You have been appointed as the head of a clinical department. You don’t officially transition into the role for three months, but already you are receiving advice from the other leaders on how you should lead. Your predecessor stresses how important it is for you to get along with everyone. A respected physician at the hospital tells you to establish yourself early; “walking into a room should raise the hair on the neck of every administrator”. Is it possible to reconcile these two bits of advice that seem entirely contradictory?

Thousands of books have been written on leadership, so the following comments are unoriginal, but are based on one approach and personal experience. Leadership involves and requires certain skills. While some individuals may have natural abilities, contrary to popular belief, leadership is teachable, and with the right teaching can be more effective (I will be writing more on the subject of Leadership Development in an upcoming post). The main point of this post is to alert the clinical leader that there is something called “leadership style” and that leaders need to make explicit decisions, not just about how they want to lead, but also how they wish to be perceived to lead.

The definition of leadership that guides this section is as follows: leadership is the recognition of the need for, and the ability to effect, positive change. Leadership is not about the position. It is common for clinicians to assume that only with a title can individuals lead – the corollary of this assumption is that with a title comes the automatic ability to effect change. The reality is that leadership does not require a title, and seldom does a title routinely create the ability to change. Given the definition of leadership provided above, anyone can lead at any time, with or without a title. While much of what follows relates to leaders in formal positions, the same principles apply to leaders without a specific mandate.

Most change comes from influencing people, not from authority. Authority is defined as the power to give orders, make decisions, and enforce obedience. Change requires convincing people that change is needed, and then the (more difficult) task of getting them to actually change their behaviour. While leadership positions come with some element of authority, seldom should leaders assert that authority. Authority should only be used when all attempts at influence have been unsuccessful AND the change is vitally important. Consistent use of authority without influence will almost certainly lead to disenfranchisement of staff and resistance to change.

Leadership positions also come with formal responsibilities. These responsibilities, along with the occasional externally-mandated change, more than occupy most leaders. While some leaders are actually harmful to their organizations, the majority of leaders just fulfil their responsibilities and no more.  Such leaders are called “transactional” leaders. Relatively few leaders search for change beyond their explicit responsibilities, recognize the need for and effect that positive change. Such leaders are called “transformational” leaders. Given the requirement for enormous energy and relentless commitment to the change, it is not surprising that few leaders are truly transformational. The intent of these posts is to encourage leaders to seek positive change and truly transform their groups and institutions.

Leadership style reflects how the leaders generally plan to lead and are perceived to lead. There are innumerable descriptions of leadership style. For example, ‘Authoritarian’ leaders use strict control and regulation. ‘Paternalistic’ leaders expect followers to be totally loyal and committed. ‘Democratic leaders’ share or delegate decision-making to the group. ‘Laissez-faire’ leaders have no explicit leadership direction. ‘Transformational leaders’ set clear direction and inspire individuals to follow. While different situations require different approaches, clinical leaders should always aim to inspire, provide clear direction and insist on accountability for positive change.

As a starting point, leaders need to decide whether their leadership will be largely one of collegiality or confrontation. Again, while each style may have its place based on the specific situation, one or the other in large part will predominate. Perhaps the phrase “nice guys finish last” has influenced many leaders. A better phrase might be “you catch more flies with honey than vinegar”. While both styles have been used with success, human nature generally responds best to positive reinforcement. While not all individuals in healthcare respect goodwill, surprisingly most do. Given that most change comes from influence, collegiality is almost always the more effective approach.

So, if you decide to lead and be seen to lead in a transformative and largely positive fashion, how do you achieve that approach? The posts that follow provide tangible and multiple strategies to achieve your leadership style. However, one important step in leading is to determine how decisions will be made and the criteria for those decisions. Decisions are largely influenced by values. Thus, decision making in groups is determined by who is being affected by the planned change and their individual values. Any decision is likely to affect members of the group differently. Even if the entire group is outwardly affected in the same way, their individual values will differ. Decisions also often involve competing values, such as should leaders improve quality or reduce cost? Leaders need to devote enormous efforts to learning those values. Constantly asking, why? The goal for the leaders is to align group decisions with the vision and mission of the institution (more on mission/vision in a future post). This latter approach articulates who and what interests should be protected, and thereby has the potential to drive decision-making more objectively.

Three rules below not only provide a framework for decisions, but also provide the process and intended outcomes of those decisions.

1. The principle by which decisions are made – do what is best for patients.
2. The process by which change is affected – team work and collegiality.
3. The outcome of decision – do what we say we will do.

While these three rules can drive many decisions, staff are not considered. Thus, after patients are established as the priority, the next most important group is staff. With that obligation to staff, comes an obligation of the staff to the institution. From this we can formulate two additional guidelines for decision making.

4. The intent and responsibility of the hospital (including the Division Heads/Department Chiefs and Managers/Directors) – to create an environment that optimizes the success of the staff in all the endeavours. “Our job is to make you successful”.
5. As members of the hospital, the staff pledge – to fully engage in, participate in and contribute to the goals of the institution as active members of the hospital. “We are the hospital”.

You may want to adopt or develop your own rules, but such “rules” should be widely circulated and constantly used in making decisions, and used to influence staff to accommodate changes.

Finally, one of the hardest parts of leadership is finding the dividing line between principle and pragmatism. Said another way, how much should a leader bend the rules to achieve a goal? More on this later, but when confronted with such dilemmas, consult trusted advisers and seek ways to achieve goals without compromising principles. Finally, leaders should always avoid personal gain and never compromise on Rule 1.

In summary, leadership is about effecting change. Leaders need to make explicit decisions about their predominant style. Leaders should aim to be transformational, positive and transparent. While discussed more in a subsequent post on Change Management, affecting change requires relentless and exhausting energy, adapting, and constantly improving strategies to get individuals to change their behaviour.