An Overview of Leadership Principles and Theories

Throughout my 10+ years of experience in both business and healthcare, I have personally moved from roles that fit the more traditional definition of a follower, to that of a manager, and more recently to that of a leader. As I have progressed to my current level of the organization, I have also witnessed, and been a participant in, areas with both effective and ineffective managers and leaders that have tremendous amounts of followers or some leaders that have no true followers.

Over the course of this chapter we will cover a high-level definition a leadership, the differences between leadership and management, why leadership has become a dynamic factor in healthcare systems, and different leadership principles and theories. These topics will also be further enhanced with personal reflections of my decade worth of experience in both business and healthcare.

What is Leadership?
There are thousands of specific ways to define leadership but most follow a definition similar to that of how Bruce E. Winston and Kathleen Patterson of Regent University define (in part) leadership: “A leader is one or more people who selects, equips, trains, and influences one or more follower(s) who have diverse gifts, abilities, and skills and focuses the follower(s) to the organization’s mission and objectives causing the follower(s) to willingly and enthusiastically expend spiritual, emotional, and physical energy in a concerted coordinated effort to achieve the organizational mission and objectives. The leader achieves this influence by humbly conveying a prophetic vision of the future in clear terms that resonates with the follower(s) beliefs and values in such a way that the follower(s) can understand and interpret the future into present-time action steps…” (Winston & Patterson, 2017).

This definition encompasses all the aspects that I personally feel an individual need to do/have to be considered a leader. Not until recently did I think of myself as a leader. This epiphany did not occur until I understood how my thoughts on the future of my organization were being perceived by others. For example, my organization was very price focused and believed that the only way to compete in a mature sector was to continue to lower price; my thought (developed through my MBA coursework) was that we should build a strategy to best serve our customers so they continue to buy our product. I, at the time, was pushing for the option to say “no” and the realization that we (the organization) cannot satisfy everyone; we need to build a strategy where we satisfy several customers and are comfortable giving away margin to our competitors. This thought process is now being implemented (since I have developed consensus and a large follower base), and we are see sustainable growth in markets we once did not.

How to Differentiate Leadership from Management
The terms leadership and management are often used interchangeably. This regularly leads to a belief that leadership and management cover the same aspects which cannot be further from the truth. Leadership is a more elusive concept than management. In leadership the key concepts are about influencing and knowing how to appropriately incentivize someone. This is not to be confused with management which is more transactional and concentrated on efficiencies than effectiveness. Also, management is about control; it is about having checks and balances in place to properly measure success, while leadership is about the people and relationships and how best to utilize them to reach a common goal. Leaders are concentrated on “innovation” where new ideas are brought to the forefront and treated as a highly valued skill derived from a creativity aspect (Bennis and Nanus, 1997).

These differences between leadership and management can be further described in the way managers and leaders see the future. Managers see the future as a bottom line, in other words as a short-term financial goal. Leaders see the horizon, they see the aspirational goal of moving the organization in a certain direction that will lead to a long standing competitive advantage. Finally, these aspirational goals that move the organization are not truly effective without the accumulation of followers (and their engagement). Having these organic followers is another key distinction between manager and followers. Alberto Silva of Keiser University recently defined this organic follower aspect of leadership the following way, “Leadership is the process of interactive influence that occurs when, in a given context, some people accept someone as their leader to achieve common goals.”

I have personally been confused about the differences between leaders and managers and, until recently, used them interchangeably. I also considered managers to be lesser than leaders and considered the evolution of an individual to be at an end state of a leader with the manager state being necessary but quick, as the final goal was to be a leader. Through my research, I have learned that not only are managers and leaders two different things, but being an effective manager can be very rewarding and necessary for certain instances. For example, in my previous role, I was a manager of operations which required constant feedback from my direct hires and metrics to be established to understand if we were hitting the benchmarks we had determined. My operations role involved thousands of transactions and several audit checks to make sure our efficiency was accurate. This type of work could only be done by a manager that can assess quickly, think short-term and always consider efficiencies/effectiveness as a cost reduction measure. A leader in this type of role might lose track of the daily transactions and be fatigued by the rigidness and certainty of each day’s deliverables.

Why Leadership Has Become a Dynamic Factor in Healthcare Systems?
As healthcare has changed drastically over the past 20 years, the correlations and similarities between business and healthcare have only increased. One such area that is similar in both business and healthcare systems is the satisfaction of the consumer or patient. In business the satisfaction of the consumer leads to a relationship of continual purchases and loyalty, in healthcare, satisfaction of the patient leads to referrals of other patients, additional medical services and more effective community outreach.

As businesses constantly aspire to achieve sustainable competitive advantage, so do healthcare systems and public health institutions. While it might be hard to ascertain, it is in the best interest of healthcare systems or public health institutions to implement strategies that will foster an edge against other systems, or in public health institutions, a better network to facilitate protocols and community outreach.

One such way that healthcare systems and public health institutions can create an edge is through differentiation. This is very similar to the strategy first devised from Michael Porter. This strategy, created in business, says that for sustainable growth, an organization must either work to be a cost leader or differentiate themselves from their competition (Tanwar, 2013). While cost leadership might not be a tool at the disposal of healthcare systems, differentiation is. Most healthcare systems have started to find that their best chance at differentiation is through their people and the leadership they implement. In fact, Dr. Mark Britnell of KPMG recently wrote “that a typical (healthcare) organization can become around 15 percent more efficient purely through operational, administrative and workforce improvements.” Scaled up to a global level, this suggests that the prize of better managed healthcare services may be in the order of one trillion dollars (Britnell, 2016).

While my experience in healthcare systems and public health institutions is relatively limited, my current employer has several longstanding contracts with these types of organizations. These longstanding contracts have afforded me the opportunity to collaborate with several leaders of local healthcare systems and public health institutions. As I have been in my role for six years, I have witnessed the healthcare landscape change and profit margins become a more and more important metric. While discussing the business models of these leaders, I learned that to be different in a crowded segment, you have find your niche and run with it (which is very similar to what my business organization does). As David Blom, CEO of Ohiohealth mentioned in an interview from 2016, their advantage is leadership. Below is an excerpt from that interview:

Q: If you could teleport back in time and counsel yourself, what lessons from now would you impart?

Blom: If there’s one thing I wish I had learned earlier in my career, its leadership. I never had a leadership course in high school, college, or even in graduate school. Had I understood leadership more clearly earlier in my career, I could have avoided a lot of mistakes.

Q: Speaking of leadership, you talk about focusing on “hands, heads, and hearts.” Can you explain that philosophy?

Blom: First I consider, do I have the hands to do the job? You’ve got to recruit the right people, those who have the values, competence, and character you want. As far as heads, we do a lot of work to explain what we’re doing and why. There are no strategic secrets in the organization. Then you also need to light people up, and you do that with their hearts.
If you get all three of those things, it’s something really special.

Different Leadership Principles and Theories
Healthcare systems are made up of numerous professional groups and departments with competing goals and constraints that often lead to inefficiencies when it comes to obtaining goals and an overall strategy. This is where leadership comes into play. Through leadership, the organization can utilities the diversity of the organization and efficiently work to properly manage processes and teams to maintain a common organizational goal.

As mentioned previously, over the course of my 10 years of experience, I have witnessed and partaken in several leadership principles here is a curated list of the leadership types I view as most effective:

Servant Leadership
Servant leadership is the theory that suggests that in order to lead, one must first be a servant. A servant leader knows that through emotional intelligence there is a better chance of encouraging passion in others. Servant leaders exhibit immense amounts of care for others, have the ability to set good examples for others to follow, provide a standard set of ethics that are never put into question and hold an immense drive to support others.

The core values that makes servant leadership such a great fit for healthcare systems are as follows (Montgomery, 2016):

1. Prioritize Service: Servant leaders strive to serve the most vulnerable first. Much like that of a triage nurse that determines those that need immediate attention, servant leaders will look to prioritize resources towards those issues that need the greatest need first.
2. Share Power: By nature, servant leaders want their followers to assume leadership responsibilities when appropriate. With servant leaders, decision making is shared and each individual feel like they have a voice that is treated equally.
3. Demonstrate Care: In this core value, the leader strives to show empathetic interest. Of course, having empathy is especially crucial in the healthcare industry.
4. Develop Others: A servant leader really measures success by developing others. Through empowerment, the follower often stakes on more ownership and provides additional activities and outcomes.
5. Eschew Wealth: Servant leaders will work for the greater good, not for an accumulation of money. Their aspirations are about principles and not about what the job market dictates.
6. Build Trust: Much like the other theories to come, trust is a vital part of those that are of a servant leadership mindset. Without trust, followers will not stay continually engaged.
7. Create a Safe Space: A servant leader also has the core value that the workplace should be safe, where measurable mistakes can occur and individuals will feel like they need to hide an issue.

A current co-worker of mine is the quintessential Servant Leader. Her team of direct and indirect reports realize that she “cares” and that she wants every one of her individuals to succeed. She works by always being available for questions, prides herself not by hitting certain metrics, but by, how safe her followers feel in making mistakes and learning from them. She also knows her job is never done in mentoring those of her group who have moved onto other roles. Several of my direct reports have come from her team, and she makes a point to check in to make sure they know that she is always available to help (even if she is not their direct supervisor).

Transformational Leadership
While transactional leadership is more in alignment with manager styles of measuring supervision and process, transformational leadership theory emphasizes that people work more effectively if they believe in the mission of the organization. Transformational theory requires leaders to communicate the vision in a meaningful way that not only creates motivation but also a sense of empowerment in the follower. Typically, transformational leadership is a byproduct of a healthy relationship between the leader and the follower. The core factors of a healthy relationship follow these four elements: trust, mutual respect, support and communication (Manion, 2011).

1. Trust: In this element, the leader must learn and implement the virtues of trust. This means that not only is the follower trusting the leader, but the leader trusts the follower. As the relationship grows and each participant understands that they can be a trustor and a trustee at times, the relationship creates a bond that allows calculated risk and reward to occur (Green, 2012).

2. Mutual Respect: This element covers the power of humbleness. When a leader and follower relationship incorporate mutual respect, the follower feels no recourse for communicating adverse news, incentivize learning on both sides of the relationship, and finally implement the need for discipline as a mechanism for producing leadership, either in a transformational state or shared leadership state.

3. Support: As described in the article How Team Leaders Show Support–or Not, support as an element can only be created if the follower feels that the leader is exhibiting the following four types of effective behavior: 1) Reviewing the work effectively by giving proper actionable feedback that is timely. 2) Providing support through reducing stress, socializing, articulating personal information and offsetting a follower’s negative outlook. 3) Recognizing great work through public and private means. 4) Creating an environment where a leader can consult their follower on the creation of new ideas and issue resolution (Lagace, 2004).

4. Communication: This core element means the leader must communicate the message or strategy that connects with the follower. As Bill Black, the CEO of Maritime life said, “a leader must communicate, communicate and then communicate some more.” Communication, by definition, supplies the messaging but communication can also play a role in being transparent to help garner a healthy relationship between the leader and the follower. This communication can take many shapes both formally (via meetings/emails) or informally (via quick chats or walking meetings), and an effective leader will use both interchangeably (Beslin, 2004).

With these core elements in place, I have personally watched transformational leaders change their approach to their respective followers to be more of colleagues that can provide guidance and reliability on issues that the leaders might not know.

One example comes to mind of a transformational leader. About five years ago, I worked with a transformational leader that oversaw the health information systems department for a large pharmaceutical distribution company. He noticed that the company was relying on data more and more and needed to put in place an effective tool that could grow with the company. He envisioned a switch in how the company cared for and stored and utilized their data to make important financial decisions. His vision of data interpretation is still being implemented and followed by his followers to this day, even though he has moved on to a new company and his original blueprint is five years old.

How is Transformational Leadership Reflective in the Healthcare Setting?
One study provided the following outputs on a review of transformational leadership in a healthcare setting. The focus on transformational (and transactional) leadership was also identified in a systematic review performed by Gilmartin and D’Aunno (2007), examining health care leadership research from 1989 to 2005. They concluded that studies in health care provide strong support for transformational leadership theory and identified links with staff satisfaction, unit or team performance, organizational climate and turnover intentions. They suggest these effects are stronger when assessed among more junior than senior staff (West, 2015).

Collaboration/Meta Leadership Theory
Collaborative/Meta leadership involves communicating information to coworkers and associated organizations to allow them to make their own informed decisions. This approach creates strategies that enhance dialogue between multiple stakeholders, the sharing of knowledge and experience and the overall simplification of the healthcare organization structure. Of course, levels of responsibility will prevail and need to be engaged with this leadership process, but the overall engagement at every level will lead to quicker adaptiveness and agility with the ever-changing demands of the healthcare organization. This meta leadership requires a work environment in which varying levels of the organization are encouraged to work collaboratively toward the implementation of effective practices with the patient in mind. Through this collaboration diverse thought, each stakeholder will be in lockstep with the shared vision and goals and work to build synergies through motivation.

The Five Elements of Collaborative/Meta Leadership
According to a recent Harvard study there are five main elements of Meta Leadership (Marcus, 2009):

1. The person behind the leadership. This means that the leader of the group needs to have a good understanding of their impact and a high emotional intelligence so they can effectively collaborate with others at different levels within the organization.
2. Understanding the issue at hand. This element is reflective in the sense of identifying the issue at hand, the amount of evidence available to understand the issue and how to navigate the different needs/wants of different levels of the organization.
3. Leading your core followers. This element discusses the necessity of having a core competency of certain skills within the organization. Through a trusted group of followers (typically in this case the main department the leader oversees), the meta leader can have consensus built and leverage that when rolling out larger solutions with other groups not under the direct leadership of the meta leader.
4. Leading up. This element discusses the impact of “managing up” and not letting hierarchical rank be a deterrent. This element is tricky as those that have a direct manager/leader need to be aware that through meta leadership they might obtain more informal power than their direct manager. Additionally, meta leaders will be able to effectively call out and challenge the status quo that is instructed from above. Typically, this delivery of critical advice/guidance manifests through leveraging their direct team, their subject matter expertise and their overall proximity to the work.
5. Leading across the system. In this element the impact of meta leadership “spills over to other areas of the system. This impact leads to more cohesive and impactful change. By leading across the system change becomes a concerted effort with results that are beyond what a singular leader can obtain.

I personally think I am a meta leader since I have found myself leading across the system and bridging the gap/dismantling the silos of areas that partner with my area. One example of this is how my current employer treats business specific knowledge. In my role, I noticed that we were defining things in different ways, causing unnecessary confusion. I quickly noticed the gap in common knowledge and worked with six teams to build a common vocabulary. As simple as this sounds, it required knowing the impact of the change, addressing any issues from high levels of leadership, finding core followers that would be “agents of change” and managing different priorities/needs of the six teams.

Shared Leadership Theory
The principles of shared leadership work through empowering staff/team members to make decisions on processes within the confines of their work. This chance to develop new strategies has proven to be a great way to increase morale and satisfaction. Of course, this increased morale and satisfaction cannot be sustained without efficient teamwork that leverages efficiencies that align with the values of the team. Through shared leadership, the group and organization can obtain improved patient results. From the case The shared leadership challenge in strategic alliances: Lessons from the U.S. healthcare industry (Mcsweeney-Feld, M. H., Discenza, S., & Feis, G. L. (2010), one can ascertain that having a more ingrained shared leadership (at least at the executive level) can lead to a departure from a short-term view of decision making to that of long term view. This case also echoes the theory that alliances, created through shared leadership, equate to better customer value and care and not a 100% focus on bottom-line financial decisions.

According to Voss Graham, there are seven key factors that need to exist for Shared Leadership to exist:

1. A common goal: By creating a goal there is meaning and purpose. If you do not have a goal, productivity and focus drop. The group also runs the risk of someone else assigning the goal and not having the right version of value.
2. Respect for everyone: Diverse thought is a key piece of what each individual brings to the group. By incorporating diverse thought and incentivizing where appropriate, the unity of the group increases. When the unity increases there is a larger opportunity to pledge to a larger purpose.
3. Trust in each other: Trust connects everyone to the larger group. When there is a lack of trust, factors like fear of failure, low self-esteem and an over reliance upon rules and laws become commonplace.
4. Personal accountability for results: Accountability is a major contributor to high performance for individuals and teams. Personal accountability is the understanding that under-performing and over-performing are all about the right type of goals being obtained.
6. Effective communication: Communication drives results and productivity, and it is a two-way street where you must over-communicate and truly make sure that your communication is effective. While most people articulate in a way that they understand, without the feedback of their group, they will never know if their messaging is being understood.
7. Discipline to stay the course: Without discipline, the scope of work can widen and cause the goals to be unattainable. Throughout the course of work, distractions and roadblocks will occur. Discipline is the key element to face those adversities head on and work to find ways to stay the course. A lack of discipline could very easily lead to failure and improper implementation of new processes

While barriers to shared leadership exist, I believe the intent and impact of shared leadership cannot be discounted. Possible constraints with this leadership theory include: large workloads, increased turnover rates, transactional/mundane work, and poor scope of goals. Additionally, shared leadership has the additional work of continuously evaluating whether or not the impact is measurable in a quick paced environment like healthcare. This additional work might not be seen as value added, but the impact of shared leadership can not only affect the team in which it is occurring but can have longstanding effects of influencing and increasing the perspective of the group in the overall hierarchy of the organization.

One individual with whom I currently work is what I would consider a Shared Leader. He is currently the leader of an account management team and through alliances has implemented several key initiatives that were created in his organization but affect several other areas. The methodology that he implements is that his team cannot be truly effective if there are inefficiencies up or downstream from his department. So, he has worked to create key alliances with organizations on both sides, and this has led to key learnings and enhanced commitment from all internal stakeholders and the solidification of broad goals.

Conclusion
Through reading this chapter, you will notice that are is not one specific leadership style, principle or theory. Great leaders can follow a shared leadership style, a meta leadership style or even a transformational leadership style and be equally effective. As each style might seem different, they all have a base definition of the core relationship of leader to follower. The only way this relationship stays healthy and effective is through communication that not only works top down (leader to follower) but should also work from bottom up (follower to leader). This transparency of communication leads to the ability to adjust tactics, strategies and styles.

As I have lead multiple teams now in my decade long career, I have learned that the only true way to create a great base of followers is to be authentic, transparent and ethical. In my career, I have also implemented different versions of these different leadership styles with great effect. As previously mentioned, sometimes taking on a manager type of approach is useful, so to are the correct usage of these leadership styles. For example, in my organization I have been a part of teams that had leaders that were transformational to get a sustainable business model fleshed out, and then the leader switched the style to more of a shared leader to get buy-in from other areas, finally creating an environment where meta leaders in the organization can broaden the interest and collaboration across the organization.