Leadership for the Sustainability of the Health System: Part 2 - Key ...

ForewordI am pleased to present this three-part report on Leadership for the Sustainability of the HealthSystem. It addresses the challenges involved in improving and sustaining an effective health systemto meet the needs of the Australian community and makes recommendations for future activity.Health Workforce Australia (HWA) is an initiative of the Council of Australian Governments and hasbeen created as a cross-jurisdictional body operating in the government and non-governmenthealth sectors, as well as the higher education sector, to address Australia’s critical healthworkforce planning, training and reform challenges.In August 2011 the Ministers approved the National Health Workforce Innovation and ReformStrategic Framework for Action 2011–2015 1 . This policy framework will guide the innovations andreforms necessary to deliver a sustainable health workforce into the future. Leadership for theSustainability of the Health System is a key domain for action.At the national level there are major reforms foreshadowed or underway, and strong leadershipcapacity will be required to guide the workforce changes required to support national reforms.Effective leadership will build and support capacity for innovation and change.In order to ensure evidence-based approaches to its work in the leadership domain, HWAcommissioned a study to guide consideration of the priority steps. The report provides a thoughtfulanalysis of some the challenges faced by health leaders nationally and internationally.Recommendations include:improving the content, delivery and evaluation of current leadership development offeringsemphasising leadership at all organisational levels and in every area of health caresupporting the integration of both clinical and corporate leadership developmenttransforming organisational cultures to foster innovation, creativity and changethinking in system terms and engaging with others across sectors and jurisdictionsengaging with consumers, patients and communities as a critical part of systemimprovement.The report also highlights the need to increase the number of leadership developmentopportunities available to Aboriginal and Torres Strait Islander people in the health workforce. HWAis collaborating with Aboriginal and Torres Strait Islander organisations and key leaders to determinean appropriate course of action.1Health Workforce Australia (2011). National Health Workforce Innovation and Reform Strategic Framework for Action 2011-2015 Adelaide www.hwa.gov.auLeadership for the Sustainability of the Health System: Part 2 – Key Informant Interview ReportPage i

This is in line with a commitment in the National Health Workforce Innovation and Reform StrategicFramework for Action 2011–2015 to ‘Accelerate progress in achieving the goals of Closing the Gapby building and supporting the leadership capacity of the Aboriginal and Torres Strait Islanderhealth workforce’ 2 .The report makes a worthwhile contribution to the leadership discussion with particular resonancefor those interested in health. I commend it to leaders and to those working in the areas of healthworkforce development and leadership education.Mark CormackChief Executive Officer, HWA2Health Workforce Australia (2011). National Health Workforce Innovation and Reform Strategic Framework for Action 2011-2015 Adelaide www.hwa.gov.auLeadership for the Sustainability of the Health System: Part 2 – Key Informant Interview ReportPage ii

ContentsContents .................................................................................................................................................................. iiiExecutive summary ................................................................................................................................................ 1Major challenges facing health leaders ....................................................................................................... 1Suggested improvements to leadership programs ..................................................................................... 2Introduction ............................................................................................................................................................. 5Background ......................................................................................................................................................... 5The case for change and the place of leadership ..................................................................................... 6About Health Workforce Australia .................................................................................................................. 7Key informant interview report ............................................................................................................................ 9Methodology ...................................................................................................................................................... 9Results ................................................................................................................................................................. 11Major challenges facing leaders in the health sector .......................................................................... 11Leadership development ........................................................................................................................... 15HWA’s potential role .................................................................................................................................... 23Leadership for the Sustainability of the Health System: Part 2 – Key Informant Interview ReportPage iii

Executive summaryOne of the five domains of the National Health Workforce Innovation and Reform StrategicFramework for Action 2011–2015 3 concerns leadership for the sustainability of the health caresystem. Work to ensure that health care systems can be sustained is an urgent priority forgovernments globally. Leadership capacity is essential to success in introducing the innovation andchange that will sustain the health care system. Health Workforce Australia (HWA) commissioned areport to inform the next steps to develop that capacity.The report comprised:an environmental scan of national and international activity in leadership as it applies toimplementing innovation and changea literature review of the theories, research and evidence on leadership, leadershipdevelopment, and other organisational and system enablers that affect the return oninvestment of leadership developmenta summary of the findings of informant interviews on the current status and future direction ofleadership developmentan analysis of the material captured in the environmental scan, informed by the conclusionsand recommendations of the literature review and interviewsa synthesis of the key findings and recommendations from the literature review, interviewsand environmental scan to provide advice and recommendations for HWA on how to bestbuild on and support existing efforts in leadership development in Australia.This paper presents the findings and recommendations of a review of the literature on effectiveleadership and its development in health systems.Major challenges facing health leadersThe central challenges facing health leaders, identified by key informants, were how best to:address the interrelated challenges of changing demography, epidemiology and workforceprovide leadership that focuses services and providers on consumer and community needlead leaders and autonomous health professionalsmaximise productivity to meet increasing and changing demanddisseminate innovation and effect changereduce scepticism, change weariness, and change wariness and work with persistence andcouragebring about culture changenavigate the political nature of health.3Health Workforce Australia (2011). National Health Workforce Innovation and Reform Strategic Framework for Action 2011-2015 Adelaide www.hwa.gov.auLeadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 1

Suggested improvements to leadership programsIn reflecting on the adequacy of the leadership development opportunities of which key informantswere aware, they made several suggestions to increase return on investment.ContentKey informants recommended the following improvements to leadership development programs:incorporate training in building measurement and evaluation into change programsprovide education on how to transform an organisation’s culture to foster innovation,creativity and changedevelop health leaders’ ability to think in systems terms and effect change in complexadaptive systemsprovide support for health leaders from clinical backgrounds to develop the level of businessacumen necessary to meet the broad fiduciary responsibilities (financial, clinical andpopulation outcomes) of leadership positions in health care systemssupport the development of personal and interpersonal skills necessary to hold others toaccount and promote the ethical use of influence, avoid conflicts of interest, and meet theimplicit contract of trust between the health system and the communitybuild understanding that consumer feedback and information is an essential source of theintelligence necessary to inform the kinds of innovation, improvement and redesign of healthsystems that will reflect the patient experience, and support population health outcomesincorporate training in building political support within organisations “small ‘p’” and acrosspolitical parties “big ‘P’” to manage the overall politics in health.centre the focus of leadership development on emotional awareness/intelligence, thecapacity to build trust and relationships, leading by influence instead of positional authority,engaging with staff and communicating a shared vision, and using intrinsic motivation toinspire staff in the direction of a desired goal.DeliveryKey informants suggested the delivery of leadership programs could be improved by:involving senior managers in the presentation and delivery of leadership programs toincrease engagement and share ‘real world’ experienceembedding leadership development in quality improvement, safety or lean health caretraining, as this would go some way towards rectifying the misconception that clinicalleadership is about placing clinicians in formal leadership positions and would promoteleadership development as something that has the potential to support improvements inservice deliveryproviding ongoing support for health leaders, including establishing ‘communities of support’Leadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 2

uilding connections across boundaries by including people from across professional silos,jurisdictions and the government, non-government and private sectors in health, and evenother industriesoffering mentoring opportunitiesensuring wherever possible that training and development is conducted interprofessionallyembedding leadership development in undergraduate and postgraduate trainingdeveloping the most senior health leaders in the system as a group using strong relationalmodelsincluding leaders from the Australian Department of Health and Ageing in leadershipdevelopment opportunities and activities with senior state and territory staff.CoverageKey informants suggested the coverage of leadership development programs could be improvedby:offering leadership development opportunities to all administrative and clinical healthprofessionalsdeveloping the capacity to identify emerging leaders and select them for leadershipdevelopment and formal leadership positionsoffering incentives to participate in leadership development opportunities, such asarticulation of leadership courses with postgraduate diplomas or other qualificationsoffering senior leaders ongoing development, as a large percentage of this cohort has notreceived formal development in a number of decades.HWA’s potential roleKey informants made suggestions about possible roles HWA could play in facilitating thedevelopment of health system leaders. These included:developing the most senior leaders of the health system by:establishing cross-jurisdictional leadership development opportunities for theseindividuals to provide them with a community of support and a source of guidanceexposing them to best practice internationallybringing them together with health educators, course accreditors and regulators todiscuss the development of future health system leaderstraining them in managing small ‘p’ and big ‘P’ politics in health carebuilding and maintaining a national pool of evidence on what works in leadershipdevelopment and what is available both nationally and internationallydeveloping a national evaluation strategy that could assess the return on investment ofleadership development programs run nationally and by the jurisdictionsLeadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 3

developing a national leadership competency framework to ensure a common languageand understanding is shared by all the jurisdictionsworking to ensure the national competency framework is embedded into healthorganisations by the jurisdictionsplaying a role in the development of Aboriginal and Torres Strait Islander health leadersworking with key professional associations and health organisations to build a betterunderstanding in the health system and in the community of the contribution of sound policy,management and leadershipworking with jurisdictions and other stakeholders, such as the Australian College of HealthService Management, to build governance and leadership support for emergingorganisational forms (Medicare Locals and Local Health and Hospital Networks) undernational health reform.Leadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 4

The case for change and the place of leadershipIn December 2005 the Productivity Commission identified the demand and supply issues in healththat Australia must confront in the next decade. These issues included:a changed mixture of disease burdens, including increasing numbers of people who will besuffering type 2 diabetes and dementiaincreased individual spending on health care, and increased expectations of timely accessto high-quality health servicesthe need for different models of care and new workforce practices to accommodate andutilise the wider range of treatment possibilities arising from new technologiesan ageing and longer-living population that will significantly increase health expenditure andthe incidence of chronic diseasethe increasing average age of health workers and the need to replace greater numbers ofretiring workers, in a context where health workforce supply already fails to keep up withdemand.In all OECD (Organisation for Economic Co-operation and Development) countries, total spendingon health care is rising faster than economic growth, and it has been predicted that the cost ofhealth care could reach 20% of gross domestic product by 2020 owing to the increasing affluenceand longevity of populations in developed countries. 6 Australia’s changing age profile willsignificantly increase health spending. Spending on the over 65s may be as much as four timesmore per person than on those under 65. 7In light of the global nature of health and health workforce challenges, and the results of researchand evidence both at home and overseas, the momentum towards health service redesign mustincrease, and the workforce reform and innovation necessary to support it must also increase. Thepace, level and nature of the needed change and innovation demand significantly increasedleadership at all levels of the system.The current focus is on:increasing numbers in the workforce—increasing numbers of clinical training places,encouraging re-entry, supporting retentionredesigning to support increased productivity—organisational and service redesign toincrease engagement in direct patient care by health professionalsrole redesign—efforts to ensure all professions work to full capacity and maximise return oninvestment in specialist training, and creation of assistant roles to free higher-skilled parts ofthe workforce arising from activities that only require a lower level of skill6Fogel RW (2004). The Escape from Hunger and Premature Death, 1700–2100: Europe, America, and the Third World.Cambridge Univ Press, Cambridge UK.7Productivity Commission (2005). Australia’s health workforce. Productivity Commission Research Report, Canberra,Australia.Leadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 6

quality and safety efforts to reduce adverse outcomes and avoidable admissions andattendances at health services.While these are important aims, the evidence strongly suggests that they will be inadequate toaddress threats to the sustainability of the health system, the appropriateness of models of servicedelivery, and the structure and availability of the health workforce. The extent and nature ofpopulation needs are changing rapidly and require a different order of change at national,regional and global levels.What is considered possible is constrained by thinking that continues to focus on working forwardfrom the existing professions and their interests, skill demarcations and responsibilities. What isrequired is leadership capable of promoting a paradigm shift in ways of thinking about healthsystem and workforce design and planning—ways that work backwards from outcomes forconsumers and communities and population need.Leadership development to achieve this paradigm shift demands new ways of thinking. The systemneeds increased capacity in its leaders to design health systems that follow the patient journey,engage patients and communities in the change process, and promote and support wellness as wellas treat disease.About Health Workforce AustraliaHWA is an initiative of the Council of Australian Governments and has been established to addressthe challenges of proving a skilled, flexible and innovative health workforce that meets the needsof the Australian community, now and into the future.HWA was established following the development of a $1.6 billion National Partnership Agreementon Hospital and Health Workforce Reform, by the Commonwealth and State and TerritoryGovernments in November 2008.HWA reports to Health Ministers and will operate across health and education sectors to devisesolutions that integrate workforce planning, policy and reform with the necessary andcomplementary reforms to education and training.HWA’s functions include:the provision of comprehensive, authoritative national workforce planning, policy andresearch advice to Ministers, governments and key decision makers in the health andeducation sectorsimproving and expanding access to quality clinical education placements for healthprofessionals in training across the public, private and non-government sectors; this will beachieved through programs that expand capacity, improve quality and offer diversity inlearning opportunities; this also includes a national network of simulated learningenvironments, or SLEs, to enhance the quality, safety and efficiency of clinical trainingLeadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 7

developing and implementing a national program of health workforce innovation andreform; this will encourage the development of new models of health care delivery, facilitateinterprofessional practice, and equip health professionals for current and emerging demandson the health care sectorfacilitating a nationally consistent approach to international recruitment of healthprofessionals to Australia.Leadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 8

Key informant interview reportMethodologyParticipantsBased on the environmental scan and after consultation with the jurisdictions, a sample of43 recognised health service leaders, expert commentators on the health system and experts inleadership development in other sectors were approached for interview. They represented all thestates and territories of Australia, and also the United Kingdom and Canada. They comprised 27people from the health sector, and 16 from the corporate or non-government sectors. Of the 43people invited to participate, 18 did not reply to the invitation, six declined, 19 accepted and 16were available to be interviewed in the available time period (a response rate of 37%).The majority of the nominated leaders from outside the health sector were either unavailable or didnot respond to the invitation. As a result, all the respondents had some formal or informalconnection to the health industry. Nevertheless, several of those interviewed had a breadth ofleadership experience in industries outside health care, such as finance, information technologyand construction, as well as non-health-related government departments and non-governmentorganisations. The 16 people interviewed came from three groups:four senior and executive managers of state or territory health departments, service deliveryorganisations and professional associationseight directors of human resource management or organisational development of healthorganisations and institutesfour health industry commentators, academics and senior educators.DesignIn a semi-structured interview, the interviewer outlined five broad headings, and then usedinformation from the literature review and the environmental scan to prompt discussion, clarifyaspects of the environmental scan the interviewee had direct knowledge of, and seek moredetailed reflection. The five areas for discussion were:what are the major challenges facing leaders in the health sector?what leadership development opportunities are they aware of?what is the adequacy of current leadership development efforts?what else might be done to develop leadership or increase return on investment in currentleadership development efforts?what could HWA do to add value to leadership development efforts?The questions posed were tailored to the interviewees on the basis of their capacity to answer (forexample, people not employed in the health system were not asked about leadershipdevelopment opportunities in the system). The interviews were conducted from early June to earlyLeadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 9

July 2011 and the results were subjected to a ‘framework analysis’ approach following Krueger’s 8 , 9method, which draws heavily on the framework analysis procedure first described by Ritchie andSpencer. 10Framework analysis can be thought of as a continuum of analysis ranging from the mereaccumulation of raw data to the interpretation of data, although it is not a linear process, andeach step overlaps the next, as shown below:The five key stages outlined by Krueger are familiarisation; identifying a thematic framework;indexing; charting; and mapping and interpretation. The other distinctive aspect of frameworkanalysis is that, although it uses a thematic approach, it allows themes to develop both from theresearch questions and from the narratives of participants. Qualitative research generates largeamounts of data, and it is important that the purpose of the study drives the analysis. At the sametime, it is important to capture emerging themes from interviews that will further inform the project.Because of the volume of data generated from qualitative research, it is important to ensurereliability of the coding of data, since more than one researcher is likely to be independentlycoding the data. Codes are words or devices for identifying themes. The process developed byHruschka et al. 11 maximises inter-coder reliability in coding open-ended data. The process involvessegmenting the data, developing a draft codebook, testing the reliability of a sample of data by atleast two independent coders, checking and modification of the codebook before final coding,and finally quality control of all data by the lead coder.The framework analysis and inter-rater reliability testing builds a database of coded qualitativedata that can be sorted into various themes and is traceable for verification and checking of thefinal analysis and interpretation that will form part of the report. The differences and commonalitiesin the themes identified by the coders are discussed and resolved to produce a summary of theimplications of the informants’ views.The findings documented in the following sections of this report are the result of a thematic analysisof the views of the respondents, not of the consultants.8Krueger RA (1994). Focus Groups: A Practical Guide for Applied Research. Thousand Oaks, CA: Sage Publications.9Krueger RA & Casey MA (2000). Focus Groups: A Practical Guide for Applied Research (3rd ed.). Thousand Oaks, CA: SagePublications.10Ritchie J & Spencer L (1994). Qualitative data analysis for applied policy research. In A Bryman & RG Burgess (eds),Analysing Qualitative Research. London: Routledge: 173–94.11Hruschka DJ, Schwartz D, Cobb St John D, Picone-Decaro E, Jenkins RA & Carey JW (2004). Reliability in coding openendeddata: lessons learned from HIV behavioral research. Field Methods 16(3): 307–31.Leadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 10

These findings have been synthesised with the findings from the literature review and environmentalscan to provide advice about options for HWA to consider for its role in the leadership space.ResultsMajor challenges facing leaders in the health sectorIn general, respondents who had recent experience in line management of health services said thebiggest challenge was developing individuals capable of leading the health system throughrapidly changing epidemiology and demography.Those in human resources or organisational development positions spoke most about buildingbusiness acumen and developing the skills required for change management and culture change.Health industry commentators and academics focused more on developing leaders capable ofnavigating the party politics surrounding health, and the small ‘p’ politics of vested interests andprofessional groups involved in the delivery of health services.Service leaders and health industry commentators, educators and academics stressed theabsence of an authentic consumer focus as a major challenge for health leaders.The major high-level themes that emerged from analysis of interview transcripts were:addressing the interrelated challenges of changing demography, epidemiology andworkforceproviding leadership that focuses services and providers on consumer and community needthe distinctive nature of the health workforce—leading leaders and autonomous healthprofessionalsmaximising productivity to meet increasing and changing demandleadership for the dissemination of innovation and change managementreducing scepticism, change weariness and change wariness, and the need for persistenceand courageculture changenavigating the political nature of health.vested interests and the ethical expression of influence and powerThese major themes will be illustrated in turn.Addressing the interrelated challenges of changing demography, epidemiologyand workforceThe imminent impact of the ageing of the population, the dramatic increase in chronic illness andworkforce maldistribution present challenges to health service leaders and systems that are of ascale not experienced by most in their careers to date.Leadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 11

The solutions of the past, the demarcations among and between the professions, and the way theiraccountabilities have been defined (facility and profession based) are proving inadequate.In this context the priority of leadership and leadership development tasks involve focusing on thesystem from the patient journey perspective across the full continuum of care and dramaticallyincreasing the level of consumer engagement in policy, planning, facility and patientmanagement.Providing leadership that focuses services and providers on consumer andcommunity needDespite recent national and international effort, the deep culture of health services (and theprofessions that work in them) remains facility, disease and profession focused. The financial andnon-financial incentives in the system, while changing, still mainly support traditional role andpractice demarcations. These traditional demarcations no longer always match the pattern andlevel of need or the reality that the bulk of the management of chronic illness and aged carehappens away from service providers and, in fact, is ‘self-management’ facilitated or supported bythe health system. Unlike other innovative and successful industries, the use of ‘customer’ orconsumer views in the design of individual care plans, health services, facilities and systems is verylow. Health leaders themselves are most often a product of the formal and informal education thathas permitted this lack of deep interest in the consumer experience of health, ill health and healthcare.Building appreciation of, and capacity and confidence in, consumer engagement was seen as amajor determinant of health leaders’ influence with their colleagues and a key to successful culturechange with health professionals who are patient rather than corporately focused.The distinctive nature of the health workforce: leading leaders and autonomoushealth professionalsThe nature of the work in health services and the enculturation of health professionals result in aworkforce most focused on individual or group clinical outcomes, research and teaching.Corporate loyalties, where they exist, are to professions and the protection of professionalautonomy rather than to the achievement of organisational goals such as cost containment.Where organisational loyalties exist, they are often to the facilities in which people train and workbut not to the broader health system and even less to health departments. Leading system-widechange that requires the sustained buy-in of autonomous health professionals or healthprofessionals intent on the preservation of their alma mater or their role takes different skills fromthose that might be successful in other industries. It requires the ability to lead leaders andindividuals who are often enormously self-confident, independent and not trained for, orcomfortable in, follower roles.Leadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 12

Maximising productivity to meet increasing and changing demandThe use of the health workforce was considered by interviewees to be inefficient, an issue that iscompounded by the increasing service delivery demands being placed on health organisations,coupled with ever-increasing budget constraints and workforce pressures.Additionally, valid productivity data is not available to managers of health organisations, whilemanagers of other industries are awash in it. Inefficiencies were believed by interviewees to becaused to a large extent by a maldistribution of the health workforce, resistance to innovation andchange in workforce structure, and the rigidity of existing professional demarcations and ‘turf wars’between some professions, which prevent professionals from being used to their full capacity.Inefficiencies were also thought to be the result of a general lack of business acumen in healthleaders.Leadership for the dissemination of innovation and change managementThe rapid increase in the availability of new treatments, information and communicationapplications relevant to health, coupled with the demographic and epidemiological changesreferred to earlier, provide opportunities to address other challenges noted by respondents but arealso challenges in and of themselves. Leaders need a deep understanding of how to effectivelydisseminate innovation and manage change, making maximum use of the advantages forpatients, cost containment, and workforce development and distribution.Reducing scepticism, change weariness and change wariness, and the need forpersistence and courageManaging the rate and frequency of change in the health system, particularly change resultingfrom structural reforms, coupled with the perceived failure of some past initiatives, has led to acynicism in the health workforce about change. Additionally, the sheer pace of technological andscientific developments means that leaders and their colleagues face continuous change.Leading this level and type of continuous change, and encouraging and supporting the uptakeand dissemination of innovation and new evidence, corporately and clinically is a majorchallenge.Change weariness and wariness means leaders must be persistent and have courage in the faceof often significant resistance to change. Leading through the active political and internal lobbyingby vested interest groups within and outside the health system means leaders need support and afocus on outcomes.There are concerns expressed by interviewees that because the health system has been subjectedto so many structural and financial changes, the standing of health leaders and managers hasbeen damaged. This in turn is thought to impact on the quality and number of people who arewilling to step up to leadership roles. To be sustainable, the health care system needs to be able toattract and retain the best management and leadership capacity it can.Leadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 13

While leadership development opportunities are available to provide support for those who dotake on these roles, the perception of the sustainability of these careers is increasingly negative.Culture changeImproving the culture of health organisations is a major challenge facing health leaders. Leadershipdevelopment is the key to building the capacity for culture change.Navigating the political nature of healthBig ‘P’ politics and political astutenessBecause of the expense of health, the scarcity of resources available, the extent of conflictingviews on all health-related subjects, and the often competing needs and wants of stakeholders(professional, consumer and community), leading health care organisations and systems will alwayshave a significant political overlay.Only one participant believed that there was more consensus between political parties than wascommonly thought to exist and that the idea of health being used as a ‘political football’ wasoverstated.Building political support (small ‘p’ within professions, and big ‘P’ across political parties) was seento be essential in bringing about the changes necessary for the sustainability of the health system.Furthermore, building bipartisan support was thought to be desirable as it would:encourage leaders to be braver and less risk averse and therefore more likely to beinnovative and encourage innovation among their staffbuild media coverage and interest in the real issues and challenges facing the health systemversus a focus on the next ‘scandal’reduce the high turnover within upper leadership, which causes instabilityencourage talented lower-level managers to aspire to higher positions, which are currentlyperceived as being too unstable due to their vulnerability to the political process.The opposite side of the same coin is the need for leaders to be very politically astute, therebybuilding political support at all levels for innovation and change. This is seen to involve:effectively and appropriately interacting with and influencing politiciansbuilding relationships with Ministers and Shadow Ministers in health and related and relevantportfolioslining up the political coalitions and anticipating how their opponents may react beforeimplementing any changes (see below, on intrapreneurship, for more on this)rallying after a loss so that forward movement can be maintained.One participant contended that, among senior leaders, clinical leaders were especially in need ofdevelopment in political astuteness.Leadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 14

Leadership exists at all levelsAchieving the scale of change needed in the health system will require leaders who are deeplycommitted to the mission of their organisation and who are prepared to navigate through itspolitics in order for the organisation to be able to achieve its mission. These leaders are known as‘intrapreneurs’; they are employees who take personal responsibility for the change process, staybelow the radar while mobilising support for their ideas, and rise above the radar to facilitate thechange process once sufficient support has been built to ensure they cannot be defeated.Vested interests and the ethical expression of influence and powerVested interestsManaging the multiple and often conflicting expectations of vested interest groups is a majorchallenge facing leaders in and of itself. ‘Turf wars’, demarcation disputes, and the protection ofprofessional boundaries often enshrined in regulation, legislation and industrial awards preventleaders from structuring their workforce to meet needs and increase productivity.The ethical expression of influence and powerHealth professionals occupy a particularly privileged position in society. Their expert knowledge andskills lend credibility to their lobbying efforts. Developing leaders who exercise this influence ethicallyand in the public—rather than a particular profession’s interest —is seen as a necessary addition tothe outcomes of leadership development and a challenge for leaders.Leadership developmentIn reflecting on the adequacy of the leadership development opportunities the respondents wereaware of, they made several suggestions to increase return on investment. As expected, theawareness of leadership development opportunities varied across the three groups of respondents.Those involved in human resources and organisational developments were more aware of whatwas available and the evidence for leadership development. Those in senior leadership positionswere aware of the availability of leadership development only in more general terms, and healthindustry commentators were largely unaware of development opportunities.Some respondents said that even if all of the suggestions outlined below were followed, leadershipdevelopment would still be limited by the complexity of the challenges leaders face. Leadershipdevelopment programs should therefore include training in interventions at the organisational level(for example, changing rewards and incentives), system level (for example, addressing the deepcultures and silos of professions) and community level (for example, addressing communityexpectations to build community support for the changes necessary in health service delivery toensure sustainability). Improving the nature and extent of leadership is clearly only one part of themuch larger task of improving the sustainability of the health system.This section begins with some general observations on the adequacy of effort and suggestedimprovements in leadership development, and then outlines some more specific recommendationsLeadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 15

for each category of health worker. At the end of this section are the solutions suggested byinterviewees that are beyond a focus on leadership, but are listed here for completeness and tohighlight the range of measures that might be needed to support a greater return on investment inleadership development.General recommendationsDeveloping leaders’ business acumenA suggested solution to the lack of business acumen and capacity to lead organisations like abusiness is to link health leaders up with leaders from other sectors/industries in cross-industryleadership development. It was proposed that this would enable health leaders to see issues froman outsider’s perspective and solve problems in a more efficient way. Another solution is to providetraining to increase the financial competency of leaders, especially those from professions notgrounded in finance or management. Finally, it was recommended that valid productivity data begathered and made available to leaders.Increase accountabilityIncreasing accountability in the workforce would go a long way towards dis-incentivising archaicand inefficient practices and reducing wasteful spending. To increase accountability in healthorganisations, leaders need to be encouraged to have a clear line on what is acceptable andwhat is not and provide clear, persistent and consistent rewards.Develop the capacity to identify emerging leadersThere is room for improvement in how talented people are identified and selected for leadershiptraining and formal leadership positions. Opportunities are currently being missed by keeping staff inroles they have moved beyond and failing to notice talented individuals. Similarly, some talentedpeople are reportedly not seeking advancement due to perceptions of instability at the seniorleadership level.Ensuring the health system has the right leaders also entails good executive recruitment andselection. Placing adequate emphasis on merit and on leadership ability during recruitment andselection is essential. Often in the health system the best clinician or technical person is promoted,which does not ensure either management or leadership capacity. More emphasis on how toidentify leadership in recruitment and selection processes is needed.Making leadership development more ‘real’Senior management should present some parts of leadership programs themselves and shouldchampion and actively reward participation in programs. Through the interaction andengagement of the senior managers with the participants and the real world experience they canoffer, the accessibility of the training is increased and the transfer of learning is better facilitated.Leadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 16

Building ‘engaging’ leadershipTraditional cultures within health have encouraged and supported ‘authoritarian enterprise logic’,top-down hierarchical approaches and ‘heroic’ leadership styles. Respondents suggested theneed to centre the focus of leadership development on emotional awareness/intelligence,capacity to build trust and relationships, and leading by influence instead of positional authority.Health leaders are generally very good at consulting with stakeholders when introducing changebut poor at engaging with the people within the organisation who will have to implement thechanges, namely the staff. If staff are not consulted, given ownership of an initiative, andencouraged to see the meaning behind what they are being asked to work towards, they will notbe engaged and the change will not occur. The simple act of recognising staff as a keystakeholder will lead to an improvement in how they are treated and regarded. Clearly,communicating a shared vision and creating a sense of urgency are also central to engaging staff.An overemphasis on the use of financial incentives was suggested to be the result of amisunderstanding of what really motivates professional workforces. Leaders need to understand thepower and importance of intrinsic motivations such as intellectual stimulation, recognition andmeaning in work.Close the gap between leadership development and service improvementPrograms should link leadership development with efforts to improve the core business of health—the quality and safety of patient care, prevention, promotion and support. In such a programleadership teams are taught the leadership skills required to deliver small but meaningful change inthe form of a local service improvement in their organisations. These programs help staffunderstand the underlying issues of improvement that the change is attempting to address, andclearly demonstrate that the change is not just for political reasons. Development programs canalso help increase user engagement by incorporating patient stories and using the language of thepatient journey to shift the focus from process and corporate outcomes to health status outcomes.Build evaluation into change effortsLeaders need to be taught how to build measurement and evaluation into change programs toinform change efforts and ensure that the reporting of this information is as transparent as possible.This also promotes confidence, knowing that the potential for change efforts to do harm will bemonitored and acted on. This can address some of the change wariness noted earlier.Support the transfer of learning back to the workplaceThere is a need to ensure that there is support back in the workplace for the expression ofleadership skills. It is suggested that there is often a lack of community and upper-managementsupport for leaders who have to lead against the tide and that this must be addressed. Leadersoften leave development programs energised, committed and passionate, but they are sometimesworn down by the lack of support from their colleagues and senior managers and the culturalLeadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 17

arriers within the organisation. It was therefore suggested that ongoing support for health leadersis necessary to increase persistence and courage in the face of inevitable resistance. One way thatwas proposed to provide this support was the creation of communities of support, which wouldenable leaders to engage with each other as both teacher and student and to exchange andlearn from experiences. It was suggested that within such communities learning accelerates andinnovative practices develop and spread rapidly.Build connections across boundariesLeadership development activities could be planned to include people from across thegovernment, non-government and private sectors in health, crossing professional silos, jurisdictionsand even industries. Importantly, stakeholders suggested that joint leadership developmentopportunities for those in policy/head office positions and those in the clinical and service deliveryparts of the system may assist in stitching the system together more collegially.Stakeholders also suggested that developing and piloting a leadership program for leaders fromMedicare Locals and hospital networks based around working together to develop improvedclinical pathways and better models of care (particularly for those with chronic disease) couldreduce the divide between the primary care sector and the hospital sector and pave the way forbetter integration and leadership across the continuum of care.There are existing examples of how this can work in some jurisdictions and these could be usefullyrolled out nationwide.MentoringReturn on investment should be increased by complementing leadership development withmentoring opportunities.Offer incentives to participateThe importance and value of leadership development is not embedded in the culture of health tothe same extent as it is in other industries, and people perceive it as a sign of weakness to needtraining in leadership. There is a need for incentives to participate, such as articulation of leadershipcourses with postgraduate diplomas or certificates or other qualifications to increase the perceivedvalue of the training and to get more people involved.Thinking in systems termsLeadership development needs to assist the workforce to think in systems terms and buildawareness of how the various parts of the complex system work together currently and how theycould be made to work together better in the patient’s interest.Training in political astutenessOnly one jurisdiction in Australia currently offers training in political astuteness within its leadershipdevelopment programs, through a course to senior leaders called ‘Strategic Communication’.Leadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 18

An additional solution offered is collaborative leadership training involving both senior governmentofficials and health provider leaders. Participants suggested that this would encourage apartnership attitude among policy makers and health leaders and would help government officialsbetter understand the operational issues facing health leaders. Another suggestion is theintroduction of a program similar to one used by the UK National Health Service (NHS) in its TopLeaders Program, called ‘The Westminster Experience’. This program allows senior leaders of healthsystems to present to mock committees. A scenario is played out where something has gone wrongin the organisation and the senior leader is held to account by a very challenging all-partycommittee formed of Members of Parliament, ex-Members of Parliament and ex-Ministers. Thisprogram is a strong introduction to the political domain and teaches senior leaders to be clear andwell briefed when speaking with politicians.Ethical use of expert powerLeadership development courses need to have a focus on encouraging the ethical expression ofprofessional influence and power in the public interest.It was also suggested that the term ‘professional’ be redefined to incorporate the ethicalexpression of influence. To achieve this, it was recommended that clinical leadership developmentat all levels should tap back into the core ethical qualities that were once found in the norms andvalues of traditional professionalism.Rebuild the prestige and profile of health leadersThere is a need, it was suggested, to rebuild the prestige of, and respect for, formal healthleadership positions, regardless of whether they are taken up by people with clinical, financial,organisational development or management backgrounds. This would hopefully increase thequality and number of people willing to step into formal leadership roles.Training in effecting culture changeLeadership development should be tied to, and promoted as, the means to improve culture. Toeffect successful culture change, leaders should be trained to:unrelentingly communicate organisational goals, values, beliefs, rewards and expectedbehaviours from top downcreate linkages and alignment between individuals’ actions, motivations and values, and theorganisations’ values and beliefsconnect with followers through effective communication, and instil trust.Specific recommendationsAll health professionalsLeadership training is required in all professions. Changing models of care and changing scopes ofpractice require that all health professionals develop the capacity to lead when the circumstancesLeadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 19

equire it. Having a deep multidisciplinary pool of leadership and management talent will enrichhealth system capacity. Additionally, health professionals should be encouraged to lead acrossprofessions, not just within their silos.Leadership training programs should be multidisciplinary. Leadership development should beconducted in multidisciplinary groups. Stakeholders suggest that interprofessional education inAustralia is weak and not taken seriously. Interprofessional leadership training can contribute tobreaking down professional silos and the issues that are caused by these current divisions in thehealth workforce, fostering a greater understanding and appreciation of the roles of other healthprofessionals. The earlier this interprofessional education occurs in health professionals’ training, thebetter.Embed leadership development into undergraduate and postgraduate training. Respondentsexpressed strong and consistent views about the benefits of embedding leadership developmentin undergraduate and postgraduate training. They suggested that this early development shouldinclude education in the ethical use of influence by the professions. Leadership developmentneeds to be ‘hardwired’ into undergraduate, postgraduate and continuing professionaldevelopment (CPD) efforts of all disciplines.CliniciansWe need clinicians to be better at leading, rather than placing more clinicians in formalmanagement or leadership roles. The lack of engagement of clinicians in leadership behaviourswas noted as a significant concern for the system. Clinical leadership, however, should not just beseen as only putting clinicians into management positions. It is about getting clinicians involved indecision making and giving them the skills to positively influence their colleagues by promotinginnovation and change (clinically and in systems) and ways of working that support better clinicaloutcomes. Embedding leadership development in quality improvement, safety or lean health caretraining would go some way towards rectifying the misconception that clinical leadership is aboutplacing clinicians in formal leadership positions and would promote leadership development assomething that has the potential to support improvements in service delivery.Engaging clinicians in leadership and management development is vital because:approximately 80% of the opportunities to save costs lies with clinical decision makersissues that arise in health care are normally caused by a lack of leadership or managementskills rather than a lack of clinical skillssenior clinicians deal with budgets and scarce resourcesmany very senior clinical leaders have little if any skills or training in leadership ormanagement.A separate but related issue is the practice of selecting clinicians without experience or training inleadership or management for formal leadership/management positions.Leadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 20

These clinicians are selected based on their clinical skills and content knowledge rather than theirleadership and management qualities and skills. There was unilateral support by interviewees for areappraisal of this process, as they believed it can result in severe financial and non-financialconsequences if not carefully managed.It was a shared view that while an understanding of clinicians and what it means to service patientsis beneficial when managing operations, there is no need for formal leadership or managementroles to be filled exclusively by doctors, as managers from non-clinical backgrounds can readilyobtain these skills on the job. One interviewee noted that the findings of focus group testingindicate that managers with a clinical background start at a lower leadership competency basecompared with managers with a business background.The overriding view was that there is not one answer to whether health organisations needclinicians in formal leadership roles or non-clinician managers who understand clinicians andservice delivery; it appears that health organisations need both.Senior leadersGroup development. It was suggested that the most senior formal health leaders are bestdeveloped as a group using strong relational models rather than as individuals. It is suggested thattraining individuals away from their peer group works well at the levels of middle management andemerging leaders, but not among senior executives. Developing senior leaders as a group allowsthem to:come up with group solutions to organisational problemsget buy-in around what is required of them as a collectivehold each other to account, thereby improving accountabilityget to know each other—district managers have often never been in the same room beforeleadership developmentbecome more aware of collective strengths and weaknesses and identify what is workingand what is not.It was suggested that linking the most senior people in the health system, across jurisdictions andacross the government, non-government and private sectors could build a more mobile leadershipcadre with deeper understanding of the issues each sector faces and encourage cooperation inthe community’s interest.Ongoing leadership development. The importance of ongoing development for senior leaders wasnoted. A large percentage of senior health leaders have not had leadership development in anumber of decades and as one interviewer said:Leadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 21

We have a lot of people who are in their 50s who have been throughMBAs [Masters of Business Administration] in the 80s or 90s who will stillbe around for the next 15 years or so, but we have stoppeddeveloping them because we look at the younger ones as thepotential. We need to focus on redeveloping these people.Commonwealth staffHealth reform and its impact on leadership development. Most of the leadership developmentinvestment has happened at the state and territory level. It was suggested that as the AustralianDepartment of Health and Ageing moves into more operational engagement with the system, itwould be useful for those officers to be included with state and territory staff in leadershipdevelopment.Directors general and departmental secretariesPeople at this level were seen as a particularly important group for leadership support anddevelopment. It was acknowledged that these people had a need for separate and differenttypes of venues and processes due to the highly political nature of their jobs. The current informalnetworks at this level were seen to need strengthening.Organisational, system and community-level interventionsA number of respondents, acknowledging the broad system determinants of return on investmentfor leadership development, recommended some interventions at the system, organisational andcommunity levels. Most of the interventions are outside the brief for this project and HWA but arelisted below for completeness:charge the Productivity Commission with the task of identifying how best to reduce barriers toproductivity inherent in current industrial and professional demarcations and role delineationstransparently track productivity within and across health organisations and publish this dataincrease transparency through a pricing authority that publishes costs in the system and aperformance authority that publishes performance in the systemwork backwards from consumer and community outcomes rather than forward from existingprofessional silos and demarcations to determine how to best allocate resources to meetneedsauction provider numbers by postcode—under such a scheme, obtaining Medicare rebatesfor a general practice in a highly sought after area would be expensive, while in someregional and remote areas general practitioners might get paid to take up a providernumber; the respondents’ line of argument behind this suggestion is that if generalpractitioners wish to have access to government subsidy, the government should have aninterest in where they practice to ensure the needs of the populace are best servedLeadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 22

governance was identified as being central to overcoming issues caused by vested interestgroups and bringing about the big structural changes needed in the health system—to thisend, it was suggested that Commonwealth and State Governments should considerintroducing an independent health commission that would loosely follow the model of theReserve Bank; the government would provide the health commission with some generalpriorities and guidance and leave the commission to do the restset up systematic processes to consult community members to determine their values andthe principles they would like health leaders to apply to resource allocation, and theplanning, delivery and targeting of health services; these processes could include:introducing citizens' juries—once the jury is informed, it makes great decisions onvalues and priorities, which strengthens the arm of politicians to take the right actionintroducing patient experience surveys that extend beyond quality- and safetyrelatedquestions (such as ‘were you happy with the quality of care provided?’) toquestions that seek to improve the user experience (such as ‘what do you thinkcould have been done better?’)creating patient and family advisory councils.An example provided by one participant of a successful user community engagement strategywas this:A group of 100 randomly selected members of a community werechosen to participate in a forum in [Western Australia]. The participantswere asked about their views and opinions on the potential closure ofa local hospital. The Local Government believed the community wouldbe fervently opposed to this closure. However, once they were madeaware of the parameters around how they could contribute to theprocess and the issue was clearly explained to them, theoverwhelming majority of the participants were in favour of the closureof the hospital in exchange for an improvement in services that theyvalued.HWA’s potential roleThis section outlines the potential roles respondents suggested that HWA could play in facilitatingthe development of health system leaders.Senior executive developmentSome thought that the return on investment in leadership development for HWA would be greatestat the most senior levels of the health workforce.Leadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 23

In particular, cross-jurisdictional learning and development would be highly valuable, as a lot ofexecutives are highly mobile and there is a lot that can only be learned from interacting andworking with each other. This would also offer them a community of support and a source ofguidance—two things that interviewees believe are currently unavailable to senior leaders.A model similar to that used in the HEALS (Health Executive Action Learning Sets) program could beused, where participants first decide what they wish to learn from each other and then meet in adifferent jurisdiction every four to six months to visit facilities and institutions and learn firsthandabout the issues being faced in the jurisdiction and how they are being dealt with.HWA could also have a hand in exposing senior leaders to best practice internationally.Additionally, they could bring representatives from health educators, course accreditors andregulators together with senior leaders to discuss the development of future health system leadersand how their respective responsibilities contribute to the level and type of leadership that willsupport the future sustainability of health services and attract and retain the best workforce.Discussions should draw on information and views gleaned from the recent Workplace Innovationand Reform and Rural and Remote consultations.Finally, HWA could play a role in improving the political acumen of senior health leaders. Thevehicle recommended for this could be something similar to The Westminster Experience, whichwas explained in an earlier section of this report.National pool of evidenceIt was recommended that HWA build an evidence base on what works in leadership development,both internationally and in the jurisdictions, and then provide this information to healthorganisations so they can make more informed decisions on the leadership development of theirstaff. In this regard they would be playing more of a facilitative role rather than a directive one. Thecontents of the literature review 12 and environmental scan 13 completed for this project provide afoundation for this work.National evaluation frameworkInformation provided by Queensland, Western Australia, the Northern Territory and the AustralianCapital Territory indicates that the extent and nature of current evaluative effort consists of preandpost-tests of program participants, usually via 360-degree feedback, which do not cover theoutcomes for organisations and systems. In some jurisdictions, trends in ongoing culture and climatesurveys are attributed to the impact of leadership development. These short-term individual12Miller M, Elliott C & Siggins I (2012). Leadership for the Sustainability of the Health System: Literature Review. Reportprepared for Health Workforce Australia by Siggins Miller. www.hwa.gov.au13Miller M, Elliott C & Siggins I (2012). Leadership for the Sustainability of the Health System – An Environmental Scan. Reportprepared Health Workforce Australia by Siggins Miller. www.hwa.gov.auLeadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 24

measures, and the more distal and complexly determined measures of organisational culture andclimate, are not adequate evaluations of leadership development programs. They do not addresssustained change post-program nor do they deal with the complex issues of contribution andattribution.Interviewees who were currently in leadership and management positions felt that the current lackof strong outcome evaluation of the effectiveness of leadership development programs was a riskto their future sustainability.It was proposed that HWA be responsible for developing a national evaluation strategy that couldassess the return on investment of leadership development programs run nationally or by thejurisdictions. This statement was qualified by interviewees who were responsible for the monitoring ofjurisdictional leadership programs and who were concerned that any national evaluation built on—and did not undo—‘the good work that is already happening in the jurisdictions’.National leadership competency frameworkIt was proposed that a national leadership competency framework be developed by HWA toensure that a common language and understanding is shared by all the jurisdictions on whatleadership is and how it is best developed. This framework would outline a single set of leadershipcompetencies for all health professionals based on what all, many, some and few employees needskills-wise.It was suggested that HWA bring together relevant representatives from all of the jurisdictions toenable them to link up the effective aspects of each of these jurisdictions’ frameworks in thenational framework. Queensland, Western Australia and the Northern Territory all use their ownvariants of the NHS Medical Leadership Competency Framework and Clinical LeadershipCompetency Framework (which have recently been built on and incorporated into themultidisciplinary NHS Leadership Competency Framework, released in June 2011). Intervieweesfrom these jurisdictions advised that the national framework should either be based on the NHSframework or at least be compatible with it; that is, it should use a comparable conception ofleadership and similar language and terminology to ensure it is adopted by these jurisdictions.Finally, it was recommended that HWA include all the professional, regulatory and educationalbodies, as well as patient representatives, in the process of developing the framework.Integrating the national frameworkThe following strategies were recommended to ensure the National Leadership CompetencyFramework is embedded in health organisations by the jurisdictions:work closely with the education sector to incorporate the competencies into pre-registrationand post-registration clinical professional educationemphasise the importance of selecting graduate trainees who display the competenciesLeadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 25

encourage the jurisdictions to use the framework to inform the selection of seniorleaders/managersuse it in the design of all leadership development programs.Link the leadership framework with outcomesThe importance of making the framework outcomes-based was stressed. In particular, it wasrecommended that clinical improvement, quality and safety, culture change and patientexperience topics be embedded in the content of leadership development programs. In this wayleadership development is refocused on the core business of health organisations. An example ofthis linkage was provided by a senior employee of a health department, who stated that all ofhis/her leadership development works from the following equation—leadership affects culture,which affects teams, which affects performance and outcomes. It was advised that HWA shouldmake the link between leadership and outcomes very clear.Aboriginal and Torres Strait Islander leadership developmentHWA was considered to be well positioned to play a role in developing Aboriginal and Torres StraitIslander health leaders. Only two jurisdictions, Western Australia and the Northern Territory, offerleadership development that is specifically for Aboriginal and Torres Strait Islander people in thehealth workforce. The lack of available evidence on what works and what does not when it comesto Aboriginal and Torres Strait Islander leadership development would make this undertakingchallenging. It was therefore suggested that a good starting point may be to promote the workdone by Western Australia and the Northern Territory in other states and territories and evaluate it inthe health sector.Building understanding of the importance of leadership and management in thehealth systemIt was noted that health system leaders and managers are often used as ‘punching bags’ by theprofessions, the media and politicians. This does not make health service management andleadership an attractive destination for the next generation or contribute to the retention of thecurrent generation of leaders. HWA was seen to have a potential role in working with keyprofessional associations to build a better understanding in the health system and in the communityof the contribution of sound policy, management and leadership.Assisting in leadership development in new structures under health reformHWA could assist nationally by working with the jurisdictions and other stakeholders, such as theAustralasian College of Health Service Management, to build governance and leadership supportfor emerging organisational forms (Medicare Locals and Local Health and Hospital Networks) undernational health reform.Leadership for the Sustainability of the Health System: Part 2 – Key Informant Interview Report Page 26