Explain the significance and impact of leadership in promoting well-being
Measure and improve leader behaviors to improve team satisfaction and reduce burnout
Leaders matter. They matter for a thousand reasons. Quiz Ref IDBehaviors 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.
Measure Core Leadership Behaviors
Assess and Share Results
Provide Growth and Development Opportunities
Standardize and Scale Across the Organization
Build a Culture of Trust and Communication
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).
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. Quiz Ref IDEffective leaders must perform well from both the perspectives of their team members and the organizational leadership.
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).
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.
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:
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.
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
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 4).4
How should an organization respond if a leader has a low score that does not improve despite opportunities for leadership development, mentorship, and coaching?
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.
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
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
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.
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
Journal Articles and Other Publications
Swensen SJ, Shanafelt TD. Agency action: measuring leader behaviors. In: Mayo Clinic Strategies to Reduce Burnout: 12 Actions to Create the Ideal Workplace. Oxford University Press; 2020: 105-120.
Swensen SJ, Shanafelt TD. Coherence action: selecting and developing leaders. In: Mayo Clinic Strategies to Reduce Burnout: 12 Actions to Create the Ideal Workplace. Oxford University Press; 2020: 169-180.
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About the AMA Professional Satisfaction and Practice Sustainability Group
The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity, and reduce health care costs.
Disclaimer: AMA STEPS Forward® content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward® content provides information on commercial products, processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward® content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward® content.
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