REFLECTION

Co-leadership in health services: a dyad case study

Abraham Rudnick, MD, and Patrick Daigle, MSW 

Providing health services is complex. In the Canadian public sector, such services commonly involve formal co-leadership dyads of physicians and administrators, yet not much is published about these arrangements. This article aims to address this gap in knowledge by briefly reviewing related publications and then describing and reflecting on a co-leadership dyad in specialized mental health services. The article illustrates associated quality assurance and improvement activities and their outputs and presents reflections on pertinent challenges and opportunities for co-leadership, concluding with suggestions for related progress across mental and other health services. 

KEYWORDS: co-leadership, dyad, mental health, services

Rudnick A, Daigle P. Co-leadership in health services: a dyad case study. Can J Physician Leadersh 2023;9(3):78-83

https://doi.org/10.37964/cr24773 

Health services address complex issues. For example, patients often experience comorbidities and other complicating factors (such as social disadvantage) that require a combination of various types of health care (and sometimes social) services. Such multiple services are ideally integrated or at least collaborative. As a result, health services — particularly public health services, such as those in Canada — commonly involve formal co-leadership dyads pairing physicians and administrators, who are expected to be person-centred, evidence-informed, and socially responsible.¹ 

Such dyads typically divide labour, with the physician leader most responsible for quality of clinical care and the administrator more responsible for the service budget, human resources (other than physicians), and more. The physician and administrator are expected to collaborate fully with each other. For example, in terms of quality improvement (QI), the physician may lead the safety assurance part of the initiative, the administrator may lead its efficiency enhancement part, and both may jointly lead its culture change part.²

Co-leadership of physicians and administrators seems important in health services. Yet not much is published about it, at least not the dyad aspects involved, with a few exceptions that do not involve rigorous inquiry.³ For example, co-leadership activities and their outcomes are implied yet not focused on in much work related to clinical practice standards⁴ and health care technology.⁵ Furthermore, physicians (and administrators) are often not formally trained in co-leadership.^6,7 

This article aims to address this gap in knowledge by describing and reflecting on a particular co-leadership dyad in specialized mental health services. We illustrate associated QI activities and their outputs, and then reflect on pertinent challenges and opportunities for co-leadership, concluding with suggestions for related progress across mental and other health services. 

Background

The co-leadership dyad discussed here is based at the Nova Scotia Operational Stress Injury Clinic (NSOSIC), which is part of the Nova Scotia Health Authority (NSHA) and is affiliated with Dalhousie University. This federally funded specialized mental health service is part of a national network and provides mental health related assessments and interventions to members of the Canadian Armed Forces (CAF) who are soon leaving the military, CAF veterans, and Royal Canadian Mounted Police members and retirees.

The NSOSIC provides clinical biopsychosocial care, including nursing intake, psychiatric and psychological evaluation, psychotropic medications management, individual and group psychotherapy (trauma focused and other), occupational therapy (e.g., for daily functioning, neurocognition, pain, and sleep), and physical care for Veterans Affairs Canada clients with operational stress injury).⁸ Its services are evidence-based/informed and person-centred.⁹ It also provides training to medical learners and other health care professionals and leads as well as collaborates in research.^10-12 The NSOSIC started offering services in 2016. Its clinical director (AR, who is a psychiatrist and a physician leader) and program leader (PD, who is a social worker and an administrator) have been co-leading it since 2018. 

Since its inception, the NSOSIC has been federally mandated to provide core services, such as disability (re)assessments and trauma-focused (psycho)therapies. As well, it has been federally mandated to use standardized mental health outcome measures for clinical monitoring and program evaluation. The NSOSIC is permitted to add clinical interventions at its initiative, such as other evidence-based/informed psychotherapies, and it is expected to collaborate with its clients’ other health care providers, such as primary care providers, private-sector psychotherapists, and residential mental health care facilities. 

Quality improvement activities and outputs

Soon after we started co-leading the NSOSIC, it became clear that we had to formalize a collaborative division of leadership labour as well as develop processes and structures to support NSOSIC in continuous QI. As part of this, we recruited a half-time clinical team lead (a clinical social worker) to further support the non-physician clinicians (the clinical director supervises the physicians). We then clarified the division of labour (and partial overlaps) between the NSOSIC’s program leader, clinical director, and clinical team lead (Table 1). 

We also re-configured and formalized standing committees and ad hoc task forces, including a quality assurance and improvement committee, an education committee, a research committee, and a client and family advisory council. We initially each chaired or co-chaired some of these committees and their task forces, but, over time, we delegated some chairpersonship to other team members with ongoing guidance by us as needed. We also initiated a logic model with the team and other stakeholders and completed its first version, which is revised as needed. These and more were general QI activities and their outputs helped the NSOSIC prepare well for more specific QI initiatives. 

A specific QI activity that we led was a rapid shift to online/virtual health care soon after the COVID-19 pandemic started. As in the first stage of the pandemic no in-person care was allowed by the NSHA other than what was absolutely necessary, we provided and arranged clinical guidance and practical support for all the clinicians to work from home. PD was the main lead for this process, as the main challenges were administrative. Before the pandemic, few NSOSIC clients received remote care, but during the first stage of COVID-19 the vast majority received this remote care.⁵ Subsequently, more NSOSIC clients have been choosing to return to in-person care, although a small majority of clinical encounters are still remote. 

Another specific QI activity that we led was peer review of clinical documentation by the psychiatrists. AR was the main lead for this process, considering that the main issues involved were primarily clinical. Another NSOSIC psychiatrist contributed considerably to this process, for example by adapting a pre-existing template to document the peer reviews, and all NSOSIC psychiatrists contributed to planning with input from all other interested team members. This activity was implemented as a pilot project and met the expectations of the psychiatrists involved. Unfortunately, it was paused because of a temporary reduction in the number of NSOSIC psychiatrists and, hence, their increased clinical workload (to be reviewed in 2024). 

A QI activity that we led equally was enhancement of outcome measurement completion and review by NSOSIC clients and clinicians, respectively. This is a federal requirement with related periodic national comparisons of operational stress injury clinics across Canada, as outcome measurement has been shown to improve mental health care and its outcomes.¹³ The NSOSIC had historically not done well (< 50% implementation) on this metric. Hence, we engaged an external facilitator for a year to increase the level of implementation, and we also tasked the clinical team lead to address implementation regularly with each clinical team member (other than the psychiatrists as AR is their clinical supervisor). To date, the NSOSIC has made considerable improvements in terms of clinicians’ reviews of outcome measures completed by clients, but not yet in relation to clients’ completion of outcome measures. A change for clients may be more complex than for clinicians, perhaps because they are busy with many other things in their lives, and, hence, a more complex approach may be needed to improve their rate of completion of outcome measures. 

Finally, a QI activity that we led equally but differently is a multi-year education/training plan for NSOSIC clinicians (with less focus on the psychiatrists who typically have less time and less need for such clinical capacity upgrading compared with other clinicians). Turnover of clinicians is expected at the NSOSIC, and the evidence base of care for people with operational stress injury continues to change. Hence, the NSOSIC must plan education and training in core practices as well as in emerging and promising practices for the clinicians. In this activity, AR focused primarily on the clinical practices involved, whereas PD focused on the administrative process. Together we engaged the NSOSIC’s clinical team and some of its clients and family members, as well as external content experts, to develop this plan, which is has been put into practice and will be revisited periodically as needed. 

Although we have led other QI as well as quality assurance activities as a dyad, those noted above illustrate our co-leadership, especially our QI activities and their outputs. For the purpose of this article we particularly addressed activities and outputs, recognizing that other aspects of leadership, such as inputs, outcomes, and costs, are also important to report for other purposes. 

Reflections

To date, our experience in co-leadership has been satisfying and successful. We may have learned from past dyads to prevent unnecessary conflict between us while challenging each other to address our individual and joint blind spots and other biases. We also complement each other’s strengths. Yet, there are opportunities for us and others to develop further as a dyad. A few examples are noted below in relation to such expected growth. 

First, either of us can sometimes act without sufficiently consulting the other on matters that are pertinent to both of us in our NSOSIC leadership roles. This may be related to emergent situations, although it may help to keep in mind the adage that urgent issues are not necessarily important, as that may help to prevent unnecessarily acting in the moment in some of these situations. 

Second, having a more pre-planned agenda for our dyad meetings may help too. To date, we have held regular dyad meetings (usually weekly) as well as ad hoc meetings as needed. We would benefit from a more structured agenda for our regular meetings, including standing items, while also protecting time in those meetings for other matters as they arise. PD has been structuring our meetings, and we hope this will help address gaps in our joint work. 

Third, our co-leadership division of labour (including with the NSOSIC clinical team lead) has some overlaps that could be reduced. That said, such redundancy is not necessarily harmful and can even be beneficial, e.g., to provide more than one leadership view on a matter as well as to co-decide on high priority issues of strategic and operational importance. This division of labour is documented (Table 1), but is also a “work in progress” that can be revised as needed. 

Fourth, continuous learning (education and training) about co-leadership for health services is needed, especially in the public sector which is particularly complex. This learning is not readily available, even in formal leadership learning programs and especially for dyads. Hence, evidence-informed solutions for such learning can be developed, such as communities of practice of physician leaders and administrative co-leaders. Physician leadership associations such as the Canadian Society of Physician Leaders could facilitate such learning opportunities, preferably in collaboration with relevant partners, such as the Canadian College of Health Leaders. 

Conclusion

Co-leadership dyads of physicians and administrators are needed in health care services and are commonly used, particularly in the public sector. Yet, not much knowledge has been published about them, including how to optimize their joint work. This article illustrates and reflects on our experience as such a dyad in specialized mental health services. In particular, we illustrate our co-leadership’s quality improvement activities and their outputs and reflect on related challenges and opportunities for co-leadership growth. Related progress across mental and other health services may include more rigorous research on co-leadership, including more structured implementation and evaluation of it, as well as more formal education and training in it for both physicians and health services administrators, preferably jointly, at least in part. 

References

1.Rudnick A. Principled physician (and other health care) leadership: introducing a value-based approach. Can J Physician Leadersh 2014;1(1):7-10.

2.Scott T, Mannion R, Davies HTO, Marshall MN. Implementing culture change in health care: theory and practice. Int J Qual Health Care 2003;15(2):111-8.

3.Zismer DK, Brueggemann J. Examining the “dyad” as a management model in integrated health systems. Physician Exec 2010;36(1):14-9.

4.Corring DJ, Speziale J, Desjardins N, Rudnick A. Relentless incrementalism: shifting front-line culture from institutional to recovery-oriented mental healthcare. Healthc Q 2016;18(special issue):17-21. https://doi.org/10.12927/hcq.2016.24477 

5.Daigle P, Rudnick A. Shifting to remotely delivered mental health care: quality improvement in the COVID-19 pandemic. Psychiatry Int 2020;1(1):31-5. https://doi.org/10.3390/psychiatryint1010005 

6.Pallaveshi L, Rudnick A. Development of physician leadership: a scoping review. Can J Physician Leadersh 2016;3(2):57-63.

7.Rudnick A. Building blocks or connecting dots: steps toward physician leadership. Can J Physician Leadersh 2017;4(1):24-5.

8.Rudnick A, Shaheen A, Lefurgey S, Nolan D. Operational stress injury. Encyclopedia 2023;3:1332-44. https://doi.org/10.3390/encyclopedia3040095 

9.Akhtar N, Forchuk C, McKay K, Fisman S, Rudnick A. Handbook of person-centered mental health care. Boston: Hogrefe; 2021. 

10.Rudnick A, Nolan D, Daigle P. Sharing of military veterans’ mental health data across Canada: a scoping review. J Mil Veteran Fam Health 2022;8(2):7-17. https://doi.org/10.3138/jmvfh-2021-0064 

11.Ryk J, Simpson R, Hosseiny F, Notarianni M, Provencher MD, Rudnick A, Upshur R, Sud A. Virtually-delivered Sudarshan Kriya Yoga (SKY) for Canadian veterans with PTSD: a study protocol for a nation-wide effectiveness and implementation evaluation. PLoS One 2022;17(10):e0275774. https://doi.org/10.1371/journal.pone.0275774 

12.Taillefer S, Nolan D, Rudnick A. Other specified trauma- and stressor-related disorder: challenges in differential diagnosis and therapeutics. Psynopsis 2019;41(2):13-14,29. Available: https://cpa.ca/docs/File/Psynopsis/2019/Psynopsis_Vol41-2.pdf 

13.Roe D, Slade M, Jones N. The utility of patient-reported outcome measures in mental health. World Psychiatry 2022;21(1):56-7. https://doi.org/10.1002/wps.20924 

Authors

Abraham (Rami) Rudnick, MD, PhD, FRCPC, CCPE, MCIL, DFCPA, mMBA, is the clinical director of the Nova Scotia Operational Stress Injury Clinic at the Nova Scotia Health Authority and a professor in the Departments of Psychiatry and Bioethics and in the School of Occupational Therapy, Dalhousie University. He is the incoming Editor-in-Chief of the Canadian Journal of Physician Leadership. 

Patrick Daigle, MSW, RSW, CHE, is the program leader of the Nova Scotia Operational Stress Injury Clinic. He has led other services and has published with Dr. Rudnick on administrative aspects of the Nova Scotia Operational Stress Injury Clinic. 

Authors’ attestation: AR originally conceived this article; both authors contributed to the draft and approved the final version. 

Disclosure: The authors declare no related conflicts of interest. 

Ethics: Research ethics review and informed consent were not required for this article. 

Correspondence to: [email protected] 

This article has been peer reviewed.