Primary Research

Health Services Management Research

2022, Vol. 35(1) 2­–6
Role of hospital leadership in combating ! The Author(s) 2021
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DOI: 10.1177/09514848211035620
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Zhaleh Abdi1, Federico Lega2, Nadine Ebeid3 and

Hamid Ravaghi4

Abstract
Hospitals all around the world play an essential role in response to the COVID-19 pandemic. During an epidemic event,
hospital leaders frequently face new challenges requiring them to perform unaccustomed tasks, which might be well beyond
the scope of their previous practice and experience. While no absolute set of characteristics is necessary in all leadership
situations, certain traits, skills and competencies tend to be more critical than others in crisis management times. We will
discuss some of the most important ones in this manuscript. To strengthen those managerial competencies needed to face
outbreaks, healthcare leaders should be better supported by competency-based training courses as it is more and more
clear that traditional training courses are not as effective as they were supposed to be. It seems we should look at the
COVID-19 pandemic as a learning opportunity to re-frame what we expect from hospital leaders and to re-think the way we
train, assess and evaluate them.

Keywords
competence, COVID-19, hospital, leadership

Introduction clusters of changes taking place in the health sector

Hospitals all around the world play an essential role in
response to the COVID-19 pandemic. COVID-19 as a
public health emergency not only has posed an extreme
clinical challenge to hospitals but also organizational
and managerial ones.1 Hospitals had to adapt their oper-
ational processes to maintain the regular service provi-
sion and meet the pandemic’s new surging demands.
This global public health crisis has required hospitals
to respond to a growing volume of infected patients in
a short period despite a lack of resources, including the
availability of personal protective equipment (PPE),
mechanical ventilators, medications, and personnel.
The COVID-19 pandemic invites reflection on good
practices in hospital leadership.
As a matter of fact, in turbulent times, such as the
ones being experienced by health systems and organiza-
tions worldwide, it is crucial to investigate what we know
that can make the difference in leading hospitals, as the
COVID-19 crisis represents a great “learning oppor-
tunity” in face of changes that were already hitting hos-
pitals (the “new normal” that was already emerging in
healthcare well before COVID-19). There are two
that are reshaping the context for management and the
expectations on leaders of hospitals.2 The first cluster
concerns “evolutions” currently in progress. Health
organizations face several challenges due to varying
patient epidemiology (e.g. aging, frailty, and dependen-
cy), technical and technological innovation in service
1
National Institute of Health Research (NIHR), Tehran University of
Medical Sciences (TUMS), Tehran, Iran
2
Department of Biomedical Sciences for Health (SCIBIS) and Director of
the Center of Research and Advanced Education in Health Administration
(CRC Head), Università degli Studi di Milano, Milan, Italy
3
Department of Universal Health Coverage/Health Systems (UHS), World
Health Organisation Regional Office for the Eastern Mediterranean, Cairo,
Egypt
4
Department of Universal Health Coverage/Health Systems (UHS), World
Health Organization Regional Office for the Eastern Mediterranean, Cairo,
Egypt
Corresponding author:
Hamid Ravaghi, Department of Universal Health Coverage/Health Systems
(UHS), World Health Organisation Regional Office for the Eastern
Mediterranean, P.O. Box 7, Monazamet El Seha El Alamia Street, Extension
of Abdel Razak El Sanhouri Street Nasr City, Cairo, Egypt.
Email: ravaghih@who.int
Abdi
2 et al.
delivery, expectations of improved flow and quality of
care, greater transparency in accountability on out-
comes. Furthermore, there is the second cluster of
issues, the “revolutions”, represented by disruptive inno-
vation (e.g. robots, precision medicine, etc.), new busi-
ness models, relationships between public and private
players, co-creation and co-production of services with
patients, task shifting and skill mix.
Therefore, in view of these disruptive revolutions and
consolidation innovations, what types of leadership
practices are vital for these changing times? What can
we learn from COVID-19 crisis, and which reflections
should not be lost?
Leadership: Trait, skills and competency
Leadership — the process of engaging with others to set
and achieve shared goals — is indispensable in organi-
zations, more so in times of crisis. Leadership involves,
among other things, an array of assessment skills, a
series of characteristics (traits and skills) that the
leader brings to a leadership setting, and a wide variety
of behavioral competencies.3 The literature on crisis
leadership identified various leadership styles that effec-
tively combat public health crises, including transforma-
tional, transactional, participative, and contingency.4
Leader’s style refers to the dominant and defining
behavioral patterns of the leader. Good leaders generally
have alternate modes to not depend on a single style and
adjust to situational needs. In reality, very few effective
leaders have a single style that they use all of the time. In
general, leader behaviors are categorized as mainly being
task-oriented (i.e., focuses primarily on production
through clarifying roles and monitoring tasks,
problem-solving and innovation), people-oriented (i.e.,
team building and managing, motivating and managing
conflict) and organization-oriented (i.e., strategic plan-
ning scanning environment, networking, managing orga-
nizational change and decision making).
To respond effectively to public health crises, includ-
ing infectious disease outbreaks, hospital leaders need a
wide array of competencies. The term “competence” is
defined as certain skills, values, knowledge, capacities,
and capabilities of individuals who use them while per-
forming a task.5 Further, research has shown that lead-
ership is enhanced and augmented by specific
personality traits. Below we discuss some of the most
critical traits, skills and competencies needed for hospital
leaders to battle COVID-19 as a public health crisis.
While no absolute set of characteristics is necessary in
all leadership situations, certain traits and skills tend to
be more critical than others in crisis management times.
A hospital leader should show psychological stability
and balance to inspire his/her team, has confidence
and self-assurance to confront the crisis, handle stress
Health Services Management Research 0(0)3
and remain calm, and focused amid chaos. Courage
is also needed to make difficult decisions regarding
bold and potentially controversial strategies that involve
some degree of risk. They have to be willing to make
hard decisions, even when they are based on incomplete
and limited information. To deal effectively with the out-
break, healthcare leaders should be educated and alert
about the current situation, have a sense of emergency,
demonstrate emotional intelligence, and tolerate ambi-
guity. By being self-disciplined, they can effectively stand
on top of the situation and deal with overwhelming tasks
and challenges. Transparency, visibility and availability,
having effective communication and listening skills, and
avoidance of dogmatism are among other fundamental
qualities of hospital leaders battling public health
crises.6,7 Last but not least, hospital leaders must devel-
op a sense of psychological safety with their collabora-
tors, that feeling of trust that supports decision-making
in situations characterized by high degree of uncertainty
and risk. A “no-blame” culture is part of this approach.
In addition to the traits, a number of leadership compe-
tencies are critical to respond under pressure and during
times of uncertainty, which some of which some of the
important ones are listed below:
Problem solving
Problem-solving competency is an essential factor during
a crisis. Leaders need to have an analytical mind to quickly
and logically analyze problems, recognize reasons for
issues, and find permanent and coherent solutions.
Hospital leaders should have the ability to look at an
event from multiple perspectives and “think outside of
the box” before deciding on specific contingency plans
and solutions. During the outbreak crisis, hospital leaders
need to promote collaborative problem solving by consid-
ering others’ perspectives. They should empower their
team to provide opposing viewpoints to leverage collective
knowledge, perspectives, experience, and skills. The
COVID-19 pandemic has created a multitude of acute
challenges for hospitals, including inadequate capacity,
shortage of intensive care beds, the need for care redesign,
supply shortages and financial loss. Many hospitals seek
creative solutions to grapple with the challenges by pro-
moting collaborative problem solving and benefiting from
the staff’s creative and innovative ability. For instance, a
public hospital in Milan, Italy has shared its experience in
forming a dedicated multidisciplinary team with tasks of
establishment of dedicated, cohosted intensive care units
for COVID-19 patients, redesigning care processes and
designing appropriate procedures for pre-triage, diagno-
sis and isolation of suspected and confirmed cases, and
providing trainings for staff. Being successful in perform-
ing the tasks, in this case, was attributed to the multidisci-
plinary, multi-level involvement of healthcare providers
4Abdi et al.
and hospital managers in problem solving process, all
working towards a common goal of best patient care.8
Planning
Strategic and operational planning are means for hospi-
tal leaders to manage crises in all phases including pre-
vention, preparedness, response, and recovery. During
the COVID-19 pandemic, hospitals should switch from
the conventional mode of leadership to crisis mode with
an appropriate incident command structure. A compre-
hensive strategic plan for crisis management, covering
emergency preparedness and response plan for infectious
disease outbreaks, can be regarded as one of the strategic
tasks whose importance was highlighted during the
COVID-19 pandemic. Likely, the hospital’s existing
emergency preparedness and response plan and infection
control policies require reviewing and updating. Besides,
hospitals were obliged to develop and disseminate a
range of operational policies and procedures, including
providing non-COVID-19 clinical care during the
COVID-19 pandemic, plans for protecting patients,
healthcare personnel, and visitors from COVID-19,
supply chain management, surge capacity and so on in
a short time to respond to the outbreak quickly.
Decision making
There is no doubt that every crisis is unique and may
require different types of efforts and interventions.
During an infectious outbreak crisis, a hospital leader
needs to make quick decisions with limited information
under time pressure to respond to the crises. They have to
detect the problems correctly without losing the complete
picture and making correct decisions by considering the
possible consequences. They have to react differently
during the crisis, although nervous, they became more
focused and solutions-oriented. Further, making
evidence-informed decisions through consulting core
internal and external documents related to managing the
disease can be regarded as another essential competency
for hospital leaders during outbreak emergencies.
Scanning the environment
Environmental scanning is another competency crucial
for hospital leaders during the outbreak crisis, referring
to searching for opportunities and risks that may come
from outside of a particular entity or organization.
During the outbreak of infectious diseases, hospital lead-
ers must gather information from other governmental
entities, neighboring hospitals, private sector organiza-
tions, customers, and legislative and supervisory agen-
cies that influence the organization. Effective leaders can
assess whether the information is vital and pertinent and
Health Services Management Research 35(1)3
ensure that this information is obtained from various
sources rather than a single source.
Crisis communication
Communication during an outbreak is a significant and
essential skill for hospital leaders. Knowing how to speak
to every level of the organization is a crucial skill that
hospital managers must have, especially during emergen-
cies, to ensure everyone understands the actions required
and business impact. During the COVID-19 crisis, it has
been prominent that interpersonal relations and commu-
nication between the leadership and the hospital teams are
crucial and helps to build trust. External communication
and relations between hospital managers and different
stakeholders are equally important. The COVID-19 pan-
demic has resulted in a burden on healthcare facilities,
necessitating good communication between various
neighboring hospitals and close collaboration with uni-
versities and local authorities.
Networking and partnering
Networking and partnering involve developing contacts
outside the hospital by formal and, especially, informal
means. During an outbreak crisis, leaders must periodi-
cally contact external stakeholders, politicians, and
other strategic allies. They need to exchange information
continuously with other organizations in the network
and they should be open to partnerships during crisis
intervention and answered to others’ collaboration
needs at the maximum level. During COVID-19, many
hospitals worldwide leveraged their expertise and resour-
ces to help other organizations as part of their mission to
serve their communities. For instance, a partnership
between an acute-care hospital in Toronto, Canada,
and a nursing home experiencing a COVID-19 outbreak
is a successful collaboration between health facilities’ to
battle COVID-19.9 Further, quite often hospital leaders
face “wicked” issues, that is problems that cannot be
treated successfully with traditional linear, analytical
approaches. They are difficult to clearly define as the
nature and the extent of the problem depend on who is
involved: different stakeholders have different versions
of what the problem is. Therefore, leaders must step in
and take coordinating action as they are expected to not
only “steer” but also “connect” and be capable of build-
ing consensus around decisions and coordinating efforts
to address complex issues.
Planning and organizing human resources
Ability to care for infected patients depends on the health-
care workforce’s well-being — physical and emotional.
Healthcare workers faced many challenges during the
Abdi
4 et al.
COVID-19 pandemic including increasing workload,
shortage of resources particularly PPE, high risk for con-
tracting infection, need for training and updated knowl-
edge and skills, emotional strain and physical exhaustion,
psychosocial stress, violence and stigma against them due
to public fears of contracting the virus from healthcare
workforce. Staff absenteeism due to both personal sick-
ness and the staff member’s uncertainty about their ability
to work safely for fear of infecting is another challenge
that hospital leaders must be prepared for it through
having plans and procedures in place. Hospital leaders
should demonstrate the ability to optimize the health
workforce and face the challenges to guarantee their well-
being and safety. Managers must take a strong lead on
headline issues such as PPE supply (both on its quality
and quantity), precise infection control and contamina-
tion pathways, and follow-up contact tracing. During
COVID-19, some hospitals seek a new way to provide
emotional support to their staff. For example, in the
early stages of the COVID-19 pandemic, some hospitals
in China set up an online psychological counseling group
to provide emotional support to healthcare workers.10
Further, hospital leaders should support the quick health-
care workforce training necessary for outbreak response,
particularly for those without infectious disease expertise,
including proper infection control practices and how to
treat, isolate and report cases.
Motivation
Leaders need to understand the strengths and weak-
nesses of the staff to optimize their performance through
motivation. During an outbreak crisis, hospital leaders
should establish a positive relationship with the staff by
highlighting the importance of staff’s contribution,
appreciate the staff’s efforts in timely and appropriate
manner, fairly evaluate the staff’s contribution to crisis
response, and explain how rewards and significant com-
mendations are distributed and used to motivate fol-
lowers. Main responsibility of the leader might be to
generate sense-making, as to increase the task signifi-
cance of what done by staff during the crisis period.
Team building
Team building competency refers to the leader’s ability to
quickly organize cohesive teams with special training,
skills, and competencies that are well-suited for the tasks
at hand. Creating a multidisciplinary planning committee
or team specifically addressing COVID-19 preparedness
planning is an essential step in battling COVID-19. An
example of a successful team building experience is form-
ing a dedicated COVID-19 task force by a hospital in India
that consisted of experienced staff who had witnessed the
H1N1 pandemic in the past and motivated younger staff
Health Services Management Research 0(0)5
to balance the staff ratio. The successful management of
the initial few patients by the team led by a senior inten-
sivist helped to build confidence among staff in battling
with COVID-19 in a resource constraint setting.11
Conclusion
The COVID-19 pandemic has drawn widespread atten-
tion to limited hospitals’ capacities and preparedness, as
a critical component of health systems. Education and
training are integral constituents for hospital leaders’
preparedness and competence in outbreak management.
During an epidemic event, hospital leaders frequently
face new challenges requiring them to perform unaccus-
tomed tasks, which might be well beyond the scope of
their previous practice and experience. A range of spe-
cific managerial competencies is needed for healthcare
leaders to face outbreaks, which might be better sup-
ported by competency-based training courses as it is
more and more clear that traditional training courses
are not as effective as they were supposed to be. They
can provide an introduction to the role, and some useful
techniques (i.e. project management, business planning,
lean approaches, etc.), but no more than this.
Competency frameworks developed over recent years,
such as the ones drafted by the International Hospital
Federation (IHF), are helpful to outline the complexity
and variety of skills that need to be focused on. In this
respect, the COVID-19 pandemic should be a learning
opportunity to re-frame what we expect from hospital
leaders and to re-think the way we train, assess and eval-
uate them. This is a clear and unavoidable responsibility
for health systems and hospital administrations, as to
prepare for coping more effectively with the “new nor-
mal” of healthcare that was already emerging before
COVID-19 and will accelerate right after it thanks to
what we learn during the crisis.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Hamid Ravaghi https://orcid.org/0000-0003-2717-920X
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