BackgroundThe “Triple Aim” – provision of a better care experience and improved population health at a lower cost – may be theoretically sound, but paradoxical in practice as it forces together the logics of management and medicine. The aim of this study was to explore how staff and managers understand the change imperative inherent to the Triple Aim and the mental models underlying their understanding.MethodsThis qualitative study builds on thirty semi-structured interviews conducted with managers, nurses, midwives, medical secretaries, and physicians at a department of Gynecology and Obstetrics in Denmark who successfully cut costs through staff and bed reductions and, from what we can ascertain, maintained care quality. Mental models were articulated from a content analysis of the interviews.ResultsStaff and managers identified with the different dimensions of the Triple Aim along classic professional divides, i.e. nurses and midwives focused on patient experience, physicians on health outcomes, and manager on all three. Underlying these, we found four mental models. The understanding of change was guided by a Professional ethos (inner drive to improve care) and a Socio-political discourse (external requirement to become more efficient) mental model. The understanding of economics was guided by a You-get-what-you-pay-for and by a More-bang-for-the-buck mental model. A complex interplay could be discerned between all four, which led staff to see the Triple Aim as a dilemma between quality and economics and a threat to clinical care and quality, whereas managers saw it as a paradox that invited improvement efforts. Despite these differences, managers chose a change strategy in line with staff mental models.ConclusionsThe practical challenges inherent to the Triple Aim may be symptomatic of the interactions between the different mental models that guide staff and managers’ understanding and choice of change strategies. Pursuit of quality improvement in the face of financial constraints (the essence of the Triple Aim) may be facilitated through conscious exploration of these empirically identified mental models. Managers might do well to translate the socio-political discourse into a change process that resonates with the mental models held by staff.

ObjectiveThe influx of management ideas into healthcare has triggered considerable debate about if and how managerial and medical logics can coexist. Recent reviews suggest that clinician involvement in hospital management can lead to superior performance. We, therefore, sought to systematically explore conditions that can either facilitate or impede the influence of medical leadership on organisational performance.DesignSystematic review using thematic synthesis guided by the Enhancing Transparency in Reporting the synthesis of Qualitative research statement.Data sourcesWe searched PubMed, Web of Science and PsycINFO from 1 January 2006 to 21 January 2020.Eligibility criteriaWe included peer-reviewed, empirical, English language articles and literature reviews that focused on physicians in the leadership and management of healthcare.Data extraction and synthesisData extraction and thematic synthesis followed an inductive approach. The results sections of the included studies were subjected to line-by-line coding to identify relevant meaning units. These were organised into descriptive themes and further synthesised into analytic themes presented as a model.ResultsThe search yielded 2176 publications, of which 73 were included. The descriptive themes illustrated a movement from 1. medical protectionism to management through medicine; 2. command and control to participatory leadership practices; and 3. organisational practices that form either incidental or willing leaders. Based on the synthesis, the authors propose a model that describes a virtuous cycle of management through medicine or a vicious cycle of medical protectionism.ConclusionsThis review helps individuals, organisations, educators and trainers better understand how medical leadership can be both a boon and a barrier to organisational performance. In contrast to the conventional view of conflicting logics, medical leadership would benefit from a more integrative model of management and medicine. Nurturing medical engagement requires participatory leadership enabled through long-term investments at the individual, organisational and system levels.

PurposeThe aim of this study was to explore the qualities and capabilities effective physician leaders attribute to their success in leading change and how they developed these.MethodThe authors interviewed 20 emerging and senior leaders using a semistructured interview guide informed by appreciative inquiry. Data were subjected to an inductive qualitative content analysis to identify themes related to qualities, capabilities and learning approaches.ResultsThe qualities identified were clarity of purpose to improve care, endurance, a positive outlook and authenticity. They were considered innate or developed during participants’ upbringing. Capabilities were to ground management in medicine, engage others, catalyse systems by acting on interdependencies and employ a scientific approach to understand problems and measure progress. Capabilities were developed through cross-pollination from a diversity of work experiences, reflection, when education was integrated with practice and when their organisational environment nurtured ambition and learning.ConclusionsThis study reframes current leadership thinking by empirically identifying qualities, capabilities, and learning approaches that can contribute to effective physician leadership. Instead of merely adapting leadership development programmes from other domains, this study suggests there are capabilities unique to effective physician leadership: ground management in medicine and employ a scientific approach to problem identification and solution development. The authors outline practical implications for individuals and organisations to support leader development as a cohesive organisational strategy for learning and change.

Objectives: Health care is undergoing changes and this requires the participation and leadership of all health-care professions. While numerous studies have explored leadership competence among physicians and nurses, the physiotherapy profession has received but limited attention. The aim of this study was to explore how leadership manifests in the patient-therapist interaction among physiotherapists in primary health care and how the physiotherapists themselves relate their perception of leadership to their clinical practice. Methods: A qualitative study with semistructured interviews was conducted with a purposive sample of 10 physiotherapists working in primary health care. The interviews were analyzed using inductive qualitative content analysis. Results: Five themes were identified related to how leadership manifests in the patient-therapist interaction: (1) establishing resonant relationships; (2) engaging patients to build ownership; (3) drawing on authority; (4) building on professionalism; and (5) relating physiotherapists clinical practice to leadership. Conclusion: This study describes how leadership manifests in the patientphysiotherapist interaction. The findings can be used to empower physiotherapists in their clinical leadership and to give them confidence in taking on formal leadership roles, thus becoming active participants in improving health care. Future studies are needed to explore other aspects of leadership used in physiotherapy clinical practice. ARTICLE HISTORY

Introduction: The influx of management ideas into health care has triggered considerable debate about if and how managerial and medical logics can co-exist. Recent reviews suggest that clinician involvement in hospital leadership can lead to superior performance. Objective: To systematically explore the conditions instrumental for medical leadership to have an impact on organizational performance. Methods: We searched PubMed, Web of Science, and Psychinfo for peer-reviewed, empirical, English language articles and reviews published between January 1, 2006 and August 12, 2018. We performed a thematic synthesis through inductive line-by-line coding of the included studies. Results: The search yielded 1447 publications, of which 62 were included. Three major themes were identified that described a movement 1. From medical protectionism to management through medicine, 2. From command and control to participatory leadership practices, and 3. Organizational practices to support incidental versus willing leaders. Based on these themes, the authors developed a model to depict conditions that facilitate or impede the influence of medical leadership through a virtuous cycle of management through medicine or a vicious cycle of medical protectionism. Conclusions: This review helps individuals, organizations, educators, and trainers better understand how medical leadership can be both a boon and a barrier to the performance of health care organizations. In contrast to the conventional view of conflicting logics, medical leadership would benefit from a more integrative mental model of management and medicine. Nurturing medical engagement requires participatory leadership enabled through long-term investments at the individual, organizational, and system levels. These combined efforts will enable a shift to new leadership paradigms suitable to the complexity of health care, and establish conditions favorable for large-system transformation and health care reform. Key words: medical leadership; literature review; hospital performance; physician executive