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<h2 class="hd hd-2 unit-title">Why is leadership development needed for innovation in global health?</h2>
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<h4>Leadership in Global Health</h4>
<p>In order to successfully bring new technologies, modes of care delivery, and other innovations to under-resourced communities, effective leaders must manage the interests of multiple parties. Funders, government officials, existing healthcare structures, and the needs of the community must all play a role in successfully implementing new approaches and technologies. To achieve these goals, leaders and innovators must have the skills to address the needs of competing parties while they provide care that is accessible, and has both high quality and low cost. Though these challenges apply to healthcare in all settings, they are amplified and especially daunting in resource-poor countries.</p>
<p>Overcoming these challenges in healthcare requires many critical success factors, arguably the most important of which is effective leadership. This section reviews the issue of leadership needs for innovating in global health. Specifically, we first discuss why leadership development is especially important for healthcare providers. Next, we review leadership competencies, both in general and in the specific context of healthcare. Finally, we review the leadership competencies that are most relevant to healthcare in resource-poor settings.</p>
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<h4>Leadership and Innovation</h4>
<p>Leadership skills are needed for innovators in global health to address the competing priorities and other challenges in this area. The need for leadership development is compounded by the fact that, at least in the case of physicians, the training experience cultivates behaviors that are antithetical to teamwork and collaboration. In pointing out the features of medical training that conspire against physicians' having teamwork behavior (long and hierarchical training, a heavy emphasis on individual performance throughout training, and deficit-based thinking), Stoller suggested that "doctors are collaboratively challenged. A recent literature review suggests that similar dynamics confound nursing education and practice. These insights are not new; writing in 1978 regarding "why organizational development had not worked (so far) in medical centers". Weisbord pointed out that Science-based professional work differs markedly from product-based work. Health professionals learn rigorous scientific discipline as the 'content' of their training. The 'process' inculcates a value for autonomous decision-making, personal achievement, and the importance of improving their performance rather than that of any institution. Taken together, this divergence between the need for effective leadership and teamwork in healthcare and the innate and trained behaviors of healthcare providers creates a paradox that must be addressed by developing leadership competencies among healthcare providers.In business sectors outside of healthcare, leadership skills are widely acknowledged to drive success and leadership development programs have been widely implemented in a range of businesses, e.g., General Electric, IBM, Boeing, Federal Express, Toyota, Motorola, etc. Requirements for a successful leadership development program have been studied and include:</p>
<ul>
<li>
<p>Having an influential champion,</p>
</li>
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<p>Having an institutional perspective that leadership is needed throughout the organization,</p>
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<p>Ensuring that the development program is tied to a current business imperative,</p>
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<p>Ensuring that programs are integrated as a process in an over-arching strategy, not as standalone activities,</p>
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<p>Having dedicated facilities, with preference for an off-site location, and</p>
</li>
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<p>Patience by organizational leadership.</p>
</li>
</ul>
<p></p>
<p>For example, General Electric (GE) invests $1 billion/year in supporting the Jack Welsh Leadership Development Center in Crotonville, New York, which annually invites both junior and senior GE employees to engage in progressive learning about leadership competencies. Reflecting a longstanding commitment to developing leaders at GE, the Center was established in 1956. In addition to similar commitments to developing leaders in other traditionally successful companies, leadership development programs also continue to be important in younger, emerging companies like Mozilla, developer of the Firefox browser.</p>
<p>Multinational companies also recognize the need for leadership competencies to ensure the success of global business endeavors. Terrell and Rosenbusch examined the characteristics of successful global leaders and reported that they:</p>
<p></p>
<ul>
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<p>Develop through first-hand global leadership experience,</p>
</li>
<li>
<p>Understand the importance of cultural sensitivity, relationships, and networks, and</p>
</li>
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<p>Are driven by curiosity, openness, and a desire to learn.</p>
</li>
</ul>
<p>The healthcare industry has generally lagged behind other business sectors in focusing on leadership development; indeed, in healthcare organizations (and particularly in academic medical centers), the selection of leaders has usually been based on traditional criteria of academic, clinical, or scientific prowess rather than on candidates' distinctive leadership competencies. These traditional criteria overlook the fact that leadership competencies differ from scientific, clinical, or academic competencies and are not generally taught as part of traditional healthcare training. As such, attention to developing the leadership competencies of healthcare workers has been relatively sparse.</p>
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<h2 class="hd hd-2 unit-title">What is Leadership?</h2>
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<p>The following videos are presented by:</p>
<p>Deborah Ancona, PhD<br />Professor of Organizational Studies<br />Director, MIT Leadership Center<br /><br /></p>
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<h3 class="hd hd-2">Leadership Models</h3>
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<h2 class="hd hd-2 unit-title">Leadership for Healthcare</h2>
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<h4>Components of Leadership</h4>
<p>Many models of leadership have been proposed and debated; much of the debate has centered on the discussion of leadership as an innate 'trait' (e.g., as something analogous to extraversion) versus as an 'ability' a set of skills that can be learned, practiced, and developed by individuals. The latter models, in which leadership is characterized as a set of competencies that can be evaluated and cultivated, are especially relevant for healthcare providers.</p>
<p>In our experience, the leadership model proposed by Kouzes and Posner offers a useful approach in healthcare, because the competencies can be both evaluated and developed. The leadership assessment instrument for the Kouzes and Posner model, called the Leadership Practices Inventory (LPI), was developed by surveying leaders in the public and private sectors from a variety of countries; factor analysis was then performed to confirm the validity and reliability of the instrument.</p>
<p></p>
<p>In this model, Kouzes and Posner describe five components of leadership:</p>
<ul>
<li>
<p>"Challenging the Process" describes the drive of leaders to grow, improve, take risks, and to learn from mistakes,</p>
</li>
<li>
<p>"Modeling the Way" describes those leaders who describe and then act on high standards in all aspects of their work,</p>
</li>
<li>
<p>"Inspiring a Shared Vision"describes those leaders who are able to inspire and appeal to all of their team members to create a vision together,</p>
</li>
<li>
<p>"Enabling Others to Act" is the skill of cultivating leadership in the whole team, and</p>
</li>
<li>
<p>"Encouraging the Heart" describes leaders who understand and recognize the critical contributions of each team member to the overall success of the team, and who celebrate those accomplishments regularly.</p>
</li>
</ul>
<p>All five of these competencies have been consistently identified in great leaders and can be evaluated by an individual, by persons who are their supervisors, their peers, and by the individual who reports to them. In other words, these traits are amenable to analysis in a so-called "360° feedback analysis" Such a 360° evaluation is a key component of a successful leadership development program, as it provides leaders with others' feedback and with the self-awareness that is necessary to develop areas of relative weakness. As an example of many such instruments, the LPI has 30 items which are scored on a Likert scale, and the instrument can be used to identify areas of strength in individual leaders, or to identify where leaders can improve on their already existing skills and practices. The inventory has been consistently useful in studies of persons in a wide variety of fields, and offers a concrete resource for measurement of leadership, and targeting improvement. Many other examples of such feedback tools exist, including the Emotional Competence Inventory, the Global Leadership Life Inventory, books and reviews dedicated to the various tools, and several healthcare-specific tools, often used in evaluating physicians.</p>
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<h4>Competencies Required of Global Health Leaders</h4>
<p>In her scholarship on the competencies of exceptional leaders in a wide variety of settings, Goodall suggested that technical competency is necessary but not sufficient for great leadership. Boyatzis agrees, and frames this notion as being composed of two different sorts of competencies. First, 'threshold competencies' are the baseline skills that are necessary to be considered for a leadership position. In the case of healthcare workers, the threshold competencies for leadership are expertise and experience in one's field of clinical or scientific specialty, knowledge, and cognitive competencies such as memory and deductive reasoning. Examples of "threshold competencies" include what are traditionally considered as criteria for advancement to leadership positions in academic settings like grantsmanship, academic accomplishments, achievement of funding, clinical respectability, etc.</p>
<p>In contrast to these threshold competencies, so-called "ifferentiating competencies" may have little to do with traditional promotional criteria and are the traits that will determine one's leadership effectiveness. These differentiating competencies include more complex cognitive competencies like pattern recognition and systems thinking and, most importantly, Emotional Intelligence.</p>
<p>Emotional Intelligence, defined as 'the ability to perceive and express emotion, assimilate emotion in thought, understand and reason with emotion, and regulate emotion in the self and others,' describes a set of behaviors that are explicit and can be taught to and cultivated by leaders seeking to increase their skills. These models are often chosen by healthcare institutions that wish to develop leadership skills in their providers, with frequently favorable results. For example, in a review of key competencies in programs devoted to physician leadership development, Stoller proposed the following clusters of competencies as differentiating competencies in healthcare providers:</p>
<ol>
<li>
<p>Technical knowledge and skills (i.e., of operations, finance and accounting, information technology and systems, human resources [including diversity], strategic planning, legal issues in healthcare, and public policy),</p>
</li>
<li>
<p>Knowledge of healthcare (i.e., of reimbursement strategies, legislation and regulation, quality assessment and management),</p>
</li>
<li>
<p>Problem-solving prowess (i.e., around organizational strategy and project management),</p>
</li>
<li>
<p>Emotional Intelligence (i.e., the ability to evaluate self and others and to manage oneself in the context of a group),</p>
</li>
<li>
<p>Communication (i.e., in leading change in groups and in individual encounters, such as in negotiation and conflict resolution), and</p>
</li>
<li>
<p>A commitment to lifelong learning.</p>
</li>
</ol>
<p></p>
<p>Similarly, Davidson et al. interviewed 21 senior leaders in health research organizations using the Health Leadership Competency Model found that the most critical skills needed for leadership in their organizations included: talent development, collaboration, strategic orientation, and team leadership. They differentiated those priorities for senior members of leadership teams - financial skills and scientific achievement - from those needed by emerging leaders - scientific competence, information seeking, and a strong work ethic. Also, in a study of nurses, residents, and physicians in an academic medical center, Dine et al. found that four leadership concepts were important but lacking in training of leaders: management of the team (utilizing the skills of the persons on the team to maximum effect), establishing a vision (inspiring persons to push themselves for the sake of improved care), communication, and personal qualities such as being approachable and supportive. In a survey of chairs of departments of Psychiatry, Keith et al. found that 46% of respondents prioritized interpersonal communication skills in leaders, and that 36% described altruism, perseverance, integrity, and honesty as critical features of successful academic chairs. Finally, Taylor et al. reported that critical differentiating competencies for established leaders in healthcare organizations included organizational altruism - the ability to subjugate one's personal advancement to the needs of the organization and of those being lead.Others have framed this in the concept of "servant leadership".</p>
<p>Leadership matters not only for navigating the financial and administrative components of healthcare, but can also directly impact patient outcomes. For example, Goodall reported a significant association between physician leadership and hospital performance (e.g., in U.S. News and World Report rankings), Bulmer-Smith 'endorsed attention' to emotional intelligence and patient outcomes in hiring and evaluating nurses, and Stoller and Wheeler summarized a large number of studies showing that teamwork, an important leadership competency, enhances patient outcomes in critical care medicine and in respiratory care. Also, Baggs et al. endorsed nurse-physician collaboration as a critical concept in enhancing outcomes in the critically ill. Lobas and Buckley et al. advocated using an assessment of emotional intelligence in assessing candidates for leadership positions in academic medical centers, noting that great leadership was associated with greater organizational effectiveness. Importantly, effective leadership is associated with increasing satisfaction from employees as well as patients.</p>
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<h4>Leadership vs. Management</h4>
<p>Leadership must be distinguished from management. Both are complementary and are required for organizational success. Management focuses on preserving order and structure with activities like ensuring adequate staffing and budgeting. In contrast, leadership regards engaging and aligning people and effecting change to improve organization al performance. In the specific context of a field project, management is required to ensure that the budget is defended and that adequate staffing is available on all shifts whereas leaders change the way that services are delivered in order to enhance the project’s effectiveness.</p>
<p>In the context of specific leadership competencies for providing healthcare in resource-poor areas, the question arises: What are the leadership and management competencies needed to optimize health in under-served or under-resourced areas? To what extent, if any, do these competencies differ from the more generic healthcare leadership competencies discussed above? The issue has received some formal attention in the peer-reviewed, published literature and has also been the subject of active discussion in on-line forums.</p>
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<legend id="03f81f4c89ba4f96b6163f334842c120_2_1-legend" class="response-fieldset-legend field-group-hd">Which of the following is considered the most important element of healthcare leadership?</legend>
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<p>Business leaders around the world have long recognized the necessity for effective leadership and many models exist to train individuals to be effective leaders. Healthcare providers have increasingly recognized that healthcare requires effective leadership but that these skills are not traditionally taught during training.</p>
<p>The generally lauded competencies in healthcare - clinical or scientific expertise and technical mastery - appear insufficient to bring innovations to under-resourced settings. The innovative leaders that are especially needed for global health must navigate and negotiate the various interests involved in implementing new interventions. They must have a clear vision that is aligned with healthcare goals and must be champions of their own strategies, while working collaboratively with stakeholders to advance this vision. Healthcare providers today generally have a dearth of resources or mentors to learn these skills. We must advocate for capacity-building and training in leadership as a key component of success in global health. There are many benchmark models available from the business sector and some, though fewer, best practices in healthcare. The literature suggests that many of the identified skills for effective leadership translate to under-resourced settings, particularly those of vision, collaboration, community orientation, systems thinking, and the ability to cultivate leadership at all levels of organizational authority.</p>
<p>As we continue to understand the role of leadership in helping to achieve accessible, high-quality and low-cost healthcare, the nuances of leadership skills that are needed for specific environments and communities will become even clearer. Overall, the leadership competencies that are needed for innovation in global health call upon generalizable leadership skills- clinical expertise; emotional intelligence; deep commitment to mission; and respect for patients, colleagues, and collaborators.</p>
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