By Health, for Health Leadership
By Health, for Health Leadership

Using LEADSas an enabler to create change in Canadian Healthcare 

Leadership is the collective capacity of an individual or group to influence people to work together to achieve a common constructive purpose: the health and wellness of the population we serve. 

Dickson and Tholl1

Strong leadership is essential to advancing the health of Canadian citizens. Chris Ham from the King’s Fund in the UK stated, “leadership is the golden thread that runs through any discussion of NHS reform and improvement”.2  The Health Council of Canada in its summative report3 concluded that “…strong leadership (is) an absolute necessity if meaningful transformation of our health system is to occur. “We view leadership as the foundation for the other key enablers (of health system transformation) because it supports and provides momentum to move actions towards attaining health system goals.” The report goes on to stress that “leadership needs to be continual, dynamic and responsive to changing needs” (p 24). This is particularly true when trying to create an organizational culture respectful of, and dedicated to, patient safety and quality improvement.

The need for stronger leadership has been acknowledged as a national priority by the countries of Australia, Brazil, the Netherlands, and the United Kingdom (NHS Scotland and NHS England). As l-Borie and Abdullah (2014) state: “…(we)…must recognize and appreciate the role of tactical-level leadership – the implementers, from institutional cultural transformation to bridging policy implementation gaps, on the basis of their expertise and experience, or both”.4 

Leadership has three essential functions. The first is to integrate otherwise disconnected processes to ensure access to maximum quality personal health care. The second is to create safe, healthy workplaces. The third is to facilitate meaningful and sustainable health reform, where necessary. Effective change in all three requires exceptional leadership: from leaders in management, nursing leaders, physician leaders, and community leaders. In addition, the system must identify leaders at all levels—within each community, each hospital, each health enterprise—who will work together to champion collaborative improvement in patient safety and quality. 

Leadership as LEADS 

The LEADS in a Caring Environment capabilities framework (LEADS) provides a customized By Health, For Health framework for responding to this growing need for a concerted, coherent, and sustainable strategy for strengthening health leadership capacity in Canada5. The LEADS capabilities framework features five domains: Lead Self, Engage Others, Achieve Results, Develop Coalitions, and Systems Transformation. Each of these five domains consists of four core measurable capabilities. The 20 capabilities make up what we refer to as your DNA as a health leader.

LEADS is being used across Canada as a foundation for leadership development country-wide; it unites health clinical professionals with health administrators in a common quest for improved leadership through sharing a common language. The evidence that supports each of the five domains has been updated on an ongoing basis by subject matter experts to reflect the most recent research. Although the LEADS framework represents a solid, research-based approach to leadership, its application needs to be adapted to specific health systems and their cultural context. Health Workforce Australia adopted a version of the LEADS framework in July 2013, based on this principle. After all, leadership is situational; what good leadership looks like in one country may differ from another—behaviorally speaking—even though the principles are the same.6 

The Canadian Health Leadership Network (CHLNet) has been instrumental in increasing awareness about the importance of leadership in general and about LEADS in Canada and abroad7. CHLNet is a value network committed to helping its partners enhance the capacity to identify, develop, support, and celebrate excellence in health leadership. CHLNet includes over 40 national and provincial network partners (and is growing) that have all endorsed the LEADS in a Caring Environment capabilities framework.

LEADS, as a By Health, For Health framework is the result of an extensive review of the literature and a systematic review of the wide range of existing competency frameworks used to advance health leadership8. It also reflects the results of early pilot projects across the country and a series of key informant interviews and focuses groups from across Canada focused on identifying leading practices across Canada and internationally.  It has been validated in myriad ways, both via independent academic evaluation and in terms of being put to work in practices across Canada.9  

In terms of creating organizational changes necessary to embrace the goal of improving patient safety and quality improvement, LEADS is a helpful guide for leaders in thinking through the change leadership challenge. For example, the L in LEADS—Lead Self–suggests that the leader must be absolutely clear about his or her own personal values align with the goal of improving patient safety; that we understand the strengths and limitations we bring to the challenge of creating those changes; that we are willing to learn and adapt our own behavior to reflect the demands of those changes, and that we need to be conscious of the demands on their character such changes will require.

E—Engage Others—asks the leader to ensure there are developmental opportunities in place to assist health providers in developing the knowledge, attitudes, and skills needed to improve patient safety and quality It also asks them to contribute to creating an environment in the workplace that is healthy and conducive to change; to communicate effectively to engage providers and employees in creating the changes necessary; and to build the inter-professional or multi-disciplinary teams needed to create the change. 

A similar rubric of expectations for leaders—and therefore a guide to them for their own practice of leadership, as well as a foundation for learning leadership–is implicit in the other three domains of LEADS. For example, A–Achieve Results emphasize clarity of purpose, alignment of action, and measurement of success. D–Develop Coalitions expects leaders to ensure that all partnerships—internal and external—focus on the patient; are deliberately and effectively stewarded; appropriate knowledge is shared across boundaries, and that political skill is utilized to facilitate collective action.  S–Systems Transformation expects the leader to think critically, see patient safety and quality improvement in the context of the larger system, encourage innovation, and champion the changes necessary for the improvements in patient safety and quality to take hold. 

The LEADS in a Caring Environment framework provides a robust response to the challenges of taking good managers and building organizational capacity for excellence in leadership. As Colin Powell, former US Secretary of Defense, found, “leadership is the art of accomplishing more than the science of management says is possible”. 

All leadership is a function of time, place and context.  Although the LEADS framework is a great starting point for a workshop in developing leadership skills in support of change—its implementation has evolved in keeping with the evolving Canadian health organizational context.  Consequently, any workshop must ensure that the interpretation of the framework reflects the cultural and organizational context of the specific organization and its communities. This workshop asks the participants to take on that task! 

The developers of LEADS are committed to a future of modern health leadership, where leadership is defined not in sole terms of the power a leader wields or by the resources at a leader’s command, but also by a leader’s ability to engage and mobilize others toward a constructive common purpose.  The basic premise is that your locus of influence far exceeds any locus of power or authority you may have.  This concept of distributed leadership —in the case of any health organization in Canada, fully embraces patients and their families as leaders and changes toward promoting people-centered care in the health system.10 

LEADS as a Process for Change 

The five domains of the LEADS in a Caring Environment framework—Lead Self, Engage Others, Achieve Results, Develop Coalitions, and Systems Transformation—reflect leadership in action in health. This action is the “doing” part of leadership, which follows a deep commitment to caring for others (“caring”—the identity of the health system) and recognition that the person you are, is the leader you are (the “being” component of effective leadership) (see Figure 1). 

Figure 1: The three components of effective health leadership

Being (who the leader is) and caring (the why of doing leadership in health) take expression (doing) as the five domains of effective leadership in the LEADS in a Caring Environment framework. Each domain entails four leadership capabilities, for a total of 20 capabilities in the framework. These capabilities are actionable in that they represent caring and being in action and, therefore, are observable by others. 

It is appropriate at this point to say a few more words about the concept of a caring environment. Almost anyone who works in the health system cares about the health and wellness of the population; at least, we assume it is a force impelling individual to choose this line of work. And thus, the focus on people-centered change leadership in this program. 

Yet despite how well-motivated all of us may have been initially to care in our job or profession, the routines, policies, procedures, protocols, and practices—imposed, professionally valid, and derived from a caring motivation—can quickly become ends in themselves. Caring, in terms of truly connecting with the welfare of another human being, can become buried beneath such administrative provisions. After a while, it is easy to simply use the concept of caring as a mantra, without truly practicing it. But what does this situation mean for leaders?  

First and foremost, it means ensuring that caring, as a real and situational response to a need, drives a leader’s behavior, personal, interpersonal, and strategic. Second, it relates to the Engage others domain in the framework. Leaders create healthy and caring environments—cultures, climates—in which others work. At the core of that caring environment is tangible evidence of an ethos of compassion and empathy for others, which plays itself out as putting the patient, client, or citizen’s welfare at the center of the decision-making process. Caring manifests itself through the leader’s actions, either personally or strategically, in response to the follower’s needs. The leader must then ensure that actions taken by and within his/her unit meet those needs.  

One of the greatest challenges for those who take on the mantle of leadership is to retain a personal perspective and emotional maturity that enables them to bear the inevitable burden—and joy—that creating a caring environment entails. The LEADS in a Caring Environment framework outlines what such an ethos of caring looks like in action—it details the capabilities that leaders need to create a caring environment as they try to create change in their organization, or the health system more broadly. 

The five domains of the LEADS in a Caring Environment framework are, at once, both independent in terms of behaviors and interdependent in terms of net effect. Although the domains can be observed separately as discrete sets of capabilities, they also interact with one another to create effective leadership. For example, the capabilities relevant to the Systems Transformation domain come into play with the capabilities of the Lead Self domain to leverage success in providing the courage and confidence to generate strategic change in different contexts: the latter for the individual who chooses to lead; the former for the leader who operates in an organizational or systems context. 

Similarly, the five domains of the framework are a regimen, or approach, to leading change. The diagram in Figure 2 below shows how the five domains work together to guide change. 

Figure 2: The LEADS in a Caring Environment Framework as a Guide to Change

Figure 2 is explained as follows. The LEADS framework consists of one outcome domain: Achieve Results, and four process domains: Lead Self, Engage Others, Develop Coalitions, and Systems Transformation. The four process domains are employed by the leader to achieve the outcomes identified by the Achieve Results domain.  

The logic is as follows. When a change is envisaged in a system (i.e. a shared vision for change based on a caring ethos), the leader needs to articulate the Achieve Results in the LEADS framework (i.e. the results that need to be achieved by this change) in a clear, concise and compelling way. These results represent the future state, in terms of envisaged outcomes for the change; they are the tight components of the change plan: its North Star if you will. Achieve Results is at the pinnacle of the hierarchy of leadership capabilities because it is the product that all the processes of leadership, both personal and strategic, are aiming to achieve.  

Figure 2 suggests that there are two processes associated with leading change: change dynamics and relationships. These are the loose elements of a change plan: i.e., the leader is free to adjust and alter his/her processes to adapt to the situational environment to ensure the envisaged results are achieved. 

Lead Self and Systems Transformation are sets of capabilities that leaders employ to address change dynamics. Systems Transformation is a strategic set of capabilities: i.e., the ability to deal with employee receptivity to change, public support, change resistance, etc. It is leadership at a distance, exercised through policy, procedure, structure, and culture. Lead Self is a personal set of capabilities: i.e., the ability of leaders to deal with their mindset on change, take steps to change their habits, recognize their mental models, and meet the challenges to their character that leading the change will require of them.

The second process element in the hierarchy is the challenge of building relationships. Engage Others and Develop Coalitions are the two dimensions of the relationship process. The Engage Others domain and capabilities address the people’s challenges of effective interpersonal relationships. The Develop Coalitions domain addresses relationship building at a strategic level; that is, building support across units, across organizations, and with customers and the public in support of the change. 

Collectively the four process domains of the LEADS framework and the one outcome domain, Achieve Results, comprise a model to guide change. If the leader uses this model to structure and focus their influence to create change, and if that influence is implemented effectively, the outcome will be the achievement of the anticipated results of the change. If they are not, the approaches taken need to be re-assessed and adjusted to achieve the defined results in keeping with a standard Plan-Do-Study-Act or PDSA cycle. Ultimately, the LEADS framework is a model for thinking through and implementing system-wide change: one that the leader is encouraged to use to scope out the true challenges and demands of making change work in the context of a system.


LEADS in a Caring Environment has been used across Canada as a By Health, For Health leadership capabilities framework, in all ten provinces. It has been adopted as a preferred leadership platform by health organizations from coast to coast and by national accrediting bodies such as Accreditation Canada and the Canadian College of Health Leaders. It is still evolving, and we are still learning about how best to bring evidence and concepts into practice.  We believe it is a great foundation for self-directed leadership development.  

As you learn more about the LEADS capabilities framework as an “enabler” for leadership development, please also keep the LEADS change model in mind, as it can become a guide to positive change in your organization. We believe it provides a solid foundation for both large-scale, complex change leadership and smaller-scale change management. Once you have determined that you wish to lead a change and have clarified the desired results of that strategy, you must determine why you need to lead it, and exercise self-leadership to begin that journey. At some point, you will need to engage people around you by creating an environment in which learning, working in teams, keeping healthy, and communicating effectively thrive. To transform systems, you then need to build the coalitions across the system that supporting the change, and implementing the mindsets, tools, and techniques of transformational change.