For a good part of my career, I was a front-line stakeholder, providing healthcare to patients and collaborating with them to achieve best outcomes. So in this sense, I was a follower, not a leader, and therefore in a particularly good position to judge the quality of the leaders of the institutions where I worked.
My viewpoint has always been that although some leaders may view those on the front-lines as individuals who work for the leaders, the truth is somewhat different.
The key responsibility of leaders is to enable those carrying out the day-to-day work of health care to be successful, to take pride in their work and to experience joy and meaning, which is so significant to professional success and a personal sense of well being. So, who best to judge the quality of leaders than those whom the leader serves?
The Institute for Healthcare Improvement (IHI) in the USA has produced a white paper* that discusses key elements of high-impact leadership and these are:
• Person-centeredness – Being consistently person-centered in word and deed with respect to staff and patients
• Front-line engagement – Being a regular authentic presence at the front line and visible champion of improvement
• Relentless focus – Remaining focused on the institutional vision and strategies to achieve that vision
• Transparency – Requiring transparency about results, progress, aims, defects and challenges to overcome
• Boundarilessness – Encouraging and practicing systems thinking and collaboration across boundaries
Each of us periodically undergoes a review of our performance with our direct manager or other leaders, depending on organizational structure. Wouldn’t it be interesting if, in an ideal universe, the front-line employees, the stakeholder clinicians, were to give performance reviews to the leaders, with particular focus on these five key elements? We could then grade the leaders’ abilities, and possibly link their professional compensation and promotional prospects to their performance. You may think that this model is strange and unrealistic, but you would be incorrect. Once again we look to the aviation industry, in this case military aviation, for an example of how this might work.
Military aviation is a career field in which leaders uniformly have come from the front-lines. It nearly always is the case that senior officers have come from the same aviation backgrounds as their subordinates and therefore are intimately familiar with the stresses, challenges and skills of an aviator. In order to maintain flying proficiency, senior officers – the leaders – usually will continue to fly periodically, both because they love to do so and also because they want to continue to be seen by the aviation community, i.e., the “guild”, as being part of the aviation fraternity. They want to be seen as authentic, and continuing to fly is the badge of authenticity and belonging that cohesively binds the flying unit.
Because the leaders are senior in rank, they have additional duties and responsibilities that take them off the flight deck or out of the cockpit to well beyond flying operations. Thus, they have less current flying experience than front-line pilots, who may be their juniors in age and military rank. When they fly with these junior officers, either side-by-side or front and behind in the cockpit or in separate jets as a two-ship formation, the junior front-line pilot is in charge of the mission. After the flight there is a debriefing, where the junior pilot evaluates the performance of the senior pilot, the leader, in a cordial and informative dialogue that goes something like this: “Sir (or increasingly Ma’am), these are the things you are doing very well and these are the areas in which you need to work harder to improve and sustain your skills. I am going to schedule you for some time in the flight simulator and then we will reassess your performance in a few months’ time.”
Confused yet? Got that?
Now, try to envision a similar interaction between front-line clinicians and the leadership in hospitals, with the “front-liner” saying something like “Ma’am (or Sir), you are doing very well in many areas but you really need to work harder on your person-centeredness and transparency skills. I am going to recommend that you have some refresher training in these areas and then plan to reassess your performance again in six months. Your compensation is linked to your performance, of course, so please take these recommendations to heart.”
Got that?
You see, in my view, leaders are not only accountable to their boards of directors but also to their subordinates, whom they should be enabling to succeed and to experience professional joy and meaning. Of course, leaders AND followers are most assuredly and specifically accountable to patients and their family members through an ethical covenant.
Perhaps those very unique front-line stakeholders also should provide performance assessments. Wouldn’t this be a wonderful world?
Ref:
*Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org