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Perspectives in Primary Care: Values-Driven Leadership is Essential in Health Care

Why is it that in spite of many reports that identify the limitations of current health care systems and recommend transformative solutions, change has been painfully slow and disappointingly limited? One critical factor is the influence of leaders who understand that health care is a complex adaptive system.1–3 Because of their training and experience as generalists who deal with undifferentiated illness, family physicians are particularly suited to leadership in current health care environments where evidence is often incomplete and the way forward is uncertain. These limitations are especially evident in primary care. We are challenged both to include education for values-driven leadership as a core competency and to inspire family physicians to seek out and embrace leadership opportunities. 
 
In a 2011 response paper1 to an article by Lindstrom et al2 on collaborative health policy making, Allan Best and I suggested a 6-factor framework for implementation of change in health systems, including values, governance, learning networks, innovation research, systems thinking, and leadership (Figure 1). A key principle in this framework is leadership—and not just any kind of leadership. We argue that leaders are needed who can develop working partnerships, grounded in shared values and understanding of the need for systems thinking in health care. Core values are patient and family-centered care, social responsibility, and equity; commitment to change in outcomes; and an evidence-informed approach that integrates research, theory, and practice knowledge in action. If change is to be achieved, these core values must be shared by leaders across the health professions, administration in our institutions, and relevant government departments. 
 
 
 
Figure 1 
 
Implementation framework for change in health care. 
 
 
 
Leaders who understand complex systems know they can and must rely on facilitation and empowerment and participatory action methods, rather than on “command and control”; that they must continuously evaluate outcomes and make further changes iteratively: “Instead of attempting to impose a course of action, leaders must patiently allow the path forward to reveal itself.”4 Leaders must model openness, risk taking, and reflection, and communicate a compelling vision of what will be achieved by implementation of change. They need to provide support and advocacy to lead others to embrace the vision while appreciating diversity of opinions.5–7 They must recognize that their colleagues may be risk averse or overloaded with other demands, and that change may come slower than desired. Patience and excellent team and communication skills are essential. 
 
At the same time, the environments where leaders work need to encourage risk taking and to see unsuccessful interventions as opportunities for learning and modification, rather than personal failures. This is not the case at present. Can our health care institutions become safe and encouraging places for health care leaders and innovation, and improve the likelihood that attempted changes are both effective and sustainable? How can leaders from medicine, nursing, and other health professions advocate effectively for our health care environments, including community-based settings, to become learning organizations and networks? 
 
Meanwhile we can develop and nurture medical leaders within primary care. We can incorporate formal leadership education for medical students and family medicine residents8,9 that goes beyond traditional leadership skills training, to ensure that our graduates understand how complex systems function and how to lead within self-organizing structures. We can provide opportunities for participation in real-life change situations within hospitals, outpatient practices, health care/community partner collaborations, and other situations so learners can experience how shared leadership models work. Medical learners can appreciate that sometimes change strategies will be best led or co-led by leaders from other health professions, particularly nursing, or by managers. We can drive home the message that, by being values-driven leaders, physicians can influence contemplated solutions to health care problems so that changes result, not only in cost savings, but also in improvements in patient and family-centered care and equity. 
 
If we really want our future family physicians to become leaders, we must model leadership ourselves. Instead of complaining about the system, we can take up leadership opportunities and advocate for patients and families, for equitable care, and for healthy communities.10 By demonstrating values-driven principled leadership, we can inspire our colleagues to invest their time and energy into leading change. If enough leaders emerge who have a sophisticated appreciation of how the system operates, optimism that change is possible, and an unshakeable belief that evidence-informed change with measurement of outcomes is the only sensible way to deal with health care problems that confront us, maybe we can actually move from talk to action.