Hospital Infection Control

Leadership, management and politics: issues for health-care epidemiology

What are the key concepts related to leadership, management and politics?

Leaders are recognized by the number and dedication of their followers. Some of the qualities of leaders include their integrity and authenticity, their decision making in the face of controversy, their humanity and ethics, their sense of social justice, and their big ideas that transcend the daily concerns of the organization. Leaders are creative, provide the vision, and articulate the mission of the institution, and these skills are distinct from the managers' focus on making things happen. Leaders are recognized not by their answers but by their questions.

Leaders and politics are close companions, and in this context politics refers to the effective management of the interests of diverse stakeholders.

Managers - in contrast to leaders - focus on ensuring that policies and practices are adhered to in an efficient fashion. They have the responsibility of setting up the metrics by which an effective program will be measured.

What principles need to be adhered to for effective infection control?

The leader must prioritize the key goals, articulate their value, and support the vision with thoughtful statements based on the best available data. Leaders are by nature optimistic and effective communicators who seek to do more than most people think is likely. Former Secretary of State, Colin Powell said that "Leadership is the art of accomplishing more than the science of management says is possible".

What are the conclusions of clinical trials or meta-analyses that guide infection control practice and opinion?

Unfortunately, no prospective controlled studies have evaluated the roles of leaders and managers or their interactions with politics. The fact that there are thousands of books on leaderships attests to the difficulty of identifying traits that easily predict good leaders.

What are the consequences of ignoring key leadership, management, and political principles and concepts?

Failure to lead can result in failure of the infection control program with a poor understanding of the goals and a poorly responsive management team. This can be associated with increased infection rates and also job-related infections among health care providers. As a result there could be a loss of confidence of the staff and a deterioration of good practice. The possibility of poor publicity, failure to pass a joint commission review and of increased malpractice suits also exist at this time.

What other information supports the key studies, e.g., case control studies and case series?

Although no systematic studies have examined the role of leadership in poor outcomes in hospitals and clinics, a large number of individual case reports would seem to be the current evidence supporting the relationship.

Summary of current controversies.

Controversies regarding leadership surface prominently at the time of recruitment when the search committee formulates its vision of the ideal candidate. Search committees should be schooled on the definition of leadership, the attributes of leaders, and how to recognize the exceptional leader. If they fail to define leadership correctly, they may be looking for a "distinguished investigator", an "accomplished teacher", or a "proven clinician". A leader may in fact have one or more of these attributes, but none of them alone defines a leader. Search committees rarely ask the question, what is a leader?

What is the impact of leadership, management, and politics on infection control?

Talented infection control personnel with strong epidemiological skills will be critical to a successful program. However, a great program will have a leader with a vision, a management team to provide the detailed support essential to get the job done, and the political skills to navigate the many varied interests of the constituents. This author recommends a yearly review of the current vision, management activities, and political challenges and responses. An important question for great programs is, "what big ideas do we have in focus?"

At the annual review of the program leaders and managers may ask, are we are on track? A key review for managers is to examine the last twelve months' minutes of the Infection Control Committee: How many decisions were made? Some institutions will find that none were made, each meeting ending with a note stating that more data is needed. This culture of indecision needs correction.

Is the program meeting measurable milestones that had been set up earlier? Is the team responsive to current needs? In that respect a balanced scorecard may be a starting point. Do we have a viable business plan? Do we have highly effective teams? The latter question is best viewed in light of the book by Katzenbach and Smith, The Wisdom of Teams. There, the authors define a team as a “small number of people with complementary skills who are committed to a common purpose, performance goals, and an approach for which they hold themselves mutually accountable". They go on to define a "high performance team" as one in which the members are deeply committed to each other's growth and success. This definition is much different than one for a committee or task force that meets occasionally but lacks the critical attributes of a high performance team, especially the commitment to each other's goals. Members of a high performance team often are housed together and have a great deal of interaction on most days. This is an argument for the geographic clustering of all members of the Infection Control Team.

Managers need to ask if they have the pulse of the institution, and if they know what people think works and does not work? This is to suggest that managers learn by "walking around" the institution, not staying in their office glued to the computer. Management by walking around is sound advice popularized by Tom Peters. Ideally all managers would also have had an important experience themselves in the field before the promotion to management. It is in the field that one encounters the reality of uncertainty. In a telling remark in his book, Zen and the Art of Motorcycle Maintenance, Robert Pirsig addresses a serious flaw in education:"The trouble with school-taught mechanics is that they know everything except how to handle something new". That statement should not be said of effective managers in Infection Control.

A separate question might be; do most people in the institution have a clear understanding of the vision of the Infection Control Program? Do they have a sense of the varied management activities that support the vision, and do they appreciate the efforts to meet the goals of the many diverse stakeholders?

Controversies in detail.

The major confusion that exists in hospitals relates to a misunderstanding of leadership and its differentiation from management. The best leaders are free thinkers who provide a culture that seeks excellence, and they are not restricted in their thoughts by established conventions. By definition they will be at odds with some managers who exist to keep all staff members focused on the existing thinking of the institution.

Leaders provide the energy, develop the management team, and provide a perspective on important issues challenging the institution. One measure of leadership skills relates to the major decisions made by the leader. Were they wise, and did they lead eventually to outcomes favorable to the entire program and its constituents?

In contrast to leaders, managers oversee the systems and the individuals who accomplish tasks, and they perform the measures of success or failure. Managers make things happen in a complex organization. Managers also oversee the costs of the program, wisely preserving the financial assets.

Note that nothing in the definition of an accomplished investigator, a teacher with a history of successes or an outstanding clinician defines a leader or a manager. Yet far too often these are labels that senior administrators link to both. Most institutions never examine the definitions of leaders or managers.

References

Charan, R. "Conquering a Culture of Indecision". Harv Business Rev April. 2001. pp. 75-82.

Katzenback, JR, Smith, DK. "The wisdom of teams". New York: Harper Business. 1994.

Pirsig, R. "Zen and the Art of Motorcycle Maintenance: An inquiry into Values". William Moprrow. New York. 1974.

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