Prompt: Whether it be a global pandemic, or a crisis of another kind, leaders within the healthcare industry must act appropriately to create an environment where care givers feel safe and where patients receive the care they need. What leadership competencies should administrators have to be prepared for the difficult aspects of the healthcare industry? Explain.
Journal of Healthcare Leadership
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/djhl20
Developing a model for effective leadership in
healthcare: a concept mapping approach
Charles William Hargett, Joseph P Doty, Jennifer N Hauck, Allison MB Webb,
Steven H Cook, Nicholas E Tsipis, Julie A Neumann, Kathryn M Andolsek &
Dean C Taylor
To cite this article: Charles William Hargett, Joseph P Doty, Jennifer N Hauck, Allison MB Webb,
Steven H Cook, Nicholas E Tsipis, Julie A Neumann, Kathryn M Andolsek & Dean C Taylor (2017)
Developing a model for effective leadership in healthcare: a concept mapping approach, Journal of
Healthcare Leadership, , 69-78, DOI: 10.2147/JHL.S141664
To link to this article: https://doi.org/10.2147/JHL.S141664
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Journal of Healthcare Leadership
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open access to scientific and medical research
Original Research
Open Access Full Text Article
Developing a model for effective leadership in
healthcare: a concept mapping approach
This article was published in the following Dove Press journal:
Journal of Healthcare Leadership
28 August 2017
Number of times this article has been viewed
Charles William Hargett 1
Joseph P Doty 2
Jennifer N Hauck 3
Allison MB Webb 4
Steven H Cook 5
Nicholas E Tsipis 4
Julie A Neumann 6
Kathryn M Andolsek 7
Dean C Taylor 6
1
Division of Pulmonary, Allergy,
and Critical Care Medicine,
Department of Medicine, 2Feagin
Leadership Program, 3Department of
Anesthesiology, 4School of Medicine,
5
Department of Neurosurgery,
6
Department of Orthopaedic Surgery,
7
Department of Community and
Family Medicine, Duke University
School of Medicine, Durham, NC, USA
Purpose: Despite increasing awareness of the importance of leadership in healthcare, our understanding of the competencies of effective leadership remains limited. We used a concept mapping
approach (a blend of qualitative and quantitative analysis of group processes to produce a visual
composite of the group’s ideas) to identify stakeholders’ mental model of effective healthcare
leadership, clarifying the underlying structure and importance of leadership competencies.
Methods: Literature review, focus groups, and consensus meetings were used to derive a representative set of healthcare leadership competency statements. Study participants subsequently
sorted and rank-ordered these statements based on their perceived importance in contributing to
effective healthcare leadership in real-world settings. Hierarchical cluster analysis of individual
sortings was used to develop a coherent model of effective leadership in healthcare.
Results: A diverse group of 92 faculty and trainees individually rank-sorted 33 leadership
competency statements. The highest rated statements were “Acting with Personal Integrity”,
“Communicating Effectively”, “Acting with Professional Ethical Values”, “Pursuing Excellence”,
“Building and Maintaining Relationships”, and “Thinking Critically”. Combining the results
from hierarchical cluster analysis with our qualitative data led to a healthcare leadership model
based on the core principle of Patient Centeredness and the core competencies of Integrity,
Teamwork, Critical Thinking, Emotional Intelligence, and Selfless Service.
Conclusion: Using a mixed qualitative-quantitative approach, we developed a graphical representation of a shared leadership model derived in the healthcare setting. This model may enhance
learning, teaching, and patient care in this important area, as well as guide future research.
Keywords: core competencies, healthcare leadership, medical education, mental models,
mixed methods research
Introduction
Correspondence: Dean C Taylor
Department of Orthopaedic Surgery,
Duke University Medical Center, Box
3615, Durham, NC 27710, USA
Tel +1 919 668 1894
Fax +1 919 681 6357
Email Dean.Taylor@Duke.edu
Physicians must become effective healthcare leaders in order to influence the care of
individual patients, the performance of diverse clinical teams, and the direction of major
healthcare organizations and beyond. The importance of effective healthcare leadership
is difficult to overestimate as leadership not only improves major clinical outcomes in
patients, but also improves provider well-being by promoting workplace engagement
and reducing burnout.1–5 We define the ability to influence as the foundation of our
definition of healthcare leadership: Healthcare leadership is the ability to effectively
and ethically influence others for the benefit of individual patients and populations.
Over the last ten years, we have created, implemented, and refined several
undergraduate medical education (UME) and graduate medical education (GME)
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you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For
permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).
http://dx.doi.org/10.2147/JHL.S141664
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Hargett et al
leadership development educational programs. We have
found that medical students, residents (synonymous with
junior registrar), and fellows (postgraduate trainees; synonymous with advanced specialist registrar) are exposed
to little intentional education to prepare them for their current and future personal and professional leadership challenges. Importantly, from a developmental and educational
perspective, omitting topics such as leadership in medical
education “is a powerful, if unintended signal, that these
issues are unimportant”.6 Our programs are not designed to
prepare individuals for specific leadership roles. Rather, they
facilitate individuals’ learning and development of leadership
skills that will prepare them to influence many facets of life,
including healthcare.
We have found that leadership models are extremely
helpful for learners to grasp new concepts, make sense of
lessons learned through their experiences, afford structure
that facilitates lasting comprehension through reflection, and
provide a basis for learner assessment and program evaluation.7 In the formative years of our programs, we used business leadership models as the foundation to teach leadership
skills. Our review of other leadership development schools
and professions (for example, the Wharton School of Business – University of Pennsylvania, the Fuqua Business School
at Duke University, the United States Service Academies, and
the Department of the Army) were helpful, yet they lacked
emphasis on subtle aspects unique to healthcare leadership.
We then looked for explicit healthcare leadership models and
found that few existed. Further, none seemed to facilitate
effective leadership learning in UME and GME.
Our inability to find an appropriate healthcare leadership
model led us to create a leadership model specific to healthcare. This model needed to be based on competencies that
were recognized as the most important attributes for effective
healthcare leadership. The purpose of the paper is to present
the research process that resulted in the Duke Healthcare
Leadership Model, as shown in Figure 1.
Methods
The study was a mixed method study using a modified concept mapping approach to derive, prioritize, and thematically
structure the fundamental competencies of healthcare leadership. Concept mapping is a mixed methods approach that
combines qualitative group processes such as brainstorming
and interpretive sorting with rigorous quantitative data analysis to produce a visual depiction of the composite thinking
of the group. This process of structured conceptualization
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Figure 1 The Duke Healthcare Leadership Model.
Note: ©2017 Dean C. Taylor, MD. All rights reserved.
has been used to address complex issues in healthcare, and
provides a framework that can guide action planning, program development or evaluation and measurement.8,9 We
used a comprehensive literature review and focus groups to
develop a set of statements that described healthcare leadership competencies. Next, we implemented a card sorting
task, followed by analysis and interpretation. Finally, we
created and refined a graphical representation of healthcare
leadership. These successive steps are illustrated in Figure 2
and will be explained in more detail in following sections.
The study was approved by the Duke Health Institutional
Review Board after it was determined to be exempt from full
review. Participation was voluntary, and informed consent
was not required.
Literature review
Building upon our prior meta-analysis exploring leadership
curricula used to teach medical students, we performed an
updated literature search and review of existing leadership
models.10 Information gleaned was used to develop semistructured focus group interview questions, a list of common
healthcare leadership attributes, and a script to be used in
focus group discussions.
Focus groups
Participants were recruited to collect expert opinion on the
leadership competencies required of a healthcare leader in
any environment. Each focus group lasted approximately two
hours, and was led by the same team of moderators. Moderators used the script developed from the semi-structured
Journal of Healthcare Leadership 2017:9
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Reduction of
competency statements
Derivation of representative
competency statements
(n=33)
Electronic sorting
of statements
Focus groups
and
semi-structures interviews
Prioritized sorting of competency
statements by diverse stakeholders
(n=92)
Analysis and
interpretation
Literature search and
review of existing
leadership models
Hierarchical cluster analysis
and interpretation
Representation and
refinement of model
Generation of
competency statements
A healthcare leadership model developed with concept mapping
Graphical representation and
refinement of the
leadership model
Figure 2 Sequence of steps in the concept mapping approach to derive, prioritize, and thematically structure the fundamental competencies of leadership in medicine.
focus group interview questions to lead the discussions.
One of the moderators took notes of the comments from the
group members and from subsequent debriefing sessions.
The focus groups were also asked to critique the leadership
attributes identified from the literature. Participants were
asked to rank the top 10 attributes required of a healthcare
medical leader. The focus group data were analyzed through
constant comparison analysis by identifying common themes
through saturation within each group and across groups. An
initial set of competency statements was derived and further
Journal of Healthcare Leadership 2017:9
refined by eliminating duplication and targeting specifically
for healthcare settings. The resulting competency statements
formed the basis for the quantitative card sorting and cluster
analysis.
Card sorting task
The sorting procedure was administered online with the open
source program FlashQ.11 Following an introduction with
instructions, participants were presented with the focus group
leadership competency statements in random order and asked
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Hargett et al
to sort them in order of importance based on their individual
point of view. More specifically, participants were asked to
rate the relative importance of each leadership attribute based
on its value or importance in contributing to effective leadership performance in real-world clinical situations. During the
sorting process, participants placed one unique statement in
each box on a grid with a fixed quasi-normal distribution.
Competency statements could be allocated to a ranking position ranging from +5 (most important) to −5 (least important).
Respondents could change the placement of cards until the
final positioning of all statements reflected their ranking of
the statements relative to each other in importance. After
completing the card sorting, participants were asked to provide their rationale for placing the competency statements
at the extreme ends (+5 or −5 columns) of the sorting grid.
All responses were anonymous, though respondents could
elect to enter demographic data, including sex, current role,
and leadership experience.
Hierarchical cluster analysis
Demographic data and importance scores were calculated
using descriptive statistics. All data were analyzed with
JMP Pro 13.0 (SAS Institute Inc., Cary, NC, USA). Cluster
analysis is a statistical technique to find similar groups of
cases in a data set and is particularly useful in the development of a classification or conceptual scheme. Hierarchical cluster analysis (Ward’s method, squared Euclidean
distances) was used to classify leadership competency
statements based on the similarity of individual sorting
responses of each participant. Guided by the dendrogram
and agglomeration schedule, investigators (CWH, JPD,
DCT) determined the final number of clusters by consensus
and based on the criterion that the clusters should reflect
meaningful, distinct domains related to effective leadership
in a healthcare setting.
Mixed methods analysis
We analyzed the quantitative data in conjunction with the
qualitative data obtained from the focus group discussions
and the statements provided by card sorting participants.
This mixed methods analysis helped us define the primary
healthcare leadership competency themes. Earlier versions of
the model originated within our Feagin Leadership Program
and the Leadership Education And Development (LEAD)
Curriculum, which are internal initiatives within our UME
and GME programs. The initial models were refined based
on input and feedback obtained from multiple faculty, house
staff, and residents over a three-year period.
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Results
Literature review
The literature review found that healthcare leadership is a
skill that must be12–14 and can be15–17 intentionally taught. Further, the literature review provided information on healthcare
leadership attributes and content18–25 that we used to guide
the discussion to the semi-structured focus group interview
questions. Thirty-nine healthcare leadership attributes were
identified and used to determine the competency statements
in the focus groups.
Focus groups
Three focus groups were carried out with a total of 19 participants, many being clinical faculty with administrative or
leadership roles. From the 39 healthcare leadership attributes
identified through the literature review, the focus groups’
work led to a set of 33 competency statements that represent
important aspects of healthcare leadership (Supplementary
material). These statements formed the basis for the card
sorting task. Each one of the statements:
1. Described some of the fundamental knowledge, skills,
or attitudes related to leadership (influencing others) in
a healthcare setting
2. Represented the basic competencies that may be demonstrated by successful physician leaders, regardless of
their work setting
3. Described the knowledge, skills, and attitudes that combine to enable residents and fellows to demonstrate behaviors that help assure effective leadership performance in
real-world clinical situations
In addition to identifying the statements for our quantitative card sorting task, the focus groups also provided
important qualitative data. All three focus groups emphasized that Patient Centeredness and Selfless Service are two
competencies essential to effective healthcare leadership.
Further, each focus group emphasized that Patient Centeredness was essential to any healthcare leadership model as this
principle differentiated healthcare leadership from leadership
in other fields.
Card sorting task
Approximately 200 faculty (attending physicians and nonphysician professionals) and learners (medical students, residents, and fellows) were recruited via email to participate in
the card sorting exercise. Ninety-two participants responded
(46 percent) (22 medical students, 29 physicians-in-training,
25 attending physicians, and 16 non-physician professionals).
Journal of Healthcare Leadership 2017:9
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A healthcare leadership model developed with concept mapping
Sixty percent were men, and two-thirds reported prior formal
leadership training. Table 1 presents a basic summary of the
participants in the card sorting task. Table 2 summarizes
the mean values for importance of the top competency
statements.
Hierarchical cluster analysis
Through hierarchical cluster analysis, the competency
statements fell into five domains. We labeled four of the
domains based on the predominant themes of the competency statements in those domains: Integrity, Teamwork,
Critical Thinking, and Emotional Intelligence. A fifth
domain comprised a set of low-rated competency statements
for which no unifying theme could be identified (Figure 3).
Fundamental leadership domains with mean importance
scores for each leadership competency statement are presented in Table 3.
Mixed methods analysis
Mixed methods analysis of the quantitative and qualitative
data resulted in two additional competency themes for the
healthcare leadership model. We used the qualitative input
from the focus groups and the card sorting comments to
separate Patient Centeredness and Selfless Service from the
Emotional Intelligence domain (Figure 3). The focus group
affirming that Patient Centeredness is a unique, defining
component found in effective healthcare leaders was confirmed through feedback and experience we received when
testing early versions of the model in leadership education
settings. We concluded that Patient Centeredness is more than
a competency for healthcare leadership; it is a core principle.
We also identified the highly rated statement of “Communicating Effectively” (originally clustered in the Integrity
domain) as essential to each domain, and not a separate
competency. Similarly, “Pursuing Excellence”, although
highly rated and part of the Critical Thinking domain, is a
statement that is an aspirational goal and, as such, a part of
each competency.
Finally, we modified the graphic representation of the
model based on its use in teaching students, residents, and
fellows, along with the feedback we received from these
learners and faculty. The resulting model (Figure 1) features
that the central core principle of Patient Centeredness is
surrounded by the overlapping five core competencies. We
recognize Emotional Intelligence26,27 as the core competency
that holds the other competencies together, and therefore it
is positioned as the “keystone” in the model; if Emotional
Intelligence is removed, the model will crumble. Integrity
and Selfless Service are intentionally positioned at the base
of the model; although they may be difficult to teach, they
are extremely important to effective healthcare leadership
and must be recognized and emphasized as essential “foundational” core competencies. Critical Thinking and Teamwork are positioned as the “framework core competencies”,
holding the model together and overlapping with the other
three competencies.
Table 1 Characteristics of participants in card sorting
Characteristics
Sex, no. (%)
Female
Male
Leadership training, no. (%)
Prior formal training
Medical
students
(n=22)
Physicians
in training
(n=29)
Attending
physicians
(n=25)
Non-MD
professionals
(n=16)
Total
(n=92)
8 (44%)
10 (56%)
14 (50%)
14 (50%)
7 (32%)
15 (68%)
4 (29%)
10 (71%)
33 (40%)
49 (60%)
12 (57%)
15 (54%)
19 (83%)
11 (73%)
57 (66%)
Note: Discrepancies in totals are due to incomplete responses as demographic questions were optional.
Table 2 Top competency statements ranked by mean (SD) importance score
Competency statements, mean (±SD)
Total
(n=92)
Acting with Personal Integrity – behaving in an open, honest, and trustworthy manner
Communicating Effectively – ability to communicate with patients and team; successfully navigating difficult conversations and
providing feedback
Acting with Professional Ethical Values – applying medical ethical principles to difficult situations
Pursuing Excellence – striving for excellence in all areas of personal, team, and organizational life
Building and Maintaining Relationships – listening to and supporting others, gaining trust, and showing understanding
Thinking Critically – being able to think analytically and conceptually to evaluate and solve problems
3.07 (±2.24)
2.98 (±1.8)
Journal of Healthcare Leadership 2017:9
1.98 (±2.27)
1.2 (±2.75)
1.15 (±2.17)
1.12 (±2.5)
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Communicating
Effectively
Thinking Critically
Developing and
Implementing
Strategy
Planning
Managing
Resources
Facilitating
Transformation
Encouraging
Improvement and
Innovation
Adapting to Change
Motivating
Managing People
Encouraging
Contribution
Managing Personal
and Team
Performance
Optimizing Team
Dynamics
Building and
Maintaining
Relationships
Having a Strong
Knowledge Base
Applying
Knowledge and
Evidence
Pursuing
Excellence
Critical Thinking
Fostering Vision
Being Decisive
Teamwork
Serving Selflessly
Maintaining
Patient
Centeredness
Patient Centeredness
and Selfless Service
Developing Self
Awareness
Continuing Personal
Development
Managing Self
Cultivating Personal
Resilience
Maintaining
Personal Balance
Emotional
Intelligence
Figure 3 Organization of competency statements based on hierarchical cluster analysis and mixed quantitative and qualitative assessment.
Acting With
Professional Ethical
Values
Acting with
Personal Integrity
Integrity
Competencies for effective leadership
in healthcare
No Unifying Theme
Developing Networks
Evaluating Systemic Impact
Understanding Historical
Context
Understanding Community
Impact
Understanding Situational
Context
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A healthcare leadership model developed with concept mapping
Table 3 Five fundamental competency themes in leadership in medicine with mean importance score for each competency statement
Themes with statements, mean (±SD)
Integrity
Acting with Personal Integrity
Communicating Effectively
Acting with Professional Ethical Values
Critical Thinking
Pursuing Excellence
Thinking Critically
Having a Strong Knowledge Base
Applying Knowledge and Evidence
Selfless Service
Maintaining Patient Centeredness
Serving Selflessly
Emotional Intelligence
Developing Self-awareness
Continuing Personal Development
Managing Self
Cultivating Personal Resilience
Maintaining Personal Balance
Teamwork
Being Decisive
Building And Maintaining Relationships
Optimizing Team Dynamics
Managing Personal and Team Performance
Motivating
Managing People
Encouraging Contribution
Fostering Vision
Planning
Developing and Implementing Strategy
Managing Resources
Adapting to Change
Encouraging Improvement and Innovation
Facilitating Transformation
No Unifying Theme
Developing Networks
Evaluating Systemic Impact
Understanding Situational Context
Understanding Community Impact
Understanding Historical Context
Medical students
(n=22)
Physicians
in training
(n=29)
Attending
physicians
(n=25)
Non-MD
professionals
(n=16)
Total (n=92)
2.86 (±2.51)
2.77 (±2.09)
1.36 (±2.48)
2.24 (±2.52)
3.59 (±1.78)
1.21 (±2.21)
3.56 (±1.85)
2.76 (±1.64)
2.28 (±1.97)
4.06 (±1.18)
2.5 (±1.51)
3.75 (±1.44)
3.07 (±2.24)
2.98 (±1.8)
1.98 (±2.27)
1.41 (±2.5)
2.09 (±2.11)
0.09 (±3.29)
−0.68 (±2.83)
0.83 (±2.9)
1.41 (±2.47)
−1.03 (±2.98)
−0.62 (±2.44)
1.16 (±3.1)
0.32 (±2.67)
−2.36 (±2.94)
−0.8 (±2.68)
1.63 (±2.36)
0.5 (±2.42)
0.56 (±2.58)
−0.69 (±2.77)
1.2 (±2.75)
1.12 (±2.5)
−0.85 (±3.13)
−0.7 (±2.62)
0.86 (±2.92)
−0.45 (±3.43)
0.28 (±3.22)
−1 (±3.36)
0.36 (±2.94)
0.72 (±2.7)
1.56 (±2.58)
−0.56 (±2.71)
0.66 (±2.96)
−0.33 (±3.13)
0.18 (±2.84)
−0.45 (±2.32)
−0.82 (±2.32)
−0.27 (±2.12)
−1.09 (±3.04)
−0.97 (±1.84)
−0.55 (±1.86)
−0.03 (±2.5)
−0.93 (±2.05)
−1.24 (±2.89)
1.08 (±2.77)
0.04 (±2.52)
−0.24 (±2.76)
−0.84 (±2.48)
−0.88 (±2.76)
0.13 (±3.05)
−0.88 (±2.03)
−0.25 (±2.21)
−0.13 (±1.63)
0.38 (±2.45)
0.05 (±2.66)
−0.42 (±2.19)
−0.32 (±2.46)
−0.61 (±2.12)
−0.83 (±2.83)
0.23 (±2.74)
1.68 (±1.96)
0.59 (±3.11)
0.27 (±1.96)
1.05 (±2.19)
−0.09 (±2.56)
0.27 (±2.69)
−0.09 (±3.46)
0.23 (±2.29)
−0.36 (±1.71)
−1.18 (±2.15)
0.36 (±2.06)
−0.09 (±1.8)
−1.09 (±1.34)
0.17 (±3.16)
1.17 (±2.11)
1.55 (±1.96)
0.34 (±2.21)
0.86 (±2.22)
1.72 (±1.89)
0.45 (±1.86)
−0.1 (±2.91)
1.03 (±2.46)
−0.1 (±2.16)
0.34 (±2.48)
0.83 (±2.39)
0.55 (±2.1)
−0.76 (±2.46)
0.08 (±2.16)
0.88 (±2.51)
0.24 (±1.54)
0.44 (±1.66)
1.24 (±2.13)
0.28 (±2.3)
0.32 (±2.48)
0.16 (±3.05)
0.16 (±1.93)
0.16 (±3.09)
−0.96 (±2.28)
0.36 (±1.93)
−0.24 (±2.7)
−0.88 (±2.73)
1 (±1.86)
0.81 (±2.07)
0.44 (±2.58)
0.31 (±2.44)
0.44 (±2.99)
0.56 (±2.73)
−0.44 (±2.13)
−0.19 (±2.64)
−1.81 (±2.69)
0.13 (±2.09)
−0.75 (±2.02)
0 (±2.16)
0.81 (±2.79)
−1.19 (±1.97)
0.3 (±2.59)
1.15 (±2.17)
0.77 (±2.33)
0.35 (±2.02)
0.93 (±2.31)
0.7 (±2.4)
0.22 (±2.28)
−0.04 (±3)
0.11 (±2.48)
−0.05 (±2.32)
−0.57 (±2.33)
0.45 (±2.14)
0.23 (±2.34)
−0.95 (±2.22)
−2.5 (±2.11)
−0.68 (±1.78)
−1.05 (±2.28)
−1.82 (±2.67)
−3.59 (±1.79)
−1.86 (±2.52)
−1.48 (±2.23)
−1.55 (±2.06)
−2.97 (±1.8)
−3.38 (±1.72)
−0.92 (±2.72)
−1.04 (±1.72)
−1.52 (±2.06)
−3.04 (±1.62)
−2.88 (±2.32)
−2.13 (±2.31)
−1.81 (±1.8)
−2.69 (±1.74)
−3.06 (±2.21)
−3 (±2.34)
−1.8 (±2.48)
−1.23 (±1.93)
−1.62 (±2.1)
−2.73 (±2.1)
−3.23 (±2.01)
Discussion
From curricular, pedagogical, and assessment perspectives, a
model serves as the foundational starting point for learning
and as an organizing framework for the developing leadership
curricula. The model presented here addresses this need. We
used a concept mapping approach to create a model specific
to the needs of learning in healthcare leadership.
Our model was developed based on a comprehensive
literature review, focus groups, concept mapping, and
Journal of Healthcare Leadership 2017:9
hierarchical clustering. Each of the 33 competency statements is an important concept of healthcare leadership. Our
methods determined which statements were most important
and which coalesced into themes. We began with an initial
model that had been drafted within our UME and GME
leadership programs (the Feagin Leadership Progam and
LEAD Curriculum). Those initial drafts were further refined
over a three-year period based on feedback we received from
numerous people within our institution with varied levels of
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75
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Hargett et al
healthcare experience and training (faculty, fellows, residents,
students, administrators, and non-physician educators). That
input led to a model that has face validity, is well accepted,
and can be used in pedagogical processes that help all of us
learn to be better leaders.
Recent literature emphasizes the importance and need
for the intentional, explicit promotion of leadership development curricula and training in medical education.28–31 Clearly,
leadership development education should be intentional and
not informal or implicit. The model presented here provides
a framework for intentionally teaching leadership skills in
healthcare education.
There continue to be efforts to appropriately characterize “content”32 and define competencies.33 Sonnino argues
for two dozen competencies, the most important of which
are finances and economics, emerging issues and strategic
planning, personal professional development, adaptive
leadership, conflict management, time management, ethical considerations, and personal life balance.34 Seven of
those eight align well with our model; we would argue that
finances and economics are more managerial skills and
context dependent. Further emphasizing the significance
of leadership development in postgraduate medical education, in 2015 the Canadian residency CanMeds competency
framework replaced their role of “manager” with that of
“leader”.35
There are several limitations to our study. Foremost,
model creation is not an exact science. Our mixed methods
approach involves subjective interpretation of how to organize overlapping concepts. For example, communication
could be considered a separate competency. Instead, we chose
to include communication as essential for all core competencies – learning to communicate better enables one to be better
at each healthcare leadership competency. Others’ subjective
assessments may have led to different interpretations.
This model is also derived from research done at a single
institution, and as a result may not be generalizable to other
settings. We do not suggest that ours is the only or best
healthcare leadership model. It is offered as a model that
others can use and refine for their own environments. The
methods we describe can serve as a guide if others desire to
create their own institutionally specific model. Nonetheless,
this model has guided our teaching of skills and concepts
that lead to improved competency in areas recognized as
essential for effective, ethical healthcare leadership. It has
subsequently led to an assessment of learners and an evaluation of our programs.
76
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Models are most useful when validated. Preliminary
validation of our model is complete. Our group is committed
to re-validate the model in more diverse and larger healthcare settings. Our next steps involve developing, refining,
and validating an evaluation instrument that assesses the
competencies and core principle in the model. This work
is underway through the Health Evaluation Assessment of
Leadership.36
Conclusion
We designed a leadership model specific to healthcare using
concept mapping. The research led to a model based on the
core principle of Patient Centeredness and core competencies
of Emotional Intelligence, Integrity, Selfless Service, Critical
Thinking, and Teamwork. We have found this model useful
for teaching leadership skills, and are currently designing a
relevant evaluation instrument.
Acknowledgments
The authors thank members of the Feagin Leadership Program for their extensive backing of this project. The authors
acknowledge all of the participants of the focus groups and
other non-author members of their team including Prinny
Anderson, MBA, Med; Jane Boswick-Caffery, MBA, MPH;
Matthew Boyle, MD; Thomas Mullin, MD; and John Yerxa,
MD. We also thank Saumil Chudgar, MD, MS, for feedback
and editing work on this paper.
The authors acknowledge the assistance of Donald T
Kirkendall, ELS, a contracted medical editor, for his assistance in preparing the manuscript for submission.
The views, opinions, and/or findings contained in this
report are those of the author(s) and should not be construed
as an official Department of the Army position, policy, or
decision. Citation of trade names in this presentation does
not constitute an official DA endorsement or approval of the
use of such commercial items.
Disclosure
Allison MB Webb is currently a resident in the National
Capital Consortium’s program Combined Internal Medicine – Psychiatry Residency at Walter Reed National Military
Medical Center, Bethesda, MD, USA. Nicholas E Tsipis is
an Emergency Medicine Resident at Georgetown University
Hospital/Washington Hospital Center, Washington DC, USA.
Julie A Neumann is a sports medicine fellow at Kerlan-Jobe
Orthopaedic Clinic. The authors report no conflicts of interest in this work.
Journal of Healthcare Leadership 2017:9
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Hargett et al
Supplementary material
Competency statement definitions
1. Acting with Personal Integrity – behaving in an open,
honest, and trustworthy manner
2. Communicating Effectively – ability to communicate
with patients and team; successfully navigating difficult
conversations and providing feedback
3. Acting with Professional Ethical Values – applying medical ethical principles to difficult situations
4. Pursuing Excellence – striving for excellence in all areas
of personal, team, and organizational life
5. Building And Maintaining Relationships – listening
to and supporting others; gaining trust; and showing
understanding
6. Thinking Critically – being able to think analytically and
conceptually to evaluate and solve problems
7. Motivating – inspiring oneself and others to achieve goals
8. Optimizing Team Dynamics – understanding team members’ roles, strengths, and weaknesses; influencing diverse
talents to achieve common goals
9. Managing People – delegating, providing direction, and
promoting equality and diversity
10. Maintaining Patient Centeredness – focusing on patients’
best interests; working in partnership with patients; ensuring patient safety
11. Adapting To Change – flexibility, adapting to change
readily, being the first to change when required
12. Managing Personal and Team Performance – the ability to assess successes and failures of oneself and team
members and make adjustment as needed
13. Being Decisive – using values and evidence to act decisively, especially in difficult situations
14. Encouraging Improvement and Innovation – creating a
climate of continuous quality improvement and identifying areas for growth
15. Encouraging Contribution – creating an environment
where others have the opportunity to share their thoughts
and ideas without fear of criticism
16. Planning – developing short-term and long-term plans to
achieve personal, team, and organizational goals
17. Developing Self-awareness – being aware of one’s own
values, principles, and assumptions
18. Fostering Vision – developing an organizational vision,
communicating that vision, and embodying its principles
19. Developing and Implementing Strategy – integrating and
aligning plans, resources, and people to achieve goals
20. Managing Self – organizing and self-regulating actions
and emotions
21. Serving Selflessly – ability to put others’ needs before
one’s own; demonstrating great concern for common
good/other people
22. Continuing Personal Development – learning through
continuous professional development and being open to
feedback
23. Managing Resources – knowing what resources are available and using one’s influence to ensure that resources
are used efficiently and safely, reflecting the diversity of
needs within given populations
24. Cultivating Personal Resilience – ability to cope with
demanding situations
25. Applying Knowledge and Evidence – the ability to
translate research and evidence-based practice in order
to optimize outcomes
26. Maintaining Personal Balance – prioritizing activities to
maintain mental and physical health
27. Having A Strong Knowledge Base – being an expert in a
given field and demonstrating mastery of core knowledge
28. Facilitating Transformation – actively contributing to
positive change
29. Evaluating Systemic Impact – measuring and evaluating
outcomes; taking corrective action where necessary
30. Understanding Situational Context – seeking broader
perspectives on problems; understanding community and
stakeholders perspectives
31. Developing Networks – developing professional connections with stakeholders inside and outside the institution
32. Understanding Community Impact – having awareness
that decisions about patient care impact population health
33. Understanding Historical Context – being aware of the
history, culture, and traditions of the institution and
including these in decision-making
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Journal of Healthcare Leadership 2017:9
International Journal of Surgery 81 (2020) 122–129
Contents lists available at ScienceDirect
International Journal of Surgery
journal homepage: www.elsevier.com/locate/ijsu
Review
Health policy and leadership models during the COVID-19 pandemic:
A review
T
Maria Nicolaa,∗, Catrin Sohrabib, Ginimol Mathewc, Ahmed Kerwand, Ahmed Al-Jabird,
Michelle Griffine, Maliha Aghaf, Riaz Aghag
a
Imperial College Healthcare NHS Trust, London, United Kingdom
Barts and the London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
c
UCL Medical School, London, United Kingdom
d
GKT School of Medical Education, King’s College London, United Kingdom
e
Stanford University, Palo Alto, United States
f
IJS Publishing Group, London, United Kingdom
g
Barts Health NHS Trust, London, United Kingdom
b
ARTICLE INFO
ABSTRACT
Keywords:
Novel coronavirus
COVID-19
Leadership
Healthcare policy
Management
On March 11, 2020, the spread of the SARS-CoV-2 virus was declared a pandemic by the World Health
Organization (WHO). Approximately 19.3 million people have now been infected and over 700,000 have died.
This global public health crisis has since cascaded into a series of challenges for leaders around the world,
threatening both the health and economy of populations. This paper attempts to compartmentalise leadership
aspects, allowing a closer examination of published reports and the analysis of current outcomes, thus enabling
the authors to formulate a number of evidence-based recommendations on the de-escalation of restrictions.
1. Introduction
2. Leadership compartmentalisation
On March 11, 2020, the spread of the SARS-CoV-2 was declared a
pandemic by the World Health Organization (WHO) [1]. The pandemic
has caused a worldwide turmoil in all aspects of life; it has swamped
healthcare systems, continues to threaten the economy into a recession
expected to be worse than that seen in 2008 [2,3] and continues to
challenge established leadership models [4].
Shingler-Nace [5] identifies five elements to successful leadership
during this crisis: Staying calm, communication, collaboration, coordination and providing support. We have expanded on these elements
and have further focused on situation monitoring, funding and surgical
preparation. As world leaders, healthcare executives and clinical leads
scramble to establish ‘best practice’ models moving forward, we describe these strategies and assess their efficacy based on published reports, analyse current outcomes and offer evidence-based recommendations on de-escalation of restrictions in an attempt to aid
policy makers during these crucial times. We also identify leadership
issues and ethical dilemmas which may arise amidst the pandemic and
describe their effect on implementation of policy.
2.1. Planning and coordination
Planning is key in any national crisis and especially in a pandemic
that affects every element in society; effective coordination is therefore
essential. This coordination must happen at a national, regional and
local level with lines of communication between each. Under these
unique circumstances, this should be done virtually [6]. As part of
planning, it is also prudent to utilise previous pandemic preparedness
plans and mitigation strategies which will be discussed in section 2.5 as
an independent entity.
At a local level, hospitals are advised to set up local incident management teams [7] consisting of a clear chain of command including a
clinical director, a managerial director, a single point of reference to
regional command centres [8] as well as public health specialists. This
is important for the relaying of national directives to clinical staff delivering care and to ensure they follow the latest up to date best practice
whilst able to use individual clinician discretion. A similar structure
should also be followed in individual hospital service delivery settings
with lead clinicians identified who are capable of coordinating an
Corresponding author.
E-mail addresses: maria_n02@hotmail.com (M. Nicola), ginimol.mathew.13@ucl.ac.uk (G. Mathew), ahmedkerwan@live.co.uk (A. Kerwan),
ahmed@aljabir.co.uk (A. Al-Jabir), 12michellegriffin@gmail.com (M. Griffin), maliha@ijspg.com (M. Agha), mail@riazagha.com (R. Agha).
∗
https://doi.org/10.1016/j.ijsu.2020.07.026
Received 29 May 2020; Received in revised form 28 June 2020; Accepted 12 July 2020
Available online 17 July 2020
1743-9191/ © 2020 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.
International Journal of Surgery 81 (2020) 122–129
M. Nicola, et al.
effective response in their area of expertise.
Regionally, coordination must be also established within a local
health system. This is relevant both for large urban conurbations with
closely linked populations as well as more sparsely populated rural
health systems [9]. Regional coordination is needed for the pooling of
resources, the sharing of clinical best practice, the coordination of
workforce sharing and redeployment as well as being essential for the
interface between primary, secondary and emergency care providers to
collaborate and manage patient pathways. Regional response teams can
consist of small municipal regions or larger national subdivision regions, such as Federal States or Administrative Regions, who link with
national systems.
Finally, national coordination. Strong national leadership provides
unity of purpose and strategy as well as coordination with other
countries [9] for resources and coordinated responses. Each country
uses its nationally agreed upon procedures with the most common response team consisting of the Head of Government, Health Minister,
Chief Medical Officer/Lead Public Health Officer, Epidemiologists and
Virologists as well as civil defence/military representatives. A similar
structure can also be replicated on a more regional basis.
the general public and speed recovery. This ensures that any risk at
both the population and individual level is mitigated.
The delivery of continual and factual information to the public and
all stakeholders on the pandemic’s current state, and throughout every
stage of planning, response, and recovery, is equally as significant. Such
delivery has to be clear and focussed. If mistakes happen or performance falls short, governments should be honest with the public.
Although the potential mortality, morbidity, life and economic disruptions may be difficult to predict, it is nevertheless vital that these
concerns and harsh realities be communicated. Since leaders are public
figures upon which others will depend for reassurance and guidance, in
turn fostering resilience and recovery, they must refrain from communicating any false or non-evidence-based scientific information that
may lead to panic and negative health outcomes. Evidently, reducing
any negative consequences relies heavily on gaining the trust and cooperation of a substantial body of countrywide entities. Post-pandemic,
leaders should publicly acknowledge the contributions of all keyworkers, services and communities. Leaders also play a critical role in
detailing the lessons that have been learned, to enable prompt action in
the event of future public health crises. These lessons can lead to the
active incorporation of those approaches proven to be most effective
into existing governmental strategies. Overall, communication is key to
building trust, developing effective guidelines and principles, and to
ensure the prevention and containment of disease. However, it is
nevertheless important to note that good communication practices will
not substitute for poor planning or misconceptions.
2.2. Situation monitoring and assessment
Given the expeditious nature of its transmission and severity of
disease, accurate monitoring and assessment is crucial for enabling an
effective response. Despite transparent reporting and collaboration
between the majority of national and international public health
agencies, variability in testing criteria may contribute to a misleading
epidemiological picture [10]. For example, due to a limitation in laboratory testing capacity, countries such as Spain and Italy have recalibrated their eligibility guidelines resulting in more stringent criteria
(e.g., only those with severe symptoms or at high risk due to comorbidities will receive testing) [10]. This may lead to expressions of a
flattened epidemic curve, potentially causing a misinterpretation of the
epidemic’s true status. Furthermore, some countries, such as South
Korea, have shifted to more liberal eligibility guidelines (i.e., a greater
number of people are tested) which may result in a steepening of the
curve’s gradient [11]. Appreciating the evolving nature of national
testing efforts is crucial when formulating a plan of action for COVID19. Garcia-Basteiro et al. [10] argue the two indicators most resilient to
changes in testing capabilities – and thus should be relied upon when
monitoring and assessing a situation – are incidence risk of hospital
admissions and mortality rate.
2.4. Funding, PPE and testing
It is important that global leaders ensure the appropriate allocation
of funds towards medical supplies and personal protective equipment
(PPE) to help meet the ever increasing demand. This fundamental
priority is key to protecting frontline healthcare staff and to preventing
further viral transmission within the hospital setting. Examples of necessary PPE include masks, visors, gloves, aprons and gowns. In the UK,
the British Government has endeavoured to allocate £6.6 billion from
the Government’s coronavirus emergency fund to the NHS, following on
from an initial contingency fund of £5 billion [13]. The European
Commission have also announced plans to create a strategic stockpile of
medical equipment with an initial budget of €50 million to support EU
countries [14]. Funding may additionally be used to free up hospital
beds, purchase intensive care medical equipment including ventilators,
diagnostic kits, therapeutic supplies, and laboratory equipment to
support research and development.
Regarding testing, leaders must ensure the development of sustained diagnostic capacity, the establishment of adequate testing
schemes, and ensure the rapid validation and deployment of serological
testing. In the UK, the implementation of a nation-wide coronavirus
testing programme (via a home testing kit or a pre-booked regional test
site) enabled all individuals who develop symptoms of the disease to be
tested [15]. In the EU, aggressive testing of all 3,300 inhabitants of the
town of Vò, near Venice, irrespective of the presence of symptoms,
enabled the spread of infection to cease [16]. As of July 20, 2020, Italy
has conducted approximately 6,238,049 tests [17]. In Asia, Taiwan has
achieved international praise for its handling of the COVID-19 pandemic. As of July 20, 2020, Taiwan has conducted 79,645 tests, with
455 confirmed cases and 7 deaths [18]. These successes have highlighted the importance of testing and isolation, in otherwise healthy
individuals, to leaders on a global scale.
2.3. Communication
Effective communication is a key attribute of successful leaders
during a public health crisis since even the most efficient and best
strategies may be rendered ineffective by inadequate or ineffective
communication at government level, or communication that fails to be
integrated successfully into the community. In fact, poor communication may exacerbate the existing threat. The plans employed by national authorities must reflect a thoughtful, effective, informative, and
evidence-based approach [12].
As a result of the dynamic nature of a pandemic, complete transparency and prompt communication of both real and potential risks is
necessary. Social marketing and health promotion, particularly during
the preparation phase of a public health risk, ensures the delivery of
crucial health protection messages. Evidently, these factors are important because the quality of the resulting societal response such as
social distancing and self-isolation, depends partly on meeting these
specific communication and outreach needs. In addition to the importance of communication as part of the preparation phase of a pandemic, leaders should be mindful of the importance to continually inform, update, and promote its population on the existence of known,
proven, and/or recommended guidelines and interventions to protect
2.5. Mitigation and containment
The overwhelming cases of COVID-19 have forced global leaders to
adopt containment measures in an attempt to suppress the spread of the
disease. South Korea has taken the global lead in containment of the
virus as they have focused greatly on mass testing, early contact tracing
123
International Journal of Surgery 81 (2020) 122–129
M. Nicola, et al.
and successful quarantine. In other parts of the world, namely China,
Spain, Italy and the US, raising numbers of daily cases prompted governments to switch from containment to mitigation strategies [19]. In
doing so, non-pharmaceutical interventions (NPIs) have been implemented worldwide having a great effect in managing and limiting
social contact [20].
A recent Belgian study suggests that ‘Flattening the Curve’ strategies
in an attempt to develop herd immunity – in essence reducing the
Reproduction number (Ro) to less than 1 – are ‘unfeasible’. Using the
susceptible, exposed, infected, and recovered (SEIR) model, they predict that supplemental ICU capacity will need to be maintained for
several years, inadvertently overwhelming healthcare systems worldwide. Moreover, an outbreak of the disease will be observed if R0 raises
above 1, overloading an already saturated healthcare system. When Ro
falls to less than 1, the disease is predicted to disappear for a period,
effectively extending the time required to build up herd immunity [21].
It is clear that as countries enter different stages of the pandemic,
leaders must develop the courage to abruptly alter the course of the
health policy when needed. As new scientific evidence emerges rapidly,
it is prudent that policy makers regularly update their response to meet
this scientific evidence, learn from other countries’ responses and aim
to enhance their own. In doing so, they can adjust lockdown measures
in an accurate and timely manner and maneuver through implementation of NPIs appropriately.
Table 1
The Royal College Surgeons of England stratification of patients for surgery
[32].
Priority Level
Operation Timetable
Priority level 1a Emergency
Priority level 1b Urgent
Priority level 2
Priority level 3
Priority level 4
Operation needed within 24 h
Operation needed with 72 h
Surgery that can be deferred for up to 4 weeks
Surgery that can be delayed for up to 3 months
Surgery that can be delayed for more than 3
months
worldwide, emphasizing the need for prioritization [27,28]. One specific strain for surgical leaders is the need to risk-stratify elective surgery during the COVID-19 pandemic. Following the WHO declaration
of the pandemic, the United States Surgeon General advised the cancellation of all elective surgeries in hospitals to prevent the spread of
the virus [29]. However, the American College of Surgeons (ACS) later
advised the prioritization of surgical resources [30]. The organization
advised that each hospital should ‘review all elective procedures to
minimize, postpone or cancel elective surgery until the predicted point
in the exposure graph is passed, to support the healthcare infrastructure’ [30,31]. The careful consideration of which surgical procedures to perform during COVID-19 is of utmost importance, due to the
risk of spreading the virus further. The Royal College of Surgeons of
England provided advice on how to stratify surgical procedures during
the pandemic [32]. The guidance advised that prioritization of surgery
for patients should be according to a specific classification (Table 1).
The categorization of patients aims to help managers plan the allocation
of resources, allows surgeons to appreciate the needs of other surgical
specialties and facilitate the development of regional surgical networks
to sustain the delivery of surgery in a timely fashion [32].
The guidance highlights the importance of documenting the surgical
procedures that are deferred to plan for the increase in the time and
quantity of the surgical waiting lists [32]. The ACS similarly provided
guidance on the surgical prioritization of patients during the pandemic
[33]. The guidelines highlight that leaders of institutions should follow
a collaborative process to identify principles and frameworks for
prioritization, ensuring input from surgery, anaesthesia and nursing
[33]. The ACS recommends transparency of the framework utilized in
hospital institutions to ensure consistency, reliability and public assurance [33].
One critical aspect of surgical leadership during COVID-19 is to
provide roadmaps to ensure scheduling of elective surgery, when it is
safe to do so [34]. The ACS, American Society of Anesthesiologists,
Association of Perioperative Registered Nurses and the American Hospital Association provided a joint statement on April 17, 2020 to ensure
the smooth transition of rebuilding elective surgery following the end of
the pandemic [34]. The statement highlighted the need to consider
appropriate timing for reopening, COVID-19 testing within the facility,
case prioritization and scheduling. With the ongoing unknown timelines of COVID-19, it will be critical to design and implement clinically
relevant and patient-safe surgical management guidelines by the leaders of individual healthcare institutions [30].
2.6. Predictive mathematical modelling
Varying mathematical models have been formulated across countries, offering direction to governments regarding appropriate interventions. It should be noted, however, the utility of modelling largely
stems from its ability to define the effect of interventions rather than
providing precise quantitative predictions [22]. Nevertheless, the predictive function of mathematical modelling holds an important role for
governmental responses and target-setting.
Crucially, the values produced by these models are dependent on
the quality of the data employed. At the primordial stages of an epidemic, quality of data is limited by inconsistencies in national detective
efforts and inadequate documentation [23]. Indeed, execution of decisions without reliable data has been a key concern of epidemiologists
[24]. Moreover, even as many countries are in the midst of the pandemic, factors such as accuracy of tests, population characteristics, and
the possibility of reinfection add a layer of complexity when modelling.
Thus, when relying on models, attention should be paid to the key assumptions of the report – particularly, how sensitive to errors these
assumptions are.
A model released by the Institute of Health Metrics and Evaluation
(IHME) has purported specific predictions in relation to the US which
include the day on which cases will peak [25]. This model has subsequently been widely referenced by officials in Washington, D.C. as
guiding decisions for policy. Predictive modelling becomes further
complicated when faced with large countries, such as the US, as the
epidemic unravels differently in sub-populations. Variability in prevalence of comorbidities, age, environment, and genetic disposition
may result in a wide range of feasible outcomes which differ dramatically from state to state [26]. Indeed, the long-term mortality projection
for New York by the IHME model shifted upwards by 60% in under a
week at the end of March. This volatility and dynamic nature demonstrates the importance of avoiding the overinterpretation of models:
leaders should be appropriately circumspect in their claims when basing their communication on predictive mathematics.
3. Discussion
3.1. Ethical dilemmas
COVID-19 is raising many ethical medical dilemmas for the leaders
of healthcare institutions. Treatment rationing is one of the main problems that is faced among healthcare professionals [35]. With the surge
in cases it is unclear how the leaders should ration resources fairly,
particularly ventilators for patients on the intensive care unit [35].
Institutional protocols are one way in which healthcare professionals
can be guided to making such critical decisions [36]. On April 11, 2020,
2.7. COVID-19 surgical adaptation phases
The COVID-19 pandemic causes a challenge for the optimal and safe
surgical management of patients. Al-Jabir et al. summarise the vast
effects of the pandemic, spanning across all surgical specialties
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the American Medical Association (AMA) released guidelines, a code of
medical ethics for healthcare professionals during the pandemic [37].
The guidance provided criteria for limited resources by considering the
urgency of medical need, likelihood and anticipated duration of benefit
and change in quality of life following the treatment [37]. With the
shortage of PPE, physicians themselves will be asked to care for patients
infected with COVID-19 without sufficient protection, raising many
ethical dilemmas. The AMA guidelines discuss how physicians may
ethically decline to provide care if PPE is not available after considering
the anticipated level of risk. Unique circumstances of the healthcare
professional, including an underlying health condition, may justify the
refusal of care. The ACS provided some ethical framework for the allocation of resources in the event of shortages. The ACS advised the use
of well-known objective measures to predict mortality, to help guide
healthcare professionals treat individual patients [38].
During the crisis, leadership is of utmost importance in helping to
solve these medical dilemmas. The AMA advised that as leaders of the
healthcare team, such healthcare professionals should advocate for
resources and support [37]. The British Medical Association (BMA)
provided advice on medical dilemmas during the COVID-19 pandemic
[39]. The institution advised that senior leadership should make the
decisions on how resources are allocated in difficult situations [39]. The
decisions should be based on the best available evidence, agreed in
advance where practicable, communicated openly and transparently
and subject to modification and review as the situation develops [39].
Advice on which patients should be treated during the COVID-19
pandemic was also provided by the BMA. They advised that manager
and senior clinicians must set the thresholds for admission to intensive
care units and the use of highly limited treatments including mechanical ventilation.
3.3. Exemplar leadership
South Korea features on the list of countries that are being internationally lauded for their response against COVID-19. On April 30,
2020, South Korea revealed that they did not record any domestic cases
of COVID-19, for the first time since their peak on February 29, 2020
[43]. South Korea seems to have managed to turn the tide of COVID-19,
despite emerging as the second biggest virus hotspot, behind China, in
the first two months of this pandemic and despite South Korea’s
proximity to China, the epicentre of the COVID-19 pandemic [43].
Notably, South Korea achieved control over their outbreak without
imposing a nationwide lockdown and hence minimising the impact of
COVID-19 on their economy [43]. South Korea’s strategies to curb
COVID-19 were brought to fruition as a result of a combination of
strong national leadership and coordinated, intersectoral response [43].
Their key strategies included:
● Being prepared and acting quickly – Unlike several western
countries, South Korea didn’t take the threat of a COVID-19 outbreak lightly, partly due to its proximity to China but also due to the
bitter lessons learned from its Middle East respiratory syndromerelated coronavirus (MERS-CoV) outbreak in 2015 [43]. This is in
contrast to China where an outbreak of severe acute respiratory
syndrome (SARS) occurred in 2003 but according to Yanzhong
Huang, a global public health expert, China’s response to epidemics
“has not changed at all” and it responded to both epidemics with
“inaction, denial and deception” [44].
The aftermath of MERS-CoV outbreak saw the establishment of a
rapid response process for emerging infectious diseases such as the
emergency use authorisation (EUA) system by the Korea Centres for
Disease Control and Prevention (KCDC), the Korean Society for Laboratory Medicine (KSLM) and the Korean External Quality Assessment Scheme (KEQAS) [45]. In 2016, an external quality assessment (EQA) of the molecular diagnostics, carried out by nongovernmental South Korean medical laboratories, for Zika virus and
MERS-CoV was sponsored by KCDC and conducted by KEQAS. In
addition to evaluating the proficiency of molecular tests performed
by non-governmental medical laboratories for Zika virus and MERSCoV, recommendations were made to conduct regular EQA of nongovernmental laboratories involved in the diagnosis of emerging
infectious diseases in South Korea in order to bolster the capacity of
laboratories able to deal with new pathogens [46].
On January 7, 2020, Chinese authorities confirmed that a novel
coronavirus was behind the spike in pneumonia cases of unknown
aetiology seen in the country since early December 2019. On January 12, 2020, China shared the genetic sequence of this novel
coronavirus with the rest of the world [47]. By the time the first case
of COVID-19 was detected in South Korea on January 20, 2020,
South Korea had already developed a diagnostic test for COVID-19,
KCDC had established public-private partnerships for the development and execution of diagnostic tests to allow for rapid expansion
of testing capacity and Korean Food and Drug Administration had
expeditiously approved the use of these diagnostic tests for suspected cases [43].
● Testing – Diagnostic tests were rapidly rolled out across the country
by joining forces with local governments [43]. Both South Korea and
the US recorded their first case of COVID-19 on the same day in late
January; by March 25, 2020, South Korea had tested more than one
in every 150 people, in comparison to the US which had only tested
around one in every 780 people – this highlights how considerably
South Korea increased its testing capacity [48].
South Korea pioneered drive-through COVID-19 testing; this innovative method of testing is now being used by several countries
across the world [49]. Drive-through testing has several advantages;
traditional airborne infection isolation rooms (AIIRs) used for
testing would have limited South Korea’s testing capacity as a result
3.2. De-escalation strategies
De-escalation strategies are required to ensure that societies gradually return to normal practice. A number of considerations are required for successful implementation, since de-escalation that is too
rapid or inappropriately timed carries the risk of a rapid upsurge in
transmission. In particular, surveillance data and seroepidemiological
population surveys may be used to provide information on the extent
and speed of population immunity, which may guide subsequent decisions on de-escalation [40]. Large scale surveys may be achieved via
commercial SARS-CoV-2 antibody testing, on the collection of specimens at symptom onset, admission, and discharge. Such tests will additionally form a crucial element to informing first-line responders, key
workers, and healthcare professionals of their infection status and to
thereby guide safe return to work. Individuals having recovered or
endured an asymptomatic transmission may also be able to return to
employment without the risk of increased transmission.
For countries having implemented strict physical lock-down measures, a review of existing strategies to ensure the presence of adequate
contact tracing (to reduce the risk of disease re-emergence) is required
before de-escalation measures are employed. Since stringent physical
lock-down can be disruptive at both the societal and economical level,
placing further strain on existing nationwide issues, there are already
reports of individuals having failed to adhere adequately to these public
health recommendations, due to a so-called ‘isolation fatigue’ [41].
Since de-escalation requires the incidence of infection to be reduced to
very low levels, there is significant interest in formulating an effective
and logical approach to de-escalation with regards to physical distancing interventions. In order to mitigate the possibility of an unprecedented recurrence of increased transmission, inevitably placing
vulnerable populations at risk, such approaches should be mindful not
to prematurely uplift current bans [42]. Overall, de-escalation strategies should be based on existing public health principles and underscored by scientific evidence and advice.
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of limited availability of AIIRs as well as conventional testing procedure in AIIRs taking longer (~30 min) than drive-through testing
procedure which takes around 10 min [49]. In addition, drivethrough testing was devised to limit the exposure of healthcare
workers to the virus while taking samples for COVID-19 testing and
minimize the consumption of PPE [50].
● Tracing – In order to expand its contact tracing programme, South
Korea redeployed government health centre officers across the
country to rapidly create a temporary workforce of epidemiological
intelligence service (EIS) officers [43]. South Korea’s extensive
contact tracing programme allowed it to pick up several clustered
cases of COVID-19; for example: cases picked up among the members of the Daegu branch of Shincheonji Church of Jesus was linked
to patient 31 [51].
● Triage – In anticipation of a surge in the number of COVID-19 cases
and impending saturation of hospital capacity, a system of triage
was created. At the district level, district health centres/hospitals
were turned into triage centres assessing people with a fever or respiratory symptoms [43]. A group of university hospitals and university-affiliated hospitals with facilities such as negative pressure
intensive care units, ventilators, availability of extracorporeal
membrane oxygenation and the expertise of respiratory/infectious
disease specialists, were reserved for critically ill COVID-19 patients
[43]. Several general hospitals with negative pressure units and
respiratory/infectious disease specialists attended to severe but not
critically ill COVID-19 patients [43]. Non-clinical facilities were
turned into clinical facilities (e.g. accommodation facilities that
were previously used for vocational refresher training); this generated more beds that could be used as temporary isolation units,
staffed by healthcare workers, for mild to moderate COVID-19 cases
[43].
The healthcare system was divided into: COVID-19 healthcare
system and non-COVID-19 healthcare system; this was done to ensure that non-COVID-19 healthcare needs continue to be addressed
while the outbreak is managed [43]. COVID-19 healthcare system
was responsible for public quarantine, primary health care triage
and depending on severity of illness, admitting patients to primary
care level temporary isolation units for observation or transferring
patients to secondary/tertiary hospitals [43].
● Transparent communication with the public – South Korea’s
Deputy Minister of Health and Welfare and the Director of KCDC
held daily briefings to keep the public updated on the number of
new cases, number of people being treated, number of deaths and
regional distribution of cases; they also kept the public up to date
with South Korea’s COVID-19 response strategies and informed them
about any revisions to regulations [50].
In addition, South Korea used technology for contact tracing as well
as to facilitate open communication with the public. When a person
tested positive, their city/district alerted the people living nearby
via text messages and a detailed map of their movements, in the
days leading up to testing positive, was included; these maps were
generated using information gathered from patient/proxy interviews, mobile phone tracking, credit card transaction history and
CCTV footage [50]. These text message alerts allowed people to
judge their risk of contracting COVID-19 and encouraged them to
self-isolate or get tested [50]. Using technology for contact tracing
minimised the risk of recall or confirmation bias arising from patient/proxy interviews causing omissions of critical details; in addition, this transparent method of communication helped allay
public fear and confusion surrounding their risk of contracting
COVID-19 [52].
Transparent communication with the public is essential to build
public trust which in turn is important to ensure that the public
complies with government guidance. When South Korea rolled out a
campaign urging the public to wear masks, observe social distancing
and wash hands regularly, the public willingly obeyed these
guidelines, without the country having to impose a nationwide
lockdown [53]. Also, the panic buying observed in countries across
the world did not occur in South Korea which is a testament to the
fact that through transparent communication they were able to allay
public fear and build public trust [53].
However, using technology for contact tracing gave rise to privacy
concerns. There were concerns that the detailed map of movements
of COVID-19 patients may give away their identity and expose them
to social stigma; hence, there were worries that this might deter
people from coming forward to get tested [54]. In addition, there
were concerns that the businesses visited by COVID-19 patients
would be negatively impacted [50]. Having said that, there is
overwhelming public support in South Korea for publishing the map
of movements of COVID-19 patients; this was demonstrated by the
research carried out by Youngkee Ju, a health journalism researcher
in Hallym University, Chuncheon [54].
South Korea was able to turn the tide of COVID-19 through a range
of leadership strategies such as being prepared, acting quickly, transparent communication with the public, extensive testing and contact
tracing and effective triage and resource allocation. In addition to South
Korea, some of the other countries being widely praised for their leadership in combating their COVID-19 outbreak include Taiwan, New
Zealand, Germany and some nordic countries such as Iceland.
3.4. Lessons learned
The key leadership lessons learned during this global pandemic are
described below:
● Openly communicate with the public – This is perhaps the biggest
takeaway from this global pandemic. On March 19, 2020, China
reported that they did not record any domestic cases of COVID-19,
just over three months on from the emergence of COVID-19 in the
country [44]. However, China’s successful efforts in controlling its
COVID-19 outbreak are largely overshadowed by grave errors made
by China, in the beginning of the outbreak.
Under the rule of Xi Jinping, a culture of “lazy governance” arose in
China; inaction and paralysis on the part of Chinese officials grew as
a result of their fear to take initiative or risks. This set the scene for
the chain of events that took place in the beginning of the COVID-19
outbreak in China. On December 12, 2019, the first case of COVID19 was detected in Wuhan. Although, the WHO was notified by
China on December 31, 2019 regarding cases of pneumonia of unknown aetiology in Wuhan, China did not warn the public and
concealed the seriousness of the outbreak from the public and the
rest of the world. On December 30, 2019, Dr Li Wenliang warned
that the outbreak was caused by a SARS-like virus; however, he was
silenced by Wuhan authorities and was compelled to sign an
apology letter for “spreading rumours”. It is understood that president Xi Jinping knew about the outbreak by January 7, 2020;
however, he did not take any action until January 22, 2020 when he
ordered a lockdown of Wuhan and only then the public realised the
seriousness of the outbreak. During this period of 15 days of inaction
on the part of Xi Jinping, 5 million Wuhan residents travelled to
other Chinese cities and other countries [44].
Estimates suggest that between December 30, 2019 and January 22,
2020, 11,000 people from Wuhan left for Thailand, 10,680 for
Singapore, 9,080 for Japan and 7,000 for Hong Kong – recipe for a
global pandemic [44].
● Act early and decisively – This was a leadership strategy common
to most countries who successfully tackled their COVID-19 outbreak, including New Zealand.
New Zealand recorded its first case of COVID-19 on February 28,
2020. On May 4, 2020, New Zealand announced that they did not
record any new cases of COVID-19, for the first time since mid126
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M. Nicola, et al.
March; as of May 8, 2020, their total number of COVID-19 cases
stands at 1490 and their death toll stands at 21 [55].
New Zealand had already been asking all incoming travellers to selfisolate for 14 days; however, on March 19, 2020, New Zealand
decided to take the historic step of closing its borders to everyone
apart from citizens and permanent residents. Just under a week
later, on March 25, 2020, the country went into a nationwide
lockdown, although the total number of COVID-19 cases stood at
only 102 and the death toll was zero [55]. A few days before announcing a nationwide lockdown, under a month after recording its
first case of COVID-19, New Zealand calculatedly decided to follow
an elimination strategy to control its COVID-19 outbreak rather than
following the usual mitigation strategy [56].
In contrast, when the UK announced a nationwide lockdown on
March 23, 2020, their total number of confirmed COVID-19 cases
stood at 6,650 and death toll stood at 359 [57]. On May 10, 2020,
the UK had the second highest number of COVID-19 deaths in the
world, behind the US [58].
● Test, trace and isolate – Another feature shared by countries who
were successful in controlling their COVID-19 outbreak is their aggressive testing, tracing and isolating programme.
Iceland has one of the highest testing coverages in the world; approximately 13% of its population has been tested for COVID-19
[59]. This has been attributed as one of the factors behind Iceland’s
success in controlling its COVID-19 outbreak; the country recorded
its first case of COVID-19 on February 28, 2020 and as of May 4,
2020, their total number of COVID-19 cases stands at 1,799 and
death toll stands at 10 [59]. In addition to testing individuals who
are symptomatic, are close contacts of someone who tested positive
or have returned from a high-risk country, Iceland joined forces with
deCODE Genetics, a biopharmaceutical company based in the
country’s capital, to offer testing to asymptomatic individuals;
testing offered by deCODE Genetics was open to all Icelanders [60].
● Invest in pandemic preparedness – Some of the countries who
were successful in limiting COVID-19, were experienced in dealing
with outbreaks of infectious diseases. For example: South Korea
suffered from a MERS-CoV outbreak in 2015 and Taiwan suffered
from a SARS outbreak in 2003; subsequently, both countries invested in pandemic preparedness, which proved useful in their fight
against COVID-19 [43,61].
● Do not ignore any sections of the community; everyone living
within a country’s borders is at risk of contracting and transmitting COVID-19 – Earlier on during this global pandemic,
Singapore was hailed as a success story. On March 23, 2020, around
two months after the first case of COVID-19 was detected in
Singapore, the total number of COVID-19 cases stood at 509 and the
number of COVID-19 related deaths stood at 2 [62]. These admirable statistics, despite Singapore’s proximity to China, were a testament to Singapore’s exemplar leadership strategies which included
acting quickly, keeping the public informed, testing all pneumonia
patients, intensive care unit (ICU) patients and patients who died of
a probable infectious cause, contact tracing extensively, prompt
isolation of confirmed/suspected cases of COVID-19 and placing
close contacts under mandatory quarantine while placing lower-risk
contacts on phone surveillance [63]. However, certain oversights
made by the Singaporean government led to a surge of COVID-19
cases in Singapore; as of May 8, 2020, the total number of COVID-19
cases stands at 21,707 and the death toll stands at 20, making Singapore one of the worst hit countries in Asia [64]. Singaporean
leaders ignored the risk posed by densely populated dormitories,
housing low-paid migrant workers, where up to 20 workers live in
one room and hence acted as a breeding ground for the virus. Although this oversight made by the Singaporean government led to a
surge in COVID-19 cases, Singapore continues to marginalise these
workers; this is highlighted by how the Singaporean Ministry of
Health (MOH) splits the daily reports of the number of cases in to
cases in the community, cases among work permit holders who do
not live in dormitories and cases among work permit holders who
live in dormitories [65].
● Leading by example – Leadership in the UK was challenged as
several government officials and chief medical advisors [66] failed
to ‘lead by example’ with some being forced to resign following
criticism for breaking lockdown rules. Failing to maintain a consistent public health message triggered feelings of mistrust and loss
of faith in leadership. In the US, an example of split messaging arose
regarding face coverings; with the Centres for Disease Control and
prevention (CDC) [67] urging the population to use them and President Donald Trump refusing to do so [68], this split messaging led
to confusion and sparked fears around which precautions should be
implemented.
In the UK, calls have been made for focused public health messages
with a central resource ‘hub’ where common questions could be
curated and high quality information could be housed. With such
platforms, government and public health messages would be transmitted clearly and accurately, limiting the amount of ambiguity
around guidance.
4. Conclusion
The COVID-19 pandemic continues to cause worldwide turmoil
across all aspects of life. In response, current global leaders have taken
to numerous ‘best practice’ models and leadership strategies, aiming to
achieve rapid situation monitoring, viral mitigation and containment,
and the appropriate and adequate delegation of funds to areas of most
need. Moreover, such strategies have highlighted the importance of
being mindful of the ethical dilemmas that may arise. It is now clear
that exemplar leadership requires an amalgamation of characteristic
traits and unified actions capable of achieving an effective response
nationwide. In particular, compassionate, open, and highly communicative leaders foster a sense of purpose that can act to strengthen a
unified public health approach. The energy, focus, and resilience of a
leader also becomes a precious commodity. During times of unprecedented crisis, embracing adaptive capacity in evidence-based
strategies can help to establish long-standing resilience in the face of
COVID-19.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Data statement
The data in this review is not sensitive in nature and is accessible in
the public domain. The data is therefore available and not of a confidential nature.
Ethical approval
No ethical approval required.
Sources of funding
No funding received.
Author contribution
Maria Nicola, Catrin Sohrabi: Paper design, Conceptualization,
Resources, Writing original draft, Editing drafts, Approval of final article.
Ahmed Kerwan, Ahmed Al-Jabir: Conceptualization, Writing original draft, Editing drafts.
Ginimol Mathew: Conceptualization, Writing original draft, Editing
127
International Journal of Surgery 81 (2020) 122–129
M. Nicola, et al.
drafts, Approval of final article.
Michelle Griffin: Writing original draft, Editing drafts.
Maliha Agha, Riaz Agha: Editing drafts, Approval of final article.
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Guarantor
Riaz Agha – Senior Author mail@riazagha.com.
Declaration of competing interest
No conflicts of interest.
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