EXCELLENCE

IN HOSPITAL
LEADERSHIP
Inspire. Empower. Engage
Healthcare Leaders

|1
 EXCELLENCE
IN HOSPITAL
LEADERSHIP
Inspire. Empower. Engage
Healthcare Leaders

Editors
Prof. Nirmal Kumar Ganguly, Editor-in-Chief
Prof. Piyush Kumar Sinha, Executive Editor

Editorial board members

Dr. D.S. Rana
Dr. Devi Shetty
Dr. Naresh Trehan
Sangita Reddy

Indian Institute of Management Ahmedabad

2| |3
 TABLE OF CONTENTS
Published By:
Editorial board 06
Indian Institute of Management Ahmedabad
Vastrapur, Ahmedabad 380015 Acknowledgment 07
Note from the Executive Editor 09
Leadership in Healthcare: Values at the Top 10
Copyright @ 2017 Indian Institute of Management
Ahmedabad a. Leadership in Healthcare 12
b. Personal Values 14

First edition, 2016 c. Team Values 18

d. Evaluation 20
No part of this book may be reproduced, stored in a retrieval
Engaging Physicians 25
system, transmitted in any form or by any means electronic,
mechanical, photocopying, recording or otherwise without a. Importance of Physician Engagement 26
either written prior permission of the publisher. Any opinion b. Barriers to Physician Engagement 26
expressed in this book is personal of the speakers and the
authors and not of their organisations. i. Dissatisfaction with the Profession 27
ii. Lack of Understanding of Management Policies 27
Printed and Bound by:
iii. Lack of Motivation 27
Sky Print c. Strategies to Engage 28
22, A2 Shah and Nahar Industrial Estate,
i. Building Trust 28
Dhanraj Mill Compound, Sitaram Jadhav Marg,
Lower Parel (W), Mumbai - 400013 ii. Value Alignment 29
Tel. : 43471715 / 14 iii. Enhanced Communication 29

This publication is supported by iv. Developing a Partnership 29

Abbott Healthcare Pvt. Ltd. v. Physician Leadership 30
vi. Highlight Data 30
www.abbott.in vii. Drive Motivation 31
viii. Linking to Performance 31
Medical doctors in healthcare leadership: theoretical and practical challenges 32

This Publication has been developed and designed by Velocita Brand Consultants Pvt. Ltd., Pune in association with
a. Challenges in Reconciling Professional and Organizational
Indian Institute of Ahmedabad and Abbott Healthcare Pvt Ltd for education intended to be circulated only to
hospital leaders. The views and opinions expressed in this article are those of the authors and do not necessarily Logics in Healthcare 36
reflect the views of Abbott Healthcare Pvt Ltd. Although greatest possible care has been taken in compiling,
checking and developing the content to ensure that it is accurate and complete, Abbott Healthcare Pvt. Ltd., is not b. Transforming the Role of the Medical Profession 39
responsible or in any way liable for any injury or damage to any persons in view of any reliance placed on or action
taken basis of the information in this presentation or any errors, omissions or inaccuracies and/or incompleteness
of the information in this presentation, whether arising from negligence or otherwise. Abbott Healthcare Pvt. c. Engaging Medical Doctors in Healthcare Leadership 44
Ltd. neither agrees nor disagrees with the views expressed in this publication and does not constitute or imply an
endorsement, sponsorship or recommendation of any kind. d. Lessons from the Systems 48
4| |5
 EDITORIAL BOARD
Prof. nirmal kumar ganguly
Exdirector General, ICMR, Editor-in-Chief
He is a distinguished research professor of Biotechnology, Department of
Biotechnology (DBT), Government of India. He has published 757 papers
and supervised 130 PhD/MD thesis.
Prof. Piyush Kumar Sinha
Professor (Retailing and Marketing), Executive Editor
With a stint of over 20 years spanning across academics and corporates,
he has a long-standing association with the world of marketing and
academics.
Dr. D. S. Rana
Chairman, Sir Gangaram Hospital, Member
He is an honorary senior consultant at Sir Gangaram Hospital, New Delhi,
the chairman of the Dept. of Nephrology, and the secretary of SGRHs
board of management.
ACKNOWLEDGMENT
This book has been made possible because of
the support and guidance from the leaders of
the healthcare industry from all over the world,
who participated in the summit. The knowledge
they shared at the forum is truly invaluable. We
are grateful to the participants for sharing their
experiences, and their inquisitiveness, which
has become a hallmark of Hospital Leadership
Summit. Their support and guidance has helped
us expand intellectual horizons in the healthcare
sector.
Finally, we would like to acknowledge our
patrons, the team at Abbott, technical support,
researchers and the individuals who have helped
us shape this book its content and structure.
Their dedication and hard work has been
instrumental in the success of the project.

Dr. Devi Shetty

Chairman, Narayana Health, Member
He is a philanthropist and a cardiac surgeon. He has leveraged economies
of scale to provide affordable healthcare.

Dr. Naresh Trehan

Chairman and Managing Director, Medanta, Member
He is a renowned cardiothoracic surgeon. He has served as personal
surgeon to the President of India.

Sangita Reddy
Joint Managing Director, Apollo Hospitals, Member
A member of the founding family, Sangita has been associated with the
Apollo group for over 30 years. Her association spans patient care, human
resources, and operations.
6| |7
 NOTE FROM THE
EXECUTIVE EDITOR
Towards Stronger Healthcare
Leadership
We prize and admire leadership skills, yet we have little
understanding of how and why some people are more
effective leaders than others. Leadership is an adaptive
ability and acts on a setting. Leadership means different
things to different people around the world, and different
things in different situations. However, certain aspects are
common in good leaders across industries and nations.
Tata Consultancy Services, Indias leading IT company
credits its success to human capital development. It
PROF. PIYUSH KUMAR SINHA allocates approximately 60 days of formal training for new
Professor of Marketing and hires; its companies often spend months training even
Retailing at IIM Ahmedabad experienced workers hired from other firms.
Hindustan Unilever, Indias largest fast-moving consumer
goods company has given over 500 CEOs to corporations
across the world. HUL believes in starting early and a
majority of the companys senior leaders emerge from
this program centered on the Leaders Build Leaders
philosophy.
ICICI Bank, Indias largest private bank has made
empowering talent at an early age a cornerstone of its
leadership development philosophy. It has cultivated the
culture of grooming and nurturing talent across every level
by identifying people with leadership potential early, and
entrusting them with challenging jobs ahead of time.
Mahindra & Mahindra, with operations in more than 100
countries worldwide, has a diverse mix of talent at every
level. It gives a unique opportunity to its leaders to interact
with the most knowledgeable minds in academia to enhance
strategic thinking as well as to connect with art, sociology
or design, thus, increasing perceptive capabilities and
prompting unexpected insights.
These companies have proved time and again how to be
the pioneers in their respective fields through meticulous
leadership planning. Indigo maintained its low-cost
8|
airfare despite the competition. Amazon, on in India can grow leaps and bounds but it
the other hand, is the worlds largest internet needs great leaders to reach its potential. In
company by revenue and market capitalization. light of Indias unique challenges, leaders
All these companies have identified early in healthcare must draw examples from
the importance of investing in leadership various industries to guide themselves.
development and enriching the leaders. Progressive health systems must invest in
leadership development of the entire senior
Young leaders in India are making an impact
management team for significant return
on the Indian economy. Leaders like Nishant
on investment in terms of organizational
Rao, MD, LinkedIn India, founded Indias first
effectiveness.
voice-based call center in the late 90s; Jairam
Sridharan, President, Retail Lending and Leadership in healthcare needs to
Payments, revolutionized retail in the banking focus on the development of effective
sector transforming Axis into a strong retail collaborative relationships through
bank; Siddharth Adya, Vice President, Regional support and task delegation, based on
Lead - South Asia, APL Logistics, moved the widespread implementation of the shared
business away from mere traditional logistics leadership model. It encourages shared
operations to a more solutions driven model, governance, continuous workplace learning
focused on value creation for the customer; and development of effective working
Bhavish Aggarwal, Co-founder and CEO, Ola, relationships.
launched Indias first mobile application for
personal transportation; they and many more are
an inspiration.
These leaders have transformed their industries.
Though they come from diverse industries
they shared common leadership skills. They
aspired to make a difference and were adaptive
in their leadership approach. They had faith in
their vision and firmly believed that if people
connect with their vision, they will staybe it
investors, customers or employees. Leadership
development is not done individually; it includes
looking for leadership potential in others. It is
an essential component of the development of
the organization by developing leadership skills
within the team. The healthcare industry
|9
 LEADERSHIP IN
HEALTHCARE
VALUES AT THE TOP
Reviewed by Prof. Piyush Kumar Sinha and
Kopal Agrawal Dhandhania

10 | | 11
 The author Carson F. Dye, MBA, FACHE, is an executive search consultant with
Witt/Kieffer and teaches leadership courses for the Master of Science in Health
Administration Program at the University of Alabama at Birmingham.
Jared D. Lock has contributed and written the last chapter of the book. Mr. Lock is
president of Carr & Associates, dedicated to helping organizations maximize human
productivity.
This is the second edition of the book Leadership in Healthcare Values at the Top.
Although the major concepts discussed in the first edition remain the same, the
current edition deals with more recent issues of healthcare leadership. Challenges
of internet era for leaders are more pressing and demands high turnaround. The
book evokes the importance of values and its meaning in effectiveness of leaders. It
has highlighted refreshing concepts in leadership like servant leadership, change
makers, employee engagement, emotional intelligence, and groupthink.
The book aims to deliver three messages The dire need for effective leadership,
Values-based leadership can be learned and Values are a primary contributor to
great leadership performance.
The book does not just talk about the leader as an individual but it also discusses the
leadership in context to team, and the team leader.
The author has reviewed literature and woven personal experiences of various
leaders in the industry along with his own investigation of the topics to define,
develop and execute the book. The books structure divides the various theories of
value based leadership into four sections:
1. Leadership in Healthcare
2. Personal Values
3. Team Values
4. Evaluation
Leadership in Healthcare
It discusses industry realities that healthcare leaders have to confrontever
changing issues, like keeping up with the digital age, higher consumer expectations,
dearth of right talent, growing regulations and accountability.
Leadership imperative
In the evolving environment, physicianorganization relations continue to be among
the most challenging issues, along with strategic conflicts that could result from
mergers or other steps to gain economies of scale or increase market share. The
12 |
industry and the people they service need leaders who can rebuild trust, restore
efficient processes, and ensure quality across uncertain environmental trends and
practices, societal and economic flux, and organizational transitions.
There is a constant necessity for leaders to be learning and adjusting their skills and
knowledge. They always have to anticipate what is coming just past the horizon. Aside
from coping with the current realities of the industry, healthcare leaders also navigate
the common obstacles of running a multifaceted operation. An imperative action is a
step that a leader may take to overcome obstacles, such as complex organizations, low
employee engagement and commitment, dissatisfied physicians and patients, and lack
of succession planning.
The values-based definition
The section discusses literature on leadership theories on Leadership vs.
Management, comprehensive theory of Stogdills Handbook of Leadership,
Competency-Based Leadership Theory, Process Theory of Organizational
Behavior by Robert Kreitner and Angelo Kinicki and Contingency Theory. The
author defines values as ingrained principles that guide behaviors and thoughts; the
difference between personal values and team valuehow both are important aspects
of effective leadership and how values enable leaders to go through the stages in
leadership growth.
The senior leader challenge
The imperative challenges of senior leaders in the industry are; The complex
organizational structure -Rapid growth has also diversified the composition and
enlarged the size of organizations, spreading it into multiple business lines and
complex networks; Haphazard executive search process, little preparation or
forethought into executive hiring process leads to election of leaders with inadequate
leadership competencies; litigious environment; fast pace of change; lack of time;
and lack of shared vision. These are obstacles to effective leadership and, hence, the
reasons for having an effective leadership.
Behavior and
Above the surface Thoughts
}
Below the surface
Personal Values
Both are cohesive for
effective leadership
Values
(Ingrained principles, driving
Team Values
force of behavior)
| 13
 Personal Values Ethics and integrity
Ethics is a persons moral scope and integrity, personal code. This will act as a guide
This section lists the key values that influence the leaders behavior, priorities, the persons capacity for staying within that in difficult decisions. Small changes in
thought processes, and actions. moral scope. Effective leaders are those who are leadership can make a big difference,
recognized by others for their integrity and ethical for instance: by being true to the
uprightness. context, doing as you say, using power
Respectful
Stewardship Every decision a leader takes is evaluated on ethical appropriately, admitting mistakes,
grounds and critiqued. In the healthcare industry having clarity of personal values, being
specifically ethical dilemmas are an everyday trustworthy and managing expense
struggle for leaders. Ethics offer an effective tool accounts judiciously. These traits will
to steady leadership focus in uncertainty times and help in build an ethical base and build
Emotional Ethics and
Integrity strengthen their resolve to do right no matter what. integrity in leadership.
intelligence
To imbibe ethics and integrity in their conduct,
leaders should adopt an organizational and
Personal
Values Interpersonal connection
Interpersonal Leaders can improve interpersonal skills: listen, Leadership is about building and
Commitment Connection show respect and compassion, meet the staff, maintaining relationships. It is a
manage perceptions by reasoning, recognize efforts, value so subtle that it can be easily
manage and channel emotions appropriately, smile, undermined but so powerful that it can
show courtesy, focus on needs, being optimistic, make or break an organization.
and practice simple courtesies (such as share
Desire to make Servant
Leadership
everything, play fair, dont hit people, put things
a change
back where you found them, clean up your own
mess, dont take things that arent yours, say you are
sorry when you hurt somebody. and so on).
Respect in stewardship
If leadership is a journey, then respect for constituents is establishing a feedback system,
its fuel. Respect is the value that multiplies the desire of showing genuine involvement, Servant leadership
both the leader and follower to work harder and deliver giving credit, offering help The healthcare industry was established with a continuing education, provide
consistently excellent performances. The author defines or coaching, looking inward, simple, altruistic purpose: to serve the public. A opportunities, establish a succession
the fine line between self-esteem and self-centeredness in taking responsibility for servant leader is motivated by the desire to serve. plan, learn about the work, provide
context to respect. Self-esteem is an individuals respect for mistakes, learning affirmation They follow a bottom-up approach of command. mentorship, celebrate simple joys,
her own convictions, actions, imperfections, and abilities. and showing appreciation. Practice elements that enrich servant leader change the focus of performance
Self-centeredness, on the other hand, is an individuals skills: share information, exchange ideas, delegate reviews from criticism to development,
overly favorable sense of his own abilities, views, decisions, authority, take missions to heart promote and be accessible.
and needs.
Leader can practice this by being collaborators, recognizing
everyones human dignity and basic need for respect,

14 | | 15

A servant leader is marked by the following characteristics:
Focuses on the needs of followers
Eschews selfish behavior, personal biases, and pursuit of personal ambition
Sincerely respects all people
Realizes that the contributions of followers are what enable the organization to
fulfill its mission
Helps, encourages, and counsels followers to hone their skills and become better
at their positions because doing so brings the organization closer to its goals
Desire to make a change
Change makers are proactive, innovative, and welcome challenges. They are goal
oriented and uphold high standards of performance. They operate well and even
flourish despite high levels of stress and unceasing demands. Change makers have
restless discontentthe inability to live with the status quo. They have the ability to
sense opportunities.
To develop change maker characteristics, leaders should: pay equal attention to
all measures of performance, engage employees, be objective driven and progress
oriented, welcome change, celebrate accomplishments, establish a problem-solving
method, learn quality improvement concepts, look for areas to refine, network and
benchmark, learn change management, make a change for progresss sake.
Change Makers Have Achievement Motivation 1
High achievers address problems rather than leave them to chance
The goals of high achievers can be accomplished; they are neither too difficult
nor too easy
High achievers are more interested in accomplishment than in reward
High achievers seek workplaces and positions that offer ample feedback
High achievers constantly think about improvement, excellence, and perfection,
they seek out organizations that will allow them to make changes
16 |
Commitment
Commitment binds the executive to his work; it generates a strong work ethic,
loyalty, pride, productivity, ownership, and even joy. To committed leaders, work
is not drudgery or toil; instead, it offers great satisfaction. Strategies to maintain
commitment are to stay focused on the vision, balance work and life, find an
enjoyable outlet, show initiative, make sacrifices, think positively, be mindful of
body language, engage employees, and develop systems that help manage difficult
situations.
For example, new health administration program graduates are assigned tasks, such
as copying and cold calling that do not require an advanced degree. Similarly, middle
managers are sent out to attend time-consuming, low-level meetings or to handle
face-to-face patient complaints. The purpose of these seemingly menial assignments
is not to punish the staff members but to test their team orientation, get-to-it-
tiveness, and commitment to their careers.
Emotional intelligence
Emotional intelligence is the subset of social intelligence that involves the ability
to monitor ones own and others feelings and emotions, to discriminate among
them and to use this information to guide ones thinking and actions. Emotionally
intelligent leaders are confident, are enthusiastic, and have self-esteem and a
positive attitude. They use a self-awareness lens that enables them to see the
communication and behavioral patterns that showcase the worst in people,
including themselves.
Principles that enhance emotional intelligence are development of personal
competence and social competence, empathy, collaboration, and teamwork. Seek
feedback, set a personal path, have annual retreats, get a coach or mentor, manage
your emotions, take setbacks as a challenge, and maintain physical and mental
health through healthy living.
Characteristics of Emotionally Intelligent Leaders
Comfortable and self-aware
Reflective listener
Non-threatening and non-intimidating
| 17
 YOUR FIRST AND FOREMOST JOB AS A LEADER
IS TO TAKE CHARGE OF YOUR OWN ENERGY
A classic example of how not to be a leader is
Nathan Jessup, the fictitious well-decorated
lieutenant colonel played by actor Jack
The example given by the author to
explain this concept says the team must
first gain approval from department
AND THEN TO ORCHESTRATE THE ENERGY OF Nicholson in the 1992 movie A Few Good directors before implementing a

Men. Here is how Colonel Jessup defends his
THOSE AROUND YOU leadership: I have neither the time nor the
Peter Drucker (1997) inclination to explain myself to a man who
rises and sleeps under the blanket of the very
freedom I provide; then questions the manner
Team Values in which I provide it! Id rather you just said
thank you and went on your way. Although
This section explores the values that guide a leadership team. Decision making, Colonel Jessup has achieved much, he is not
problem solving, brainstorming, planning, and implementation are activities that are
someone a team will choose as, or be proud to
most effective when executed by a team, not by one person alone. These values form
call, its leader.
the base of the team and form the core.
process, but the team should include all
levels of employees in decision making.
In this way, the team knows which
boundaries are off-limits and which are
flexible. To promote cooperation, one
leader told his team: I expect all of you
to work together as though you had
authority over the entire organization.
Leave your claims of functional turf at
the door.

Cohesiveness and collaboration

Cohesiveness increases team productivity, morale, and camaraderie; however it does
Team Values at times lead to territorial battles and other issues like proliferation of groupthink.
Groupthink is, simply, unanimous thinking. When the team is cohesive, its members
tend to lose their individual perspectives. As a result, new and creative thoughts are
Cooperation Conflict
Management
blocked off, objections are stifled, and concurrence becomes the standard. Instead of
and Sharing
pursuing the goals of the organization as a whole, keeping the solidarity of the team
becomes the teams main purpose.
Collaboration, on the other hand, pulls together divided parties to work toward a
mutually accepted goal. Both are equally important for each other and to build an
effective team. Methods to form both are: minimize selfishness, assess team size,
increase interaction, minimize cliques influence, evaluate the teams purpose, treat
Cohesiveness and
Collaboration Trust equally, designate team roles, reassess the compensation policy to team work, and
rally the team.
For example, at the end of every meeting, the leader exclaims, Were a great team!
Lets get those quality numbers up! However, at the next meeting, the leader
publicly berates one group for the poor outcomes it achieved while extolling another
group for its remarkable performance. Worse, he does not offer guidance or advice
Cooperation and sharing to those who are struggling. This leaders mixed message facilitates unhealthy
competition, retards collaboration, and discourages improvement. At the end of the
Cooperation and sharing demand team members to sacrifice some of their
day, team members will only hear were a great team! but not believe in it.
individuality for the benefit of the entire team. Suggested practice strategies are to
build the right team, discuss team values and demonstrate, determine the purpose,
engage in team-building exercises, develop a code of conduct and self-police
behaviors, match words with actions, and challenge boundaries. Trust
Trust is the first value all team members must learn. Without trust, team members
engage in fierce competition, back stabbing, and hypocrisy.

18 | | 19
 The five components of building trust are: integrity, competence, consistency,
loyalty, openness. Guidelines to enhance trust among team members are:
acknowledgement of the quid pro quo, consistency of behavior, removal of fear,
become accepting and accessible, follow full disclosure, be candid, welcome
resistance, do not take criticism personally, do not take advantage of position or
opportunity, and grant authority appropriately.
Conflict management
Conflict is expected of social interaction; however, managing conflict is a leaders
task for a healthy and uninterrupted flow of work. In team functions, conflict also
presents benefits, for instance it ends complacency, help starts dialogue, activates
a plan and also forces participation. Strategies to prevent and respond to team
conflicts are by creating a conflict management policy, being proactive, practicing
direct speaking, prohibiting personal attacks, insisting on collaboration, and
visualizing ideal outcomes.
my team? To what extent do my team members rely on each other for support and
input in decision making? Are team members independent or empowered to make
decisions? If not, what improvement can be made?
Evaluating team effectiveness
The teams structure (size, hierarchy, and membership) and primary activities
(decision making, holding meetings, and establishing team protocols) greatly
affect its effectiveness, just as team values do. Regular monitoring and
evaluation ensure that the structure and activities of the team always function
in its favor.
Examples of an Imbalance of Power in a Leadership Team
The public relations director is a member. She is in charge of disseminating
organizational information to all staff
The senior vice president of patient care services and the vice president of

A LEADER IS BEST WHEN PEOPLE BARELY

KNOW HE EXISTS, WHEN HIS WORK IS DONE,
nursing are members. Both have a nursing background and thus skew clinical
discussions toward nursing issues
Although not vice presidents, the director of human resources and the chief
HIS AIM FULFILLED, THEY WILL SAY: WE DID IT information officer are members

The director of the medical staff regularly attends team meetings, but he is not a
OURSELVES. member
-Lao Tzu

Evaluation
In this section the author provides tools for assessing team values and effectiveness
leadership at all stages.

Evaluating team values

Team members should regularly evaluate the teams values. This activity reveals
areas of deficiency and curtails harmful practices. The key values that the author
recommends for evaluation by team members for better performance are: technical,
decision making and interpersonal skills. Together they strengthen the leader
and make him/her a sustainable member of the team. Team members should be
aware of each others roles as well as the teams purpose, standards (or norms),and
goals. Leaders should encourage active participation, cohesiveness, commitment,
communication, high energy and camaraderie.
Also, they should be able to balance between independence vs interdependence of
teams. It can be done by asking the following questions: How interdependent is
20 | | 21
 Self-evaluation at all career stages
Values are evolutionary in nature and stem from peoples basic social needsnamely,
Values-driven leaders are self-assessors. They study their own moves and thought to get along with others, to get ahead in our pursuits, and to create order in our lives.
processes, with the dual intention of personal improvement and professional
achievement. Leaders at all stages should have a personal mission statement. They
should have an understanding of their personal and professional style and constantly
review their values. Team or executive retreats, performance reviews, self-reflection
exercises, and mentor meetings can be used as forums for such discussion and
thinking.
Professionals as a mid-point in their careers are at the most challenging position.
Leaders values often mirror Values
They have to quickly learn to balance work and home life. They are at the stage Experience
(and, over time, could eclipse)
where they have people working for them and they report to a higher authority.
organizational values.
360 degree feedback and building a comprehensive network help them grow at this
Organizational values then reflect
stage. They will look for mentoring and teaching opportunities.
what the leader wants, how she
At the last stage of the career, the professionals are most busy and active however wants to treat and be treated by
they have to plan their retirement for easy departure. They should have a positive others, and what activities and
attitude toward younger colleagues and aspiring leaders. interests she would like to pursue. Judgement Positive
Characteristics

Maximizing values-based leader effectiveness

After the review of executive literature on the link between values and success, the
author (Jared D. Lock) finds these studies insufficient, some have private interest
of sponsors in the studies, some have just the personality test as the indicator of
effectiveness, which is based on subjective opinions and personal preferences and
none have an unified or practical approach towards understanding the effect of the
leaders values on organizational success. Hence, the author presents a framework
the whole-person evaluation modelfor understanding leader effectiveness in the
context of values.
The model rests on the premise that a leaders performance is affected by the
conditions surrounding the individual. The models five components are made up of
the traits and conditions that through research have been indicated as contributors
to effective performance: Experiences, Judgment, Values, Positive Characteristics,
and Negative Characteristics.
Although Values contribute to only 20% of leaders whole persona, the author
through extensive literature review has established the importance of values in
building effective leadership and has created a link between human needs and
values, and a link between values and leadership.
Negative
Characteristics
The author has ended each chapter with a set of self-evaluation questions to
enhance and measure understanding of the chapters contents. Lists of suggested
reading related to each topic have been provided to further fine-tune the theories
deliberated within. At the end of the book the author has provided three appendices
quantifying the elements of leaderships discussed in the chapter. Although these
exercises are not standardized for reliability and validity, they exemplify the
element. The book is overambitious and proactive in its approach to leadership. It
has idealistic solutions and does not provide contingencies.
The book highlights the following issues, which are most relevant to the current
healthcare industry need for an effective and ethical leadership practices:
tackling the constant stress of high attrition and burnout, focusing on leadership
development, importance of values in effective leadership. And it advocates that the
effective leadership can be learned.

REFERENCES
1. David McClelland (1961)

22 | | 23
 ENGAGING
PHYSICIANS
Author - Prof. Piyush Kumar Sinha and
Kopal Agrawal Dhandhania

24 | | 25
 Physicians play a major role in the intricate mechanisms of healthcare delivery. Dissatisfaction with the profession
Decisions taken by physicians in their everyday practice have an impact on various According to a survey 4 out of 10 physicians (42%) are dissatisfied in their
facets of patient care and functioning of the organization. From providing frontline medical practice and 59% of physicians would not recommend their profession
care to filling leadership positions, physicians drive 75 to 85 percent of all quality
to others 6. Physicians feel overwhelmed and ill-equipped to implement change.
and cost decisions. Physicians must regard themselves as active contributors in
They face heavy work loads and unrealistic expectations. Difficulty in adapting
offering high-quality care and they must engage at the systemic level of planning,
delivering, and transforming on-going health services. Active participation of to work methods, insufficient information on policies, procedures, and reporting
physicians throughout the healthcare value chain, from individual practices to the structures, all lead to physician burnout.
national level, is a prerequisite to eliminate unnecessary costs and capture value.
Researchers have found evident cost of low levels of engagement to physician
burnout7. Organizational psychologists view burnout as the negative end of
Importance of Physician Engagement a work experience continuum, with engagement on the positive end. When
physicians are burned out, or close to it, they are disengaged from their
Physician engagement is proactive physician involvement rates, and improved patient professional role. The cynicism, emotional exhaustion, and lack of professional
and meaningful physician influence aimed at moving a satisfaction scores and patient efficacy that characterizes burnout exists as the opposite of the energy and sense
healthcare organization toward a shared vision and a outcomes. Physicians influence of contribution experienced by highly engaged physicians.
successful future 1. resource utilization, deliver
care and influence its quality,
Physician engagement is becoming increasingly important and affect the speed and
to healthcare organizations as there is an increasing demand
Lack of understanding of management policies
extent of healthcare change
for higher healthcare value (quality, service, and efficiency), processes 3. Hence, to achieve Physicians feel threatened, overwhelmed, and frustrated with the changes. The
which requires clinical knowledge and experience of good patient outcomes at a cost use of business logic to justify such changes and non-medical professionals
physicians to be brought into the healthcare delivery system society can afford, researchers defining what constitutes acceptable treatment elevates the clinician frustration
that is transitioning to an integrated network 2. claim that physician and reluctance to embrace the changes8. Physicians have a poor understanding of
involvement in healthcare management policies along with being risk-averse. The poor communication and
Research from countries around the world show that when improvement processes is understanding of processes highlights the reasons of disengaged physicians.
physicians are engaged the organization tends to perform needed 4.
better, have higher satisfaction levels, lower turnover Hospitals and payers feel that employing physicians is the primary means of
securing alignment9. They tend to neglect the holistic approach of the alignment
at multiple levers (e.g., personal autonomy, clinical autonomy, colleagues, IT
Barriers to Physician Engagement department) that would be more effective. The challenge is also about getting
Lack of physician engagement and accountability is a common point of frustration in doctors to engage with each other to improve quality, safety and value rather
healthcare management. This is also a cause of disparity in interpretations of physician than per se engaging with organizations.
engagement between physician and managers. Mangers talk about physician engagement
in terms of what they would like physicians to do but cannot get them to do; but physicians
talk about engagement in terms of what they already give that is not appreciated, valued or Lack of motivation
supported by the administration 5. There is a lack of incentive for physicians to take on leadership and/or
management roles, and participation in quality improvement initiatives in the
organization. On the contrary, participating in these types of activities are often
Dissatisfaction Lack of seen as a punishment or as going over to the dark side10. Physicians need more
Lack of
with the understanding of than just compensation to drive them to engage in management.
motivation
profession management policies

26 | | 27
 Strategies to Engage
Enhancing physician engagement requires a multistep process that includes
trying to understand their world; encouraging opportunities for input and
participation in care redesign; providing education, training, guidance, and
support; and making the effort to recognize and thank them for what they do. To
achieve a high level of engagement, both providers and payors must understand
physicians attitudes about healthcare delivery and how those attitudes compare
with their own goals and perspectives.11
integrity and they will always be treated fairly with satisfactory resolution for
problems that may occur12 .Hence, hospitals need to have a trustful relationship
with the physicians to consistently deliver on its commitments, such as promising
to make OR slots available so surgeons can perform surgeries in a timely fashion.
Honesty, transparency, consistency, courtesy, empathy, and unfailing respect
all facilitate development of trusting relationships13 . Developing trusting
relationships is critically important to physician engagement. Trust engages the
mind and heart, while strengthens resolve to shared vision and teamwork.

Physician engagement strategy consists of various components, such as Value alignment

building trust, enhanced communication and values alignment, right leadership
Hospital-physician alignment may be defined as a close working relationship
appointment and opportunities, training and development, physician
in which a hospital and physicians place priority on working toward common
performance measurement. The process of engaging physicians in development
fosters collaboration, transparency and respect. It can be used as a framework economic and patient-centered goals, and they avoid conduct that damages
to enhance ongoing dialogue on quality improvement between the hospital and the other.14 Alignment must be of authority with responsibility. If physicians
physicians. are engaged in adoption of processes and policies they are more likely to
understand the rationale behind the standards. To do so, hospitals can assess
the organizations strategic goals, values, and objectives, as well as those of the
medical staff, departments, and divisions. Achieve alignment in areas of common
Building Value value, focused on quality. Clarify roles and responsibilities. And get physicians
Trust Alignment involved early in the strategic phase of quality improvement initiatives by using a
shared decision-making approach throughout the organization.

Linking to Enhanced Enhanced communication

Performance Communication Management need to build a communication channel to listen to what
physicians have to say. Improved conversations contribute to enhancing trusting
Strategies to environment. The management can work on it by understanding the activities of
Engage medical personnel and appreciating the value added by them, such as providing
timely and effective care. It is essential that management understands the
perspective of those who work on the front lines of care. It is not effective to ask
Drive Developing
Motivation a Partnership
physicians to engage in programs that they find is not effective in solving their
issues 15.

Highlight Physician Developing a partnership

Data Leadership Physicians should be treated as partners with the hospital. Involve them in
strategic planning, capital planning, board membership, and senior leadership
deliberations. Allow them to review improvement ideas or tests of change. Show
Building trust them how they fit into the process and why they are important to the success of
Physicians are passionate about caring for their patients and they view hospitals as an the initiative. It will increase their level of engagement and support.
integral part of their practice. Physicians must also believe that the hospital has

28 | | 29
 Physicians and administrators must agree to work together on the issues towards
improving healthcare outcomes. They can learn from one another, and develop
tolerance for alternative points of view, through mentorship and shadowing. They
have a joint responsibility to understand each others mental models, being motivated
to change environmental factors, and developing and implementing a plan.
Physician leadership
Effective leadership balances independence and entrepreneurial drive with
willingness to evolve new team-based models of care delivery. The processes and
delivery system of hospitals are largely controlled by physicians and hence the
importance of their skills and behaviors are critical to improve overall health system
performance. A critical step in engaging physicians and establishing their trust is
by identifying champions among them who can bridge the communication gap and
provide leadership, accountability, and clinical oversight for initiatives intended to
meet standards or improve processes17.
Healthcare organizations must invest in physician leadership education to help
physicians balance and understand the often-competing demands of clinical care
and managerial responsibility. For example, physicians need to know the industry
and marketplace trends that are driving changes in the health care environment.
Doctors require a range of leadership and service improvement competencies from
the moment they graduate, which becomes increasingly important as they progress to
become consultants and general practitioners.18 The chief medical officer and other
physician leaders should be provided in-depth knowledge of health care finance and
payment methodologies, leading population health strategies, quality management
and health care technology.
Highlight data
Physicians are scientists and respond objectively to data presented along with
workable solutions. Initiatives that are supported by up-to-date, appropriate, and
relevant data ensure sustained interest of physicians. Data is an effective tool for
driving changes in physician behavior and practices.
Presentation of data can eliminate opinion and room for disagreement. Its important
to show structural leaders, such as department heads or medical directors, the
evidence through data as they are in position to influence change. Evidence-based
decision making requires specific data, such as the number andtype of emergency
room visits, bed occupancy rates, cost of laboratory testing, etc. This data is
important before the decision making and for continuous tracking of the process
implementation. It is easier to demonstrate effective change and to engage physicians
in the process through such data presentation.
30 |
Drive motivation
Striving for professional fulfillment has been found to be the core to motivate physicians
engagement. Professional fulfillment is described as the satisfying inner experience of
being useful and developing. It has emerged as a continual motivational drive in physicians
decision making, affecting both their clinical engagement and healthcare development
engagement19.
However, to be effective, plans for physician engagement must be segmented, catering to
different needs of different subgroups20 . The segmentation must be based on role,specialty,
tenure, political position, etc. For example, a standing order sets in the cardiac care unit will
save time for the cardiologists and empower nurses to take actions that save the physicians
from having to disrupt office hours to come to attend to a worsening patient. These will be
meaningful to the cardiologists but will do nothing for the orthopedists.
Linking to performance
Linking clinical performance information to severity and financial information tends to
get physicians attention. Physicians will be more engaged in a shared vision for healthcare
organizational success if their efforts to achieve the vision are rewarded. Although
compensation is typically considered in monetary terms, physicians may be rewarded in
multiple ways other than through salary, for instance, physicians who lead and participate
in quality improvement initiatives could be recognized in their annual performance review.
The key point is to reward physicians for objective and measurable behaviors that forward
the organizations mission.
Physicians should feel gratitude for the opportunity to participate and a renewed sense of
ownership for thequality agenda21 .Furthermore, the performance, brand, and positioning
of the physician enterprise will likely rival or eclipse the reputation of the sponsoring
hospital.22 Healthcare systems that proactively engage physicians in the transition to
comprehensive models will be most capable of delivering value care.
1. https://cph.uiowa.edu/ruralhealthvalue/files/RHV%20Physician%20Engagement%20Primer.pdf, accessed on 19thSept, 2017
2. ibid
3. McAlearney AS, Fisher D, Heiser K, Robbins D, Kelleher K. 2005. Developing effective physician leaders: changing cultures and transforming organizations. Hospital Topics: Research and Perspectives on
Health Care 83: 1118.
4. Berwick DM, Nolan TW. 1998. Physicians as leaders in improving health care: a new series in Annals of Internal Medicine. Ann Intern Med 128: 289292.
5. Clark, J. (2012). Medical leadership and engagement: no longer an optional extra. Journal of health organization and management, 26(4), 437-443.
6. http://www.beckershospitalreview.com/hospital-physician-relationships/survey-42-of-physicians-are-dissatisfied.html, accessed on 22ndSeptember, 2017
7. Leiter, M.P., Frank, E., & Matheson, T.J. (2009). Demands, values, and burnout. Canadian Family Physician, 55(12):1224-1225; Shanafelt, T.D., Balch, C.M., Bechamps, G., et al. (2010). Burnout and
medical errors among American surgeons. Annals of Surgery, 251(6):995-1000.
8. Choi S, Holmberg I, Lwstedt J, Brommels M. 2010. Executive management in radical changethe case of the Karolinska University Hospital merger. Scand J Manag. DOI: 10.1016/j.scaman.2010.08.002
9. http://healthcare.mckinsey.com/sites/default/files/MCK_Hosp_MDSurvey.pdf, accessed on 21st Sepetember 2017
10.Mountford, J., Webb, C. (2009). When clinicians lead. The McKinsey Quarterly. Retrieved from http://www.mckinseyquarterly.com/Health_Care/When_clinicians_lead_2293
11. https://www.ncbi.nlm.nih.gov/pubmed/26665482, accessed on 22nd September 2017
12. https://www.healthcatalyst.com/wp-content/uploads/2016/11/The-Best-Way-Hospitals-Engage-Physicians-Nurses-and-Staff.pdf, accessed on 25thSeptember, 2017
13. https://cph.uiowa.edu/ruralhealthvalue/files/RHV%20Physician%20Engagement%20Primer.pdf
14. Bader, Barry. Developing a Hospital-Physician Alignment Strategy. Great Boards. Vol. VIII, No. 4, Winter 2008.
15. http://www.accreditation.ca/sites/default/files/qq-2012-december.pdf
16. Clark, J. (2012). Medical leadership and engagement: no longer an optional extra. Journal of health organization and management, 26(4), 437-443.
17. http://www.healthleadersmedia.com/physician-leaders/strategies-increasing-physician-engagement#, accessed on 19th September 2017
18. Clark, J. (2012). Medical leadership and engagement: no longer an optional extra. Journal of health organization and management, 26(4), 437-443-
19. Lindgren, ., Bthe, F., &Dellve, L. (2013). Why risk professional fulfilment: a grounded theory of physician engagement in healthcare development. The International journal of health planning and
management, 28(2).
20. Reinertsen, J. L. (2008). Finding common cause in quality: confronting the physician engagement challenge. Physician executive, 34(2), 26.
21. Scott, C. G., Thriault, A., McGuire, S., Samson, A., Clement, C., & Worthington, J. R. (2012). Developing a physician engagement agreement at the Ottawa Hospital: A collaborative approach. Healthcare
quarterly (Toronto, Ont.), 15(3), 50-53.
22. Paul Keckley. My Take: A Fresh Look at Physician Employment by Hospitals. The Weekly Memo from Paul Keckley. July 27, 2015.
| 31
 MEDICAL DOCTORS
IN HEALTHCARE
LEADERSHIP:
THEORETICAL AND
PRACTICAL CHALLENGES
Jean-Louis Denis 1* | Nicolette van Gestel 2

32 | | 33

Background: While healthcare systems vary in their structure and available
resources, it is widely recognized that medical doctors play a key role
in their adaptation and performance. In this article, we examine recent
governmentand organizational policies in two different health systems that
aim to develop clinical leadership among the medical profession. Clinical
leadership refers to the engagement and guiding role of physicians in health
system improvement. Three dimensions are defined to conduct our analysis
of engaging medical doctors in healthcare
leadership: the position and status of medical doctors within the system; the
broader institutional context of governmental and organizational policies to
engage medical doctors in clinical leadership roles; and the main factors that
may facilitate or limit achievements.
Methods: Our aim in this study is exploratory. We selected two contrasting
cases according to their level of institutional pluralism: one national health
insurance system, Canada, and one etatist social insurance system, the
Netherlands. We documented the institutional dynamics of medical doctors
engagement and leadership through secondary sources, such as government
websites, key policy reports, and scholarly literature on health policies in
both countries.
Results: Initiatives across Canadian provinces signal that the medical
profession and governments search for alternatives to involve doctors
in health system improvement beyond the limitations imposed by their
fundamental social contract and formal labour relations. These initiatives
suggest an emerging trend toward more joint collaboration between
governments and medical associations. In the Dutch system, organizational
and legal attempts for integration over the past decades do not yet fit well
with the ideas and interests of medical doctors. The engagement of medical
doctors requires additional initiatives that are closer to their professional
values and interests and that depart from an overly focus on top down
performance indicators and competition.
Conclusions: Different institutional contexts have different policy
experiences regarding the engagement and leadership of medical doctors
but seem to face similar policy challenges. Achieving alignment between
soft (trust, collaboration) and hard (financial incentives) levers may require
facilitative conditions at the level of the health system, like clarity and
stability of broad policy orientations and openness to local experimentation.
Keywords: Medical engagement, Clinical leadership, Health system
improvement
34 |
Background
While healthcare systems vary in their structure
and available resources, it is widely recognized that
medical doctors play a key role in the adaptation
and performance of these systems [1, 2]. Physicians
have a unique influence on the utilization of
healthcare resources by prescribing treatments and
drugs. They can play various formal and informal
roles that help creating a rich environment for
improved practices and ultimately increase the
performance of healthcare organizations [3, 4].
Studies on health system performance and clinical
governance emphasize the importance of strong
clinical leadership to drive improvement efforts and
initiatives [5, 6]. Hospital performance is increasingly
associated with medical specialists taking up
tasks beyond direct patient care and develop their
cooperation with executive boards [7, 8]. Leadership
and engagement of other professionals are also
crucial for health system improvement; yet,
the unique status and influence of the medical
profession may require a specific focus of attention.
In this article, we examine recent government
and organizational policies that aim to develop,
implement, sustain and scale-up clinical leadership
among the medical profession. Clinical leadership
refers to the engagement and guiding role of
physicians in health system improvement.
This role goes further than their involvement
in formal leadership positions. It refers to an
active role of doctors in activities for healthcare
improvement that goes beyond their immediate
clinical duties and responsibilities in delivering
care to patients [9]. Spurgeon and colleagues
(2008) suggested that these activities can include
the participation of doctors in managing risks
and quality; the evaluation of programs or
technologies at organizational or system levels; the
involvement in strategic committees that influence
the development of the organization; or the
involvement of physicians in executive roles [10].
Those roles and expectations regarding
professionals and more specifically
medical doctors have been designated
as professional-managerial hybrids or
clinical leaders [11, 12]. Clinical leadership
thus incorporates a variety of roles and
resources that help front-lines clinicians
to introduce new ways of working and
to redesign care for improvements [4].
It is expected that clinical leaders will
influence their peers through their
professional knowledge and skills in
promoting improvement of care within
the context of available resources. They
will also collaborate with managers in
developing organizational strategies that
are aligned with quality improvement [13].
While studies have shown benefits in
the development of clinical leadership
where clinical expertise is combined
with other capacities; the materialisation
and broad-scale diffusion of clinical
leadership for improvement within
healthcare systems is not without
challenges [2, 12]. Professional power
may resist attempts by clinical leaders
to reframe the context of work and the
relationships between organizations
and professions. The position of a
professional elite that gains power and
control over their peers in exchange of
the protection of professional autonomy
- the restratification thesis of Friedson
(1984) - may be contested [14, 15].Because of
those potential challenges, governments
and organizational policies search
for strategies to mobilise a broader
professional base to improve
| 35
 care such as collaborative quality improvement The paper is structured as Several studies have focused on the theme of the organizational, hybrid interact to create
initiatives [16]. A large-scale development of clinical follows. We first review integration and alignment of the medical profession a kind of situated professionalism,
leaders for improvement within healthcare systems needs literature on the challenges within US healthcare organizations [2426]. These influenced by broader changes in
the support of institutional conditions, such as career in engaging medical doctors researchers examined organizational models and the institutional context. These
perspectives and the development of skills and capacities in system and organizational strategies that promote a stronger connection studies stay relatively silent on how
to engage in mediating roles between organizations and leadership roles. Then we between the medical profession and healthcare increased social demands for more
the professions [11, 17]. Studies of organized professionalism investigate how two different organizations and systems through various accountable professions influence the
and hybrid roles [13, 18] have suggested the importance of healthcare systems shape structural and incentives arrangements. One of development, transformation and use
institutional factors that promote or impede the emergence or limit the opportunities the key insights gained from these works is that of clinical capacities for leadership.
of such leadership roles. Studies of medical doctors in for physician engagement structural and economic integration of medical More specifically, we lack knowledge
management have focused on the incorporation of new and leadership. We use the doctors within organizations are not sufficient to on how contingencies at the level of
logics or imperatives in clinical practices (for example illustrative cases of Canada enable genuine engagement and leadership for (healthcare) systems and organizations
accounting in medicine in Finland [19]), impact of quasi- and the Netherlands to improvement. induce a reframing of professional
market in NHS-England on the emergence of medical- analyze recent experiences engagement and clinical leadership.
Other studies have paid attention to the
managers roles [20], and more recently, forms of identities in of medical doctors Attempts to incorporate physicians into
accommodation of the managerial and professional
hybrid roles among medical managers [12]. While these works leadership and engagement. organizational structures are common
logic in knowledgebased and professional
are very informative on the emergence and characteristics Based on key studies in the now, but appear insufficient by itself
organizations [27]. Medical doctors and other
of hybrid roles among the medical professions, they do not field, we discuss strategies for engaging doctors in the redesign
healthcare professionals face increasing pressures
take a system-wide context and health policy perspective on to better engage medical and regulation of health care systems [4].
to work within organizations and to become more
the strategies used to engage medical doctors in hybrid roles doctors and develop their The political context and government
involved in formal organizational settings [28, 29].
and more broadly in improvement efforts. In this paper we leadership for health system policies, in particular policy capacity
Evidence regarding the impact of organizational
look at recent developments in the institutional context of improvement. and coherence [33], can also influence
context on the professional status and practices
medical doctors in two very distinct healthcare systems. the propensity of doctors to engage in
indicates however that the medical
[27, 30, 31]
healthcare improvement and in new
profession has adapted quite well to practice regulatory roles and functions.
in more formal organizational contexts. Such
Challenges in Reconciling Professional and Organizational adaptation can reflect a new balance between
The transition of (some) medical
Logics in Healthcare professional norms and organizational demand
doctors to leadership positions in
healthcare organizations and systems
Professions have incarnated an idealized form of expertise in contemporary for accountability while revealing at the same
is thus associated with several
societies, with an ability to skillfully apply complex knowledge to the resolution of time the ability of some professions to operate a
conceptual and empirical challenges.
problems. The medical profession still represents an ideal-typical form of profession kind of organizational closure [32] or to restructure
One challenging issue is about the
where competent individuals provide highly valued services in unselfish their work in favour of more collaborative forms of
capacity of professionals to invest in
devotion [20] and where professional autonomy is exercised in the context of work to simultaneously achieve professional and
more collective levels of application of
accountability to patients and peers [21]. Sociological studies of the medical organizational goals [30].
professional knowledge and expertise
profession have emphasized the professionals capacity to preserve monopoly over
Although a process of accommodation between while maintaining their specificity
specialized knowledge and to create boundaries that protect the status and roles of and identity in more collective and
the medical profession and organizations has been
doctors in society [22, 23]. distributed forms of leadership [34].
observed in these studies, they do not provide much
Initiatives that aim at involving medical doctors in roles that go beyond the delivery insight into how to convert such accommodation Specifically, the perceived needs
of clinical services will necessarily imply a combination of their professional into resources for professional renewal and health for increased regulation to produce
expertise with other forms of knowledge, and the application of this expertise to high quality and safety of care [35]
system improvement. Analysis by Waring [15], Schott
more collective problems and issues [9]. This is also recognized in the notion of may support the emergence of a new
& al. [18] and Muzio et al. [32] suggest that the roles of
organized professionalism where medical practice is perceived as increasingly professional elite [14, 15] and a new
professionals and their autonomy are in a constant flux science of healthcare improvement that
embedded in a broader organizational context, due to a set of political, economic
and social forces and contingencies that challenges the traditional representation of where various forms of professionalism - occupational, may contradict with the broader
professional work and independence [13].
36 | | 37
 movement of engaging physicians and other front-line professionals in large-
scale improvement [36]. Also, the development of new regulatory tools for making
clinical work more manageable and visible will necessarily impact on the relationships
of medical doctors with their work context and practice settings [2].
Based on our literature review, we clearly reveal three dimensions that are
related to the theme of engaging medical doctors in healthcare leadership:
the position and status of medical doctors within the system; the broader
institutional context of governmental and organizational policies to engage
medical doctors in clinical leadership roles; and the main factors that may
facilitate or limit achievements. We will analyze these three dimensions in the
public healthcare systems of Canada and the Netherlands, and evaluate recent
initiatives to engage medical doctors and develop their leadership for health
system improvement. In the next section, we first explain our methodology.
Methodology
Our aim in this study is exploratory and based on the assumption that the broader
institutional context of government an organizational policies influences the
propensity of medical doctors to move beyond their traditional role as the patients
agent to develop clinical leadership. We selected two cases for the current study
with different institutional characteristics: the Canadian and the Dutch healthcare
systems. These systems represent two contrasting cases [37] regarding the influence
of broad institutional and health system context on the development of clinical
leadership for improvement. The two countries have been categorized in a recent
health system typology as a National health insurance system (Canada) and an
etatist social health insurance system (the Netherlands) [38].
The two cases vary on key organizing dimensions: financing for Canada is through
fiscal resources, regulation is operated by the State and the system relies on private
or not-for-profit providers that are covered by public money for medical and
hospitals services. In the Dutch case, regulation is also operated by the State, but the
role of private providers (like insurers companies) in the governance and finance of
healthcare has been significantly increased since the reform in 2006. A key feature
of the Canadian healthcare system is the strong autonomy of the medical profession
with a focus on negotiating provision and compensation directly between the State
(provinces) and medical associations [39]. In the Dutch case, the system is much more
diverse, and leaves more space for various arrangements or levels of integration
between the medical profession and delivery organizations. The Dutch system is
by its pluralistic nature, as compared to Canada, apparently less centralized, with
probably more space for organizational-professional initiatives than the Canadian
one.
38 |
Based on the work of Tuohy [40] on hybridization process in mature healthcare
systems we argue that some systems leave more space for professional
entrepreneurship and are more receptive for reforms to improve and adapt
the healthcare system (for example the Netherlands), while some other
systems will be more characterized by inertia (e.g. Canada) [39]. Consequently,
systems may offer more or less opportunities for the involvement of doctors
in clinical leadership at both the organizational and system levels, for example
in professional-managerial hybrid roles [12] or in broader improvement process
such as collaborative quality improvement. Aligned with the exploratory
scope of this article, we have documented the institutional dynamics of
medical doctors engagement and leadership in both jurisdictions through
secondary sources, such as websites of governments in each jurisdiction,
identification of key policy reports, and scholarly literature on health policies
in both countries.
Transforming the Role of the Medical Profession:
The Canadian Case
In Canada, provinces and territories are responsible for
the management, organization and to a large part for
the financing of their healthcare system. Each province
and territory develops its healthcare system within
the broader context of the Canada Health Act (CHA or
the Act, adopted in 1984). The Act is Canadas federal
legislation for publicly funded health care insurance
and sets out the primary objective of Canadian health
care policy [41]. Overall, the costs of the healthcare
system in Canada are estimated at 11.2 % as a share of
GDP for an average of 9.3 % for OECD countries [42].
Cost is considered an important policy issue while
for provinces the cost of healthcare represents more
than 42 % of the expenditure in public programs. The
Commonwealth Fund ranks the Canadian healthcare
system poorly to some dimensions of quality, patient
experience and access [43]. Pressures are important to
improve the functioning of these systems and the care
that is delivered.
| 39
 The position of medical doctors in Canada
The basic social contract of Canadian medicine is
one of autonomy, professional entrepreneurship and
arms-length relationships with health systems and
governments. At the time of the creation of the public
healthcare systems in various provinces, it was agreed
that physicians would not be considered as employees of
public healthcare organizations. They mostly maintained
a capacity to operate as autonomous agents in the system,
paid by an independent public agency or third-party
payer [39]. Physician unions (Quebec) or professional
associations negotiate directly their status and practice
conditions through labour agreements with provincial
and territorial governments. Concretely, medical doctors
obtained the privileged right to practice in hospitals/
public healthcare organizations, through the boards of
healthcare organizations and local medical councils,
and medical doctors are more or less regulated by their
peers through various organizational arrangements and
professional colleges depending on the provinces or
territories.
This type of social contract between the medical
profession and the health care systems and more largely
with the society, has been overall very beneficial for the
profession. They still benefit from a lot of autonomy in
regard of their location of practice and development
of their professional career; they have a very high
social status, and they are very well paid. The income
of physicians relative to average wage in Canada is
estimated at 4.7 for specialists and 3.1 for generalists [43].
Recent statistics from OECD (2014) shows that medical
workforce has grown since 2000 but the number of
physicians in Canada (2.5 doctors per 1000 population)
still remained below the OECD average of 3.2 [44]. The
growing number of physicians may put more pressures
on costs and consequently push governments in a better
position to develop initiatives to better engage medical
doctors in health systems improvement.
40 |
Overall, recent analysis [39]
suggests that one of the key
obstacles to reform healthcare in
Canada is related to the ability
of the medical profession as an
organized body to defend their
interests and resist changes
that are perceived against these
interests. Those authors used
the term paradigm freeze to
qualify the inertia within the
Canadian healthcare system that
emanated, at least partly, from
the fundamental social contract
between the medical profession
and the state that somewhat
consecrated a situation of arms-
length relationship between
doctors and governments. We will
now look at strategies that aim
at transcending these structural
limitations in order to better
involve medical doctors in broad
system improvement.
Initiatives to engage medical doctors in leadership for healthcare
improvements
Within the broader context just described,
there are emerging initiatives across Canada to
better engage medical doctors and develop their
leadership for health system improvement. We will
describe here some of these initiatives in various
provinces and assess how they depart from a more
regulatory approach and support the development
of the commitment of the profession for broader
health system goals [45]. The purpose of this case
description is not to provide an exhaustive account
but to briefly account for illustrative purposes of
some trends that are informative on how clinical
leadership of medical doctors develop within and
depart from the situation of paradigm freeze as
we described earlier.
Our analysis of these initiatives reveals two
emerging trends in the Canadian health policy
scene with regards to doctors and the healthcare
system: the emergence of collaborative work for
improvement between the med-ical profession
and governments and a growing emphasis
on accountability relations and performance
manage-ment in shaping the relation between the
profession and public authorities. Those trends
are not mutually exclu-sive, they can compete
for legitimacy which may create tensions in the
relation between medical doctors and government.
We will now describe some initiatives in different
provinces to illustrate the dynamic that surrounded
efforts to develop clinical leadership for health
system improvement among the medical profession.
In British Columbia, the third larger province in
Canada, the Shared Care Committee is created
in 2006 [46]. The committee is a joint initiative
between the British Columbia Medical Association
(BCMA) and the British Columbia Ministry of
Health. The purpose of the committee is to support
initiatives among the medical profession to improve
care in the system. Government funding is provided
to support such initiatives For example, in 2013,
$8 million has been provided to support
21 medical-led initiatives through the
SCC. These initiatives appear to be
based on two principles: they leave a
lot of flexibility to local and re-gional
initiatives in the design of the different
projects and they are essentially
collaborative where the professions
and more specifically the medical
profession is a key driving force.
These initiatives can be considered as
a political trend toward the adoption
of a less adversarial approach in the
relation between the medical approach
and government [47]. It also suggests that
a medical leadership for improvement
agenda becomes integrated within the
discus-sions between the state and the
medical association and consequently
broaden the negotiation space beyond
the working conditions of professionals
Saskatchewan, a province from central
Canada, provides illustration of a
different approach with the launch
in 2008 of a large-scale improvement
program - the Accelerating Excellence
program [48] - to develop quality
improvement initiatives and capacities
across their healthcare system. This
program is strongly driven by the
central government and the diffusion of
the Lean approach has been privileged
as the main driver of improvement:
Saskatchewan is the first jurisdiction
in Canada to apply Lean processes
across its entire health system. More
than 1000 Lean projects have been
launched in Saskatchewan
| 41
 health regions and within the Ministry of Health
and Saskatchewan Cancer Agency (http://www.
saskatchewan.ca/government/health-care-ad-
ministration-and-provider-resources/saskatchewan-
health-initiatives/lean). It is within this broader
provincial effort to improve the system that medical
association and profes-sional college in collaboration
with the government the Champions for Quality
Improvement initiative to support the adhesion of
doctors to the Accelerating Excellence program [47].
Policy trends in favour of health system im-provement
provide opportunities for the development of clinical
leadership among the medical professions. The level at
which the involvement of doctors in the imple-mentation
of the quality agenda will culminate in a large-scale
development of medical leadership for improvement
still an open question. As in British-Columbia, policy-
makers and professional association have agreed that to
involve medical doctors beyond their immediate clinical
duties specific strategies need to be developed taking into
account their singular position and status in the system.
One of the driving forces across Canada behind a greater
co-optation of the medical profession in improve-ment
initiatives are pressures from governments for in-creased
accountability and performance. For example, Ontario,
the largest province in Canada, has promulgated the
Excellent Care for All Act in 2010. A set of initiatives
have cascaded down from this act including new funding
and incentive mechanisms and approaches that place
dis-tinct emphasis on quality and on the role of medical
doc-tors in achieving improvements in healthcare [47].
In addition, the Act introduced Health Quality Ontario,
an agency responsible for the provincial emphasis on
quality. Medical compensation has also been increasingly
tied to evidence based recommendations and
performance tar-gets, with a major emphasis on primary
care [49]. Ontario, somewhat similar to the situation in
Saskatchewan, illus trates a situation where a strong
policy-drive from the provincial government set up a
new context to approach the role of medical doctors in
improvement. An important role is attributed here to the
management of performance and to the use of incentives
to stimulate involvement in quality improvement.
Quebec, the second largest province of Canada, has
42 |
promoted the engagement and
the leadership of medical doctors
for health system improvement
through time with various
structural arrangements like the
creation of medical advisory or
planning bodies at the central
government and regional
levels and various executive
positions for medical doctors
within the health care system.
A current healthcare reform
combined elements of massive
restructuring across the system
(effective April 1, 2015), budget
rationalization and a new policy
to set productivity targets for
primary care physicians. Medical
doctors union engaged in intense
negotiations with the govern-
ment to postpone the application
of the new bill in ex-change of a
guarantee to meet productivity
targets [50].
These major policy initiatives
reflect the importance played by
the regime of labour relations
and the social contract between
the medical profession and the
State in shaping the involvement
of doctors in improvement ini-
tiatives. Development of clinical
leadership for improve-ment
among medical doctors is also
strongly influenced by the broader
context of big-bang reform in
the Quebec healthcare system.
Compare to the three others
provinces, the implementation of
large-scale restructuring may have
left less space for the development
of collaborative work for
improvement between medical
doctors and the government.
While in all provinces the institutional arrangements associated with the
labour negotiation regimes influence the framing of expectations and the
roles taken by the medical profession in im-provement initiatives, the history
of broad structural reforms in Quebec suggests that it has somewhat made
more challenging to develop a more collaborative policy agenda.
Facilitative and limiting factors within the Canadian cases
These initiatives across Canadian provinces signal that the medical
profession and/or governments search for alternatives to involve doctors in
improvement initiatives beyond the limitations imposed by their fundamental
social contract and formal labour relations regimes. While the examples we
discussed kept the attributes of a topdown policy process (Quebec, and to a
lesser degree Saskatchewan and Ontario); the shared objective of improving
patient care and the pressures for increased performance and account-ability
seems to favour the development of a more collaborative approach around
specific policy initiatives. Joint improvement work and more affirmative
performance management can be a way to transcend a situation of paradigm
freeze that have characterized healthcare reforms in Canada [39].
One may retain from our analysis of the Canadian cases that the ability
to engage the medical profession in large scale improvement cannot be
understood without paying attention to the broader health system policies
and governance context. Strategies to engage doctors are, at least partly,
conditioned by the labour regime and by the policy-drive of governments
to support large-scale improvement. Collaborative work between medical
doctors and the state is still an emerging phenomenon. It is too early to assess
the implications of these policies and initiatives for the evolution of medical
professionalism including for the constitution of a new medical elite that
will carry on the improvement agenda. In addition, the capacities of medical
doctors involved in improve-ment work to impose themselves or to mobilise
rank and file doctors at a sufficiently large-scale are still an open question. It
is also too early to assess the performance agenda within the regulation of the
medical profession and its influence on their behaviors as providers of care.
| 43
 Engaging Medical Doctors in Healthcare Leadership: The
Dutch Case
In the Netherlands, the national government is responsible for regulating the
healthcare system and setting main strategic priorities. Hospitals and primary
healthcare services develop their management and care activ-ities within the context
of the Dutch Health Insurance Law (the Zorgverzekeringswet, Zvw), introduced on
1 January 2006. The Health Insurance Law is a mandatory basic insurance that
covers common medical care and medicines. For long-term nursing and care, there
is an-other statutory form of insurance, the Long-term Care Act (Wet Langdurige
Zorg, WLZ), introduced on 1 January 2015. Dutch residents are automatically insured
by the government for WLZ, but have to choose and pay individually for their basic
healthcare insurance. Health in-surers have to offer a universal package for everyone,
re-gardless of age or health conditions, but may compete for price. Contrary to many
other European systems, the Dutch government is responsible for the accessibility,
quality and ultimate costs of the healthcare system, but not in charge of its
management [8]. Private health in-surers have a pivotal role since the Health Insurance
Law in a system of managed competition. Although private (mainly not-for-profit)
organizations play a main role in executing the Dutch healthcare system, 85 90 % of
the health care sector is collectively financed through compulsory contributions and
taxes.
Overall costs of the healthcare system in the Netherlands are estimated at 11.8 % of
Dutch GDP in 2012 [44], which is around the level in Canada and above the OECD
average. Cost containment is one of the most important issues in the negotiations
between the Dutch national government, health insurers and healthcare providers,
such as hospitals. In comparing healthcare systems in Europe on indicators such as
patient rights and information, accessibility, prevention and outcomes, the annual Euro
health consumer index (EHCI) found in 2014 that the Netherlands maintained its top
position from the past five years. The Commonwealth Fund also shows that the Dutch
system has generally high scores on performance; however, several aspects such as
accessibility, prevention, and the varying quality and costs of healthcare providers
show a clear room for improvement [43].
The position of medical doctors in the Netherlands
Traditionally, medical doctors have a strong position in other European countries.
the Netherlands. This is due to their high professional While nearly all physicians in
status, but also to relatively low numbers, compared to hospitals in France, England,
many other European countries. For example, Germany Denmark and Germany are
and Denmark have twice as much medical specialists employees; in the Netherlands
per 1,000 inhabitants than the Netherlands [51]. Within only 40 % of the approximately
healthcare organizations, and in particular hospitals, the 21,000 medical doctors in
position of medical specialists is distinct from most hospitals have an employee
44 |
status. The other 60 % is entrepreneur and allied to the hospital with a
special management agreement[51]. In 2012, the Dutch government decided
for a revenue ceiling for self-employed doctors, which will be implemented
gradually over the next years. Although the position of medical doctors
with an entrepreneurial sta-tus in the Netherlands is still strong, there are
(ongoing) political pressures for more standardization and integration of
medical doctors in hospital governance
Initiatives to engage medical doctors in leadership for
healthcare improvements
Over the past decades, there have been main attempts in the Netherlands
to integrate medical specialists in hospital governance [8, 52]. Already in the
1980s, medical specialists were supposed to play a more crucial role by
getting involved in management tasks on a clinical- (organising care) and
organisational level (hospital as a whole) ([8] p. 325). Such initiatives to engage
medical doctors in leadership roles beyond immediate patient care were
however accompanied by governmental policies to restrict their independent
status as non-employees and related (higher) incomes [52]. The initiatives to
involve doctors in hospital management while simultaneously limiting their
revenues led to tensions and barriers between hospital boards and medical
specialists in developing common policies for healthcare improvements.
In a context of growing concerns about rising health care expenditures, in the
mid-1990s, medical specialists and ex-ecutive boards of hospitals started to take
up joint responsi-bility for setting up and launching a strategic direction for the
hospital; the so called Integrated Medical Specialist Organisation model [52]. In
these initiatives, medical specialists were expected to take more responsibility
for organ-isational tasks and development, which meant that medical work no
longer contained medical activities alone, but con-sisted of inter-disciplinary
managerial activities ([8] p.325).
At the level of the broader healthcare system, major national healthcare
organizations provided joint agreements for healthcare improvement. For
example, the joint Health Care Sector Organisations (hospitals included)
took the ini-tiative to establish the Care-Wide Governance Code for good
management and supervision [53]. This Governance Code is accepted and
applied by every healthcare organisation in the Netherlands; it defines among
others the responsibilities of the executive board, having the final responsibility
for managing the healthcare organisation and its risks, and for ensuring
that all medical specialists, either employees or entrepreneurs, fulfil their
responsibilities. Given increasing pressures for cost containment, and growing
concerns for healthcare quality, the various stakeholders at different levels in
the healthcare system thus took initiatives to develop closer ties and common
views between hospital management and medical doctors.
| 45
 Over time, the theme of governance, quality and safety
received ever more attention in healthcare, with an
in-creasingly prominent role for professionals, such
as medical specialists. In 2009, the Council for Public
Health and Care delivered its opinion that healthcare
governance cannot function without professionals
being held accountable for their actions in the report
Governance and Quality of Care (2009) [54]. This
report was supplemented with an advisory letter on the
Relationship between the medical specialist and the
hospital in the light of the quality of care. (2010) [55].
Other influential organizations also argued for improving
the healthcare system on quality indicators. For example,
the Netherlands Court of Audit produced a critical report
on the Evaluation of the Quality of Care Institutions
(2009) stating that quality standards are insufficiently
and should be better monitored [56]. And the Healthcare
Inspectorate expressed its critical vision in the report
Beyond permissiveness. Control and monitoring of
quality and safety (2009) [57]. These critical views were
incorporated in a new regulatory framework of the IGZ-
Toezichtkader [58] for supervision of healthcare systems
quality and safety. The Order of Medical Specialists,
being the largest professional association of medical
doctors, published a Quality Framework (2010) about
the relationship between medical specialists and boards.
A most critical issue in this code of conduct is that
medical specialists and executive boards should work
together to guarantee quality and improving specialist
medical care. We thus perceive a growing emphasis on
the necessity for engaging medical doctors in integrated
efforts for improv-ing the Dutch healthcare system.
In the Netherlands this has resulted in a recent
government reform (2015) for a new financial structure
and incentives for collaboration between hospital boards
and medical specialists. From 1 January 2015 onwards,
an in-tegral tariff has been introduced for hospital
medical care and two budgets which were formerly
distinct and separated are now allied: the budget of the
hospital and the fee budget for medical specialists. The
government reform aims to encourage hospitals and
medical specialists for a more intensive and long term
collaboration, to en-sure that the hospital is sufficiently
46 |
prepared for the future in
terms of care functions and
costs. The government reform
is meant to stronger unite
the goals of hospitals and (in
particular self-employed)
medical doctors, to let them
develop jointly the strategy and
future of hospital care.
The introduction of bundled
payment implies that the
hospitals and medical doctors
should discuss together the
hospitals policy and have to
negotiate the fees of medical
specialists. As a result of the
recent reform, the hospitals
and medical doctors are
searching for a new model for
management and organization.
Until 2015, most self-employed
medical doctors in the
Netherlands were organized in
so called partnerships: a group
of specialists, who usually
share the same specialty and
provide care to a particular
patient group. Given the 2015
government reform, this
partnership form is currently
under discussion. Basically,
there are three alternatives
[8].
First, the Salaried Model
where the self-employed
medical doctors become
employed at the hospital as
employees. A second model
is the Cooperation Model,
where medical specialists
organize themselves in their
own organizations (Medical
Specialist Companies) that can
conclude an agreement on
collaboration with the hospital. A third option is the Participation Model
where medical doctors become co-owners of the hospital. So far, in most
hospitals in the Netherlands, medical doctors have chosen for the second
model and started Medical Specialist Companies (MSCs) on a cooperative
basis. Much attention has been spend and is still focused on the new structure
for management and organization, which does not necessarily imply
increasing engagement of medical doctors in activities beyond direct patient
care or formal leadership roles.
Facilitative and limiting factors within the Dutch case
Within the broader healthcare system in the a better basis for a collaborative
Netherlands, the position of the medical specialist effort in developing the hospital
in relation to the hospital has been developed from strategy and improving healthcare;
coexistence to dialogue and formal models for it seems as if it does not guarantee
integration in the past decades [59]. Several system more collaboration yet and even may
reforms, in particular the market-based reforms work out in opposite direction. For
with the Health Insurance Law in 2006 and a new example, the new Medical Specialist
funding system for reimbursing medical treatment Companies have increased the
(DTCs), have created a strong mutual dependence collective autonomy of self-employed
be-tween organizations and professions in the medical doctors, which result in a
healthcare field for improving and controlling the stronger position for negotiation
quality of care, the vol-ume (production) and cost/ with the hospital boards but does not
benefit ratios [59]. Mutual dependence between necessarily lead to more engagement
healthcare organizations and medical doctors is of medical specialists in leadership
also evident in the internal organization of hospitals roles that go beyond patient care [60].
wherein hospital units are increasingly headed It seems as if the evaluation of earlier
by a medical specialist and a manager of business initiatives [52] is relevant here as well:
who are together fully responsible for quality,
[] the effectiveness of government
production, personnel and finances. The new
policy is rather limited because
regulations, financial incentives and organizational
of counter strategies of medical
changes are aimed to facilitate health systems
specialists. Led by the self-employed,
progress. They may create the conditions for
medical specialists have opted in
medical doctors to become stronger involved in
favour of a strategy of collective
roles for improvement that go beyond their direct
organisation in hospitals. This
responsibilities for patient care and collaborating
strategy is taking the medical
with peers.
specialists and the hospital in
Limitations of the initiatives so far seem to be a different direction from that
found in the emphasis on structure, finance envisaged by the government. []
and organization rather than on process, The way in which the integration
communication, and professional values. Although has evolved might equally well be
the 2015 governmental reform aimed for integrating designated as separation rather than
the medical specialists in hospitals and created integration ([52], p.137).
| 47
 Overall, the organizational and legal attempts for integration over the past decades do policy guidance with bottom-up and joint initiatives and the need to better connect
not yet fit well with the ideas and interests of medical doctors in the Dutch hospital between medical bodies and governments. Health medical practice to broader
sys-tem. A recent evaluation of the new system of bundled payment since 2015 [60] systems in Canadian provinces are structur-ally organizational and system goals. In
shows that medical doctors in the boards of Medical Specialist Companies (MSBs) more centralized than the Dutch healthcare system the Dutch case, with a very different
often perceive more influence on improving the quality of patient care; but express and less players are involved in their regulation. For policy background and a much more
that in general, medical specialists seem less engaged: the involvement of medical health systems in Canada, the main challenge with plural healthcare system, the situation
specialists can be improved and their attendance at MSB-meetings is often limited. regard to medical engagement and leadership is to of the medical profession in terms of
([60] p.5). A large majority of the hospital boards in this study is negative about the promote collaborative and large-scale improvement autonomy and ability to protect itself
benefits of the cooper-ation model. 80 % of the hospital boards in this study perceives initiatives that can provide an arena that is from engagement and leadership in
the new system as a costly and time consuming exercise, while the changes in daily sufficiently distinct and attractive to mobilize extra clinical roles appears basically
practice have little or no positive impact on patient care ([60] p.5). Engagement of the medical profession, and to escape from the similar to the Canadian cases.
medical doctors in leadership roles for and beyond direct patient care may require constraints and somewhat conflicting tone of the
The challenge for the health system
additional initiatives that are closer to their professional values and interests, to labour regime and the fundamental social contract
in the Netherlands is there with
let them become engaged in collaborative efforts for more quality and safety and between the State and the profession. While joint
also somewhat similar to the one
create better cost containment. Governmental and organizational policies with an work carries a more voluntary tone, we observed
found in the Canadian cases, to
overly focus on top down performance indicators and competition seem to turn out that any serious and enduring medical engagement
promote collaborative and large-
counterproductive. and leadership development strategy will require
scale initiatives that are able to
some innovative policy for physician compensation
mobilize the medical profession
and performance management, to take into
Discussion: Lessons from the Two Healthcare Systems account the time that physicians are dedicated to
for healthcare improvements
beyond a single focus on efficiency
Medical professions have been historically influential extraclinical roles and to move from local initiatives
and cost containment. For both
in shaping the healthcare systems and the delivery healthcare systems is to broader changes in the system. In addition, the
jurisdictions, the development of
of care[52]. Of course, the degree of autonomy and the the capacity to create an capacity to compensate physicians for leadership
medical leadership for health system
influence exerted by the medical profession may vary intermediate space in these development activities, such as training, appears
improvement in various capacities
across various systems and jurisdictions, but it is widely systems [64] to mediate and important. Such an innovative policy coupled with
(formal senior executive positions,
recognized now that medical leadership and engagement ac-commodate potentially capacity development is required to transcend
leaders of improvement initiatives
in roles that go beyond individual doctor excellence is conflicting forces or pressures current structural limits of the system.
etcetera) seems a pre-requisite to
an important asset for the performance and the future to develop transformative
In the Dutch case, government policies have support the wide engagement of the
of healthcare system [61, 62]. Most health care systems, in and improvement capacities.
evolved to-ward a more market like model that on profession in improving the system [62].
a more or less expli-cit way, address through reforms This implies that governments
the one hand seems to confirm the desire of the However, this is not easy to achieve.
or policies the challenge of engaging medical doctors and healthcare organizations
medical profession for maintaining a high degree of An empirical study of medical
and developing their leader-ship for health systems have to search for strategies
autonomy, but on the other restricts this autonomy doctors by Kurunmki [19] shows
improvement [63]. to locate clinical/med-ical
due to limitations set by private health insurance that in the health system in Finland
practice at a more collective
In this paper, based on two jurisdictions, we have companies and financial policy conditions. One considerations for cost management
level and also to install medical
analysed the strategies used to mobilize and convert of the challenge of the Dutch system, somewhat are incorporated in medical practice,
leadership and engagement
the expertise, ability to influence and legitimacy of the similar to the Canadian case, is to channel the blending clinical expertise with
in so-called less structured
medical profession in an asset to transform and improve variety of initiatives within a coherent and global accounting principles. The expansion
systems like networks [65].
health systems. We depart from works in the field of regulatory framework. As observed, a majority of a process of hybridization
hybridity and medical managers by taking a system of physicians choose for a model of practice (the to generate large-scale quality
To address these challenges
approach to the emergence of these roles and attempt to Medical Specialist Company) that affirms their improvement appears a persisting
faced by mature healthcare
elucidate some of the policy challenges and opportunities status of quasiautonomous entrepreneurs in the challenge, despite earlier initiatives in
systems [39], governments have
to achieve broader engagement of medical doctors in system. As in Canada, there is a constant tension that direction in the two systems that
promulgated policy changes
health system reforms and improvement. One of the between the desire to nurture professional we analyzed.
that appear both in Canada
fundamental policy challenges with regard to the role of entrepreneurship (and autonomy) in the system
and the Netherlands as a
48 |
the medical profession in the evolution of contemporary combination of top-down | 49
 Overall, based on a comparison of the two jurisdictions, Canada and the Netherlands,
it appears that broad health systems differences leave open the question how the
autonomy and expertise of the medical profession can become a driver of large-scale
improvement. In both cases, specific initiatives at the level of the healthcare systems
have to be developed to support the involvement of medical doctors in health system
improvement. Laissez faire in this regard will probably provide only small scale and
local improvement initiatives in which the role of the medical profession in terms of
leadership and engagement is underdeveloped. The development of broader clinical
engagement and leadership for health system improvement requires deliberate
policy initiatives that can engage the medical profession and governments in some
form of joint or collaborative policy-making [66]. Regulatory approaches without
such engagement and medical leadership appear insufficient for real healthcare
improvement.

Conclusion
Our paper dealt with the relation between the health transcend current limitations.
system context and the opportunities and constraints for Joint and collaborative
medical doctors to engage in health system improvement, policy initiatives that pay
and provide leadership beyond their traditional, though serious attention to capacity
still extremely relevant and demanding, role of care development and policy
for patients. In this article, we have used illustrations coherence can be a promising
of policy initiatives in two jurisdictions that aimed venue. Capacity development
to influence the role of the medical profession in and collaborative work around
achieving broad health system improvement goals. im-provement were discussed
While individual clinicians can be fully motivated in the context of the Canadian
and engaged in delivering the best care, they seem to cases as an alternative
depend on a sup-portive environment to achieve high approach to support the
standards of prac-tice and to use resources wisely [3]. The involvement of medical doctors
medical profession plays a key role in developing such in broader organizational
environment. The status of the medical profession makes and health system goals. In
them a unique case in the healthcare system when it this analysis, strong policy-
is time to foster a more collective view on professional drive and incentives reveal
practice. The embeddedness of the medical profession to be essential components
within a highly institutionalized context (labour regimes, to stimulate interests in joint
tradition of autonomy and arms-length relationship with work at a sufficient scale.
government and management) obliges policymakers and In the Dutch case, the use
the professionals to elaborate strategies and initiatives of financial incentives to let
to compensate the limitations imposed by current the executive board and the
institutional rules and discipline [67]. medical doctors in hospitals
agree on common goals has
We suggest through this analysis that the use of
been predominant. Both
regulatory constraints is not sufficient to create a durable
countries can learn from these
momentum within the medical profession in order to
different approaches to
50 | | 51
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 Contact Information:

Prof. Piyush Kumar Sinha,

Professor in Retailing and Marketing,
Wing 10, IIMA
Ahmedabad - 380015, India
Phone: +91 98250 70891
Email: pksinha@iima.ac.in

The Core Team:

Aakanksha Sinha, IIMA

Kopal Agrawal Dhandhania, IIMA
Jyotishman Boruah, Abbott
Kunal Kanera, Abbott
Minali Shah, Abbott
Rohit Ardeshana, Abbott
Samprita Sinha, Abbott
Vishwanath Swarup, Abbott

Disclaimer:
The views expressed in this are personal of speakers and authors.
IIMA and Abbott are not responsible for the same.

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