LEADS Book - English - 2019

BRANCHES OF KNOWLEDGE: COMPREHENSIVE ARTICLES ON LEADERSHIP
LEAD SELF
ENGAGE OTHERS
ACHIE VE RESULTS
DE VELOP COALITIONS
SYSTEMS TR ANSFORMATION
BRANCHES OF KNOWLEDGE | COMPREHENSIVE ARTICLES ON LEADERSHIP
Foreword
H ealth leaders of the 21st century will need to have the capacity to
see the future faster, to manage and mentor talent better, and to
service growing health needs within increasingly restrained budgets.
Stronger leadership is essential to improving the performance of our

health system and, ultimately, advancing the health of Canadians.
Investing in excellence in health leadership development is an
investment in our future.
The emerging community of practice of health leadership across Canada is working to ensure we have
the capabilities and capacity to create healthy workplaces; workplaces that can engage in successfully
transforming our systems for the future. Leadership is vital to both.
J. C. Spender, in his forward to Barbara Kellerman’s book entitled Professionalizing Leadership (2018),
states that “Each category of “problem” implies a specialized leadership needed to create order in the
face of disruption and disorder.” Healthcare needs leadership: and a leadership language respectful of
its people-centred vision that unites us all in its pursuit.
In Canada, we use the LEADS in a Caring Environment capabilities framework as a guide to developing
and practicing the leadership Canada’s health system needs. Similar frameworks—based on Canada’s
LEADS—are at work also in Australia.
All leadership is situational: so it is with the special circumstances affecting health and healthcare in
Canada. Indeed, due to our highly decentralized system of financing and delivering healthcare services,
Canada’s health delivery system is amongst the most complex organizationally in the world. Complex,
adaptive systems require complex, adaptive leaders: those who have the capacity to form networks,
inspire others, think at a system level, and create change in that system (Ford, 2009).
The LEADS in a Caring Environment leadership capabilities framework provides a customized

For Health, By Health framework for responding to this complexity and to the growing need for a
concerted, coherent, and sustainable strategy for strengthening Canada’s health leadership capacity.
I
The framework features five memorable and intuitive domains: Lead Self, Engage
Others, Achieve Results, Develop Coalitions, and Systems Transformation. Each of
these five domains consists of four core, measurable and observable capabilities.
At the core of LEADS is the fundamental value of caring. Health and healthcare
systems are quite diverse, but share the overall identity, or ‘raison d’être’, of caring:
leaders, at whatever level, care about the health of Canadians; care about the health
of the healthcare system; and care about their staff and their peers. This is why “in
a Caring Environment” has become embedded in and integral to the application of
the LEADS framework.
The framework builds on the seminal work undertaken on behalf of the

Government of British Columbia by the Health Care Leaders Association of BC. In
2019 the LEADS framework is now endorsed across Canada: by health authorities,
extended care homes, provincial regions, and by most national healthcare
organizations. The LEADS Collaborative consisting of the Canadian College of
Health Leaders, the Canadian Health Leadership Network, and the co-founder of
LEADS, Dr. Graham Dickson, are working together to facilitate a national strategy
for leadership development based on LEADS.
The LEADS in a Caring Environment leadership capabilities framework has both

construct and face validity. In terms of construct validity, LEADS is the result of
an ongoing review of the leadership literature and a systematic review of the wide
range of existing competency frameworks used to advance health leadership. It
also reflects the results of key informant interviews across Canada and abroad on
identifying leading practices across Canada and internationally.
Face validity refers to its strength in accurately representing the real-world

experience of leadership as attested by those in leadership roles in the health sector.
Given that LEADS in a Caring Environment leadership capabilities framework has
now been embraced across jurisdictions and disciplines as a preferred leadership
learning platform, its face validity is strong. In an article entitled A Journey of
Leadership, from Bedside Nurse to Chief Executive Officer, Margaret Comack states
that “The LEADS framework provided a structure to situate my career path and my
personal journey toward the position of chief executive officer (CEO). In addition,
there were many process concepts that I was able to relate to in considering the
stages of the LEADS capabilities framework.”
The LEADS framework has been approved by the Canadian College of Health
Leaders as the leadership capabilities framework for career-wide learning and
the accreditation of the College’s Certified Health Executive (CHE) credential and
maintenance of competency programs.
II
FOREWORD
Other important recent developments in terms of adoption of the LEADS

framework as the preferred leadership development platform across Canada
include:
• Accreditation Canada’s standards for leadership and governance are informed by

the LEADS framework.
• Its use in the health authorities in all western provinces, as well as in many health
jurisdictions in Ontario, New Brunswick, PEI and all of Newfoundland, for
leadership talent management solutions including succession planning, leader
selection, leadership development, and in some instances as a model for creating
change.
• HealthcareCAN (HCC), the Mental Health Commission of Canada, and the

Canadian Collage of Health Leaders (CCHL) have collaborated on a resource
document that shows how the LEADS framework supports implementation of
the MHCC’ 13 workplace standards for psychologically healthy workplaces.
• CCHL and HCC have recast the scientific program for the annual National
Health Leadership Conference around the LEADS framework.
The LEADS in a Caring Environment leadership capabilities framework provides

a robust response to the challenge leader/managers face in having to demonstrate
excellence in leadership that is necessary to improve Canada’s performance in
healthcare.
We are committed to continue to work together as a team to build a better future of

health leadership in Canada, where leadership is defined not in terms of the power
a leader wields or by the resources at a leader’s command, but by a leader’s ability to
engage and mobilize others toward a constructive common purpose (Dickson et al.,
2007).
Alain Doucet, President & CEO, Canadian College of Health Leaders

Dr. Graham Dickson, Principal Investigator, Founder & Strategic Advisor
Canadian College of Health Leaders (www.cchl-ccls.ca)

LEADS Canada (www.leadscanada.net)
Foreword revised: March 2019
III
BRANCHES OF KNOWLEDGE | COMPREHENSIVE ARTICLES ON LEADERSHIP INTRODUCTION
Introduction
T his booklet, devoted to the LEADS in a Caring Environment

leadership capabilities framework domain of Lead Self, is one of
five booklets outlining leading practices of effective health leadership
in Canada. The five domains of the LEADS framework—Lead Self
(the focus of this booklet), Engage Others, Achieve Results, Develop
Coalitions, and Systems Transformation—reflect leadership in action
in health. This action is the doing part of leadership, that follows a deep
commitment to caring for others (the identity of the health system)
and recognition that the person you are, is the leader you are (the being
component of effective leadership): (Dickson et al., 2007): see Figure 1.
Caring (why) Doing (how)

Being (who) Commitment to Leading self, engaging Effective
Being true to health of patients, others, achieving results, Health LEADS
oneself; clients, to wellness, to developing coalitions,
authenticity organization service, and transforming Leadership
vision & mission systems
Figure 1: The Three Components of Effective Health Leadership

Note. From Dickson et al., 2007.
The Pan-Canadian Health Leadership Capability Framework Project: A
collaborative research initiative to develop a leadership capability framework
for healthcare in Canada. A Final report submitted to Canadian Health
Services Research Foundation, Ottawa, Ontario. Copyright 2007, G. Dickson,
reprinted with permission.
Being (who the leader is) and caring (the why of doing leadership in health) take
expression (doing) as the five domains of effective leadership in the LEADS in
a Caring Environment leadership capabilities framework. Each domain entails
four leadership capabilities, for a total of 20 capabilities in the framework. These
capabilities are actionable in that they represent caring and being in action and,
therefore, are observable by others.
IV IV
INTRODUCTION
It is appropriate at this point to say a few more words about the concept of a
caring environment. Almost anyone who works in the health system cares
about health and wellness; at least, we assume it is a driving force impelling
individuals to choose this line of work. Yet despite how well motivated they
may have been initially to care in their job or profession, the routines, policies,
procedures, protocols, and practices—imposed, professionally valid, and
derived from a caring motivation—can quickly become ends in themselves.
Caring, in terms of truly connecting with the welfare of another human being,
can become buried beneath such provisions. After a while, it is easy to simply
use the concept of caring as a mantra, without truly practising it.
But what does this situation mean for leaders? First and foremost, it means First and foremost, it
ensuring that caring, as a real and situational response to a need, drives their means ensuring that
behaviour, both personal and strategic. Second, it relates to the Environment
term in the framework. Leaders create environments—cultures, climates—in
caring, as a real
which others work. At the core of that caring environment is tangible evidence and situational response
of an ethos of compassion and empathy for others, which plays itself out as to a need, drives their
putting the patient, client, or citizen’s welfare at the centre of the decision- behaviour, both personal
making process. Caring for the patient or citizen’s welfare must manifest itself
through the leader’s actions, either personally or strategically, in response to the
and strategic.
follower’s needs. The leader must then ensure that actions taken by and within
his/her unit meet those needs. Note also that one of the greatest challenges for
those who take on the mantle of leadership is to retain a personal perspective
and emotional maturity that enables them to bear the inevitable burden—
and joy—that creating a caring environment entails. The LEADS framework
outlines what such an ethos of caring looks like in action—it details the
capabilities that leaders need to create a caring environment in their role in
the health system.
It is also important to note that the five domains of the LEADS framework
are at the same time both independent (i.e., separate from one another) and
interdependent. Although the domains can be observed separately as discrete
sets of capabilities, they also interact with one another to create effective
leadership. For example, you will see in this booklet that the capabilities relevant
to the Lead Self domain come into play with the capabilities of the Systems
Transformation domain to leverage success in creating change in different contexts:
the former for the individual who chooses to lead; the latter for the leader who
in an organizational or systems context.
V
BRANCHES OF KNOWLEDGE | COMPREHENSIVE ARTICLES ON LEADERSHIP INTRODUCTION
Similarly, the five domains of the framework can be seen as a regimen, or

approach, to leading change. The diagram in Figure 2 shows how the five
domains work together to guide change.
Achieve
Results
Str
es
ess
ate
oc
gic
l Pr
Pro
The five domains work
na
ces
Engage Relationships Develop
rso
ses
Others Coalitions together to guide change.
Pe
Shared
Vision
Lead Change Dynamics Systems

Self Transformation
Figure 2: The LEADS in a Caring Environment leadership capabilities Framework

as a Guide to Change
Figure 2 is explained as follows. The LEADS framework consists of one outcome
domain: Achieve Results, and four process domains: Lead Self, Engage Others,
Develop Coalitions, and Systems Transformation. The four process domains
are employed by the leader to achieve the outcomes identified by the Achieve
Results domain. The logic is as follows. When a change is envisaged in a system
(i.e., a shared vision for change based on a caring ethos), the leader needs
to articulate the A in the LEADS framework (i.e., the results that need to be
achieved by this change). These results represent the future state, in terms
of envisaged outcomes for the change; they are the tight components of the
change plan: it’s north star if you will.
Achieve Results is at the pinnacle of the hierarchy of leadership capabilities

because it is the product that all of the processes of leadership, both personal
and strategic, are aiming to achieve. Figure 2 suggests that there are two
processes associated with leading change: change dynamics and relationships.
These are the loose elements of a change plan: i.e., the leader is free to adjust
and alter his/her processes to adapt to the situational environment so as to
ensure the envisaged results are achieved.
VI VI
Lead Self and Systems Transformation are sets of capabilities that leaders
employ to address change dynamics. Systems Transformation is a strategic
set of capabilities: i.e., the ability to deal with employee receptivity to change,
public support, change resistance, etc. It is leadership at a distance, exercised
through policy, procedure, structure, and culture. Lead Self is a personal set
of capabilities: i.e., the ability of leaders to deal with their mindset on change,
take steps to change their habits, recognize their mental models, and meet
the challenges to their character that leading the change will require of them.
It is at home leadership.The second process element in the hierarchy is the
challenge of building relationships. Engage Others and Develop Coalitions are
the two dimensions of the relationship process. The Engage Others domain
and capabilities address the people challenges of effective interpersonal
relationships. The Develop Coalitions domain addresses relationship building at
a strategic level: that is, building support across units, across organizations, and
with customers and the public in support of change.
Collectively the four process domains of the LEADS framework and the one
outcome domain, Achieve Results, comprise a model to guide change. If the
leader uses this model to structure and focus their influence to create change,
and if that influence is implemented effectively, the outcome will be achievement
of the anticipated results of the change. If they are not, the approaches taken
need to be re-assessed and adjusted to achieve the defined results. Ultimately, the
LEADS framework is a model for thinking through and implementing system-
wide change: one that the leader is encouraged to use in order to scope out the true
challenges and demands of making change work in a systems context.
As you read this booklet, please keep the LEADS change model in mind. Once
a leader has determined that a change is necessary in the health system and has
clarified the results that change needs to achieve; they then need to determine As you read this booklet,
why he or she needs to lead it and exercise self-leadership to begin that
journey. At some point they need to engage people around them by creating an
please keep the LEADS
environment in which learning, teamwork, keeping healthy, and communicating change model in mind.
effectively thrives. They then need to build the coalitions across the system
to support the change and implement the mindsets, tools, and techniques of
strategic and transformational change to generate systems transformation.
This booklet provides the research foundation for the Lead Self domain and
its four capabilities. They are a foundational attribute of effective leaders in
changing environments, such as health.
Graham Dickson, Professor Emeritus, Royal Roads University
VII
LEAD SELF
LEAD SELF
LE AD SE L F
LEADS IN A CARING ENVIRONMENT
ENGAGE OTHERS
ACHIEVE RESULTS
DEVELOP COALITIONS
LEADERSHIP CAPABILITIES FRAMEWORK Paul Mohapel
LEAD SELF
Table of Contents
ii Executive Summary
iii Self-Aware
iv Manages Self
v Develops Self
vi Demonstrates Character
1 LEADS in a Caring Environment leadership capabilities framework –

Lead Self
2 The Four Capabilities of the Lead Self Domain
5 Self-Aware
6 • Self-Aware – Awareness of Emotions
8 • Self-Aware – Awareness of Assumptions & Paradigms
11 • Self-Aware – Awareness of Values & Principles
14 Manages Self
15 • Manages Self – Emotional Management
18 • Manages Self – Personal Mastery
21 • Manages Self – Life Balance
23 Develops Self
24 • Develops Self – Developing Soft Skills
26 • Develops Self – Life-Long Learning
31 Demonstrates Character
32 • Demonstrates Character – Personal Integrity
36 • Demonstrates Character – Emotional Resiliency
38 Conclusion
41 Bibliography
I
LEAD SELF
Executive Summary
T his report examines and reviews the literature supporting the

Lead Self domain of the LEADS in a Caring Environment
leadership capabilities framework. Lead Self consists of four
capabilities: A leader (1) is self-aware, (2) manages self, (3) develops
self, and (4) demonstrates character. The underlying assumption of
this framework is that effective personal leadership is associated with
a set of definable skill sets or capabilities that can be learned by
conscious and intentional effort.
Emotional intelligence is one of the core concepts that underlie all

four of the Lead Self capabilities. The term describes the intra- and
inter-personal aspects of intelligence. It underlies most components
of self-leadership, including: attitude, motivation, trust, influence,
interpersonal communication, self-control, and problem-solving.
II
Self-Aware
T he Self Aware capability refers to the awareness of one’s own

assumptions, values, principles, strengths & limitations. Self-
aware leaders are adept at examining their own emotional triggers,
thinking patterns, assumptions, values, principles, and strengths
and limitations. Self-Aware can be further divided into awareness of
emotions, awareness of assumptions and paradigms, and awareness
of values and principles.
Emotional self-awareness refers to the ability to recognize one’s own emotions

and determine their impact on others. It requires the ability to be able to
accurately assess one’s own emotional triggers and weaknesses, as well as one’s Successful leaders align their
emotional strengths. Leaders that are highly emotionally aware tend to have a values to effective leadership
greater sense of their own self-worth and capabilities. They take the time for
quiet reflection rather than act impulsively, they strive to understand their own
principles.
emotional reactions and trigger points, they are able to continuous monitor
their own emotional states, and they are able to leverage positive feelings to
drive their motivation and actions.
Awareness of perceptions and assumptions is a key aspect of developing self-

awareness. It is the ability to understand the impact our perceptions have
on our sense of reality. Individuals’ perceptions are often distortions of
reality because each person has their own unique personalities, experiences,
information, perspectives, biases, and discriminations. Our perceptions are the
basis of creating frameworks, or paradigms, that often shape the way we select
data and perceive events. Effective leaders test and compensate for distorted
paradigms by continually challenging their own assumptions through a process
of inquiry and advocacy.
Awareness of values and principles is critical for personal leadership, since these
drive the choices and actions leaders take. Values are what may be personally
worthy, relevant and important; while principles are the collective standards,
guidelines, or rules that we use to guide our behaviour. Successful leaders align
their values to effective leadership principles. Developing a personal vision or
mission statement is an effective strategy for leaders to discover their true values.
III
LEAD SELF
Manages Self
T he Manages Self capability refers to taking responsibility for one’s

own performance and health. Effective leaders realize that in
taking responsibility for their own choices, they empower themselves
to have greater freedom to choose their responses. Manage Self can be
further divided into emotional management, personal mastery, and
life balance.
Emotional management refers to the ability to regulate both the expression

and experience of emotions. The leadership competencies associated with
emotional management include: emotional self-control, transparency, Emotionally intelligent
adaptability, achievement, initiative, and optimism. A leader can engage in leaders exhibit high
emotional regulation in two ways: through emotional reappraisal or emotional
resiliency, defined as the
suppression. Appropriate emotional expression is also important for leaders,
since it is effective for rousing and motivating followers. ability to successfully
change, adapt, overcome,
Personal mastery is about creating what one wants in life and in work. It can be and cope with unexpected
developed by creating a personal vision and understanding one’s own reflexive
reactions. It’s about taking control of one’s life instead of blaming, not allowing setbacks, unwanted
external circumstances or mood to define one’s choices, continually growing adversities and general
and learning, exercising discipline, and taking proactive control of one’s own life challenges.
choices, decisions, and actions.
Life balance is closely linked with emotional intelligence. High resiliency is

defined as the ability to successfully change, adapt, overcome, and cope with
unexpected setbacks and general life challenges. Resilient leaders have particular
mindsets, which include: being curious, optimistic, less sensitive, and being able
to resist being reactionary, blaming others, or dwelling on unhappy feelings. One
of the key strategies they employ is directly challenging their negative self-talk
and maintaining control over their personal feelings and behaviours.
IV
Develops Self
T he Develops Self capability refers to actively seeking opportunities

and challenges for personal learning, character building, and
growth. Effective leaders know that Self-development is life-long
process, where the right attitude is as important as the right skill sets.
Develops Self can be further divided into developing soft skills and
life-long learning.
Developing soft skills becomes increasingly important as leaders develop in

their careers. Soft skills could include motivation, communication skills, team
management, confidence, versatility, reliability, and emotional and social Effective leaders know that Self-
intelligence. Recent research has identified soft skills, such as authentic and development is life-long process,
honest two-way communication, trust, empathy and genuine compassion for
where the right attitude is as
employees, as being most important for effective leadership.
important as the right skill sets.
Life-long learning refers to a mindset, where every experience, opportunity,
change, situation, challenge, and conflict is seen as an opportunity to
learn. Adult learners need be autonomous and self-directed, use their own
experiences and knowledge, have goals, learn only what they deem relevant,
have practical information, and be shown respect. Self-directed learning works
most effectively when a learning plan is made that addresses the gaps between
ideal self and real self. Learning occurs in a cycle, which is associated with four
learning styles: accommodating, converging, diverging, and assimilating.
V
LEAD SELF
Demonstrates Character
T he Demonstrates Character capability refers to the modeling

of qualities such as honesty, integrity, resilience & confidence.
Character can be defined as the behaviour one portray to others, to
the inward motivation to do what is right, or to abiding by ethical
principles and values. Demonstrates Character can be further divided
into personal integrity and emotional resiliency.
Personal integrity has four elements: consistent in words and action, consistent
in adversity, being true to oneself, and displaying moral and ethical behaviour.
The characteristics most often cited as important are a sense of morality “The Five E’s Of Character
and ethics, honesty, trustworthiness, respect, justice, openness, authenticity,
Development”: Example,
empathy, and compassion. Integrity as foundational, followed by respect and
responsibility, followed by empathy, emotional mastery, lack of blame, humility, Education, Environment,
accountability, courage, self-confidence, and focus on the whole. Developmental Experience, and Evaluation.
strategies for personal integrity include The Five E’s Of Character Development:
example, education, environment, experience, and evaluation.
Emotional resiliency refers to the ability to bounce back from setbacks and
overcome adversity, to cope well with high levels of ongoing change and
constant pressure, and to change and adjust from old ineffectual habits that
may be dysfunctional or maladaptive. Research suggests that emotional
related competencies, such as self-confidence, optimism, social support, and
established coping reactions can account for differences in resiliency between
people. A new avenue of research suggests that positive emotional experiences
may help build resiliency.
VI
LEAD SELF
LEADS in a Caring
Environment leadership
capabilities framework —
Lead Self
1
The Four Capabilities of the

Lead Self Domain
“Leadership is an art—a performing art—and the instrument
is the self.”
— Kouzes & Posner
Lead Self’s four sub-domains:
L eadership starts with one’s self. This particular paper will focus
in on the Lead Self component of the LEADS framework.
Lead Self embodies personal leadership: the arena of influencing an
1. Self-aware
2. Manages self
3. Develops self
individual’s own mindsets, beliefs, values, and intentions. This form 4. Demonstrates character
of leadership looks to the fields of psychology, business, and
spirituality to understand the levers of influence one has to change
oneself. This is the core element of leadership that sets the foundation
for all of the other four LEADS leadership dimensions. Lead Self ’s
four capabilities are: (1) are self-aware, (2) manages self, (3) develops
self, and (4) demonstrates character.
Table 1: Main Descriptors for Each Capability within the Lead Self Domain
Lead Self Capabilities Capability Description

Shows awareness of; one’s own assumptions, values, principles, strengths,
Are Self-Aware
and limitations.
Manages Self Takes responsibility for their own performance and health.
Actively seeks opportunities and challenges for personal learning, character

Develops Self
building and growth.
Demonstrates Character Models qualities such as honesty, integrity, resilience, and confidence.
The underlying premise of the LEADS framework is that leadership needs

to be developed. Contrary to the old romantic notion that great leaders are
born, the current research literature overwhelmingly suggests that effective
2
LEAD SELF
leadership is associated with a set of definable skill sets or capabilities that need Effective leadership is
to be consciously and actively developed (Parks, 2005). As such, leadership associated with a set of
development can be defined as expanding an individual’s capabilities to
effectively carry out leadership behaviours and processes. However, before one
definable skill sets or
can effectively lead others, one must first be able to lead himself or herself. capabilities that need to
Therefore, leadership development starts with focusing on understanding be consciously and actively
and developing your own personal beliefs, attitudes, capabilities, and skills developed.
(Boyatzis, 2008; Mumford, Marks, Connelly, Zaccaro, & Reiter-Palmon, 2000).
Leadership of self has been defined in the academic literature as the influence
individuals use to understand and control their own behaviour and thoughts
(Manz & Neck, 2004; Neck & Houghton, 2006). It is comprised of specific
behavioural and cognitive strategies intended to increase personal effectiveness
and performance (Frese & Fay, 2001). The fundamental idea behind Lead Self
is that individuals intentionally look first within themselves to understand
their own internal state, as well as apply the necessary tools and strategies to
motivate and control behaviour and thought.
Strategies to enhance self-leadership are typically classified into two categories: Strategies to enhance
(1) cognitive or thought pattern strategies and (2) behaviour-focused strategies self-leadership are typically
(Manz & Neck, 2004; Prussia, Anderson, & Manz, 1998; Sims & Manz,
1996). Cognitive strategies tend to focus on changing individual thought
classified into two categories:
patterns by reframing. Cognitively focused self-leadership can be defined as 1. cognitive
deliberately attempting to control, influence, and enhance an individual’s own
thinking in productive ways (Sims & Manz, 1996). Research has shown that 2. behaviour
individuals who apply cognitive-focused strategies experience heightened
mental performance, positive effect, and job satisfaction (Neck & Manz, 1992).
Cognitively focused strategies include mental imagery, mental rehearsal,
self-talk, and managing beliefs and assumptions. Behavioural strategies
tend to focus on shaping an individual’s actions through deliberate choices.
Behaviourally focused self-leadership involves using action-oriented strategies
to accomplish tasks that may be unpleasant, challenging, or de-motivating.
Behaviourally focused strategies include self-observation, self-reflection, self-
goal setting, self-evaluation, self-reward, and self-visioning (Sims & Manz,
1996). Recent research has demonstrated that employing these self-leadership
strategies contributes to greater organizational innovation and creative thinking
(DiLiello & Houghton, 2006), teamwork (Bligh, Pearce, & Kohles, 2006), and
resiliency (Boss & Sims, 2008).
Both cognitive and behavioural strategies are critical components of emotional

intelligence: one of the core concepts that underlie the Lead Self framework.
The term emotional intelligence was first coined by the researchers Peter
Salovey and John Mayer (1990) to describe social and inter-personal aspects
3
of intelligence. Whereas intelligence is classically defined in terms of

mental and cognitive abilities, many argue that effective leadership and job
performance is also heavily dependent on emotional attributes, and thus
constitutes a separate type of intelligence (Goleman, 2004; Goleman, Boyatzis,
& McKee, 2002). Emotional intelligence emerged as an important topic of study
in the mid-1990s, in part, owing to publication of Daniel Goleman’s (1995)
worldwide best-selling book, Emotional Intelligence. Since that time, scholars
have attempted to refine and enhance the way that emotional intelligence is
conceptualized (Matthews, Zeidner, & Roberts, 2002).
Emotional intelligence has also been argued to be critical for job performance Emotional intelligence
and leadership (Cote & Miners, 2006; Lam & Kirby, 2002; Prati, Douglas, Ferris, has also been argued
Ammeter, & Buckley, 2003; Stubbs-Koman & Wolff, 2008; Riggio & Reichard,
to be critical for job
2008). Daniel Goleman believes that emotional intelligence underlies most
components of self-leadership, such as: attitude, motivation, trust, influence, performance and
inter-personal communication, self-control, and problem-solving (Goleman, leadership.
1998). For a more comprehensive review on the role of emotional intelligence
in leadership, see Humphrey (2002). The key components of emotional
intelligence required for effective leaders are presented in Table 2. Goleman
(2004) also identified similar components.
Table 2: Main Descriptors for Each Component of the Self-Aware Capability
Component Description
Self-awareness Being aware of & in touch with your feelings & emotions
Being able to manage various emotions and moods without denying or

Self-regulation
suppressing them
Self-motivation Being able to remain positive & optimistic
Social awareness Being able to read other’s emotions accurately and putting yourself in their place
Social skills Having the skills to build & maintain positive relationship with others
4
LEAD SELF
Self-Aware
“Know thyself.” — Socrates
A leader must know what it is that he or she is doing, or has been

doing, before attempting to change behaviour. Skills such as self-
reflection and self-observation increase self-awareness and provide
valuable insight into why, how, and when an individual behaves in
certain ways. After raising self-awareness through reflection and
observation, the skill of self-evaluation helps to determine the degree
to which a particular behaviour is positive or negative, desirable or
undesirable, and necessary or unnecessary (Manz & Neck, 2004). This
section examines the importance of being self-aware as a leader and
some of the skill sets and strategies that have been shown to be critical
for building self-awareness. Self-aware leaders are adept at examining
their own emotional triggers, thinking patterns, assumptions, values,
principles, and strengths and limitations.
The following elements of Self-Aware will be further elaborated in the sections

below in awareness of emotions, awareness of assumptions and paradigms, and
awareness of values and principles.
5
Self-Aware – Awareness of Emotions

“The worse a person is the less he feels it.” — Seneca
R ecent research demonstrates that an essential element of self-

awareness is the ability to monitor one’s own emotional state.
Research has shown that the effectiveness of leadership performance
is directly related to the degree that leaders can accurately self-assess
their emotional state (Caruso, Mayer, & Salovey, 2002; Cooper &
Sawaf, 1997; Goleman, 2004; Goleman et al., 2002; Higgs & Aitken,
2003; Morris & Feldman, 1996; Sosik & Megerian, 1999).
Daniel Goleman and colleagues (2002) define emotional self-awareness as the

ability to recognize one’s own emotions and their impact on others. It requires Emotional self-awareness
the ability to accurately assess one’s own emotional triggers and weaknesses,
as well as one’s emotional strengths. Leaders that are emotionally aware tend
is the ability to recognize
to have a greater sense of their own self-worth and capabilities. Emotionally one’s own emotions and
self-aware leaders understand and have a deep emotional connection to their their impact on others.
values, goals and dreams. They are able to trust their intuition and make
effective decisions based on principles and long-term goals.
Goleman and colleagues (1998, 2002) suggest that effective leaders employ
several strategies to enhance their emotional self-awareness. First, effective
leaders take the time for quiet reflection rather than act impulsively. They strive
to understand their own emotional reactions and trigger points. Emotionally
aware leaders reflect on how their emotional states impact their actions and
thinking. Second, they are able to continuously monitor their own emotional
states. By being constantly aware, they are able to leverage positive feelings to
tap into what is important and meaningful to them to drive their motivation
and actions. Psychological research shows that intrinsic motivators are by far
more effective than external rewards in job performance (Elliot & Harackiewicz,
1996). Third, they are open to learning more effective strategies to deal with their
emotions and constantly seek feedback from others. They are open to taking in
new perspectives, challenging their perceptions and assumptions, and strive for
self-development. This will be further elaborated on in the next section.
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LEAD SELF
Example 1
Barb Stoddard, Director of Medical Administration

In my professional experience as a director, I would say, hands down, that the most critical factor to effective leadership
is emotional awareness and management. I find that people who are most successful in dealing with challenging
situations do so by tapping into their own awareness of their feelings and reflecting on them. They engage in an action
research loop: thinking, acting, and reflecting. They are able to ask themselves, “What is happening for me right now,
how do I feel, and what do I need to do?” I believe the key is to pay attention to what is happening inside oneself 
being responsive rather than being reactive. It’s the ability to listen to the inner voice and balance that with the external
voice. Emotional awareness allows one to have the flexibility in listening to your inside and shifting to the outside. I recall
a situation where I had to lead a team debrief around a prenatal incidence. In this conversation, only five out of twenty
people were speaking the entire time. We were about to disband the meeting, when my inner voice said, “We’re not
done.” Not everyone had spoken, and I felt critical information had not surfaced. I had trepidation in saying something,
due to the potential adversarial impressions this might have. However, as I reflected on my discomfort, I realized I had
to act on my gut feeling and raise my concerns. In doing so, our team surfaced some critical information that had been
missed about the incident. I would have not been able to act had I not been present in the moment and reflected inwards on
my emotional state. This was a powerful experience and it reminds me to listen to my inner voice and give it expression.
7
Self-Aware – Awareness of
Assumptions & Paradigms
“We see the world not as it is, but as we are.” — The Talmud
A key aspect of developing self-awareness is the ability to

understand the impact our own perceptions and assumptions
have on our sense of reality. Self-awareness cannot be achieved
without first exploring the source of our own perceptions and
assumptions.
Perception is defined as the process of interpreting information from our five Perception is defined as
sensory organs: sight, sound, touch, taste, and smell. We often assume that our the process of interpreting
perceptions are derived primarily from bottom-upsensory organs, but in
information from our five
fact are equally influenced by top-downwhat we already know and believe
impacts the way we see the world (Argyris, 1990). We know from psychological sensory organs: sight,
research that people’s perceptions are often distortions of reality because we see sound, touch, taste, and
the world more as a function of who we are rather than what is. Since we each smell.
have our own unique personalities, experiences, information, perspectives,
biases, and discriminations, we each have different perceptions (Gentner &
Stevens, 1983). Often leaders can lose sight of the inherent subjectivity of their
perceptions and falsely assume that only their interpretations of the world hold
validity. To avoid this pitfall, leaders need to shift from the mindset of judging
to openness, acknowledging that their perceptions may be potentially limited
and distorted and that the perceptions of others can also hold validity. Leaders
who are self-aware accept that there is no absolute right or wrong, only differing
viewing points. By doing this, leaders can better connect and influence others
in more meaningful ways (Caldwell, Bischoff, & Karri, 2002; Senge, 1992).
Our perceptions are the basis of creating frameworks of the world, which are
often referred to as paradigms or mental models. Peter Senge (1990) defines
mental models as “deeply ingrained assumptions, generalizations, or even
pictures and images that influence how we understand the world and how
we take action” (p. 8). Paradigms or mental models act like a lens or filter,
providing us with implicit rules or norms (that we may not be consciously
8
LEAD SELF
aware of) of how the world works and how one should behave in a given
situation. They represent attempts to provide simplified explanations of our
complex world and, thus, allow us to deal with uncertainty, even if these
explanations may be incorrect. Often our own paradigms are invisible,
and we do not become aware of them unless we encounter situations that
challenge their accuracy (i.e., a paradigm shift). Chris Argyris (1990), in his
book Overcoming Organizational Defenses, uses the metaphor of a ladder
to describe the process in which we construct our paradigms. He argues
that our perceptions are based on self-generated beliefs that often remain
largely untested. Psychologically, we acquire beliefs based on conclusions
that have been inferred from assumptions and meaning that we have given
to past observations and experience. Over time, we identify patterns and add
meanings to the data we observe through our senses to create our beliefs,
which eventually become facts and objective truths. As we re-experience
similar events, we often take short cuts in our thinking, and we jump straight
from observing data to our beliefs, without taking time to go through all the
steps to test out assumptions. This process of jumping to beliefs, which Argyris
calls running-up the ladder, distorts the way we see the world. Therefore,
perceptions often distort the way we select data and perceive events.
Effective leaders test for their sense of reality and compensate for distorted Effective leaders test for their
paradigms by continually challenging their own assumptions through a process sense of reality and compensate
of inquiry and advocacy (Argyris, 1990; Senge, 1992). They are able to explain
the reasoning and data that led to their assumptions and are able to make
for distorted paradigms by
their views and thinking explicit to others. They are aware that distortions are continually challenging their own
compounded when they ignore information that contradicts their preconceived assumptions through a process of
beliefs and assumptions. Awareness of one’s paradigms is also achieved by inquiry and advocacy.
actively seeking out feedback from others. Instead of judging, effective leaders
are more likely to ask questions of themselves and about the data that inform
their thinking and to seek more information (Senge, 1990, 1992). Effective
leaders, in fact, seek out opportunities to create paradigm shifts to help gain
greater insight into their own paradigms (Boyatzis & McKee, 2005).
There are several strategies and activities leaders can use to help them avoid the
pitfalls of distorted perceptions and develop their learning. The University of
Exeter’s Centre for Leadership Studies (as cited in Bolden, 2005) has surveyed
different strategies employed by various organizations and found that self-
awareness can be developed in several distinct ways, including: facilitated
leadership workshops; coaching, counselling or mentorship programs;
reflective writing; action learning, role play, and simulations activities;
leadership exchange programs; and psychometric development assessments.
9
One of the most common strategies is the use of psychometric testing to assess One of the most common
a person’s current attitudes and preferences. Typically, these tests tend to be strategies is the use of
self-assessments that can provide personal information about an individual’s
personality (e.g., Myers-Briggs Type Indicator), emotional intelligence (e.g., psychometric testing to
Bar-On EQ-i), or thinking styles (e.g., Hermann Brain Dominance Instrument). assess a person’s current
These instruments are designed to provide personal insight that promotes attitudes and preferences.
paradigm shifts and self-awareness and, thus, are frequently used in leadership
training workshops (Van Velsor, McCauley & Moxley, 1998). Another effective
psychometric test used by leaders is employing multi-source feedback systems,
such as a 360-degree assessment. With 360-degree feedback, the leader receives
input on their particular skills or personality from their peers, followers,
managers, or sometimes clients/patients. These types of strategies can provide
insights over and above those with self-assessments, since they address
personal blind spots (Alimo-Metcalfe, 1998). Of all the variety of strategies
available to nurture self-awareness, it has been suggested that self-reflective
practices, such as keeping a journal or practicing mediation regularly, may
be the most effective for providing information about one’s own motivations,
scripts, beliefs, and perceptions that shape our paradigms (Conger, 1992;
Vitello-Cicciu, 2003). Understanding our paradigms require us to look at what
we value. The next section will examine the role values and principles play in
self-awareness.
Example 2
Monica Olsen, Health Care Leadership Consultant

I was called in to mediate a “conflict” situation at a small community hospital recently, where the OR surgeons were
refusing to work because of perceived tensions with some of the OR nurses. When I consulted with the OR nurses in
question, they were shocked to learn about the surgeon’s concerns. In fact, they were adamant they had no issues with
any of the surgeons and felt that they got along quite well with them. Upon further exploration, I learned that these
nurses were frustrated with some of the newer nurses, who were struggling to keep pace with some of the demands of
the OR. The real issue was really about frustration between the nurses around the slower working style of the some of the
new nurses. It turns out that these surgeons were picking-up on the nurses’ frustration and made the faulty assumption
that this frustration was directed at them. Instead of checking-out their assumptions directly with the nurses, they
immediately involved the OR manager and CEO, which lead to unnecessarily involving many other people, including
myself at a great expense. The lesson learned by these surgeons is to test your assumptions before running up your
ladder of inference!
10
LEAD SELF
Self-Aware – Awareness of Values

& Principles
“A people that values its privileges above its principles soon loses both.”
— Dwight David Eisenhower
Values are critical for leadership, since they drive the choices and actions leaders
take. Values impact where leaders focus their attention, what they believe,
and how they make choices and defend positions that are deemed as right.
Therefore, developing a clear idea of one’s core values is an essential requirement
of self-awareness. If leaders do not know their values, then they often continue Developing a clear idea of
to make false assumptions by clinging to their distorted paradigms of the world.
Unfortunately, our newspapers are filled with examples of leaders who have one’s core values is an essential
made disastrous choices because of a lack of insight to their own values and requirement of self-awareness.
principles (Seeger, 2003). The emphasis on becoming aware of our personal
values stems from the belief that societal and organizational expectations have
caused many of us to lose touch with our true values and passions. Exploring
values, therefore, helps a leader reconnect with their mission and goals, and
these values then can emerge in their work and roles as leaders (Rue, 2001).
Often the terms values and principles are used synonymously in the leadership
literature. However, several authors have made distinctions between these two
concepts (Covey, 1992; Edgeman, 1998). Values can be defined as something
that is seen to have personal worth, relevance, and importance. However,
personal values may not necessarily reflect what others see as ethical or moral. Values can be defined as
Principles, on the other hand, are the collective standards, guidelines, or rules something that is seen to have
that we use to guide our behaviour. They are what one would consider right
or wrong, good or bad, worthy or unworthy. Stephen R. Covey makes a clear
personal worth, relevance and
distinction between values and principles, where values are “subjective and importance.
internal … [while principles are] objective and external” (p. 19). Covey argues
that effective leadership requires our personal values to be aligned with correct
principles or standards. When values are aligned with principles, they provide
Principles, on the other hand,
leaders with an internal moral compass that allows for effective navigation
of ethical or ambiguous challenges (Greenleaf, 1977; Hodgkinson, 1983; are the collective standards,
O’Toole, 1996). Principle-based leadership is increasingly relevant in complex guidelines, or rules that we use
environments, such as the health care sector (Cross, 1997; Prilleltensky, 2000). to guide our behaviour.
11
Developing a clear idea of what one’s core values are, and whether they are Values such as loyalty
aligned to effective leadership principles, is a critical task for leaders. Getting in and integrity in a leader
touch with one’s values and principles carries many benefits (Rue, 2001). First,
it enables leaders to gain deeper insight into the consequences and effectiveness
create follower’s trust, and
of their decisions and actions. If leaders find they are not achieving the this ultimately builds the
satisfaction or results they expect, then they are in a position to consciously leader’s influence over
change or realign their values with more effective principles (Covey, 1992). others.
Second, leaders who explore their values are more likely to remain connected
with what is truly important and meaningful to them (Rue, 2001). Often one’s
motivation and desire to achieve results is directly tied to his or her ability to
articulate what is important and meaningful about their work (Kouzes & Posner,
2002). In addition, leaders that possess clear awareness of their values tend to
be more resilient when bad things happen, and can generally cope better with
complex challenges (Copper & Sawaf, 1996; Goleman, 1998; Goleman et al., 2002;
Kouzes & Posner, 2002). When leaders actions are congruent with their values,
this often reassures followers because they know they can trust a leader to be
consistent. Values such as loyalty and integrity in a leader create followers’ trust,
and this ultimately builds the leader’s influence over others.
Becoming clear about one’s core values and their alignment with principles
can be a considerable challenge, given that it takes time and much reflection.
One of the most common and effective strategies to gain awareness of one’s
own values is to develop a personal vision or mission statement (Lee & King,
2001). A personal vision statement is a picture of the person’s ideal life as he A personal vision
or she views it. It includes a reflection of one’s personal values and how they
statement is a picture of
contribute to their leadership. It allows one to visualize their potential as a
leader, and tap into that vision to motivate and guide their current and future the person’s ideal life as
actions (Goleman et al., 2002). The personal vision allows leaders to make the he or she views it.
necessary changes to their own habits, skills, and behaviours, such that they
align with their values. They provide direction and guidance during times of
increasing responsibility, stress, and rapid changes (Covey, 1992). A number
of writers have attempted to describe the essential qualities of a useful vision
or value statement (Beck & Cowan, 1996; Kotter, 1996; Kouzes & Posner, 2002;
Nanus, 1992). In essence, value statements should make reference to behaviours
(i.e., how to treat others), contribution (i.e., to workplace/society), and
standards of excellence (i.e., what constitutes effective performance). Effective
value statements are not just grocery lists, but clearly indicate their relative
priority, how they are interrelated, and how they will be expressed or achieved.
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LEAD SELF
Example 3
Stephen Harris, Former Health Care Communications Consultant

When I was at Interior Health from in the early 2000s, we were going through some much needed, but highly unpopular,
redesigns of the healthcare system. These included downgrading and consolidating services from rural/remote centres
and developing new levels of care and housing for seniors. Not surprising, as most change initiatives in health care, this
was met with angst, hostility, and political opportunism of staggering levels. So, as we were going through the changes,
one of the members of the Senior Leadership Team in the region where I worked was constantly under personal attack in
her small, rural community. Instead of reacting and becoming defensive, she took time to deeply reflect on her personal
values around her role as a health care provider. Reconnecting with her personal sense of service, she was able to reframe
the crisis as an opportunity to embrace and positively impact the community. She took many opportunities to engage
with them and validate their angst and frustrations, which allowed her to better explain the rationale of the proposed
changes to health services. In particular, she also took ownership of the name Interior Health and put a human face to it.
In her interactions, she would speak about what it meant to be a member of Interior Health and the pride in making the
organization a successful one. How she dealt with that crisis, by articulating and living by her values and principles, had
a positive impact on the community. Her ability to live by her values left a long-lasting impression on me.
13
Manages Self
“Our greatest fear is not that we are powerless, it is that
we are powerful beyond measure.” — Nelson Mandela
F rom self-awarenessunderstanding one’s emotions, assumptions

and valuesflows self-management: the focused drive that all
leaders need to achieve their goals and influence others. Manages
Self, which builds upon self-awareness, encompasses the individual’s
ability to take responsibility for one’s own performance and health.
Effective leaders realize that, in taking responsibility for their own
choices, they empower themselves to have greater freedom to
choose their responses. The elements of Manage Self will be further
elaborated in the following sections on emotional management,
personal mastery, and life balance.
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LEAD SELF
Manages Self – Emotional Management

“The deepest feeling always shows itself in silence; not in silence, but
restraint.” — Marianne Moore
Emotional management refers to the ability to regulate both the expression Emotional management
and experience of emotions. The ability to regulate one’s emotional expression refers to the ability to
has been shown to be a critical skill for leaders (Cooper & Sawaf, 1997; Cote
regulate both the
& Miners, 2006; Goleman, 2004; Goleman et al., 2002; Gross, 2007; Riggio &
Reichard, 2008). Whereas strong emotions, positive and negative, are often expression and experience
difficult to contain or express at the best of times, in the context of leadership, of emotions.
the implications of poor emotional management are great. Since the leader’s
primary currency is their inter-personal relationships with others, and they
often act as appropriate role models for others, how they control themselves
in the grip of a strong emotional reaction is vital (Riggio & Reichard, 2008).
Moods are a powerful pull on thought, memory, and perception, and effective
leaders learn to take control of their emotions and harness them to work
for their advantage. They are able to manage their impulsive feelings and
distressing emotions; they remain composed, positive, and are able to think
clearly and stay focused under pressure (Goleman, 1998).
Daniel Goleman and colleagues (2002) have identified several leadership

competencies associated with emotional management, including: emotional
self-control, transparency, adaptability, achievement, initiative, and optimism.
Emotional self-control is the ability to manage disruptive emotions and
impulses effectively. Transparency refers to the ability to display honesty,
integrity, and trustworthiness. Adaptability refers to the ability to remain
flexible when dealing with changes and challenges. Achievement is the drive
to set and maintain high standards and to continually improve performance.
Initiative refers to the readiness to take action on what needs to get done and
seize opportunities. Optimism refers to one’s outlook, the ability to see the
positive in situations and to remain persistent in pursing goals despite obstacles
(Goleman et al., 2002).
15
Effective leaders use various strategies to build their emotional management Emotionally intelligent
capacities. Using some of the self-awareness skills discussed in the previous leaders are able to
section, emotionally intelligent leaders are able to anticipate their emotional
reactions and then act preemptively to control or guide them. Gross (2002) anticipate their emotional
identifies two basic ways that a leader can engage in emotion regulation: reactions and then act
through emotional reappraisal or emotional suppression. Emotional reappraisal preemptively to control or
refers to the ability to look at a potentially emotion-eliciting situation and guide them.
reframe it in non-emotional terms. It is the ability to engage the rational mind
to shift the emotional reaction. Examples of effective strategies for reframing
emotions include being able to accurately identify feelings as they occur, without
minimizing them or exaggerating them, and directly challenging the negative
scripted voice inside one’s head (i.e., self-talk) (Caruso & Salovey, 2004).
Emotional suppression is the ability to inhibit or hide emotionally expressive Emotional suppression or
behaviour. In the academic literature, this strategy is referred to as emotional emotional labour is the
labour: the ability to manipulate the expression of one’s emotions in order to
display organizationally desired emotions during interpersonal transactions ability to inhibit or hide
(Grandey, 2000). Organizationally desired emotions, also referred to as display emotionally expressive
rules, are considered the standards of behaviour that indicate not only which behaviour.
emotions are appropriate in relationship with others, but also how these
emotions should be publicly displayed or expressed (Grandey, 2000; Salovey
& Mayer, 1990). Examples of effective strategies for suppressing inappropriate
emotions include techniques such as emotional filtering, whereby one
selectively attends to positive emotions without avoiding or denying other
negative emotions (Caruso & Salovey, 2004).
Besides suppressing emotions, emotional expression has recently been shown Emotional expression has
to be paramount for leadership effectiveness (Conger, 1992; Grandey, 2000; recently been shown to be
Groves, 2006; Riggio & Reichard, 2008). Emotional expressiveness is the ability
to convey emotional messages to others. Emotionally expressive leaders are able paramount for leadership
to rouse and motivate followers and to build strong emotional ties with them. effectiveness.
Emotionally expressive leaders are evaluated to be more effective, are seen more
positively in social encounters, are rated as being more physically attractive,
have a broader network of social ties, and are more confident public speakers
(Groves, 2006). Not surprisingly, emotional expressiveness in leadership
has been closely associated with charismatic leadership (Cherulnik, Donley,
Wiewel, & Miller, 2001; Riggio & Reichard, 2008).
16
LEAD SELF
Example 4

I recall a situation when I was called in to deal with a surgeon who would have temper tantrums in the OR. He
would often yell obscenities at the nurses because he was not getting his instruments “fast enough”. Sometimes his
rage would lead to him throwing instruments, including scalpels in the OR! Clearly he lacked appropriate emotional
control, and would go to rage instantly. In our coaching sessions together, it was clear he lacked awareness of his rage
patterns. We worked on getting awareness around his feelings and worked at taking control of his rage. We focused on
getting him to act in a way that pulled positive emotion to the foreground and this consequently helped him manage
better his destructive emotional outbursts.
17
Manages Self – Personal Mastery
“Most powerful is he who has himself in his own power.” — Seneca
Personal mastery builds on top of the cornerstones of self-awareness and self- Personal mastery is about
understanding. Peter Senge (1990) defines personal mastery as “the discipline creating what one wants
of continually clarifying and deepening our personal vision, of focusing our
in life and in work.
energies, or development of patience, and of seeing reality objectively” (p. 7).
Personal mastery is about creating what one wants in life and in work. To
develop personal mastery, one must work towards a number of key principles
and practices, including: personal vision, personal purpose, holding creative
tension between vision and current reality, mitigating the impact of deeply
rooted beliefs that are contrary to principles, commitment to truth, and
understanding your own reflexive reactions (Senge, 1990). Personal mastery
is about taking control of one’s life and not blaming or allowing external
circumstances or mood to define one’s choices or ability. Persons with high
personal mastery view life as an opportunity to continually grow and learn.
They constantly strive for self-improvement and personal growth. Effective
leaders have just as many demands placed on them as others; however, they
understand that the way they spend their time at any given moment is a
function of their conscious choice. Managing self involves making disciplined
and conscious choices each day. It requires the ability to forgo less-important,
short-term goals for more important long-term goals. It is the ability to make
and keep promises and commitments to one’s self (Covey, 1992).
One of the critical elements of personal mastery is discipline. In his recent

book Building Character Gene Klann (2007), cites various research reports
that indicate a lack of self-discipline is a primary reason why many leaders do
not succeed. Self-discipline refers to a person’s ability to keep their behaviours,
passions, and impulses under the direct control of his or her will. This includes
the willpower to follow through on those things that are good for you, but
which may not arouse your interest or motivation. Many of these elements are
connected to emotional self-management, which was raised in the previous
section. Perhaps one of the most powerful examples of the self-discipline
comes from Victor Frankl (1959), a Jewish prisoner held in a World War II Nazi
concentration camp. In his book, Man’s Search for Meaning, Frankl explores
his discovery that the choice of attitude is the last of the human freedoms.
18
LEAD SELF
At the core of self-discipline is the individual’s ability to accept responsibility At the core of self-discipline is the
for being in control of their own choices, decisions, and actions. Rotter (1966) ability to accept responsibility
first proposed the idea of locus of control, where he suggests people have a
general tendency to believe the control of events in their lives is either internal for being in control of one’s own
or external to themselves. Individuals with an internal locus of control tend to choices, decisions, and actions.
believe in their own competence to control events, while those with an external
locus of control believe others or events primary influence their circumstances.
Such personal attributions of control significantly influence a leader’s
understanding of their internal motivation and impact their beliefs about the
effectiveness of their future actions (Howell & Avolio, 1993). Locus of control
is closely tied to self-confidence, where leaders with high self-confidence have
strong expectations about their competence to perform in a variety of settings
and view their success and efforts as being directly linked to their own actions.
Leaders with high self-confidence set challenging goals and believe they are
capable of attaining them (Goleman et al., 2002).
One of the more influential authors on the topic of personal mastery and Proactive leaders work from
leadership is Stephen Covey (1992), who distinguishes between two types of their strengths, have a clear
leaders: those who are reactive and focus on things they have little or no direct
purpose and vision, have a plan,
control, and those who are proactive and focus their energy on things they have
direct control over. Reactive leaders tend to focus on the things they cannot and understand that they have
directly control, such as others’ choices, actions, and reactions. They focus choices in any given situation.
their efforts on the weaknesses of other people, problems in the environment,
and circumstances that they have no direct sway over. Often they are seen as
blaming, accusing, or feeling like victims. By focusing their energy on changing
others, they inadvertently place less time on the things they can controllike
improving or changing themselves (Covey, 1992). In contrast, proactive leaders
work from their strengths, have a clear purpose and vision, have a plan, and
understand that they have choices in any given situation. They achieve greater
success by focusing on things over which they have direct control, such as their
own behaviour and reactions, and spend less time on things they have indirect
or no sway over, like other people’s behaviour and reactions. It is not that
proactive leaders do not care about the actions of others, but they realize that
to have a greater impact on people they need to focus on what they can directly
control (i.e., themselves). By changing their own response and behaviours,
proactive leaders actually indirectly influence others, thereby expanding their
circle of influence. In a way it may seem paradoxicalto gain greater influence
on others, one must focus more on themselves (Covey, 1992).
19
Example 5
Stephen Caron, Pediatric Transport Registered Nurse

(Alberta Children’s Hospital)
The Pediatric Transport team at the Alberta Children’s Hospital strives for innovative practices. While attending a
pediatric conference in Edmonton it became apparent that the Alberta Children’s Hospital team had achieved greater
success than other transport teams. I immediately recognized the potential for our team to build upon that success.
Adopting the personal vision of the transport team as the pediatric transport centre of Canada, I espoused a ‘best for
the world’ paradigm in delivering critical care attention to children in need. From a personal perspective, my view
shifted from a ‘what must I do’ to a ‘what can we do as a team’ mindset. This vision has contributed to improved
recruitment and retention initiatives in our team. It has helped to secure improved funding to support new initiatives
and to enhance our operations. This personal vision has sustained me for the past four years, solidified my vow to be a
life-long learner, and has acted as the catalyst in my achievement of a Master’s degree in Leadership.
20
LEAD SELF
Manages Self – Life Balance

“Balance is not better time management, but better boundary
management. Balance means making choices and enjoying those
choices.”
— Betsy Jacobson
There is mounting evidence that physical stamina, emotional health, and stress There is mounting evidence that
tolerance are directly related to leadership effectiveness (Hernez-Broome physical stamina, emotional
& Hughes, 2004). The workplace is increasingly demanding more from its
employees, with as many as 40% of Canadian workers reporting high levels of
health and stress tolerance are
stress, which are related to longer hours, hectic pace, and greater pressure to directly related to leadership
perform (Duxbury & Higgins, 2001). Stress is now known to contribute to heart effectiveness.
disease (it causes hypertension and high blood pressure); impairment of the
immune system leading to increased risk of infections, strokes, irritable bowel
syndrome and ulcers, diabetes, muscle and joint pain; miscarriage during
pregnancy; allergies; alopecia; and even premature tooth loss (Schabracq,
Winnubst, & Cooper, 2003). Stress also significantly reduces brain functions
such as memory, concentration, and learning, all of which are central to
effective performance at work (Fredrikson & Furmark, 2006). Successful
leaders are able to cope with these demands by paying attention to their
physical vitality, emotional resiliency, and stress tolerance.
Today’s rapidly changing work environment is creating greater stressors than

ever before. Some of the more common sources of psychological stress include:
bullying or harassment, feeling powerless and uninvolved in determining one’s
own responsibilities, unreasonable performance demands, lack of effective
communication and conflict resolution, lack of job security, long working
hours, excessive time away from home and family, office politics and conflict,
not receiving compensation commensurate with one’s responsibility, and poor
diet and insufficient exercise (Michie & Williams, 2003).
Leaders who have mastered life balance tend to exhibit high emotional
intelligence (Cooper & Sawaf, 1997; Goleman et al., 2002). Emotionally
intelligent leaders exhibit high resiliency, which is defined as the ability to
successfully change, adapt, overcome, and cope with unexpected setbacks,
unwanted adversities, and general life challenges (Coutu, 2002). Resilient
leaders overcome adversity, bounce back from setbacks, and can thrive under
extreme, on-going pressure without acting in dysfunctional or harmful ways.
21
They recover from traumatic experiences, becoming stronger, better, and

wiser. Recent research suggests that emotional management skills are key
determinants for successful resiliency in leaders (Boss & Sims, 2008). The topic
of resiliency is further addressed in the Demonstrates Character section.
Resilient leaders are generally more aware of their own use of self-scripts or Self-talk can increase stress
self-talk and have developed methods of gaining and maintaining control over levels, limit our potential,
their personal feelings and behaviours. Self-talk (the words our inner voice uses
when we think) can increase stress levels, limit our potential, and distort our
and distort our experiences.
experiences. It is well-known that negative statements, not only from others,
but also ourselves, can erode our sense of self-worth. Self-talk subtly colours
what you perceive and what you dwell on. Negative self-talk can increase
one’s perception of stress and limit one’s ability to think and solve problems.
Research has shown that when people tell themselves that they can’t handle a
difficult situation, they tend to stop looking for solutions (Helmstetter, 1990).
Negative self-talk tends to be a self-fulfilling prophecy: The more you tell
yourself you can’t cope, the more likely it will come true. Well-balanced leaders
are aware of their own scripting and patterns of negative self-talk. They develop
effective strategies to directly deal with negative self-talk, including substituting
positive self-talk that is optimistic rather than pessimistic and avoiding critical
or judgmental statements of any kind (Helmstetter, 1990). Research has shown
that these types of strategies reduce stress, improve productivity, and increase
health (Neck & Manz, 1992).
Example 6
Paul Mohapel, Health Care Educator and Leadership Consultant

I believe that concept of work-life balance is a misnomer. Balance implies that one needs to be constantly weighing
up one thing against another, such that when you’re doing one thing you’re missing out on or sacrificing something
else. A better concept is work-life integration, in that activities of your work are not actually separate but are in fact
interconnected and integrated. Work-life integration is about seeing work as a part of improving one’s overall quality
of life. It’s about integrating the rewarding and enjoyable part of one’s work into their lives. Integration brings greater
flexibility and is a more realistic and holistic approach when dealing with the complexity of the health care system.
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Develops Self
“The aim of life is self-development: to realize one’s nature
perfectly—that is what each of us is here for.” — Oscar Wilde
P ersonal leadership development can be defined as expanding

an individual’s capabilities to effectively carry out leadership
behaviours and processes. Develops Self, which builds upon self-
awareness and self-management, encompasses the individual’s ability
to actively seek opportunities and challenges for personal learning,
character building, and growth. Effective leaders realize that self-
development is an on-going life-long process that is as much about
having the right attitude as it is about having the right skill sets. The
following elements of Develops Self will be further elaborated in the
sections below: developing soft skills and life-long learning.
23
Develops Self – Developing Soft Skills

“The relationship is the communication bridge between people.”
— Alfred Kadushin
Leaders need to develop somewhat different skills throughout their careers.

Though some conceptual, technical, and interpersonal skills are needed by Leaders need to develop
nearly all effective leaders, the relative importance of these skill sets shifts as somewhat different skills
leaders progress through their careers. A leader’s technical competence and
conceptual expertise generally develop with education, training, and work
throughout their careers.
experience. However, as leaders progress, their soft skills become increasingly
important (Bunker & Wakefield, 2004; Hernez-Broome & Hughes, 2004).
The term soft skills refers to a wide umbrella set of traits and skill sets that
deal with interpersonal relationship building and are complementary to the
hard skills acquired through formal technical education and training. Soft
skills could include such elements as motivation, communication skills,
conflict management, team management, confidence, adaptability, reliability,
trustworthiness, and empathy, among others (Bunker & Wakefield, 2004).
In a recent study by the Centre for Creative Leadership (Martin, 2007), leaders
in a wide variety of industries were polled to evaluate what worked best when Leaders in a wide variety
leading organizations through a transition. The greatest challenges identified of industries were polled to
by these leaders where: motivating staff in uncertain times, being able to clearly
communicate the rationale for changes, working within a team format, and evaluate what worked best
developing staff for redeployment rather than layoffs. Among the necessary when leading organizations
characteristics of leadership, the leaders identified traits such as authentic through a transition.
and honest two-way communication as being most crucial. It was felt that the
softer skills of trust, empathy, and genuine compassion for employees were
needed to help the organization through transitions. Over the last ten years,
there has been a shift in the priorities of leaders, moving more toward building
and mending relationships, replacing other skills such as resourcefulness,
decisiveness, and doing whatever it takes (Martin, 2007). Other research has
shown a direct correlation between the long-term success of an organization
and the degree to which its leaders practice soft skills. Not only is there a strong
connection between the soft skills of a leader and its organization, but the
strength of this correlation also increases with the degree of authority the leader
holds (Bunker & Wakefield, 2004). Many other scholars have also made the
argument for the importance of soft skills in effective leadership, including the
24
LEAD SELF
vast emotional intelligence literature ( Boyatzis, 2008; Caruso et al., 2002; Cote The most effective way for
& Miners, 2006; Goleman, 2004) and organizational management literature leaders to develop soft skills
(Schriesheim & Neider, 2006).
is through adult learning
The most effective way for leaders to develop soft skills is through adult principles, such as self-
learning principles, such as self-directed learning, meta-cognitive, and directed learning.
experiential based strategies. These concepts will be elaborated further in the
life-long learning section.
Example 7

After delivering one of my programs, I had a nurse come to my office who was clearly upset and ready to let me have
it! I closed the door and took a deep breath. The first thing I had to tell myself was that her yelling at me was not really
about me. This reframing allowed me to be present for her. Rather than directly challenge her accusations, I started
by asking open-ended questions. The one that stopped her in her tracks was: “What was your role in what you just
experienced?” After some silence, she came to the realization that the real issue was the service, not about me. She
had personalized something I had said earlier and took it to be a criticism of her. To me, this was an excellent example
of using relationship skills, such as asking the right questions, to diffuse a potentially volatile situation. I also had to
remind myself that my role was to understand what was happening for her, rather than judge her. The success of my
job is completely dependent on my ability to apply these kinds of skills.
25
Develops Self– Life-Long Learning

“We now accept the fact that learning is a life-long process of keeping
abreast of change. And the most pressing task is to teach people how
to learn.”
— Peter F. Drucker
The term life-long learning refers to the fact that learning or personal growth
does not necessarily end or begin in the classroom. It really refers to more of
a mindset, where every experience, opportunity, change, situation, challenge,
conflict, and so forth is seen as an opportunity to learn. Malcom Knowles
(1975) was one of the first scholars to identify that adults continue to learn, but
through different processes than children. He coined the term adult learners
and identified six unique characteristics of adult learners.
1. Adults are autonomous and self-directed. Knowles (1975) argues that

adults need to be free to direct themselves and to be actively involved in
their own learning process. Specifically, they must focus on topics that
reflect their own interests in order for them to assume responsibility for
their learning.
2. Adults have accumulated a foundation of life experiences and knowledge,
which may include life and professional responsibilities and previous
education. They need to connect their learning into this knowledge/
experience base and find their own relevance to what they are learning.
3. Adults are goal-oriented. They must have freedom to set their own goals
and decide how to acquire the knowledge they need.
4. Adults are relevancy-oriented, and must see a reason for learning
something. They need to relate theories and concepts to their own
experiences in order to see the value of learning. Learning has to be
applicable to their work or other responsibilities to be of value to them.
5. Adults are practical, focusing on the aspects of information that is most
useful to them in their work or lives. They may not be interested in
knowledge for its own sake.
6. Adults need to be shown respect. Adult learners need to have the wealth of
their experiences acknowledged to feel fully engaged and not inferior in
their potential to learn.
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LEAD SELF
Research suggests that self-directed learning is one of the more crucial elements Research suggests that self-
for effective personal development (Brockett & Hiemstra, 1991), including in directed learning is one of
the health care sector (Secomb, 2008). The concept has been steadily gaining
the more crucial elements for
great momentum over the last few years for building leadership capacity
(Guglielmino & Murdick, 1997; Smith, Sadler-Smith, Robertson, & Wakefield, effective personal development.
2007). In terms of personal leadership development, the essential elements
required for effective self-directed learning require both internal and external
conditions to be recognized. These elements include: personal ownership of
the goals and process of learning; a willingness to accept responsibility to
the consequences of their own thoughts, feelings, and actions; choices in the
direction the learning takes; the learning process meets the personality and
individual learning styles; and an environment where mistakes are tolerated
(Brockett & Hiemstra, 1991; Hiemstra, 1994).
Building on these concepts, Boyatzis and McKee (2006) have constructed what
they call the Intentional Change Model to help leaders to engage in successful
personal transformation. Derived from various studies over the past few years,
their model is based on five components.
1. Ideal Self, which is based on an individual’s personal vision of who they

want to be as a leader.
2. Real Self, which captures the leader’s current behaviour, as seen by them-
selves and others. The difference between a leader’s ideal self and real
self allows one to identify gaps and areas of strengths and weaknesses.
3. Learning Agenda, which is a plan designed to capitalize on the leader’s
strengths, and address weaknesses, to move them closer to their ideal self.
4. Experimentation and Practice, which is based on integrating new habits or
reinforcing and affirming the leader’s strengths.
5. Developing and Maintaining Relationships, whereby the leader This process of self-directed
engages with others to support them as they move through these self- learning is cyclical.
discoveries (Boyatzis & McKee, 2006; Goleman et al., 2002). This process
of self-directed learning is cyclical, and it requires constant renewal and
re-evaluation to deepen the learning and self-discovery.
Boyatzis and McKee (2006) allege that specific emotions need to be linked to
each of the five steps in order to maintain the momentum of the learning cycle.
The first component, the ideal self, requires the leader to generate excitement by
tapping into their dreams and passion of what could be. It needs to be a process
of discovery in capturing what is meaningful to the individual. The second
component, the real self, requires courage and self-confidence to look carefully
27
at one’s strengths and weaknesses. Having a high self-regard is crucial for this Having a high self-
component, since a person might feel vulnerable. Also, being emotionally aware regard is crucial for this
is required to get a sense of any personal resistance that may arise. For the third
component, since a person
component, the learning agenda, problem-solving skills and the courage and
self-confidence to ask others’ feedback about one’s potential blind spots are might feel vulnerable.
required. For the fourth component, experimentation and practice, the leader
needs to depend on their emotional management skills to ensure they stay on
track and resist the temptation to fall back into old patterns. Motivation is key,
and keeping a mindset of discovery and exploration is invaluable. Finally, the
fifth component, developing and maintaining relationships, allows the leader
to draw on others to help maintain their motivation and encouragement when
they encounter difficulties and challenges (Boyatzis & McKee, 2005, 2006;
Goleman et al., 2002).
For a leader to develop themselves, they need to be aware of the fundamental

process of learning. As has been demonstrated through the discussion of
the Intentional Change Model, learning takes place in a cyclical process
(MacKeracher, 1996). David Kolb (1984) was one of the first to construct a
model that described the cyclic nature of learning. Kolb’s model is expressed
as a four-stage cycle of learning, in which immediate or concrete experiences
provide a basis for observations and reflections. These observations and
reflections are then assimilated and distilled into abstract concepts, producing
new implications for action that can be actively tested and experimented, and
in turn create new experiences.
Active Concrete
Experimentation Experience Kolb’s cycle touches upon
all components necessary
for learning: experiencing,
reflecting, thinking, and
Abstract Reflective
Conceptualization Observation acting.
Kolb’s (1984) cycle touches upon all components necessary for learning:
experiencing (or feeling), reflecting (or watching), thinking, and acting (or
doing). Moreover, Kolb’s cyclic learning model also offers a way to understand
individual people’s different learning styles, since each person has a natural
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LEAD SELF
tendency to gravitate between pairs of points along the cycle. Various factors
influence a person’s preferred learning style: namely, personality, previous
learning experiences, and demands of one’s environment or workplace
(MacKeracher, 1996). Kolb identified four learning styles with each pairing:
accommodating, converging, diverging, and assimilating.
Table 3: Learning Style Paired with Factors that Impact Learning
Active Experimentation Reflective Observation
Concrete Experience Accommodating Diverging
Abstract Conceptualization Converging Assimilating
The diverging (feeling and watching) learning preference is characterized by

being able to look at things from different perspectives, gather information,
and use imagination to solve problems. Diverging learners prefer to work in
groups, to listen with an open mind, and to receive personal feedback. The
assimilating (watching and thinking) learning preference is characterized by
taking a concise, conceptual, and logical approach. Assimilating learners are
less focused on people and more interested in ideas and abstract concepts.
The converging (doing and thinking) learning preference is characterized
by the ability to use theory to experiment and solve problems by practical
means. Converging learners are more attracted to technical tasks and problems
than social or interpersonal issues. The accommodating (doing and feeling)
learning preference is characterized by using intuition rather than logic to solve
problems, preferring to take a practical, experiential approach. Accommodating
learners will tend to rely on others for information rather than carry out their
own analysis, and they work well in teams.
Effective leaders are aware of their learning styles and, thus, are able to create
the optimal learning environment to continually develop themselves. Finally,
the importance of having the proper attitude about learning cannot be stressed
enough: to see life as an opportunity to continually explore and improve
(Goleman et al., 2002).
29
Example 8

Often in my role as a leadership coach, I see physicians who move into formal administrator positions often struggle
in the transition from a clinician to leader. The skills required to be an excellent physician don’t always transfer to what
it takes to be an effective leader. It takes particular mindset to make that transition more successful–the being curious
and open to learn. I remember one client I was coaching, a director of mid-sized teaching hospital. This director at first
would never speak unless she had a solution, since this is what made her successful in her practice. However, this director
was unaware that by not speaking enough was eroding her credibility in the eyes of others, since they saw this response as
detachment and incompetence. In my coaching sessions, I was able to help her start asking good questions, instead of only
speaking when she had solutions. It was her willingness to remain curious about how her actions were impacting others that
taught her the important lesson that good leaders ask good questions and don’t necessarily have to have all the answers.
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LEAD SELF
Demonstrates Character
“By constant self-discipline and self-control you can develop greatness of
character.”
— Grenville Kleiser
W ith leadership comes power and responsibility. Those who

succeed at leadership will invariably have developed a strong
leadership character. The definition of character, from a leadership
perspective, can mean many things, such as: the behaviour you
portray to others, even when you’re not watching; to the inward
motivation to do what is right; or to abide by principles and values
that lead to effective leadership. This section outlines the core
qualities that create the kind of underlying character all leaders
require to be successful. Demonstrates Character encompasses the
ability to model qualities such as honesty, integrity, resilience, and
confidence. The following elements of Demonstrates Character will
be further elaborated in the sections below in personal integrity
and emotional resiliency.
31
Demonstrates Character – Personal Integrity

“Integrity is what we do, what we say, and what we say we do.”
— Don Galer
The word integrity comes from the Latin work integri, meaning wholeness
or completeness. Palanski and Yammarino (2007), having conducted a
comprehensive literature review of integrity within leadership, define integrity
as having four elements:
1. being consistent in words and action (i.e., trust)

2. being consistent in adversity (i.e., courage)
3. being true to oneself (i.e., authenticity)
4. displaying moral and ethical behaviour (i.e., virtuous).
Interestingly, leaders who demonstrate integrity are perceived by others as

being consistently honest, trustworthy, and authentic (Grover & Moorman, Leaders who demonstrate
2007; Palanski & Yammarino, 2007). Recall from the Self-Aware section of this integrity are perceived by
paper, a distinction was made between the terms values and principles. Covey
others as being consistently
(1992) asserts that principles are objective and external standards, guidelines,
or rules for effective leadership. What exactly are these principles that we need honest, trustworthy, and
to align our personal values with? Palanski and Yammarino, having surveyed authentic.
the vast personal character literature, identified the following characteristics as
emerging most often in the leadership literature: a sense of morality and ethics;
honesty, trustworthiness, respect, and justice; openness and authenticity; and
empathy and compassion. These characteristics also correspond closely with
the soft skills discussion from earlier in this section.
It has been proposed that integrity is the building block of a leader’s

character (Kets de Vries, 1994; Sankar, 2003). It lays the foundation for the
ethical principles, values, and decision-making of the leader. The Turknett
Leadership Group (Turknett & Turknett, 2005) has identified integrity as
the core foundational cornerstone of their The Leadership Character Model,
a prescriptive leadership theory developed in 1995. Using the metaphor of
a scale, The Turknett Leadership Character Model places integrity as the
supporting base, while respect and responsibility are balanced on either side on
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LEAD SELF
top of it. When a leader embodies respect, they portray a sense of equality and
fairness to others. When a leader displays responsibility, they are more likely
to take initiative and act for the good of the entire organization. Turknett and
Turknett further break down respect into the component qualities of empathy,
emotional mastery, lack of blame, and humility. Responsibility is developed
by the component qualities of accountability, courage, self-confidence, and
focus on the whole. To keep the scale in balance, equal portions of the respect
and responsibility component qualities are required for effective leadership
character. Each of these qualities will be further elaborated on in this section.
On one end of the scale, Turknett and Turknett (2005) view respect in leaders
as showing unconditional high regard for others, acknowledging their value as Respect is demonstrated
human beings, regardless of their behaviour and without judgment. Respect through empathy, the ability to
is demonstrated through empathy, the ability to understand the points of
understand the points of view
view and emotions of others, including the views of those who are different.
Emphatic leaders demonstrate genuine concern for others and listen with the and emotions of others.
intent to understand. Empathetic leadership has been shown to be particularly
relevant for the health care sector (Skinner & Spurgeon, 2005). Respectful
leaders also display emotional mastery, which is similar to the emotional
management skills discussed in previous sections of this paper. Recall that
emotional mastery is displayed in a leader when they do not take their
emotional outbursts out on others, and they are able to reflect and consciously
choose an appropriate response. Respect is demonstrated when leaders refrain
from blaming others and are not defensive. They are able to reflect honestly on
their own behaviour and are willing to admit mistakes. When things go wrong,
they don’t spend time assigning blame; they spend time fixing the problem.
Finally, respectful leaders show humility by keeping their egos and arrogance
in check. Arrogance derails more leaders than any other factor (Rosenthal & Respectful leaders show
Pittinsky, 2006). To be humble is to recognize that all people are fallible and to humility by keeping their egos
recognize that we all have our own unique strengths and weaknesses. It is the
ability to admit one’s own limitations and failings and not to be afraid to show and arrogance in check.
vulnerability to others (Turknett & Turknett, 2005).
On the other end of the scale, Turknett and Turknett (2005) view responsibility
in leaders as the acceptance of full ownership for their own success, as well as
the success of others. Becoming responsible requires developing and refining
the core qualities of accountability, which reflects the leader’s ability to take the
initiative to get things done, no matter where in the organization it is required.
They also hold themselves accountable for making relationships work, but are
not afraid to hold others accountable (Wood & Winston, 2005). Responsibility
is also demonstrated through courage, which is the ability to be assertive
and to take risks. Courageous leaders are willing to risk conflict to have their
33
ideas heard and will speak up when they see a problem. They, however, accept
feedback and are able to deeply listen to others, even if they don’t agree.
Responsible leaders embody self-confidence, which is being self-assured,
adaptable, and open to change without feeling threatened. Leaders with self-
confidence can easily give others credit and rarely feel inferior or superior to
others (De Cremer & van Knippenberg, 2004). Finally, responsible leaders
are able to focus on the whole and think in terms of what’s best for the entire
organization rather than just what’s good for them. They are able to see the
entire system at play and all the various interdependencies. Peter Senge (1990)
identifies this quality as essential for effective learning organizations.
Recently, scholars have been focusing on assessing and developing strategies

to build integrity within leaders. Within the leadership field, two main Scholars have been
measurement instruments have been developed to measure integrity: The focusing on assessing and
Perceived Leader Integrity Scale (PLIS) developed by Craig and Gustafson
(1998), which focuses on the actions of a leader and is designed to assess the
developing strategies
presence or absence of unethical behaviour from a leader; and the Behavioral to build integrity within
Integrity (BI) scale (see Palanski & Yammarino, 2007), which examines leader leaders.
behaviour and espoused values. With respect to developmental strategies,
Gene Klann (2007), in collaboration with the Center for Creative Leadership,
has devised a five-step process for character development. Referred to as The
Five E’s of Character Development, leadership development needs to focus on
example, education, environment, experience, and evaluation.
Klann (2007) defines example as leveraging the natural human tendency to

emulate the behaviour of individuals, especially those who are held in high A leader’s behaviour
esteem. A leader’s behaviour sets the standard for the entire organization, and sets the standard for
modeling is considered one of the most powerful ways to influence others
(Schriesheim & Neider, 2006). Education refers to explicitly addressing the the entire organization,
needs of character and the challenges of maintaining integrity under pressure. and modeling is
Effective educational practices might include discussions of case studies and considered one of the
scenarios that involve difficult moral or ethical choices (Allio, 2005; Klann, most powerful ways to
2007). Environment refers to the organizational culture and how it shapes
the values and actions of people. Leaders with high integrity can set the tone influence others.
of the organization environment by surfacing the standards or values of the
organizational and acting congruently with them (Klann, 2007; Lord & Hall,
2005). Experience is about providing stimulating and challenging environments
that allow for others to grow and develop their character. Finally, evaluation
refers to providing clear expectations and feedback on the patterns of behaviour
of others. Leaders can use feedback sessions and performance evaluations to
gauge their progress, reviewing specific instances when their integrity may have
been challenged (Klann, 2007).
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Example 9
Joana Gil, Medical Researcher and Educator

As a physician educator, probably the most important leadership attribute I’ve learned is to “walk your talk”. What you
do, rather than what you say, speaks volumes more to your character and how you will impact people. In the clinic,
ones attitudes about patients has a profound impact on the behaviours of the students. Telling medical students that
they should be empathetic with patients, and then treating a patient as an “object” during rounds defeats the impact.
The students invariably end-up modeling what you do over anything you will ever say. When I think back to the most
influential leaders in my life, it has been those that acted with integrity, in that their words were aligned with their
actions. This takes great discipline and intentionality.
35
Demonstrates Character– Emotional Resiliency
“Character cannot be developed in ease and quiet. Only through experience

of trial and suffering can the soul be strengthened, ambition inspired, and
success achieved.”
— Helen Keller
A nother character trait that seems to be highly relevant for

effective personal leadership is emotional resiliency (Cooper &
Sawaf, 1997). Resiliency refers to the ability to bounce back from
setbacks and overcome adversity, to cope well with high levels of
ongoing change and constant pressure, and to change and adjust from
old ineffectual habits that may be dysfunctional or maladaptive
(Siebert, 2005). Emotional intelligence appears to be intimately
intertwined with resilience. It has been proposed that our ability to
cope effectively with stress and change is related to the degree of
mastery one has with the emotional competencies of optimism,
self-regard, empathy, flexibility, and stress management (Stein &
Book, 2000).
Al Siebert (2005) has studied resiliency and discovered that people move
through five different stages of resiliency when adapting to difficult situations.
The first level of resiliency deals with establishing emotional stability and
physical health, with the primary focus on developing awareness of one’s body
and psychological state. The second level focuses outward on the challenges
that must be handled, by managing through problem-solving and coping
appropriately with the situation. The third level focuses inward on the roots
of resiliency, by developing strong self-esteem, self-confidence, and a positive
self-concept. The fourth level is about developing long-term emotional and
cognitive skills that will allow better coping skills when future challenges
arise. The final level of resiliency is highest and is referred to as the talent for
serendipity: the ability to convert misfortune into good fortune with little
hardships or negativity when addressing challenges.
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LEAD SELF
Al Seibert (2005) believes that everyone is capable of acquiring effective Resiliency training has
resiliency skills. In the health care sector, resiliency training has been shown to been shown to improve the
improve the ability of nurses to cope with workplace adversity, such as excessive
workloads, lack of autonomy, bullying, and organizational restructuring ability of nurses to cope with
(Jackson, Firtko, & Edenborough, 2007). It appears that resilient people have workplace adversity.
particular mindsets, which include: being curious, optimistic, and less sensitive
(i.e., they do not take themselves too seriously) (Zander & Zander, 2000). They
do not easily become emotionally upset about difficulties, blame others for their
feelings, or dwell on their unhappy feelings.
One of the most intriguing research questions currently is why some leaders Some leaders thrive,
thrive, whereas others are impaired, when experiencing similar challenging whereas others are impaired,
events. Recent research suggests that differences in self-confidence, optimism,
social support, and established coping reactions can account for differences
when experiencing similar
in resiliency (Carver, 1998). Indeed, most of these variables are related challenging events.
to emotional intelligence competencies. Moreover, a recent report has
demonstrated that positive emotional experiences may help build resiliency.
According to Tugade and Fredrickson (2007), it seems that, during stressful or
challenging events, negative emotions are aroused that focus and narrow one’s
thoughts and actions (i.e., fight-or-flight response). However, given that positive
emotions broaden thoughts and actions, cultivating positive emotions during
times of stress actually build resilience for future stressful events. One might
conclude that intentionally cultivating positive emotions and developing positive
aspects of leadership character, such as integrity, respect, and responsibility, may
actually increase one’s resiliency to stressful or challenging events.
Example 10

Often we preach “balance” in dealing with our stressful workloads. I, however, think we need to emphasize harmony
more. In health care, we constantly deal with “surges” and “valleys”, which makes balance next to impossible and
ultimately sets one up for burnout. By focusing on harmony, we can tap into one’s inner strength to rise above the
situation. This is where we find resilience. I also think emotional resilience is found in the relationships. I find that the
thing that really wears people down are feelings of being marginalized or the feeling that they are facing the situation
alone—this is no different for physicians or staff. I believe that we often internalize situations and make them personal,
and if we do not reach out to others for support, we risk compromising our ability to bounce from the day-to-day
challenges we face in health care.
37
Conclusion
It’s only been about the last two decades that the concepts of
Lead Self have moved beyond the self-help field to being more
systematically researched in the context of leadership. At this point,
little research has been directed toward the application of personal
leadership in the health care sector. However, that trend appears
to be rapidly changing, as health practitioners are discovering the
critical importance of self-leadership in dealing with health care
challenges (Woods, 2001).
The leadership-of-self literature points to a number of interesting trends, and First, the burgeoning field of
potential opportunities, with the application of personal leadership strategies emotional intelligence has
to the health care sector. First, the burgeoning field of emotional intelligence
has contributed substantially to our understanding of how emotions underpin
contributed substantially to
almost all dimensions of the Lead Self framework, particularly the self- our understanding of how
awareness and self-management dimensions. Given the unique nature of the emotions underpin almost all
work demands in health care, with potentially higher levels of stress and greater dimensions of the Lead Self
requirement for controlling emotions, developing and training emotional
intelligence skills will be paramount. Further research will be required to
framework.
explore the unique emotional challenges various workers in the sector may be
facing. Second, greater attention and research needs to focus on identifying
the critical principles that are required for effective leadership for each of
the different health care sectors. As this booklet has demonstrated, effective
leadership begins with surfacing the underlying assumptions, values, and Second, greater attention
principles. What principles and values do the different members of the health and research needs to focus
care sector hold in common? How does that impact how the different elements on identifying the critical
cooperate with each other? How does it impact our ability to learn and adapt to principles that are required for
the increasing demands on the system? Given the ever increasing complexity of
the health system (Glouberman & Zimmerman, 2002), the best way to adapt to effective leadership for each
unpredictable change will be through our ability to learn. Our ability to learn is of the different health care
directly related to our ability to be aware of our own personal blind spots and sectors.
perceptual distortions, our ability to keep our minds clear so we can remain
flexible in our thinking, our ability to nurture a learning mindset and attitude,
and our ability to act with integrity when navigating ethically turbulent waters.
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Neck and Houghton (2006) conducted an extensive meta-analysis of the entire

personal leadership literature, and have extracted six important outcomes,
or independent variables, associated with the application of self-leadership:
(1) commitment and independence, (2) creativity and innovation, (3)
trust and potency, (4) positive affect and job satisfaction, (5) psychological
empowerment, and (6) self-efficacy.
1. Commitment to the organization and commitment to one’s own

values and needs may initially appear to be in conflict with each other.
However, when individuals develop their personal self-leadership, they
gain a sense of ownership over their tasks and work processes, and they
invariably demonstrate higher levels of commitment to their tasks,
goals, teams, and organizations (Neck & Houghton, 2006).
2. The more self-leadership is developed, the more creative and innovative
leaders become in their work. The key elements for creativity are
autonomy and self-determination (Neck & Houghton, 2006). Autonomy
and self-determination lead to greater independence, accountability, and
decision-making.
3. Trust and potency have been suggested to have important implications
for team effectiveness. Trust is defined as the belief that others will be
honest, upholding commitments and will not take unfair advantage of
others (Cummings & Bromiley, 1996). Team potency is a belief jointly
held among team members that the team is effective in accomplishing
its goals and objectives (Neck & Houghton, 2006).
4. Developing one’s personal leadership capabilities can lead to more
positive emotions about the workplace and greater job satisfaction.
Positive emotions can vary between feeling enthusiasm, excitement,
or happiness (Neck & Houghton, 2006). Practicing intentional positive
emotions in challenging situations helps offset negativity.
5. Developing personal self-leadership has been demonstrated to increase
psychological empowerment. This occurs by focusing on and creating
perceptions of meaningfulness, purpose, self-determination, and
competence. Specifically, strategies such as self-reflection, self-goal
setting, and self-reward nurture feelings of self-control, competence,
and purpose (Neck & Houghton, 2006).
6. Neck and Houghton (2006) report that self-efficacy is the single most
commonly mentioned outcome with self-leadership development. This
points toward the power of intrinsic motivation and choosing tasks that
are naturally rewarding. Engaging in these kinds of activities builds one’s
competence and self-determination.
39
To summarize, there seems to be a solid base of research that supports the Developing one’s personal
notion that developing one’s personal leadership capabilities is a critical leadership capabilities
strategy for dealing with fast-paced and complex environments, especially
those that are decentralized like many health care organizations. The Lead is a critical strategy for
Self capabilities means members at all levels throughout the organization take dealing with fast-paced
greater responsibility and accountability for their own work, behaviours, and and complex environments,
attitudes. Developing the Lead Self capabilities has the potential to lead to a especially those that are
more empowered, healthy, adaptable, and resilient workforce in the health
care sector. As more research is conducted, we will be able to further refine the
decentralized like many
methods and strategies to develop and employ personal leadership. health care organizations.
40
LEAD SELF
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E NGAG E OT H E R S
ENGAGE OTHERS
ENGAGE OTHERS
ACHIEVE RESULTS
DEVELOP COALITIONS
LEADERSHIP CAPABILITIES FRAMEWORK Debbie Payne
Don Briscoe
ENGAGE OTHERS
Table of Contents
1 LEADS in a Caring Environment leadership capabilities framework —

Engage Others
2 The Four Capabilities of the Engage Others Domain
8 • Foster Development of Others
14 • Contribute to the Creation of a Healthy Organization
20 • Communicate Effectively
24 • Build Teams
29 Leading Change
34 Conclusion
35 Bibliography
I
Executive Summary
E ngaging and connecting others is an essential element of

leadership. Without willing, energized, and engaged followers,
a leader is unable to accomplish results on any significant scale.
Leaders engage others through personal influence, teamwork,
communication, and through the creation and management
of performance expectations. Leaders also focus on the whole
organization, by providing an engaging vision and by paying attention
to the health of the organization. The research on leadership provides
insight into all of these dimensions of engagement, and provides
guidance on strategies that can help leaders effectively engage others.
In this research booklet, we present evidence of how leaders engage
others noting both the unique complexities of the health care system
as well as the common challenges of leaders in all contexts.
II
ENGAGE OTHERS
Leaders do not exist in isolation—they exist in context and in relationship.

In fact, leadership has been defined in the literature as existing only when there
are followers, be these employees or others who are drawn to follow for various
reasons. Job positions often require or expect us to lead and engage others;
however the term leadership is as much a process as it is a description of a
position. We can lead within the context of any position or situation, should
The LEADS framework focuses on
we first of all choose to, and secondly engage others to follow.
five key domains of leadership
The LEADS framework focuses on five key domains of leadership for health for health care leaders:
care leaders:
1. Lead Self
1. Lead Self 2. Engage Others
2. Engage Others 3. Achieve Results
3. Achieve Results 4. Develop Coalitions
4. Develop Coalitions 5. Systems Transformation
5. Systems Transformation
When leaders develop the capabilities in all five domains and express these
through corresponding behaviours, leadership becomes visible and contributes
effectively to the effectiveness of the health care system.
This booklet explores the leadership domain of Engage Others, and examines
research that supports each of the corresponding four sub-domains as a key
dimension of leadership. The four capabilities (or sub-domains) are:
1. Foster the development of others: Support and challenge others to achieve

professional and personal goals
2. Contribute to the creation of a healthy organization: Create an engaging
environment where others have meaningful opportunities to contribute
and the resources to fulfill their expected responsibilities.
3. Communicate effectively: Listen well and encourage an open exchange of
information and ideas using appropriate communication media.
4. Build teams: Facilitate an environment of collaboration and cooperation
to achieve results.
This research booklet explores conceptual models and theories of engagement,
leadership styles, emotional intelligence, strength-based development,
organizational health, language of communication, and teamwork as they relate
to engaging others, with some evidence through examples from health care.
The review also addresses research literature that focuses on the four
capabilities identified above. The evidence in the literature supports the key
III
action points or leader behaviours that actually do engage others. Others in

this definition refer to subordinates and other employees, but may also mean
suppliers, partners, stakeholders, or patients.
Fostering the development of others is a relatively new area of investigation Leadership is no longer
that stems from the recognition that leadership needs to be enacted at all focused solely at the top
organizational levels. As leadership is no longer focused solely at the top of
of the organization.
the organization, it becomes imperative to hold management at all levels of an
organization accountable for the development of others. This ensures leadership
bench strength and creates a culture of growth and development that is more
holistic and less hierarchical. When the bench strength is strong and there is an
investment in development, there is healthy growth.
Leaders contribute to the overall health of an organization by ensuring

employees have the human, financial, and tangible resources they require to
perform optimally. By creating opportunities for people to have professional
relationships and make meaningful contributions, they engage people in
communication, encouraging and supporting them toward objectives.
There is much in the literature that supports effective communication as an Effective communication
essential skill for leaders. Effective communication is more than just sharing is more than just sharing
information. It is through an open exchange of thoughts, stories, ideas,
questions, and images that employees are drawn to leaders and encouraged
information.
to participate in dialogue and interactive collaboration that is the foundation
for meaningful communication. Effective communication contributes to
the creation of shared meaning and understanding, which supports an
environment for pooling the work of others and achieving collective success.
As people work together collaboratively, they form teams. These teams may be
typical department or work teams, but may also span internal boundaries to
include cross-disciplinary project teams, virtual teams, or teams that include
suppliers and others. Leaders need to develop the ability to effectively build
these kinds of teams, using technology and media, where appropriate, and
pushing the boundaries of traditional team planning, thinking, and doing.
As leaders go about fostering the development of others, creating a healthy

organization, communicating effectively, and building effective teams, they
are contributing to an engaging leadership culture that, when added to the
other four domains in the LEADS competencies of Lead Self, Achieve Results,
Develop Coalitions, and Systems Transformation, creates a strong framework
that will guide the development of leaders in the health care system and,
ultimately, a transformation of the system itself.
IV
ENGAGE OTHERS
LEADS in a Caring
Engage Others
1

Engage Others Domain
I n the LEADS framework, Engage Others focuses on four specific

capabilities, or sub-domains. These capabilities focus on what the
leader does to engage othersregardless of who the other is. That
is, the behaviour is about process, about being a whole leader, not
necessarily about leading subordinate employees. This domain is
inclusive of relationships cultivated by leaders with others in many
different contexts.
Table 1: Main Descriptors for Each Capability within the Engage Others Domain
Engage Others Capabilities Capability Description
Foster development of others Support and challenge others to achieve professional and personal goals.
Create an engaging environment where others have meaningful

Contribute to the creation of a healthy
opportunities to contribute and the resources to fulfill their expected
organization
responsibilities.
Listen well and encourage an open exchange of information and ideas
Communicate effectively
using appropriate communication media.
Facilitate an environment of collaboration and cooperation to
Build teams
achieve results.
The concept of leadership has been studied extensively and from a variety
of perspectives. It has also remained one of the most complex and difficult
to define concepts in social science. According to Yukl (2006), “There is no
consistent, overall definition of leadership performance” (p. 20).
The reasons lie in the fact that leadership is, at its core, about human
relationships, with all of the complexities that implies. For example, in the
health care system, these professional relationships may be with government,
superiors, colleagues in the same or a related profession, clinic staff, clients or
patients, community practitioners, hospital employees, professional association
members, alternative health practitioners, and members of the general public.
2
ENGAGE OTHERS
This booklet explores the capabilities required of leaders who are learning to
Engage Others within the context of these professional relationships.
The wide-ranging body of literature on employee engagement in organizations

offers one a useful perspective on the leadership capability of Engage Others.
Surveys from various companies, such as Hewitt or the Q12 survey from Gallup,
provide ways of measuring employee engagement, and results are sometimes
used to identify the Top 50 or Top 100 employers.
Creating a culture of engagementone in which people want to

contributeinvolves fulfilling basic human needs. Although not directly
discussing engagement, Alderfer (2002) explains his ERG theory, which Creating a culture of
includes relatedness and how it correlates to Maslow’s well-known Hierarchy
engagement—one in which
of Needs. Maslow’s third and fourth level of belonging and self-esteem with
co-workers, family, and friends illustrate the need that human beings have people want to contribute—
to engage with others. Leaders who support and encourage this need for involves fulfilling basic
engagement are meeting one of the most basic human needs. human needs.
In the workplace, the term engagement has come to mean more than
communicating or being with others. It has evolved to refer to our effort,
sometimes referred to as discretionary effort, where we immerse ourselves and,
with committed focus, obtain results. In fact, when we are engaged, we are open
to collaboration and strive for innovation, a critical element that we need in our
Canadian health care system as noted in Prada (2010), where she explains that
it requires strong collaboration for innovation as it is a complex process.
Loehr (2005) demonstrates how engagement begins: “Full engagement begins

with the personal commitment to invest your best energy every day” (p. 14). He
also helps us see that this commitment begins within ourselves. We would find Full engagement begins with the
it difficult to engage others if we are not engaged ourselves. Loehr (2003) states, personal commitment to invest
“Performance, health and happiness are grounded in the skilful management
of energy” (p. 5). Keeping our energy high requires us to be engaged and
your best energy every day.
aware in all parts of our lives: “physically energized, emotionally connected,
mentally focused, and spiritually aligned” (p. 5). Loehr’s model of engagement
helps us see holistically, as his premise is that full engagement is about optimal
energy (e.g., physical, emotional, mental, and spiritual) in the context of high
performance.
The literature also tells us happiness is closely linked to engagement, and

according to Vazire, Mehl, Holleran, and Clark (2010) and their study on the
relationship of conversation to happiness: “The happiest were people who
3
engaged often in more meaningful and substantive discussions, as opposed to

those who filled conversations with idle chit-chat and small talk” (p. 1). The
relationship Loehr (2005) speaks of between happiness and engagement gives
hope that, as we engage with others in more effective and valuable dialogue, we
will raise each other’s level of happiness and engagement.
You can sense the engaged energy and discretionary effort of engagement that Leaders create this sense
Axelrod (2002) refers to with his definition of an engaged organization. Leaders of purposeful energy
create this sense of purposeful energy in their organizational environment
in their organizational
by focusing on fundamental relationship strategies. Simple and effective,
they require leaders to suspend judgment and place their trust in connected environment by focusing on
relationships with others. The growing use of coaching, which is essentially fundamental relationship
deepening our ability to have trusted conversations, is evidence of our need and strategies.
opportunity to engage.
The concept of servant-leadership by Greenleaf (1970/1991) has a strong focus

on the development of others through building trust, creating community, and
listening empathetically to the needs of individuals. Blanchard’s (1968) seminal
work on situational leadership speaks strongly of the need of leaders to engage
others, adjusting their own leadership style to accommodate others’ needs.
Two of the quadrants in his model, S2 coaching and S3 supporting, illustrate
behaviours that leaders need to demonstrate to engage others and encourage
them to perform. Other theories of leadership styles also emphasize engaging
others and finding ways to move people toward improved performance.
For example, House’s (1971) four styles of leadership: directive leadership,
supportive leadership, participative leadership, and achievement-oriented
leadership, are all dependent on responding to situations and specifically to
addressing others’ needs. Dickinson and Ham (2008) also point out direct links
between engagement and performance when they state, “by engaging doctors
with change processes, improvements in performance may be achieved” (p. 2).
Goleman’s (2002) model of Emotional Intelligence, widely accepted as

foundational in developing leaders, has four domains: self-awareness, self-
management, social awareness, and relationship management. This fourth
domain is entirely about engaging others through influence, teamwork,
collaboration, and creating change. Goleman’s model reinforces that the
foundation for a healthy organization begins with our own emotional health
and the health of our relationships. When we are emotionally healthy, we create
solid, meaningful relationships based on open, effective communication.
Communication is almost synonymous with leadership, as illustrated

in Fairhurst’s (1996) work on framing. He explains how using different
4
ENGAGE OTHERS
communication approaches can engage others and help them see complex or
new ideas. The list includes using “metaphors, stories, traditions, artefacts, spin,
contrast, or slogans” (p. 1), all of which help others feel connected or engaged
by capturing their attention differently. This model helps us to understand
that to engage others we need to first attract them to listen. In a research study
on the communication between leader and follower, Salter (2007) confirms
this with his model of dyadic leadership. He proposes that leaders who
communicate with transformational language (e.g., peer, vision, innovative,
openly, etc.) are more effective leaders than those who communicate with
transactional language (e.g., tell, schedule, more, instead).
When communicating, leaders
When communicating, leaders need to use language that is inspiring to others. need to use language that is
However, they also need to effectively communicate expectations. Vroom’s
inspiring to others.
(n.d.) Expectancy Theory helps us understand this focus on results. He explains
that we raise our expectations when we have a performance goal that is linked
to motivation and reward. This suggests that leaders who clearly articulate
goals, keep expectations high, and provide the right motivation and reward can
engage people to raise their own expectations of their work.
High expectations and clarity are also implied in Senge’s (2006) model of the
Five Disciplines: personal mastery, mental models, building shared vision, team
learning, and systems thinking. Having a clear, shared vision requires us to
influence and engage others and also to help teams learn. Senge’s work on the
learning organization leads us to see how important teams are to leaders. Being
able to build an effective team leads to team members being engaged with each
other, as well as team engagement within the larger organization. An effective
team not only gets excellent results, it also uses the strengths of each member
effectively to produce superior results.
Ensuring that people are put into
Ensuring that people are put into jobs that fit them, and that are in their area jobs that fit them, and that are in
of strength, also keeps them engaged. Jim Collins’ (2001) work on Level 5
leaders has a strong focus on engaging others towards large goals. Collins
their area of strength, also keeps
suggests getting the right people in the right positions, coupled with humility them engaged.
and a strong will, leads to success. This model supports and serves to validate
again that engaging others in their work, both on their own and in teams, is
fundamental to being a successful leader.
As one examines team dynamics, it is helpful to be reminded of Janis’ (n.d.) work

on Groupthink. We want people aligned, we want them to work together and
yet we also need diversity of opinions and ideas. Too cohesive a team can result
in groupthink, a process in which all agree too quickly and decisions may be
not well-thought through. Perhaps this is why building an effective team means
ensuring broad, diverse representation, as well as a collaborative approach.
5
We shift now to look at an aspect of leadership that is larger than the The concept of the healthy
leader-follower or individual engagement and look at a concept that gives organization develops from
us a perspective of the health of organizations. The concept of the healthy
early writers in a number
organization develops from early writers in a number of disciplines and draws
in aspects of holistic health and emotional intelligence. of disciplines and draws in
aspects of holistic health
This is of particular relevance in health sector organizations that typically and emotional intelligence.
measure effectiveness not only in financial terms, but also in terms of the health
of their patients or clients and the health and well-being of their employees.
The Canadian Medical Association (2010), as one example, has four pillars to
its strategic plan: healthy profession, healthy population, healthy physicians,
and effective organization. This last pillar speaks to elements such as being
financially and administratively strong: elements that are often a major, if not
the only, raison d’être of organizations in other sectors.
Organizations in the health sector, particularly those involved in delivery of

care, face added complexity when they try to engage clinicians, some of whom
are not employees, but independent professionals with a variety of relationships
and affiliations with their organizations. For example, physicians and dental
surgeons who have established independent clinics may have privileges at
a hospital. These individuals may be highly engaged in their profession, but
have a different level of engagement with their hospital organization. This
poses a particular set of challenges for those who lead and manage affiliated
clinicians in our health care organizations. Dickinson and Ham (2008, pp. 32-
34) elaborate on this in their discussion of what they call clinical microsystems
and assert that effective leadership of such microsystems and engaging those
clinicians is a key factor in achieving high levels of performance.
The concept of clinical microsystems is based on an understanding of systems The concept of clinical
theory, which is often used as an organizational model to enhance patient safety. microsystems is based on an
Microsystems emerge in health care organizations because of the independent
yet highly interdependent nature of health providers. The Dartmouth-Hitchcock
understanding of systems
Medical Center in Lebanon, New Hampshire, USA, on its Institute for Healthcare theory, which is often used
Improvement website, provides a useful definition that illustrates both the as an organizational model
independence and interdependence of health care professions. to enhance patient safety.
6
ENGAGE OTHERS
A clinical microsystem is a small, interdependent group of people who work

together regularly to provide care for specific groups of patients. This small
group is often embedded in a larger organization. Formed around a common
purpose or need, these groups may comprise discrete units of care, such as a
neonatal intensive care unit or a spine center. A general clinical microsystem
includes, in addition to doctors and nurses, other clinicians, some
administrative support and a small population of patients, with information
and information technology as critical “participants”. (Institute for Healthcare
Improvement, n.d., para. 3)
Furthermore, Mohr and Batalden (2002) list the characteristics of effective

microsystems as follows:
• Integration of information
• Measurement
• Interdependence of the care team
• Supportiveness of the larger system
• Constancy of purpose
• Connection to the community
• Investment in improvement
• Alignment of role and training. (p. 47)
These are just a few of many references in the literature to support Engage
Others and its four categories as a crucial set of skills for health leaders to
develop: in particular, given the challenges and complexities of our health care
system in Canada.
We now turn our attention to each of the four capabilities, or sub-domains,

that make up Engage Others and also note some practical health care system
evidence and examples.
7
Foster Development of Others
A n important part of the role of a leader is to grow and develop

other leaders. Developing other leaders contributes to effective
succession planningdeveloping the next generation of leaders.
Byham (2000) tells us research has shown that a primary reason

people leave companies is lack of personal growth and job challenge
opportunities. His work goes on to help us understand that in
providing development for all employees, and through targeted
development for pools of specific employees, we allow our talent to
shine and optimize the potential and effectiveness of our people.
This shows how important it is to support leadership at all levels of
the organization.
We know that we are influenced by leaders indirectly and directly, and Naylor
(2006) supports this.
Most physicians have worked at some point with leaders who were not
particularly adept at management, but who had an ability to win loyalty and
carry others with them through their clarity of vision, generosity of spirit,
and “people skills” Ironically, then, leadership may be most obviously exerted
when others follow a person who has no direct authority over them. (p. 490)
When leaders foster the development of others they provide the foundation for
leadership to emerge and grow. Learning is inextricably linked to leadership,
and Fulmer (2004) explains that there is not a dramatic difference between
developmental activities in organizations. They do vary in content, in approach,
and in cost, depending on the level or function within an organization;
8
ENGAGE OTHERS
however, when compared across organizations, there are many similarities. This
provides us with encouragement that we can learn from other organizations
and share development approaches. Bernthal (2001) studied what keeps
employees in organizations. Employees indicated the number one factor
was the quality of relationship with their supervisor or manager, and HR
professionals rated opportunities for growth and advancement as number one
(pp. 10-13).
As leaders learn how to
As leaders learn how to foster development in others, relationships improve, foster development in others,
which further encourages retention. Gifford, Davies, Edwards, and Graham
relationships improve, which
(2006) give us evidence in health care of how important this support is.
“Support from nursing managers and administrators, together with the role of further encourages retention.
a dedicated project lead, are consistently identified as important strategies for
nurses to be able to use research evidence in their practice” (p. 72).
Kouzes and Posner (1995), in their classical leadership research study,

identified five fundamental practices that enable leaders to earn followers’
confidence and get great work done. Three of these practices: inspiring a
shared vision, enabling others to act, and modeling the way, are all focused on
engaging others. The final practice of encouraging the heart is about celebration
and recognizing achievementso important a practice, in fact, that they
wrote an entire book on the subject. Kouzes and Posner (1999) helped us
see the linkages between recognition and engagement, although not actually
referencing this term.
Soon after putting a more encouraging leadership approach into place ...
productivity increased, absenteeism decreased, and a stronger human bond
developed between co-workers. The more cooperative environment led to
better communication and fewer conflicts ... unless this issue [of engagement]
is addressed, the goal of achieving a high-performance workplace will remain
unattainable. (p. 5)
9
The International Coaching Federation Prism award-winning program,

Leaders Supporting Learning, has had solid success shifting culture to one
of safety and engagement. In 2005, British Columbia Children’s Hospital and
British Columbia’s Women’s Hospital developed the program to help frontline
leaders, particularly nurses, adopt a coach approach with staff. The emphasis
was on growing leadership and coaching capacity and shifting conversations
about patient safety events from one of blaming to a culture of learning. More
than 350 people have participated in this collaborative program, which is now
offered in three health organizations in British Columbia, and it continues to
expand to other disciplines beyond nursing and to other Provincial Health
Services Authority sites. According to Dori van Stolk (2009), Senior Leader,
Clinical Education, BC Children’s Hospital,
Traditionally, there has been a lack of support for clinical staff when they Traditionally, there has
move from front-line to leadership roles. We wanted to help formal or
informal leaders gain the skills they need to support more open dialogue and
been a lack of support for
shift our culture. (p. 3) clinical staff when they
move from front-line to
leadership roles.
Participants in the program perhaps speak to the value of the shifts that occur
as a result of the focus on coaching conversation, as shared by Dori van Stolk
(personal communication, April 23, 2010):
...the conversation was different and what she said was that she walked away
feeling intact ... that she felt engaged …
I’ve worked in a lot of different places and no one has had ever had this kind
of conversation with me before and I appreciate it so much because this is
what I have needed from this (job) for a while.…
It was truly gratifying yesterday to look at my “competency wheel” and see

how much I have developed in the LEADS competencies over the past six
months.... I realize that what I have learned has been seeping into my practice
in ways that I’m not even consciously aware of.
10
ENGAGE OTHERS
Managers and leaders today are enhancing their business leadership by both
accessing coaching and developing their own coaching skills to aid in the
development of others. Coaching in the workplace has grown exponentially Coaching in the workplace
over the last few years as a way to accelerate learning and development, to has grown exponentially
increase leadership awareness, to improve communication, and to stretch
and grow individuals. Several research studies note that coaching accelerates
over the last few years.
development. Sabo, Duff, and Purdy (2008) explain how peer coaching can be
of value to nurses in building their leadership capacity:
Hospitals must create a workplace where staff are supported to develop

professionally as knowledge workers. In 2003, University Health Network
(UHN) partnered with Donnerwheeler career planning and development
consultants, to provide a program for its 2,700 nurses. One component of this
project, a peer coaching program called Coach Mastery … (with a goal of)
building internal leadership capacity. (p. 27)
In the current reality of generational challenges, it is important to find ways

It is important to find
to support leaders to grow faster. Coaching has been shown to provide good
return on investment: in fact up to 20-fold over 18 months according to ways to support leaders
Stephenson (2000). to grow faster.
Nurses at Baycrest Centre for Geriatric Nursing (2009) in Toronto, Ontario,
have been recognized for their achievements in introducing coaching and
mentoring for nurses in management roles. They have been recognized as
an organization committed to a coaching style of management that moves
away from the traditional, hierarchical paradigm to team-based, collaborative
decision-making. “We see this initiative as critical to our vision of developing
shared leadership in nursing,” says Mary Ferguson-Paré, Vice-President of
Nursing Services at Baycrest. Burns, Eagleton, Golden, and Thompson (2009)
provide further evidence of the value of nurse executive coaches engaging in the
development of charge nurses: “A new coaching model can transform charge
nurses into high performers who produce quality outcomes that enhance a
hospital’s financial picture” (p. 2).
Mentoring, distinct from coaching, is another method that leaders increasingly Mentoring, distinct from
use to engage those around them. Whether it is formal or informal, long-term
or short-term, it is a powerful connection between two people. Generally, coaching, is another method
mentoring is a relationship between someone who has recognized expertise that leaders increasingly use
or experience (i.e., mentor) with someone who believes they can learn from to engage those around them.
this person (i.e., mentee). There is willingness to share stories, experiences,
11
suggestions, and ideas to grow the career of the mentee. The mentor grows
their own leadership through the process of developing the mentee. A strong
engagement process, some organizations openly build formal mentoring
programs, others more subtly encourage informal mentoring, and others
build it into their succession management or leadership development strategy.
Sometimes mentoring occurs at a distance, even unbeknownst to the mentor.
Goldsmith (2000) explains mentoring as follows:
Individuals can be mentors without knowing that they are playing this
Think about your
role. The power of our mentors may not lie in a particular model they give
us, but may be in their capacity to wake us up to an important lesson, the willingness and capacity
significance of which we realize later.... Think about your willingness and to mentor others, as well
capacity to mentor others, as well as your openness to having others mentor as your openness to having
you. (p. xxii) others mentor you.
Later in that same work, Goldsmith introduces the concept of heart hero, in
which the mentee feels the mentor has truly fostered their development and
touched them deeply with a connection and meaning that often lasts a lifetime.
The Ontario Medical Association (OMA) recognizes the value of mentoring,

OMA - This program is the
and in September 2001 developed the OMA Mentorship Program (OMA,
2006). The program is the first of its kind in North America and has received first of its kind in North
international recognition. It was developed in response to concerns expressed America and has received
by female medical students about the lack of female physician mentors. After international recognition.
witnessing the success of the program within the female student population,
the male medical students voiced their concerns about the lack of mentor
opportunities. In response to this demand, the OMA now facilitates male
student and male physician participation. The program has since grown to
include more than 375 mentor−student relationships.
What can leaders do to not only engage others, but to try to avoid disengagement?
Rath (2007) provides us with research on the idea of encouraging individuals’

strengths as it relates to engagement. This work demonstrates that, if we focus
on strengths, we can reduce disengagement. In fact, the simple act of helping
people work in their strengths, of acknowledging what they are good at, and
continuing to give them work aligned with their strengths can be extremely
effective. His research tells us that, if a manager ignores an employee, the
chances of being actively disengaged are 40%. If a manager focuses on the
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ENGAGE OTHERS
weaknesses of an employee the number decreases to 22%. However, if the

manager focuses on the employee’s strengths, the chances of being actively
disengaged drop to only 1%.
Buckingham (2001) also provides us with some interesting thoughts on how

to uncover our strengths. If managers are able to notice strengths in employees
and provide opportunities to use more of their strengths, employees become
more engaged and, therefore, productive in their work. Two questions can
provide guidance while doing a particular activity: “When will this be over?”
and “When can I do this again?” The latter question generally means the
individual is using a strength. Other ways of detecting strengths are to notice
and listen for clues, such as spontaneous reactions, yearnings, rapid learning,
and satisfaction.
Linking learning to real business issues is something leaders strive for. Most Linking learning to real
real learning occurs when people are able to learn directly in the context and business issues is something
situations in which they will apply the skills. The 70-20-10 rule of development,
as noted in Kramer (2006), helps us see that 70% of learning comes from
leaders strive for.
job experiences, 20% comes from other individuals (coaching, mentoring,
assessments), and 10% comes from education and training programs. When
these are integrated together, they are the most effective. Tichy (2002), in his
work on teachable point of view and action learning, tells us that, if we use real
business situations when we teach others, it is likely they will be engaged and
make a difference while they are learning.
Leaders can best foster the development of others by providing opportunities

for employees to develop and learn, but more importantly, in engaging with
them by modeling learning and teaching, in participating in mentoring and
coaching, and informally sharing their own learning and leadership journeys.
13
Contribute to the Creation

of a Healthy Organization
T here has been research in recent years that focuses on

organizational health or the healthy organization. As we learn
more about individual health and about workplace wellness and
balance, we are able to see what contributes to our organizational
health and what leads to optimal performance. Schuyler (2004, p.
60) helps us see the difference between organizational effectiveness,
performance, and health, which supports the work of Bruhn. Bruhn
(2001) builds off the definition developed by the World Health
Organization: “Health is a state of physical, mental, and social well-
being and not merely the absence of disease” (p. 147). Bruhn then
applies this to the health of an organization:
Body refers to the structure, organizational design, uses of power,

communication processes, and distribution of work;…
Mind refers to how underlying beliefs, goals, policies, and procedures
are implemented, how conflict is handled, how change is managed, how
members are treated, and how the organization learns;…
Spirit is the core or heart of an organization … what makes it vibrant, and
gives it vigour. It is measurable by observation. (p. 147)
All of these areas need addressing as we move toward creating healthier

organizations. Leaders in health care need to engage others towards creating
cultures that make our organizations healthier for employees, as this leads to
healthier, safer, and more effective patient care. This is supported in a recent
paper by the Ontario Health Quality Council (2010): “There is a growing
consensus that the future sustainability, cost-effectiveness and performance
of Canada’s health care system depends on the quality of the environments in
which workers provide patient care and related services” (p. 7).
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ENGAGE OTHERS
The Annapolis Valley District Health Authority (AVH) in Nova Scotia

recognized this in 2005 and, since then, has been actively involved in measures
designed to create a healthy and supportive workplace (Quality Worklife,
Quality Healthcare Collaborative, 2010b). A history of constant change,
downsizing and re-organization, low morale, loss of knowledge and experience,
budget constraints and increasing costs prompted the AVH to embark on this
journey (para. 2).
AVH developed a process by which formal leaders in AVH participated in AVH developed a process by
leadership assessment, programs, and leadership development sessions. which formal leaders in AVH
Leadership champions have responsibility to actively support leadership
participated in leadership
development across the organization. Leadership assessments were integrated
with recruitment and selection processes. Promotion and distribution of assessment, programs, and
monthly leadership notes engage people in thinking about leadership (Quality leadership development sessions.
Worklife, Quality Healthcare Collaborative, 2010b, para. 5).
Ulrich (1998) helps us understand that intellectual capital is not just about
having talented, knowledgeable, and competent employees, but also about
ensuring that these employees are engaged and committed, thereby avoiding
burnout. Gaining employees’ commitment requires a strategic approach, and
he suggests several, many of which have been incorporated by organizations
over the last decade, including wellness and work flexibility initiatives. He tells
us “Building commitment involves engaging employees’ emotional energy and
attention. It is reflected in how employees relate to each other and feel about the
firm” (p. 16). When people are committed, they are more easily engaged; however,
the challenge is to ensure they also stay balanced and healthy, or the entire
organization can become toxic with overworked and overwhelmed employees.
According to Goleman (1998), “Effective leaders are alike in one crucial way: Effective leaders are alike in one
they all have a high degree of emotional intelligence” (p. 3). We know that crucial way: they all have a high
a workplace with emotionally intelligent leaders and employees is a strong
degree of emotional intelligence.
component of a healthy organization. To engage others, we need Goleman’s
“empathy and social skills … [which are defined as] thoughtfully considering
employees’ feelings along with other factors in the process of making intelligent
decisions … [and] friendliness with a purpose-moving people in the direction
you desire” (p. 16).
Goleman (2002) also goes on to tell us that, in health care, the traditional
leadership style of command and control has created a culture where people
15
are not encouraged to challenge authority to the point that mistakes and even
deaths occur due the fear of repercussion in the culture:
If medicine were to adopt the zero tolerance for mistakes that sets the norm
for the airline mechanic industry, we’d cut our medical errors drastically....
Creating a hospital culture that supported zero-tolerance would mean
building in a far greater level of systematic checks and cross-checks than
the medical field has thus far accepted and it would mean challenging the
pacesetting and commanding leadership styles that hierarchical cultures
encourage. (pp. 193−194)
Goleman (1998, 2002) gives us much to think about on the subject of emotional
intelligence and how it becomes even more important to shift our leadership
styles and find ways of engaging others through an increase in not only our own
self-awareness, but also in helping others become more emotionally intelligent.
Healthy relationships in organizations indicate a healthier organization. When

people relate well to each other, when they engage each other in meaningful,
valuable, and respectful conversation, and when you know the people at work Healthy relationships in
well enough to trust them, then work is more productive and less conflict exists. organizations indicate a
Lauren Brown, Director of Health at the Skidegate Health Centre in Haida healthier organization.
Gwaii, shares her story of working towards building a healthy organization.
In 2002, the Health Centre had extremely low morale, rotating through five
directors in five years and became unionized. Employees had also experienced
vicarious trauma in their community, and it was a toxic, disruptive, unhealthy
work environment. In 2003, Lauren joined the organization. Through her
gentle, committed, persistence in creating a shared vision and building trust
through such basic communication techniques as cooking together, the This is challenging work,
organization now, in 2010, is healing. People are communicating much more but I’ve learned there are
respectfully and appear happier to come to work. Lauren, as a leader, held
true to her goals and vision, was open and consistent, created communication
better ways to come to
policies designed to work within the culture and community, and has continued agreement and inspiring
to use support and praise to help people rebuild their relationships in new ways. a shared vision plus
As Lauren says, “This is challenging work, but I’ve learned there are better ways leading with your heart,
to come to agreement and inspiring a shared vision plus leading with your
helps.
heart, helps” (personal communication April 27, 2010; for further information:
[email protected]). Skidegate Health Centre employees are more engaged and
on their way to becoming a healthier organization, which ultimately makes for
a healthier community.
Regine and Lewin (2002), in their online article “Leading at the Edge”, further
help us with this, as they explain thinking about organizations organically
16
ENGAGE OTHERS
and relationally rather than mechanistically. They use complexity science

theory as a way of thinking to give us a new perspective on the growth of an
organization. Much is said about healthy relationships: “mutual and connected
relationships ... where you can speak to me openly all the time.... You have to
be interactive and keep working at it.... the way of being in relationship defines
him as a leader, not his position” (p. 1). As leaders engage in relationship with
others, they model the way for employees to engage with each other: “Healthy
employees in healthy and productive environments must be valued in the
organization’s culture and championed by its leaders” (Ontario Health Quality
Council, 2010, p. 5).
In Winnipeg, Manitoba, the Seven Oaks Hospital launched a wellness initiative

in 2001 that included employee health risk assessments, wellness teams to plan
programs, and interventions that addressed employee needs. The program grew Seven Oaks was recognized in
and expanded across the whole organization over several years. Significant 2006 as a Top 100 Employer,
results noted in 2005 were reduced employee turnover and reduced Workers
Compensation Rates (3.8% to 1.97%). Seven Oaks was recognized in 2006 as received the Manitoba Gold
a Top 100 Employer, received the Manitoba Gold Award for HR Leadership, Award for HR Leadership.
and is part of a wellness demonstration program sponsored by Health Canada
(Canadian Council on Learning, 2006).
By focusing on interconnecting leaders in multi-disciplinary organizations, it

may be possible to influence the culture to be healthier, as noted by Anonson,
Conroy, Healey-Ogden, Palmer, and Shawara (2005) in their discussion of the By focusing on interconnecting
College of New Caledonia: leaders in multi-disciplinary
[The College of New Caledonia’s] health sciences and social services division organizations, it may be possible to
undertook a leadership campaign called “Expect a Leader”. This campaign influence the culture to be healthier.
was a challenge to all of the division’s programs to strengthen their focus
on leadership and to build interdisciplinary links. One aim of the Expect
a Leader campaign, therefore, was to increase interdepartmental unity
while retaining the unique identity of each department. This uniqueness
helped create a mosaic of professionals working toward the ultimate goal of
demonstrating quality and excellence in health care. Working relationships
between all levels of management are critical to both role effectiveness and
satisfaction. (p. 25)
Gobillot (2007), in his book on the connected leader, gives us much to learn
about engagement with employees and with external stakeholders. He defines
connected leadership as having three key components.
17
They are trustworthy and have trust in others ... enabling co-creation with
customers. They give meaning to relationships, and they encourage dialogue
and powerful conversations as a way to secure engagement. (p. 6)
He also helps us see the paradoxes of our time in this people economy, by
observing that people are becoming ever more focused on themselves as
individuals yet they cry out for membership and community. Most individuals
want to be secure in deeper relationships, yet they do not want to be dependent
on each other. As Gobillot tells us, these paradoxes have shifted our thinking
on leadership and a connected leader of a healthy organization looks more like
this, having what he calls moral rather than positional authority: Most individuals want
1. Being prepared to exercise personal risk in the pursuit of a key goal. to be secure in deeper
relationships, yet they do
2. Influencing another person towards positive engagement with a goal.
not want to be dependent
3. Creating the perception of support and challenge within another person.
on each other.
At the Interior Health Authority in BC, a significant program has been offered
for several years, called Next Generation Clinical Leadership. Reports from
leaders in the region indicate that the program has had a transformational
effect on the culture of the organizations in their region. As noted in Koehle,
Bird, and Bonney (2008), focusing intensely with a six-month program, front-
line leaders working with their teams has improved the organizational culture
and health from typical ingrained trigger-responses, in which leaders own
others’ problems and find solutions to more of a coaching culture with a focus
on helping new leaders develop their own decision-making and find their own
solutions. One participant perhaps says it best:
I was approached about how to solve a problem about a co-worker and I was
able to give them the direction without becoming involved in their problem;
the approach really does work. (p. 179)
The program also helps front-line teams create trust, align their values, improve
relationships, and develop a shared visionall of which are components of building
a healthy organization (M. Koehle, personal communication, April 27, 2010).
Another powerful example of building a healthy organization by aligning values

comes from Saskatchewan. Saskatoon Health Region’s ability to attain its vision
of healthiest people, healthiest communities, and exceptional service has been
achieved through a strategic focus on actions to create a values-based culture
18
ENGAGE OTHERS
(Quality Worklife, Quality Healthcare Collaborative, 2010c). Their “Our Values

in Action” process has served to
build a more stable, effective and positive work environment and has created
a foundation to build a positive and supportive culture where people feel
heard, respected, and valued and, ultimately, are able to provide quality care
and service. It is supported by existing policies and procedures as well as the
Contagious Kindness program developed in response to recommendations
from the Employee Opinion Survey (2005) Working Group. (para. 4)
The impact of Our Values in Action has been felt throughout the Region since
its launch in the Fall of 2008. Saskatoon Health Region values are used as a
filter in decision-making at all levels, including Program/Department level,
the Senior Leadership table and the Saskatoon Regional Health Authority
(Board).
The Contagious Kindness program, which serves as the action component to

breathe life into the values and code of conduct, has been very well received
by staff and is now included in the Welcome Onboard Week, Phase 1 of the
Onboarding program for all new hires. Open sessions are consistently full and
often over capacity. (Explain the Impact section, para. 1-2)…
Our Values in Action played a substantial role in assisting Saskatoon Health

Region to be named one of Saskatchewan’s Top 15 Employers 2009, and to
achieve NQI PEP Healthy Workplace, Level 1 certification in May 2009. (How
Did It Improve section, para. 2)
As these examples and references illustrate, we are shifting and evolving

our viewpoints about how leaders at all levels can contribute to a healthy
organizational climate. Leaders must focus on engaging with others in
relationships so that ultimately they become so connected we co-create a better
whole organization with the body, mind, and spirit components that Bruhn
(2001) suggests.
19
Communicate Effectively
L eadership and communication are so intimately linked that

it is really not possible to be successful as a leader without
well developed communication skills. When we use the word
communicate, we are referring not only to the words used to transfer
factual information to others, but also to interpret messages that are
sent and received. Workplace communication in the 21st century
requires both knowledge of sophisticated technologies as well as
enhanced skills such as active listening, dialogue, and coaching.
What leaders do and what they do not do explicitly tells employees what is
valued. It is important to match words with actionwhat we often hear as
“walking the talk.” In becoming conscious of all methods of communication it
helps us understand that they reinforce each other. Not communicating is also a
form of communication.
Most of us are aware
Most of us are aware that the most effective way to communicate is informally, that the most effective
face-to-face, and one-on-one. However, even that form of communication holds
many opportunities for misunderstanding. We have created many alternatives
way to communicate is
to this effective form of communication: written publications, intranets, large informally, face-to-face,
and small meetings, email, voice mail, webinars, social networking and media, and one-on-one.
phone, handheld communication devices, web-shared documents, and online
courses as we strive to communicate crossing time and distance. Then we
wonder why communication efforts fail. Sometimes, we begin to think that
sharing information is the same thing as communicating, and this is where we
can fall short.
The reciprocal nature of communication is an important element to consider.

Kegan (as cited in Lambert et al., 2002) discusses this when he writes about
the need to construct meaning in dialogue with others: “Reciprocity, or the
mutual and dynamic interaction and exchange of ideas and concerns, requires a
maturity that emerges from opportunities for meaning-making” (p. 44).
The Colchester East Hants Health Authority (CEHHA) in Truro, Nova Scotia,
recognized the need for improved communication as a way to engage their
20
ENGAGE OTHERS
physicians. They conducted an employee/physician satisfaction survey in 2005. The physicians working
The results of this survey indicated that the physicians working in CEHHA in CEHHA did not feel
did not feel that they had a positive or effective relationship with the health
authority. As a result, a Physician Engagement Steering Group was formed and
that they had a positive
decided to base the implementation of the physician engagement strategy on or effective relationship
the principles of the IHI White Paper “Engaging Physicians in a Shared Quality with the health authority.
Agenda” (Quality Worklife, Quality Healthcare Collaborative, 2010a).
The practice has improved the dialogue and relationship between the health
authority and physicians. They list the benefits as follows:
• The improved relationship between the physicians and the district has
enhanced communication and therefore issues can be more readily
addressed before they escalate.
• The district has a better understanding of how to effectively engage
physicians so that they feel valued and are able to have input on
appropriate clinical issues.
• Increased collegiality between physician groups.
• Physicians feel that they are increasingly part of the solutions and
decision-making processes, rather than have things done to them.
• With improved feedback processes, the district has been able to
be responsive to physician issues and concerns and this had built
a better trust with the group. (Quality Worklife, Quality Healthcare
Collaborative, 2010a, How Did It Improve section, para. 1-5)
Fraser Health Authority
Over the past 10 years, Fraser Health Authority in BC has recognized clear in BC has recognized
communication as a key enabler to effective and powerful results. They clear communication as
have developed and sustained leadership practice in convening powerful
conversations at an interpersonal, team, and systems-wide level. These a key enabler to effective
conversations lead to new learning and changes in the patterns of interaction. and powerful results.
Leading for Engagement is Fraser Health’s flagship leadership development
program, with over 900 leaders completing this program. A core element of this
program is Gervase Bushe’s (2009) concept of Clear Leadership, that has been
built into a five-day highly experiential skills training program that enables
learning conversations to clean up the mush, and create space for work to
move forward.
Lambert et al. (2002) elaborate further on the value of relationship conversation

and place the notion of reciprocity in relationship-building with others:
“reciprocal relationships … are the basis through which we make sense of our
world, define ourselves, and ‘co-evolve’, or grow together” (p. 44).
21
Wheatley (2005) tells us that improving our listening will create improved
relationships, thereby creating shared understanding. With shared understanding,
we have less conflict and more productivity, and we will actually be able to create
the change we each want to see in the world. She helps us know that listening
is a leadership action. She helps us know that, as we listen more deeply, our
relationships are transformed, we can get past the labels and stereoptypes and
discover that we want to work together. Listening in this manner is hearing
meaning expressed through consistent messaging. Leaders will be asking more
questions in the future and listening for answers, looking to connections and
relationships in the people economy where information flows freely. In addition
leaders will notice followers listening and asking with new intention.
It is vitally important to seek alignment in all of our communication methods It is vitally important
and especially to validate that messages are interpreted correctly through to seek alignment in all
one-on-one dialogue. Numerous studies, as cited in Larkin and Larkin (2009),
demonstrate repeatedly that
of our communication
methods and especially
employees would rather receive information directly from their immediate to validate that messages
supervisor.... Rarely does research speak in such a consistent voice. How
are interpreted correctly
should you respond to these findings? Spend 80% of your communication
time, money, and effort on supervisors.... Front line supervisors greatly through one-on-one
influence the attitudes and behaviours of others, they are critical to the dialogue.
success of any change efforts. (para. 4)
Walsh (2008) provides us with a viewpoint on communication that is slightly

different. He advocates leaders need to find their authentic voice stemming
from deeply held beliefs, values, and experiences in order for followers to
believe them. You will then be able to communicate your vision with conviction
and meaning that opens to new possibilities.
Finding ways to express this consistently in all messaging is most important.

Finding ways to express
Leaders must know what to communicate, as well as ensure that they
consistently demonstrate the what through all the hows. Leaders need to this consistently in
reinforce and provide opportunities for people to hear through these various all messaging is most
channels and, even more importantly, to listen carefully through all the important.
methods to see how the what has been interpreted.
Goldsmith (2006), a world authority on coaching and leadership, helps us

understand that leaders need to take action and, in particular, need to execute
leadership development themselves and continuously ask questions and listen
to the answers: “Since knowledge workers know more about their job than
their managers, they can’t just be told what to do. Leaders will need to ask,
22
ENGAGE OTHERS
listen and involve their key staff members” (p. 6). He also goes on to tell us that
leaders need to be responsible for the leadership development process, see it
as a continuous process, and not just events or programs. With the busyness of
leaders today he believes that “peer coaching is going to be the
next breakthrough in this field” (p. 7).
Payne and Hagge (2009) indicate that “engaged people give wholly of Engaged people give
themselves and are possibility thinkers” (p. 19) and “peer learning and wholly of themselves and
coaching encourages people to be self-directed and thus optimally and
are possibility thinkers.
powerfully engaged” (p. 228). As leaders learn to coach, listen to, and engage
their employees and as employees become more self-directed learners,
communication in organizations will be more effective.
More recently, Scharmer (2007), in his work on Theory U, gives us four

dimensions of listening: “downloading, factual, empathetic, and generative”
(p. 11). As we move to generative listening, we listen from the emerging field of
future possibility. `This is the kind of listening we need to use in coaching, as it
transforms us and “connects us to a deeper source of knowing” (p. 13). When
we are listened to deeply, we feel engaged with others. When we know we are
heard, we feel valued and honoured. As leaders learn to listen more, rather than
tell, they will find others around them being more engaged by their leadership.
The interactivity of collective communication, as noted in Rouhiainen (2007), As leaders engage with others as
is fundamentally a dialogue. Although in his research, he refers to leaders partners, stakeholders, in teams
who believe communication is only information dissemination. He does
note that the skill of dialogue is required in any kind of collaborative work.
and across the organization, and
As leaders engage with others as partners, stakeholders, in teams and across to customers and suppliers, skills
the organization, and to customers and suppliers, skills of interpersonal of interpersonal communication
communication become more valued and essential. become more valued and essential.
23
Build Teams
A ttempts to improve leadership in health care often focus on

building teams as a primary way to improve performance.
Stephenson (2009) states, “Being a good doctor does involve being
more than a clinical expert. It involves working with other teams,
communication skills, service improvement” (p. 1170).
Tichy (1996), in his seminal article, describes how involving executive leaders
in development through his teachable point of view changed the culture at
Pepsi-Co. His work helps us understand how leadership can be developed
throughout an organization. He makes an important point for us learn from.
The skills of HR professionals must include an ability to identify resources and
people at all levels with the personalities, experiences, interpersonal skills,
and internal respect required to lead this type of program. In seeking out these
internal resources, helping them learn how to share their knowledge and facilitate
teams, leaders can become effective at building teams in multitudes of ways. We learn both from the
We know that adults learn in the workplace from their direct experiences. We collaboration itself as
also know that, in the workplace, we collaborate to produce work. We learn both well as the experience of
from the collaboration itself as well as the experience of the work. Peters (2005) the work.
reminds us of the importance of collaboration as it relates to learning and also
challenges us to see that dialogue between participants is fundamental to the
creation of knowledge. It is the basis for what they cannot create individually.
Kramer (2006), in discussing the diverse requirements of leaders of the future,

emphasizes that it becomes increasingly important to identify individuals
who exhibit a collaborative approach and provide development that crosses
organizational silo boundaries. Clearly, engaging others collaboratively needs
to be an important element in a leadership framework.
Bennis (1997), in his in depth work on great groups, helps us understand that
a team is not just a group of people who like each other, who get along well,
and who feel like a team. At their heart, a strong team or great group is about
“successful collaborations or dreams with deadlines. They are places of action,
not just think tanks or retreats.... They make and create great things” (p. 214).
Through persistence, curiosity, and focus they are driven collectively and by
24
ENGAGE OTHERS
the leader to get results. Leaders of teams are able to attract talented people,
to work collaboratively and effectively with diverse talent, and to hold a focus
on both the process and the product. Being able to build an effective team,
contribute to the team, and also recognize the kind of team or group that needs
to be built are characteristics of leaders at all levels in an organization.
When the struggles gave
Payne (2001), in her study on collaborative teams, found that, as participants way to a flow of energy and
became more engaged and aware of the energy of collaboration, they
experienced “a sense of elation, of breakthrough wisdom to either a new
productivity is when the leader
creation or a common understanding ... and there is a lightness in the air” sensed group engagement.
(p. 56). When the struggles gave way to a flow of energy and productivity is
when the leader sensed group engagement.
In health care there is a drive at many levels to foster the concept of teamwork,
including at the most senior level. As noted by Cava (2008),
The Canadian first ministers’ meetings have stressed the importance of

teamwork and collaboration in health care delivery and indicate that these
ideas are at the forefront for many Canadians and their decision-makers.
Health Canada has also been involved in many recent initiatives that have
called for improved inter-professional collaboration in health care. The
practice area also needs to change its philosophy about how professionals can
work together given the resistance to change and the attitudes towards scopes
of practice….
Collaborative care and improved teamwork have been shown to improve many
aspects of the health care system in both public health and primary care…
In 2001, the Canadian Health Services Research Foundation (CHSRF)

sponsored Listening for Directions, a priority-setting exercise on health
services and policy issues. One of the themes which emerged was teamwork
but primarily for clinical organizations. (p. 59)
25
A high-performing team is created in a gradual process from a group of

people who work together and realize they need to be more effective. They
engage in various work projects and activities, sometimes with development
interventions, and eventually become a strong team. At Fraser Health
Authority, a major restructuring resulted in a significant number of new
teams being formed.
We work from a principle of connection before content in each of the new We work from a principle
teams being formed and in all the work that we do,” explains Helen Lingham, of connection before
Senior Organization Development Consultant. “For example, with our newly
formed Program Management leadership teams, our clinical executive
content in each of the
brought together their senior administrative and medical leaders for three new teams being formed
days to forge new relationships, identify strengths, clarify roles and establish and in all the work that
agreements for the future. When we first started including connection time we do.
in our workshop designs, senior leaders would resist spending time on these
“soft” activities, seeing them as superfluous to the work that needed to be done.
Today, our leaders understand that relationships form the foundation of the
work we do together and are therefore a critical success factor. (S. Good,
personal communication, April 25, 2010)
In traditional team building, we think of a manager or leader working

We see people on virtual
directly with their team in the same location or at least able to connect face-
to-face on a daily basis. More recently, we see people on virtual teams in the teams in the same
same organization being managed and led over distance and time, using organization being
communication technology and occasionally, coming together. We are faced managed and led over
with mass numbers of people able to co-create, co-produce, and generate
distance and time, using
work in new ways. Tapscott (2006) helps us see beyond our typical internet
communication, searching, and learning and explains the explosion of peer communication technology
production, a way of producing goods and services that relies entirely and occasionally, coming
on self-organizing, egalitarian communities of individuals who come together together.
voluntarily to produce a shared outcome. Leadership comes from the most
skilled and experienced members of the community who help integrate
contributions. (p. 67)
26
ENGAGE OTHERS
Clements, Dault, and Priest (2007) help us understand why there have been so
many struggles in health care to move to a teamwork environment and why it
is important to move past this: “One of the greatest challenges to implementing
effective teamwork is the hierarchical structure of health care” (p. 26).
A focus on inter-professional collaboration through partnerships and joint Learn about the expertise
workshops can lead to inspiration, and encourage people from different health and roles of other health
disciplines to seek out new learning. As experienced in Newfoundland, team
professionals. They reported
members: “Learn about the expertise and roles of other health professionals.
They reported that they felt inspired to work more closely with team members that they felt inspired to
in the future” (Centre for Collaborative Health Professional Education, 2007, p. 1). work more closely with team
members in the future.
Similar to the old community barn-raising, it is a huge opportunity for
health care today to tap into social networking strategies, to harness creative
talent, to create self-selected systems for learning, and to encourage teamwork
that goes beyond the boundaries of the organization, creating “collaborative
self-organizing business-web (b–web) models where masses of consumers,
employees, suppliers, business partners, and even competitors co-create value
in the absence of direct manager control” (Tapscott, 2006, p. 55).
Health care professionals with a patient-focused approach will be relying on

and creating more diverse teams to provide services. These diverse teams need
new kinds of leadership. At the Jewish General Hospital in Montreal, Quebec,
implementation of new technologies
will be complemented by an ever-increasing emphasis on teamwork and

collaboration among those who provide treatment and care to patients. Instead
of being “passed” from one healthcare professional to the next, the patient
is treated by a coordinated team that includes doctors and nurses, as well as
affiliated professionals such as pharmacists, physiotherapists, nutritionists and
social workers. (Jewish General Hospital, 2010, The Future section, para. 3)
27
An example of the value of collaboration and how it may, in fact, help heal the
health care system is provided by Nicklin and Stipich (2005):
The EXTRA program philosophy is grounded in the belief that the health
system can be improved through collaboration among professionals…
Away from home residency sessions, home organization intervention
projects, networking activities, and mentoring give fellows and their home
organizations the experience, the insight and skills necessary to lead the Leaders in health care
research-intensive system of tomorrow. (p. 35) need to find ways to
build different kinds of
Leaders in health care need to find ways to build different kinds of teams, to teams, to encourage the
encourage the use of new technologies and approaches, and to engage others use of new technologies
in the world of mass collaboration. and approaches, and
to engage others in
the world of mass
collaboration.
28
ENGAGE OTHERS
Leading Change
A s Dr Janet Dollin, Family Physician Ottawa, ON (2009) states,

“Leadership? For me it’s engaging others and helping them see
how privileged we are to make important changes” (p. 17).
Leaders are agents of change; and because leadership is a

relationship-based activity, successful leaders must have the
capacity to engage others in change initiatives.
Change that is guided by a clear leadership vision and a culture that values
open communication and staff participation will contribute to a positive
transition. It is important for leaders to acknowledge the need to maintain
a healthy work environment during periods of rapid change and to clearly
communicate this to staff. (Ontario Health Quality Council, 2010, p. 4)
In Alberta, to address a need to improve patient access to services, two

non-traditional engagement conferences were held as part of a larger change
integration effort that successfully drew together a non-typical group of
stakeholders. Bichel, Erfle, Wiebe, Axelrod, and Conley (2009) noted,
Engagement of several hundred stakeholders in redesigning referral and

access at the outset raised some concerns with respect to time and financial
commitment.... It was important to trust that people involved directly in
the work were in the best position to provide creative solutions and support
implementation. (p. 64)
29
Highly developed communication skills are essential for leaders who are
stewarding change initiatives, both to create understanding and to influence.
For health professionals, who operate in an environment increasingly
characterized by distributed leadership modelsmodels in which the ability
to influence others with whom there are no direct lines of authoritythe
capacity to engage others in a leaders vision and mobilize action is a necessary
part of every leaders tool kit. Mountford and Webb (2009) say it clearly: “Large
health care systems and providers rely on complex and rapid decision making
from thousands of people hundreds of times a day, often with life-or-death
consequences” (p. 3). Major change initiatives often require different leadership
development approaches as noted in the example from Fraser Health Authority
that has 19,000 employees to develop.
Fraser Health Authority in BC is in the midst of system transformation and Historically, organizations
restructuring with new teams forming throughout the organization, and at the
have driven their change
same time undergoing an integration of corporate services with other health
authorities. “Historically, organizations have driven their change entirely from entirely from a top-down,
a top-down, directive approach. At Fraser Health, we’ve chosen a different path. directive approach. At
We’ve looked for opportunities to bring people together, to engage them in Fraser Health, we’ve chosen
discerning the direction of their programs and to create a compelling future,” a different path.
says Susan Good, Director of Leadership and Organization Development
(personal communication, April 25, 2010).
For example, with our new program management structure, groups are
coming together across the Health Authority that might not normally ever
be in the same room together. Our Maternal, Infant, Child, and Youth
program leadership team is now partnering with our Health Protection,
Health Promotion and Prevention portfolios. We brought 130 stakeholders
together five times, in a series of concentrated conferences designed to
integrate services and create new possibilities for patient care. These
included a Visioning Conference, Partners Conference, Clinical Interfaces
Conference, Design Conference and Planning Conference. The result of this
high-engagement methodology is a three-year service delivery plan that
represents the best thinking of leaders across the portfolios and high levels
of commitment and energy to move this work forward. (S. Good, personal
communication April 25, 2010)
Golden (2006) asserts that change leaders need to be influential, connected

(i.e., cultivate strong relationships) and skilled to be effective in that role. All
of these attributes point to the need to develop the capacities detailed in the
Engage Others domain within LEADS.
30
ENGAGE OTHERS
If we consider Engage Others within the three underlying constructs of the Caring is a foundational
LEADS framework (Dickson, 2007; see also the Introduction of this booklet): mind-set; it is why leaders
Caring, Being, and Doing, we can see how leaders in the health sector steward
change initiatives and how they employ their skills and capacities in a manner
in health care bring with
unique to this sector. Caring is a foundational mind-set; it is why leaders in them a commitment to
health care bring with them a commitment to service, to patients and clients, service, to patients and
and to health. When this is combined with an understanding of personal and clients, and to health.
positional leadership combined with their values and beliefs as individuals
(Being), we begin to see how their actions emerge and are driven (Doing), and
are better able to influence change.
At Vancouver Coastal Health, George Phipps, Project Manager, explains,
As part of our allied health career development and succession planning

we have created learning communities to support change. ‘Communities of
interest’ are a great and effective way for people to get together to discuss their
professional development and support each other in their learning. These
‘communities’ also provide effective networking and relationship building
opportunities. (personal communication, April 26, 2010)
This is further supported by Wenger (1996) when he explains the value of social
learning within the workplace that engages people while they are working:
Understanding what constitutes a learning organization is particularly

relevant to the health care industry. In a fundamental way, health care is In a fundamental way, health
about learning. It is learning how to care for the sick. It is learning how to care is about learning. It is
create an infrastructure to make care possible. It is also, more generally, learning how to care for the sick.
learning how to live in a healthier manner, as individuals, as communities,
as organizations, as societies.…
If a new perspective on learning can help us learn more effectively, it is

relevant to all these areas. In health care, in fact, it is almost a business
imperative: Effective learning that integrates all these areas may well be,
in the final analysis, the greatest cost-cutting measure of all. And with
the industry in the process of reinventing itself, those who can translate a
workable perspective on learning into an integrated health care system are
likely to chart the future. (para. 5-6)
31
Change imposes challenges for all leaders, whether in health or other Change imposes challenges
sectors of the economy. Many change initiatives are responses to financial or for all leaders, whether in
strategic challenges. Regardless, the effective leader needs to also consider the
health or other sectors of
human element. Effective leaders continue to build and maintain intact and
functioning teams; they communicate effectively when the messages are not the economy.
positive or when employees are demoralized or confused by what is happening
around them, or to them personally.
It is important to recognize the kind of change we are talking about. Leaders

need the capacity to engage others in adaptive change, rather than technical
change. The differences between these two types of changetechnical and
adaptivehave been described by Dr Ronald Heifetz (1998), a physician who
teaches leadership at Harvard’s John F. Kennedy School of Government. In his Leaders need the capacity
book, Leadership Without Easy Answers, Heifetz asserts that a common cause to engage others in
of failed change is that leaders promote technical solutions to what are largely
adaptive change, rather
adaptive problems.
than technical change.
Jack Silversin (2009) explains why the capacities needed to lead adaptive change
are critical:
Changes that cause stress, disequilibrium or tension between competing values

are called adaptive because they challenge deeply held assumptions or values
and require a deeper transformation of beliefs or relationships. For example,
asking physicians to practice according to protocols challenges many physicians’
beliefs that their own experience and judgment is best. (p. 49)
The effective leader finds a balance between the need to achieve, and the need
to sustain followers and other stakeholders. As authors Spreier, Fontaine, and
Malloy (2006) assert,
By relentlessly focusing on tasks and goals—revenue or sales targets, say—an

executive or company can, over time, damage performance. Overachievers
tend to command and coerce, rather than coach and collaborate, thus stifling
subordinates. They take frequent shortcuts and forget to communicate crucial
information, and they may be oblivious to the concerns of others. Their
teams’ performance begins to suffer, and they risk missing the very goals that
initially triggered the achievement-oriented behavior. (p. 1)
32
ENGAGE OTHERS
The health care sector poses certain unique challenges, asserts Brian Golden (2006):
Health care managers frequently face additional challenges because (1) they
face disparate stakeholder groups, (2) health care organizations have multiple
missions (e.g., provide health care to their communities, remain fiscally solvent
and - frequently - be a primary employer in the community), ( 3) professionals
such as physicians and nurses value professional autonomy, and their decisions
influence a major portion of health care expenditures and (4) the information
necessary to manage the change process is often sorely lacking in health care
organizations. (p. 11)
A complex change initiative undertaken by Providence Health Care in BC,

involving multiple sites (Walker, 2006) credits the skills described in Engage
Others to its success.
Forming a powerful coalition of strong nursing leaders to propel this

initiative forward was of paramount importance, and this was accomplished
by involving leaders from both sites in developing a shared vision and in the
planning and creation of new forms. (para. 10)
All four of these challenges, also outlined by Golden (2006), call for the All of these capacities need to be
capacities described within the Engage Others domain of the LEADS developed and employed if leaders
framework.
are to successfully steward change
Effective communication, team building, and supporting and challenging in the complex environment of
others to achieve goals: All of these capacities need to be developed and Canadian health care.
employed if leaders are to successfully steward change in the complex
environment of Canadian health care.
33
Conclusion
H ealth care leaders today live in a multi-dimensional, traditionally

structured, academic-research-and-patient-driven environment.
The challenges are immense. Leaders face resource limitations,
a demand for talent that surpasses supply, and the continuous
introduction of new technologies and practices and treatments.
Leaders are bombarded with decisions to be made and people
in highly diverse professions to lead. The focus of this research
bookletleaders engaging others to get effective resultshighlights
the key capabilities required for leading in
such an environment.
Finding ways to engage others, to lead them with a strong intentional vision,
to capture their commitment and energy, and to help them grow as leaders Leaders need to learn
will make our system stronger. Leaders need to learn how to lead with balance, how to lead with
drawing on their expertise of formal systems and processes, while at the same
time fostering and supporting informal communities and networks of engaged balance, drawing on
colleagues and followers. their expertise of formal
systems and processes.
The clear evidence of strong practical examples and pockets of excellence
illustrated in this booklet exist within our health care system in Canada today.
They demonstrate we recognize we are in the transformational stage, we
understand the need to engage and connect with others, and we are striving to
create engaging cultures.
As leaders engage others, they create purposeful energy: an energy that sustains
the solid foundation of relationships needed to support the transformation of
our Canadian health care system. Our hope for the system lies in connecting
and continuing to learn.
34
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LEAD SELF
ACHIE V E R E SU LTS
ENGAGE OTHERS
ACHIEVE RESULTS
ACHIEVE RESULTS
DEVELOP COALITIONS
LEADERSHIP CAPABILITIES FRAMEWORK Lorna Romilly
William Tholl
A C H I E V E R E S U LT S
Table of Contents
iii Set Direction
iii Strategically Align Decisions with Vision, Values, and Evidence
iv Take Action to Implement Decisions
iv Assess and Evaluate

Achieve Results
2 Four Capabilities of Achieve Results Domain
4 • Set Direction
7 • Strategically Align Decisions with Vision, Values, and Evidence
11 • Take Action to Implement Decisions
13 • Assess and Evaluate
18 Leading Change
20 Conclusion
21 Bibliography
I
Executive Summary
T here is no doubt that achieving results is a set of core capabilities

for all leaders. The LEADS in a Caring Environment leadership
capabilities framework describes the Achieve Results domain as
“Leaders are accountable for managing the resources of the organization
to achieve results.” The four capabilities of setting direction; strategically
aligning decisions with vision, values, and evidence; taking action to
implement decisions; and assessing and evaluating are all supported in
the research and literature on leadership.
Research and literature support the ideas of leaders creating a

compelling future, identifying specific, challenging goals and outcomes,
driving for results, gathering data to make evidence-informed decisions,
and taking responsibility for their actions and the actions of their group.
The actions do not occur in isolation from other capabilities, because
achieving results, in such complex adaptive systems as those of health
care organizations, requires all of a leader’s wits—leading self, engaging
others, developing coalitions, and transforming systems.
II
Health care leaders do not achieve results alone. What this review points out is
that leaders need to engage others, collaborate to set direction and strategies
that are embedded in the organization, and work for acceptance of goals.
They must align all of the elements of the organization—the structure, human
resources and skills, and culture and values—to realize their strategies and
desired outcomes. But they need not wait until everyone is on board. Leaders
take action despite some not being ready to act, and with imperfect plans.
They clarify the strategic focus, desired outcomes, and measures of success,
and let go of the rest. They use tools to assess and evaluate, such as a Balanced
Scorecard or a program logic model, focusing on a few indicators, as a key
component of those efforts.
Set Direction
Leaders inspire vision by identifying, establishing, and communicating clear and
meaningful expectations and outcomes
Leaders are expected to be visionary—that is, to have a sense of direction and
concern for the future of the organization. Setting the direction of a health care
organization encompasses scanning the environment, listening to customers/
clients/patients, collaborating to develop a compelling vision and specific
challenging goals for the future, communicating that vision and goals clearly,
and gaining commitment from those who have to act. Setting direction also
involves broadening the scope from a focus on the organization to one that
includes the community and society.
Strategically Align Decisions with

Vision, Values, and Evidence
Leaders integrate organizational missions, values, and reliable, valid evidence to
make decisions
Strategically aligning decisions with vision, values, and evidence requires
understanding the complexity of the health system; aligning strategy with
structure, culture, and skills; integrating information from various sources;
surfacing tensions and conflicting points of view; and balancing the use of
evidence with experience. It also requires integrative thinking: the ability to
integrate the advantages of one solution with another, rather than choosing
one or the other. Leaders build systems out of fragmented parts, make people
partners in decision making, and create high-speed transformation by being
clear, direct, and predictable.
III
Take Action to Implement Decisions

Leaders act in a manner consistent with the organizational values to yield effective,
efficient, public-centred service
Taking action requires technical management skills to work across functions
and manage projects, time, resources, and budgets. It also requires a focus on
detail, developing organizational objectives, policies, plans, program budgets,
and structures to achieve optimal performance. And when things fail to go as
well as expected, taking action requires dogged determination, a search for
creative ways around barriers, and a continued focus on the vision. Effective
leaders have an absolute focus on results and are able to command and let go
of control at the same time. They acknowledge the finiteness of funds available
to them but also seek to maximize their value. They work with those who are
ready to act, reducing time associated with decision making in order to deliver
results more rapidly. They clarify the strategic focus and the desired outcomes,
determine the non-negotiable and transparent measures of success, and then
let go of the details. They overcome inertia by engaging in as many two-way
conversations as they can.
Assess and Evaluate

Leaders measure and evaluate outcomes. They hold themselves and others account-
able for results achieved against benchmarks and correct the course as appropriate
Health care leaders measure and evaluate outcomes against benchmarks and
reliable evidence, to be able to correct course if necessary. Competencies for
translating vision and strategy into optimal organizational performance include
accountability and performance measurement. The leader has to be able to
hold people accountable to standards of performance, and to understand
and use statistical and financial methods in setting goals and measures for
both clinical and organizational performance. Tools for performance-based
accountability include project management, the Balanced Scorecard, and logic
models. Measuring the achievement of results requires data collection, good
information systems, and analysis.
Leaders achieve change results by using all of their capabilities. Successful

change also requires recognition of the complexity of the health care system
and its interactions. This complexity means they need to foster critical
connections and networks of relationships, and create opportunities for people
to work together in achieving results.
IV
LEADS in a Caring
Achieve Results
1
Four Capabilities of Achieve

Results Domain
T his booklet gives an overview of research and literature

supporting the Achieve Results domain of the LEADS framework
and considers how leaders achieve results in practice. Taxpayers invest
in a health system not for the system itself, but to generate health
and wellness outcomes. Leaders are accountable for managing the
resources of the organization to achieve results. The four capabilities
are set direction; strategically align decisions with vision, values, and
evidence; take action to implement decisions; and assess and evaluate.
These actions do not occur in isolation from other capabilities, because
achieving results in such complex adaptive systems as those of health
care organizations requires all of a leader’s wits—leading self, engaging
others, developing coalitions, and transforming systems.
Table 1: Main Descriptors for Each Capability within the Achieve Results Domain
Achieve Results Capabilities Capability Description
Inspire vision by identifying, establishing, and communicating clear and

Set direction
meaningful expectations and outcomes
Strategically align decisions with Integrate organizational mission, values, and reliable, valid evidence to
vision, values, and evidence make decisions
Take action to implement Act in a manner consistent with the organizational values to yield effective,
decisions efficient, public-centred service
Measure and evaluate outcomes
Assess and evaluate Hold themselves and others accountable for results achieved against
benchmarks and correct the course as appropriate
2
The four capabilities in the Achieve Results domain can be found in

competency frameworks used by the following: the Canadian College of Health
Leaders (CCHL), the Canadian Medical Association (CMA), senior leaders
in the British Columbia Government (BC Govt 4E), US health professional
associations (US HLA Orgs), and the UK’s National Health Service (NHS).
The following table shows the inclusion of the four capabilities within these
competency frameworks (Y=yes).
Table 2: Four Health Leadership Capabilities
Health Leadership Capabilities CCHL CMA BC Govt 4E US HLA NHS

Orgs
Set direction Y Y Y Y Y
Strategically align decisions with

Y Y Y Y Y
Achieve vision, values, and evidence
Results
Take action to implement decisions Y Y Y Y Y
Assess and evaluate Y – Y Y Y
A review of recent research and literature on the Achieve Results domain

highlights the importance and relevance of the domain and its capabilities in the
Canadian health sector. Leaders have always been expected to achieve results, but
only in the past couple of decades have they been held accountable for achieving
results in the public and health care sectors. Significantly, there is more talk about
the Balanced Scorecard (Kaplan & Norton 1996), which allows measurements Leaders have always been
against objectives, and program logic models, which generate objectives and
outcomes that can be evaluated. In cross-cultural leadership research, one expected to achieve results, but
managerial issue—drive for results —was consistently seen as a critical success only in the past couple of decades
factor across a sample of seven European countries and the US: (Robie, Johnson, have they been held accountable
Nilsen, & Hazucha, 2001). for achieving results in the public
and health care sectors.
3
Set Direction
Leaders inspire vision by identifying, establishing, and communicating

clear and meaningful expectations and outcomes
S etting the direction of a health care organization encompasses

scanning the environment, listening to customers/clients/
patients, collaborating to develop a compelling vision for the future,
Leaders passionately
believe that they can make
a difference. They envision
communicating that vision clearly, and gaining commitment from the future, creating ideal and
those who have to act (Bolden & Gosling, 2004; Dye & Garman, 2006; unique images of what the
Kouzes & Posner, 1987). Rather than developing a personal vision, organization can become.
the leader’s role is to create dynamic and interactive processes that
result in a truly shared vision (King & Peterson, 2007a, 2007b), and
to assist staff by creating enabling structures that permit flexibility
and variation (Ford, 2009). Leaders also set out what they expect
from those who have to act, what outcomes they want, and how those
outcomes will be measured.
Leaders are visionaries. “Leaders passionately believe that they can make a The vision should be
difference. They envision the future, creating ideal and unique images of what challenging, but realistic ...
the organization can become…. Leaders enlist others in these dreams. They
it should not be a wishful
breathe life into visions and get people to see the exciting possibilities of the
future” (Kouzes and Posner, 1997, p. 62). In a subsequent research study on fantasy, but rather an
what qualities followers look for in their leaders, Kouzes and Posner (2004) attainable future grounded
found in their research that more than 70% of people surveyed re the qualities in the present reality.
of effective leadership selected the ability to look ahead as one of the most
sought-after leadership traits. Yukl (2006) states that “The vision should be
challenging, but realistic… it should not be a wishful fantasy, but rather an
attainable future grounded in the present reality” (p. 294).
4
Increasingly, leaders are expected to set direction in collaboration by engaging

others. Rosabeth Moss Kanter (as cited in Silverthorne, 2009), in a recent
interview on her new book, SuperCorp, says that a company needs an
underlying set of principles out of which strategy develops and that these are
embedded in the organization through conversations, engaging employees
in broad discussions of what these principles should be and how they apply.
One example is IBM, where the CEO led a conversation in which all 400,000
employees could participate in a web-chat over 3 days on what the company’s
values should be for the 21st century—referred to as a values jam.
More recently, setting the direction also includes broadening the scope to
include not only the organization, but also the community and society. One of One of IBM’s values from its
IBM’s values from its values jam was “innovation that matters for our company values jam was “innovation
and the world” (as cited in Gash, 2009, para. 12). Organizations are looking
at what their community, province, or country needs and asking how their
that matters for our company
capabilities can contribute, how they can serve. With the currently volatile and the world.”
environments, leaders need a strong sense of purpose and a willingness to
collaborate to set directions.
Evidence-based principles of cause and effect might be applied to both

direction setting and goal setting (Locke & Latham, 1984). On the topic of goal
setting, Rousseau and McCarthy (2007) wrote,
Among these principles are that
1. Specific goals are more effective motivators of performance than general goals.
2. Challenging goals are more effective motivators of high performance
than less challenging goals.
3. Goal acceptance is critical to goal achievement when goals are not set
by the employee.
4. Prevention or control-oriented goals (with a ceiling or a natural limit,
such as 100% safety or zero defects) create vigilance and negative emo-
tion in employees, whereas promotion or growth-oriented goals (with
no limits such as increasing staff competency) promote eagerness and
positive emotion. (p. 86)
5
Example 1 describes one organization that has redesigned a more effective

goal-setting process over several years.
Example 1: Set Direction
Toronto General Hospital

In 2003, Toronto General Hospital (TGH), a large quaternary academic centre, recognized that its goal-setting process
was no longer effective and redesigned the goal-setting process “with an intention to create focus, improve leaders’/
managers’ satisfaction, enable site momentum in achieving results and aligning with strategic directions” (Escaf,
McGrath, & Costello, 2009, p. 15). In 2006, Toronto’s University Health Network introduced a Balanced Scorecard around
five directions: We (People), Caring (PCC & Program Integration), Creative (Research & Innovation), Accountable
(Resources & System Integration) & Teaching (Academic) and the organization identified initiatives and targets for each
of these directions. This work led to TGH settings goals within those five domains. (Escaf, McGrath, & Costello, 2009.)
6
Strategically Align Decisions with

Vision, Values, and Evidence
Leaders integrate organizational missions, values, and reliable, valid
evidence to make decisions
S trategically aligning decisions with vision, values, and evidence

requires understanding the complexity of the health system,
integrating information from various sources, managing tensions
and conflicts, and balancing the use of evidence with experience
(Glouberman & Zimmerman, 2002). It also requires integrative
thinking: the ability to integrate the advantages of one solution with
another, rather than choosing one or the other (Martin, 2007).
“What we know about complex system design is that, until and unless there is
alignment of the component parts of structure, culture and skills, the strategic
outcomes and the vision will never be realized” (Ball, 2009a, p. 12). Alignment
“refers to the degree of integration of an organization’s … core systems,
structures, processes, and skills; as well as the degree of connectedness of
people to the organization’s (or system’s) strategy” (Ball, 2009b, p. 13).
Two models review the components that must be aligned to achieve the
required results: the star model originally developed by Golden & Martin,
(2004) and the strategic alignment model (Ball, 2009b). The star model (see
Figure 3) shows how strategy drives structure, culture, and people’s actions
and skills, and concomitantly, how structure, culture and people’s behaviours
support the implementation of strategy.
7
Strategy
Informations & Structure

Decision-Making
Cultures & Figure 3: The Star Model

Values
Incentives Human Resources
Figure 3: The Star Model

Note. As it appears in “Designing Integrated Healthcare Service Delivery
Systems,” by T. Ball, 2009b, Managing Change, p. 13 Copyright 2009 by
Quantum Transformation Technologies, Reprinted with permission.
Ball’s (2009) strategic alignment model, a “systems thinking-based tool for

organizational design” (p. 13), also shows the alignment that is required to
realize strategic themes, outcomes, and the mission and vision (see Figure 4).
Mission & Vision
Customer & Financial

Strategic Outcomes
Strategic Themes in
a Balanced Scorecard
Figure 4: The Strategic
Strategy Alignment Model
Skills Structure
• Technical Culture • Information systems
• Analytical • Rewards/incentives &
• People Strategic Budgeting
• Organizational • Design
• Communications • Decision-making &
accountability
Culture
• Norms • Behavior
• Values • Leadership
• Language • Stewardship
Figure 4: The Strategic Alignment Model
8
Note. As it appears in “Designing Integrated Healthcare Service Delivery

Systems,” by T. Ball, 2009b, Managing Change, p. 13 Copyright 2009 by
Quantum Transformation Technologies, Reprinted with permission.
Ball’s (2009) strategic alignment model also includes strategic budgeting. In

2001, the U.S. General Accounting Office (now known as the U.S. Government
Accountability Office) developed a framework that ties results to agency budget
practices. A major component of this framework required agencies to establish
missions, goals, and performance measures, as well as clearer linkages between
resources and results. The framework, which leads to improved ability to
manage for results, includes four themes:
• Theme 1: Performance informs budget formulation and implementation

• Theme 2: Produces reliable estimates of costs and resources
• Theme 3: Can relate performance, budget, spending, and workforce
information
• Theme 4: Continuously seeks improvement. (p. i)
In a study of in-depth interviews with 26 CEOs of large companies in Europe

and North America with a history of sustainable, above-average financial
performance, researchers set out to understand how top managers work
strategically to create such organizations (Fredberg, Beer, Eisenstat, Foote,
& Norrgren, 2008). The CEOs achieved alignment by:
• Finding systems in fragmentation

• Employing proactive approaches to gain control and align the organization
• Pushing down decisions to make people partners in decision making
• Being driven by values and aspirations that are broader than quarterly earnings
• Creating high-speed transformation by being clear, direct, and predictable.
9
The benefits of strategically aligned decision making are shown in Example 2.
Example 2: Strategically Align Decisions with Vision, Values, and Evidence
US Veterans Health Administration

The US Veterans Health Administration went through a major transformation from 1994 to 1999 that decentralized
decision making and established a performance measurement system that rewarded according to outcomes. Directors
were given substantially greater freedom to determine appropriate clinical and financial measures for their staff. They
invested in a computerized patient record system that would give reliable and valid data.
Results were a 25% cost reduction while providing higher quality of care; the closure of 55% of acute care beds; a 12% reduction
in staff, with 24% more patients receiving care; a 36% reduction in inpatient admissions; and a 68% reduction in bed days.
Golden and Martin (2004) attribute this success to system alignment and identify two common causes of misalignment:
• Principal–agent problems. Agents throughout a health care organization make choices as to how to use the
organization’s resources, i.e. those in charge of the different agencies or hospitals made local decisions without
reference to the national organization.
• Knowledge management problems. Agents often use their specific knowledge. The leader has to create incentives for
individual agents to use their specific knowledge optimally in making choices that will further the organization’s interest.
Golden and Martin (2004) suggest using the allocation of decision-making

authority, performance measurement and accountability systems. Another example
of strategically aligning the decision-making process is given in Example 3.
Example 3: Strategically Align Decisions with Vision, Values, and Evidence
North York General Hospital

After being the epicentre for five months and caring for SARS patients, North York General Hospital (NYGH) saw an
opportunity for organizational change (Adamson & Kwolek, 2008). The senior team listened for hundreds of hours
to NYGH staff, physicians, community members, patients, and families, and developed a plan with four themes in a
strategy-driven Balanced Scorecard. The shift to moving to a culture of accountability and stewardship with teams and a
systems approach could “only occur with consistent leadership aligned with the organizational direction and strategy” (p.
51). The senior team aligned skills and structures with strategy and culture, engaging in multiple improvement activities.
The successes have included a 49% increase in the number of patients cared for by physicians; a 52% reduction in
turnaround time for beds; a 27% reduction in patient length of stay for sub-acute care; and a 19% reduction in the time
of a patient’s arrival in the Emergency to discharge. NYGH is using a strategic Balanced Scorecard and management
system to sustain the changes and report “across four themes: operational and clinical excellence; patient and family
driven care; responsiveness across the continuum; and leading and partnering in system transformation” (p. 53).
10
Take Action to Implement Decisions
Leaders act in a manner consistent with the organizational values to

yield effective, efficient, public-centred service
T aking action requires technical management skills to work across

functions and manage projects, time, and resources (Hamlin,
2002). It also requires a focus on detail in developing organizational
objectives, policies, plans, programs, budgets, and structures to
achieve optimal performance (Vincent, 2002). When things do not
go as well as expected, it requires dogged determination, a search for
creative ways around barriers, and a continued focus on the vision
(King & Peterson, 2007a, 2007b).
Ulrich, Zenger, and Smallwood (1999) say that “leaders do much more than Leaders do much more than
demonstrate attributes. Effective leaders get results” (p. 1) .There should be demonstrate attributes.
an absolute focus on results, with clear targets and expectations; results will
Effective leaders get results.
not improve without constantly taking action and increasing the pace or
tempo. A recent study conducted interviews with 40 health care and public
service leaders who had successfully led a change initiative involving multiple
organizations. A “key finding was that successful leaders were able to command
and let go of control at the same time” (King & Peterson, 2007c, p. 58). They did
not try to find a balance, but used tension to deliver results on an ongoing basis.
Command, in this article, refers to a leader providing direction or demanding
action, and letting go refers to letting answers or direction emerge. Leaders
focused on those who were ready to act, did not worry about those who were
not ready, and did not wait for an ideal plan. “This reduced time associated
with decision making and enabled them to deliver results faster” (p. 59). In order
to take action, successful leaders engaged both individuals who had reputation,
credibility, and influence, and emergent leaders with passion, energy, and a desire
to be involved. The leaders clarified the strategic focus and desired outcomes,
identified what others wanted and expected, determined the non-negotiable, clear
and transparent measures of success, and then let go of the details.
11
One of the impediments to executing strategy, or taking action, is inertia. In an Over time, organizations
interview, Iansiti (as cited in Silverthorne, 2010) said “Over time, organizations tend to optimize the
tend to optimize the efficiency of their operating model” (para. 12), and
they fail to adapt with new structures, processes, and behaviours. Part of a
efficiency of their
solution is conversations, maintaining as much as possible “a rich, two-way, operating model.
and informal exchange of ideas to make sure that the strategy is perfected and
the priorities are universally shared” (para. 23). An example Iansiti gave is of
the CEO of Dell writing a detailed Web log on his management philosophy—
potentially a highly effective approach in aligning an organization and jump-
starting two-way conversations.
A barrier to achieving results in some provinces is the degree of autonomy the

health care leader has to act and the level of external interference from the provincial
government. Successful change can occur when governments and health care leaders
work together, such as in the Ontario wait time strategy (see Example 4).
Example 4: Take Action to Implement Decisions
Ontario’s Wait Time Information System

In 2004, Ontario took leadership successfully over its wait times after falling behind in addressing the issue of access
to care (MacLeod, Hudson, Kramer, & Martin, 2009). The main challenges in developing and deploying the wait time
strategy were time, scope, and complexity. Leaders decided to run policy, strategy, and execution in parallel, and
started the initiative quickly by “leveraging and capitalizing on the existing public pressure, industry interest and
government support for improving access to care” (p. 11).
Taking action involved government allowing solutions to emerge from within the health care system while providing
leadership and support. The focus was kept on broader system and process views, with champions at each level of
the health care system and also clinical expert panels. An important part of the strategy, in addition to funding for
participating, was holding hospitals accountable for maintaining a base volume of cases, performing additional cases
with incremental funding, and managing wait times. Another critical part was regular communication updates to all
stakeholders on progress to date and challenges to come.
12
Assess and Evaluate
Leaders measure and evaluate outcomes. They hold themselves and

others accountable for results achieved against benchmarks and correct
the course as appropriate
L eaders measure and evaluate outcomes against benchmarks

and reliable evidence in order to be able to correct course if
necessary. The National Center for Health Care Leadership (2009)
says that competencies for translating vision and strategy into optimal
organizational performance include accountability and performance
measurement. The leader has to be able to hold people accountable
to standards of performance, and to understand and use statistical
and financial methods to set goals and measures for both clinical and
organizational performance.
In order to continue to achieve results, leaders must continually improve In order to continue to achieve
by assessing and evaluating, revising, and clarifying goals that move the results, leaders must continually
organization toward its vision and strategy. Empirical research has consistently
improve by assessing and
supported the prediction that clear, challenging, but acceptable goals enhance
work performance (Bandura, 1989). The results of Jung and Rainey’s 2008 study evaluating, revising, and clarifying
of 767 federal US programs support these findings, implying that managers goals that move the organization
should establish targets and time spans for performance goals in order to toward its vision and strategy.
improve performance. The Institute for Healthcare Improvement (2010)
in the US captures this concept in what they call the Triple Aim of health
reform, encouraging leaders to consistently assess and evaluate measures of
performance relevant to three dimensions of performance:
• Improve the health of the population.

• Enhance the patient experience of care
(including quality, access, and reliability).
• Reduce, or at least control, the per capita cost of care.
(Institute for Healthcare Improvement, 2010, para. 2)
13
They must also hold themselves and others accountable for achieving results.
One stream of “accountability demands centers on performance, built on the
premise that the organization should be held to account for what they deliver.
The purpose of such accountability is to demonstrate ‘results’” (Ebrahim, 2010,
p. 9). Tools for this performance-based accountability include the Balanced
Scorecard and logic models, with objectives and expected results described and
with indicators used to measure and verify progress.
One of the ways of gaining consistent alignment between a strategic vision One of the ways of gaining
and its execution, as McWilliams (1996) states, is the Balanced Scorecard. In consistent alignment
a presentation on the Canadian Blood Services’ successes in its progress on
between a strategic vision
redressing the tainted blood scandal, Dr Graham Sher, the Canadian Blood
Services’ CEO, stated that the use of Kaplan’s and Norton’s (1996) Balanced and its execution is the
Scorecard was a key element in his organizational change strategy (Sher, 2010). Balanced Scorecard.
The Balanced Scorecard includes a customer perspective, an internal business
process perspective (the business processes at which the organization should
be successful), a continuous improvement perspective (how the organization
sustains its ability to learn and improve), and a financial perspective. The
scorecard needs to be developed and derived directly from the organization’s
vision and priorities. There is a need to focus on a few meaningful performance
measures that improve service results and delivery. Producing a Balanced
Scorecard includes the following:
1. Establishing overall strategic goals

2. For each goal identifying the key actions or initiatives required
to achieve this goal
3. Grouping these actions/initiatives into the four, or five, scorecard
perspectives to check for balance
4. For each action or initiative, determining appropriate performance
measures—relevant, unambiguous, cost-effective and simple
5. Monitoring the measures and taking action as appropriate.
(Accounts Commission for Scotland, 1998)
14
Kaplan’s and Norton’s (1996) most recent work links strategy and operations, and
Kaplan (2010) offers a closed loop management system for strategy execution:
1. Develop the strategy.

2. Translate the strategy.
3. Align the organization.
4. Plan operations.
5. Monitor and learn.
6. Test and adapt the strategy.
Leatt, Pink, and Guerriere (2000) adapted Kaplan’s and Norton’s (1996)
Balanced Scorecard to devise a framework for monitoring the performance of
a health system by adding the category of community benefit. Their framework
includes the following elements:
• Financial perspective —how does the system look to funders?

• Consumer perspective —how do patients view the system?
• Internal business perspective —at what must the system excel?
• Innovation and learning perspective —how does the system continue
to improve?
• Community benefi t—how does the system impact the health
of the population?
The addition of community benefit is a form of accountability that asks that

non-profit organizations demonstrate progress toward achieving their mission.
This approach embraces a long-term view of performance measurement by
emphasizing iteration and learning, and assumes that solving social problems
“requires an ability to cope with uncertainty and changing circumstances”
(Ebrahim, 2010, p. 10).
15
Another approach to align strategy with action and assessment is a program A logic model sets
logic model. A logic model sets out how a particular intervention is understood out how a particular
and intended to produce particular results. It also provides a way to track
intervention is
activities, inputs, outputs or processes, and outcomes. Researchers at The
University of British Columbia (UBC) published a results-based logic model understood and
for primary health care (PHC) in 2009, using a Treasury Board of Canada intended to produce
framework for accountability (http://www.chspr.ubc.ca/research/phc/ particular results.
logicmodel). The immediate outcomes “for which the PHC workforce of
policy makers, managers and practitioners can reasonably assume control,
responsibility and accountability are:
• Increased knowledge about health and healthcare among the population

• Reduced risk, duration and effects of acute and episodic conditions
• Reduced risk and effects of continuing health conditions
• Maintenance or improvement of the work life of the PHC workforce”.
(Watson, Broemeling, & Wong, 2009 pp. 38–39)
Watson et al.’s (2009) model also includes intermediate outcomes over which
the leader has less control but is still expected to have an impact and make
linkages. Using indicators developed by the Canadian Institute for Health
Information (CIHI, 2006a, 2006b), Watson et al. (2009) developed performance
indicators for their logic model, available on the UBC website (http://www.
chspr.ubc.ca/research/phc/measuring).
Other tools or processes that can be used to demonstrate performance include:
• Reports and disclosure statements

• Evaluations and performance assessments
• Industry self-regulation
• Participation
• Adaptive learning. (Ebrahim, 2010)
Measuring the achievement of results requires data collection, good Measuring the
information systems, and analysis. Hazy (2004) says that in complex social achievement of results
systems, strategy-directed leadership activities require the development of a
correlation between key measurements and the business area affected. In his
requires data collection,
conference presentation, Hazy gave some sample metrics beyond the Balanced good information systems,
Scorecard outlined in the following table (Slide 24): and analysis.
16
“Strategy Driven Leadership Metrics”
Group Area Affected Sample Metrics
Business • Revenue growth and mix—old vs. new

Measure a capability from a results
Outcome • Gross margin vs. benchmarks
perspective
Metrics • Operating margin vs. benchmarks
• Energy on creating a shared future vision

Leadership Measure the type and frequency of • Creation of new internal and external communication
Activity leadership activities within a capability; channels
Metrics target mix varies by capability • Attention to effective operations
• Investment in exploitation and exploration
Leadership • Collective foresight and cognition

Measure the quality of the leadership • Communication and alignment on goals
Quality
activities within the organization • Leadership development programs
Metrics • Appropriateness of appetite for risk
The value of comprehensive evaluation to one Toronto-based network is

described in Example 5.
Example 5: Assess and Evaluate
Child Health Network for the Greater Toronto Area

A number of health organizations are using the performance dashboard, such as the one used in the evaluation of the
Child Health Network for the Greater Toronto Area. (Alidina & Jordan, 2007) The Child Health Network comprises
20 hospitals, 9 community care access centres, and a number of health service providers such as physicians, nurses,
allied health professionals, administrators, researchers, and educators. Evaluating this network of multiple distinct
organizations involved reaching consensus on issues, criteria for success, and measurable outcomes. The framework
for the network’s evaluation included an evaluation dashboard with these outcome measures: satisfaction, appropriate
care, accessibility, accountability, affordability, integrated and coordinated care, and effectiveness.
Lessons the participating organizations learned from this project were to do the following:
• Limit the number of clear, measurable indicators and clearly link them to system objectives and network purposes.
• Engage stakeholders early and often with a good communication strategy and keep decision-makers informed.
• Encourage champions and strong leadership.
• Clarify roles and the decision-making structure.
• Balance consistency and flexibility in data collection.
17
Leading Change
I n order to achieve change, results-oriented leaders need to use

together all of the domains in the LEADS framework, as outlined
in the introduction to this booklet. The fact that such an array of skills
of great complexity is required to achieve change probably explains
why, in a recent international survey of senior business executives
(McKinsey & Company, 2008), respondents indicated that fewer The main factors
than half of their change initiatives over a five-year period had been contributing to
successful, and successful transformations occurred in only a third achieving successful
of their organizations. In the survey, respondents reported the main transformations were
factors contributing to achieving successful transformations were planning, visibility,
planning (Achieve Results domain), visibility and involvement of the involvement of the
leader, and good communication (Engage Others, Develop Coalitions, leader, and good
and Systems Transformation). In health care, such change must also communication.
germinate from a clear sense of caring as experienced and manifested
in the leader’s personal purpose—the substance of the Lead Self
domain of the framework.
A number of authors conclude that leading transformation, or change, requires

both art (soft skills, people skills) and science (tools, techniques, planning),
the balance of which are captured in the overall LEADS framework (Schroeder
(2009); Economist Intelligence Unit, 2008; McKinsey & Company, 2008). Golden’s
(2006) research-based model of how to lead change in health care organizations
has four similar stages: determining desired end state; assessing readiness for
change; broadening support and organizational redesign; and reinforcing and
sustaining the change. Planning and delivering on change actions involves
both the art—for example, stakeholder relations, interpersonal skills, and
adaptability—and the science—for example, analysis, project planning and
management, risk management, problem solving, and analysis (Schroeder, 2009),
all of which are captured in the domains of the LEADS framework.
18
The link between leading change and achieving results is highlighted in Example 6.
Example 6: Lead Change to Achieve Results
BC Patient Safety Task Force

Established by the province in 2004, the BC Patient Safety Task Force (now the BC Patient Safety & Quality Council)
has utilized all of the capabilities described in the Achieve Results domain to generate effective change within the BC
health system. It created the “BC Patient Safety and Learning System (PSLS), a web-based adverse event reporting
system that facilitates system-level learning and improvement” (Cochrane et al., 2009, p. 148). Prior to a large-scale
rollout of PSLS, the group undertook a pilot study with “executive leaders to ensure high-level, visible support and
alignment with organizational priorities and directives” (p. 149). The task force members used a “robust change
management plan,” identifying and assessing stakeholders according to interest, impact, and influence, and detailing
stakeholder engagement and communication plans and training for staff.
Significant improvement was identified on a number of operational indicators, showing an increased willingness of
staff to report on all types of events, with greater participation of non-nurses. Cochrane et al. (2009) believe that “the
primary reason for the outstanding adoption of PSLS during our pilot was our use of the implementation as a vehicle
to engage staff in discussions about patient safety” (p. 152) and also the use of a flexible framework. As well, PSLS
reinforced reporting behaviours by providing managers and others with immediate notification of reports and with
the ability to give feedback.
Another example of the Achieve Results domain in action is the Hamilton

Family Health Team’s approaches to leadership and change (as cited in Peterson
& King, 2007d); the team is part of the transformation of primary health care in
the province of Ontario: see Example 7.
Example 7: Lead Change to Achieve Results
Hamilton Family Health Team

Family health teams coordinate the work of doctors, nurses, nurse practitioners, and other health care professionals
to improve patient access and increase the quality of care. In one project in Ontario, the Hamilton Family Health
Team encouraged and supported emergent leadership, and chose to go forward with those who were ready and not to
impose a “one size fits all” approach. The team also left room for multiple models to emerge. Physicians have a choice
about how they work, while information on programs that are successful is shared.
Results have shown substantial improvements in the quality of care and access to care. This approach requires
“courage, fortitude and hard work.… The results, however, can exceed expectations when real synergy builds and
leadership emerges from throughout the system” (Peterson & King, 2007d, p.59).
19
Conclusion
T here is no doubt that achieving results is a core capability for all

leaders. The four capabilities of setting direction; strategically
aligning decisions with vision, values, and evidence; taking action to
implement decisions; and assessing and evaluating are supported in the
research and literature on leadership. The ideas of creating a compelling
future, identifying specific, challenging goals and outcomes, driving for
results, gathering data to make evidence-informed decisions, and taking
responsibility for your actions and those of your group are identified as
characteristics of effective leaders.
Health care leaders do not achieve results alone—that is why the Achieve Successful change also
Results domain of the LEADS framework is married to the other domains involves the recognition
of Engage Others and Develop Coalitions. What this booklet points out is
of the complexity of the
that leaders need to engage others and collaborate in setting the direction and
strategies that are embedded in the organization and in ensuring acceptance of health care system and
the goals. To realize their strategies and desired outcomes, they must align all of its interactions.
the elements of the organization—the structure, human resources and skills, and
culture and values. But leaders do not need to wait until everyone is on board.
Leaders take action without those who are not ready to act and with imperfect
plans. They clarify the strategic focus, desired outcomes, and measures of success,
and let go of the rest. They use tools to assess and evaluate, such as a Balanced
Scorecard or a program logic model, and focus on a few key indicators.
Leaders achieve change results by using all of their capabilities. Successful

change also involves the recognition of the complexity of the health care system
and its interactions. This complexity means leaders need to foster critical
connections and networks of relationships and create opportunities for people
to working together to achieve results.
20
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29
LEAD SELF
DE VELO P COA L I T I O NS
ENGAGE OTHERS
ACHIEVE RESULTS
DEVELOP COALITIONS
LEADERSHIP CAPABILITIES FRAMEWORK Monique Cikaliuk DEVELOP COALITIONS
William Tholl
DEVELOP COALITIONS
Table of Contents
ii Purpose
ii Methods
ii • The centrality of collaboration to health care coalitions
iii • The relationship of coalition capabilities to the knowledge foundation

Develop Coalitions
2 The Four Capabilities of the Develop Coalitions Domain
4 • Purposefully Build Partnership and Networks to Create Results
11 • Mobilize Knowledge
16 • Demonstrate a Commitment to Customers and Service
20 • Navigate Socio-Political Environments
24 Leading Change
26 Conclusion
27 Bibliography
I
Executive Summary
Purpose
The aim of this executive summary is to highlight the relevant
findings of the research and practices of collaboration as it relates
to the Develop Coalitions domain of the LEADS in a Caring
Environment leadership capabilities framework and the role of the
four Develop Coalitions capabilities in leading change in health care
in Canada.
Methods
A search of empirical studies related to health care in Canada and
coalitions, partnerships, alliances, and networks, along with inter-
organizational relationships, was conducted. As this result was
sparse, the search was expanded to incorporate insights from the
fields of management, public administration, and social service.
This was supplemented with case studies of the capability in practice
in Canada. The health care exemplars were identified through the
literature and by individuals involved in the collaborative initiatives.
The centrality of collaboration to health care coalitions

In a complex and complicated environment, organizations can typically choose
to collaborate to achieve an objective. It may involve public policy development
or reformation, restoring or soliciting funding, or changing service delivery
among other goals.
II
DEVELOP COALITIONS
This strategy recognizes the synergy between two or more partners in which
a goal may be achieved more readily by working together rather than acting
independently. This is the concept of collaborative advantage. Collaborative
advantage is a term used by Rosabeth Moss Kanter (1994), in the article
“Collaborative Advantage: The Art of Alliances.” It has been extended and
elaborated by C. Huxham and S. Vangen (2000a, 2000b, 2003a, 2003b) into
the Theory of Collaborative Advantage. It demands a sophisticated set of skills,
knowledge, and abilities to envision, form, and implement.
It underscores the understanding that collaborative initiatives do not just

happenand they do not just remain successful. They demand an approach
that balances the tensions between the advantages of autonomy and the
strengths of interdependence. In this view, the Develop Coalitions capabilities
are ideally about continuous adaptation and evolution.
The relationship of coalition capabilities to the knowledge foundation

There is a wide variety of empirical studies from various theoretical
perspectives that inform the knowledge foundation of the domain, Develop
Coalitions. Against this backdrop, the practices of this domain in Canadian
health care illustrate the challenges as well as the successes of collaborative
initiatives. The four capabilities that comprise Develop Coalitions are that leaders:
Purposefully Build Partnerships and Networks to Create Results

• Collaborative forms include: joint venture, network, consortium, alliance,
service delivery association, and interlocking directorate (e.g., the practice
of health board directors serving on the boards of multiple organizations).
• Collaboration can be a strategic imperative or mandated by a third party.
• Trust begins with the initial intent to collaborate and evolves

throughout the relationship; trust moderates performance results.
• Motives include: minimize costs, gain access to resources—including

knowledge-based resources, share costs of R&D development,
coordinate and refine service delivery design models, expedite access
to health populations, share risks, and enhance legitimacy.
• They proceed through a lifecycle: formation  operation  dissolution.
III
Mobilize Knowledge
• Processes can be used for picking up trigger signals
from the external environment.
• Individuals are conduits of, or sensors for, learning and knowledge.
• Coalitions provide opportunities for continuous interaction: Knowledge

is dynamic and requires time and resources to result in better solutions.
• Better interactions and results occur with a balance

of know-how along with know-why.
Demonstrate a Commitment to Customers and Service

• Health care delivery models across organizational boundaries are
being redesigned with the patient and family at the centre of care.
• Developing a sense of customer/patient requirements

involves learning about their needs.
• Health organizations may be involved in different types

of collaborative initiatives simultaneously.
• Health organizations with greater partnership experience

are better positioned to be successful.
• Capturing learning through after-action reviews or post-

project reviews can inform the development of robust routines
and processes that enable service improvement.
Navigate Socio-Political Environments

• Collaborative initiatives need to balance both (a) autonomy and
interdependence and (b) competition and cooperation.
• The quality of relationships is accrued and evaluated as the partners

learn from their interactions with each other over time.
• Perceptions of efficiency and equity and alignment of

values that underpin the relationship between partners
are critical to building a collaborative initiative.
• A process for managing conflict needs to be in place before an issue erupts.
• Sources of conflict include changes in the external

environment, changes within the partner’s organization,
and changes among the collaborating partners.
IV
DEVELOP COALITIONS
LEADS in a Caring
Develop Coalitions
1

Develop Coalitions Domain
O ur aim is to advance a shared understanding and practice of

coalitions across the Canadian health system by addressing
the complementarities that exist between theory and the real world
of health care coalitions. We adopt the perspective that a tighter
relationship between theory and practice not only enhances the
relevance of research for those leaders developing coalitions, but also
advances research knowledge among disciplines such as management.
Successful coalitions do not just happenand they do not just remain

successful. They are made up of individually successful people who do the right
things, at the right time, with the right structures and processes, in the right
context, for the right purpose.
We understand that the leaders involved in these coalitions work to

purposefully build partnership and networks to create results. They
mobilize knowledge and navigate socio-political environments, all the while
demonstrating a commitment to customers and service. While cooperation
among organizations is not a new phenomenon, there has been a discernable
increase in the use of collaborative initiatives in health care, public sector, non-
for-profit sector, and business (Dickinson, Peck, & Davidson, 2007; Huxham
& Vangen, 2004; Rodriguez, Langley, Beland, & Denis, 2007). At the same
time, the success rate indicates mixed results, with failure to achieve desired
outcomes described as high as 50% (Bleeke & Ernst, 1991).
To better understand the nature of the challenges of developing coalitions

and what leaders in health care as well as the public, private, and not-for-
profit sectors can do about them, we draw on published scholarly research
along with real-life health care case studies in Canada. To guide this review,
two concepts are central to the Develop Coalitions domain. The first is
collaborative advantage, first introduced by Kanter (1994), in the article
“Collaborative Advantage: The Art of Alliances.” It demands a sophisticated
2
DEVELOP COALITIONS
set of skills, knowledge, and abilities to envision, form, and implement. It has To gain real value or advantage
been extended and elaborated by C. Huxham and S. Vangen (2000a, 2000b, means that a goal may be
2003a, 2003b) into the Theory of Collaborative Advantage, which recognizes
synergy between two or more partners. To gain real value or advantage means achieved more readily by
that a goal may be achieved more readily by working together rather than working together rather than
each organization, group, or individual acting alone. The second concept each organization, group, or
recognizes coalitions as a multidimensional construct. This concept serves as individual acting alone.
a useful compass to guide the exploration through the four capabilities of the
Develop Coalitions domain of the LEADS framework. The four capabilities are:
(1) purposefully build partnerships and networks to create results, (2) mobilize
knowledge, (3) demonstrate a commitment to customers and service, and (4)
navigate socio-political environments. Each of these capabilities plays different but
complementary roles in understanding how to affect change through coalitions.
Table 1: Descriptors for Each Capability within the Develop Coalitions Domain
Develop Coalitions Capabilities Capability Description
Purposefully Build Partnerships and They create connections, trust and shared meaning with individuals
Networks to Create Results and groups.
They employ methods to gather intelligence, encourage open
Mobilize Knowledge exchange of information, and use quality evidence to influence action
across the system.
Demonstrate a Commitment to Customers They facilitate collaboration, cooperation and coalitions among
and Service diverse groups and perspectives aimed at learning to improve service.
They are politically astute. They negotiate through conflict and

mobilize support.
3
We begin by introducing the four capabilities of Develop Coalitions as the

change mechanisms through which collaborative initiatives emerge and evolve.
We maintain that these change mechanisms generate the strategic situations
with collaborative efforts to build a health system that maximizes the potential
for universal, efficient, and effective service delivery to all Canadians. We
then review empirical studies in which the four change mechanisms become
instrumental for creating coalitions that typically cross organizational
boundaries. Following this, we introduce exemplars from across Canada
whose practices contribute to a better understanding of the role of coalitions in
affecting change in Canadian health care. We conclude by discussing how the
capabilities of Develop Coalitions, and the associated empirical studies and case
studies, contribute to understanding some of the important challenges faced
by health care leaders, policy makers, and researchers in effecting change in
Canadian health care.
Purposefully Build Partnership and Networks to Create Results

Successful collaboration between organizations of all types depends on the
partners’ strategic fit: their ability to align their organizations and develop
mutually compatible goals. This is relevant for collaboration among public health
organizations, as well as public−private partnerships and social service agencies.
Gaining agreement on a common or shared set of goals and determining how
they are best achieved is essential to purposefully building partnerships and
networks that create results. As noted in the LEADS framework, this capability
entails that “they create connections, trust and shared meaning with individuals They create connections,
and groups” (Leaders for Life, 2010, p. 2). Knowing the different forms that trust and shared meaning
collaborative initiatives can take, along with the various motives of those involved,
is a useful and appropriate starting point for leaders. with individuals and
groups.
Typically, there is variety of arrangements between organizations that
range along a continuum. At one end of the continuum, there are informal
arrangements with no equity involved: for example, an agreement to
share facilities between extended care homes or to make a rehabilitation
pool available in one to residents from the other as part of an individual
resident’s care plan. At the other end of the continuum, there are mergers and
acquisitions with full equity participation: for example, two extended care
homes coming together under one board to share corporate services. At the
extreme ends of the equity continuum, the two forms of collaboration merit
scrutiny. First, in the case of informal arrangements, there is no equity and
no contract typically involved. It may include an exchange of personnel or
benchmarking. While largely overlooked in the literature, this form appears to
be frequently used. In a study of firms involved in technical development, more
4
DEVELOP COALITIONS
than two thirds of the collaborative initiatives involved informal arrangements

(Hakansson & Johnson, as cited in Salk & Simonin, 2003). Second, the full
equity participation through mergers and acquisitions is the complete integration
of processes, structures, legal entities, and cultures, among others. This form of
collaboration, like informal arrangements, has also received disproportionately
less empirical attention when compared with other forms (Salk & Simonin, 2003).
One empirical study to explore the effects of a third-party mandated health

merger is a case study in which the government mandated a merger between
health and social care into one organization in a region in the United Kingdom.
The findings reveal that the anticipated beneficial effects were not realized, in
that potential opportunities to affect change by doing things differently may
have been missed by a perceived need to maintain continuity (Dickinson et
al., 2007). The researchers conclude that, while consistency was a key message
and the continuity of care was maintained, the anticipated synergy of a single
management and governance system, simplification of administration, and
overall reduction of complexity was not realized.
In an in-depth, longitudinal, multiple-case study among a network of public

health organizations in Canada, Rodriguez et al. (2007) examine the processes
of mandated collaboration in what is viewed as an inherently political process.
They demonstrate in three collaborative initiatives that, without the provision
of formal and clear rules by the mandating agency, the partner organizations
were in an ambiguous context and unable to resolve differences. They conclude
that multiple types of complementary governance mechanisms need to be in Multiple types of
place, with each one playing a different role; particularly where there is little
prior experience of collaboration, there are different sources of power and
complementary
divergent values and interests. governance mechanisms
need to be in place.
5
In a review of the structural forms of collaboration, Barringer and Harrison

(2000) identified and classified six forms according to the degree to which the
partners are linked. They are:
1. Joint venture: An entity that is created when two or more organizations

pool a portion of their resources to create a separate, jointly owned
organization.
2. Network: A hub and wheel configuration, with a local organization at
the hub organizing the inter-dependencies of a complex array of orga-
nizations.
3. Consortia: Specialized joint ventures encompassing many different ar-
rangements. Consortia are often groupings of organizations oriented
toward problem-solving and technology development.
4. Alliance: An arrangement between two or more organizations that es-
tablishes an exchange relationship, but has no joint ownership involved.
5. Trade association: Organizations (typically non-profit) that are formed
by organizations in the same industry to collect and disseminate
information, offer legal and technical advice, provide industry-related
training, and offer a platform for collective lobbying.
6. Interlocking directorate: This occurs when a director or executive of one
of the organizations sits on the board of a second organization. This
serves as a mechanism for information sharing and cooperation.
Beyond identifying the forms of collaboration, it is also valuable to re-affirm

that collaborative initiatives exist in many sectors, as well as within health.
These include non-profit organizations, public agencies, and businesses.
Collaborative arrangements exist between each type of organization and with
other types (Gray & Wood, 1991). Examples of the variety of collaborative
initiatives in practice are plentiful. The interlocking directorates between
non-profit organizations such as the Canadian Health Leadership Network
and 21 national organizations, including the Canadian Medical Association,
Accreditation Canada, and the Canadian Patient Safety Institute, are examples
of this form of collaboration within the health sector. A university-association
research consortium, such as Royal Roads University and the Health Care
Leaders’ Association of BC, is an example of a cross-sector case.
6
DEVELOP COALITIONS
The typical duration of a collaborative initiative depends on the type. Generally,

joint ventures and networks are long term, alliances are flexible, consortia
are medium term, and others like sub-contract or service/supplier relations
are short term. The key here is that there is no single optimal form for a
collaborative initiative. It is context specific and depends on the organization’s It is possible to identify a
culture, strategic considerations, and aim. series of stages through
Despite the variety of forms and the specific characteristics of collaborative which most collaborative
arrangements, it is possible to identify a series of stages through which most initiatives progress.
collaborative initiatives progress (Das & Teng, 2002a, 2002b; Kanter, 1994;
Salk, 2005; Spekman, Isabella, & MacAvoy, 2000). Typically, the lifecycle of a
collaboration arrangement includes:
1. Formation: This involves selecting mode of entry, partner identification,

selection, negotiation, and structuring.
2. Operation: This includes the day-to-day operations and activities of coor-
dinating, managing, developing, and delivering.
3. Change or discontinuation: This refers to a change internal to the alliance
or within one of the organizations, or an external environmental change
(e.g., policy change), as well as the renewal or termination.
Different issues and challenges present themselves at each stage of the

collaboration. At the formation stage, building trust and developing mutually
compatible goals are key activities (Das & Kumar, 2007). As cooperation evolves
over time, the initiative needs to be reviewed and assessed based on where it
is in the collaborative lifecycle (Spekman et al., 2000). Over time, familiarity
with partners’ expertise may increase, and attachment may develop (Inkpen
& Beamish, 1997). This may prolong the alliance beyond its lifespan. A new
mutually determined goal may need to be identified, or the arrangement
should be dissolved. An example of the renegotiation of a mandate is
provided in Example 1.
7
Example 1: Purposefully Build Partnerships and Networks to Create Results
The Health Action Lobby

The Health Action Lobby (HEAL) was formed in 1991 as an issue-specific, time-limited coalition, with a focus on
persuading the federal government to restore funding for Canada’s Medicare programs. It was also “purposely built”
in terms of its membership. It was comprised of the: Canadian Nurses Association; Canadian Medical Association,
Canadian Hospital Association, Canadian Long Term Care Association; Canadian Psychological Association; Canadian
Public Health Association (CPHA); and Consumers’ Association of Canada (CAC). Together, HEAL brought together the
perspectives of those responsible for providing publicly financed services (nurses, physicians, hospitals), those not (yet)
covered by the Canada Health Act, and those that represent the health continuum (CPHA) and the customer perspective
(CAC). This made it impossible for senior policy decision makers to argue that the coalition was in any way “self-serving”.
Success was achieved in September 2004 with the signing of the First Ministers’ Health Accord, which restored federal
‘Medicare’ funding to pre-1995 levels and committed to a six percent per annum increase in federal cash transfers.
HEAL celebrated and then began to recalibrate around another shared objective, namely, realizing a sustainable health
human resources strategy for Canada. HEAL’s work continues (see Example 6).
Example 2 illustrates the origins of a coalition and the outcomes achieved to date.
Example 2: Purposefully Build Partnerships and Networks to Create Results
The Canadian Coalition for Public Health in the 21st Century

The Canadian Coalition for Public Health in the 21st Century (CPH21) was born out of shared frustration and concern
about the failure to impress upon governments across the country the need to take public health more seriously,
whether dealing with infectious disease issues such as the SARS outbreak in 2003 or the epidemic of obesity that is
increasingly gripping Canadian society. The coalition was co-sponsored by the Canadian Public Health Association
and the Canadian Medical Association so that issues would be presented as a single voice that would limit a divide-
and-conquer response from governments.
The challenge in the early stages was to be clear about what success looked like. Along with developing a shared
common vision, membership criteria was a consideration: Would CPH21 be a coalition of individuals or
organizations? It also grappled with the question as to who would call the shots in developing and promulgating
policy. Ultimately, the coalition needed all partners to shoulder that responsibility, which supplemented limited
resources. It also created the opportunity for immediate strategic impact.
Today, the coalition can point to the creation of the Public Health Agency of Canada, with a Deputy Minister chosen
from the community, as one successful outcome. The recent reinstatement of the Canadian Task Force on Preventive
Health is another success.
8
DEVELOP COALITIONS
So what are the motives for coalition building? As organizations bring different
resources and expertise to a collaborative initiative, they also bring different
reasons for being involved. Some of the motives may be explicitly stated Some of the motives may
upfront, while others may remain hidden or implicit (Eden & Huxham, 2001). be explicitly stated upfront,
This means that there are often multiple objectives that need to be considered
when forming a coalition. Some of the typical motives include reducing costs, while others may remain
gaining economies of scale, increasing access to markets, or sharing risk hidden or implicit.
(Doz & Hamel, 1998; Doz, Hamel, & Prahald, 1989; Todeva & Knoke, 2005).
Additionally, organizations can increase their legitimacy by selecting a partner
with a strong reputation and gain access to new knowledge (Hamel, 1991). For
some, it may be a strategy for achieving a core purpose or mandate.
Enthusiasm for collaboration may differ across organizations. Some might

see and endorse the advantage; others may be less enthusiastic. Collaborative
initiatives may also be externally mandated or strongly encouraged (Dickinson
et al., 2007; Rodriguez et al., 2007), such as the regionalizations in New
Brunswick and Alberta and the shared service unit established in British
Columbia. Similarly, individuals who participate in collaborative initiatives may
also have different expectations of what may be achieved collectively and how
(Cortvriend, 2004). The key here is to seek out the potential for synergy for the
greatest likelihood of success.
Given the mixture of motives for collaborating to achieve results that cannot
readily be realized by any one organization working alone, establishing and
maintaining trust is identified consistently as an essential component (Das &
Teng, 1998; Kale, Singh, & Perlmutter, 2000; Spekman et al., 2000). The quality
of relationships is a critical factor that contributes to the success of collaborative
arrangements. Ideally, establishing trust begins with partner selection
and extends through to the conclusion of the collaboration. Practically, Organizations may not have the
organizations may not have the opportunity to select partners with whom they opportunity to select partners
collaborate. It may be mandated through policy (e.g., government directs it) or
imposed by a senior leader or board. In these instances, the starting point, then,
with whom they collaborate.
is developing trust between partners generally and individuals specifically.
9
Trust permeates all interactions. Trust can exist at multiple levels, and there
are different sources of trust that have been identified by researchers (Vangen
& Huxham, 2003a, 2003b; Tidd, Bessant, & Pavitt, 2005; Zaheer, McEvily, &
Perrone, 1998). For example, six bases of trust are:
1. Contractual: Honouring accepted or legal rules of exchange,

but can also indicate an absence of other forms of trust
2. Goodwill: Mutual expectations of commitment beyond
contractual requirements
3. Institutional: Trust based on formal structures
4. Network: Trust based on personal, family, or other ties
5. Competence: Trust based on reputation for skills
and know-how
6. Commitment: Mutual self-interest, committed
to the same goals.
Higher levels of trust are linked to realizing performance outcomes (Das &
Teng, 2003; Inkpen & Currall, 1997). For instance, inter-personal trust often
starts off with small acts that gradually accumulate. This serves to reinforce
knowledge sharing and other trust-related aspects of collaboration; it also
provides the foundation for additional inter-organizational activities, such as
establishing mutually compatible goals. As Doz (1996) concluded in his case
study of three alliances, partners may struggle with issues of trust and control,
particularly in the formation stage, as trust is a dynamic and evolving concept
that often required a longer time horizon to develop.
There are different strategies to develop and nurture trust in the formation and
operations stage of collaborative initiatives. It can be especially fragile as an
alliance moves from one stage to the next (Child & Faulkner, 1998). The key to
success in collaboration lies in the ability to predict others’ behaviour and that
“trust management is about managing risk and vulnerability inherent in the
collaborative situation” (Vangen & Huxham, 2003a, p. 26). Each time partners
interact, they are taking a risk that the other will work towards achieving the
intended outcome.
10
DEVELOP COALITIONS
Additional factors that contribute to the success of collaborative efforts to build

coalitions include, but are not limited, to the following:
• It is perceived as important by all partners;
• A collaboration champion exists;
• A substantial degree of trust exists;
• Cultural mismatch is minimal;
• Clear project planning and defined task milestones are established;
• There is frequent communication between partners;
• The collaborating parties contribute as expected; and
• Benefits are perceived to be equally distributed.

(adapted from Hoecht & Trott, as cited in Tidd et al., 2005)
Mobilize Knowledge
Collaborative success depends not only on clear strategic direction and
mutually compatible goals underpinned by trust, but also on being able to
mobilize knowledge. This capability involves working across organizational
boundaries, regardless of sector or industry, to access knowledge and resources
to affect change. This, in turn, requires that “they employ methods to gather
intelligence, encourage open exchange of information, and use quality evidence
to influence action across the system” (Leaders for Life, 2010, p. 2). Mobilizing
knowledge involves identifying, acquiring, and linking resources and
knowledge, sharing knowledge, and ensuring that quality evidence is used for
determining decisions about changes.
Knowledge gathering in collaborative initiatives begins with picking up Knowledge gathering in

trigger signals. They may be about shifts in policies, changes to the regulatory collaborative initiatives begins
environment, changes in the political environment, new practices in health,
with picking up trigger signals.
new needs/demands from patients/consumers, and emerging technologies,
among others. The trigger signals can come from within an organization, a
network, a broader environment, a country, or internationally.
11
This requires an exploration of the selection environment in which the Three methods in the search
initiative sits and, more generally, within fields germane to the aim of the process are:
collaborative initiative. As this search process can be far-reaching, there is a
variety of effective methods that can be used to thoroughly and systematically 1. spotting/monitoring
explore the environment. The three methods of spotting and monitoring trends, trends
future search, and learning from others are described below (adapted from
2. future search
Tidd et al., 2005).
3. learning from others
1. Spotting and monitoring trends: This involves picking up emerging trends
from unexpected sources. It requires active search and scan, often at
the periphery, through websites, conferences, exhibitions, research
institutes, professional associations, universities, suppliers, and interna-
tional bodies. It can also include communities of practice as a source of
knowledge that brings together unexpected elements in ways that can-
not be predicted (Lave & Wenger, 1991). The key here is to have multiple
channels through which knowledge can flow.
2. Future search. This method involves creating scenarios of alternative
parallel futures. They provide an opportunity for diverse perspectives
to come into play at local, sectoral, and national levels. One of the most
well-known is the Club of Rome (Meadows, Meadows, Randers, &
Behrens, 1972), which created possible scenarios where they forecast
an explosive growth in the world’s population and the demands for food
outpacing supply. The goal is not necessarily to create the right answer of
what the situation will look like by that time, but, for example, to explore
opportunities and identify threats that may impact health care.
3. Learning from others. Another set of methods deals with comparisons be-
tween organizations and systems. It looks at best practices by adopting
a strategy of copy and implement—essentially learning by working with
already developed products or services. For instance, St. Paul’s Hospital
in Vancouver, BC, is recognized as a world leader for specialized cardiac
treatment. They provide opportunities for physicians worldwide to learn
first-hand about the treatment regime. A variation on this method is the
concept of benchmarking. In this process, organizations make compari-
sons with others to try and identify new ways of working. The learning
triggered by benchmarking may emerge from comparisons between
12
DEVELOP COALITIONS
similar organizations, or it may come from looking outside the sector,

but at complementary products, processes, or systems.
It includes comparisons between similar activities:
• within the same organization
• in different units or departments of a large organization
• in different organizations within a sector
• in different organizations and sectors.
Scanning the environment consists of searching, filtering, and evaluating

potential opportunities from outside the boundaries of an organization that can
be used by applying or combining with existing resources and competencies. For
example, the study tour made available each year through the Canadian College of
Health Leaders is designed to facilitate learning from other health systems, such
as Sweden, to improve service delivery in Canada. The last comparison, that is,
similar activities in different organizations and sectors, is the most challenging
as it generates new perspectives and insights. For example, by looking at how
an airport manages its passengers, completely new insights can be gained into
logistics by emergency rooms. Many companies use this system, including 3M,
Rolls-Royce, and Motorola, and it is widespread among the pharmaceutical
industry working with biotechnology firms (Tidd et al., 2005). Different knowledge
characteristics, different
Regardless if the collaborative initiative does not have a well defined and clear
intent to acquire knowledge, the emergence of learning outcomes cannot be forms for collaboration, and
precluded (Beamish and Berdrow, 2003). Different knowledge characteristics, experiences of partnership
different forms for collaboration, and experiences of partnership influence influence learning outcomes.
learning outcomes. Typically, in non-profit organizations, fundraising and
grant proposal skills are important knowledge-based skills. In the public sector,
executive and legislative expertise represents valuable assets (Collins, 2005).
In health, for instance, the positive deviance change projects in Ontario are
aimed at improving hospital-acquired infection rates (Ontario Agency for
Health Protection and Promotion, 2010). The BC Care Delivery Model Redesign
(CDMR) Structured Learning Collaborative, which is aimed at redesigning
how care is provided on the medical and surgical units at several different sites
across the province, is a collaborative of interprofessional care teams that provide
hospital based care. (L. Stevenson, personal communication, May 5, 2010)
13
In business, knowledge related to competitive advantage such as marketing,

research and development, procurement and logistics, production and
manufacturing processes, innovation, human resource management practices,
finance and accounting and strategy represent critical assets (Salk and Simonin,
2005). Despite this diversity of knowledge types within alliances, learning among
other collaborative forms, such as mergers and acquisitions, among government
entities, or non-government organizations are only marginally considered
(Dickinson et al., 2007; Rodriguez et al., 2007; Salk and Simonin, 2005).
As individuals are conduits of, or sensors for, learning and knowledge in a

collaborative setting (Nonaka, 1994), they play an important role in knowledge
gathering, sense-making, and application (Cohen & Levinthal, 1990; Zahra &
George, 2002). There are identified behaviours that enhance the capacity to
learn and facilitate an open exchange that may prevent core capabilities from
becoming core rigidities or how things around here are always done (Leonard-
Barton, 1992).
1. Create porous boundaries: Be open to new ideas and not limited by the
status quo.
2. Scan broadly: Expand your sights from what is familiar to what may be
outside of the comfort zone.
3. Provide for continuous interaction: Knowledge is dynamic and requires
time and resources to result in better solutions.
4. Nurture gatekeepers and boundary-spanners: Look for individuals who
have extensive networks inside and externally. They can facilitate the
flow of information.
5. Fight not-invented-here syndrome: Be open to new ideas from unexpected
sources, even they were not created inside the organization or sector.
Leveraging the use of knowledge is the application of knowledge to new Leveraging the use
tasks (e.g., reusing proven practices or routines in a new project, unit, or of knowledge is
organization) or objectives (e.g., improving existing products and/or services or
developing new ones) (Chakravarthy, McEvily, Doz, & Rau, 2003). Collaborative
the application of
initiatives need to balance protecting knowledge (i.e., prevent knowledge knowledge to new
spillovers of sensitive information, such as a membership database) with tasks.
sharing, leveraging, and accumulating. This is particularly relevant to efforts
to create an electronic patient record that has to be acceptable to many health
professions. This requires that partners are clear about what is being shared
14
DEVELOP COALITIONS
and the rationale: that is, the know-how along with the know-why (Khanna,
Gulati, & Nohria, 1998; Inkpen, 2002). It also suggests that gaps in knowledge
may need to be filled through the creation or recombination of assets so that
evidence-based decisions can inform practice. The example of the Canadian
Health Leadership Network (2010) provided in Example 3 is an illustration of
this capability in practice.
Example 3: Mobilize Knowledge
The Canadian Health Leadership Network

The experiences of the Canadian Health Leaders Network (CHLNet) are informative in regard to the capability, mobilize
knowledge. Formed in 2006 with the purpose to “identify, develop, support and celebrate health systems leadership
across the country and over the lifecycle of leadership” (CHLNet, 2010, para. 1), CHLNet has identified tools, research,
and networking as three pillars to works towards their aim (para. 2). They use a combination of methods to gather
intelligence, encourage open exchange of information, and use quality evidence to influence action across the system.
First, a series of regularly scheduled meetings among the CEOs and Executive Directors were held to discuss the
prospect of a looming health leader shortage in Canada. Some members had detected signals that there were difficulties
in recruiting and retaining health administrators and executives. Others had scanned the demographic profile of their
current health leaders and realized that they were at risk owing to retirement and spotty succession planning.
This exploration collectively involved using the acquired knowledge from having scanned databases, publications,
newspapers, and search-placement firms for reliable data about the nature and scope of the impending health care leader
shortage. The individuals involved used techniques to mine the wide range of data sources.
Second, this search process was complemented by the commission of a respected research company, The Conference
Board of Canada, to enable a process of sense-making of the data. This involved the identification and distillation of the
data and the identification of potential opportunities to understand the scope and scale of the issue.
Third, the report was distributed widely in hard copy through the CHLNet distribution channels and made available on
the CHLNet website.
Finally, a series of activities were embarked on in tandem with the development of the LEADS in a Caring Environment
leadership capabilities framework (Leaders for Life, 2010, in collaboration with Canadian College of Health Leaders,
Canadian Health Leadership Network, & Royal Roads University). Evidence of the ability to influence action across the
system includes the following: (1) the development of Leaders for Life through the Health Care Leaders’ Association of BC in
2007, (2) the endorsement of the LEADS in a Caring Environment leadership capabilities framework by the Canadian Health
Leadership Network in 2009, (3) a commitment in 2009 for the rejuvenation of the Canadian College of Health Leaders
curriculum for certification, and (4) securing substantial federal funding to help create a network of centres of excellence in
health leadership research.
15
Demonstrate a Commitment to Customers and Service

The capability, demonstrates a commitment to customers and service, not only
involves extensive interaction and integration within the specific collaborative
initiative, but also needs to foster continuous development of learning. This
capability finds its current expression in efforts across the health system to
redesign health care delivery processes around patient-centred care (Institute
for Health Improvement, n.d.).
Demonstrating a commitment to customers and services is not an end itself, Demonstrating a

but needs to be directed and continuously translated into desired outcomes commitment to
over time. While the structures, processes, and leadership necessary for health
customers and services
organizations to demonstrate a commitment to customers and service are
complex, they are more intricate in collaborative initiatives. This capability is not an end itself...
entails that “they facilitate collaboration, cooperation and coalitions among
diverse groups and perspectives aimed at learning to improve service” (Leaders
for Life, 2010, p. 2). An illustration of this capability in practice is provided in
Example 4.
Example 4: Demonstrate a Commitment to Customers and Service
Patient-Centred Care
The capability, demonstrates a commitment to customers and service, finds its current expression in efforts across the
health system to redesign health care delivery processes around patient-centred care.
Beginning with the provider−patient partnership and rippling out from there to engage family, community, specialist,
and hospital services, patient-centred care suggests that the services the patient receives are customized and adapted
to his/her specific needs. Examples of coalition building to achieve patient-centred care are coalitions (a) among
physicians to create primary-care centres; (b) between care providers to ensure inter-professional care services
(i.e., group patient visits, physiotherapy); (c) between home and community care providers and the family; and
(d) between palliative care providers and the community.
In Alberta, for example, large coalitions of family physicians are working together to create primary-care centres that
address population needs related to chronic care delivery. In British Columbia, integrated health networks are being
developed with the same objective.
Each of these approaches requires significant coalition building among numerous provider groups, emergent patient
advocacy groups, and community agencies.
16
DEVELOP COALITIONS
In collaborative initiatives and among organizations, the ability to achieve

performance outcomes relevant to effective patient care or customer service can
demonstrate timely responsiveness when coupled with management capability
to effectively co-ordinate and redeploy internal and external capabilities
(Teece, Pisano, & Shuen, 1997). This ability points to a way of developing and
reconfiguring processes and routines that enables value creation for the patient
or client of health service. In the public sector or health care, this may involve
cost reduction; continuity of care across organizations; improved access times
for appointments or timely surgery; access to a family physician; or models
of care that integrate service delivery approaches across professions, and that
engage the patient in actively shaping his or her health. In the business sector,
this capability translates into competitive advantage. The lack of the capability
may explain many failures, even among long-standing and large organizations.
For example, the:
• Inability to see and act on new ideas (i.e., the not-invented-here syndrome)
• Problem of being too close or too far from existing customers/

clients/patients to meet their needs quickly enough
• Problem of implementing a new strategy or program without

understanding the full implications for the patient because In health, as in the public
“everyone else is doing it” (adapted from Tidd et al., 2005). sector context, there is an
In health, as in the public sector context, there is an ever-increasing number of ever-increasing number of
partnerships and inter-agency initiatives (Dickson, 2008; Huxham & Vangen, partnerships and inter-agency
2004; Rodriguez et al., 2007). While this capability is aimed at learning to
initiatives.
improve service, learning to improve the formation and implementation of
collaborative initiatives also yields service improvement by increasing the
likelihood that stated goals are achieved. Research indicates that organizations
with greater partnership experience are better positioned to be successful
(Anand & Khanna, 2000; Simonin, 1997; Zollo, Reuer, & Singh, 2002). In a
study of more than 200 organizations, it was concluded that organizations
that invest in structures to coordinate partnership activities and systems to
capture, codify, communicate, and coach alliance know-how gain multiple
benefits. In another study, it was determined that organizations that make
proactive investments to establish structures and processes to coordinate and
manage their partnership activities are better positioned to actually achieve
their aims (Dyer, Kale, & Singh, 2001). Related to this work has been another
strand of research that examines how organizations can develop their partnership
abilities. Organizations that invest in developing skills to manage alliances, such
as training, appointing an alliance specialist, and evaluating alliances, are linked
with success (Draulans, deMan, & Volberda, 2003). In short, learning matters.
17
Demonstrating a commitment to customers and service is essentially about Demonstrating a

learning and change, and it is often disruptive, risky, and costly. It is, perhaps, commitment to customers
understandable that individuals and organizations develop so many ways (i.e.,
cognitive, behavioural, and structural) to reinforce the status quo. Collaborative
and service is essentially
initiatives require energy to overcome this inertia and the determination about learning
to change things by placing a commitment to customers and service at the and change.
forefront of their activities and to continuously champion change. As adapted
from Huxham and Vangen (2004), Spekman et al. (2000), and Tidd et al.
(2005), some of the challenges in collaborative initiatives aimed at improving
patient/customer services are:
• How to manage or lead something we do not own or control
• How to see systems-level effects and not narrow self-interests
• How to build trust and shared risk-taking without

tying up the process in endless red tape
• How to avoid free riders and information spillovers
• How to appreciate each other’s cultural differences by accommodating

the other’s norms and values (i.e., cultural compatibility)
• How to avoid being pulled in all directions.
This is, in part, the rationale for why learning plays such an important part for
how collaborative initiatives may succeed.
A core characteristic
A core characteristic associated with successful collaborative initiatives is the associated with successful
extent to which they involve others (i.e., diverse groups), particularly those collaborative initiatives is
with different perspectives. For example, to what degree are patients and the extent to which they
family members actually involved in care redesign? A consistent theme in the
literature concerns the necessity to understand the needs of the customer/ involve others.
patient. Developing a sense of this customer/patient requirement is integral to
improving service by developing widespread awareness of customer/patient
needs. The issue here is building relationships that facilitate clear and regular
communication, sharing ideas, and providing knowledge and resources for
problem-solving. Closely linked to the high involvement/participation is seeing
knowledge and learning as essential to the success of the collaboration. One
way of looking at this capability is as a continuous learning cycle, involving a
processes in which initial understanding informs action and reflection upon the
18
DEVELOP COALITIONS
intervention informs further exploration and development (Eden & Huxham, The concept of higher levels of
1996). An important ability is to manage this learning cycle in explicit form participation has been recognized
within a collaborative initiative.
in a number of fields.
The argument here is that the ability of a collaborative initiative to make the
best use of its knowledge and resources to affect change depends, on a large
extent, on the knowledge and skills of those involved. Underpinning such
involvement is the culture to support and encourage participation throughout
the lifecycle of the collaborative initiative. The concept of higher levels of
participation has been recognized in a number of fields, including quality
management and lean thinking. A good illustration of this capability is the
Health Charities Coalition of Canada’s experience described in Example 5.
Example 5: Demonstrate a Commitment to Customers and Service
The Health Charities Coalition of Canada

The situation in the mid-1990s for the Canadian health research community, and the charities that supported the
community, was very bleak. Two exceptional leaders stepped up to take on this challenge.
The first was Dr Henry Friesen. He gave a series of “Imagine Speeches” that outlined a brave and bold vision for
research in the future. The brighter future he described would be built on one of Canada’s greatest strengths: working
together through partnerships. The other leader to emerge from this crucible of change was Ms Dorothy Lamont, the
then CEO of the Canadian Cancer Society. She first reached out to the CEOs of other large health charities, such as the
Heart and Stroke Foundation, by pointing to the need to look beyond the body bag index in terms of competing for a
share of diminishing donor dollars.
Similar to other coalitions, the formation of the Health Charities Coalition of Canada (HCCC) emerged in a context in
which the perceived risk of working together was exceeded by the explicit external threat of not working together. The
terms and conditions of engagement, both across the charities and with governments, had to explicitly put the overall
health of Canadians and the welfare of health researchers ahead of the short-term interests of any one charity or cause.
As a first result of these efforts, in June 2001, the federal government announced the creation of the Canadian Institute
of Health Research (CIHR). The Friesen vision of the CIHR, which focused on promoting inter-disciplinary research
teams and the knowledge transfer imperative, successfully captured the imagination of the senior decision-makers
and attracted worldwide admiration. Now, ten years later, the total amount of federal dollars spent on health research
has more than doubled. There is an array of partnerships among health charities that bridge government, private
industry, and charities.
HCCC has had to reinvent itself on an ongoing basis. It continues to maintain a focus on raising the bar of health
leadership funding; it promotes partnerships that continue to put the health of Canadian patients first and the
integrity of a distinctly Canadian health research enterprise at the core of its activities.
19
All of this points to the need for a review of collaborative initiatives to capture
learning from the experience and to attempt to decrease the risk of repeating
mistakes and increase the components that contributed to success. This type
of learning requires a commitment to open and informed review; otherwise,
it may turn into blame avoidance and a cover-up of mistakes.
One approach to capture learning is the use of after-action reviews or post- One approach to capture
project reviews. In a collaborative initiative, they can be conducted at the learning is the use of
conclusion of the activities. They can generate learning that can inform the
development of robust routines and processes that enable service improvement. after-action reviews or
post-project reviews.
This capability deals with navigating socio-political environments.
It requires of leaders that “they are politically astute. They negotiate
through conflict and mobilize support” (Leaders for Life, 2010, p. 2).
Collaborative initiatives do not emerge in a vacuum. One important
influence on the achievement of aims is the context in which they
are created and managed; navigating the political environments of
that context is vital to success.
Difficulties inevitably arise in collaborative initiatives. They stem, in part, Difficulties inevitably arise
from their paradoxical need to balance autonomy and interdependence, as in collaborative initiatives.
well as competition and cooperation. Difficulties also arise from the need to
communicate across different professional and native/natural languages, along
with different organizational and professional cultures (Huxham & Vangen,
2004). Health care has more professional bodies and agencies than any other
vocational sector (Dickson, 2008). Given the complexity of collaborative
initiatives working in complex systems, two research streams have emerged.
One stream of research, the structural perspective, has concentrated on the
choice of contractual mechanisms and governance structures that minimize
the sum of production and transactions costs. Another stream of research
addresses the exchange of information and knowledge, which, in turn, evinces
interest in behaviour and cognition. It is the latter relational perspective, which
brings the human processes of learning and cognition underlying change, that
is explored here in more detail.
Obtaining the benefits of collaborative initiatives is not an automatic process—

it requires considerable effort in the areas of political acumen, negotiation,
conflict management, and relationship management (i.e., power/decision-
making). In one such longitudinal case study of the interactions between two
20
DEVELOP COALITIONS
partners in an international joint venture, these all come into play (Arino &
de la Torre, 1998). The authors trace a series of events, such as culture clashes,
shifts in strategy, and changes to the composition of the board membership,
to examine the impact that external shocks have on the quality of the
relationship between the two partners. According to their findings, partners
attempt to restore balance to the relationship by renegotiating a new mutual
understanding of equity or by taking unilateral action until the relationship
deteriorated to a point where the venture was ultimately dissolved. Arino and
de la Torre conclude that perceptions of efficiency and equity between partners, A positive attitude towards
and that relationship quality, are critical to building a collaborative initiative. renegotiations and additional
The implications of uncertainty in situations where is it is simply not feasible or commitments over time
necessarily desirable to spell everything out in a contract or agreement ex ante becomes critical.
have caused researchers to stress an emergent view of the process. For instance,
Doz (1996) and Doz and Hamel (1998) maintain that a positive attitude towards
renegotiations and additional commitments over time becomes critical. Ring
and Van de Ven (1994) propose that the relationship is cyclical and constantly
reconstructed by continuing interactions and events. They maintain that the
personal relationships, tacit understandings, and psychological contracts
are increasingly replacing formal roles, agreements, and legal contracts as
a collaborative initiative evolves over time. In a similar vein, a longitudinal
case study of three collaborative initiatives (Marshall, 2004) found that the
quality of the relationship is accrued and evaluated as partners learn from their
interactions with each other over time. Marshall concludes that, while contracts
are needed, active management is essential through all stages of the dynamic
process. It is the responsibility of each partner to act as a co-participant. Lack of
achievements during any of the stages may be seen as a warning signal for the
relationship’s continued progress.
Research also suggests that a number of core processes are needed. For
example, a collaborative initiative with no clear routes for resolving conflict is
likely to be less effective than one with established protocols that can handle
the inevitable conflicts that emerge (Mohr & Spekman, 1994). There has also
been a shift from formal legal dispute resolution mechanisms to informal (i.e.,
relational) approaches (Das & Teng, 2003; Dyer & Singh, 1998).
The risk that the whole is not greater than the sum of the parts (i.e. synergy) is
a theme of this capability, navigate socio-political environments. Simply linking
together a group of organizations appears to lead to sub-optimal performance
with the whole being considerably less than the sum of the parts if there is poor
communications, persistent conflicts about objectives, resources, processes, and
governance, among others, as Huxham and Vangen (2000a, 2000b, 2004) and
Vangen and Huxham (2003a, 2003b) conclude based on their extensive research
with practitioners of collaboration.
21
Commitment from top management is a prescription frequently associated

with collaborative initiatives and overall change in general. The challenge is to
translate the concept into reality by developing processes that demonstrate and
reinforce the strategic priority, commitment, and support for the collaborative
activity. This may not be easy to provide as aims may not be achieved quickly,
and the demands for results have to be reconciled with a long-term perspective.
An example of such leadership in action with the Health Action Lobby is
provided in Example 6.
Example 6: Navigate Socio-Political Environments
The Health Action Lobby

The Health Action Lobby (HEAL) was formed when even the largest national health advocacy organizations realized they
were not being effective in creating the political need for active funding from the federal government for health. HEAL is
still evolving, but there are already several lessons that can be drawn from the experience regarding political acumen.
The first success factor is that the composition of the coalition needs to be strategic (see example 1). The strategic
makeup of the coalition’s membership enhanced its credibility and influenced its impact. This was immensely
important to HEAL’s success.
A second critical success factor was to ensure that HEAL reached out to experts in the field. This involved acquiring
the best available evidence from a variety of sources, and sharing the information among its members, so that a
common understanding of the issues could be developed to inform policy options. Developing personal relationships
between decision-makers and with key individuals in these fields was important to HEAL’s success.
Another critical factor was the willingness and ability to share the same destination (i.e., vision intended results,
and values). Coalitions that do not, for example, take transparency and professionalism very seriously are less likely
to succeed. An additional critical factor was the willingness and ability to share in the risks (financial, legal, and
reputational) as well as in the credit. No one organization or individual can take the credit for the achievements
realized through HEAL. Indeed, credit, as it turns out, is infinitely divisible … and, like compounding interest on an
investment certificate, can build exponentially over time.

Conflict among partners is a component of collaborative initiatives and often
tests political astuteness. Spekman et al. (2000) identified three sources of
conflict and their effects on alliances. They note that from to time there may be
noise or static that comes from within one of the partnering organizations. This
form of static is identified as internal static. There is also the noise that occurs
in the broader environment outside of the alliance, but it still has an effect. It is
external static. Within the alliance itself, there is inherent noise called alliance-
based static. These various forms of static require skill and effort to understand
the changes and the nature of their impact in collaborative situations.
22
DEVELOP COALITIONS
It may involve a renegotiation process to readjust respective contributions, a

redefined shared aim, or development of relationships with new individuals as
employment roles change. Collaborative initiatives are dynamic and evolving
over time. In this sense, navigating socio-political environments is a continuous
process throughout the collaborative lifecycle.
Table 2: Sources of Static (adapted from Spekman et al., 2000)
Static Sources Examples

Changes in government or government policy
Changes in the regulatory environment
External
Shifts in market or competitive dynamics
New and significant technological breakthroughs
Poor financial health or financial crisis
Internal Change in strategic intent
Restructuring or reorganization
Breaches of faith
Time zone differences
Alliance-based Change in alliance managers
Lack of parity of contribution
Cross-functional/cross-cultural differences
Of the top sources of static, approximately one third is attributed to each static
source: external, internal, and alliance-based. Spekman et al. (2000) identify the
top 10 sources of static cited as most disruptive or problematic. They are:
1. Changes in market place dynamics 6. Changes in the number of competitors

2. Breach of faith between partners 7. Changes in the management assigned to the alliance
3. Changes in the nature of competition 8. Differences in managerial cultures between partners
4. Shifts in partners’ strategic intent 9. Differences in the partners’ allocation of resources
5. Shifts in individual’s strategic intent 10. Changes in the technology affecting the alliance
External and alliance-based static represent a greater proportion of problem-

causing static than internal (organization) static. Awareness of the type of
static (i.e., external, internal, or alliance-based) and the source is essential
to navigating through these circumstances and using the appropriate method
for this inevitability.
23
Leading Change
In the domain Develop Coalitions, each of the four capabilities
interacts with each other. Similarly, each of the other capabilities
of the LEADS framework interacts with the others to affect change.
The capabilities of Lead Self, Engage Others, Achieve Results, and
Systems Transformation play different, but complementary, roles in
understanding how to effect change through coalition development.
Developing coalitions is built on the foundation of a systems perspective.

A leader in coalitions has a personal vision or mental model of the complete
end-to-end system of value creation (Lead Self), converts that to a shared,
strategic vision and results required in a collaborative or system context
(Achieve Results), and understands the inter-dependencies within it, and
how to affect change (Systems Transformation). A leader in coalitions A leader in coalition
inspires improved health service delivery by engaging others inter-personally
(Engage Others) and through purposefully building strategic partnerships development sees linkages
and networks (Develop Coalitions) to create results. This perspective locates, within the system from
for each individual, her or his role within that larger system and clarifies for multiple perspectives.
them the effects of their behaviour on other parts of the system, as well as
on its outcome. A leader in coalition development sees linkages within the
system from multiple perspectives. He or she also sees connections to other
systems, the relationship between the collaborative strategy to the broader
health care context, and the personal choices he or she makes on a daily basis.
A leader in coalitions takes responsibility for her or his own performance, seeks
opportunities for growth, and models integrity and resilience (Lead Self).
Developing coalitions is intent-driven. A sense of direction is conveyed

by identifying, establishing, and communicating clear and meaningful Developing coalitions
expectations and outcomes. Strategic intent provides the focus that allows the is intent-driven.
engagement of others for meaningful opportunities to contribute and ensures
that resources are available to fulfill their expected responsibilities (Achieve
Results). A leader in coalitions builds teams and encourages an open exchange
of information and ideas (Engage Others). She or he acts in a manner consistent
with the organization and coalition-based values to generate effective, efficient
public-centred service.
24
DEVELOP COALITIONS
One way to characterize the development of coalitions is about creating

alignment between external demands and collective internal capabilities.
Developing coalitions may be viewed as one strategy that is focused on closing
the gap between the current reality of the Canadian health care system and
the envisioned intent for the future through collaboration. This strategic
orientation to the future, in turn, involves creating an environment that
supports continuous improvement, innovation, and systemic change (Systems
Transformation). It requires the use of critical thinking and creativity to query
the status quo and to take action to solve problems through processes across
systems and stakeholders.
The Develop Coalitions domain includes operational capabilities that govern The Develop Coalitions
the implementation of the collaborative initiative. It requires that decisions are domain includes
aligned with vision, values, and evidence. Along with extensive and effective
communication, it also needs an assessment and evaluation of outcomes as the operational capabilities
environment or expectations change over time. that govern the
implementation of the
In this view, Develop Coalitions is ideally a capability about continuous
collaborative initiative.
adaptation and dynamic evolution that balances the incongruity between
change that is too boldly disruptive of the status quo or too incremental to
have much impact and between collaborating to collectively influence action to
improve health service delivery and competing for a larger piece of the system’s
pie (i.e., funding, prestige, etc.).
Finally, in order to effect change in this environment through developing

coalitions, a new way of thinking about and implementing change is called
for—a set of capabilities that bring with them an emphasis on leadership.
Good coalitions succeed by persuading and great ones by inspiring.
25
Conclusion
Building on recent literature about the development of coalitions
and several Canadian case study exemplars, it is clear that successful
coalitions do not just happenand they do not just remain
successful. There is a scholarly body of research complemented by
real-life exemplars that point to a combination of skills, knowledge,
and behaviours that enable or hinder the emergence, evolution, and
dissolution of collaborative initiatives in which partners contribute time
and resources and interact across boundaries in an effort to achieve a
collectively defined or envisioned outcome (Cikaliuk, in press).
The knowledge foundation and the examples of the Develop Coalitions

capabilities in practice revolve around the following: (1) purposefully create
partnerships and networks to create results, (2) mobilize knowledge, (3)
demonstrate a commitment to customers and service, and (4) navigate
socio-political environments.
Collaboration among organizations is complex and complicated. It is too easy Leaders must be careful
to find prescriptions or check-lists for collaborative initiatives that highlight not to fall into the trap
the need to eliminate bureaucracy, flatten hierarchies, and overcome barriers
to communication, along with other factors inhibiting the desirable and highly of avoiding collaborative
sought-after aims of collaborative initiatives. Yet, leaders must be careful initiatives because they
not to fall into the trap of avoiding collaborative initiatives because they are are difficult.
difficult. They need to determine the appropriate situation to purposefully build
partnerships and networks to create results. Equally, developing coalitions
implies more than a structure; it is a dynamic constellation of components,
antecedents, processes, contingencies, and outcomes that can work together
to create and reinforce the kind of change that takes place synergistically and
enables health care transformation to flourish.
Creating change also calls for the recognition of the interactions among the
other capabilities of Lead Self, Engage Others, Achieve Results, and Systems
Transformation with the Develop Coalition capabilities. As the empirical studies
and real-life examples illustrate, each of these capabilities plays different but
complementary roles in understanding how to affect change through coalitions.
26
DEVELOP COALITIONS
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34
LEAD SELF
SYSTE MS T R A NSF O R MAT I O N

ENGAGE OTHERS
ACHIEVE RESULTS
DEVELOP COALITIONS
LEADERSHIP CAPABILITIES FRAMEWORK Graham Dickson
Ronald R. Lindstrom
SYSTEMS TRANSFORMATION
S Y S T E M S T R A N S F O R M AT I O N
Table of Contents
ii Special Acknowledgement
iii Executive Summary

Systems Transformation
2 The Four Capabilities of the Systems Transformation Domain
3 • The Context for Systems Transformation
6 • Lenses for Understanding Change in the Context of Systems Transformation
8 Research and Literature on the Four Capabilities for System Transformation
9 • Demonstrate Systems/Critical Thinking
11 • Encourage and Support Innovation
13 • Orient Themselves Strategically to the Future
17 • Champion and Orchestrate Change
23 Strategies and Tactics to Implement Change
24 • Facilitating Change across Professional Cultures
27 • Creating Capacity and Assessing Readiness for Change
28 • Engaging Physicians More in Systems Transformation
31 Conclusion
32 Bibliography
I
Special Acknowledgement
T he authors would like to acknowledge the significant

contribution made to health care in Canada and to the thinking
in this booklet by Dr. John Hylton, who with Zoe MacLeod was one
of the two original authors. John passed away unexpectedly and
peacefully at home on April 20, 2010 at the time that this booklet
was being finalized. As well as being an exemplary husband and
father, John held a number of senior executive positions, was widely
published, and was recognized as an international expert on health
care leadership. His significant contributions to this booklet are
included and are highly valued. We wish to express our thanks to
John for all of his efforts on behalf of improved leadership of health
care in Canada throughout his distinguished career.
II
Executive Summary
N umerous studies, commission reports, media editorials, and

professional organization reports have been calling for major
reform in the Canadian health sector. Expectations for change—
driven by funding pressures, demographics, public expectations,
and technology—suggest that transformation to reform the health
sector is both expected and required.
Over the past 3 years, significant efforts have been undertaken

across Canada to prepare tomorrow’s leaders to take on the
looming challenges of Systems Transformation. The result of
these collective efforts has been the development and adoption
of a forward-looking health leadership capabilities framework:
LEADS in a Caring Environment.
III
This document looks at Systems Transformation, the fifth domain of the The Systems Transformation
framework. The Systems Transformation domain of leadership capabilities is domain of leadership
aimed at generating the strategic ability to create the changes required. This
capabilities is aimed at
domain is increasingly more important than ever, because more sophisticated
leadership is required to address the fiscal, technological, and professional generating the strategic
challenges, particularly in the large, integrated health systems that are ability to create the
becoming the norm in Canada. changes required.
In the context of Systems Transformation, leaders need to better understand
how they perceive change and what change actually means: i.e., their
experience of the dynamics of change. It is valuable to distinguish to a greater
extent how change is perceived, and also to perceive change differently,
depending on personal qualities such as worldviews, beliefs, and mindsets,
which demonstrates the link between the Lead Self domain of the LEADS
framework and Systems Transformation. Leaders are asked to reflect even more
fundamentally on whether and how they learn to change, and through this
reflection, decide to take action. And to increase the likelihood of success, there
is a pressing need to actively identify and engage all pertinent key players in a
system in the conceptualization and framing of the issues related to Systems
Transformation, as well as in collaborative planning and implementation.
The Systems Transformation domain of the LEADS framework requires that

leaders have four capabilities:
• Demonstrate systems/critical thinking. They think analytically and

conceptually, questioning and challenging the status quo, to identify
issues, solve problems, and design and implement effective processes
across systems and stakeholders.
• Encourage and support innovation. They create a climate of continuous
improvement and creativity aimed at systemic change.
• Orient themselves strategically to the future. They scan the environment for
ideas, best practices, and emerging trends that will shape the system.
• Champion and orchestrate change. They actively contribute to change
processes that improve health service delivery.
The first capability of demonstrating systems and critical thinking suggests

that leaders need to pay more attention to the dynamics of complex systems—
i.e., large, complex health delivery organizations in which the variables are
huge and interactions among them impossible to predict—and using their
knowledge of those dynamics, to apply critical thinking skills in determining
what will work to create the health system of the future.
IV
Leaders are also expected to encourage and support innovation. There has been Leaders are also expected
a strong movement over the past 15 years to integrate quality improvement to encourage and support
into the health system at a unit level, using models such as the Plan-Do-Study-
Act (PDSA) cycle of innovation. (IHI, 2010; http://www.ihi.org/IHI/Topics/
innovation.
Improvement/ImprovementMethods/HowToImprove/testingchanges.htm).
Drawn from change management thinking, these approaches need to be integrated
into and combined with approaches to change using the lens of organic, complex
systems. This capability pulls in both perspectives, as it addresses the leadership
demands of change in human systems such as health.
Leaders orient themselves strategically to the future. Leaders are visionaries: Leaders are visionaries: they
they envisage a brighter, progressive future, and they express hope in that
envisage a brighter, progressive
future. They enroll others in a common understanding of that future, and
utilize strategy to define and engage people in creating it. The health sector’s future, and they express hope
size, number of professionals involved, and political sensitivities pose particular in that future.
challenges. Meeting these challenges entails that effective leaders gather the
knowledge that foreshadows the future, and anticipate issues that need to
be addressed to move toward that future (e.g., chronic disease challenges,
sustainability challenges). Leaders are also encouraged to identify tools,
techniques, and approaches for generating enthusiasm for that future.
In order to champion and orchestrate change, effective leaders are aware of

the dynamics of stakeholder and professional engagement and take action
to stimulate it. They make efforts to assess capacity for change and change
readiness, and see where these may have to be enhanced. Many of the tools,
techniques, and approaches for championing and orchestrating change emphasize
inter-professional interaction, giving power to those affected by the change
in order for them to help design it. Leaders are also aware that when patients,
clients, or citizens are affected by a change, methods to activate their engagement
must also be employed.
The tools, techniques, and approaches used to champion and orchestrate

change are also profiled in the other four domains of the LEADS framework.
This emphasizes the inter-dependent nature of the framework’s five domains
and 20 capabilities for leaders in a modern complex health system. This booklet
reviews how the domain of Systems Transformation can make renewal of the
Canadian health system possible.
V
LEADS in a Caring
1

Systems Transformation Domain
In order to explore the domain and capabilities of Systems

Transformation, the following approach is used:
• The context for change and therefore the domain of Systems Transformation
are presented. Major reports over the past 10 years (both federal and
provincial) that analyzed and made recommendations about the most
common and pressing issues facing Canada’s health system were reviewed
to determine if they call upon health leaders to exhibit the Systems
Transformation capabilities identified in the LEADS framework.
• A lens for understanding the Systems Transformation

capabilities, based on understanding the dynamics of change
as outlined in the introduction to this paper, is presented.
• Relevant literature on leadership, systems thinking, and change management

that was identified is discussed with particular reference to the four specific
capabilities that are part of Systems Transformation in the LEADS framework.
• The need to integrate disparate bodies of knowledge is highlighted

as an effective means to bridge theory and practice and to propose
approaches that will enable Systems Transformation to occur.
2
The Context for Systems Transformation
A major assumption lying beneath the emphasis on leadership

and the creation of the LEADS framework is that major reform
and renovation of existing approaches to health delivery are expected
of leaders in the Canadian health system. To put emphasis to this
point, the Canadian Medical Association (CMA) has announced
its intentions to engage in a major project on health systems
transformation. In a document titled Toward a Blueprint for Health
Care Transformation, the CMA (2009) stated that it “has previously
approved several directional resolutions aimed at transformational
change. … In terms of next steps, this document is intended to
provide a framework for discussion and debate to advance health care
transformation in Canada” (p. A3-2). The document is a starting point
for the creation of an action plan to begin that transformation.
However, physicians are not the only individuals calling out for change in Physicians are not the only
the Canadian health system. In a recent leadership conference in Toronto, individuals calling out for change
speakers such as Dr. Graham Sher, CEO of the Canadian Blood Services, and
Vickie Kaminski, CEO of the Eastern Region of Newfoundland, outlined both
in the Canadian health system.
the challenges of change and the scope of change facing health care leaders
in Canada and the need for leaders to develop a willingness to champion,
encourage, and support innovation (Kaminski, 2010; Sher, 2010). A key theme
in their talks was that the leadership required to achieve such change is, as
mentioned earlier in this paper, complex, challenging, and likely very different
in style and approach than what health leaders have been used to.
A number of national research organizations have also been championing

change. For example, the Canadian Health Services Research Foundation’s
(CHSRF, n.d.) report, CHSRF Strategic Directions 2009–2013, includes a
priority for “accelerating evidence-informed change” (p. 4), highlighting that
despite significant investment in health service improvement experiments
across the country, these experiments are still largely unproven approaches
to change. Similarly, in its strategic plan for 2009/10–2013/14, the Canadian
Institutes of Health Research (CIHR, n.d.) has identified a priority in the area
of knowledge translation in order to integrate research evidence into practice
3
to effect health service and system change. The latest multi-agency national
consultation on health services and policy for 2007–2010, titled Listening for
Direction III (Law, Flood, & Gagnon, 2008) includes change management
as a priority theme. Highlighted is the need for “better evidence and tools A need for better evidence
regarding how to bring about change” (p. 10). Recently, to better understand and tools regarding how
the dynamics of health systems change and the role of leadership in it, a large
to bring about change.
group of researchers, knowledge translators, and decision-makers received a
grant from CIHR to study leadership in health system redesign (Alain Baudet,
President, Canadian Institutes of Health Research, personal communication,
2010).
Such calls for change and transformation are not new. Over the past 10 years,
a number of commissions, task forces, and reviews have been undertaken to
analyze pressing issues facing the transformation of Canada’s health system.
Included are:
1. BC’s Royal Commission on Health Care and Costs (known as the Seaton
Commission). The report, Closer to Home, was completed in 1991.
2. Quebec’s Health Review, (known as the Clair Report), was completed in 2001.
3. The federal Standing Senate Committee on Social Affairs, Science and
Technology (known as the Kirby Commission). The Report on the State
of Health Care in Canada, was completed in 2002.
4. The Romanow Commission, or the Royal Commission on the Future of
Health Care in Canada, completed its final report in 2002. Building on
Values: The Future of Health Care in Canada. Final report of the
Commission on the Future of Health Care in Canada.
5. The Saskatchewan Commission on Health Care, known as the Fyke
Commission, released its report, Caring for Medicare: Sustaining a
quality System in 2001.
6. Alberta’s Premier’s Advisory Council on Health completed its report,
A Framework for Reform in 2001. It is known as the Mazankowski
Report.
BC Conversation on Health was completed in 2007 (Ward, 2007).
These reports and the practical examples they contain are particularly germane
to Systems Transformation because they identify the most complex and
pressing issues standing in the way of improving health system performance.
Ward (2007) completed an analysis with a slightly altered set of reports (all of
the above reports, excluding the Clair Report but including the BC Standing
Committee report in 1991).
4
From the perspective of Systems Transformation, Ward (2007) identified a

number of common and recurring themes occurring in these reports. They
include, for example, quality and patient safety, access and wait times, health
human resources, chronic disease management, first nations health, public
health challenges, primary health reform, pharmacare, new technology, capital
infrastructure, financial management and sustainability, cultural diversity,
mental health and addictions, environment, personal responsibility, and a
challenging planning environment. The major underlying systems issues
highlighted by all the reports and frameworks can be summarized as follows:
• A short-term outlook on investments and returns, too much flavour of the

day, and not enough long-term thinking, planning, budgeting, and visioning
• Lack of coordination, lack of integration, and too much turf protection
• Too many silos and the wrong models for organizing people and services
• A too-rapid pace of change, too much reaction to the urgent, and a failure
to adequately consider consequences
• A failure to reach consensus on which priorities and investments
are most important
• A failure to speak up
• Inadequate human resources capacity to meet service demands and to
bring about improvements within complex systems.
All of these issues, either independently or as a holistic list, suggest major

change in how health services are delivered and how they are managed. When
combined with changes happening in other facets of society—e.g., economics,
technology, communications, and societal values—they also suggest a
magnitude, breadth, and scope of change that are unprecedented in health care.
5
Lenses for Understanding

Change in the Context of Systems
Transformation
B efore addressing the specific capabilities that comprise the

domain of Systems Transformation, it would be helpful to
better understand what challenges leaders face in perceiving change
and what change actually means. First, it is valuable to define what
is meant by the terms change, innovation, and transformation.
These terms are often used interchangeably in the context of health
system reform. However, they have distinct qualitative differences.
Austin and Claassen (2008) define change as “the adoption of an
idea or behavior—whether a system, process, policy, program, or
service—that is new to the adopting organization” (p. 324). They
go on to suggest that change can be fundamental or incremental.
Incremental change is consistent with the definition of innovation,
and fundamental change with transformation.
Innovation is defined as “a dynamic and iterative process of creating or Innovation is a dynamic and
modifying an idea and developing it to produce products, services, processes,
iterative process of creating
structures, or policies that are new to the organisation” (Read, 2000, p. 96),
such as LEAN process engineering (de Sousa, 2009). Innovation tends to focus or modifying an idea and
on small changes in well-defined contexts (Luis Denis, 2002), but in a large- developing it to produce
systems context, it is not just innovation that is needed, but transformation, products, services, processes,
“a process of profound and radical change that orients an organization in
structures, or policies that are
a new direction and takes it to an entirely different level of effectiveness”
(BusinessDictionary.com, 2010, para. 1). new to the organisation.
6
Cathy Ulrich, CEO of the Northern Health region in British Columbia,

expressed her understanding of the current challenges facing health leaders in
the following way:
Change is usually smaller scale around the things that we try in an “I think of a number of small
organization to change and shift, usually for the purposes of improving changes that come together to
outcomes or improving [patient] care or services that we provide to the enable that transformation.”
community or to individuals. … When I think about transformation … I’m
beginning to think of something that’s going to be sustained into the future
and is shifting the system overall. I think of a number of small changes
that come together to enable that transformation. (C. Ulrich, personal
communication, March 3, 2009)
A further challenge in understanding change is to be conscious of the metaphor

or mindset an individual has adopted in thinking about change. Leaders
will perceive change differently according to their worldviews, beliefs, and
epistemological perspectives. For example, in the physical sciences, depending
on the epistemological frame brought to observation of light, an individual
can perceive light as either a wave or a photon. A similar paradox faces the
leader in observing and understanding change. Change can be perceived
from a mechanistic perspective (i.e., a Newtonian perspective [Ford, 2005])
in which change is seen as a positive or negative discrete event, externally
imposed on people and disturbing to or enhancing their personal comfort level.
This worldview sees change as linear and cause-and-effect related, with the
potential to be organized in a logical, rational fashion (Ford, 2005). Conversely,
like the photon view of light, change can be perceived as a continual process
in which reality is but a moment in time. In a complex adaptive systems
environment, change is more closely aligned with a continual process, such as
self-organization, emergence, and adaptation—a process that is non-linear and The focus on transformation in
inter-dependent (Ford, 2005). this booklet reflects our view that
How individuals conceptualize the change process in the health system also the LEADS domain of Systems
largely influences how they characterize and accept or react to change, what Transformation is most suited
approaches they take, what models they use, and whether they are proactive to the confusing, multi-actor,
or reactive. The focus on transformation in this booklet reflects our view that
interactive environment that
the LEADS domain of Systems Transformation is most suited to the confusing,
multi-actor, interactive environment that characterizes large systems. In characterizes large systems.
addition, our understanding is that when the context for change is minimalist
and discrete (e.g., inside a specific work unit), innovative practices drawn from
a change management perspective (e.g., LEAN) are helpful.
7
Research and Literature on the

Four Capabilities for System
Transformation
H aving provided the reader with both the context for leadership
of change, and an understanding of the transformative
challenges that change is taking in health care, it is appropriate now
to move on to provide the knowledge foundation for each of the four
Systems Transformation domain capabilities. Table 1 outlines the main
descriptors for each capability for the Systems Transformation domain.
Table 1: Descriptors for Each Capability in the Systems Transformation

Domain
Systems Transformation Capabilities Capability Description
Think analytically and conceptually, questioning and challenging the status

Demonstrate systems/critical thinking quo, to identify issues, solve problems, and design and implement effective
processes across systems and stakeholders
Create a climate of continuous improvement and creativity aimed at
Encourage and support innovation
systemic change
Orient themselves strategically to Scan the environment for ideas, best practices, and emerging trends that
the future will shape the system
Champion and orchestrate change Actively contribute to change processes that improve health service delivery
8
Demonstrate Systems/Critical Thinking
T o undertake Systems Transformation, health leaders need to

demonstrate systems and critical thinking. They are required to “think
analytically and conceptually, questioning and challenging the status quo,
to identify issues, solve problems, and design and implement effective
processes across systems and stakeholders” (Leaders for Life, 2010,
Systems Transformation section, para. 1).
Framework of thought
Systems thinking is a “framework of thought that helps us to deal with complex
concepts or situations in an holistic way” (Kalim, Carson, & Cramp, 2006, p. 174). It
that helps us to deal with
is required of leaders, because most systems in the health arena are complex “in that complex concepts or
they consist of many interacting stakeholders with often different and competing situations in an holistic way.
interests” (Trochim, Cabrera, Milstein, Gallagher, & Leischow, 2006, p. 539). A team
of researchers at the US National Cancer Institute recently concluded that:
Systems thinking in public health cannot be encompassed by a single discipline or

even a single approach to “systems thinking” (e.g., system dynamics); instead, it
consists of a transdisciplinary integration of public health approaches that strive
to understand and reconcile linear and nonlinear, qualitative and quantitative, and
reductionist and holist thinking and methods into a federation of approaches to
systems thinking and modeling. (Trochim et al, 2006, p. 540)
In the health care setting,
Kalim et al. (2006) also contend that “in the health care setting, many professionals many professionals only
only have a vague understanding of what systems thinking is and why it is used” have a vague understanding
(p. 174). They suggest that there is irony in that people who run the health system, of what systems thinking is
including clinician leaders who are accustomed to working within the framework of and why it is used.
organic, evidence-based physiological systems toward improving health status, are
often ill prepared to lead or navigate the health system. The reader is not asked to
judge whether this notion is true; however, it does suggest that in order for leaders to
be truly effective in changing systems, such knowledge is valuable and important.
A number of qualities of a systems mindset have been mentioned earlier: a system

is a holistic entity, comprising loosely connected, interdependent components (i.e.,
bound together by mutual cause and effect); is greater than the sum of its parts;
and is subject to the vicissitudes of both human reason and emotion. Nowhere is a
systems mindset more applicable than in the system of health service delivery.
9
Although the patient is a common denominator in all health care delivery processes,
the number of potential organizations and care-giving professionals involved during
a citizen’s lifetime is huge—broader in scope and depth than in almost any other
enterprise. Consequently, administrative infrastructures for leading and managing
health care delivery systems are inherently complex enterprises and growing more
complex over time. For example, current efforts at regionalization in many provinces
across Canada, as well as Local Health Integration Networks in Ontario and many
collaborative enterprises in Quebec, suggest dramatic movement toward a systems
approach to creating efficiency and effectiveness in health service delivery. Example 1
describes two instances of this movement.
Example 1: Demonstrate Systems/Critical Thinking
Expanding Health Systems in Canada

Geoff Rowlands, CEO of the Health Care Leaders’ Association of BC, stated recently, “The Canadian health system has
gone from a large number of independent corner stores to a few large conglomerates. The leadership skills needed to
steward these large systems are dramatically more complex than the ones I grew up in my career with. To lead them
really requires the systems thinking and critical thinking capability in order to create changes in service delivery”
(G. Rowlands, personal communication, March 25, 2010).
To look at the experience in one province, “in Ontario, with the introduction of Local Health Integration Networks
(LHINs) and increased provincial government interest in promoting supply chain efficiencies, there are now budding
regional efforts towards supply chain collaboration among health care providers across the province” (Motiwala,
McLaughlin, King, Hodgson, & Hamilton, 2008, p. 23). This circumstance has given rise to the Blue Sky Partnership
at St Michael’s Hospital in Toronto.
Usually the larger and more complex an enterprise—e.g., large health authorities
or the provincial health system—the greater the propensity for disorder in the
enterprise. Although not initially designed as a holistic system of care, these large
entities represent efforts to coordinate and align previously disconnected service
delivery models across larger and larger geographical areas, and create layers of
organizational infrastructure of greater and greater complexity (Luis Denis, 2002).
In doing so, “the industry is witnessing new hybrid organizational forms that are
emerging and exhibiting diverse relational-structural alliances between physicians,
hospitals and/or insurers” (Ford, 2009, p. 102). Other new structural connections
are also developing. Leading change in these nested, interdependent components
of a whole system requires leaders to understand the dynamics of such systems,
the interactions, the key agents and actors at each level of the system, and of course
the political interplay that characterizes decision making within a specific context
(Dickson, 2009b; Ford, 2005, 2009; Uhl-Bien & Marion, 2009).
10
Encourage and Support Innovation
E arlier in this booklet, innovation was defined as the introduction

of new aspects or methods usually characterized as applicable to
smaller contexts rather than large systems. In a meta-analysis of the
change management literature, Read (2000) argues that there are types
of innovation (products vs processes, radical vs incremental, and
technical vs administrative); stages of innovation (generation of In health care, the levels
innovation and adoption of innovation); and, levels of innovation of innovation begin at the
(national, industry, organizational, group, or individual) (pp. 97–98). clinical micro-system level.
In health care, the levels of innovation begin at the clinical micro-system level.
A clinical micro-system is a small, inter-dependent group of people who work
together regularly to provide care for specific groups of patients (Institute for
Healthcare Improvement, n.d., para. 3). This small group is often embedded in
larger and larger organizational contexts that might be termed meso (department),
macro (hospital, region, program), or mega (province or country). These four
levels represent progression from what might be called simple environments (e.g., In this environment of
limited variables); to complicated environments (significant number of variables
in which prediction is difficult), to complex environments, in which the number progressive complexity,
of variables are so numerous and the interactions so unpredictable, such that the when large systems change,
leader must treat those environments like complex adaptive systems (Glouberman so do micro-systems, and
& Zimmerman, 2002). In this environment of progressive complexity, when large
systems change, so do micro-systems, and vice versa. Predictable change may
vice versa.
start in a micro-system and have relevance across larger systems, stimulating
transformation. Similarly, unpredictable changes in the large system can catalyze
change at a micro-level. For example, in what is now the Winnipeg Health Region,
efforts in the 1990s to build quality improvement and program management into
one hospital was a catalyst for regionalization when a provincial funding crunch
was experienced (B. Wright, personal communication, March 29, 2010).
Some of the best examples of innovative practices are derived from the quality
improvement efforts using Plan-Do-Study-Act (PDSA) models for change
(Impact BC, 2007; Institute for Health Improvement, 2010). Similarly, LEAN
management (De Sousa, 2009; Tsasis & Bruce-Barrett, 2008), Business Process
Redesign (Brennan, Sampson, & Deverill, 2005), Total Quality Improvement (Croxall,
2003; Huq, 2005), and force field analysis (Baulcomb, 2003) are all evidence-based
approaches to innovation that have been applied in a micro-systems health context.
When used in a larger systems context, approaches such as action research have been
11
used to create innovation on a large scale (see Chiarella, 2007, who describes a
project in New Zealand that aimed at identifying, encouraging, and disseminating
innovations in nursing care and delivery).
For years, leaders across all facets of the Canadian health system have been
called upon to create a climate of continuous improvement and creativity aimed
at systemic change. The Canadian Patient Safety Institute was established to
support such changes. Yet it remains challenged by making micro-changes
macro in scale. Is that because the urgency of the change (Connor, 2006; Kotter,
1995) is lost on Canadians? Tenner (2006) says that “big changes sometimes
arise from the gradual evolution of ideas and techniques. But many of the most
striking re-inventions have been born in times of crisis” (p. 1). Spurgeon (2000)
wrote that “the prime minister and the premiers agree that the healthcare
system is in crisis. … According to the latest poll, eight in 10 Canadians believe
the system is in crisis, and only one in four rates it highly” (p. 400). And, this
was 10 years ago; if the health care system was in crisis then, it is now well
overdue for innovation. As Wheatley (1999, p. 9) emphasizes, “we need to
look internally, to see one another as the critical resources on this voyage of
discovery. We need to learn how to engage the creativity that exists everywhere
in organizations” (p. 9).
Prada and Santaguida (2007) add another important dimension to innovation:
“the process through which social or economic value is extracted from Good practice will spread
knowledge—through the creation, diffusion, transformation, and use of
ideas—to produce new or significantly improved products or processes” (p. 7).
more quickly within
These authors suggest that a framework for innovation exists in four processes: the health care system
creation of knowledge; diffusion of knowledge; transformation of knowledge; if leaders acknowledge
and, use of that knowledge. Interactions and interconnections exist between and respect the patterns
and among all components of the framework. A high-performing system will
only be as high performing as the components and relationships of which it reflected in the past efforts
is comprised. “Good practice will spread more quickly within the health care of others to innovate.
system if leaders acknowledge and respect the patterns reflected in the past
efforts of others to innovate” (Plsek & Wilson, 2001, p. 746). Strengthening the
innovation environment “entails achieving transformations in areas such as
cultural attitudes and behaviours (including a move to greater risk tolerance),
regulatory policies and procedures, infrastructure, and communications systems”
(Prada & Santaguida, 2007, p. 17).
Innovation — either drawn from other sectors or stimulated within the health
context — is the engine of creativity and change. In the view of Zander and
Zander (2000),
We can open a window on a world where all is sound, our creative powers are
formidable, and unseen threads connect us all. Leadership is a relationship that
brings this possibility to others and to the world, from any chair, in any role. (p. 162)
12
Orient Themselves Strategically

to the Future
L eaders are visionaries: they are always aiming to create a future

that does not yet exist. Consequently, they are constantly scanning
the environment for futuristic trends that will shape future contexts,
to “sniff out the signals in the environment and sense what’s going
on without having anything spelled out for them” (Goffee & Jones, 2000,
p. 66). This personal trait appears, when we look at the examples they
provide, to be a combination of intuition, interpersonal connectivity, and
vigilance—the latter being a fine-tuned receptor always open to shifts in
the field of business that the company is engaged in (Dickson, 2004).
Similarly, systems leaders must employ systemic intelligence gathering aimed Collecting and interpreting
at finding the situations that need to be addressed; in addition, collecting soft data relevant to those
and interpreting soft data relevant to those situations is important for the
company’s continued health and economic survival. Tools and techniques such
situations is important for the
as future searches, SWOT analyses, strategic forums, and large-group scenario company’s continued health
planning are mechanisms to gather intelligence in a strategic fashion and to and economic survival.
engage others while doing so (Holman, Devane, & Cady, 2007). Also, within an
organization, leaders need to know the morale and future orientation of staff.
In this instance, instruments such as 360 assessments, organizational culture
surveys, talent surveys, and employee engagement surveys can be constructed
to produce information that suggests future challenges with staff morale, and
also identify talent to be groomed for the future (Dickson, 2004).
Some of the futuristic trends that leaders have to address in health systems
transformation in Canada were outlined earlier in this paper: e.g., demographic
challenges, sustainability challenges, growing advances in clinical and
biological technologies, environmental sustainability concerns, and steadily
growing public expectations. In this booklet, we do not go into the implications
of those challenges, but we do suggest that if systemic, productive responses
are to be generated that will aid in the creation of Canada’s future health care
system, then understanding the causes that are giving rise to new and different
societal dynamics affecting the health and wellness of Canadians is vital to
effective practice of the LEADS domain of Systems Transformation. Leaders
will be expected to pay attention to emerging trends, and to strategize how to
13
change the approaches to service delivery in response to those trends. They will
have to do so by being aware of not only how the issues impacting the health care
system are interconnected, but also how each part contributes to the whole.
Example 2 highlights some ways that leaders can help transform the health care
system in Canada.
Example 2: Orient Themselves Strategically to the Future
Canadian College of Health Leaders Conference

At a Canadian College of Health Leaders conference of CEOs in 2009, senior leaders spent 2 days examining the futuristic
implications of a number of issues and concerns. These senior health leader participants demonstrated a growing
awareness of a collective vision of where the health system is headed, and the transformational changes in leadership
approach required of them. Participants participated in a dialogue to identify the leadership activities required to
respond to them. In their view, to build the Canadian health care system of the future, senior leaders should do
the following:
• Create a cultural connection with society (the public taxpayer) and focus on the value benefits of good health.
• Stimulate a wholesale attitudinal shift of Canadians toward health through social marketing campaigns.
• Encourage, enable, and empower the acute care system to understand the power of investments in population health.
• Pursue changes in governance and service delivery models so as to sort out the constantly shifting dynamics between
the provinces, the federal government, and regional mechanisms for organizing service delivery.
• Create national, provincial, and local policy frameworks that support innovation.
• Undertake a national activity for the population and government to identify the needs (which should be funded in a
universal health system) versus the wants that continue to grow.
• Accelerate the implementation of technology—e.g., e-health, electronic health records, improved information systems,
and new technologies for diagnosing and treating health conditions.
• Create policy and service delivery models that encourage and enable patient responsibility for own health care,
particularly in primary care and in dealing with multiple chronic disease conditions (particularly as it pertains to care
of the elderly).
• Invest in staff safety and wellness, and in employee accountability and empowerment.
• Invest and support information technology in support of health and work redesign, such as the LEAN initiatives in BC
and Quebec (Dickson, 2009b).
14
Another example relates to how future leaders might respond strategically

to the demographic challenges of the future workforce and health human
resources planning. Barrett and Beeson (2002) observe that “senior leaders
will increasingly need to possess highly refined skills in strategy development,
change leadership, relationship/network management, and the creation of
executive teams” (p. 4). Leaders need to pay attention to not only building Senior leaders will increasingly
teams, but also to building geographically dispersed, diverse, and yet integrated need to possess highly refined
teams. It is likely that future workers will be increasingly diverse in terms of
gender, race, and ethnicity. Thomas (2006) says, “Leaders who recognize that
skills in strategy development,
they must manage representation and diversity will gain a competitive edge change leadership, relationship/
in fully accessing the potential of their associates” (p. 46). He suggests that network management, and the
“what must be kept in mind is that many if not most social justice issues can creation of executive teams.
be conceptualized as challenges in making quality decisions in the midst of
differences, similarities, and tensions” (p. 49). Leaders will need to “emphasize
relationship building/management, influence, communication, and negotiation
… [and] the demographic trends and the skill sets younger workers bring
in a technological age will continue to demand that leaders respond to the
expectations of younger workers” (Barrett & Beeson, 2002, p. 16).
Being strategically oriented to the future requires that leaders articulate a

compelling vision that brings others to a place they have not been before. By
virtue of the fact that the future has yet to be created, it is difficult for many
actors to clearly see what the future will look like, even though they know what
needs to be shifted. Until individuals change the way they see, they will not
change what they see. In this regard, Bennis (1994) suggests that “reflection Until individuals change the
may be the pivotal way we learn” (p. 107), and that it is important to continue
way they see, they will not
“looking back, thinking back, dreaming, journaling, talking it out … asking
for critiques, going on retreats” (p. 107). Leaders face an as-yet-unwritten and change what they see.
uncertain future, and “as we view this new landscape, we must anticipate both
the visible and the unseen” (Tyler, 2006, p. 71); individuals also need to be
comfortable in the ambiguity and potential chaos that unseen landscape creates
(Kaye, 2003). In addition to this reflecting, it is incumbent on leaders not to
simply wait for the system to respond; they must be the change the system
needs in order to change direction.
The theme of the LEADS domain of Lead Self is that leaders who wish to create
change take on the responsibility of being that change. This notion was simply,
yet elegantly, put forward by Barack Obama in his closing speech after Super
Tuesday on February 4, 2008: “We are the people we have been waiting for.” In
this context, the strategies of holding town hall meetings for local dialogues on
health reform; using social marketing and Internet technologies to engage and
assess public support; applying constant and relentless pressure in the media;
15
and giving concrete examples of individuals in need of health care reform, for
example, as models of that need were employed to generate the first action on
true health reform in the US in our lifetime.
This situation, more than any other, shows that true transformation will
engage all, and will require tools, techniques, and approaches to involve all in
the proposed reforms. As Plsek and Wilson (2001) suggest, “The leader’s role
is to create systems that disseminate rich information about better practices, True transformation will
allowing others to adapt those practices in ways that are most meaningful to engage all, and will require
them” (p. 748). Systems Transformation means that leaders not only create such
systems, but also assist in creating the enabling conditions so that others can
tools, techniques, and
adapt and use what is relevant to them and the types of change that they are approaches to involve all in
trying to make in their particular health setting. the proposed reforms.
16
Champion and Orchestrate Change
I t is not good enough just to talk about change, study change, and
write reports on change. Leaders have to act to create change.
Many leaders in health care are arguing that Systems Transformation
Leaders have to act to
create change.
cannot happen unless leadership inaction is converted to leadership

in action, and that the time for deep change is now (W. Tholl,
personal communication, April 25, 2010). To reinforce this viewpoint,
Porter (2009) stated, “We need to act, as indecision is getting us
nowhere fast” (p. 32). It is important to note that the language used
in this capability is, champion and orchestrate change—to “actively
contribute to change processes that improve health service delivery”
(Leaders for Life, 2010, Systems Transformation section, para. 4).
But how do leaders act—or in the terms of the LEADS capability,
champion and orchestrate change?
Actions that leaders should take to create change need to be consistent with Leaders drive change.
the organic systems view that has been brought to the LEADS framework. That is what is expected
Earlier leadership mantras suggested that “leaders drive change. That is what
of real leaders today
is expected of real leaders today” (Senge, 1999, p. 2). However, Senge goes on
to say that this might not be the best language to use in today’s post-industrial
world: “In all types of institutions a disturbing pattern is emerging. Faced with
practical needs for significant change, we opt for the hero-leader rather than
eliciting and developing leadership capacity throughout the organization” (p.
3). As opposed to driving change, Senge instead suggests that leadership be
defined as “the capacity of a human community—people living and working
together—to bring forth new realities” (p. 4). This gives rise to the term
orchestrate in the champion and orchestrate change capability of the LEADS
framework.
Collaboration in leadership,
Collaboration in leadership, including shared resolve and belief, is a crucial including shared resolve and
element in championing and orchestrating change in health (Dickson, 2009b;
Weiner, 2009). The ability of leaders to contribute in these areas will have
belief, is a crucial element in
direct implications for health system improvement. Indeed, it is increasingly championing and orchestrating
understood that the application of the discipline of leadership is the driving change in health.
force needed to provide coherence and integration in organizations and
17
systems through evidence-informed policy formulation, strategic thinking,

and sustainable system-wide change management (Begin, 2009; Lewis, 2007).
Working in large systems requires that leaders develop catalytic, co-creative, or
synergistic approaches to leadership (Joiner, 2010).
Leadership in large
These concepts are a natural extension of what Luis Denis (2002) called complex health systems
collective leadership, which refutes “individualistic and grandiose” perspectives
must come from various
on organizational leadership that dominated the literature for many years (p.
17). In his report to the Romanow Commission, Luis Denis went on to state that agents, when needed, in a
collective leadership must be “distinct, specialized and complementary” (p. 17). complementary rather than
Another way of putting this is that leadership in large complex health systems a competitive fashion.
must come from various agents, when needed, in a complementary rather than
a competitive fashion. While leadership capability still resides in individuals,
those individuals work together to transfer leadership responsibility to the
appropriate agent at the appropriate time. Another term for collaborative
leadership is distributed leadership (Avolio, Walumbwa, & Weber, 2009). The
result is a collective of people who work together to ensure the system operates
as a system.
Once people start to see
Senge (2006) believes the future involves creating learning partnerships systemic patterns and
of larger communities—business, non-government, and government
understand the forces
organizations. He says leaders need to have “a set of deep capacities … systems
intelligence, building partnership across boundaries, and openness of mind, driving a system, they
heart and will.… Two particular systems thinking skills are vital: seeing also start to see where the
patterns of interdependency and seeing into the future” (p. 24). Senge says that system is headed if nothing
“once people start to see systemic patterns and understand the forces driving changes.
a system, they also start to see where the system is headed if nothing changes”
(p. 25). In this world, leaders must be open to not having all the answers.
“There is no ‘right model’ for a complex system” (p. 26). “When placed in
the same system, people, however different, tend to produce similar results”
(Senge, 1999, p. 42). This last quote suggests a need to “look into the underlying
structures which shape individual actions and create the conditions where
types of events become likely” (p. 43).
Numerous studies have profiled examples of where collaborative and

participatory approaches to leadership have changed in health systems. Sharon
King and Larry Peterson (2007a, 2007b, 2007c, 2007d) interviewed 40 senior
leaders who had been successful in transformational change and determined
that leaders who used a systems perspective and adopted participatory methods
to engage stakeholders, public, and professionals were key to success. In one
example, they stated:
18
One leader was tasked with reducing overcrowding in the Emergency Room
and was given three months to achieve results. From the beginning the
leader reframed the project away from being an emergency room problem.
She began by engaging a large group of participants, including physicians,
occupational and physical therapists, Community Access Care Centres,
long term care facilities, and staff from all the medical areas of the hospital.
There were over 50 people on the team. … The result was a 70% decrease
in the number of patients waiting in the emergency room for beds. (King &
Peterson, 2007a, p. 54)
It should be noted that the process that the 50-person overarching team
with the vision for change used a SWOT analysis (Strengths, Weaknesses,
Opportunities, and Threats), and developed nine inter-professional and
inter-disciplinary work teams (which reinforces the LEADS Engage Others
capability of build teams). They also involved a significant number of affected
stakeholders in order to redress the issue (which emphasizes another domain
of LEADS, Develop Coalitions) (King & Peterson, 2007a).
Championing and
Championing and orchestrating change also requires active participation, not orchestrating change
just of health providers, but also of citizens, communities, patients, and families also requires active
(Gilson, 2007; McGrath et al., 2008). “If the customer is not the architect of the
participation, not just of
transformation, a company may find that it has reinvented itself but has done
little or nothing to improve the customer’s lot” (Martinez, 1995, p. 166). In health providers, but also
health, a customer focus suggests that leaders need to find ways to transform of citizens, communities,
the health system to focus on patient-centred care. One of the primary issues patients, and families.
facing leaders in so doing is to understand the true implications of such a
shift in focus. Does it mean, for example, as found in Sweden (a country often
profiled as an exemplar of health service delivery in the Western world), that
the system should embrace competition? Build electronic medical records
and other electronic communication features that allow the patient to choose
physicians, hospitals, and treatments over the Internet? Establish standards and
measures of meeting the patient’s needs in a timely fashion? Championing the
patient’s interests as more important than any individual provider’s interest, as
the union leader of the nurses’ union in Sweden has done? All of these features
characterize changes currently happening in the Swedish health care system
(Dickson, 2009a).
The vision for care in Sweden is the patient at the centre of care. Multiple
examples of the power of the patient-first vision were observed during the
visit to Sweden of one of the authors of this booklet, as part of the Canadian
College of Health Leaders Study Tour in 2009. As part of the tour the author
19
heard the vision expressed by union leader Karin Ann Eklund, who stated that
the primary function of her role was to ask her union to adapt the patient-first
principle; and by politician Jonas Andersson, who stated that a major goal in
his jurisdiction is to empower patients.
Example 3: Champion and Orchestrate Change
Southern Stockholm Hospital, Sweden

Another example of patient-focused change comes from Southern Stockholm Hospital. The hospital has implemented
a number of innovations in its emergency ward aimed at improving patients’ experience, such as:
• A new triage system based on two components: vital signs and patient history. This system allows a better
determination to be made of the severity of the patient’s presenting conditions.
• All guidelines, schedules, and free beds are posted on an intranet; all patient records are also computerized.
• The Emergency Department has trainee doctors and specialists on staff, ensuring a strong complement of
physicians and physicians in training 24/7.
Sweden is also using IT, first, to give patients access and self-management tools
that permit them to personalize the system, and second, to adopt and measure
standards for patient service (e.g., the care guarantee at Olskroken Primary
Care Centre that 100% of calls will be answered on the day they are received).
Also, the national registry of quality indicators contains a number of measures
consistent with a patient-first vision (Dickson, 2009a).
Championing change is
Championing change is also about creating a sense of urgency or compelling also about creating a sense
need to change (Connor, 2006; Kotter, 1995). This is one of the reasons of urgency or compelling
for governments initiating royal commissions in provincial and national
contexts, and is why royal commissions and the most recent British Columbia
need to change.
Conversation on Health are initiated to signal Systems Transformation (Ward,
2007). They reflect recommendations to endorse both bottom-up and top-down
strategies to engage care providers, the general public, administrators, and local
communities—all groups in a true health system—in system-wide change.
However, it should be pointed out that most of the efforts described above are
efforts to gather intelligence from the public about what changes are necessary
and acceptable to them. Championing and orchestrating change also require
active participation of the public, patients, and citizens in the implementation
of those changes. Indeed, this is often where execution of major systems change
goes awry. Jacobs (2004), who states that “the views of doctors, nurses, the
public and patients are all important in influencing improvement initiatives in
20
health” (p. 148), describes such approaches as Soft Systems Methodologies and

profiles how stakeholders, managers, and customers were involved in reshaping
health service delivery in the United Kingdom. This is not a new concept.
For example, Kotter (1995) cautions, “Just getting a transformation program
started requires the aggressive cooperation of many individuals. Without
motivation, people won’t help and the effort goes nowhere” (p. 60). While
leaders are expected to champion and orchestrate change, it is only through
the relationships they generate with others that real and sustainable Systems
Transformation can actually occur. The challenge is to understand the tools,
techniques, and approaches that leaders can use to generate true cooperation.
Finally, there is a need to actively identify and engage all pertinent actors It is important to acknowledge
early in the conceptualization and framing of the issues related to change,
and address both power
and engage them in collaborative planning and implementation, to increase
the likelihood of success. In keeping with this approach to change, it is also and control issues, as such
important to acknowledge and address both power and control issues, as approaches suggest sharing
such approaches suggest sharing power and generating collaborative action. power and generating
These issues of power are well documented (see, for example, Chambers, 1997;
collaborative action.
Cornwall & Jewkes, 1995; Greenwood & Levin, 1998; Nelson & Wright, 1995;
Rocheleau & Slocum, 1995). In the context of transcending and connecting
otherwise entrenched hierarchies in the health system, there is a need to
address these issues (Luis Denis 2002; Martin, 1996; Meyer, 2009). In change
initiatives, it is entirely feasible in a collaborative milieu that the different actors
and organizations hold divergent aims; thus, acknowledging the transition
from independent power and control to interdependent power and control
is essential. Many of the authors referenced in this paragraph describe the
power in relationship dynamic as consisting of three forms: power over the
relationship, power to help the relationship, and power for transferring power
to others in the relationship. Similarly, an article by King and Peterson (2007b)
suggest that successful leaders were able to command and let go of control at The need to explicitly
the same time. Power concepts are integral to Systems Transformation: the acknowledge the role of
need to explicitly acknowledge the role of power and to work out the power- power and to work out
sharing needs required to facilitate overall systems change. Without attention the power-sharing needs
to power in the context of developing relationships between, say, the public,
professional associations, health authorities, and decision-makers who are
required to facilitate overall
collaborating around change and transformation initiatives, the prospect of systems change.
success diminishes considerably (see Example 4).
21
Example 4: Champion and Orchestrate Change
College of Physicians & Surgeons of Alberta

In November 2009, the College of Physicians & Surgeons of Alberta (CPSA) decided to develop a 10-year strategic
directions exercise aimed at laying the vision, mandate, and purposes of the CPSA within the context of the constantly
fluctuating Alberta health system. Recent actions by the government to adjust legislation re governance of professions,
controversy related to infection outbreaks in some regional hospitals, and the amalgamation of nine health regions
into a single Alberta Health Services had created a climate of turbulence and uncertainly in which CPSA saw a need to
establish direction. To achieve this, the college is using a three-step approach that involves its members, its stakeholders,
and the public, not just in providing input into the direction, but also in validating and supporting it through a series of
interactive methods to gain their support, such as public dialogues and planning sessions. The three approaches are:
• Environment scan (gathering views of stakeholders, Council and staff)

• Direction Setting (establishing a vision and strategic priorities for the ten years)
• Validation (ascertaining, through public dialogue, that the directions are sound)
(Trevor Theman, Registrar, personal communication, May 22, 2010).
22
Strategies and Tactics to

Implement Change
T o orchestrate change, the leader needs to embrace a plethora

of potential approaches (strategies and tactics) that maintain
momentum once change has been initiated (King & Peterson, 2007a).
The literature suggests that a number of challenges must be met
to keep the change evolving as the leader intends. Many of these
challenges are common to a range of sectors undergoing change:
for example, how to create or respond to urgency (Connor, 2006;
Kotter, 1995); generate resources to support change (Cummings
& McLennan, 2005); ensure staff have the appropriate knowledge
and skills to implement change (Brunton & Matheny, 2009); create
cultural momentum to support change by overcoming cultural inertia
and building on supportive attributes of culture (Austin & Claassen,
2008); and, maintain focus for the duration of change (i.e., coping
with political interference, shifting priorities, and personal transitions
during change) (Dickson et al, 2007; Gioia & Dziadosz, 2008).
However, three particular challenges stand out for leaders attempting to

orchestrate change in health systems:
• Facilitating change across professional cultures

• Creating capacity and assessing readiness for change
• Engaging physicians.
23
Facilitating Change across

Professional Cultures
A common theme in change literature is the challenge of

integrating desired technical (administrative or clinical) changes,
at whatever level of scope, into the customs, traditions, and actions
of individuals engaged in creating the change. Austin and Claassen
(2008) conducted a modified systematic review of the literature
relevant to organizational change and culture. They defined culture as
having three distinct components: at the core are basic assumptions
or mental models that people bring to the practice of their work;
surrounding those are the values and beliefs individuals think “ought
to be” (p. 342) part of their work; and, on the outer ring are artifacts—
stories, symbols, customary practices, traditions—that reflect the
other components of culture in practice. Leaders are reminded that
these notions are equally applicable to citizens, patients, and clients
of a health system, as citizens, patients and clients are responsible for
self-managing their own health in that system, and therefore have a
role to play in change.
Any form of change requires a shift of behavior. Individuals therefore would Any form of change
benefit by being led through an awareness of what the impact of that change requires a shift of
will be on their existing culture: that is, the customs, traditions and precedents
behavior.
they bring to the carrying out of their work. Sometimes these individuals
perceive these changes as negative, in that it requires an individual to shift
from a preferred way of operating to a new way of operating that requires
additional effort, possible training, and shifts in day-to-day practice. This shift
sometimes leads to feelings of low self-esteem, experience of loss, and threats
to professional capacity (Austin & Claassen, 2008; Bridges, 2010). Bridges
draws the important distinction between change and transition, seeing change
as situational and transition as psychological. Transition, on the other hand,
is a three-phase psychological reorientation process that people go through
when they are coming to terms with change (i.e., ending, neutral zone, and
new beginnings). Transition can sometimes be perceived as change resistance;
whereas, in fact, it is a natural response to the requirement to change, caused
24
by a psychological sense of loss and grieving. Such resistance is absolutely

normal, and the leader can minimize its negative impacts on those involved
in the change by building readiness (Austin & Claassen, 2008) and, of course,
acknowledging the inevitability of the transition process. Monitoring resistance
is also a valuable intelligence gathering exercise in strategic leadership. As one
senior leader stated,
I use resistance as a barometer as to the organization’s uptake of the change,

rather than be perceived as a problem to be fixed. The key is to recognize that
monitoring resistance requires communication that is listening, constant,
forthright and respectful. (D. Briscoe, personal communication, March 31,
2010)
Professionals tend to resist

Achieving a cultural fit between the behavioural changes of a proposed change, change, operating instead on
be it an innovation or a transformation, is more challenging in health because
of the many professional groups involved. “Professionals tend to resist change, the premises of internalized
operating instead on the premises of internalized norms and care strategies, norms and care strategies,
developed through professional socialization, training, experience, peer developed through professional
culture and organizational structures” (McWilliam & Ward-Griffin, 2006, socialization, training,
p. 130). Required to meet standards set by their independent self-regulatory
colleges, working within a well-defined scope of practice, and encouraged
experience, peer culture and
to retain significant independence of craft, professionals of the same stripe organizational structures.
working together can easily be reluctant to practise in light of changes initiated
outside their purview of work. Yet, “the adoption of reform-driven changes
substantially affected the way healthcare professionals were required to work”
(Brunton & Matheny, 2009, p. 603) in a major health reform in New Zealand. It
should be noted that this study also demonstrated that the reform changed how
patients went about their work as well. After studying the change dynamics
for a year, Brunton and Matheny concluded that different professional groups
create “divergent acceptance”: that is, “when two or more constituent groups
accept change objectives but differ in their interpretation of change-related
stimuli and enactment of change” (p. 611). One can imagine what happens if
they also do not accept the change objectives!
Brunton and Methany (2009) went on to say that, in these situations, leaders
need to raise consciousness of the change (the communication factor described
earlier), surface and address latent conflict between professional groups or
sub-cultures, and employ methods to connect individuals involved in the
change across professional boundaries. Communicating across boundaries
suggests that strategic leaders need to tailor their approaches to different
groups and stakeholders (Cummings & McLennan, 2005). It is also valuable to
25
recognize that the “use of evidence-based thinking supports the engagement

of key stakeholders … to orchestrate effective change” (Cummings &
McLennan, 2005, p. 61). Other tools that leaders can use are action research
(Chiarella, 2007); soft systems methods (Jacobs, 2004); dialogue (Stacey, 2010);
cooperative conflict (Comber, 2010); inter-profession work teams (Chiarella,
2007; Gil, Rico, Alcover, & Barrasa, 2005); and numerous tools and techniques
described in The Change Handbook: The Definitive Resource on Today’s
Best Methods for Engaging Whole Systems (Holman et al., 2007). These tools
are indispensable to the leader attempting to orchestrate change.
The leader must take care
For a specific example of some of these strategies and tactics in action, Ford to determine which tool
(2009) compares sets of leadership behaviours consistent with engaging and which approach are
professionals through an approach he calls complexity leadership, with previous
approaches used by a more traditional command-and-control leader (p. most appropriate to the
107). The leader must, however, take care to determine which tool and which context of the change and
approach are most appropriate to the context of the change and the scope and the scope and breadth of
breadth of the change. the change.
26
Creating Capacity and Assessing

Readiness for Change
I n orchestrating change, the leader must be conscious of

the individual, group, organization, or system’s capacity
to understand and implement the change. Change requires
investments of time to make sense of the change and to learn new
skills; it also requires funds to ensure new materials or products are
available and to pay for training, and a psychological willingness
and ability of the individuals affected by the change to support it.
Given that most health professionals are very busy, discretionary
funds are scarce, and management often has huge spans of control
(Coumont, 2008; Startup, 2008), capacity for change is an issue
that needs to be determined as part of leaders’ needs to “orient
themselves strategically to the future” (Leaders for Life, 2010,
Systems Transformation section, para. 3), a Systems Transformation
capability already discussed in this booklet.
For change to be orchestrated, it is also wise for the leader to assess It is important to examine
readiness to change: “It is important to examine the readiness for change the readiness for change
within the organization from the individual as well as the organizational
perspective” (Austin & Claassen, 2008, p. 334). Elements of readiness include
within the organization from
the compelling rationale for change; levels of individual readiness (e.g., the individual as well as the
psychological resiliency, self-motivation, adaptability); source accessibility; and organizational perspective.
organizational or system features such as access to professional development,
culture (e.g., supportive of innovation, autonomy to act), time available, and
political will (adapted from Austin & Claassen, 2008). Austin and Claassen also
give examples of how to go about assessing change readiness in a change context.
To address both capacity and readiness issues, it is wise for the leader to assess
the state of being of his/her change context prior to committing to change, and to
keep in mind potential differences among professional and sub-groups.
27
Engaging Physicians More in

P hysicians are the key to any future renewal of the health sector
in Canada. However, whereas physicians are actively engaged in
delivering clinical practice, they are less engaged in leading health
Physicians are the key to
any future renewal of the
health sector in Canada.
reform. Consequently, the Canadian Medical Association (2010) has
stated that engaging physicians in transformation is a priority for
the CMA in the next few years. The CMA itself wishes to raise the
engagement quotient for physicians. And for leaders who are not
physicians, relationships with physicians is highly important. “Ask
hospital chief executive officers (CEOs) about the top 10 challenges in
health care facing them today and on the list, usually in the top 5, will
be at least 1 mention of relationships with physicians” (Guthrie, 2005,
p. 235). In Canada, where physicians have a different relationship
with health organizations, primarily as independent business people
and consultants, the challenge of encouraging and actively keeping
physicians involved in significant health system change, at micro,
meso, macro or mega levels, requires a unique leadership approach.
Models and approaches that work in the UK, for example, and
in the US do not necessarily apply to the special context of Canada
(M. Wales, MD, personal communication, May 5, 2010).
Guthrie (2005) suggests that leaders of change need to “encourage a culture Encourage a culture in
in which staff and physicians consciously agree” (p. 236) on the priority of which staff and physicians
patient safety and improvement; regularly communicate in forms that are
“carefully crafted in the language of physicians’ needs and aspirations” (p. 236); consciously agree.
establish organizational goals; set target measurements of the desired changes;
and appeal to the staff and physicians’ competitive instincts (p. 236). These
statements suggest the importance of the Achieve Results domain of the LEADS
framework, and also the Engage Others domain as key to effective orchestration
of systems change.
28
In a recent Canadian study by the Centre for Health Leadership and Research at
Royal Roads University in partnership with the Canadian Medical Association
(Snell and Briscoe, 2010), researchers interviewed physicians to determine their
experience of engagement. The recommendations for health leaders who wish
to facilitate physician engagement in transformation included the following:
• Formally recognizing the role of physician leaders

• Sponsoring and funding leadership learning opportunities
• Implementing recognition programs for physician participation
• Providing remuneration for time spent on leadership activities
• Developing meaningful roles for physician leaders within the health
care system
• Developing networking and mentoring strategies
• Addressing the issue of compensation and incentives for leadership activities.
For physician engagement to
Similarly, for physician engagement to occur, physicians need to show up when occur, physicians need to show
invited to attend meetings and other events, and to volunteer for projects. They
up when invited to attend
also need to recognize others’ contributions, be a team player, listen carefully,
and participate in leadership programs (Snell & Briscoe, 2010). Snell also goes meetings and other events,
on to say that for engagement to happen in a systems context, medical schools and to volunteer for projects.
must provide a more holistic education for physicians, an education in which
collaborative leadership skills are fostered.
To this point, we have discussed the capability of championing and

orchestrating change, the role of understanding change dynamics at a personal
and most often at a strategic level, the issues facing a leader who chooses to
transform systems, and the tools and approaches to creating relationships
that facilitate change. It is important to mention one other key approach to
championing and orchestrating change: the use of descriptive and outcome
measures related to an individual’s or a population’s health as the compass by
which change is monitored, adjusted, and adapted. This issue is addressed in
detail in the booklet on Achieve Results, but we note here that well-defined,
context-specific, accurate, and reliable measures of the envisioned change outcomes
are key to maintaining change momentum. Sher (2010), for example, states that the
Kaplan-Norton Balanced Scorecard was an invaluable tool in guiding the Canadian
Blood Services change process over the past 10 years. In Sweden, massive efforts
to design information systems derived from accessing electronic patient records so
that care providers can monitor the needs of catchment area populations and allow
for targeted responses by Primary Care Centres and hospitals have been successful
in germinating change (Dickson, 2009a).
29
This concept is also at the core of quality improvement efforts in micro-systems,

and is now being expanded to larger contexts (Impact BC, 2010). For example,
efforts at broad clinical practice redesign in BC have been based on the use of a
sophisticated data set that profiles population health needs and that documents
the time providers spend on the various care provision activities. Using this
data, practitioners and their leaders then determine the changes needed to
improve care delivery so that it is more responsive to the care needs of patients. One of the most powerful
(Lynn Stevenson, personal communication, May 5, 2010). One of the most tools that a leader can
powerful tools that a leader can use to stimulate and guide change is good
use to stimulate and
information, but information that is consistent with the change context and
appropriate to the actors in the change process. guide change is good
information.
30
Conclusion
T he LEADS in a Caring Environment leadership capabilities

framework identifies four sets of process capabilities and one
set of outcome capabilities that together comprise a model to guide
change. By using this model to structure and focus their influence,
health leaders can help to bring about changes that will achieve
meaningful and long-lasting improvements in Canada’s health system.
This booklet has outlined the fifth capability domain: Systems Transformation.
This domain is more important now and for the future, because more As leaders, we need to
sophisticated modes of leadership are required to address the many challenges
improve how we lead
in the large, complex health systems that are becoming the norm. As leaders, we
need to improve how we lead change in the context of Systems Transformation. change in the context of
We need to better understand how we perceive change and what change actually Systems Transformation.
means in the context of leadership. New health leadership capabilities are
required to move from using traditional management approaches, to creating
enabling conditions for this leadership. This booklet has outlined the four
capabilities in Systems Transformation and their basis in the literature.
Unless we truly re-examine and alter our habitual ways of thinking, we are Unless we truly re-examine
doomed to repeat the approaches and methods used in the past with exactly and alter our habitual ways
the same results. The health system needs to be re-conceptualized by leaders
of thinking, we are doomed
through a new lens: the lens of complex systems. Attempts to transform
the system need to be made in ways that acknowledge and respect systems to repeat the approaches and
characteristics. Otherwise, our efforts will continue to naively contribute to the methods used in the past with
vast number of well-intentioned, but poorly understood, hastily implemented, exactly the same results.
and rarely evaluated system changes that collectively have unsurprisingly
brought us to examining what leadership really means in the context of
Systems Transformation.
31
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BRANCHES OF KNOWLEDGE: COMPREHENSIVE ARTICLES ON LEADERSHIP

Stronger leadership is essential to improving the performance of our

The LEADS in a Caring Environment leadership capabilities framework provides a customized

The framework builds on the seminal work undertaken on behalf of the

The LEADS in a Caring Environment leadership capabilities framework has both

Face validity refers to its strength in accurately representing the real-world

Other important recent developments in terms of adoption of the LEADS

• Accreditation Canada’s standards for leadership and governance are informed by

• HealthcareCAN (HCC), the Mental Health Commission of Canada, and the

The LEADS in a Caring Environment leadership capabilities framework provides

We are committed to continue to work together as a team to build a better future of

Alain Doucet, President & CEO, Canadian College of Health Leaders

Canadian College of Health Leaders (www.cchl-ccls.ca)

Foreword revised: March 2019

T his booklet, devoted to the LEADS in a Caring Environment

Caring (why) Doing (how)

Figure 1: The Three Components of Effective Health Leadership

Similarly, the five domains of the framework can be seen as a regimen, or

Lead Change Dynamics Systems

Figure 2: The LEADS in a Caring Environment leadership capabilities Framework

Achieve Results is at the pinnacle of the hierarchy of leadership capabilities

Graham Dickson, Professor Emeritus, Royal Roads University

1 LEADS in a Caring Environment leadership capabilities framework –

T his report examines and reviews the literature supporting the

Emotional intelligence is one of the core concepts that underlie all

T he Self Aware capability refers to the awareness of one’s own

Emotional self-awareness refers to the ability to recognize one’s own emotions

Awareness of perceptions and assumptions is a key aspect of developing self-

T he Manages Self capability refers to taking responsibility for one’s

Emotional management refers to the ability to regulate both the expression

Life balance is closely linked with emotional intelligence. High resiliency is

T he Develops Self capability refers to actively seeking opportunities

Developing soft skills becomes increasingly important as leaders develop in

T he Demonstrates Character capability refers to the modeling

The Four Capabilities of the

Lead Self’s four sub-domains:

Lead Self Capabilities Capability Description

Actively seeks opportunities and challenges for personal learning, character

The underlying premise of the LEADS framework is that leadership needs

Both cognitive and behavioural strategies are critical components of emotional

of intelligence. Whereas intelligence is classically defined in terms of

Table 2: Main Descriptors for Each Component of the Self-Aware Capability

Being able to manage various emotions and moods without denying or

Self-motivation Being able to remain positive & optimistic

A leader must know what it is that he or she is doing, or has been

The following elements of Self-Aware will be further elaborated in the sections

Self-Aware – Awareness of Emotions

R ecent research demonstrates that an essential element of self-

Daniel Goleman and colleagues (2002) define emotional self-awareness as the

Barb Stoddard, Director of Medical Administration

A key aspect of developing self-awareness is the ability to

Monica Olsen, Health Care Leadership Consultant

Self-Aware – Awareness of Values

Stephen Harris, Former Health Care Communications Consultant

F rom self-awarenessunderstanding one’s emotions, assumptions

Manages Self – Emotional Management

Daniel Goleman and colleagues (2002) have identified several leadership

Monica Olsen, Health Care Leadership Consultant

Manages Self – Personal Mastery

Develops Self– Life-Long Learning

Demonstrates Character– Emotional Resiliency