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Cultivating LeadershipMeasure and Assess Leader Behaviors to Improve Professional Well-Being

Learning Objectives
1. Explain the significance and impact of leadership in promoting well-being
2. Measure and improve leader behaviors to improve team satisfaction and reduce burnout
0.5 Credit
Interactive Module

Leaders matter. Amidst all the qualities of an organization—its culture, high-level organizational strategy, compensation models, benefits, efficiency of the practice environment, and the impact of the electronic health record—the single biggest driver of professional satisfaction for the people in an organization is the behavior of each individual's immediate leader. Learn the steps to take to implement and maintain a successful leadership development program to decrease burnout and improve professional satisfaction.

Cultivating Leadership: Behind the Module

Go behind the scenes with Author Stephen Swensen, MD, on making the module, “Cultivating Leadership”.

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Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

Module Transcript

How Will This Module Help Me?

Learning Objectives:

  1. Explain the significance and impact of leadership in promoting well-being

  2. Measure and improve leader behaviors to improve team satisfaction and reduce burnout


Leaders matter. They matter for a thousand reasons. Behaviors of leaders set the foundation of organizational culture, which is a powerful driver of well-being for health care professionals.1 In addition to shaping organizational culture, leaders directly support and nurture the well-being of their team members.2 Furthermore, the personal well-being habits of physician leaders (ie, actions to prevent burnout, finding ways to increase professional fulfillment, and self-care practices) are associated with their leadership effectiveness.3 Amidst all the qualities of an organization—its culture, high-level organizational strategy, compensation models, benefits, efficiency of the practice environment, and the impact of the electronic health record—the single biggest driver of professional satisfaction for the people in the organization is the behavior of each individual's immediate leader.

By implementing a validated approach to measure and improve leader behaviors, organizations can develop strong leaders at all levels, and collectively engender improvement in team satisfaction and decrease in burnout.2,3 For success, there should be an accountable organizational leader or office that takes the lead in implementing and shepherding the organization through improving leader behaviors (eg, Office of Leadership and Organization Development, Associate Dean, Chief Wellness Officer, Human Resources Executive). In health care, effective leadership to promote well-being has even greater significance: by achieving well-being for health care professionals, leaders, in turn, secure the well-being of the patients under their care.

Five STEPS to Cultivate Leadership that Promotes Health Care Professional Well-Being

  1. Measure Core Leadership Behaviors

  2. Assess and Share Results

  3. Provide Growth and Development Opportunities

  4. Standardize and Scale Across the Organization

  5. Build a Culture of Trust and Communication

STEP 1: Measure Core Leadership Behaviors

Studies demonstrate a relationship between leadership behaviors and esprit de corps (ie, camaraderie, engagement, and professional fulfillment).2 To gain understanding of leadership and team member relationships, senior leaders should solicit evaluations of the frontline leaders in their organizations. Physicians and team members should be asked to assess their immediate leader's behaviors once a year. Assessment questions should focus on leader actions and interactions with the team members, not necessarily if the leader is “liked.” These questions should be used in the context of a comprehensive assessment and development program for leaders (eg, senior leader feedback, work unit safety, patient experience, productivity, morale, and climate measurements).4,5 Using the results of leader assessments ensures that time, attention, and resources can be optimally deployed to drive improvement and engender esprit de corps.

The Mayo Clinic Leader Index is a validated assessment developed by Mayo Clinic that has been in use for at least 7 years across multiple organizations.2 During the assessment, each health care professional is asked 12 questions about their direct-report leader. Each item is scored on a 5-point scale, with a score of 1 being "strongly disagree" and a score of 5 being "strongly agree." The scores for the 12 individual items are summed to yield a total leader behavior score from 12 to 60. In a large study of physicians, higher scores on the Leader Index correlated to higher rates of esprit de corps and lower rates of burnout.2 In fact, for every 1-point increase on the 60-point scale, there was a statistically significant 3.3% decrease in the likelihood of burnout and a 9.0% increase in the likelihood of professional fulfillment and satisfaction among physicians.2 The Leader Index explained approximately 10% of the variation in burnout and 50% of the variation in satisfaction across work units. Subsequent studies deploying the Leader Index in a sample of more than 40 000 medical center employees across all occupations had similar findings.6 Due to high levels of correlation between several items, the Leader Index was subsequently shortened to a 9-item version, making it even easier to administer (Figure 1).

Figure 1. Mayo Clinic Leader Index Questions

Description: A graphic representation of the Mayo Clinic Leader Index listing each of the 9 survey prompts on the left with a corresponding 1–5 rating scale (with 1 indicating “strongly disagree” and 5 indicating “strongly agree”) on the right. The text content of the graphic is as follows:

The leader to whom I report…

  1. Holds career development conversations with me

  2. Empowers me to do my job

  3. Encourages employees to suggest ideas for improvement

  4. Treats me with respect and dignity

  5. Provides helpful feedback and coaching on my performance

  6. Recognizes me for a job well done

  7. Keeps me informed about changes taking place at (name of organization)

  8. Encourages me to develop my talents and skills

  9. Overall, how satisfied are you with (name of immediate supervisor)

©2015 Mayo Foundation for Medical Education and Research. For permission to use please contact MedEd Web Solutions at Dr Shanafelt is a co-developer of the Leader Index and may receive royalties from the licensing of this tool.

Historically, frontline leaders at Mayo Clinic were evaluated each year by their own supervisors (ie, senior/executive leaders) using an annual comprehensive assessment. Senior leaders rated frontline leaders on their ability to deliver expected results of the operational plan on a similar scale of 1 through 5. After the aforementioned research demonstrated the importance of leader behaviors and actions as rated by those they supervise on physician well-being, the Leader Index was added as a complementary dimension to the annual comprehensive assessment by their own supervisors. This addition brought to light that some leaders scored high on delivering results but poorly on leader behaviors and vice versa. Effective leaders must perform well from both the perspectives of their team members and the organizational leadership.

STEP 2: Assess and Share Results

Tabulate evaluation results to yield the aggregate leader behavior score for each leader. Then share results with the leaders who were evaluated in a psychologically-safe manner. It is ideal for work unit leaders to confidentially receive their results from a senior leader with whom they have an ongoing relationship. The senior leader can provide the personal feedback on individual leader evaluations as well as aggregate, de-identified results for leaders in similar positions for context (Figure 2).

Figure 2. Sample Leader Index Report

Description: A scatter plot where plotted points form the rough outline of a typical bell curve. The X-axis is divided into 7 subsections. The bell curve peaks between the 4thand 5thsections; a black arrow indicates a point on the descent of the bell curve in the 6thsubsection. Accompanying explanatory text reads:

Each dot represents the Index score for a leader. Annual Leader Index assessments tend to have a bell-shaped distribution. Each year a senior leader would meet with department and division chairs individually to share their results (black arrow) in the context of the scores for other department or division chairs. Each chair would develop an action plan to improve their Leader Index for the upcoming year. Improvement strategies included sharing goals with the members of their work group, attending a Leader Index workshop, and working with an executive coach.

STEP 3: Provide Growth and Development Opportunities

Most leaders want to improve and become as effective as possible in their role. The purpose of assessment is not to rank leaders or castigate those with lower scores, but to help individuals become better leaders. Therefore, as a part of the feedback sessions, it is important to offer each leader opportunities to improve. Common professional development opportunities may be:

  • Executive coaching

  • Peer-leader support discussion groups

  • Leader behavior workshops targeting behaviors specific to attaining professional fulfillment

  • Mentorship opportunities from leaders within the organization

Leaders at Mayo Clinic who improved their Leader Index score demonstrated more fulfillment and had happier and more engaged team members.4 Mayo Clinic found that many leaders share their index results with their department or division and transparently set an improvement goal for 1 or more leader behaviors with the team members who will be evaluating them on the next survey.

Interactive 1. Five Leader Behaviors to Cultivate Positive Leadership

The 9 items of the Leader Index evaluate 5 general categories of behavior. All 5 Behaviors build esprit de corps for the team and increase individual well-being.

Description: A flash card interactive activity feature 5 cards, each with one of the following 5 Behaviors (all caps) on one side and their corresponding meaning in the context of cultivating positive leadership (sentence case) on the other:

  • INCLUDE: Treat everyone with respect and nurture a culture where all are welcome and are psychologically safe.

  • INFORM: Transparently share what you know with the team.

  • INQUIRE: Consistently solicit input from those you lead (participatory management).

  • DEVELOP: Nurture and support the professional development and aspirations of team members.

  • RECOGNIZE: Express appreciation and gratitude in an authentic way to those you lead.

© 2015 Mayo Foundation for Medical Education and Research. For permission to use please contact MedEd Web Solutions at Dr Shanafelt is a co-developer of the Leader Index and may receive royalties from the licensing of this tool.

Successful organizations select and develop leaders for behaviors that fit their culture. These behaviors are suited to organizations who aspire to treat their team members as colleagues and build trust in each other. Organizations that have focused on developing these leader behaviors report substantive morale turnarounds in units that are facilitated solely by a change in the behavior of the department or division leader. When a leader authentically exhibits all 5 actions, a trusting environment can be nurtured. A trusting environment is one of the most valuable characteristics of high-functioning organizations and companies.5

Exemplifying the behaviors of the Leader Index requires leaders to be:

  • Confident in their position

  • Lead with participative management

  • Willing to tackle difficult problems

  • Bold enough to explore diverse views regarding new approaches and solutions

[Unlabled Image]

Description: A graphic representation of a dictionary entry for “participative management;” the text reads as follows:

  • par·tic·i·pa·tive man·age·ment \pär-‘ti-s∂-p∂-tiv’ ma-nij-m∂nt\ variants: or participatory management

    n. a management style in which stakeholders at all levels of an organization participate in the analysis of problems, development of strategies, and implementation of solutions

McMillan A, DuFrene D. Participative management. Reference for Business. Accessed October 24, 2020.,strategies%2C%20and%20implementation%20of%20solutions.

STEP 4: Standardize and Scale Across the Organization

Organizations may begin this journey by assessing leaders in a subset of the organization, for example only executives or physician leaders. As improvements and growth are realized, organizations can scale to leaders across the system at all levels of leadership and management.6 Standardizing measurement across an organization can help executive leadership have a more balanced and accurate assessment of the leadership capabilities and insight into which dimensions of professional development would be most helpful to each leader (Figure 3).4

Figure 3. A Standardized Process to Foster Improved and Consistent Leader Behaviors

Description: A 5-column graphic demonstrating a standardized process to foster improved and consistent leader behaviors. Each column focuses on 1 step of the process, including the name of the step, a brief description, and a icon representing the step. From left to right, the text and icon content are as follows:

  1. Measure

    Obtain a baseline for each leader by including the Leader Index in an annual staff survey.

    Icon: Measuring tape

  2. Share

    Provide the results of the Leader Index survey to each leader confidentially in a personal and supportive conversation. Consider also sharing information such as a percentile score showing how their score compares to those of other leaders in the organization. The leader should know that their leader behaviors are important to the organization and will be reassessed annually.

    Icon: Standard social media “share” icon

  3. Set Goals

    Set realistic targets for improving weak areas. For example, as an individual target, a leader could be asked to improve their listening skills using the INQUIRE behavior. All leaders should be informed that they are expected to have scores from the annual comprehensive assessment (as determined by their own supervisor) and the Leader Index (as determined by those they lead) within a designated range by the next annual assessment.

    Icon: Arrow striking bullseye in target

  4. Improve

    It is possible to improve leader behaviors with self-awareness and training. Ask leaders to commit to improving in 1 or 2 areas where scores were not optimal. Offer support and opportunities for development, such as workshops, seminars, online modules, mentoring, and executive coaching. It is helpful for leaders to be transparent with their team on their goals to improve specific behaviors.

    Icon: Person climbing mountain

  5. Imbed

    Incorporate accountability for the Leader Index into performance evaluations. If leader compensation includes an incentive component, the Leader Index should be one component of the formula.

    Icon: Hand imbedding smaller gear amid two larger gears


How should organizations respond if a leader's low score doesn't improve?

Leaders should be given support, resources, coaching, and mentorship to improve. This process can take 1–2 years but almost all leaders who sincerely attempt to improve are able to do so. You can expect substantial improvement within months that will be reflected in the annual staff survey.

If the leader does not improve over 1–2 years, it may mean that an individual is not motivated to improve or is unwilling to be accountable for the behaviors being evaluated. Or it could mean that they are not able to learn and practice these behaviors for various reasons. In such cases, ineffective point-of-care leaders should not be allowed to derail the organization's commitment to improving culture, trust, upholding a standard, and ultimately creating esprit de corps. Some people may have excellent professional skills but may not be cut out to be leaders.

STEP 5: Build a Culture of Trust and Communication

The best relationship health care professionals can have with the leader they report to is characterized by trust and fostered by ongoing weekly, monthly, or quarterly dialogue that includes appreciation, feedback, and support. The ongoing relationship between health care professionals and their leaders should also include an annual performance review. The annual performance review is a natural place for leaders to model the 5 Leader Behaviors and can be a good opportunity to nurture a partnership between the health care professional and their leader.7

Interactive 2. Actions to Organize Annual Review Conversations

Description: A process interactive activity featuring “slides” with the following text content:

  • Introduction

    The annual conversation between senior/executive leadership and the health care professionals who report to them is an opportune time to model good Leader Behaviors and organize the dialogue around these 5 actions: Include, Inform, Inquire, Develop, and Recognize.7

  • ACTION 1


    Ensure that the team member feels included and comfortable with your words, body language, and actions.

  • ACTION 2


    Communicate all the information that is appropriate for this one-on-one encounter transparently.

  • ACTION 3


    Ask what brings them joy. Organizations have found that few leaders know what the most meaningful area of work experience is for each of the health care professionals on their team (eg, caring for patients in a certain demographic group or with a specific disease, quality improvement work, multi-disciplinary care team assignments, community outreach, teaching medical students or residents, or leadership). Leaders frequently make basic and incorrect assumptions and may project them broadly to all team members. For example, they may assume a specialist in a given discipline is equally passionate about all disease or all activities related to that specialty or mastering a specific disease when what they may care about is patient education/empowerment or mentoring junior faculty. It may be helpful to have health care professionals complete a brief reflection to facilitate introspection and a discussion of values and motivators before the annual review. Informed by this discussion, leaders can then work collaboratively with the team member to explore how that interest may be developed, such as through training, coaching, mentorship, building new skills, taking on new duties, or taking postgraduate courses. Together, the leader and health care professional can explore how this interest may be harnessed to serve the needs of the unit, and whether there are opportunities to expand the proportion of time dedicated to the area of interest—all of which decrease the chance of burnout.

  • ACTION 4


    Every session should include dialogue about annual and career goals. Create a plan to accomplish them together.

  • ACTION 5


    The annual review is a perfect setting to express gratitude for specific accomplishments or action of the team member.

With deliberate intention and, in the context of a year-long, leader-health care professional dialogue and relationship, the annual performance review can be a compelling way for leaders to demonstrate the 5 Leader Behaviors, build alignment, nurture esprit de corps, and reduce burnout.


Leader behaviors affect the sense of well-being, professional fulfillment, and job satisfaction of the team members who report to them. A standardized, organization-wide assessment can help leaders understand their behaviors and how their direct reports perceive and respond to them. Through measurement and organizational support, leaders will be aware of what they are doing well so they can keep doing it while also accessing resources to improve in areas that are lagging. Leaders who are empowered to lead with and model good behaviors can change organizational culture for the better and promote team well-being.

AMA Pearls

  • Effective leadership has a profound impact on the well-being and satisfaction of health care professionals and ultimately patient care.

  • Evaluation of frontline leaders by those they oversee followed by feedback and development opportunities is essential for organizational well-being.

  • Five simple Leader Behaviors (Include, Inform, Inquire, Develop, and Recognize) can dramatically improve the professional fulfillment of health care professionals

Further Reading

Journal Articles and Other Publications

Shanafelt  TD, Schien  E, Minor  LB, Trockel  M, Schien  P, Kirch  D.  Healing the professional culture of medicine.  Mayo Clin Proc. 2019;94(8):1556–1566. doi: 10.1016/j.mayocp.2019.03.026Google ScholarCrossref
Shanafelt  TD, Gorringe  G, Menaker  R, et al.  Impact of organizational leadership on physician burnout and satisfaction.  Mayo Clin Proc. 2015;90(4):432–440. doi: 10.1016/j.mayocp.2015.01.012Google ScholarCrossref
Shanafelt  TD, Makowski  MS, Wang  H, et al.  Association of burnout, professional fulfillment, and self-care practices of physician leaders with their independently rated leadership effectiveness.  JAMA Netw Open. 2020;3(6):e207961. doi: 10.1001/jamanetworkopen.2020.7961Google ScholarCrossref
Swensen  SJ, Shanafelt  TD.  Mayo Clinic Strategies to Reduce Burnout: 12 Actions to Create the Ideal Workplace. Oxford University Press; 2020.
Swensen  SJ, Gorringe  G, Caviness  J, Peters  D.  Leadership by design: intentional organization development of physician leaders.  J Manag Dev. 2016;35(4):549–570. doi: 10.1108/JMD-08-2014-0080Google ScholarCrossref
Dyrbye  LN, Gorringe  G, Major-Elechi  B, Hayes  JT, Fraser  CH, Buskirk  SJ, West  CP.  Relationship between organizational leadership and health care employee burnout and satisfaction.  Mayo Clinic Proc. 2020;95(4):698–708. doi: 10.1016/j.mayocp.2019.10.041Google ScholarCrossref
Shanafelt  TD, Swensen  SJ.  Leadership and physician burnout: using the annual review to reduce burnout and promote engagement.  AM J Med Qual. 2017;32(5):563–565. doi: 10.1177/1062860617691605Google ScholarCrossref

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