ORIGINAL
ARTICLES
Development and Validation of
the Foundational Healthcare
Leadership Self-assessment
Sonja Van Hala, MD, MPH; Susan Cochella, MD, MPH; Rachel Jaggi, MA; Caren J. Frost, PhD, MPH;
Bernadette Kiraly, MD; Susan Pohl, MD; Lisa Gren, PhD
BACKGROUND AND OBJECTIVES: We sought to develop and validate a selfassessment of foundational leadership skills for early-career physicians.
METHODS: We developed a leadership self-assessment from a compilation of
materials on health care leadership skills. A sequential exploratory study was
conducted using qualitative and quantitative analysis for face, content, and
construct validity of the self-assessment. First, two focus groups were conducted with leaders in medicine and family medicine residents, to refine the pilot
self-assessment. The self-assessment pilot was then tested with family medicine residents across the country, and the results were quantitatively evaluated
with principal component analysis. This data was used to reduce and group the
statements into leadership domains for the final self-assessment.
RESULTS: Twenty-two invited family medicine residency programs agreed to
distribute the survey. A total of 163 family medicine residents completed the
survey, representing 16 to 20 residency programs from 12 states (response rate
28.9% to 34.8%). Analysis showed important differences by residency year, with
more advanced residents scoring higher. The analysis reduced the number of
items from 33 on the pilot assessment to 21 on the final assessment, which
the authors titled the Foundational Healthcare Leadership Self-assessment
(FHLS). The 21 items were grouped into five leadership domains: accountability, collaboration, communication, team management, and self-management.
CONCLUSIONS: The FHLS is a validated 21-item self-assessment of foundational leadership skills for early career physicians. It takes less than 5 minutes
to complete, and quantifies skill within five domains of foundational leadership.
The FHLS is a first step in developing educational and evaluative assessments
for training medical residents as clinician leaders.
(Fam Med. 2018;50(4):262-8.)
doi: 10.22454/FamMed.2018.835145
P
hysicians in all disciplines
are called upon to demonstrate leadership skills even if
they do not hold a formal leadership
role. Additionally, organizations led
by physicians perform better than
262
APRIL 2018 • VOL. 50, NO. 4
organizations with nonphysician
leaders.1 For these reasons, leadership skill development must become
a routine part of medical education
at all levels and in all specialties.1-20
National organizations recognize
the need for effective leadership
training. The Interprofessional Education Collaborative defined competencies in interprofessional
collaboration for a varity of medical
professionals, including physicians,
that include the use of leadership
skills to support collaborative practice and team effectiveness.21 The
Institute of Medicine’s July 2014
report Graduate Medical Education
that Meets the Nation’s Health Needs
recommended “production of a physician workforce better prepared to
work in, help lead, and continually
improve an evolving health care delivery system that can provide better individual care, better population
health, and lower cost.”19 The Accreditation Council for Graduate Medical
Education (ACGME) Milestones for
Family Medicine specify competencies in team leadership, collaboration
with public health and community
agencies, advocacy, and leadership
of systems and organizational strategies.22 The ACGME Milestones for
Internal Medicine and Pediatrics
identify competencies in team management, communication, practice
improvement, and advocacy.23,24
From the Department of Family and Preventive
Medicine (Drs Van Hala, Cochella, Kiraly, Pohl,
and Gren, and Ms Jaggi), and College of Social
Work (Dr Frost), University of Utah, Salt Lake
City, UT.
FAMILY MEDICINE
ORIGINAL ARTICLES
While many innovative curricula
have been developed, few target all
learners, use a validated assessment,
or show meaningful impact.25-30 Validated assessment is needed to
demonstrate impact and compare
curriculum.9,14,31-42 A systematic review of leadership training in health
care teams found that defining best
practices is difficult due to lack of
a standard definition of leadership,
supporting frameworks, and robust
assessments.35
Though assessments do exist for
health care administrators, practicing physicians, and surgeons’ nontechnical skills in the operating
room (including leadership), there
are no published assessment instruments of leadership skills for
physicians in residency training programs.17-20,22,30,43-45 Knowing that leadership development covers a broad
spectrum, we specifically wanted
to describe the foundational skills
that early-career physicians, specifically residents, need to learn to
be effective team leaders. Residents
routinely participate in interprofessional teams focused on clinical care
and quality improvement. Theoretically though, foundational leadership
skills should translate across a variety of settings.
The purpose of this study was to
develop a health care leadership selfassessment of foundational competencies and validate the tool among
family medicine residents.
Methods
Faculty at the University of Utah
Family Medicine Residency Program
developed the initial leadership
self-assessment from a compilation
of materials on general leadership
skills, including those for health care
executives.18,30,36,42-60 Our intent was
to identify leadership competencies
for early-career physicians, specifically resident physicians, to be effective team leaders.
To validate the self-assessment,
we used a sequential exploratory
study design, which utilizes “an initial phase of qualitative data collection and analysis followed by a
FAMILY MEDICINE
phase of quantitative data collection
and analysis.”61 The overall purpose
of this approach is “to explore a phenomenon.” This strategy may also be
useful when developing and testing a
new instrument.61 The Institutional
Review Board at the University of
Utah approved this study.
had been revised based on information from the first focus group. We
elicited their views on the clarity and
comprehensiveness of the self-assessment, and used their responses to
clarify and simplify the self-assessment items.
Quantitative Methods
Qualitative Methods
To refine the self-assessment, we
conducted two focus groups. The
primary focus group question was:
“What are the foundational leadership skills that a family medicine
physician needs to be an effective
leader of interprofessional teams?”
The focus group participants discussed the family medicine physician’s role in interprofessional teams
and described the foundational skills
that family medicine physicians need
to be effective leaders. Participants
then completed the self-assessment,
and discussed its comprehensiveness, relevance, clarity, and ease of
use. Each focus group lasted approximately 1 hour, was audio recorded,
and detailed notes were taken by the
facilitators. This qualitative data was
analyzed using open coding to identify emerging themes from the data
as they linked to the assessment.
Face Validity. In March 2015, we
conducted the first focus group with
leaders in medicine to elicit expert
opinion on the skills needed for leadership in family medicine and to
identify whether the devised items
captured the noted leadership skills.
This cross-disciplinary group included experts in community medicine,
academic medicine, family medicine
residencies, and team practice. The
insights from this focus group were
used to guide revisions of the selfassessment.62
Content Validity. The purpose of
the second focus group (June 2015)
was to further refine the self-assessment with eight third-year residents
from our home institution. We followed a focus group process, similar
to the expert focus group, to explore
resident perspective on leadership
competencies. The residents reviewed the self-assessment, which
For the second phase of this study,
we contacted 30 family medicine residency directors to distribute the pilot self-assessment to their residents.
The directors were selected by purposive sample, based on geographic
region and type of program (community versus university), in order to
increase diversity of representation.
The author (SVH) contacted the directors by email with an invitation to
participate in a validation study of a
leadership self-assessment. We sent
an email survey link to the participating directors who were instructed
to forward the survey to their entire
resident cohort. Two weeks later we
sent a second email to improve participation. REDCap, a secure web application, was the survey platform.63
We collected basic demographic
information and asked residents to
complete the 33-item self-assessment
on a scale from beginner (1) to expert
(5). We compared the demographics
of our sample to those of US family
medicine residents (as reported by
the Accreditation Council for Graduate Medical Education, 2013-2014)
using chi-square analysis and Fisher’s exact computation for P value.64
Construct Validity. We conducted
a principal component analysis with
varimax rotation, to reduce the number of assessment items, and group
these items into domains using Stata
(v 13.1 College Station, TX).65 We retained individual items with eigenvalues over 1.0. Factor loadings of at
least 0.30 were used to group items
into domains. Once the domains
were established, we calculated and
compared mean scores overall and
for each domain across demographic variables using linear regression
analysis.
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ORIGINAL ARTICLES
Domain Development
Principal component analysis
grouped the self-assessment statements into domains. Once the domains were established, we named
the domains. Our research team
completed a comprehensive review
of the scholarly and academic literature to determine the vocabulary
and categorization of leadership behaviors.38,45,47,66,67 We drew from our
collective experience in teaching
medical, public health, and social
work students about leadership. We
named the leadership domains to
represent the statements contained
within each domain.
Results
Initially, 30 program directors were
contacted to inquire whether they
would be interested in participating
in this validation study. Of these, 22
programs agreed to send the survey
link out to their residents. Of these,
13 program directors confirmed via
email that the link was sent out to
residents. For the remaining programs for which no confirmation was
obtained, it is not possible to determine which programs did distribute
the link to their residents, as survey
responses were anonymous and respondents were asked only to identify their state, but not their program.
Of the programs that initially agreed
but did not confirm sending the link,
three programs must have sent the
link, as there were responses from
that state and their program was the
only one contacted in the state. Together, these 16 programs are considered verified participants. The
participation of four programs cannot be determined, as there were
multiple programs contacted in the
same state, preventing researchers
from delineating whether these programs did in fact send the link. Finally, two programs likely did not
send the link out to residents, as the
program was the only program contacted in that state and no responses
from that state were received (Figure
1). Overall, responses were received
from between 16 and 20 programs
with a broad geographic distribution
across 12 states (West: California,
Colorado, Utah, Washington; Midwest: Illinois, Michigan, Minnesota;
Northeast: New York, Pennsylvania;
South: Missouri, North Carolina,
Texas).
The maximum number of residents potentially included in the
sample across the 20 programs
that most likely sent out the link
was 564, while the number of residents in the 16 programs verified
to have circulated the assessment
was 468. We received responses from
163 residents, giving a response rate
of 28.9% across all 20 programs, or
34.8% across the 16 programs with
verified participation. The majority
of respondents were female (64.4%)
and white (65.6%). Demographics
for respondents, US family medicine residents, and all US medical
residents are presented in Table 1.64
We compared the demographics of
our sample to all US family medicine
residents, and found significant differences by sex (P=0.015), race/ethnicity (P=0.001) and residency year
(P=0.000).
The principal component analysis
reduced the number of items from 33
on the pilot assessment to 21 on the
final assessment, which was titled
the Foundational Healthcare Leadership Self-assessment (FHLS). The
Figure 1: Participating Residency Programs
Programs initially contacted
n=30
Programs that agreed to send the survey link to residents
n=22
Programs that
confirmed link was
sent
n=13
Programs that did not confirm link
was sent, but must have sent it, as
there were responses from that
state and that was the only
program contacted
n=3
Programs that did not confirm link
was sent, and unable to determine
if they sent it, as multiple
programs in the same state with
responses from that state
n=4
Programs that did not
confirm link was sent, and
likely did not send it, as there
were no responses from that
state
n=2
Responses were received from 16–20 programs, across 12 states
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APRIL 2018 • VOL. 50, NO. 4
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ORIGINAL ARTICLES
Table 1: Demographics of FHLS Respondents
Resident Characteristic
Respondents
(n=163) n (%)
US Family Medicine
Residents (n=10,316) n (%)
US Medical Residents
(n=120,108) n (%)
Age (mean years)
29.5
30.3
30.7
Sex*
Female
Male
Unknown
105 (64.4)
54 (33.1)
4 (2.4)
5,616 (54.4)
4,525 (43.9)
175 (1.7)
52,743 (43.9)
62,115 (51.7)
5,250 (4.4)
Race and Ethnicity*
White, non-Hispanic
Asian or Pacific Islander
Hispanic
Black, non-Hispanic
Native American/Alaskan
Other
Unknown
107 (65.6)
20 (12.3)
18 (11.0)
6 (3.7)
3 (1.8)
6 (3.7)
3 (1.8)
5,286 (51.2)
1,892 (18.3)
693 (6.7)
682 (6.6)
48 (0.5)
551 (5.3)
1,164 (11.3)
52,063 (43.3)
21,670 (18.0)
5,790 (4.8)
5,594 (4.7)
262 (0.2)
7,315 (6.1)
27,414 (22.8)
Residency Year*
1
2
3
4 and above
Unknown
65 (39.9)
49 (30.1)
45 (27.6)
-4 (2.5)
3,505 (34.0)
3,443 (33.4)
3,353 (32.5)
15 (0.1)
--
43,748 (36.4)
34,072 (28.4)
30,185 (25.1)
12,103 (10.1)
--
78 (47.9)
**
18,622 (15.5)
South
26 (16.0)
**
36,635 (30.5)
Midwest
30 (18.4)
**
28,170 (23.5)
Northeast
26 (16.0)
**
36,681 (30.5)
Unknown
3 (1.8)
**
--
Region
West
*Statistically significant differences between survey respondents and US family medicine residents.
**Data of US family medicine residents by region was not available.
Source: Accreditation Council for Graduate Medical Education, Department of Applications and Data Analysis. Data Resource Book: Academic Year
2013-2014.
Table 2: Definition of Domains Within the FHLS
Domain
Definition
Accountability
Demonstrates responsibility for the impact of one’s own behaviors
Collaboration
Works with others to accomplish a mission
Communication
Creates understanding through exchange of information and ideas
Team management
Facilitates group engagement, operations, and performance
Self-management
Handles oneself with discipline and compassion
21 items of the FHLS were assigned
to five leadership domains: accountability, collaboration, communication,
team management, and self-management (Table 2).
An average score for each domain
was calculated by summing the
self-assessment values (from 1=beginner to 5=expert) from the appropriate items, and then dividing by
the number of items in the domain.
FAMILY MEDICINE
The average scores from our survey
are presented in Table 3. Regression
analysis of average scores found no
significant differences by sex, but
did find important differences by
residency year, with more advanced
residents scoring higher (P<0.01).
Additionally, there was suggestive
evidence that nonwhite residents reported higher leadership scores than
their white peers (P=0.055, Table 4).
Regression analysis for each of the
five domains revealed similar patterns, with residency year remaining
the strongest predictor of average
score (results not shown).
Discussion
We created and validated the FHLS
as a self-assessment of foundational leadership skills for early-career physicians. We validated this
VOL. 50, NO. 4 • APRIL 2018
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ORIGINAL ARTICLES
Table 3: Average FHLS Scores* (Standard Deviation) Overall and by Domain
Overall
Score
Total Sample
Accountability
Collaboration
Communication
Team
Management
Self-management
3.4 (0.6)
3.7 (0.6)
3.2 (0.8)
3.7 (0.6)
3.0 (0.8)
3.3 (0.7)
Male
3.4 (0.5)
3.7 (0.4)
3.3 (0.8)
3.7 (0.5)
3.0 (0.8)
3.2 (0.7)
Female
3.4 (0.5)
3.7 (0.6)
3.2 (0.8)
3.7 (0.5)
3.1 (0.8)
3.3 (0.6)
White
3.3 (0.6)
3.6 (0.6)
3.2 (0.8)
3.7 (0.5)
3.0 (0.8)
3.2 (0.7)
Nonwhite
3.5 (0.5)
3.8 (0.5)
3.3 (0.9)
3.8 (0.6)
3.2 (0.8)
3.4 (0.7)
1
3.1 (0.6)
3.5 (0.6)
2.9 (0.8)
3.5 (0.6)
2.6 (0.8)
3.0 (0.8)
2
3.5 (0.5)
3.8 (0.5)
3.2 (0.8)
3.8 (0.5)
3.2 (0.7)
3.3 (0.6)
3
3.7 (0.3)
3.9 (0.4)
3.7 (0.6)
3.9 (0.5)
3.5 (0.5)
3.6 (0.5)
West
3.5 (0.5)
3.8 (0.5)
3.3 (0.8)
3.8 (0.5)
3.2 (0.8)
3.3 (0.7)
South
3.3 (0.6)
3.7 (0.6)
3.2 (0.9)
3.6 (0.6)
2.9 (0.9)
3.0 (0.7)
Midwest
3.4 (0.6)
3.7 (0.7)
3.2 (0.8)
3.7 (0.8)
3.1 (0.7)
3.2 (0.7)
Northeast
3.3 (0.6)
3.6 (0.6)
3.1 (0.9)
3.6 (0.5)
2.9 (1.0)
3.4 (0.7)
Sex
Minority Status
Residency Year
Region
*Scores: 1=beginner to 5=expert
assessment using two groups—experts and users—using qualitative
and quantitative analysis for face,
content, and construct validity. A
self-assessment can be used longitudinally as a formative tool during
residency to help residents engage
in personalized leadership development.32,68,69 The FHLS is the first
step in the development of educational and evaluative assessments
for training clinician leaders.
The FHLS was developed with a
focus on foundational skills for leading interprofessional teams. During
residency, residents work in and lead
teams, in both formal and informal
roles,7 providing clinical care in ambulatory and inpatient settings, and
conducting quality improvement. We
imagine these foundational skills are
generalizable across different team
environments.
The scores from this tool showed
discernable differences by year of
residency, and no gender or age differences. Scores increased by year of
residency, which is an expected progression with advancing training. As
residents develop more experience,
they feel more skilled.
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APRIL 2018 • VOL. 50, NO. 4
Table 4: Regression Analysis of Average FHLS Score
β
95% CI
P
Sex
Male
(ref)
Female
-0.052
-0.213-0.109
0.526
0.010
-0.019-0.038
0.503
-0.003-0.322
0.055
Age
Minority Status
White
(ref)
Nonwhite
0.159
Residency Year
1
(ref)
2
0.297
0.114-0.481
0.002
3
0.591
0.399-0.783
0.000
Region
West
(ref)
South
-0.177
-0.391-0.037
0.105
Midwest
0.019
-0.187-0.226
0.854
Northeast
-0.059
-0.284-0.166
0.603
The majority of respondents to
this survey were female and white.
Compared to family medicine and
all residents nationally, respondents
to the survey were disproportionately female. However, our analysis
showed no difference in response
by gender. Nonwhite respondents
scored higher in the total score than
white respondents (P=0.055). This
phenomenon should be studied further. While respondents represented
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ORIGINAL ARTICLES
both academic and community-based
residency programs, we did not ask
them to identify the type of program,
in order to maintain anonymity. Type
of program could be evaluated in future studies with the FHLS.
The FHLS is a brief self-assessment that takes less than 5 minutes
to complete and quantifies skill within five domains of foundational leadership (Table 2).
Strengths
The strength of our study is in the
use of both qualitative and quantitative methods to validate the FHLS.
In our qualitative analysis, we involved experts and the users of the
tool, with input from both groups.
This process provided face and content validity for the items presented
in the initial tool, as we used the collective expertise of the leaders, and
feedback from the intended users.
Construct validity was assessed in
our quantitative analysis, and resulted in a streamlined tool containing
five domains. For construct validity,
we had broad geographic representation. This purposive sample targeted residents in all US geographic
regions and included respondents in
both academic and community-based
residencies.
Limitations
The FHLS was initially developed
using qualitative methods at a single
geographic location. The initial focus
group included physician leaders in
various leadership positions in the
region. Therefore, a bias may have
occurred due to the geographic location and practices of the experts who
designed and gave feedback on the
tool. However, the tool was designed
using published materials from a variety of locations, and the group of
experts had a collectively broad set
of life and leadership experiences. If
there were geographic differences,
we would expect to see differences
in response by geography, which we
did not.
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Implications
To cultivate leadership skills in medical residents, residency faculty need
validated instruments to measure
progress and to target educational
interventions.9,14,31-42 Such a tool now
exists. The FHLS is intended to be a
formative tool for resident leadership
development within a leadership
curriculum. It can inform individualized learning plans and tailored educational experiences.32,68-69 The FHLS
can be used to guide residency curricular development for educational
needs in a resident cohort.
Our assessment addresses the
ACGME Milestone for Family Medicine competency in team leadership, but does not address the other
Milestones of collaboration with public health and community agencies,
advocacy, and leadership of systems
and organizational strategies.21 These
items were not identified as foundational in our validation process,
but are present in many conceptual
models, and should be considered as
more advanced skills on the leadership spectrum.
Future Research
Although the FHLS was validated
in family medicine, we imagine the
foundational leadership skills are
relevant across many disciplines. Future research is needed to validate
the FHLS with residents in other
specialties and providers from other
disciplines such as physician assistant, nursing, pharmacy, and social
work.
The spectrum of leadership skills
that clinicians need across their career is broad, with one end of the
spectrum being foundational skills.
To complete the spectrum, intermediate and advanced leadership skills
need to be defined, and validated
tools developed.
ACKNOWLEDGMENTS: This work was supported by the Health Studies Fund (Department of Family and Preventive Medicine,
University of Utah). The authors thank Jessica Bickley for her support in manuscript
preparation.
C O R R E S P O N D I N G A U T H O R : Address
correspondence to Dr Van Hala, 375
Chipeta Way, Suite A Salt Lake City,
UT 84108. 801-587-3385, 801-581-2771.
Sonja.vanhala@hsc.utah.edu.
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