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Feasibility study: development and delivery of a clinical leadership program Print E-mail
The Quarterly 2011


Extract from a report prepared by Siggins Miller for RACMA – May 2010


The Royal Australasian College of Medical Administrators (RACMA) has a commitment to support the development and delivery of a medical leadership training program. In order to advance this commitment, RACMA engaged Siggins Miller to evaluate the feasibility of the RACMA developing and delivering a medical leadership program.

A number of Australian and international government reports have highlighted the growing issue of doctor engagement and the need for clinical leadership to improve safety, quality control, patient outcomes, and health service performances.

Effective clinical leadership is recognised as essential for improving the performance of health services and enhancing the wellbeing of patients and the quality of outcomes. A growing body of literature has also argued that clinical leadership plays an integral part in the success and effectiveness of organisational change in the health sector1.

This is largely due to the fact that clinicians in the health sector are often viewed to have greater control over decisions than workers in other areas. As such, clinicians are more likely to be influenced and persuaded by clinical leaders to bring about positive change because they believe they have 'walked a mile in their colleagues' shoes' and view them as more reliant, trustworthy, and credible.

Although the literature provides little insight and clarity about the definition and scope of clinical leadership, it has been suggested that clinical leaders 'define what the future should look like, align people with that vision and inspire them to make it happen despite the obstacles'. In other words, clinical leaders engage people who are difficult to engage, service as role models for their peers, and create an environment in which quality improvements can thrive. For individuals who are trained to manage individual cases and guard their professional autonomy above all else, the effect of being asked to take on these leadership roles in the consumer interest is considerable, and not often acknowledged.

Being an effective clinical leader clearly requires a different set of skills from being a good clinician2. It is therefore important that clinical leaders are supported and equipped with the high level skills required for their role (eg leading and developing multidisciplinary teams, understanding organisational systems, processes and interdependencies, redesigning services and working collaboratively with a wide range of stakeholders).

Indeed, reviews of clinical programs have found that individuals who participate in leadership training are more likely to feel empowered to influence the provision of patient-centred care, develop a greater sense of self-awareness and confidence to initiate positive change, and promote better team alignment3.

In light of these experiences and the growing body of literature in this area, there is a clear need to examine the feasibility of developing a medical leadership training program which aims to enhance clinical leadership skills and ultimately improve patient outcomes and safety, clinical governance, and health service performance.

1 Ham C (2003). Improving the performance of health services: The role of clinical leadership. Lancet 361:1978-1980
2 Reinersten LJ (1998). Physicians as leaders in the improvement of health care systems. Annals of Internal Medicine 128: 833-838
3 Stoller KJ (2008). Developing physician-leaders: Key competencies and available programs. The Journal of Health Administration Education 25(4): 307-328

1. Review of the literature on clinical leadership and leadership development


The quality of leadership in the health system has been identified as an important factor supporting best practice (collaboration, continuity of care, and communication) and directly and indirectly affecting the quality of patient care.

Although leadership may exist at various levels of healthcare (governance, management, clinical care), opinion and research together suggest that the quality of leadership provided by clinicians to other clinicians, and also the quality of their relationships with those who shape health service through policy setting or line management, significantly contribute to the patient’s immediate wellbeing. Although the empirical evidence to support this proposition in the healthcare sector is limited, research in other complex industries with highly professional workforces has consistently demonstrated the significant role of leadership in achieving positive organisational outcomes (Bass & Riggio 2006).

The importance of fostering clinical leadership has been acknowledged and emphasised at a national level by National Health and Hospitals Reform Commission (NHHRC). The Commission stated:

"At a national level, we have called for a systemic approach to encouraging, supporting and harnessing clinical leadership across all health settings and across different professional disciplines. This includes promoting a continuous improvement culture by providing opportunities for clinicians to participate in teaching, research and quality improvement processes across all health service settings" (NHHRC 2009)

This section examines the literature about how clinical leadership champions best practice at the service level, and how to foster it in the patient’s best interest.

Most clinical leadership emerges in an organic and informal way. However, recent attempts to foster and promote it have led researchers to analyse competencies drawing on broader organisational psychology theory and evidence about leadership and leadership development.

A brief overview of leadership research and theories

A large body of research indicates that the quality of leadership affects people, their satisfaction, trust in management, commitment, individual and team effectiveness, the culture and climate of organisations, and ultimately individual and collective performance (Burke et al 2006; DeGroot et al 2000; Dirks & Ferrin 2002; Gerstner & Day 1997; Kouzes & Posner 2007). Other factors such as economic stability, political agendas, organisational and industry history, and individual differences may also influence these outcomes, but leadership plays a central role in mobilising people towards a common goal (Avolio et al 2009; Kouzes & Posner 2007). Leadership therefore becomes vital when an organisation faces the need to mobilise a workforce in a new way towards a vision, a set of values, or to changing work practices in constrained financial times. Moreover, leadership can influence an organisation’s outcomes and the health and wellbeing of patients and staff in both positive and negative ways (Bell et al 2004).

Understanding what leadership is has been the subject of a significant body of work in the behavioural sciences. Over 90 variables have been identified across studies as elements of leadership (Winston & Patterson 2006). Identifying which of these common attributes and behaviours contribute to positive leadership practice has formed the basis of much leadership theory and research.

In recent decades, many attempts have been made to observe and then explain what makes an effective leader. The various theories have stressed personality, or behaviour, or context, or relationships. Here is a brief overview of the most influential theories.

Leadership trait theories

At first, leadership researchers were interested in individual characteristics that differentiated leaders and followers, and most of their research focused on identifying these 'leadership traits'. In line with this approach, the early theories of leadership stressed a trait approach - leaders are simply made of the 'right stuff'. These theories assumed that 'leaders are born and not made'.

A wide range of individual characteristics were investigated, such as gender, height, physical energy, intelligence, personality, need for achievement, and the need for power. This initial search for the universal leadership traits proved futile and caused researchers to turn their attention to the behaviour of leaders (Stodgill 1948).

The trait paradigm, however, later re-emerged with the introduction of a number of new trait-related leadership theories that have stood up to empirical investigations.

For example, McClelland's 'achievement motivation theory' (1961) focused on how a non-conscious concern to achieve excellence in accomplishments through one's individual efforts contributed to leadership effectiveness. More recently, McClelland (1975) also proposed a 'leader motive profile', which suggested that effective leaders have a greater innate desire to influence and direct others, than desire to interact socially and be accepted by others, as well as a high concern for the moral exercise of power.

The predominant model for leadership in many modern organisations - 'transformational leadership' - is also a trait-related theory (Burns 1978; Bass 1985).

Leadership behaviour theories

Disheartened by the initial failure of the trait paradigm, other researchers turned their attention to studying leader behaviours - what a leadership role involved, and the relationship between different leadership behaviours and effectiveness. These theories assume leaders can be made (rather than are born).

A research program with a profound impact on this paradigm was the Ohio State University leadership research program, which developed the Leader Behaviour Description Questionnaire (LBDQ: Hemphill 1950). The LBDQ revealed that a significant proportion of the variance in leader behaviour could be explained by two clusters - personal relationship skills ('consideration') and task accomplishment skills ('initiation of structure'). Identifying these clusters of behaviours proved to be an important advance in leadership development and effectiveness.

Another research program led to development of the 'managerial grid' (Blake & Mouton 1985). The grid combined the two dimensions of leadership identified by the LBDQ to describe four leadership styles: authoritarian (high task, low relationship skills); team leader (high task, high relationship skills); country club (low task, high relationship skills); and impoverished leadership (low task, low relationship skills).

A limitation of this leadership literature was that it could not identify one ideal set of leadership styles that would lead to effective outcomes in any given situation. It also gave minimal consideration to context or situation that could influence leader behaviours.

Contingency or situational theories

As a result, researchers began to investigate 'contingency' or 'situational' leadership theories. These theories suggest that the situation determines the personal traits and behaviours required in a leader.

One of the first such theories was Fielder’s contingency theory (1967), which proposed that the effectiveness of a high task- or relationship-oriented leader depended on the extent of the leader’s situational control - their level of positional power, task structure, and the nature of their relationships with followers.

Hersey and Blanchard’s situational leadership theory (1982) described four typical leadership styles, each of which involved different levels and combinations of task and relationship behaviours: encouraging, coaching, delegating and structuring. They also suggested that varying situational factors - particularly follower competence and motivation - determined which of these leadership styles was most likely to succeed.

Another well known contingency theory is 'path-goal theory' (House 1971; House & Mitchell 1974). Path-goal theory identified four leadership styles that affect follower motivation differently: directive; supportive; participative; and achievement-orientated styles. Further, each of these leadership styles was thought to be optimal in different contexts. The situational factors this theory focused on were the nature of the task, and the motivation and capability of followers.

Finally, 'cognitive resource theory' (Fielder & Garcia 1987) argued that situationally induced stress affected the leadership traits most likely to be effective. Under low stress, a leader’s intelligence was positively correlated, and experience was negatively correlated, with performance. In contrast, under high stress, a leader’s intelligence was negatively correlated with performance, and experience was positively correlated.

Contemporary theories

Contemporary leadership theories offer a more sophisticated view of leadership that considers as integral factors not just the leader, but those they lead, and the context.

'Leader-member exchange' (LMX) theory describes how relationships between leaders and followers may affect leader behaviour (Graen & Cashman 1975). It suggests that, rather than using the same style in dealing with all employees, leaders develop a different type of exchange with each employee. The key premise of LMX theory is that the quality of these relationships that develop between leaders and employees predicts outcomes at individual, group, and organisational levels.

'Transformational leadership' theories primarily address the actions of leaders that cause employees to change their values, goals, needs, and aspirations, so that they become aligned with those of the organisation (Burns 1978; Bass 1985). The leadership behaviours needed to inspire followers in this way depend on the characteristics of the leader, the followers, and the situation. Transformational leadership generally comprises four major components: individualised consideration, intellectual stimulation, inspirational motivation, and idealised influence (Judge & Piccolo 2004). It is the predominant model for leadership in many modern organisations.

'Implicit leadership' theory focuses on how follower beliefs are associated with leadership. It proposes that people have preconceived notions about the behaviours, traits and characteristics of typical leaders (Lord 1985). Further, it suggests that individuals need to exhibit leadership behaviours that embody these traits to be perceived as an effective leader. In other words, implicit leader theory suggests that perceptions of leadership depend how far an individual leader matches their followers’ implicit expectations.

In contrast to implicit leader theory, ‘social identity’ theory focuses on group norms. Social identity theory suggests that leadership perceptions are increasingly influenced by prototypes held by significant groups. It proposes that in order to be perceived as an effective leader in these groups, individuals need to embody the ideal norms of the group (Hogg 2001).

Emerging trends

A number of trends have emerged as the leadership literature has developed. It seems there is no one best way of leading - a leadership style that is effective in some situations may not be successful in others.

Accordingly, a number of leadership researchers have introduced the concept of ‘behavioural flexibility’ (eg Kenny & Zaccaro 1983; Zaccaro et al 1991). It proposes that effective leaders are competent in a large repertoire of behaviours. They are able to select the most appropriate leadership style for a specific situation, and to select alternative styles as the situation changes.

Recent research has supported this notion by asserting that flexibility in leaders' behaviour is a necessity for effective leadership (Silverthorne & Wang 2001). Studies that have examined the role of social or emotional intelligence in leader effectiveness also support this view (eg Ferentinos 1996).

In a collection of leadership fundamentals collected by the Harvard Business Review, an article on 'what great managers do' also noted the importance of behavioural flexibility (Buckingham 2005), and suggested that effective leaders tailor praise to employee preferences, and adapt coaching to employee learning styles.

Leadership vs management

While it is helpful to understand the genesis of contemporary leadership theory in order to appreciate current approaches to leadership development, it is also important to recognise the difference between leadership and management. Often confused, the two concepts differ in a number of fundamental ways. Kotter (1990) proposes that the purpose of leadership is to bring about movement and constructive change, while the role of management is to provide stability, consistency, order and efficiency. While the two processes both have essential roles in the function of an organisation they serve two distinct purposes. Generally speaking, management can be seen as necessary in order to keep an organisation "running", that is, to keep things on schedule and within budget, and to make sure predetermined targets are met. Leadership, however, is needed to provide a vision for the future, drive organisational change, align employee efforts with organisational goals, and to motivate and inspire employees to achieve results beyond expectations.

To explain the management-leadership distinction further, Levy & Carroll (2008) assert that the choice to use either a management or leadership approach may hinge on the nature of a problem at hand or the comfort level of the individual in adopting a particular approach. They suggest that problems may fall into the category of technical work (known problems solved through proven solutions), requiring a management approach, or adaptive work (unknown or uncertain problems requiring a new process to create solutions), which requires leadership. Furthermore, both the choice and capacity of executives to deal with uncertainty, and foster learning, can determine whether a management or leadership response is applied.

The qualities, skills and attributes required to be a good manager diverge from those required to be a good leader. Zaleznik (2004) differentiates managers and leaders on concepts such as personality; goal attitudes and work conceptions, describing managers as 'process engaging, stability maintaining problem solvers. In contrast, leaders are said to be able to tolerate a lack of structure and are willing to delay problem solving to understand issues more fully. Further, Carroll and Levy (2008) state that leadership occurs when leaders and followers raise one another to higher levels of motivation, drive, creativity and achievement.

Research examining the attributes of individuals in positions of leadership (e.g. management roles) across various Australian industries highlights the need to recognise this management/leadership distinction. The Report of the Industry Task Force on Leadership and Management Skills (the Karpin Report) commissioned by the Australian Government in 1995, brought to light the fact that many individuals in leadership roles were adept in hard skills (i.e. management), yet weak in people-oriented skills; the so called softer skills necessary for driving effective leadership (communication, motivation, delegation, negotiation, interpersonal skills).

Support for a transformational approach to leadership

Of the theories outlined above, transformational leadership, a person-oriented style of leadership, has robust empirical support for being the style of leadership that produces optimal organisational results and committed followership (Bass 1985, 1998; Bass & Avolio 1994; Judge & Piccolo 2004; Kouzes & Posner 2007). This leadership style readily acknowledges the value followers have within the processes surrounding leadership and in transforming organisations. Furthermore, transformational leadership has been described as one of the most suitable styles for addressing modern complexities and leadership challenges (Kouzes & Posner 2007). These complexities and challenges range from leading and managing people, working with finite resources, and supporting physical, emotional, and psychological wellbeing of staff. This degree of fit with the nature of work in healthcare and the resource constrained environment in which healthcare is delivered has led the Institute of Medicine (2003, 108), the Royal College of Nursing UK, and Clinical Leadership Programme, UK (Large et al 2005) to support transformational leadership as a strategy for achieving best practice.

Kouzes & Posner (2007) described the process of leadership as a relationship between those who aspire to lead, and those who choose to follow. This supports the notion that leadership which facilitates followership is critical for achieving change. In the healthcare industry employees are trained to think and act in the interests of their professional autonomy which in turn is thought to be the cornerstone of patient safety. In this context leaders struggle to find followers no matter how they behave. In addition, employees who are working to full capacity in facilities where resources are stretched often become change weary as they are asked to once more adapt to a new structure or way of working.

Taken together, these two dynamics mean that any strategy to build capacity for clinical leadership has to be based on a firm understanding of the importance of building a culture of collaboration and engaging people in ways that promote the reciprocal nature of the leader/follower relationship. In the healthcare context the role of the leader (clinical or otherwise) is to facilitate and support new ways of working, and to provide others with access to the knowledge, skills, and environment where change happens and where the risks of change are acknowledged and minimised.

Leadership in the healthcare sector

The healthcare sector for some time has battled with this do-more-with-less challenge at all levels (e.g. policy, governance, local/organisation-specific). Exacerbated by the healthcare workforce currently working unrealistically long hours, and potentially compounded by predicted future workforce shortages over the next two decades (National Health Workforce Taskforce 2009), these issues add to the healthcare challenges associated with deeply rooted culture, organisational structure, and social dynamics that act as barriers to adoption of practices that lead to best patient outcomes (Barker et al 2006; Jasper & Jouna 2005; Silversin & Kornacki 2000).

Within healthcare, varied leadership roles are critical for managing and overcoming diverse healthcare challenges. Ultimately, most leadership roles in healthcare incorporate some direct or indirect commonality associated with attaining best health outcomes for patients (Jasper & Jouna 2005). One role that is receiving increased attention, is the role of clinical leaders due to their ability to influence best practice, especially at the service level (Edmonstone 2009; Ham 2003; McKenna et al 2006, Victorian Quality Council 2005). In recognising the value of clinical leaders on the frontline, Edmonstone (2009) supports the notion that clinical leadership is akin to "influence-ship" and the power clinical leaders have at transforming service delivery. Thus, clinical leadership may be considered as an important factor for shaping the environment necessary for indirectly improving health care at the organisational level, and directly improving healthcare at the service level.

Healthcare organisations tend to have an inverted power structure, whereby service-level staff significantly influence the best outcomes of operational activities associated with patient care in comparison to those who are "in control" at the top (Ward 2005). In addition, frontline leaders appear to have greater influence over decision-making and immediate quality of patient care (Ward 2005). As such, clinical leaders are often the key individuals that champion the immediate healthcare quality at the service-level (Jasper & Juma 2005). Thus, ensuring behaviours and attitudes on the frontline are aligned with the organisational vision, which is generally linked with adopting best practice to enhance safety and quality of patient care, is essential. It is important to acknowledge the influence that such key individuals may have in shaping and championing beliefs, behaviours, and culture.

Clinical leadership

Limited consensus exists for a universal definition of clinical leadership. Nevertheless, a recent discussion paper by Edmonstone (2009) explored the UK National Health Service's concept of clinical leadership and highlighted how clinical leadership was differentiated from healthcare managerial leadership. Edmonstone elucidated that managerial leadership primarily focused on the overall needs of the organisation (macro-level: budgeting, planning, analysing and controlling), while clinical leadership focused on enabling and championing best practice, progression towards best patient outcomes, and meeting service-level needs (micro-level: quality of patient healthcare). Furthermore, in exploring what leadership is, and the practices that produced the best results from people delivering healthcare services at the frontline, Davidson et al (2006) identified a number of key processes including the identification of goals or targets, motivating people to act, and providing support and motivation to achieve mutually negotiated goals. In addition the authors also identified two concepts which make leadership in a clinical context unique including the responsibility for ensuring patient safety and care and the need to monitor both service and individual outcomes.

In Australia, the Victorian Quality Council (2005) defined clinical leadership as "both a set of tasks to lead improvements in the safety and quality of health care, and the attributes required to successfully carry them out." As the basis for the development of Clinical Leadership Audit Tool, the Victorian Healthcare Association (2009) adopted the following definition for their Clinical

Leadership Project:

"Clinical leadership in Community Health is the process of developing a culture and leading a set of tasks to continually improve the quality and safety of service delivery to consumers. Effective clinical leadership involves individuals with the appropriate skills and attributes, at all levels of an organisation, focussing on multidisciplinary/interdisciplinary service delivery."

In conceptualising clinical leadership, a report commissioned by the Clinical Leaders Association of New Zealand for the Ministry of Health (CLANZ 2001) described clinical leadership as, "leadership by clinicians of clinicians." This simplified definition included all health professionals (doctors, nurses, midwives, therapists, and allied health professionals involved in direct patient care), but most importantly, it acknowledged the social and organisational complexities highlighted by Ham (2003), such as the importance of incorporating bottom-up, ground-level approaches in affecting sustainable change. Further, Ham (2003) highlighted the importance of clinician engagement, and the challenges associated with whether highly educated professionals were willing to follow colleagues in a leadership role. In balancing both the need for and importance of clinical leadership and challenges associated with followership on the frontline, credibility is essential in fostering followership (Kouzes & Posner 2007). Accordingly, recognising the inverted power structure highlighted by Ward (2005), to promote followership and sustain change in service delivery, a leader must not only be connected to the frontline, but also be perceived as credible amongst their peers.

On the basis of the literature presented in the current review, we define clinical leadership as an ongoing process of engagement between a credible healthcare professional and fellow service providers and support staff, where the locally connected clinician champions the cultivation of high quality patient care at service level. Modern accountabilities linked to best practice in patient care include fostering a culture of collaboration (e.g. multidisciplinary/ interdisciplinary service delivery, shared communications, continuity of care in the patient's journey) and ongoing professional development (continuing engagement in pursuing best practice). We propose this as a working definition subject to further qualitative scrutiny.

Leadership development

The development of leadership competencies in clinicians is therefore necessary to create and maintain a culture within health services which up holds the fundament values of patient safety and best practice. Leadership development is an ongoing process of increased importance, where literature recognises the importance of merging management skills and leadership behaviours (Yukl & Lepsinger 2005; Zaleznik 2008). The literature presented in this section will outlines approaches to leadership development and methods of training implementation which have been shown to be effective in achieving desired learning outcomes.

Leadership development: what works and what doesn't

Koo and Miner (2010) have argued that health should take the same rigorous, evidence-driven approach to workforce development and it does to science, and they recommend a framework for health workforce education integrating three approaches: adult learning theory, competency-based education, and professional skills progression. Merriam (1996) said that, in undergraduate, graduate, or continuing professional education, the learning transaction was enhanced by understanding both how adults learn, and the conditions in which they learn most effectively. Self-directed and transformational learning were major contributions to the growing body of adult learning theory, with implications for training in the health professions.

Leadership is a multifaceted construct and the skills and attributes required to effectively lead an organisation and its people are varied and complex. It is not reasonable to expect that such skills can be successfully cultivated within an individual in short period of time. Empirical evidence can be provided to support this notion. For example, Malling et al (2009) failed to find a significant improvement in the leadership skills of a group of Danish doctors one year after having participated in a seven day leadership development course. The authors concluded that the time frame of one year between the implementation of the training course and the follow-up assessment might have been too short to show improvement in leadership skills.

Training design denotes that course material be delivered via methods that complement the skills to be acquired, to enhance transfer of learning (Wexley & Latham 2002). The complex reasoning and verbal skills comprised in leadership are classed as intellectual or higher order cognitive skills (Voss et al 1995; Goldstein & Ford, 2002). In order to maximise the transfer of such skills spaced learning (the repeated practice of a concept; Gagne et al 2002) and error learning, which involves identifying and rectifying mistakes made by peers, oneself, or from field-relevant case examples, are required (Joung et al 2007). A short course of two to four days duration would not provide sufficient time to implement such training methods. Spaced practice and error learning training mythologies are vital for developing higher order cognitive skills such as apperception (Levy & Carroll 2008) and conflict resolution. Furthermore, such skills may not be used on a daily basis to facilitate skill practice (Voss et al 1995; Hesketh, 1997). In addition, it is also important to consider the cognitive limitations that may apply in the early stage of skill acquisition and the constraints on the attentional capacity of the trainee (Kanfer & Ackerman, 1989). Taken together these methodological issues imply that short-course leadership development programs will not facilitate the transfer of learning to the workplace.

The successful integration of the principles acquired during training into the workplace also requires consideration of post-training variables such as practice opportunity and learning support (Salas & Cannon-Bowers 2001; Aguinis & Kraiger 2009). To achieve this, leadership development literature specifies the requirement for ongoing development in the form of a development plan (Riggio 2008). Leadership development plans may include a written agreement between an individual and a mentor figure, as well as a mentoring component. Such agreements usually outline desired goals, the required steps to achieve them and a specified timeline in which to achieve them. Kanfer et al (1994) demonstrated that goal setting combined with repeated application of a skill to be a performance facilitator. Hesketh (1997), in a review of training literature, also proposes that goal setting is effective in maintaining commitment to acquiring skill.

Reflection is also an important concept in leadership development, in terms of observing one’s own behaviour and reflecting upon feedback of other's observation of one's own behaviour (Styhre 2009). Riggio (2008) recommends investment in leadership development programs to develop leadership in practice, which include mentoring opportunities to enhance self awareness and encourage introspection. Kombarakaran et al (2008) coached executives of a global pharmaceutical company in twelve sessions over six months via telephone or email and assisted them to reframe their perspectives; understand the impact of their behaviour on others; enhance their confidence and ultimately maximise company contributions.

The literature presented suggests that leadership development programs need to be structured in a way which will enable trainees to learn a vast array of complex skills and have the opportunity to apply such skills in situ. Leadership development programs should offer spaced training, incorporate multiple methods such error learning and reflection, provide ongoing support in the form of mentoring and coaching, and enable trainees to monitor their progress in relation to a set training plan.

Clinical leadership competency frameworks

Being an effective clinical leader requires a different set of skills from being a good clinician. It is important that clinical leaders are supported and equipped with the skills required to foster a culture of collaboration; lead and develop multidisciplinary teams; understand organisational systems, processes and interdependencies; redesign service-level systems to achieve best patient outcomes; and work collaboratively with a wide range of stakeholders. Knowing the competencies required to achieve these outcomes can serve as a basis for designing effective leadership development programs. The following section provides a review of five leadership competency frameworks used in the healthcare sector which have been developed and used internationally in the healthcare sector. Each of the frameworks provided has been developed on the basis of empirical research and incorporate the ethos of a transformational approach to leadership.

The following competency models and frameworks presented comprise:

  • The National Health Service (NHS) Leadership Qualities Framework (2002) developed by the NHS Institute for Innovation and Improvement, United Kingdom.
  • The Medical Leadership Competency Framework (2008) developed by the NHS Institute for Innovation and Improvement, United Kingdom.
  • The National Center for Healthcare Leadership Competency Model (2004) developed by the National Center for Healthcare Leadership, United States.
  • The Healthcare Leadership Alliance (HLA) Competency Directory (2004) developed by the HLA, United States
  • Stoller’s (2008) key competencies of physician-leaders

It is important to note that not all competency frameworks are specific to clinical leadership: some incorporate competencies associated with general healthcare leadership, such as administration, management, and executive-level leadership within healthcare. Nevertheless, as there is limited consensus about the definition of clinical leadership, a broad approach to acknowledging competencies recognised in healthcare leadership may shed light on the competencies necessary for clinical leaders to affect real change at the service level.

The NHS Leadership Qualities Framework

The NHS Leadership Centre commissioned Hay Group in 2000 to identify characteristics that would distinguish highly effective future leaders across the health service. The process associated with the development of the Leadership Competency Framework involved: desktop research of 23 leadership competency models; in depth structured interviews (46 Chief Executives and four Directors); and focus groups with authors of the existing NHS competency models.

The NHS Leadership Qualities Framework, published in 2002, identified fifteen personal, cognitive, and social qualities essential for successful leadership across health services. These qualities are clustered into three broader domains: personal qualities, setting direction; and delivering the service. Each of these domains comprises a number of qualities deemed necessary for good leadership. Here is a brief description of the domains and their qualities:

Personal Qualities

Personal qualities underpin this framework and focus on the individual's fundamental characteristics that would enable them to see through the demands associated with leadership in healthcare. The leadership qualities in this domain include: achievement orientation, self belief, self awareness, self management, drive for improvement and personal integrity.

Setting Direction

Setting direction refers to visionary and forward-looking leadership that are essential for driving forward within such social and organisational complexity. The leadership qualities in this domain include: accountability, change leadership, seizing the future, intellectual flexibility, broad scanning, political astuteness, and drive for results.

Delivering the Service

Delivering the service refers to the leadership qualities associated with leading an organisation, and affecting change across the broader health and social care context. The leadership qualities in this domain include: leading change through people, holding to account, empowering others, effective and strategic influencing, and collaborative working.

The framework has underpinned a number of successful leadership development programs both for the NHS in the United Kingdom and in Australia.

The Medical Leadership Competency Framework

Building on various competency frameworks, the Medical Leadership Competency Framework was jointly developed by the Academy of Medical Royal Colleges and the NHS Institute for Innovation and Improvement in conjunction with a broad range of other relevant stakeholders. The Medical Leadership Competency Framework focuses on establishing competencies required by doctors for them to actively plan, deliver, and transform health services.

Since initial research began in 2006, the process of developing this model incorporated: review of the literature (medical leadership and engagement), comparative analysis of leadership competency frameworks (such as the NHS Institute for Innovation and Improvement: Leadership Qualities Framework, British Association of Medical Managers: A syllabus for Doctors in Management and Leadership Positions in Healthcare, Institute for Health Improvement: Engaging Physicians in a Shared Quality Agenda, and Health Care Leaders Association of British Columbia: Health Leadership Capabilities Framework for Senior Executive Leaders); an analysis of specialty medical curricula; consultation with members of the medical and wider NHS community; consultation with Patient Lay Advisory Groups of the Medical Royal Colleges; semi-structured interviews with medical school Deans, postgraduate Deans; and Presidents of Medical Royal Colleges; advice from the project Steering Group and reference groups; and feedback from focus groups (medical students, junior doctors, consultants, and GP's).

The fundamental tenet that underpins this model is shared leadership and teamwork. Thus, leadership can come from anyone in the organization, ideally with the purpose of focusing on achievement of the group, rather than of the individual in order to deliver a high quality service to patients, service users, carers, and the public.

The Medical Leadership Competency Framework consists of twenty elements essential for effective medical leadership that are divided into five competency domains consisting of :

Demonstrating personal qualities

Doctors showing effective leadership need to draw upon their values, strengths, and abilities to deliver high standards of care. The elements in this domain include: developing self awareness, managing yourself, continuing personal development and acting with integrity.

Working with others

Doctors show leadership by working with others in teams and networks to deliver and improve services. The elements in this domain include: developing networks, building and maintaining relationships, encouraging contribution and working with teams.

Managing services

Doctors showing effective leadership are focused on the success of the organization(s) in which they work. The elements in this domain include: planning, managing resources, managing people and managing performance.

Improving services

Doctors showing effective leadership make a real difference to people's health by delivering high quality services and by developing improvements to services. The elements in this domain include: ensuring patient safety, critically evaluating, encouraging improvement and innovation and facilitating transformation.

Setting direction

Doctors showing effective leadership contribute to the strategy and aspirations of the organisation and act in a manner consistent with its values. The elements in this domain include: identifying the contexts for change, applying knowledge and evidence, making decisions and evaluating impact.

The NHS Medical Leadership Competency Framework was purposefully designed for championing leadership on the frontline through doctors and upcoming medical students. It has been used to underpin the "Enhancing Engagement in Medical Leadership" program, a joint project by the Academy of Medical Royal Colleges (AoMRC) and the NHS Institute.

The NCHL Health Leadership Competency Model

Based upon research across practicing health leaders and managers across the administrative, nursing, and medical professions, and early, mid, and advanced career stages (Calhoun 2008), the NCHL Healthcare Leadership Competency Model was developed: Version 1.1 (2003) and Version 2.0 (2004).

During the initial development of the first Healthcare Leadership Competency Model (version 1.1), the American College of Testing and the NCHL aimed to identify core leadership constructs and related knowledge skills and other behaviours. Six competency domains consisting of 133 sub-competencies were identified through: advisory committee/expert panel oversight; literature review; practitioner interviews; draft and pilot field test surveying; field/practice analysis surveying; and analysis of survey data.

This Health Leadership Competency Model was updated in 2004 (version 2.0), in order to refine the model and for validation for individual and organisational development. The process of updating included behavioural event interviews with 84 high-performing healthcare leaders: comparative analysis of qualitative data about competency variables with the NCHL's Competency Dictionary and Hay's Competency Dictionary (performance competencies across industry); independent interviews with subject matter experts; database benchmarking across industry (e.g., insurance, pharmaceuticals, biotechnology, general healthcare); and model finalisation with an expert panel of fifteen practitioners, academics; educational psychologists; learning consultants, data analysts, and competency modelling researchers.

The NCHL Health Leadership Competency Model comprises eight technical (skills and knowledge) and eighteen behavioural competencies that have been identified as essential for effective and successful leadership across the health sector. It combined best leadership models outside of health with the unique health environment, thus enabling the NCHL to identify areas for development and training essential for leadership in 21st Century Healthcare. These qualities are clustered into three broader domains:


Transformation refers to, "visioning, energizing, and stimulating a change process that coalesce communities, patients, and professionals around new models of healthcare and wellness." The competencies in this domain include: achievement orientation, analytical thinking, community orientation, financial skills, information seeking, innovative thinking and strategic orientation


Formation refers to, "translating vision and strategy into optimal organizational performance." The competencies in this domain include: accountability, change leadership, collaboration, communication skills, impact and influence, information technology management, organisational awareness, performance measurement, process management / organizational design and project management.


People refers to, "creating an organizational climate that values employees from all backgrounds and provides an energising environment for them. Also includes the leader's responsibility to understand his or her impact on others and to improve his or her capabilities, as well as the capabilities of others. The competencies in this domain include human resources management, interpersonal understanding, professionalism, relationship building, self confidence, self development, talent development and team leadership

The HLA Competency Directory

The most comprehensive competency listing within healthcare was conducted by the Healthcare Leadership Alliance, whom recently published their competency directory in 2005. This HLA consists of these professionally recognised associations:

  • American College of Healthcare Executives
  • American College of Physician Executives
  • American Organization of Nurse Executives
  • Healthcare Financial Management Association
  • Healthcare Information and Management Systems Society
  • Medical Group Management Association and its certifying body, the American College of Medical Practice Executives

These organisations represent over 100,000 management professionals in the US health sector. Beginning in late 2002, a task force comprising of representatives from HLA associations and Mary Stefl (Professor and Chair of the Department of Health Care Administration, Trinity University, San Antonio, Texas) aimed to, "determine if there were common management competencies shared by all members of the HLA organizations" (Stefl 2008, 363).

The process of identifying shared competencies of physician-leaders involved an initial analysis of each association's credentialing and certification processes, as these association processes are designed to, "ensure individuals in a professional position meet the basic educational, skill, and/or experiential requirements of their respective profession" (Raymond 2001; cited in Stefl 2008, 363).

Through extensive analyses and reviews of credentialing and certification processes, overlapping and complementary competencies important to healthcare leadership and management were identified (Stefl 2008). Five domains were identified representing over 300 competencies:

Communications and relationship management

The ability to communicate clearly and concisely with internal and external customers, to establish and maintain relationships, and to facilitate constructive interactions with individuals and groups (consists of 25 competencies)


The ability to inspire individual and organizational excellence, create a shared vision and successfully manage change to attain the organisation’s strategic ends and successful performance. According to the HLA model, leadership intersects with each of the other four domains (consists of 24 competencies)


The ability to align personal and organizational conduct with ethical and professional standards that include a responsibility to the patient and community, a service orientation, and a commitment to lifelong learning and improvement (consists of 24 competencies).

Knowledge of the healthcare environment

The understanding of the healthcare system and the environment in which healthcare managers and providers function (consists of 22 competencies).

Business knowledge and skills

The ability to apply business principles, including systems thinking, to the healthcare environment (36 competencies). The sub-domains within Business Knowledge and Skills include financial management (35 competencies), human resources (24 competencies) organisational dynamics and governance (18 competencies), strategic planning and marketing (21 competencies), information management (36 competencies), risk management (18 competencies), quality improvement (17 competencies).

Although the HLA listings of competencies are extremely comprehensive, it must also be noted that some competencies may not be relevant to clinical leaders as they are directed towards managers and directors of healthcare organizations (e.g., business knowledge and skills – financial management).

Stoller’s key competencies of physician-leaders

Stoller (2008) reviewed sixteen available reports in his synthesis of competencies required to be an effective physician-leader. These reports encompassed data from a variety of sources ranging from expert opinions, through to a meta-analysis of surveys across a broad scope of population groups (e.g., healthcare executives, physicians, nurses, medical students, dentists). Additionally, each report included sample sizes ranging from ten to 110 participants. Stoller proposed the following six competencies are needed for effective physician leadership:

  • Technical skills and knowledge (e.g. technical knowledge and skills associated with the operations, finance and accounting, information technology and systems, human resources, strategic planning, legal issues in healthcare, and public policy)
  • Industry knowledge (e.g. knowledge of the healthcare industry’s reimbursement strategies, legislation and regulation, quality assessment, and management)
  • Problem-solving skills (e.g. cognitive abilities associated with systems thinking, organizational strategy and project management)
  • Emotional intelligence (e.g. the ability to evaluate and understand self and others, and to manage oneself in the context of a group).
  • Communication (e.g. the ability to lead change in groups and in individual encounters, such as in negotiation and conflict resolution)
  • Commitment to lifelong learning (e.g. reflective practice, and furthering professional development)

Although Stoller shortlisted these competencies, significant emphasis was placed upon the value of emotional intelligence, as this competency was a skill that was under-represented in medical curricula yet essential for understanding self, others, and the leadership process. This emphasis upon this competency may be due to the associated skills that are linked with emotional intelligence such as interpersonal skills, empathy, and social intelligence (Ashkanasy & Daus, 2002; Goleman, 2006; Riggio & Reichard, 2008).

Prepared by Siggins Miller for RACMA – May 2010


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