Healer Vs Leader--Determinants & Deterrents of Clinician Leadership in Indian Healthcare.
| Author | Raju, Prageetha G. |
Introduction
Leadership is known to exist since ages, with a tremendous influence on human performance across different sectors. Yet, it remains pretty much of a 'black box' because its inner working cannot be precisely spelled out or defined.
Let us examine the healthcare sector as a case-in-point. According to Daly, Jackson et al (2014), in the developed world, hospital care is often threatened by dynamic consumer demands, workforce challenges, financial constraints, increasing demand for access to care, patient-centric mandates, and issues relating to quality and safety standards of healthcare. Physicians/Doctors, who are masters within healthcare, should balance changes in the industry along with new demands to effectively lead teams. Long established leadership beliefs now stand to change for physicians and other healthcare professionals as team based approach is becoming more necessary to be effective. What may have worked in the past may not be successful today, thus, changes in leadership styles calls for a study. While Yukl (2012) asserts that good leadership is becoming increasingly obvious within healthcare, Mcphee, et al (2013) found that effective governance is a critical means for managing hospitals and these findings laid the foundation for leadership in hospital settings.
Given that India is experiencing 2225 % growth in medical tourism and the industry doubled its size from April 2017 (US$ 3 billion) to 2018 (US$ 6 billion), it is however essential that physicians and other healthcare professionals don the role of leaders besides healers (IBEF, 2019). New laws and regulations in the healthcare industry characterized by care coordination and payment models, novel methods of treatments to patients, and the capacity to work together is making team-based leadership styles necessary to be effective. To embrace these changes, leaders in healthcare need to focus on relationships (La Bier, 2014) and empathetic listening (Riordan, 2014). To achieve this, decentralized structures, and team approaches should be fostered through new work designs enabling executives to exercise informed judgements.
The question to ponder here is : do great doctors become great leaders too? Since leadership in healthcare began vigorously moving towards teams, the question crystallizes: does the image of a leader collide with the image of a healer? Siriwardena (2006) and Smith et al (2012) highlighted the importance of effective clinical leadership to ensure a high-quality healthcare system, but, very little is known about how medical leaders lead.
Background
For the present study, the leadership context is clinical integration, which calls for linking of physician and hospital efforts to achieve common healthcare delivery goals based on meta-leadership. The idea is collaborative problem-solving because problem solving and decision-making calls for facts and facts do not concentrate at one place. It follows a continuum from known to unknown. To know the ambiguities and factors facilitating/hindering the decision-making and problem-solving that clinician leaders face, it is essential to assess the leadership styles and explore the context of the leadership.
A formal discussion between the author and the Managing Director (MD) of a 30-year-old premier corporate hospital in a South Indian city highlighted the need to assess the leadership styles followed by the healthcare professionals to promote team leadership style given the above changes in the environment. The author was asked to use Managerial Grid by the hospital management. Therefore, the present study assesses the leadership styles and presents it through theoretical inputs and supplements it with practical recommendations.
Profile of the Hospital under Study
The hospital belongs to private sector and is a trendsetter in bringing medi-care of international standards within the reach of every individual. It has 50 super specialties under one roof. This hospital is unique for its best doctors, paramedical staff and services, and nurses, state-of-art infrastructure which can match world class equipment, personal care to each and every patient, treating every employee as a family member and providing utmost value for money to every patient. The golden rules of the hospital are: 'customer/patient comes first', 'doctors are the best managers', 'demand value for money', and 'uncompromising service quality'.
Objectives
Given the above, the objectives of the study are to:
Assess the present leadership styles of healthcare executives at all levels.
Explore the determinants and deterrents causing/affecting the leadership style.
Recommend guidelines and interventions that should be adopted to reach the appropriate style.
Scope of the Study
The study is conducted on healthcare executives across levels in a single corporate hospital. In this study, the term 'healthcare executive ' means doctors holding a senior managerial role as well as non-doctors playing an administrative role in a clinical setting. In the hospital under study, it is observed that doctors play two leadership roles: (i) a senior clinician with responsibility for supervising a clinical team delivering patient care, and (ii) as part of the managerial structure of the healthcare organization. The doctor may use different leadership skills in these two roles, and here, only the non-clinical role is examined.
Sample Size & Sampling
Stratified random sampling is used and a sample of 100 respondents is chosen from all levels of clinical and non-clinical executives, i.e., from Junior Executive to General Manager and all Physicians, i.e., from Residents to Consultants.
Research Instrument & Data Collection
In-depth semi-structured interviews and Managerial Grid Questionnaire with 50 items are administered. The questionnaire was piloted prior to distribution. Secondary data is obtained from research papers, job profiles of the incumbents, and health sector reports.
Semi-structured interviews were verbal and face-to-face but recorded with respondents' permission. It had many aspects broadly relating to three main questions viz.,
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What is the context for leadership for physicians to be leaders within health systems?
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How do physicians make a transition into leadership roles? Is it a conscious decision or is it dictated?
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What are the perceived benefits and drawbacks of being a physician leader within health systems?
All the respondents were requested to attend two half-day sessions in the hospital premises to learn about the study. Questionnaires were administered during the same time followed by semi-structured interviews; informed consent was obtained in writing. Thematic Analysis is used to derive insights from semi-structured interview data.
Data Computation & Analysis
Managerial Grid Questionnaire was administered and percentages were drawn. Table 1 consists of grouping based on organizational hierarchy and Table 2 was prepared with 6 columns, viz., Designation, Country club, Team, Task, Impoverished, and Middle Road indicating different categories of employees in different styles. Table 2 serves as a basis for further qualitative analysis coupled with information from interviews and job profiles. Job profiles were compared with the leadership style they were following in order to assess its efficacy and compatibility.
The responses elicited from semi-structured interviews were categorized into 9 broad themes using thematic analysis in three steps, viz., (a) Iterative Review (b) Design Analysis and (c) Design Synthesis. Analysis is through the transcription, along with the repeated listening of interviews for a deeper understanding of what the respondents described. The key themes began to emerge even before thematic analysis began. Points of discomfort were expressed by the respondents with respect to donning the leadership role, the subordinates' behavior, the culture of the organization and so on for managing their condition as well as opinions and experiences of the transitional role. But, the author avoided personal interpretations of the motivation behind the responses and also evidences displayed by the respondents. Only, data in the form of direct evidence, such as a quote, or an action is used and written on separate slips of paper and is pasted on the author's desk. Reference to the interview is done using a code (e.g P01). The slips are then grouped, and sorted into various themes.
Limitations
Questionnaire was too simple for the respondent to place himself under Team Style whether real/unreal, thus, the session led to copying and chatting despite author's appeals to work seriously and independently. Questionnaires are administered at a stretch in a group, therefore, focusing/ probing were not possible; some respondents answered it perfunctorily calling this exercise a farce. Sole reliance on job profiles vis-a-vis unstructured interviews and then comparing it with leadership styles probably led to bias; the hospital authorities didn't permit the researcher to use the plotted managerial grid for public use.
Health Sector in India
Healthcare industry comprises hospitals, clinical trials, outsourcing, telemedicine, medical tourism, health insurance, medical devices, and equipment. Weberg (2012) asserted that healthcare organizations (HCOs), with hospitals at the forefront, are large and complex contemporary organizations, owing to their advanced procedures and different resources.
In India, healthcare delivery system is provided by public and private agencies. The government/public healthcare system is limited with secondary and tertiary care institutions in key cities and rural areas providing basic healthcare facilities through primary healthcare centers (PHCs); the private healthcare system provides majority of...
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