"Medical leadership and management" describes the engagement of doctors in the leadership and management of both individual patient care and of the departments, organizations and systems within which they work. Around the world, doctors are generally accepted as the leaders of clinical teams, holding ultimate accountability for individual patient care. However, the role of doctors as organizational and system leaders within healthcare, despite evidence of benefit, shows considerable variation. In this article, we briefly explore the history of leadership development for doctors, and then, taking a UK perspective on recent developments in undergraduate education and postgraduate training, consider the opportunities and challenges for medical schools, educators and doctors in implementing these. The future of medical leadership and management development is promising although there is still a lack of evidence on the longer-term outcomes and impact on patients of current interventions. It is clear, however, that faculty need to be skilled in holding effective developmental conversations and structuring formative experiences for those they educate, and that leadership development must be integrated longitudinally throughout a doctor's career, with undergraduate development being a critical stage for helping medical students recognize and understand their wider responsibility to the system, as well as the patient in front of them.

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The Importance of Leadership Development in Medical Curricula: A UK Perspective (Stars are Aligning)

Objective The influx of management ideas into healthcare has triggered considerable debate about if and how managerial and medical logics can coexist. Recent reviews suggest that clinician involvement in hospital management can lead to superior performance. We, therefore, sought to systematically explore conditions that can either facilitate or impede the influence of medical leadership on organisational performance. Design Systematic review using thematic synthesis guided by the Enhancing Transparency in Reporting the synthesis of Qualitative research statement. Data sources We searched PubMed, Web of Science and PsycINFO from 1 January 2006 to 21 January 2020. Eligibility criteria We included peer-reviewed, empirical, English language articles and literature reviews that focused on physicians in the leadership and management of healthcare. Data extraction and synthesis Data extraction and thematic synthesis followed an inductive approach. The results sections of the included studies were subjected to line-by-line coding to identify relevant meaning units. These were organised into descriptive themes and further synthesised into analytic themes presented as a model. Results The search yielded 2176 publications, of which 73 were included. The descriptive themes illustrated a movement from 1. medical protectionism to management through medicine; 2. command and control to participatory leadership practices; and 3. organisational practices that form either incidental or willing leaders. Based on the synthesis, the authors propose a model that describes a virtuous cycle of management through medicine or a vicious cycle of medical protectionism. Conclusions This review helps individuals, organisations, educators and trainers better understand how medical leadership can be both a boon and a barrier to organisational performance. In contrast to the conventional view of conflicting logics, medical leadership would benefit from a more integrative model of management and medicine. Nurturing medical engagement requires participatory leadership enabled through long-term investments at the individual, organisational and system levels.

https://bmjopen.bmj.com/content/bmjopen/10/7/e035542.full.pdf

Medical leadership: boon or barrier to organisational performance? A thematic synthesis of the literature.

Introduction The aim of this study is to develop a conceptually sound outcome model for clinical leadership (CL) development in healthcare, linking individual professional learning and organisational change. Frontline doctors' CL is often offered as a solution to healthcare challenges worldwide. However, there is a paucity of rigorous evidence of effectiveness of CL development, or theories supporting it. Importantly, the literature currently lacks robust outcome models for CL development, impeding robust impact evaluations. Methods This multi-source, sequential integrated mixed-methods study draws on systematic content analysis of NHS policy documents and empirical data from a CL programme evaluation study: exploratory factor analysis (EFA) of 142 participants' survey responses and thematic qualitative analysis of 30 in-depth participant interviews across six cohorts. Through integrating findings from the three analyses we examine: (a) the expected organisational outcomes of CL, (b) individual learning outcomes of CL development, and (c) the mechanisms linking the two. Results The policy analysis identified three desired solutions to key healthcare problems which CL is expected to offer: Speeding up good practice, Inter-professional collaboration and dialogue, and Change and transformation. Triangulating the EFA results with the qualitative analysis produced five individual outcome constructs: Self-efficacy, Engaging stakeholders, Agency, Boundary-crossing expertise, and Willingness to take risks and to learn from risks and failures. Further qualitative analysis uncovered key mechanisms linking the individual outcomes with the desired organisational changes. Discussion Despite significant investments into CL development in the UK and worldwide, the absence of conceptually robust and operationally specific outcome models linking individual and organisational impact impedes rigorous evaluations of programme effectiveness. Our study developed a novel individual and organisational outcome model including a theory of change for clinical leadership. Our findings further contribute to professional learning theory in medical settings by conceptualising and operationalising the mechanisms operating between individual and organisational learning outcomes.

/pdf/professional-learning-organisational-change-and-clinical-5ggqs4xlku.pdf

Professional learning, organisational change and clinical leadership development outcomes.

As a discipline, health organisation and management is focused on health-specific, collective behaviours and activities, whose empirical and theoretical scholarship remains under-utilised in the field of implementation science. This under-engagement between fields potentially constrains the understanding of mechanisms influencing the implementation of evidence-based innovations in health care. The aim of this viewpoint article is to examine how a selection of theories, models and frameworks (theoretical approaches) have been applied to better understand phenomena at the micro, meso and macro systems levels for the implementation of health care innovations. The purpose of which is to illustrate the potential applicability and complementarity of embedding health organisation and management scholarship within the study of implementation science.,The authors begin by introducing the two fields, before exploring how exemplary theories, models and frameworks have been applied to study the implementation of innovations in the health organisation and management literature. In this viewpoint article, the authors briefly reviewed a targeted collection of articles published in the Journal of Health Organization and Management (as a proxy for the broader literature) and identified the theories, models and frameworks they applied in implementation studies. The authors then present a more detailed exploration of three interdisciplinary theories and how they were applied across three different levels of health systems: normalization process theory (NPT) at the micro individual and interpersonal level; institutional logics at the meso organisational level; and complexity theory at the macro policy level. These examples are used to illustrate practical considerations when implementing change in health care organisations that can and have been used across various levels of the health system beyond these presented examples.,Within the Journal of Health Organization and Management, the authors identified 31 implementation articles, utilising 34 theories, models or frameworks published in the last five years. As an example of how theories, models and frameworks can be applied at the micro individual and interpersonal levels, behavioural theories originating from psychology and sociology (e.g. NPT) were used to guide the selection of appropriate implementation strategies or explain implementation outcomes based on identified barriers and enablers to implementing innovations of interest. Projects aiming to implement change at the meso organisational level can learn from the application of theories such as institutional logics, which help elucidate how relationships at the macro and micro-level have a powerful influence on successful or unsuccessful organisational action. At the macro policy level, complexity theory represented a promising direction for implementation science by considering health care organisations as complex adaptive systems.,This paper illustrates the utility of a range of theories, models and frameworks for implementation science, from a health organisation and management standpoint. The authors’ viewpoint article suggests that increased crossovers could contribute to strengthening both disciplines and our understanding of how to support the implementation of evidence-based innovations in health care.

Understanding implementation science from the standpoint of health organisation and management: an interdisciplinary exploration of selected theories, models and frameworks

Digital health is a novel and emerging field within healthcare, with a professional group that is evolving just as rapidly. In recent years, training opportunities within digital health have become more present in research, the NHS and the private sector. This article offers a personal reflection on a digital health leadership journey and makes the case for flexibility in training and career opportunities. If policy makers and senior leaders want to realise the outcomes from successive workforce reviews, such as The Topol Review, then there is a case for more inclusive digital leadership roles open to the widest range of suitably skilled professionals.

https://www.rcpjournals.org/content/futurehosp/7/3/199.full.pdf

Digital health leadership: carving a new pathway.

Many nations are focussing on health care’s Triple Aim (quality, overall community health and reduced cost) with only moderate success. Traditional leadership learning programmes have been based on a taught curriculum, but the purpose of this paper is to demonstrate more modern approaches through procedures and tools.,This study evolved from grounded and activity theory foundations (using semi-structured interviews with ten senior healthcare executives and qualitative analysis) which describe obstructions to progress. The study began with the premise that quality and affordable health care are dependent upon collaborative innovation. The growth of new leaders goes from skills to procedures and tools, and from training to development.,This paper makes “frugal innovation” recommendations which while not costly in a financial sense, do have practical and social implications relating to the Triple Aim. The research also revealed largely externally driven health care systems under duress suffering from leadership shortages.,The study centred primarily on one Canadian community health care services’ organisation. Since healthcare provision is place-based (contextual), the findings may not be universally applicable, maybe not even to an adjacent community.,The paper dismisses outdated views of the synonymity of leadership and management, while encouraging clinicians to assume leadership roles.,This paper demonstrates how health care leadership can be developed and sustained.

The making and sustaining of leaders in health care.

To review the impact of the clinical leadership programme, in enabling the Darzi Fellows to lead change projects in health and care services, and to secure quality healthcare in the NHS beyond the lifetime of the programme A longitudinal empirical investigation of clinical leaders (n=80) over an eight-year period was framed through an Activity Theory-driven research methodology using a mixed-methods approach Activity theory illuminated how change was sustained in the NHS in London through the Darzi Clinical Leadership Fellowship By any reasonable measurement, this programme excels, with learning and positive behavioural change sustained after the Fellowship across the NHS Further recognition is needed of the continuing development needs of Fellows as they take on more responsible leadership roles in their careers Darzi fellows are a hard-to-reach group The sample represents a response rate of 34% 77% emanated from cohorts 5 to 8 programmes The investment in a clinical leadership programme focused on systems leadership for quality generates value for the NHS Countless interventions flowed through London’s healthcare community and beyond as a result of the Fellowship This research exposed how Darzi Fellows continue to lead innovation for alternative healthcare outcomes Many proactive Fellows employ a suite of learned skills and capabilities, to lead systemic change This research is the first known longitudinal clinical leadership development study undertaken The Darzi programme has created a unique clinical network of mutually supportive, team-centric systems thinkers and doers, with an evidence-based approach to systems change Many Fellows are catalysing sustainable change in the healthcare environment

Terry J. Boyle

Papers

The making and sustaining of leaders in health care.

Darzi Clinical Leadership Fellows: an activity theory perspective