Health Policy 79 (2006) 24–34

Leadership and priority setting: The perspective of hospital CEOs
David Reeleder a,∗ , Vivek Goel a , Peter A. Singer b , Douglas K. Martin c
a

Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, Ont., Canada M5T 3M6 b Department of Medicine and the Joint Centre for Bioethics, University of Toronto, Toronto, Ont., Canada c Department of Health Policy, Management and Evaluation and the Joint Centre for Bioethics, University of Toronto, Toronto, Ont., Canada

Abstract The role of leadership in health care priority setting remains largely unexplored. While the management leadership literature has grown rapidly, the growing literature on priority setting in health care has looked in other directions to improve priority setting practices—to health economics and ethical approaches. Consequently, potential for improvement in hospital priority setting practices may be overlooked. A qualitative study involving interviews with 46 Ontario hospital CEOs was done to describe the role of leadership in priority setting through the perspective of hospital leaders. For the first time, we report a framework of leadership domains including vision, alignment, relationships, values and process to facilitate priority setting practices in health services’ organizations. We believe this fledgling framework forms the basis for the sharing of good leadership practices for health reform. It also provides a leadership guide for decision makers to improve the quality of their leadership, and in so doing, we believe, the fairness of their priority setting. © 2005 Elsevier Ireland Ltd. All rights reserved.
Keywords: Priority setting; Hospitals; Leadership; Leadership guide; Accountability for reasonableness

1. Background The role of leadership in healthcare priority setting remains largely unexplored. Simultaneously, the management literature on leadership has grown substantially, as business leaders have required new models
∗ Corresponding author. Tel.: +1 416 484 6004; fax: +1 416 212 2869. E-mail address: david.reeleder@utoronto.ca (D. Reeleder).

to improve their practices in an increasingly complex knowledge-based economy [1,2]. The growing priority setting literature has emphasized the role of evidence-based medicine and health economics and the process of decision making and under-emphasized the importance of leadership [3–6]. As hospitals everywhere are struggling to fulfill mission and meet growing patient demand while keeping within their funding limits there is scant empirical data describing the contributions of leadership to priority

0168-8510/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2005.11.009

The purpose of this study is to describe the role of leadership in health services priority setting from the perspective of hospital leaders. Design We conducted a qualitative study. to group processes.30]. has been defined as the distribution of resources among competing programs or people.g. relationships and process [11–20]. dental services. to distinctions between management and leadership. Like the rest of the country. and to situational and behavioral contingencies. to our knowledge there has been no research describing how this occurs in practice. While it is commonly understood that executive leadership influences institutional priority setting [32]. leadership approaches describe a variety of values and behaviors which align with. Priority setting. but the Table 1 Accountability for reasonableness Relevance Publicity Appeals/revision Enforcement role of leadership in priority setting has not been explicitly described [9.D. Leadership has been identified as an enabler of the enforcement condition in healthcare settings.29. and can be viewed as enablers. and occurs at all levels of the health system [27]. the enforcement condition of A4R suggests that good leadership involves attention to the ethical aspects of priority setting. including the importance of vision.1. and provide a set of lessons for effective priority setting practices in health care facilities. Kotter and coworkers have emphasized ‘what leaders do’. Method 2. A clearer understanding of how priority setting in health services could be improved through effective leadership therefore has not been realized. for A4R. predominately publicly funded health care system with some privately funded services and products (e.2. setting of priorities. Reeleder et al. 2. It provides four conditions that emphasize transparency and stakeholder engagement in democratic deliberation.31]. also known as rationing or resource allocation.28]. involving semistructured interviews with Chief Executive Officers of Ontario hospitals in which we probed their views on the relationship of leadership to priority setting. the role of leadership in priority setting has not been viewed through the perspective of leaders themselves. and many framing approaches have been brought forward to describe leadership. 2. Leadership has been described as a process whereby an individual influences a group of individuals to achieve a common goal [1]. The science of leadership is elusive and fragmented [10]. Recent theories of health care priority setting have emphasized the importance of ethical processes [3. ‘Accountability for reasonableness’ is a framework for legitimate and fair priority setting. influence and power. ranging from personality traits and values. At a broad level the management leadership literature may be organized into two perspectives: ‘what leaders do’ and ‘who they are’. reasons and principles that fair-minded parties can agree are relevant to deciding how to meet the diverse needs of a covered population under necessary resource constraints Limit-setting decisions and their rationales must be publicly accessible There is a mechanism for challenge and dispute resolution regarding limit-setting decisions. but seems to hinge on two points. drugs) [9]. / Health Policy 79 (2006) 24–34 25 setting [7–9]. Second. First. and focused on character traits and values [21–26]. including the opportunity for revising decisions in light of further evidence or arguments There is either a voluntary or public regulation of the process to ensure that the first three conditions are met . including Bennis have emphasized ‘who leaders are’. alignment. There are 152 Rationales rest on evidence. Ontario is the largest province in Canada. Traditional approaches to priority setting have emphasized evidence-based medicine and cost-effectiveness analysis. Others. In particular.4. to clarify contributions from the vantage point of the chief organizational decision maker. Setting/sample With 12 million people. it is a single payor. Daniels and Sabin have proposed an ethical framework for priority setting in health care institutions called ‘accountability for reasonableness’ [Table 1] which has become a leading international model for ethical decision making under limited resources [3.

it became quickly clear that the theme of leadership was foremost on the minds of our participants. consistency of responses and decision makers’ emphasis. All interviews were audiotaped. Finally. the data was read and then segmented by identifying parts of data that related to an idea (e. with descriptive notes written into margins of the transcripts. Fourth. without their explicit agreement. 2. we refocused our questions in light of these findings (Table 2). in selective coding. which were based on prevalence. 2. A purposeful sampling strategy was utilized in which we elicited the views of CEOs from a blend of facilities of different sizes and types. Reeleder et al. voluntary board. Finally. Research ethics Approval was obtained from the University of Toronto Research Ethics Board. Each hospital has a CEO leader. the principal researcher worked with a second senior researcher in developing a coding framework. axial and selective coding [33]. and rural and northern facilities. experience and personal bias were acknowledged and examined. Written informed consent was obtained from each individual before interview. 2. with a reporting relationship to an independent.g. and placed into an electronic spreadsheet to facilitate viewing and summarization. concepts were organized into overarching themes (e. publicity. Data analysis Analysis of the data consisted of a modified thematic analysis organized into three phases: open. interim results were presented in several forums and scholarly exchanges to enhance ‘reflexivity’ and ensure that prior assumptions. We addressed the validity of our findings in five ways. the draft framework was distributed to participants who verified the verisimilitude of the findings in light of their experience and the reasonableness of the interpretations in light of their own interview. appeals/revision and enforcement? What is the role of leadership in priority setting? What is the role of technology in priority setting? What role did SARS play in priority setting? [5pt] Final questionnaire checklist How are priorities set in your institution? How do you achieve fair priority setting? What is the role of leadership in priority setting? What values are important to you in context of priority setting? Describe the importance of collaborative planning? What is your leadership style? Describe the tensions between physician and administrative leaders? What is the relationship between leadership. and sought clarification where necessary. . Units of text were underlined. alignment) according to perceived importance. The average reported hospital budget was US$ 155 million ($Cdn 6. all research activities were rigorously documented to permit a critical appraisal of the methods. values).g. pursued emerging themes. as is traditional in qualitative research. The average number of beds reported for the CEO’s 46 Ontario hospitals was 395 (28–1600 beds). Data collection One of us (DR) asked open-ended questions.3. when no new themes appeared in successive interviews. However.26 D. No individuals have been identified in dissemination. management and governance? How would you evaluate the quality of your leadership? hospitals in Ontario. leadership.e.5.4. Second. comprising a broad range of teaching. Third. we interviewed a large number of hos- pital CEOs within the health system from which we obtained diversity and comprehensiveness of views. Exploratory interviews emphasized the priority setting activities of the CEOs’ institutions. In axial coding. In open coding. transcribed and analyzed. We stopped enrolling new participants when ‘theoretical’ saturation had been reached – i. All raw data were protected as confidential and available only to the research team. / Health Policy 79 (2006) 24–34 Table 2 Interview guide Preliminary questionnaire checklist What are your priority setting goals? What is fair priority setting and how do you accomplish this? How do you set priorities? How do you operationalize priority setting? What role do stakeholders play in the priority setting process? What are barriers for effective priority setting? How do you meet the conditions of A4R—relevance. descriptions of the themes were developed using the decision makers’ own words. We conducted interviews with 46 CEOs between February 2003 and February 2004. Therefore. First. community and specialized.5–850 million).

creating alignment. very strong alignment between the community. not that we’re delivering all ourselves. I mean skills culture. CEOs stressed the importance of setting boundaries around what was feasible. physical facilities. but communicating the vision”. One leader said that “as a leader you have to have a vision and translate that vision to the organization and create some meaning so people will go in a certain direction”. The CEOs in our study reported a strong overall relationship between leadership and priority setting. realignment of resources”. standardization. Change management strategies. “I think by definition.2. A participant said “when I say alignment. surgery at one site would operate on surgery from another site. So it’s a hierarchy of complexity. Reeleder et al. it was necessary to “create focus within the organization”. One participant said his task was a “massive management process in the hospital. Results In this section. . “I would like to think that my board are the governors and they rely on my leadership. the board. and trying to determine what will survive and what won’t survive in a rationing environment”. resources. and to provide a basis for the living of shared values. Everybody’s agreed on that. Leaders described some distinctions between leadership and management. A vision provides a basis for the living of shared values. I think there are times when people lose sight of the longer term because they’re just so wrapped up in the pressures of the day to day”. And we . and I rely on my staff to manage things. Foster vision CEOs emphasized in priority setting the need for a compelling. They weren’t working together under a common leadership to look at consistencies. / Health Policy 79 (2006) 24–34 27 3. with the former bringing “a sense of direction to the overall organization. 3. A CEO distinguished between the fostering of a vision for the future and the “setting of priorities around reducing or constraining resources. Several participants described the importance for alignment of fostering a vision.D. CEOs said a vital role for leadership was the creation of alignment. And now it’s a very open and participatory and transparent process”. developing relationships. 3. Another CEO said. Visioning facilitates priority setting in helping set the agenda for consolidation. leadership is priority setting” and “leadership plays a significant role in relation to priority setting”. to set boundaries or limitations on what was feasible. A participant said she is leading “realignment away from a site model to a systems model . “efficiency and effectiveness” and “implementing the day to day activities that support the mission and values of the organization”. A CEO said “you’ve got to focus in on your core programs and services that are the basis of what you do”. we describe our participants’ views and have included verbatim quotes to illustrate. . shared vision to mobilize internal stakeholders in a common direction. but that we’re working with others to deliver”. A CEO said her vision was “to be a facilitator of a network of care and service for people. best practice. to create a vision for alignment. but that the CEO has a distinctive role to play in relation to priority setting in five specific areas: fostering a vision. Participants pointed out that leadership may reside in all levels of the organization. Another CEO said “going into this exercise of setting priorities we need a very. while management was more concerned with “operational issues”. to set an agenda for efficiencies and consolidations. a common vision and a common direction”. One leader said “we’ve set out what our future is. of thinking”. both internally and externally of—not selling. living values and establishing an effective process by which internal and external stakeholders can abide [Table 3]. In constrained fiscal environments it was not possible “to be all things to all people”. Set and promulgated in an open manner an inclusive vision promotes these values.1. and where we think that’s headed. education and communications were described as vehicles to foster this uptake. Leaders emphasized the importance for priority setting of fostering or nurturing a vision among the local institution and various stakeholders so that the vision was shared or aligned. efficiencies and service reengineering. A participant said “I’ll be honest with you. the senior team and the medical leadership. and just people’s view of what’s important”. Create alignment In setting priorities.

Many times these aligned relationships took the form of networks of providers. / Health Policy 79 (2006) 24–34 Leadership practices for priority setting Determine vision Apply strategic planning Use change management strategies. either formal or informal. values and criteria Enhance planning Engage stakeholders Align programs Enhance communications Use challenging goals Measure progress Apply clinical program management Frame choices Clarify leadership style need a decision making model that allows us to do this in a very open and transparent way”. governments and private sector partnerships to drive priority setting. a call for people . choices and process Staff: delegation Staff: create trusting milieu Funder: program advocacy Transparency: reveal agenda Evidence: use criteria and relevant information Inclusivity: involve relevant stakeholders Trust: establish trust in relationships Honesty: manifest honesty in priority setting Benefits Mobilize stakeholders in common direction Create meaning Enhance feasibility Create alignment Improve services Improve efficiencies Enhance affordability Enhance fairness Facilitate service integration Improve ‘buy in’ Shared resources Creates innovation Social capital Retain autonomy Enhances services to serve public Provides balanced perspectives Enhances inclusivity Increases organizational performance Avoids staff ‘push back’ Increases revenues Fairness Self-evaluation Cooperation Affordability Social capital Good conduct Virtue Fairness Consensus Performance Shared direction Quality Alignment Accountability Create alignment Develop relationships Live values Establish process Promotes vision. their communities. and in creating networks of interest to optimize service delivery and in meeting need through redistribution of limited resources. Alignment is concerned with ensuring shared directions. . plans and values.28 Table 3 Leadership practices and benefits Domain Foster vision D. Reeleder et al. . formed to deal with common service access. that there was “nothing like the threat of an out of control infectious and communicable disease to bring hospitals and the system together . education and communications Do not lose sight of long-term time horizon Focus on core programs Emphasize alignment Focus on key values Develop shared institutional understanding of vision. Leaders expressed a need for alignment with other hospitals. consolidation. leveraging member resources and geographical distribution. One participant said in reference to the Ontario SARS epidemic. or emergency issues. values and roles Ensure ‘power triangle’ in balance Align stakeholders Engage private sector and governments Collaborate in networks Manage networks Establish trust Physician: involve in decision making Physician: establish teams Board: respectful relationship Board: provide context.

“as long as that’s in balance. And so partnership is very much about being able to trust as you make yourself vulnerable. and we formed what’s known as the Ontario Child Health Network”. . that are different and their needs would not necessarily be represented by a group which was non-native”. provide context. There was a recognition by several that identifying and meeting needs of the population was difficult. trust is key. Another CEO from a large children’s hospital said “strategically and for the good of the province—we needed to form a collaborative network. A participant described his role. who represent consumers who have an interest”. “there’s more to be gained by sharing with the nursing home in town. It was also important to respect inclusivity “I knew this was an issue for aboriginals because they have cultural things like burning sweet grass. “frankly good leadership in this industry is all about relationships. thereby saving on traveling time and physician availability”. whether that’s dealing with doctors or dealing with the government”. and it is vital that the leader is able to enlist their cooperation in her priority setting pursuit. . as opposed to let us deciding that four Operating Rooms will go to hips this year. An effective leader needs to cultivate a respectful relationship with her board. develop a set of ground rules or processes for which priority setting decisions are made. . 3. Another CEO said. of involving physicians in decision making and making them feel valued. . rather than “horizontal integration” of provider facilities was important. A participant said. balanced expectations. within the organization . and of using an inclusive process to offset a “squeaky wheel” syndrome in which powerful physicians garner disproportionate levels of resources. A CEO of a hospital about to ally with another. A CEO described the importance of working collaboratively. “you have to create the context for them so that they know the options”. Sometimes the alliance is not necessarily the best for the institution but. interrelated and specific relationships with their boards. you almost need to do some kind of public poll that lets the community speak about their needs. and six Operating Rooms will go to cancer”. there is difficulty in setting priorities based on the needs of whole organization”. Another said. or with the mental health agency in town . Participants pointed to the importance of CEO leadership in balancing the “power triangle” between physicians. “to pose choices in a form in which the board can exercise policy setting responsibility without getting into micromanagement”. and encourage the board to provide public input into priority setting processes. know that you’re not going to be taken advantage of”. communities and patients. Develop relationships CEOs described a set of complex. “that’s something we’re poor at. Leaders need to develop processes to understand and engage the community and patients while seeking alignment. going out and really understanding needs . A CEO also said it was valuable to bring in stakeholders “knowledgeable about particular topics. administration and the board. to make sure that we’re properly integrated to best serve the taxpayers and the patients”. of establishing teams. A CEO described a network of hospitals where “we’ve got a proposal to put a joint. Working with other hospitals. Another participant said “vertical”. Leaders work however within the constraints . . . With a partnership or alignment among hospitals. teams and the development of respectful environments characterized by trust and honesty.3. physicians. “you have a bunch of people who are not our employees who spend most of our money through their decisions”. especially when priority setting leads to rationing or consolidation of existing services. of all the children’s programs in the province. you can work . alignment. . choices and information to enable the board to make informed decisions. / Health Policy 79 (2006) 24–34 29 to really be very open and transparent and honest with each other and to try to work collaboratively together”. Leaders emphasized the importance of motivation and mobilization of the workforce to meet and set priorities through empowerment and delegation. “for the good of the health system we’re going to do something that is not going to bring any advantage to us as an organization”. A CEO said of the triangle. . . Reeleder et al. staff. of trust. funders and other providers that facilitate priority setting. Physicians play a critical role in allocation of resources. “My philosophy has always been to help the doctors help the patients”. electronic record .D. if the board only listens to doctors. than there would be in sharing with a hospital three hours away”. . “Big part of my life is collaboration. As one CEO put it bluntly. said “In a small hospital there’s the threat of takeover.

“inclusivity is a question of who should be included. that programs are appropriately positioned for consideration. annual operating plans. 3. there are more ways to solve this thing than just throwing money at it”. “I think when the whole thing is transparent and you do that time after time. courage. . Establish process A CEO said. evidence. but admitted challenges in engaging the public. “with transparency people understand how you’re making decisions”. . . and were responsible for making the “tough decisions”.5. And marry up against your criteria”. . as much as who they are. A CEO said. what values they embody. the most weight. We have strategic directions that the board has identified”. . and in your communities to ensure an awareness of needs. inclusivity. the provincial ministry of health. For example. . to sort out reality from perception . So you have to be careful and cognizant of how you make decisions and why people express the views they do. Leaders said they valued multiple stakeholders in collaborative planning. It’s a rolling three year plan where there are major reviews of directions—it migrates down through the organization to guide operational priority setting in respect to resource allocation”. having the courage to say. Good managers have high levels of patient satisfaction. Another participant said his job “as a leader is to ensure that processes are set up so that things are done ethically and when they’re not. Another said. . and with embodying values in approaches and self-evaluations. Participants described the importance of relevant evidence and criteria in their decision making. A CEO emphasized the need for balance in priority setting. Participants emphasized the importance of trust in priority setting. what job they do and what tasks they take on. people understand the rules. or people in the organization feel they’re not. there’s got to be mechanisms where people can come forward and express their concern”. your ability to employ the right tactics in your government relation strategies. “everybody agrees up front to the criteria . and know who’s going to make the final decision”. Leaders said that involving the ‘right’ stakeholder was important in priority setting. which are set by the board.30 D. “Trust is absolutely paramount . A CEO said that “increasingly thoughtful leaders are much more focused not on what they do.4. willingness. . A CEO said “getting proper representation is cumbersome. / Health Policy 79 (2006) 24–34 of a complex milieu of professional associations and unions. and that it was important to consider the type of activity engaged in. 3. and that we’re not forgotten in the fray of competition”. the most voice. then they know that they’re going to trust you”. But at the end of the day you use some common sense and pragmatism. Live values Leaders emphasized that leadership in priority setting was about connecting transparency. . “before it was whoever had the most clout. Leaders said ‘honesty’ was essential for leadership. Another said transparency reinforces trust. describing it as “having the ability. the most aggressive”. Leaders described the importance of managing the relationship with their primary funders. Leaders reported that at the end of the day they “carry the can”. I think we try to be criteria driven. CEOs reported establishing strategic plans. A CEO said. limiting funds and flexibility. Leaders are transparent about their agenda and expect reasons or rationales for sharing decision. For example. “because we are driven by a vision and values that we reflect on. “one of the great aspects of leadership is just advocacy . A decision maker said establishing a fair process helps ensure that everybody’s voice is heard.. but we place a very high value on the involvement of the consumer and family members”. and frameworks for review of shorter term rationing decisions. A participant said. leadership in the context of priority setting “is a process”. what priorities they set”. and how they should be included”. Participants said it was important to engage a variety of stakeholders in priority setting. Respecting each other’s positions develops trust”. a participant described working from a “blueprint called our strategic directions. trust and honesty with conduct. A CEO said ‘trust’ facilitated tough decisions he has made. “We try to be evidence based. Reeleder et al. “I want to get out there that it’s a balancing act. and high levels of employee satisfaction—while at the same time are managing to get their finances balanced”. A participant described their priority setting as fair. when consensus cannot be reached.

D.12]. participants pointed to clinical program management or quality team approaches for better management of resources. and integrated attention to outcomes. Some participants said their style was ‘visionary’. In describing guidelines for dealing with the media. Finally. Bennis and Goleman have discussed the importance of values. Reeleder et al. “to facilitate competing forces at work in a hospital . Everyone understands the rules and we negotiate the rules openly before we start priority setting”. including what roles middle managers and physicians play in organizations while supporting CEOs. Another CEO described her style as ‘participative’. and very visible”. relationships. . Daniels and Sabin have discussed the relationship between priority setting and ethical processes. pointing out instances when other hospitals. “we’re been very public. . A CEO said. alignment. unless these enablers can be cultivated through nurtured relationships. but also points out common ground. so there was very little cooperation”. creating alignment. improvement in physician and management relationships. developing relationships and establishing processes. First. Participants described five leadership styles. / Health Policy 79 (2006) 24–34 31 Alignment of program rationing contributes to improved process and helps avoid criticism. helpful in effective priority setting. they’ll get it from somebody else. Our study of priority setting in health services organizations helps clarify the distinctions between management and leadership. Some CEOs said they were ‘results oriented’. a CEO discussed the need for alignment. and to frame questions in a way where a choice can be made”. values and process. We need to be seen to be responsible corporate citizens and the community has a right to know”. Third. For the first time however. some decision makers said their style was ‘adaptive’. particularly around corporate values. . a CEO said “state the facts as they are. .2]. “I think the most fundamental responsibility of leadership is to propose clear choices. saying “a good leader is going to be different things in different times depending on what the circumstances warrant”. not limited to the CEO who nevertheless is empowered as de facto leader through formal rank and power to influence priority setting. Further. So people are not left wondering what the direction is. we have organized CEOs’ views about leadership in priority setting into a framework of five interrelated domains. And I give a clear direction. Second. Discussion This study makes four contributions to knowledge regarding the relationship of leadership to priority setting. Timely responses are important. These domains have been identified by others—Kotter and coworkers have discussed fostering vision. While the current management literature portrays leadership as a broad based characteristic within organizations [1. If they don’t get it from you. “never asked what the impact of cutting open heart surgery would have on us . First. we have identified leadership domains in the context of priority setting from the perspective of health services leaders. and I’m very definite. involving vision. enshrined values and durable processes. “Very much focused on relationship building. and to mediate between interpreting community needs and trying to get providers to be more community population needs driven”. what the future is”. we have provided empirical data to describe the relationship of leadership to health services priority setting from the perspective of the chief organizational decision maker. For example. Fourth. both between disciplines who were very much focused on trying to protect professional turf around scope of practice. we have described leadership styles in priority setting from the perspective of leaders. walking the talk. A CEO described a ‘facilitative’ role. . we have described leadership practices reported by heath services leaders in their organizations. In evaluating the achievement of goals CEOs emphasized measurement and the need for challenging goals. it points to distinctions between management and leadership [1. “I try to push the envelope. While leadership is partly about vision and alignment. A CEO also said. with management providing order and consistency to organizations and leadership providing change and movement. we report a fledgling framework to guide decision makers or academics in priority setting.11. Additional research is required to clarify leadership and management good practices. It may be the wrong information. 4. it is debatable whether leaders and managers in priority setting will achieve their goals of order and consistency. Several CEOs emphasized the importance of communications to the public and the media within a priority setting context.

Within each self-report. task versus relationship motivated [39]. CEOs describe a set of approaches for effective priority setting in their institutions. in the context of trust and good evidence practices. but diverse set of complex stakeholder relationships. otherwise their vision will lack legitimacy or moral authority [4]. fairness of their priority setting. we report the early makings of a leadership action plan or guide for decision makers to improve the quality of their leadership. the goal of qualitative research is not generalizability. such as directive versus supportive distinctions [38].23]. leaders described five styles to enable priority setting in their institutions. In addition. authoritative leadership styles to open collaboration and stakeholder engagement. CEOs’ views were probed. This assessment need not be limited to leaders. in order to achieve this. or critical areas requiring increased attention in the future. By encouraging a values-based culture rooted in the decision maker’s own character and beliefs. performance contracts could be established between CEOs and their boards.32 D. First. create alignment and social capital. each with their own interests and challenges. this description of participants’ views on the relationship of leadership to priority setting is limited by the perspectives of hospital CEOs within a particular health system. and that decision making is transparent and based on an honest assessment of the facts so promoting good will and trust in the future (‘values’). 4. inclusively and honestly. and the operational impact of leadership style on priority setting. emphazing facilitative. As well. we believe.1. Reeleder et al. and in so doing. that decisions have been brought to the attention of government (‘process’ and ‘relationships’) for consideration. participative. social desirability bias was possible in that the views of participants expressed in these interviews may not have corresponded to what they actually believed. that the decisions make sense in view of the hospital’s mission and previous decisions (‘alignment’). Leadership self-reporting systems may be considered in which leaders within institutions report on their ability to foster collective vision. our leadership framework suggests that prior to budget-related decisions the CEO should ensure that all relevant stakeholders have been consulted (‘relationships’). Limitations Our study has three main limitations.37]. CEOs need alignment of their internal and external stakeholders for agreement on goals and ways of meeting them [34. the CEO establishes institutional mechanisms for due process in order to exchange ideas and develop or operationalize goals [19. Finally. nurture relationships with stakeholders. It may not be fully generalizable to priority setting or leadership in other contexts such as governments.35]. For example. leaders could be asked to provide examples of good practices and areas for improvement. results-oriented. Current priority setting issues. it is not known whether actual and self-reported styles are the same. live ethical values and establish fair process. Second. Priority setting review sessions could be established between hospital boards and their CEO leadership. they indicated a movement away from hierarchical.36]. A variety of other leadership styles have been described in the literature. However. and the degree to which self-reinforcing cooperative behaviors have been generated. and authoritative versus democratic [22. However. dependent on these leadership characteristics. However. leaders ensure competing priorities can be discussed openly. Third. citing concrete situations where priority setting has improved as a result. valuable and significant meaning [40]. but could include staff or community stakeholders asked to comment upon the effectiveness with which their leaders have fairly connected to them. government could take a participatory role by creating incentives for sharing of leadership and fair practices within the health system. using this leadership framework to help facilitate effective and fair practices. However. / Health Policy 79 (2006) 24–34 Second. Leaders report their role in fostering a vision for acceptance by various communities of interest. CEOs engage specific. but to provide rich description of context-specific phenomena that have an independent. regional authorities or health care agencies. or did. in which CEO actions may be evaluated against the guide. Third. could be explored. visionary and adaptive styles. Entrenching cultural change for leadership and fair priority setting will be required to sustain this health reform. From the perspective of leaders interviewed. Fourth. Finally. corroborative evidence of executive leadership . and fulsome examples were provided by decision makers in elaboration of their responses suggesting what they said matched with what they did. for a balanced airing of voices and priority setting approaches [36.20.

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