Fellowship Program in Health System Improvement: A novel approach integrating leadership development and patient-centred health system transformation

Leadership development theory and pedagogy

While there is a rich literature on leadership theory, much less attention has been given to leadership development theory and even less to the effectiveness of different leadership development approaches. In a recent review of leadership development, the King’s Fund makes the case that a culture of continuous improvement is most influenced by leadership practices, but there is little evidence on the effectiveness of leadership development programs. ⁶

The underlying philosophy for the new Fellowship program is that focusing on leadership development must be tied directly to desired heath system transformative change. In developing the Fellowship program, consideration was given to emerging trends in executive education. McNay notes that executive education must take people well beyond their internal management responsibilities and place a greater focus on the external environment. It must provide a leadership development experience that prepares people to deal with an uncertain future. This requires knowledge of the various parts of a business, understanding the interaction among the parts, and the capability to sense new trends, relationships, and opportunities. Programs that focus on action learning have shown promise. ⁷ This same point was made in an article in the Economist arguing that executive education has to do more than inform—it has to change the way things are done. Executive education that places emphasis on the use of action learning to energize debate within a group is a growing trend to accomplish this. ⁸

The King’s Fund report noted above lends support to an approach that incorporates a broad system view, a variety of teaching methods, action learning, and a heavy emphasis on working in teams across disciplines and organizational settings. There are three design features of the Fellowship that distinguish the program from others: program perspective, drivers for health system performance, and critical processes to guide the program.

a. Program perspective—Four overriding perspectives guide the program:

a system-level focus that goes beyond efficiency and effectiveness to include how the health system contributes to the health status of the population;

Each one of these drivers forms the basis of a weekend session theme along with an introductory “big picture” theme that traces the evolution and underlying values of the Canadian system, the importance of social determinants of health in transformative change, and the performance of the Canadian system relative to other countries (Figure 1). The final weekend session theme is on health system transformation where each group presents its action learning project.

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Figure 1.

Conceptual framework for the fellowship program.

The Fellowship program integrates several different approaches to learning over a span of 9 months with 6 intensive weekends that alternate between Banff and Edmonton. The sessions involve interaction with leading researchers, persons who have held significant leadership roles, and current leaders in the Canadian system and from other countries. The list of speakers used in the program for 2016-2017 is included in on-line appendix A.

Both plenary sessions and discussion sessions are used. Participants are placed in four groups to ensure a diversity of provincial experiences, professional disciplines, and roles in the health system. Each group is guided by a mentor who has had significant leadership experience in the health system and academic mentors with strong methodological expertise in health systems and health policy research. Mentors collectively bring experience in roles as deputy minister, chief executive officer, assistant deputy minister, health agency vice-president, professor, and research leader.

The International Ideas Marketplace is a key component of the weekend sessions and has been included to stretch the thinking of participants beyond what is currently happening in Canada. On a rotational basis, each group reviews current literature on the module theme from one of the reference countries—Australia, the Netherlands, New Zealand, Sweden and the United Kingdom—to identify ideas and strategies that should be considered in Canada. Of those countries, only Australia has a federated political system like Canada. However, the evolution in the two countries has taken different trajectories since the formation of the federations. ⁹

A Leadership Health System Transformation Prospectus is created by each group as a culminating step for each weekend session to integrate learnings from readings, speakers, and group discussions. The intent of this prospectus is to advance a strategy to improve performance of the Canadian system by identifying critical implementation steps and the leadership imperatives to make this happen.

An integral part of the program is the LEADS reflection, which is done on an individual basis with the mentor. The process starts with the LEADS self-assessment ¹⁰ that identifies each person’s leadership strengths and developmental needs. Following each weekend, a conversation takes place with the mentor on how the participant is using knowledge and skills gained in the program to apply new approaches in their leadership within their current work setting.

Prior to each weekend session, a list of required readings is made available. Given the busy schedules of program participants, most of the assignments are designed to be completed during the weekend session. The exception is the major Action Learning Project carried out by each group over the duration of the program.

The Action Learning Project provides an opportunity for each group of participants who have diverse backgrounds and career experience to undertake a transformative project linked to the Change Agenda. The project is undertaken over a span of 8-9 months and must have at least one sponsor organization that appoints an executive leader to guide the project and commits to having the project presented to its senior leaders in that organization. It is intended to develop strategies including leadership requirements and initial steps toward an implementation plan that will provide a transformative approach to a real-world issue. These projects must take a big system view and involve at least two sectors that impact health status/outcomes, including sectors outside the conventional health system that will integrate learnings from the program. The four ALPs in 2016-2017 and the sponsoring organizations were:

embedding a palliative approach into Alberta’s Primary Healthcare (Alberta Health Services);

All of these projects (on-line appendix B) were transformative in that they put forward approaches that were major departures from the current practices and took a broad health system approach noting changes that should be made in several parts of the existing system. In all cases, the sponsor organizations have responded positively to the recommendations contained in the final reports and provided indications of intent to incorporate many of the ideas into follow-up strategies. On-line appendix B provides an overview of the four projects in the past year. For the coming year, each of the four ALPs incorporates a person-centred approach, with one specifically looking at patient engagement in the development of performance measures.

All resources and communication for the program are made available using the learning system at the University of Alberta, known as eClass, and each participant is encouraged to develop a portfolio of their work using Mahara software, a support learning system that allows individuals to record all their work and allows for the sharing of information among participants.

Through a strategic alliance with the Canadian College of Health Leaders, participants who complete the program and become Fellows can pursue an accelerated track to achieve their Certified Health Executive (CHE) designation. For persons already holding the CHE designation, the strategic alliance provides an opportunity to use the ALP project as a platform to achieve the Fellow of Canadian College of Health Leaders designation.

The first cohort of the Fellowship program consisted of 20 participants who came from Québec, Ontario, Saskatchewan, Alberta, and British Columbia, including some who worked at the national level. The participants had a broad range of backgrounds both in terms of their roles in the system and professional backgrounds. This included physicians, pharmacists, an engineer, epidemiologist, physiotherapists, and nursing leaders. Roles included persons holding senior positions at the operational levels with health authorities, policy roles within government, regulatory agencies, quality councils, and research organizations