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Clinical Leadership - A Comparison Between New Zealand and Australia Print E-mail
The Quarterly 2012

Australia and New Zealand provide comparable health systems, sharing joint accreditation of medical training programmes. Yet the two countries have evolved quite distinct and separate approaches to clinical leadership.

New Zealand treats the clinical leader as an advisor to senior management with little or no line management responsibility. Australia, in contrast, expects the clinical leader to be an active and integral member of the executive team with line responsibility and accountability for both financial and clinical performance.

Australia supports an active training programme for clinical leaders through recruitment of young graduates into clinical leadership positions. This is formally overseen by both RACMA (for medical leaders) and ACHSM for non-medical health management training. In most Australian states, RACMA registrars receive support for their training programme, with registrars being an integral responsibility of the Medical Director in the teaching hospitals.

To provide a basis for my observations, I have contrasted the role of the clinical leader at two representative and respected tertiary institutions – that of the Chief Medical Officer (CMO) at Counties Manukau District Health Board (DHB) and the Executive Director Medical Services, Quality and Clinical Governance at Peninsula Health in Victoria.

While it is acknowledged that each State in Australia has its own health service structure, the role of EDMS at Peninsula Health is representative of the roles, expectations and accountabilities of medical leaders in larger health service organisations in Australia. Similarly, while each New Zealand DHB has its own unique structure and expectations, the role of CMO at Counties is representative of the expectations of clinical leaders in larger teaching hospitals.

The purpose of the Chief Medical Officer position is described as follows1:

"To foster excellence in clinical standards of medical practice and professional conduct throughout Counties Manukau DHB."
  • Key aspects of the role include:
  • Advising the Chief Executive Officer on clinical matters
  • Contributing to the formulation of the organisation's strategic plan
  • Co-chairing the Clinical Management Executive Committee
  • Reviewing the professional leadership and managerial responsibilities of Clinical Directors including their implementation of policies and their cooperation in cross-functional services
  • To work with other members of the Executive or Business Group in all matters relating to standards and policies affecting clinical practice
  • Ensuring the organisation's compliance with relevant statutes and regulations
  • Developing and maintaining positive relationships with external institutions and authorities, in particular other regional DHBs
  • Ensuring optimal development of the organisation's medical capability and skills in line with strategic requirements
The outcome of this will be the development of the necessary conditions and creating the environment for 'best practice' clinical standards by technically competent staff and positive recognition of high standards of clinical practice from sources both internal and external to the organisation."

In contrast the Executive Director Medical Service, Quality and Clinical Governance at Peninsula Health position is described as:

"The Executive Director, Medical Services is responsible for the professional and clinical leadership of the medical workforce across Peninsula Health. This involves leadership of the professional medical issues and the operational management of the Medical Workforce Unit which is responsible for both recruitment and rostering of junior medical staff and the recruitment, credentialing and reappointment of senior medical staff. The role is also accountable for radiology and pathology contracted services and the internal pharmacy services.

The role is also accountable for the co-ordination and management of Peninsula Health's operational quality management issues and advising the Executive, the Board Quality and Clinical Governance Committee and the Board regarding all aspects of Peninsula Health's quality and clinical governance.

The Executive Director, Medical Services, Quality and Clinical Governance liaises with Executive Directors, Clinical Directors, Operational Directors and Department Heads as well as external stakeholders including Department of Health, Universities, Medical Colleges and accrediting bodies."

An examination of the two positions descriptions further highlights the difference in the roles.

  New Zealand Australian

  • Participate in strategic development
  • Set clinical standards
  • Regional planning/strategies
  • Contribute to annual business planning
  • Develop and monitor standards of care and outcome performance indicators
  • Lead development of patient centred care
  • Encourage cross functional integration
  • Implement policies and standards
  • Communicate the vision and ensure cluster activity is aligned with vision
  • Facilitate a culture of development, learning and teaching to proactively improve practice and process
  • Advice CEO on clinical and medico-legal risk issues
  • Lead investigations of major clinical incidents
  • Identify and manage organisational risk
  • Coordinate all medico-legal issues arising from patient complaints and incidents (with legal council)
  • Point of contact with external clinical review agencies
  • Lead and direct the quality and clinical governance programmes including preparation for accreditation and audits
  • Foster growth of clinical leaders
  • Performance appraisal of clinical directors and Directors of Training
  • Oversight of credentialling
  • Use benchmarking to develop best practice
  • Develop future clinical leaders
  • Implement medical workforce plan
  • Develop medical staff attraction and retention strategies
  • Ensure medical staff contracts and rostering maximise efficiency and cost effectiveness
  • Monitor medical staff leave (annual, sabbatical, Continuing Medical Education etc)
  • Ensuring ongoing research
  • Initiating and approving key clinical projects
  • Executive sponsor of HREC
  • Supervise research secretariat
  • Point of contact for external training institutions
  • Collaboration with universities
  • Principal contact with universities
  • Lead development of medical and interdisciplinary education
  • Oversee medical student placements
  • Development of House Medical Officer mentoring program
  • Oversee induction and integration of IMGs
  • Oversee management and development of simulation centre
  • Ensure compliance with statutes and regulations
  • Comply with all relevant legislation
  • Lead continuous quality improvement initiative
  • Coordinate customer complaints management
  • Lead infection control services
  • Ensure effective management of contracts with radiology and pathology services
  • Ensure services comply with protocols, safety standards and accreditation
  • Operational oversight of pharmacy
  • Oversee and manage patient transport

Reporting line
  • Chief Executive Officer
  • Chief Executive Officer

Direct Reports
  • Deputy CMO
  • Executive Assistant
  • Manager Quality, Patient Safety and Infection Control
  • Manager Medical Workforce Unit
  • Manager – Radiology
  • Manager – Pharmacy
  • Manager – Pathology
  • Director Clinical Training
  • GP Liaison
  • Manager – Research
  • Library
  • RACMA registrar
  • Executive Assistant

  • Registered senior medical officer
  • Experience in senior management
  • Interest and record in research
  • Familiarity with quality and risk management
  • Communication skills
  • Leadership skills
  • Coaching and development skills
  • Commitment to quality
  • Passion for effective medical leadership
  • Understanding of difference between governance and management
  • Medical practitioner with experience and qualifications in medical administration
  • Experience in financial management
  • Senior leadership capability
  • Successful internal and external stakeholder relationship
  • Communication skills
  • Ability to deliver on clinical, operational, quality and financial targets

New Zealand has tended to elevate senior clinicians to the CMO role within the organisation. There is an apparent belief amongst DHB senior executives that to maintain credibility and integrity with their peers, the clinical leaders should be actively engaged in clinical practice.

The New Zealand health system has resisted the development or recognition of clinical leadership programmes for medical practitioners. There are no formally endorsed or funded training programmes in medical management. While many DHBs support short courses for promising medical leaders, there is no formal support for young doctors interested in clinical leadership to undertake training towards specialist registration in administration or management.

Clinical leaders in New Zealand are not expected to manage clinical services or departments. Rather they provide an advisory role. There appears to be a considered reticence at senior executive and Board level to entrust doctors with the management of medical workforce, pharmacy, laboratory or radiology services. Clinical leaders do not usually have financial or direct performance accountability for clinical services.

Management of quality, complaints, risk and infection control are separated from the role of clinical leadership, with the CMO primarily responsible for medical staff performance and accountability. This has lead to a rather narrow and ambiguous understanding of clinical governance.

In contrast, the Australian clinical leader is expected to shoulder direct responsibility for financial and clinical performance. It is the EDMS who is accountable for line management of clinical services, risk management, patient complaints and medical workforce issues. This responsibility demands a high level of expertise in financial management, legal issues and performance management.

The broader Australian vision of clinical leadership demands a higher standard of management skill and accountability than is expected in New Zealand. The Australian model however, gives the senior medical staff a clearer voice at the executive table, greater involvement in decision making and stronger involvement and accountability for clinical performance.

Despite the higher performance expectation, the remuneration package recently offered by Counties Manukau DHB is comparable to that provided in Victoria.

To have clinician leaders perform at the level expected of an Australian model EDMS requires doctors to have undertaken formal training in leadership and management. It is this level of accountability that young doctors interested in management should be encouraged and supported to strive for.

David Rankin
RACMA Fellow

1 http://www.hardygroupintl.com/public/NZ_CountiesDHB_CMO_CIDFFV.pdf

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Last Updated on Friday, 17 July 2015 14:14