Leading through the ‘new normality’ of health care

Abstract

Health care institutions are witnessing a ‘new normality’, which profoundly reshapes the strategic and management challenges faced by health professionals in their attempt to achieve excellence in the design and delivery of care. This ‘new normality’ triggers a transformation of conventional managing models and leadership styles, which have proved to be unfit with the changed attributes of the external and internal contexts of health care organizations. The ‘new normal’ leadership style relies on the ability of leaders to make sense out of the new challenges that are faced by health care organizations and on their capability to act managerially, sticking to an empowering approach which enables followers. However, the transformation of conventional leadership style is impossible if a rethinking of training activities and learning experiences delivered to health professionals is missing. The article provides an overview of the issues that health leaders and managers encounter in the ‘new normality’ of health care, identifying several unanswered questions which should be addressed to thrive in the changed landscape of health services’ delivery.

Keywords

change health management leadership new normality training

Introduction

Momentous transformations are reshaping the strategic, organizational, and managerial challenges faced by health systems across the world.¹ Deep epidemiological, societal, demographic, and cultural changes require a reframing of the policies and practices which have been employed by health systems to ensure a timely and effective access to care.² This is especially true in the post-Covid-19 era, which has brought unprecedented threats to the viability of health and social care systems across the world.^3,4 Such challenges are heralding a ‘new normality’ in health care, which calls for a revised managerial approach and for innovative leadership skills to steer health care organizations towards greater effectiveness and increased sustainability in a time of turbulence and uncertainty.⁵

In times of ‘new normality’, health managers and leaders can look at different leadership theories, models, and approaches to reflect on their styles and practices and to mould tailored managerial techniques and practices.^6,7 The management and leadership style emerging from this renewal should take its roots into a value-based health care delivery model, which is settled on patient-centredness and patient empowerment.⁸ To be accomplished, a value-based health care needs to be recontextualized in a digital, cyber-physical environment, which paves the way for increased timeliness, appropriateness, and personalization of health services.⁹ Besides, it relies on the enactment of a system-approach to health services’ delivery, which is nurtured by the establishment of inter-organizational relationships among different health care providers.¹⁰ Lastly, yet importantly, value-based health care involves the active engagement and participation of patients in health services’ co-production, in a perspective of value co-creation.¹¹

From this standpoint, the ‘new normal’ leadership style for clinical leaders should focus on two sets of principles. On the one hand, a patient experience and consumer engagement perspective should be embraced in designing and implementing the health care service system of the future.¹² This implies that patients should be understood as subject – rather than object – of care, being involved across a broad spectrum of participatory practices. On the other hand, a structured approach to management based on problem identification, evidence review, appraisal of evidence, practice change, and evaluation of results should be pursued, in order to foster the flexibility and the adaptability of the health service delivery system.¹³ Such a structured approach entails a continuous propensity to change, which nurtures the improvement of the health services’ delivery system in light of the evolving needs of patients. These principles should basically inspire the actions of clinical heads (CHs), i.e. those running divisions, departments, service lines, units within health care organizations. As discussed in next paragraphs, they involve the ability to combine the qualities of the leader with the skills of the manager, that is generating directions and making things happen, contributing to performance improvement at both the individual and group levels.¹⁴

A “New normal” leadership cycle in health care

Facing the ‘new normality’ of health care, the work of CHs and, in general, of leaders within health care organizations is expected to develop through a ‘strategic cycle’, which is built around three phases: envisioning, enabling and implementing.^15,16 Practices required by the three phases to the principles of ‘new normal’ leadership in health care depicted above and provide clinical heads with a sort of method to play their role. An overview of the contents of these three phases follows.

Envisioning

In substance, envisioning implies the capability to comprehensively define the strategic direction of the unit – or, more generally, of the group of people – which is overseen by the leader, aligning the visions of co-workers and collaborators.¹⁷ Through this activity, CHs enact a sensegiving of their internal and external context, make sense out of the challenges they are facing, and engage the team in defining how to fill in the ‘strategic space’ within which they can make choices.¹⁸ The perimeter of the strategic space is bound by the organizational mission, the capacity of the team, the evolving competition, and the expectations of stakeholders (both internal ones, such as top management, and external entities, here included patient associations, politicians, and scientific networks).

What to do and how to do it is the big question for health leaders and CHs. They can (and should) ask themselves and their team ‘the’ question: what makes us valuable? Once they are able to answer this big question, the long-term strategic planning should be developed, from which specific, short-term objectives are derived. Obviously, both long-term and short-term objectives should be aimed at emphasizing the drivers of value which distinguish the essence of the group overseen by the leader.

It is worth noting that the envisioning phase also encompasses the ability of the leader to act as a ‘filter’. In fact, filtering is the function that leaders play with regard to the appropriate and timely management of environmental uncertainty and internal ambiguity that often affect the performance of health organizations, especially when they have a public nature and are more exposed to environmental challenges.¹⁹ Health leaders absorb uncertainty and provide the team with clear directions and engaging guidelines, thus stimulating psychological safety and positive risk taking behaviours.²⁰

Enabling

Enabling refers to creating conditions that allow the team to acknowledge the directions which are provided by the leader and to be motivated and engaged in pursuing goals and targets related with such directions with continuity.²¹ In light of these considerations, enabling includes playmaking and compromising.²² More specifically, health leaders are expected to set smart goals for their team, to make choices about the most effective division of labour, to provide constructive feedback, to coach and to support each individual collaborator to achieve at his/her best individual and group targets. In sum, health leaders must work to generate a context (through their playmaking) of relationships that facilitates the work of the team.²³ Moreover, when necessary, they must build effective adjustments (through compromises) in order to boost individual and organizational performances.²⁴

There are three further points that deserve attention in unravelling the enabling role of health leaders. First, there is a need to adopt the right motivational factors to increase the commitment of the team. Each team member is primarily motivated by distinguishing drivers, such as financial incentives, intrinsic rewards, social recognition, status, legitimation, et similia. Hence, health leaders should be able to appreciate the manifold motivational drivers inspiring individual behaviors and should arrange targeted enabling practices, which are tailored to the peculiar needs of each team member.²⁵ Second, psychological safety should be ensured. Psychological safety is a belief that one will not be punished or humiliated for speaking up with ideas, questioning, raising concerns, or committing mistakes.²⁶ The team culture should be characterized by a sort of ‘obligation to dissent’, if anyone as a different view. Actually, what health leaders should look for is loyalty, rather than fidelity. Third, and lastly, it should be noted that enabling is about defining a social pact with the team. This is about setting the right rules of the game, ensuring that vision does not become a form hallucination, strengthening the sense of purpose across the team, and generating a context permeated by the feeling of organizational justice.¹⁶ If these three points are met, enabling is what accredits CHs and health professionals as leaders.

Implementing

In general terms, implementing can be conceived of as the ability of making things happen, addressing all the contingencies which may impair the effectiveness of leadership.²⁷ It involves designing and managing controlling systems, developing the dashboard to measure individual and collective contributions to the functioning of the system, and assessing expected and actual performances of team members.²⁸ These activities allow to set milestones and check points, that help health leaders to keep the team as a whole – and individual collaborators – on track. In sum, when attention is paid to implementing, the leading and managing roles overlap.

Implementing is never straightforward. Professionals in general – and health professionals in particular – are well-known to be resistant and resilient to changes that affect their interests. They adopt many strategies to protect the status quo, as described by Ackroyd et al.²⁹ with the idea of custodial orientation. This suggests a form of management practice that is essentially encapsulated by professional interests and which is primarily focused on maintaining the status quo, as defined by the professional community.³⁰

In this light, envisioning and enabling might not be sufficient to generate the desired change. Health leaders have to master change management processes.^31,32 From this standpoint, implementing is where health leaders combine the qualities of the leader with the capacity of the manager, which is especially relevant to enact and implement timely organizational change initiatives. Managing change in complex organizations means avoiding falling into simplicity traps, or avoiding that change implementers make sense out of their task by concentrating on a narrow set of factors, removing the complications that involve a fully-fledged organizational transition.³³ This form of selective attention might lead to an over emphasis on some aspects of change and to an underestimation of other features that, in the end, may engender the failure of the overall transition. Health leaders must control the whole organizational picture, while digging into the black box of the health service delivery processes.

Enacting a ‘new normal’ leadership cycle

In sum, very time health leaders strive for steering organizational dynamics and behaviors towards enhanced effectiveness and service excellence, they are managing a complex transition, which concomitantly involves envisioning, enabling, and implementing. As a matter of fact, through the strategic cycle health leaders are defining and executing an organizational development process, as they are re-setting the organization’s goals (strategic planning) and design (division of labour) to meet organizational-wide strategic ambitions and managerial challenges. They are expected to execute the changes necessary for the gradual achievement of a new state of their team, over a desired time-span (usually, the length of a strategic cycle is three years). A three-year span might be necessary to achieve consolidation of organizational changes and to assume new roles and responsibilities.

Further, health leaders are expected to think and react fast, recognizing that opportunities (and challenges) can emerge from within the organization, without any previous formal plan or analysis. Clinical leaders need to recognize the process of emergence and to intervene when appropriate, killing off bad emergent strategies and, at the same time, nurturing potentially good ones.³⁴ The objective is to assess whether the emergent strategy fits the needs and capabilities of their team and, more in general, of the organization as a whole. This is a function of strategic management: health leaders must be able to combine top-down rational planning with bottom-up emerging strategies, revising the deliberated strategy in course of action and, consequently, modifying organizational design and development patterns to fit the new strategy.

Reframing the strategic posture of the leader

Health professionals should embrace a specific posture when they act as leaders, that is a set of meta-expectations connected to the exercise of their leadership role.³⁵ Whilst it is clear that they are expected to deliver effective performance and adequate results, how should they behave to contribute to the search for excellence is uncertain. There is a huge body of literature on styles, behaviour, and best practices of leaders.^36,37 Without any claim for exhaustiveness, hereafter only those attributes that distinguish great clinical leaders from good ones are highlighted.^38,39 What really makes a difference seems to be their capacity to sustain the effort to develop an organizational culture of excellence. A culture which is based on:

Proactive posture: issues need to be addressed before they turn into problems. This is what sets apart great leaders;

Ambitious goals: great leaders do not satisfy easily. Satisficing is a decision-making strategy that aims for satisfactory or adequate enough results, without seeking for optimal solutions. This happens because aiming for the optimal solution (and for excellence) may necessitate a significant expenditure of time, energy, and resources, which the organization (i.e., its leaders and managers) is not willing to spend. From this standpoint, health leaders should continuously push individuals and groups within the organization to challenge their performance and to aim for excellence.

Retention of solutions: it entails the natural tendency to search for solutions to problems from past experience.⁴⁰ Organizations, like people, are mostly driven by the past, rather than pulled by the future. This creates relevant constraints on organizational behaviors and practices. A successful leader should show curiosity about what is changing in the way services are delivered, about the latest organizational transformation and the available opportunities for re-thinking the way things are organized and managed within health care organizations.

Beyond the ‘old school’ for leaders

Some steps away from the old school leadership model are needed to foster the shift towards a managing and leading model which is consistent with the ‘new normality’ faced by health care organizations. It is clear that traditional training courses are not as effective as they were supposed to be. They can provide an introduction to the leadership role, and some useful techniques (such as project management, business planning, lean approaches, et similia), but no more than this. Competence frameworks developed over recent years, including those drafted by the NHS Leadership Institute⁴¹ and by the International Hospital Federation,⁴² are helpful to outline the complexity and variety of skills that need to be focused on.

What seems to be of paramount importance for the future is investment in strengthening two specific paths for training the next generation of leaders in health care: reflection opportunities and communities of practice. Leaders and managers need to find a contemplative space in which they can do critical sensemaking of their own decisions practices. In other words, they need a place and a time where they can initiate some self-learning which spurs from the in-depth and critical analysis of their previous experiences. In this case, the role of the trainers is to provide the trainees (i.e., the leaders) with some conceptual frameworks, empowering them to interiorize lessons from the past, so that they become reflective practitioners.⁴³ Communities of practice are especially useful for this purpose. They are made of peers who participate in the execution of real work. People who are involved in communities of practice develop a shared repertoire of resources, such as tools, documents, routines, vocabulary, symbols, and artefacts, that embody the accumulated knowledge of the community. This shared repertoire serves as a foundation for future learning.⁴⁴ Health leaders called to address the ‘new normality’ of health care can greatly benefit from being involved in a community of practice, where they can freely explore their practices and learn through the comparison of experiences. Actually, communities of practices provide a contemplative space for learning, pushing to the next level the whole learning process and advancing the intellectual growth experienced by learners.

Concluding remarks and avenues for further development

The challenges brought by ‘new normality’ of health care impose a reconfiguration of conventional leadership and managing styles, urging the transition towards an approach which emphasizes the sensegiving and sensemaking abilities of leaders and managers. The ‘new normal’ health leadership model relies on a revised conceptual and practical framework, which stresses the envisioning and enabling role played by leaders and stress their active participation into the strategic and management dynamics of health care organizations.

To accomplish this transition, those who manage a team in health care institutions are called to embrace a revised strategic posture, which encourages them to act as managers and to think as leaders. Needless to say, such a strategic posture engenders a reframing of training models and practices delivered to health leaders and managers, which should be focused on their capability to enact a deep, critical learning at both the individual and group levels. Whatever will be the methodological choice that will be made to develop the training models targeted to the health leaders and managers of the future, one thing is clear beyond any doubts. It must be an opportunity to cope with the need to stimulate self-learning processes on personal practices and with the need to fill in the collective knowledge gaps of team members. Unfortunately, these issues have been largely neglected in scientific research.

In this light, there are several questions, whose discussion should be the foundation of the training and learning processes of the future. Inter alia, some of the most relevant questions are:

What are the most effective organizational and managerial model for health care institutions to pursue a patient-centred approach which is consistent with the patient empowerment and engagement imperatives?

How could we address patients’ frailty whilst making an effort to involve them in the design and delivery of care?

How is it possible to seek apparently conflicting strategic aims and operational goals triggered by the multi-disciplinarity that affects most of decisions which should be taken in the age of ‘new normality’ faced by health care organizations?

Is there a clinical governance system that really works and makes the difference at the organizational level? And, if there is, who should run it and how?

How should we organize nursing staff in relation to medical staff and how should we manage overlapping leadership and management roles?

How could we give “structure” to multidisciplinary teams?

How health professionals can effectively work in a matrix system to account for the manifold challenges that should be addressed in the ‘new normality’ of health care?

Which are the alternatives to build motivating career paths for physicians? What implications do derive from these alternatives?

Which are the professional roles that fit most with the ‘new normality’ of health care?

Executive education for health leaders and managers has the responsibility to help CHs and leaders in general to pinpoint, label, and frame these issues. In the ‘new normality’ of health care, trainers – be them scholars or practitioners – have the responsibility to bring education to the next level of meaningfulness, shaping new leadership and management styles that can be timely and effectively delivered to health professionals operating at different rungs of the organizational structure.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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