What defines outstanding primary care leadership?

11 features of effective leadership at primary care practices — from the MacColl Center’s LEAP project

In a time of global health crisis, health systems must rapidly adapt. Success requires good leadership. Since long before the COVID-19 pandemic, the MacColl Center for Health Care Innovation at Kaiser Permanente Washington Health Research Institute (KPWHRI) has studied leadership excellence, particularly in primary care. New results are in their recent paper in Milbank Quarterly.

“Primary care practices are complex environments,” says Brian Austin, associate director of the MacColl Center. “We asked what leadership attributes are critical at high-performing practices and how can they be taught?” Others from KPWHRI who worked on the study were Research Interventionist DeAnn Cromp, RN, MPH, Assistant Investigator Clarissa Hsu, PhD, MacColl Center Director Katie Coleman, MSPH, Research Associate Leah Tuzzio, MPH, and Emeritus MacColl Center Director Edward H. Wagner, MD, MPH. The first author is Benjamin Crabtree, PhD, from Rutgers Robert Wood Johnson Medical School.

The study team of MacColl Center researchers and their collaborators reviewed 9 known qualities of leaders in complex adaptive systems, which require constant creative problem-solving. The researchers then used data from the Learning from Effective Ambulatory Practices (LEAP) project to see how these qualities apply to leadership of high-performing primary care practices across the United States.

For LEAP, a team of MacColl researchers had previously visited and learned from 30 outstanding primary care practices around the country, from rural clinics to federally qualified health centers to clinics within large integrated systems. The visits explored how teams achieved superior patient and staff experience and high-quality care. Although each site had unique features, some traits could apply to many types of health care systems.

For the new study, the researchers asked: What leadership qualities support high-functioning, adaptable team-based care? They did an in-depth analysis of data from select LEAP practices that did particularly well on leadership and training scores. Their results confirmed the importance of the 9 known leadership attributes, for example being able to motivate others, create an environment of trust and mutual respect, and foster the next generation of leaders. The researchers also discovered the importance of 2 other leadership components at high-functioning primary care practices: anticipating the future and developing processes that build innovation into daily routines.

The top 11

The original 9 attributes are:

1. Motivating others to engage in change. Good leaders use reinforcement and reward and create an environment that maximizes internal motivation.

2. Managing abuse of power and social influence. Exemplary primary care leaders recognize and manage the power differentials in health systems, for example between physicians and staff.

3. Assuring psychological safety. Effective leadership promotes this attribute by encouraging input and problem solving by everyone.

 4. Instilling a collective mind. An organization with this trait has cohesive teams with common purpose and understanding.

5. Cultivating teamwork. Teamwork is how excellent leaders get people to work in groups effectively on specific tasks.

6. Enhancing communication and information sharing. Important components of this feature are using multiple communication methods that are formal and informal, written and verbal.

7. Generating a learning organization. In this type of environment, which includes learning health systems, all members enhance their capabilities to continually transform the organization.

8. Encouraging boundary spanning. Effective leaders encourage connection and information-sharing among groups and allow workforce flexibility.

9. Fostering emergent leadership. This attribute allows leadership to arise as needed from diverse organization members.

The new attributes identified in this study are:

10. Anticipating the future. Exceptional leaders look ahead for ways to innovate for future success, as difficult as that may be in this uncertain climate.

11. Developing formal processes. Well-led organizations know how to take innovations, whether processes or a team role, and build them into routines. 

The paper has multiple examples of how these properties manifested in top-performing primary care practices and how they improved the work environment and staff morale and retention. One of the most interesting parts of the paper, Austin says, are capsule descriptions of 9 very different primary care systems and what outstanding leadership looks like for them at the ground level.

Overall, Austin says, the intent of the paper is to build awareness among people who lead and set policies at health systems about the challenges of good leadership. The paper offers guidance on leadership attributes that are especially needed in these challenging times.

The main lesson, Austin says, is to be optimistic that across the country, “when we went looking for outstanding primary care leadership, we found it.” He added that the work “was one of the highlights of our professional careers and built a sense of optimism that systems can anticipate change, learn, and adapt.”

Other paper coauthors are Jenna Howard, PhD, Rutgers Robert Wood Johnson Medical School; William L. Miller, MD, MA, Lehigh Valley Health Network; and Margaret Flinter, PhD, APRN, from Community Health, Inc.

By Chris Tachibana