Groundbreaking ideas and research for engaged leaders
Rotman Insights Hub | University of Toronto - Rotman School of Management Groundbreaking ideas and research for engaged leaders
Rotman Insights Hub | University of Toronto - Rotman School of Management

What makes an effective leader in healthcare?

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Brian Golden

From his years of experience, Professor Brian Golden is emphatic about what makes a successful healthcare leader: “I’ve never seen a high performing health system that didn’t have significant clinical leadership,” he says. Whereas 30 years ago clinicians who transferred to management roles might be accused of moving to the "dark side," today doctors and other clinicians know that the system is driven by multiple stakeholders and complex dynamics — finance, regulation, human resources, etc. "They need someone who can speak their language, who is on their side [in a leader]."

“There is a bit of ‘trust edge’ when clinicians are in leadership roles, because they have been socialized to the end purpose, to the meta purpose — which is to use resources as effectively as they can to care for patients,” asserts Golden. It’s not so much that clinicians who convert to management roles have special medical knowledge, but more that they have the credibility as people who understand the nature of the profession. Leaders with clinical credibility are more able to be influential in healthcare organizations and as system leaders than those coming from outside — though there will always be notable exceptions.

Otherwise, the characteristics that make a successful healthcare leader are similar to those any leader in a complex, multi-stakeholder environment must possess—critically, the ability to lead through persuasion and influence, rather than through exercising top-down power. (The latter doesn’t work since most hospital-based physicians aren’t employed by the hospital.) Healthcare leaders must have the ability to actively listen, see alternatives, negotiate and resolve conflict.

Much recent thinking around leadership focuses on organizational culture and the need to prioritize values and purpose. Leadership at all levels with space given for individualism, creativity and innovation are widely embraced in progressive organizations today. But do healthcare leaders have time for these things, when they are consumed with technical issues and concerns — operations, finance and risk management?

Golden has a clear view on this: “We tell our healthcare program participants that we’re not training you to be the chief financial officer, the chief risk officer or the chief information officer; what we’re training you to do is to understand what those people do, to ask them tough questions, and not get the wool pulled over your eyes.” It’s the leader’s role to set the strategy, to establish the mission and the values of the organization and to select trusted people who have the technical expertise and ensure that the job they do is aligned with the organization’s goals.

He sees it as a three-tier pyramid. The broad base represents technical skills — finance, accounting, etc. The next tier, and less common, are critical interpersonal skills. The final peak of the pyramid is conceptual — the ability to see the organization and system as a whole and influence its design and progression. As Golden puts it, “having the ability to not only see all of the moving parts, but to see ways of reconfiguring them. That’s a rare skillset.”

In a busy, highly regulated healthcare environment, innovation, creativity and critical thinking may be somewhat constrained, but to meet the demands of a fast-changing world, they are really important and a key leadership priority. There are hurdles to be crossed and innovation may be slow, but it’s essential. “Healthcare, for the right reasons, is risk-averse,” says Golden. “If our system is designed to — and currently is — saving lives, we don’t want to put that at risk when we make changes. However, unless we innovate, we’re going to save fewer lives, because the demand is growing quickly.”

State-funded healthcare systems, whether in Canada or the U.K., have been very paternalistic for many years. The typical approach, observes Golden, was historically “as long as we get you better, we don’t have conversations about the quality of your life or whether you would be willing to give up three years of uncomfortable life for a shorter, comfortable life.” Today, greater focus on patients has prompted the real innovation of appreciating multiple dimensions of success in healthcare.

In a world characterized by rapid technological, demographic and social change, healthcare organizations are in a constant process of managing change. Historically, planned change was most common, but today we are seeing a greater need to lead unplanned change. “With planned change, we understand what we’re aiming to accomplish and the gap between where we are and where we want to be. Then it’s about formulating a vision that aligns with people’s values, selling your idea and creating incentives to motivate people. It’s important to note that if you want new results, you not only have to excite people to get on your side, you also have to create a supportive environment, which means ensuring people have the necessary capabilities and the right technology.”

It takes a very different kind of leadership to lead through unplanned change — where, as during the pandemic, there is no rule book. “This is more about the leader keeping people together and pushing decisions back to people closer to the problem,” suggests Golden, “managing their stress level — allowing them to be sufficiently stressed that they are willing to change, but not so stressed that they get frozen in position.” It is then about providing resources and ultimately, making decisions based on experimentation. Here, the approach is, "we’ve never done this before; we’re going to try it on a smaller scale and if it works, go through rapid cycles of innovation."

Artificial intelligence is already and will, in future, offer huge benefits for healthcare delivery, and Golden is an enthusiast. “What AI is trying to do is harness the expertise of the best and provide decision support. AI may not be better than the best radiologist or oncologist, but it will be better than the average clinician in these specialties. It’s not going to lead surgery, yet, but will develop the path.”

The first use of AI was in image matching and diagnostics. More recently, during the COVID pandemic, it was used to help governments make policy decisions about who were the highest risk cases. There is clearly a long way still to go before the technology fulfills its potential.

All organizations are grappling with virtual versus in-person activity. “We do believe the in-person learning and interaction and relationship building is absolutely critical, for the vast majority of learning opportunities, whether it’s site visits to Kaiser Permanente, or IDEO in California, or the NHS in the U.K.,” states Golden. “But we take the view that we don’t need you to travel from all over the world just to sit in a classroom. Our program participants’ time is precious, so time in the field with leaders and their organizations is incredibly valuable.”

Over the years Golden has seen enormous changes in both the way healthcare systems work and in the medical treatments that have become available as well as what research-based concepts of leadership are taught to students — all of which continue to be constantly changing. 

“I started out in the mid-‘80s working in this field,” remembers Golden. “It was a very simple world, though we didn’t think so at the time. Now, there’s so much more we can do for patients, which means the choices are tougher and our responsibilities are greater, from every perspective.”

This article was originally published on the IEDP website. It was also published in the Spring 2023 issue of the Rotman Management magazine.

Brian Golden is a professor of strategic management and the Sandra Rotman chair in Health Sector Strategy at the Rotman School of Management.