Abstract
This article looks at the current state of health leadership in terms of expectations for professionalism: controlled entry, exit, and licensure/certification; a social contract to provide public services for the good of Canadians; and a unique body of knowledge and practice generally accepted. Looking to the future, and using the same three criteria, a compelling case for pursuing the professionalization of health leadership is made using LEADS as a roadmap. The article also outlines how to realize the professionalization of health leadership in Canada and why it is important to do so.
Introduction
In Roman mythology, the god Janus is depicted with two faces, one looking into the future and one into the past—he is the god of endings and beginnings (note 1). Janus is a metaphor for the task of using past accomplishments to build a profession of health leadership for the future. Three criteria—a unique body of knowledge and practice generally accepted within the proposed profession; controlled entry, exit, and licensure/certification; and a social contract to provide public services—have been articulated as necessary for professionalism. Leadership—in health or in general—is not yet professionalized as other health disciplines are. People who practice leadership referred to in this article are formal leaders who pursue health leadership, management, and administration as a career.
A growing body of research has provided the foundation for the LEADS in a Caring Environment capabilities framework (LEADS) (note 2). This reality, combined with the growing acceptance of LEADS within the professional communities of health leaders across Canada, provides a fledgling foundation for professionalizing health leadership. Using the three criteria of professionalism, this article first outlines why professionalism in health leadership is important, then, like Janus, it looks backward to outline existing trends around the use of the LEADS framework that can be built upon to create professionalism, and finally, it looks forward to show how health leadership, using LEADS as a roadmap, can move toward professionalization.
Why professionalize health leadership?
Why is professionalizing health leadership a progressive and constructive step forward? First and foremost, a professional is someone who possesses knowledge and skill at the highest level in his/her vocation. Second, professions demand the highest quality of performance by their members. Current challenges in Canadian healthcare demand leaders with those attributes. Challenges of fragmentation of service delivery, healthy workplaces, and pursuit of health reform across Canada require the exercise of a modern, sophisticated, and evidence-based leadership. Third, leaders who strive to “do the right thing”—a definition of leadership itself—need the protection that a set of standards for professionalism provides. Too often, government sees cutting administration as the way to save money. The number and quality of leaders should not be subject to the vicissitudes of politics. Finally, health leadership needs to raise its profile vis-à-vis the quality of its service with the general public to retain confidence in the system. The future of universal healthcare in Canada demands that the people who steward it, manage it efficiently and effectively, are without parallel in terms of the quality of their service.
Janus looking backwards: The current state of health leadership in Canada
In medicine and law, the three criteria that are commonly associated with moving to becoming a profession are: (1) a unique body of knowledge and practice generally accepted within the vocational sector; (2) controlled entry, exit, and licensure/certification; and (3) a social contract to provide public services appertaining to the good of Canadians. 1 –3 We deal with each of these in turn.
A unique body of knowledge and practice generally accepted within health leadership: LEADS
Health leadership can be defined as “the capacity to influence self and others to work together to achieve a constructive purpose: the health and wellness of those we serve.” 4 This definition highlights three primary functions of health leadership. First, leadership—and persons in those formal positions—is charged with integrating service across silos and systems, regardless of size or complexity of those systems. Stephen Lewis argued that Canada’s health system is a system in name only and does not operate as systems should. 5 A recent study emphasized that Canada’s health delivery systems are fragmented and need more collaborative and distributed leadership, including an emphasis on physician leadership. 6 Leaders should be integrators. This concept gave rise to the creation of LEADS 7 : it was intended to be a common language of leadership that can help knit together otherwise fragmented health system endeavours.
Second, high-quality leadership is needed to create psychologically healthy and productive workplaces. 8 –10 Better leadership leads to a healthier workforce, and a healthy workforce leads to healthier citizens. 11,12 Effective leadership leads to higher levels of optimism and trust in the organization 13,14 and can contribute to healthy and productive workplaces through positive role modeling and manipulating working conditions. 15 –17 There is a strong relationship between psychologically healthy workplaces and employee turnover. 18 –21 Conversely, unhealthy leaders wreak havoc on any organization’s intent to improve psychological safety and wellness in the workplace. 22,23 They can be responsible for generating increased strain, poor job satisfaction, emotional distress, increased absenteeism, and dysfunctional behaviours at work. 24 In healthcare, the problem is rampant: “Rates of burnout and poor mental health issues among health professionals are high and rising, and rates of absenteeism, illness, and disability are higher in the health workforce than any other worker group in Canada.” 25 LEADS embodies many if not all of the qualities of effective leadership needed to create healthy workplaces. 26
Third, health leadership has the responsibility to generate productive change and reform, so as to improve services to patients, families, and citizens. 4,9,10,27 Leadership is essential for organizational change and for health system change. 28 –31 For example, a 2016 Manitoba government report analyzed the changes needed to create a patient-centred provincial delivery system (Manitoba’s Shared Services uses LEADS). 32 It references leadership 66 times, emphasizing the need for leadership teams (eg, Indigenous health, palliative health, mental health) to steward change. Another recent report outlined the leadership conditions necessary to create a quality and safety culture 33 and showed the LEADS relationship. Additional studies showed the role of leadership in patient empowerment, 34 development of new care pathways, 35 implementation of primary care reform, 36 and engagement of physicians in system reform. 9
The LEADS framework is recognized as the dominant leadership framework in Canada. 37 Preliminary data from a recent benchmarking study commissioned by the Canadian Health Leadership Network (CHLNet) found that 69% of Canadian healthcare organizations are using LEADS. 38 It is increasingly being recognized as a set of standards for the personal, organizational, and systems leadership that is needed to address the above-mentioned challenges. 4 LEADS is helping to cohere a growing number of Canadian leadership development initiatives. It now serves, for example, as satisfying the continuing medical education requirements for physicians in Canada and has been mapped against the continuing education requirements for Canadian nurses. The LEADS framework has been shown to enable leaders to utilize behaviours conducive to healthy workplaces and as a catalyst to meaningful health reform. 10,39 -41 In that context, LEADS provides a research-based springboard to move toward the professionalization of health leadership in Canada.
Controlled entry, exit, and licensure/certification
All professions control entry and exit to their membership. All professions have member associations that control entry and exit to their membership. To protect both public and the profession’s interests, these bodies control certification, licensure, and maintenance of certification, as well as ethical principles to guide behaviour.
Currently, there is no agreed-upon process for controlled entry into health leadership positions across Canada. As the health system is fragmented, so is the process for educating health leaders, each unique in content and format: one can attend Masters of Health Administration programs across Canada, take an MBA with a health stream, or attend related certification courses. Some individuals simply move into a management position by applying for the job and getting it. Formal licensure processes do not apply. Once hired, the only formal accountability a leader has is to his/her employer and followers.
A similar situation pertains from a certification perspective. Traditionally, all members of a profession need ongoing certification as a member within their professional body. What is the case with leadership in Canadian healthcare? There are over 100,000 administrators; but no more than 4,000 of those are voluntary members of the only certifying body, the Canadian College of Health Leaders (CCHL). Of these, approximately 1,500 are certified with the Canadian Health Executive (CHE) designation. Of the estimated total of 85,000 physicians practising in Canada, only 750 are members of the Canadian Society of Physician Leaders. Of those, 200 have a Certified Canadian Physician Executive (CCPE) designation. There is clearly much room for growth here. One might also ask the question as to why the vast number of potential members do not aspire to achieve that certification? The time is now for certification to go from desired to required.
A social contract to provide public services for the good of Canadians
The most important criterion for being classified as a profession is its contribution to the welfare of society. Whereas the Canada Health Act’s provision for healthcare to be publicly administered provides a compelling argument that health leadership is expected to deliver a social good to Canadians, this has not been translated into a formal social contract pertaining to leaders (administrators) who steward the system. 42 Unless referenced in a job description, each of which is individually developed and peripatetic to situation and circumstance, there is no explicit social contract pertaining to the role of those leading the health system. Given the importance of a highly functioning, integrated health system in Canada, it would make sense for that social contract to be explicit in a professional designation, so that everyone in a formal leadership role would know both the importance and the requirements of that role and how that role is shared together.
Looking forward: Professionalizing health leadership
Looking forward, we describe what must happen for health leadership to move from a voluntary practice to an expected professional practice.
Unique body of knowledge generally accepted within the sector
There is a generally accepted body of research and evidence defining the domain of leadership in health, and the LEADS framework reflects that body of research and evidence. It provides the foundation for standards, a performance and monitoring function, and the potential for a graduate-level educational path. It is accepted across the country. But professionalism requires more than knowledge. It is also about the practice of leadership. 1
Like other national frameworks, 43 LEADS provides a Canadian set of standards. Agreement on a set of national standards is key to overcoming issues of fragmentation, creating healthier workplaces, generating productive change, and, in the process, contributing to the development of a profession. 3 Fortuitously, Canada is the only jurisdiction that can claim broad agreement—informally at least—on a common language for leadership that spans health professions and health organizations (note 3). 44 -46 LEADS can be used to build curricula and programs for entry to the profession and long-term professional development. It provides a basis for succession planning, leader selection, and overall performance management. 47
Controlled entry, exit, and licensure/certification
All professions control entry and exit to their membership. For the professions of medicine, nursing, and law, we have independent, member-driven bodies that control entry and exit, maintenance of certification, and ethical principles to guide behaviour (note 4). Such formal bodies do not exist for health leadership in Canada. International examples for physicians exist: the Royal Australasian College of Medical Administrators in Australia is a college dedicated to leadership and medical administration, with controlled exit, entry, and licensure functions. The UK’s Faculty of Medical Leadership and Management also has a set of standards for certifying medical leaders.
From a licensure perspective, there is no agreed-upon entry requirement to the role of health leadership. Some post-secondary institutions in Canada have built graduate and degree programs based on LEADS and are available to doctors, nurses, and administrators (note 5). Much more work is needed across the post-secondary community in order to replicate the positive aspects of controlled entry and standardization of content around LEADS standards.
From a certification standpoint, since 2009 the Canadian Society of Physician Leaders (CSPL) has had voluntary certification based on the LEADS framework (CCPE). Going forward the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada (having just recently changed the CanMeds competency from manager to leader) could collaborate with the CSPL to endorse the CCPE as the appropriate professional designation for physician leaders.
Recently, the CCHL has introduced a LEADS-based CHE Select designation that “intensifies the College’s role in supporting leaders in Canadian health system to define and understand their leadership and the role they play in leading systems change.” 48 CCHL will now build support with university programs and other national and provincial health organizations for this designation. For professionalism to be realized, one or both of these certifications should be required of all health leaders.
A social contract to provide public services for the good of Canadians
Professions reassure the public that those “practicing the profession” meet certain standards pertaining to services relative to the public good. With respect to public trust and professionalization, the former Governor General of Canada, The Honorable David Johnston, recently reiterated the heavy obligations, duties, and responsibilities of practitioners of a profession. He refers to professionalization as both the glue and the grease. Professions serve vital functions that help hold a society together. When trust in a profession erodes, this glue dissolves and society is weakened. To mix my metaphors, professions also serve as grease that help societies function more smoothly. When trust in the profession dissolves, friction results.
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Conclusion
Leadership in health or in general is not professionalized yet, but research and acceptance of LEADS across Canada show that there is a strong research foundation for pursuing it. Professionalization is what the system needs to ensure the quality of its future service. Three criteria—a unique body of knowledge and practice generally accepted within the proposed profession; controlled entry, exit, and licensure/certification; and a social contract to provide public services for the good of Canadians—are in their beginning stages and significantly more work is to be done. Those who aspire to create a health leadership profession will have to exercise the very leadership upon which professionalism can be built, using LEADS as a framework.
