsibilities. Doctor managers having more formal decision-making responsibilities in strategic hospital management areas is positively associated with the level of implementation of quality management systems7. Thus, a critical factor may not be the uptake of managerial tasks by doctors in itself, but also giving them credible and meaningful decision-making responsibility in strategic management7.
A recent systematic review of sixteen studies looking at whether hospitals and healthcare organisation perform better when led by doctors, is helpful8. Twelve studies found that there were positive differences between medical and non-medical leaders, and eight studies correlated these findings with hospital performance or patient outcomes. The authors conclude that a modest body of evidence supports the importance of including doctors in the composition of governing boards to improve organisational performance.
Around the world clinical professionals have increased their involvement in the management of health services. In studying the impact of clinicians appointed to the boards of directors of English NHS hospital trust, Veronesi G et al concluded –
- There was a significant and positive association between a higher percentage of clinicians on boards and the quality ratings of service providers, especially where doctors are concerned. This positive influence is also confirmed in relation to lower morbidity rates and tests to exclude the possibility of reverse causality (doctors joining boards of already successful organisations).
- We do not find the same level of support for clinical professions such as nurses and other allied health professions turned directors9.
It is suggested this effect of doctors on NHS boards is due to increased understanding and credibility and better communication. Physician leaders can shape the hospital’s quality vision and directly influence decisions about implementation and cost-quality trade-offs. These medical leaders can also promote new innovations in the design of services9.
The benefit of doctors on boards has been also clearly elucidated in the USA8. The top performing hospitals in the USA are chosen based on previous year’s risk-adjusted patient mortality and complication rates, severity-adjusted average patient lengths of stay, expenses, profitability, proportional outpatient revenue, and asset turnover ratio. Conspicuous among the winners are physician-led organisations10. The obvious examples of this are the Mayo clinic and the Cleveland Clinic. Mayo has a rich tradition of partnering physician leaders with administrators and tapping the business management techniques and expertise the non-physician brings15. Better management = better medicine. Medical leadership is normalised, not seen as an inferior occupation or ‘the dark side’. We need this to be a universal view among the Australian medical profession also.
Medical leadership, like other leadership roles, must have passion, courage, vision and an ability to scan the horizon for health care policies which may affect health services directly or indirectly11. Medical leaders often have the skills to look at the problems in a longitudinal manner and have a broader perspective in understanding dynamics of policy11. Leaders' relational and organizational skills as well as process-management and change-management skills are considered important to improve primary care integration. In this, general practitioners are regarded as the most appropriate leaders12.
- Blumenthal DM et al. Addressing the leadership gap in medicine: residents need for systematic leadership development training. Academic medicine. 2012, 87:513-522.
- Berghout MA et al. Medical leaders or masters? – a systematic review of medical leadership in hospital settings. PLOS One. 2017, 12(9).
- Allison S et al. Expert leadership – why psychiatrist should lead mental health services. Australasian Psychiatry. 2016, 24(3):225-227.
- Warren OJ & Carnall R. medical leadership: why it’s important, what is required, and how we develop it. Postgraduate medical Journal. 2011, 87(1023):27-32.
- Goodall AH Physician leaders and hospital performance: is there an association? Social Science and medicine. 2011, 73(4):535-539.
- Fuchs RJ et al. Do Intensivist in ICU improve outcome? Best practice & research clinical anaesthesiology. 2005, 19(1):125-135.
- Rotar AM et al. The involvement of medical doctors in hospital governance and plications for quality management: a quick scan in 19 and an in depth study in 7 OECD countries.
- Clay-Williams R et al. Medical leadership, a systematic narrative review: do hospitals and healthcare organisations perform better when led by doctors? BMJ Open 2017, 7(9):1-11.
- Veronesi G et al. Clinicians on the board: what difference does it make? Social Science & Medicine. 2013, 77:182-7.
- Weber DO. Physicians lead the way at America’s top hospitals. The Physician Executive. 2001, May-June:24-29.
- Bhugra D. Medical leadership in changing times. Asian Journal of Psychiatry. 2011, 4:162-164.
- Nieuwboer MS et al. Clinical leadership and integrated primary care: a systematic literature review. European Journal of General Practice. 2018, 26:1-12.
Published: 13 Mar 2019