The purpose of this literature review was to synthesize the existing knowledge regarding physician engagement and leadership and to identify key recommendations to enhance physician leadership skills, physician alignment with other components of the healthcare system, and the capacity to foster and improve the accountability of physicians for improved organizational and system performance.
Demands for increased performance and accountability in healthcare arise from increasing expectations for improved service and higher standards of care by patients, the public, government and policy-makers. In response to these pressures, leaders in regional and provincial healthcare systems in Canada and other countries increasingly focus on system changes that improve performance and accountability and that enhance patient experiences while containing costs. The broad system changes required for such improvements rely on aligning healthcare providers with organizational and system aims and activities and, in particular, engaging physicians and the medical profession in both setting the course for system change and ensuring optimal execution of the desired system changes. Consequently, there have been increasing numbers of physicians in formal leadership roles and increased expectations regarding the roles they can play in improving health systems.
Mobilizing physicians in formal leadership roles and formal decision-making or governance bodies is important but cannot by itself respond to these expectations for greater physician engagement. However, recent research focused on developing more effective practice settings (for example, high-performing clinical microsystems) suggests that structure can play an important role in generating physician engagement and in actualizing physician leadership. It also suggests that engaging the medical profession and developing its leadership cannot be limited to initiatives located at the strategic apex of the organization or system. The growing attention paid to team-based organizations and “teamness” exemplifies this argument. Similarly, the greater interest in high-performing clinical units, or clinical management systems, shows that structures creating greater alignment for improvement, accountability and cost containment may represent fertile ground for developing physician engagement and leadership. Nevertheless, physicians need to be properly compensated for their time and involvement in team and improvement initiatives. Trust between the organization and physicians appears fundamental to aligning physicians’ and organizational goals.
A clear lesson from this review is that structural work (physicians in formal executive positions, development and management of information for clinical performance, economic incentives, etc.) is insufficient for developing physician engagement and leadership at scale. More elaborate processes of engagement and leadership development at the individual, organizational and system levels may be needed to support physician involvement in system improvement.
Research on general leadership and on physician leadership for health system improvement points toward an important new view of leadership that is more collective, distributed and relational. This concept blurs to a certain extent the distinction between engagement and leadership per se, suggesting the need to develop more active roles for physicians in improvement initiatives. Developing clinical leaders and champions across systems can make a significant contribution to improvement. This approach to leadership is consistent with recent work on using a social movement approach to improving health systems and with approaches promoted by the Institute for Healthcare Improvement in the United States. The core idea is to spread leadership by developing group norms that support continuous improvement.
One challenge is how to develop these norms of engagement. From this review, it appears that efforts to develop new skills and competencies by training individual physicians for leadership roles, including exposing them to interprofessional experiences and cultivating dyads of physicians and managers in charge of clinical units, may support the emergence of such norms. Broadening this concept, the review illustrates emerging roles in some jurisdictions where physicians work in partnership with decision-makers, or directly fill policy, strategy and funding roles, in conjunction with maintaining a clinical focus. To some extent, better recognition of physician leadership roles for system improvement can potentially support the reframing of norms and relationships between the medical profession and the system or organization. For example, using physician compacts to reframe the relations between the medical profession and the organization is one potential strategy that has been applied in Canadian and American contexts.
However, the review suggests that greater involvement of physicians implies changes not only for the medical profession. Health systems are structured and developed around well-embedded policy and managerial logics that have fuelled a more or less distant and controversial relationship with the medical profession. Within organizations and health systems, greater physician leadership and physician engagement also require changes in the way managers and policy-makers interact and work with physicians. A focus on health system improvement probably suggests a new modus operandi between the system, the organization and the profession. This idea is captured somewhat in the recently developed notion of organized professionalism, which means that professions and organizations must mutually accommodate system changes and evolution.
This synthesis also underscores the important dilemmas that physician leaders experience in assuming new roles in organizations and systems. Such dilemmas may be partly attenuated by getting involved in cultural work. Cultural work implies the promotion of a new discourse at the individual level around the incorporation of organizational and system thinking as part of the “knowledge” that physicians have to incorporate in their professional “know-how.” Such incorporation will of course be performed to various degrees depending on the propensity and involvement of physicians to assume leadership roles that go beyond the usual clinical responsibilities. At more system or organizational levels, some researchers have suggested that a cultural shift toward considering physicians as workers among workers may help in developing new norms of engagement and new leadership roles.
This shift is probably one of the biggest challenges for health systems. The exact meaning of such a cultural shift is still to be defined and will probably vary from organization to organization and system to system. The idea behind cultural work is that professional status and autonomy must likely be rethought to support more widespread engagement and leadership of the medical profession for health system improvement. Again, this goes back to the notion of organized professionalism and to the importance of identifying strategies that simultaneously encourage the inclusion of physicians as leaders in organizations and their genuine participation in improvement initiatives. At the same time, organizations and systems may have to pay more attention to the positive experiences that physicians have in their day-to-day work in organizations.
The literature reviewed in this synthesis reveals growing knowledge about the dynamics of physician engagement and leadership for health system improvement. Overall, the review suggests that diverse strategies and initiatives can be developed to strengthen physician engagement and leadership in Canadian health systems. These strategies must focus on developing capacities at the individual, organizational and system levels. The recognition of the importance of process elements (cultural and relational work, including the nurturing of a more collective view of physician leadership) implies that, to achieve the maximum benefits of any structural changes (such as financial incentives, the design of formal leadership positions, new committee structures, etc.), increased investment in cultural and relational work will also be necessary to support engagement and leadership.
Finally, the review indicates that physician leadership and physician engagement are probably part of a continuum and are mutually reinforced at the individual, organizational and system levels. Greater expectations of more active leadership by the medical profession for health system improvement will support the engagement of larger numbers of physicians in organizational and system affairs. More physician engagement will probably support the development of formal and informal medical leadership for improvement across health systems. These investments may partly alleviate the barriers to physician engagement and leadership and the tensions in developing new roles for the medical profession.
Some gaps exist in current knowledge. More empirical studies are needed on the process and practices used by organizations and systems to engage physicians and to develop physician leadership for health system transformation and improvement. In particular, such research needs to focus on how the specific structural changes and leadership training efforts made in different contexts actually link to strategies to develop facilitative environments for physician engagement and leadership. In addition, more research aiming to learn from organizations that have succeeded in creating effective physician leadership and engaging front-line physicians would provide a better understanding of appropriate and successful strategies. A broader assessment of leadership competencies and the means to foster these competencies (through both formal education programs and practice-based learning) also would be helpful.