Strengthening health leadership to tackle health system challenges: reflections from our experience

New Zealand’s health system challenges persist despite substantial structural changes and, more recently, leadership changes. The underlying challenges that led, at least in part, to these leadership changes have not diminished. This is not surprising, for these challenges are neither new nor unique to New Zealand. The Gibbs report of 1988, Unshackling the Hospitals, identified key challenges—equity, access including waiting lists, efficiency, morale, and a range of “management deficiencies”.¹

Most countries are grappling with similar workforce, service demand and funding challenges.² The COVID-19 pandemic accelerated or amplified them,³ even in New Zealand where our health system escaped the worst of the pandemic’s impacts.⁴ The fundamental driver of these challenges is ageing populations, with the associated rise in the burden of non-communicable diseases (age being the strongest risk factor for cardiovascular disease, cancers and diabetes) and frailty with its complex and resource-intensive clinical and care needs.⁵ Compounding this is a proportionately smaller labour force available to provide the tax base needed to fund and staff services.

Structural solutions are often seen and portrayed as the principal solution to these challenges. However, structural change tends to overlook the deep complexity of health systems and seldom delivers the promised improvements, not least because the substantial disruption they cause often leads to a drop in performance in the short to medium term.⁶

Structural solutions in New Zealand are not new. Returning to the 1988 Gibbs report:

“Our recommendations relate largely to changes in structure. We believe that the structure we have developed, which separates the roles of funder and provider… In the improved environment that should develop from this independence, we expect many dynamic, creative and unforeseeable adaptations to take place.”¹

Our view is that this is a critical juncture to seriously consider the health system leadership that is needed if we are to address the challenges effectively. This is based on our combined experience in health leadership roles over many years, the evidence that informs our own leadership practice and the outcomes of a focus on leaders and leadership at the former Hutt Valley District Health Board (DHB). This paper summarises the key elements of that DHB experience and draws out lessons for effective leadership of healthcare organisations and the health system in New Zealand.

The Hutt DHB experience

Hutt Hospital was previously part of the Hutt DHB and was incorporated into Health New Zealand – Te Whatu Ora in mid-2022. The hospital provides secondary healthcare services for approximately 160,000 people in the Hutt Valley and, for a few services, the greater Wellington Region and lower North Island.

In mid-2015, the wider organisational culture was strong, but some services were having difficulties, including the emergency department (ED). We commissioned an external review of the ED to identify actions to improve performance.

Response to the ED review

The review identified various issues and provided recommendations to improve the culture, staffing, efficiency and clinical processes in the ED.⁷ These recommendations were largely accepted and an implementation programme started. The response also included actions to shape the wider organisational culture, values and leadership capability as described below.

The ED reviewers also reported behaviours in the department that some staff members described as “bullying”. They reported this separately to the chief medical officer (CMO) who promptly spoke with the individuals concerned, with varying responses; the issues were resolved within a short period. This prompt action was essential as the need to address the unhealthy culture of the ED was a key finding of the reviewers.

Wider organisational actions

Concurrently, there was a significant focus on strengthening the organisational culture with all staff through an organisation-wide culture and values process. This had very wide engagement and input was sought from service users and whānau and community providers. This exercise started with finding out from staff what was the most important ingredient for a good day at work. There was resounding support for “positivity” being key—and, conversely, “negativity” was most widely cited as leading to a bad day at work.

Organisational values were developed collaboratively by the staff through an iterative process and were not “imposed” by the leaders; they were then used as a basis for strengthening organisational culture. Senior clinical leaders also openly shared their ambition for Hutt becoming the best secondary hospital in New Zealand.

Once the values were agreed, they provided the “benchmark” for the staff behaviours—both desirable and undesirable—that supported those values, and staff members were equipped with tools to address behaviours that didn’t align with the values expected. The values were also used as part of appointment processes to help ensure potential new employees understood the organisational culture and behaviour expectations, and to assess organisational “fit”. As a result, some applicants who had the qualifications and relevant experience were not employed because the interview panel was not comfortable there was a good fit with the organisation’s values and culture.

Senior medical officers (SMOs) play an important role in hospitals in modelling the values: they are influential, in positions of relative power and set an example for others—in particular, postgraduate doctors and trainees. Given this, the CMO was involved in the appointment process of all SMOs, with a particular focus on organisational fit.

The DHB also approved the establishment and “ring fencing” of a NZ$1m improvement fund, even while the overall DHB budget was in deficit, and support from project managers for small innovation and improvement projects. A group of hospital and community clinicians, convened as a clinical council, assessed and approved proposals. This fund gave “agency” to clinical teams, which were empowered to make changes, and created an opportunity for focus and meaningful action.

The initiative was well received as it conveyed that clinical improvement initiatives were valued and that changes in clinical practice were for improvement rather than being “mandated”. Clinicians were also able to access improvement training to help them identify and act on opportunities.

Collective leadership training

The executive team also approved funding for leadership training for people in senior clinical roles and aspiring clinical leaders. The most senior clinical leaders committed to doing the training and encouraged—and created the expectation for—others to participate.

The initial training was planned for up to 25 SMOs in leadership roles, but became a cross-directorate, multidisciplinary leadership course involving medical, nursing and allied health leaders. As it transpired (arguably predictably), this made the training even more worthwhile as it developed and strengthened relationships across the organisation and between professional groups. This approach was taken with subsequent courses, which also included senior operational managers, many of whom came from a clinical background, and primary care clinical leaders.

The training was 7 full days spread out over a few months and the time to attend was protected and paid. Between these sessions small interprofessional peer groups were formed, and the participants met to discuss their “homework” and support each other. These groups continued well past the finish of the training. Memorably, after the first day of training, a senior medical leader who was nearing retirement commented, “I wish I had done this 20 years ago”. The uplift in clinical leadership was palpable and great camaraderie was created between clinical leaders and service managers, and between services. This created a downstream chain reaction, notably through the establishment of collaborative relationships between clinical teams to deliver more patient-focussed care. We observed a number of “magical moments” of collaborative patient care.

Building on this training, we held quarterly meetings with all senior clinical and non-clinical leaders, including primary care leaders, to strengthen our collective leadership as a team. At each meeting, we would reflect on the last 3 months, identify what had gone well and what needed work, and agree on priorities for the next period.

Multiple supporting actions were initiated with executive sponsorship, including rolling out the Choosing Wisely programme, reshaping clinical pathways to improve patient care and developing peer support networks. There was wide engagement of staff in these activities. Several forums were created for staff to meet with executives to address staff concerns and improve patient care.

Outcomes

Shortly after the initial review of the ED, and before significant changes had been implemented, the Australasian College of Emergency Medicine (ACEM) undertook a planned review and, as a result, withdrew accreditation for registrar training.

The 2017 ACEM report (1 year after losing training accreditation) noted a substantial positive change in the morale of the trainees and specialists who were interviewed compared with the original 2016 assessment.⁸ There was general optimism and confidence in the hospital executive, which was attributed to the changes that were made over the last year, including additional specialist staffing and the appointment of a Fellow of the Australasian College of Emergency Medicine (FACEM) as co-director of the department.

The next ACEM review in 2020 stated, “It is very pleasing for the inspection team to note the positive and upbeat vibe in the ED”.⁹ The review noted that a director of emergency medicine (DEM) had been appointed since the last inspection and that the DEM and her leadership team, with strong support from the CMO, had brought about a significant culture change that had transformed the ED and impacted positively on the wider hospital. The increase in FACEMs included a new younger cohort that had re-energised the SMO group. Behaviour that was inconsistent with the organisation’s values had been “called out” and the review noted a hospital-wide focus on prioritising education and training alongside service provision. The review concluded that these developments addressed many of the concerns identified in the previous inspections.

Importantly, the changes have endured; experienced clinicians coming into the organisation have commented on the strength of the culture and relationships. Many of the current senior registrars in emergency medicine have indicated that Hutt is their preferred place to work as an SMO because of the positive culture and collaboration between the ED and other departments. An SMO from another DHB indicated that Hutt Hospital has become one of the preferred departments to work because of the strong departmental culture and collaboration with other specialities.

Discussion

Management “guru”, the late Peter Drucker, described hospitals as the most complex human organisation ever devised.¹⁰ Nearly 50 years later, they are more complex and present a demanding work environment for staff and a unique leadership and management challenge. In addition, hospitals are just one part of an even more complex system.

In such complexity, trust and relationships are key to creating an environment that delivers high-quality and equitable care, ensures resources are managed well and is rewarding for staff. The latter is important: working in health needs to be both rewarded and rewarding, so staff have agency and enjoy or “feel joy” at work. A key part of this is staff safety and wellbeing being prioritised alongside patient safety and outcomes—the two are closely linked.

Organisational culture and values need to align as much as possible with the personal and professional values of staff members. An organisational culture and values exercise helps to ensure such alignment, strengthening relationships and generating a sense of camaraderie—“we’re all in this together”.

An important part of this is addressing behaviours that undermine the organisation’s values and a positive work environment. The central pillar of good leadership is “leading self” through having an active awareness of the impact of one’s behaviours on others.

Proactively addressing negative behaviours is essential. Some people are simply unaware of the impact of their behaviour on others and are genuinely shocked when they find out. Others may be aware but have “got away with it” for so long that there is no incentive to change. Making it clear that a line has been drawn is sufficient for most people to moderate their behaviour. Others make their own decision if they don’t agree with the line and where it has been drawn.

The changes described in the case study require a deliberate and transformational—rather than transactional—approach. At the time, we were not aware of, or driven by, any specific leadership theory; rather, we considered actions that would motivate people, strengthen and empower leadership at different levels, develop a strong values-based culture and provide opportunities for innovation.

However, as we considered the factors that contributed to our success, it became clear that the approach we took was consistent with transformational leadership described by Bass.¹¹ Transformational leadership occurs where the leader can inspire others to the extent that they perform beyond expectations and apply significant discretionary effort.¹¹ This model of transformational leadership identifies four dimensions: idealised influence, individualised consideration, inspirational motivation and intellectual stimulation. The transformational leader is described as one who creates an organisational culture that converges the leader and their followers towards mutual “bar-raising” and stimulating greater productivity that could not have been achieved solely through transactional leadership.

There are examples of the impact of successful transformational change in healthcare. A detailed examination of four case studies from the United States of America, United Kingdom and Australia acknowledged that transformational change is difficult and complex, particularly in systems providing essential services, such as health in which people are understandably risk averse.¹² However, the four case studies also showed success is possible, with common factors underpinning this: a well-communicated vision, innovative redesign, extensive consultation and engagement with staff and patients, performance management, automated information management and—notably—high-quality leadership.

We also consider kindness as a key pillar of effective transformational and values-based leadership. A key recent publication emphasises the importance of the leading with kindness and taking a systematic approach to addressing the determinants of staff subjective wellbeing and healthspan.¹³ Kindness is defined in this context as “helping people do better”, and “kind organisations” have systems in place to do this by engendering agency (control over work–life), collective effervescence, (meaning energy and harmony in groups of people with shared purpose), camaraderie (social connectedness) and positivity (optimism and caring). Kindness is not the same as “niceness”, and sometimes requires courageous conversations with people about the negative impact of their behaviours, noting that this can and should be done in a way that helps them to do better.

Addressing health system challenges and transforming organisations is enabled by equipping people with leadership skills and providing ongoing support for them to lead successfully. Many healthcare leaders, both clinical and non-clinical, do not receive even basic leadership training and ongoing development as leaders, yet their behaviours set the culture and tone of the organisation.

Leadership training is generally more effective and enduring if it takes place with groups of people in their workplace as it fosters a shared understanding, strengthens relationships and promotes practical application of learned skills. We found that involving local health system leaders, e.g., from primary care, provides significant additional value.

Right now, New Zealand’s health system needs transformational leaders who are values-based, engage with and support staff and convey hope and a strong sense of purpose. They need to be transparent, insightful, trustworthy, compassionate and authentic. Developing and improving such skills takes time and training, which requires investment. Our experience is that even a modest investment reaps large dividends.

Conclusion

Leadership in the healthcare system is challenging every day—a key task is remaining positive and conveying a sense of hope. People working in the system know it is tough (it is their daily reality) but they are smart, deeply committed, innovative and want to make a difference. Our experience is that those working in health have amazing fortitude despite the constant challenges, setbacks and frustrations—because they know their work makes a difference and it only takes small wins to make it all worthwhile. Healthcare leaders need and deserve strong support to lead effectively. A focus on this is essential if New Zealand is to successfully address health system challenges, both old and emerging.