Leadership in Primary Care Practice

In a recent Milbank Quarterly study on the need for investment in leadership at the primary care practice level, Benjamin F. Crabtree and colleagues have done an admirable job of identifying 11 attributes of leadership within successful primary care practices. As team-based care becomes more prevalent through advanced primary care models such as the Centers for Medicare and Medicaid’s Comprehensive Primary Care Plus (CPC+) and its next iteration, Primary Care First (PCF), it is crucial that leadership of the team is clearly identified and communicated. The study authors rightly recognize that, all too often, organizations address leadership development in a haphazard “topic of the week” approach without giving thought to which principles come first.

As I read the study, I was reminded of Maslow’s theory of human motivation. Given that leadership is essentially the art of human motivation, I thought that insights might be gained by comparing the two hierarchical systems as they relate to the principles of leadership.

In my 30+ years of primary care practice and administration (most recently in my supervision of the CPC+ program in Ohio), I have seen receptionists, medical assistants, care managers, nurses, and physicians all play leadership roles, depending on the interpersonal dynamics active in the practice. This will no doubt increase as care delivery becomes more team-based. What distinguishes high-performing from dysfunctional practices is not who the leaders are but the ability of those leaders to create and nurture a common purpose and vision. This shared purpose and vision helps staff members achieve “self-fulfillment” and meet the “psychological” and “basic” needs outlined by Maslow.  

With this in mind, I have proposed ways that leaders could apply the principles defined in the study’s leadership model (See Figure 1) to the principles in Maslow’s hierarchy of needs (See Figure 2).

Self-Fulfillment

Why do I come to work each day? While not unique to primary care, the highest level of Maslow’s pyramid is germane in health care in general, and primary care in particular. Staff in a primary care office—many of whom have close and long-term relationships with patients—for the most part see their work as a mission in life. It is usually this unspoken collective mind that drives them. The things that prevent the fulfillment of that mission are what causes burnout. On the other hand, I have seen dedicated practitioners put up with considerable bureaucracy if good outcomes are achieved, despite the hassle. In other words, mission can make providers more resilient in today’s complex health system. Their mission is also what drives them to readily extend themselves beyond their usual job description and participate in boundary spanning, in which leaders work across organizational, functional, or geographic borders. As a primary care practice leader, how can one build on and protect primary care’s inherent meaningful and self-fulfilling qualities?

Psychological Needs

Am I being true to myself in my work to best serve those we treat? What are the outcomes that the practice pursues for an individual patient? Are they consistent with the outcomes the patient is seeking? Just as a primary care practice leader can help the team meet self-fulfillment, facilitating personal and collective answers to these questions can help the team meet psychological needs. Committing to patient-centered care requires a special effort and talent to gather such patient perspectives over time and sometimes within multiple generations of the same family. While relationships with patients are not addressed explicitly in the study, the information-sharing and teamwork principles apply here. Respect for patient autonomy should be modeled, taught, and rewarded by practice leadership and might be included as an additional foundational principle. This patient-centered process also has a reciprocal effect of building the esteem of those working in health care. Self-esteem among staff also positively affects the influence and power dynamics operating within the practice.

This approach also develops the community spirit within the staff that is needed for the other part of Maslow’s second tier: the sense of belonging. Staff are much more likely to engage in teamwork and avoid taking advantage of one another’s expertise when there is mutual respect. This spirit of working collectively to accomplish worthwhile goals for patients demonstrates the principles of teamwork and collective mind.

Basic Needs

How can I do my part?  Of course, meeting the needs at the higher end of the Maslow pyramid requires that basic needs are met. Having a higher purpose and common vision act as natural motivation to change oneself and motivate others to engage in change. Effective leaders need to ensure that a patient’s care plan (a reflection of the patient’s own goals) is understood clearly by the entire team. Once that is communicated effectively, leadership needs to establish the psychological safe zone, enabling team members to speak up when they see care diverging from that plan. It could be argued that psychological safety be listed in the study as a foundational principle rather than a second-order principle. Psychological safety requires more than managing the abuse of power. Adequate knowledge, patient empathy, self-esteem, and awareness of one’s own limitations all contribute to psychological safety.

There are also “basic needs” questions to be answered within the foundational principles of developing formal processes and motivating others. At the risk of stretching the analogy, basic needs in Maslow’s hierarchy could be analogous to the security of having a process to follow. Just as we require food and water to physically survive, many of us need a formal process and job description to survive in our work.  Process grounds our activity in ways that can also enable us to venture out. Unfortunately, most process improvement activities tend to focus on an implementation plan before addressing the higher tiers of Maslow’s hierarchy or of the principles as outlined in the study.

Creating Trust and Autonomy

There is something about leadership, like beauty, that defies definition. It is no doubt linked to trust. While trust is not explicitly discussed in the Milbank Quarterly article’s leadership model, in my experience, it is key to any leadership relationship and should be acknowledged when considering leadership in a primary care practice setting.

Trust is the result of a personal relationship. Primary care clinicians understand this in their team’s relationships with patients.  But as with patients, trust within a practice can become tenuous as leadership becomes layered in larger organizations.

Trusted leadership is its best when it allows members of the organization to experience autonomy to the extent possible while accomplishing the larger objectives and vision. By addressing these leadership attributes and motivational needs in a thoughtful and organized way, primary care practice leadership can prepare their staff to deal with the surprises of everyday practice and life.

Richard Shonk, MD, PhD, is the Chief Medical Officer for The Health Collaborative in Cincinnati, Ohio.