March 8, 2021
By Annamarie A. Fuchs. Creator, Partners in Health | Conversations.
Leadership is the art of getting someone else to do something you want done because he wants to do it.
Dwight D. Eisenhower
Our health system is designed, managed, and delivered in operational environments such as hospitals and clinics, in academic settings and research agencies, with oversight from regulators, ministries of health, and more. In all settings, leaders are tasked with the responsibility to oversee, to support, and to be accountable to the people they serve. In 2018 when I was interviewing health care leaders from various organizations across the province, I had the privilege of spending an entire afternoon in conversation with an executive who shared the following insights:
Our health system is full of leaders who function on a continuum ranging from those who are consistently effective, to passive bystanders, those who are factually incorrect, or those individuals who simply rely on perceived power imbalances as a means to exert their own authority to achieve their own ends. At the end of the day we need to ask ourselves, how did the environment evolve to a point where we allow unprofessional behavior and inconsistent leadership to contribute to the erosion of trust we are experiencing today? That erosion has ultimately contributed to the loss of our collective ability to recognize and act on the reasonable expectations that are necessary between providers and the patients they serve. We need to look back to find those influences and work to correct them. And as leaders, we need to take the first step in correcting the culture of healthcare.
According to Brenan & Monson, organizations that strategically foster a culture based on mutual respect, trust, inclusion, and mentorship in career and leadership development are more likely to retain talent and realize improved patient outcomes. In fact, Fritch and colleagues also proposed that physician leadership is essential for optimizing health system performance. Physicians are expected to act professionally in all settings, and they are by default, seen by the health system and by users as leaders in some capacity. One physician I spoke with a few years ago emphasized that “physicians either function as leaders or are looked to as being leaders whether they have the title or not. For example, today’s healthcare environment is organized largely around models of team based care and despite the fact that physicians are expected to function as team-members, they are often more at ease taking on decision making roles that are ultimately interpreted (often incorrectly) as dominance instead of collaboration.”
Regulatory colleges, professional and protective associations, ministries of health and others all have a role to play in clarifying expectations and harnessing the good will of healthcare providers in order to communicate expectations of conduct and to promote both professional behavior and engender trust. Furthermore, when they are patients, citizens have expectations of their own about how they should be treated and how they expect to contribute to decision making about their own health. While most of these organizations utilize policies and processes to highlight attitudes such as ‘trustworthiness’ as foundational to the practice of leading and caring for others, ineffective processes or expectations can destroy trust and permanently erode relationships. Exceptional leadership that focuses on building and maintaining trust is imperative for understanding and responding to risk without fear of retribution in any high stress environment. And, short of the military, there is no more high stress environment where people’s lives are at stake than the health care setting.
At Partners in Health | Conversations we’ve been discussing the concept of trust as a “system enabler and, where it is lost, a system defect.” In our December 18 article and in a more recent conversation, Dr. Scott McLeod and I talked about the role of leaders in propagating trust across the health system. When I asked Dr. McLeod about how we might re-establish trust, he offered three constructs to consider. They are ‘mission command, clinical governance, and patient safety.’ This article explores the concept of “mission command” and how it might enable more effective leadership, greater trust, and ultimately better results.
Mission command is not a new construct, at least not in the Canadian Armed Forces (CAF) and beyond. In simple terms, its intention is to enable subordinates the freedom to act in achieving the organization’s desired ends. In 2014, U.S. Army General David Perkins pointed out that it is essential for people to be led in such a way that they move from merely contemplating the values, ethics, and expectations of an organization, to where they feel empowered to confidently (and competently) act on them. He went on to explain that effective leaders must trust that the professionals and subordinates in their command will act ethically with or without oversight. Without trust in the expertise and experience of the people around you, success is unlikely at best.
In mission command, leaders simply trust that the work will get done. They don’t worry about whether a unit will defy an order and go in another direction. They worry less about ‘how’ the work gets done and focus instead on the fact that their subordinates ‘will feel empowered to exploit the intention of the initiative versus merely controlling compliance.’ Dr. McLeod simplified the definition of mission command as a means to combine centralized intent with decentralized execution. In other words, leaders must ensure that their intentions are clear, that expectations are established and communicated effectively, and subordinates know they have the freedom to execute tasks in a way that meet tactical realities, all while remaining aligned with the vision or mission of the organization. In fact, in a mission command environment, leaders often start by asking for the opinions of the most junior subordinate first before working their way up the ranks.
The challenges inherent in leading a health system have compelling parallels with the military world. In fact, since the onset of COVID-19 we often hear metaphors used to illuminate the fact that we are ‘at war’ or engaged in a ‘battle against the second (or third) wave” or whether we are winning the pandemic ‘fight’. Military metaphors are widely used when we talk about the health system. So, it begs the question; ‘if we use military language to describe the challenges we face in healthcare, can we apply military strategy? Perhaps because we are currently ‘at war’ with COVID-19 there may be an opportunity to move forward more quickly to establish and maintain a culture of reciprocal trust more than at any time in our recent history.
In the National Health Service (NHS), clinical teams are naturally hierarchical with much of the direct responsibility delegated to the most junior of medical staff. Flattening the hierarchy offers the opportunity to ensure that leaders become less of a barrier to success and more likely to enable transparent communication with relationships that embody trust. However trust is a two-way street. Leaders must trust their subordinates to interpret their intent and subsequently act accordingly while subordinates must trust the process and the people who have created that intent. Establishing and maintaining trust may be the most critical challenge facing us in health care.
In a mission command environment, leaders offer others the freedom to act which results in considerable advantages particularly in large organizations like the NHS where efforts to meet ‘intent’ aren’t suffocated by the bureaucracy. Following is a summary of how mission command principles of leadership from the National Health Service have been applied to deal with the COVID-19 crisis.
1. Unity of effort
- To achieve unity of effort, leaders must make purpose clear. More specifically, the primary effort or the fundamental priority (and the reasons why) that will result in redirection of resources from other tasks must be clearly communicated. When communicated with intention and clarity, everyone involved can focus their actions to the context and the value / relevance. As a result, people who have had programs or services scaled back as a means to achieve a higher priority will more likely understand and respond with understanding and acceptance.
2. Freedom of action
- In the military, subordinates are empowered to act to achieve the commander’s intent. By removing bureaucratic barriers, leaders can more easily redirect their efforts to allow others who work together to solve tactical and organizational challenges in real time.
- Mission command requires leaders to trust their subordinates to interpret their intent without being micromanaged so that they can work effectively together to achieve it. In command and control structures, trust in subordinates is nonexistent and the results are not unexpected. Trust among and between leaders and teams will foster mutual respect and leads to greater effectiveness.
4. Mutual understanding
- Mutual understanding is fundamental to establishing trust. In one military field manual regarding leadership development, creating shared or mutual understanding was described as “the most important step in developing a team.”
5. Rapid decision making
- In any battle, whether in the military field or in a high stress healthcare environment, accuracy and speed are essential to saving lives. These environments demand that judgements and decisions are made quickly and that people understand they are accountable for those decisions. And, according to General Colin Powell, former U.S. National Security Advisor, there comes a point where you simply have to ‘go with your gut.’ Healthcare environments often evolve far too quickly to allow time to discuss and reach consensus on the most perfect solution. Instead, the responsibility needs to be pushed to the level where decisions can be best carried out.
The Alberta Context
Dr. Scott McLeod is the Registrar of the College of Physicians and Surgeons of Alberta. He also spent 27 years in the Canadian Armed Forces where his most recent position was Deputy Surgeon General. He is uniquely qualified to discuss both the Alberta context and the value of Mission Command as a philosophy with the potential to enable the right conditions for a more positive and trusting work environment. I reached out to Dr. McLeod again and asked him to offer his insights.
- McLeod, why do you think we should consider adopting a new leadership structure such as mission command to support Alberta’s health system, particularly for Alberta Health Services?
In Alberta, we have the potential to be the best healthcare system in Canada, if not in the world. While Alberta has the necessary components and expertise to deliver a high functioning health system, in many circumstances we fall short. We have organizations, groups, associations, institutions, all working in parallel, but silos continue, and information is rarely exchanged optimally. Alberta Health Services (AHS) is Canada’s first and largest province-wide, fully integrated health system, responsible for delivering health services to nearly 4.4 million people living in Alberta, as well as to some residents of Saskatchewan, B.C. and the Northwest Territories. It is not dissimilar to any complex military operation where fluid decision making on the battlefield is essential to getting the right (or the best) result. Further, Alberta Health Services employs more people than the Canadian Armed Forces with a distributed operational environment and a budget that is also comparable to the CAF.
In any given year, thousands of AHS providers and staff deliver millions of services to millions of people. In such an environment, it is unreasonable and frankly high risk to expect that one leader or one leadership team can effectively control everything that happens and despite their size and budget, they cannot be held accountable for the lack of integration we all experience. The role of Alberta Health (AH), the ministry responsible for oversight of the health system in Alberta is to delegate clearly and consistently, their expectations to the authorities responsible for delivering health care to Albertans. Instead, like many other jurisdictions, in their effort to deliver that oversight, they sometimes find themselves engaging in day to day management responsibilities. This can create more confusion as multiple parallel processes can result in the creation of another layer of inconsistent policies and expectations.
- So why Mission Command and not another leadership model? As you know, there are numerous leadership philosophies, structures, and models that have been adopted by healthcare organizations around the world.
Mission command is unique in that it starts from a point of trust. And, it combines centralized intent with decentralized execution which is ideally suited for a province-wide fully integrated health system with one board of directors. It provides leaders with the tools necessary to allow for and to promote both resourcefulness and speed of action where, and this is key, subordinates are given the freedom to make the decisions necessary to respond to the realities in front of them. By making expectations clear and reliable, training people appropriately for their role and stepping back to allow those at the front lines to act accordingly, the result over time will be widespread integration of services and communications rather than consistently indiscriminate service delivery and confusion. Executives, while accountable to the ministry for the outcomes produced by the health system, must avoid the temptation to get into the weeds of day-to-day operations. Instead, they must clearly define the objectives and expected outcomes and trust their people to do the job. If outcomes are not as expected, it’s essential to understand why and take corrective action but in a way that is non-punitive and designed to promote further trust, greater engagement, and commitment to meeting the mission, vision, and values of the organization. But effective leaders are not born. It is critical to invest in leadership by educating them and affording them the latitude to trust those who follow them.
Since the launch of AHS in 2009, considerable progress has been made. But there is more to do. In fact, I am reminded that in the Auditor General’s 2017 report to Albertans entitled “Better Healthcare for Albertans” the AG stated that “the formation of AHS offered important opportunities to integrate care. These opportunities have not (yet) been fully maximized.” Efforts to maximize or to optimize our potential continue but remain largely unrealized. In my role as a healthcare consultant having interviewed more than 100 people over the last 3 years including executives, leaders, clinicians, and support staff, there is persisting and widespread frustration due to the complexity, inequity, and confusion of associated policies and processes. Dr. McLeod emphasizes:
We need to start by hearing from those physicians who are committed to delivering person-centered care in clinical settings, academic settings, and frankly in all roles where they are already conducting themselves respectfully and trustfully. Unfortunately, I’m not sure their voices are heard. Instead, they merely go about their day to day work not wanting to make waves.
In a 2007 address, Kirch speculated that “increasingly, it appears that the source of our discontent is a fundamental imbalance within our institutions—an imbalance that stems from a failure to put at least as much energy into improving our culture as we put into advancing our strategy.” Great leaders are not only great at bringing people together to achieve a common vision, they are exceptional strategists. They create a clear line of site between expectation and action. When they empower subordinates to use their expertise and instincts to act effectively, and when they demonstrate their own pride and commitment to the organizations they serve, others will follow. That’s ‘mission command’ in a nutshell. Great leadership should always exemplify a narrative of relationships built on trust. It’s not enough to trust that the work gets done. Leaders must embody accountability by empowering others to do the work in every setting and in every circumstance. Kirch went on to underscore that…
We have the possibility of creating a much more meaningful and gratifying culture for our faculty, staff, and learners, and especially for the patients we have committed to serve. A culture that is grounded in the values of collaboration, trust, and shared accountability. A culture that is reinforced through team-based structures and shared reward systems. A culture that encourages transparency and inclusivity, rather than exclusivity. A culture that is driven equally by our traditional commitment to excellence, and by service to others.
Physicians and other front-line health professionals provide the necessary expertise, continuity, and stability required for any healthcare system to effectively meet the needs of the people we serve, which is in the long run is why we’re here. Formal management structures and organizational designs may change but, if we’re lucky, the leaders who support providers who are on the front lines and looked to for leadership at a moment’s notice, will consistently empower them to deliver the stability that a high performing health system needs. The principles of mission command just might enable them to get there.
 Stakeholder interview, January 2018. Key points paraphrased from a conversation.
 Dr. McLeod is the Registrar of the College of Physicians and Surgeons of Alberta.
 Fritch, Brewster, et al. Leadership Development Programs for Physicians: A systematic review. Yale School of Public Health, December 20, 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4395611/pdf/11606_2014_Article_3141.pdf
 Stakeholder interview, March 2018
 Perkins, D. A Story of Trust and Mission Command: Living the Army Ethic. October 14, 2014. https://capl.army.mil/videos/a-story-of-trust-and-mission-command
 Treble, P. COVID-19 in Canda: How our battle against the second wave is going. MacLean’s, February 2, 2021. https://www.macleans.ca/society/health/covid-19-in-canada-how-our-battle-against-the-second-wave-is-going/
 Pearce, A.P., Naumann, D.N., & O’Reilly, D. Mission command: Applying principles of military leadership to the SARS-CoV-2 (COVID-19) crisis. BMJ Military Health. https://militaryhealth.bmj.com/content/167/1/3
 Pearce, A. P., Naumann, D.N., and O’Reilly, D. Mission command: Applying principles of military leadership to the SARS-SoV-2 (COVID-19) crisis. BMJ Military Health Monthly. 2020 Volume 0, No 0, pages 1 – 2.
 McBride, D. & Snell, R.L. Applying mission command to overcome challenges. January 5, 2017. https://www.army.mil/article/179942/applying_mission_command_to_overcome_challenges
 Auditor General of Alberta. Better Healthcare for Albertans, May 2017. https://www.oag.ab.ca/reports/bhc-report-may-2017/
 Fuchs, A. Trust: The Conversation Continues with Dr. Scott McLeod, Registrar of the College of Physicians and Surgeons of Alberta. Partners in Health | Conversations, January 7, 2021. https://www.partnersinhealth.ca