The role of the Clinical Director – a practical guide

Published: December 9, 2020

We hope you’ll read this guide alongside our existing advice about formal and distributive leadership. It’s intended to help you better understand and tackle this important role: to support better outcomes for patients, improve staff cultures and increase your job satisfaction.

Many of you will work as a Clinical Director (CD) at some stage during your career. SMOs are expected to lead medical and multi-disciplinary teams but many have not had specific training in clinical leadership.

Some DHBs offer leadership courses – and we agree that appropriate training and support are important. Given this, we have a new MECA clause 36.1(b) providing for “suitable funded training” in addition to the other allowances listed in the continuing medical education clauses. It’s also worth noting clause 36.6. The new training clause is intended for current and future clinical directors, heads of department and chief medical officers.

New CDs will often have an initial meeting with management at which the DHB expectations of the clinical director will be laid out. What is often not expressed so clearly, is your staff’s expectations of you as their clinical director.

There is also a frequent natural conflict for any CD when leadership directives or resource allocations do not match the FTE and resourcing your service needs.

You may face a dilemma about whether to respond to the views of clinical staff and advocate on their behalf or accept management direction without further question. Our view is that CDs are first and foremost advocates for best patient care within their particular service. If you are clear about what this looks like, and can share this view with your team, or better still reflect your team’s view of what best patient care looks like, you will be in a stronger position to succeed in the role.

Clinical Director – why bother?

There are many reasons to become a CD such as:

  • It was your turn
  • Nobody else was prepared to take it on
  • You enjoy administration and feel you have something to contribute
  • Change is needed in the department
  • It might be a pathway for further career development or promotion

The main goals of hospitals and DHBs are to provide the best possible patient care and enable staff to flourish to achieve this. These goals should be your goals too. Any consequential decisions should reference these goals, that is, will this decision improve patient care and/or enable staff to flourish within our service?

Sometimes decisions need to be made in the best interests of the department (and patients) which may not be so clearly in the best interests of the CD. The overall interests of the department should always prevail.

Duties of the Clinical Director

CDs are employed by and responsible to their DHB but ultimately your primary duty is to the delivery of high quality care to the patients in your service. If you keep this in mind, decision-making and policy development will be more straightforward.

There will be many times when compromises need to be made and limited resources shared between departments. However, if each CD is clear about what their service requires for good quality patient care, decisions on resource allocation can be made in a balanced way at CMO or senior management level. The CD and department staff jointly will almost certainly be in the best position to know what level of service and staffing is required for good patient care and it is a key function of your role to indicate this fairly and accurately to senior management. It should not be up to the CD to volunteer cost-saving initiatives that you know will adversely affect the care of patients in your service. The primary duty of a CD is to advocate objectively for their patients.

As part of that however, it is also your duty as CD to consider cost-effectiveness in decision-making. This may take the form of reconfiguring a service model of care, advocating for particular tests and treatments, and using the minimum resource required to achieve good patient outcomes.

Information Sharing

CDs see correspondence and attend meetings that other departmental staff do not. There may be a tendency not to pass on all this information for fear of overloading colleagues, or occasionally a CD may feel they have more authority by withholding information. This is usually a mistake. When staff believe they are not getting information, negative views can develop, even in the absence of a factual basis for these views. It is therefore almost always best to share relevant or potentially relevant information with department staff. Equally, it is very important to take their views with you to meetings – to keep the feedback loops functional – and to be active in sharing ideas and information within and beyond your service.

Performance Review versus Professional Development and feedback

When done with a positive mindset, annual meetings between the CD and SMO colleagues can be a worthwhile and rewarding experience. For some time, ASMS has encouraged a move away from the more reactive and potentially negative use of the term ‘Performance Review’ and the adoption of a more positive and empowering phrase, ‘Professional Development meeting’. This encourages a move from “Are you performing up to expectations?” to “How can the DHB help you flourish, enjoy your work and develop your optimal potential?”. The latter is particularly important as SMOs are often multi-skilled and talented individuals who can contribute to the department or DHB in quite exciting and valuable ways, if given the opportunity.

Where performance issues are identified or concerns emerge, these should be dealt with kindly, promptly, and without pre-determination. They must not be withheld until the time for the annual review meeting occurs. Your DHB will provide support should performance issues emerge, and ASMS is always available to provide advocacy and support to members.

Understanding contracts

CDs are called on to approve leave and may be asked for advice about job offers to new appointees (including salary step, any relevant R&R allowances, or other local ‘arrangements’). In this regard, the CD’s over-riding responsibility is to ensure all staff are treated fairly and in compliance with the collective agreement. You should not assume that a job offer will be correct, or that you don’t need to know about the details of key provisions. In some cases, a degree of interpretation is called for which in turn may call for the exercise of wisdom and judgment.  The advice of a service manager or human resources person may well be required and sought, but don’t assume that all managers and human resource personnel have a full or correct understanding of the MECA. If you have any doubts, seek advice from your local ASMS industrial officer.

It is also great practice to advise newly appointed SMOs about ASMS, and their right to get advice about their job offer directly from the Association.

Who participates in decision-making?

When you take on the CD role, you may feel a sense of pressure to make all of the decisions or sense the role brings with it an inherent ability to make correct decisions on behalf of SMOs. This is unlikely to be the case.

Clinical directorship is better viewed as a privilege rather than a right, and the task is to represent the views of the department as fairly and dispassionately as you can, rather than expecting unquestioning agreement from your colleagues. For job enjoyment and satisfaction, staff need to feel they can contribute to departmental decisions and policy. Your ability to listen, and facilitate democratic development of a group view, is key. It’s not something we are all good at, so specific training and feedback may be valuable. It’s also very important for CDs to have a sound working knowledge of the MECA consultation clause.

If you are able to support and develop a good departmental culture you will find the role of the CD stimulating and rewarding. Furthermore, your staff will have particular skills in certain areas. Their skills are not a threat to your leadership, but a strength to be harnessed; they are assets that will augment your own skills and together you will develop and support good practice across your team. The best leadership allows team members to work to their strengths and support each other to thrive.

Relationship with the service manager

This is a key relationship and it’s important to know where you stand. Scope is a useful concept here – a conversation about what each of you brings to the roles, points of cross-over, points of actual authority (for example, clinically-led decision-making), along with potential points of confusion and/or disagreement.

Whenever there is a change of CD and/or service manager it’s sensible to sit down to negotiate (if needed) and re-establish clarity of roles. This gives you and other staff in the service confidence about reporting lines, decision-making, and where everyone stands.

You don’t always have to agree with your service manager, but you do need to understand your key functions and how to have each other’s backs when it comes to advocating for your service.

It’s obvious when there are strong, high-trust relationships in place, and when there are not. The latter is hugely problematic. Developing effective working relationships with non-clinical managers is a key aspect of a CD’s work. It doesn’t mean you should lose touch with your SMO colleagues – or that you shouldn’t advocate for strong clinically-led decision-making. Quite the opposite. CDs who are confident in their relationships with health administrators are in the best position to educate for resource allocation and service management that supports SMOs and evidence-based patient care.

ASMS is available to assist in situations where CDs feel hamstrung, or not heard when it comes to advocating for their service.

Facilitating equity

All team members of a service are needed for it to function smoothly, including doctors, nurses, administration staff, allied health, receptionists, cleaners and others. All members are equally important to the service and can be involved in decision-making wherever this is appropriate. Good CDs facilitate meetings in which everyone has an equal chance to contribute to discussions and be listened to without interruption. For occasional more important meetings, such as a major service planning meeting, unless you have a high level of skill as a facilitator, we recommend that you make use of an external specialist facilitator.

As in many other fields, there is firm evidence of gender bias in medicine. CDs are in a pivotal position to either guard against this or facilitate ongoing bias (usually unconsciously). It is worthwhile for you to learn about gender bias and gender schemas. The same applies to ethnic bias and ageism. Retirement age will differ according to a range of factors including physiological ageing. It may also be appropriate to utilise the skills and experience of older staff in different ways, drawing on their strengths as appropriate.

Setting expectations for departmental culture

The CD has a pivotal role in determining departmental culture. This includes transparency, decision-making, inclusiveness and equity. ASMS research has shown high levels of burnout and bullying among New Zealand SMOs, which needs to be addressed urgently. There is often heavy pressure on CDs to achieve patient-turnover targets for their department, but this should not be at the expense of staff well-being, and in fact employment legislation prohibits this. The ASMS MECA recommends 30% non-clinical time as part of SMOs’ job-size. Advocating for adequate non-clinical time, documented and appropriate recovery time, regular service sizing and succession planning are key aspects of your role.

Uncollegial behaviour is highly damaging to staff and relationships and there are many ways in which such behaviour and bullying may become manifest. CDs will knowingly or unknowingly set expectations regarding bullying, not least through their own behaviour. It is your duty to inform yourself and your staff of what constitutes bullying so that such behaviour is quickly recognised and addressed.

Acknowledging good work

We know and understand that positive reinforcement is a powerful tool for well-being, productivity and staff relationships. However, in a busy, pressurised service it is often difficult to take the time to give staff positive feedback. Good CDs and managers make a point of regularly giving positive feedback, including celebrating special achievements, or letting staff know that they are doing their job well and are appreciated. Absence of positive feedback risks making people feel undervalued or taken for granted.

Ensuring adequate time to be a Clinical Director

To be a successful CD takes time, which will vary according to the size of the department. The size of the role requires acknowledgement and allowance in terms of time. It is up to you as the CD to assess this and request adjustment if required.

Giving responsibility without authority

As well as the provision of sufficient time to do the job a CD must also be given suitable authority to carry out the role. Basic decisions should be within the power of the CD (given suitable consultation) and the same with clinical decisions.

What makes a good Clinical Director?

Decision-making through consultative processes, based around providing best possible patient care and enabling staff to flourish
Accurately analyses service requirements to provide best possible patient care
Makes these requirements known to management to enable good decision-making
Considers cost-effectiveness of tests and treatment in decisions
Shares information freely and frequently with department staff
Encourages staff to develop
Utilises skills and talents of staff and is not threatened by this
Knows and understands staff contracts
Seeks department consensus for all important decisions
Questions themself and reassesses if their view is clearly at variance with most colleagues
Puts the department team before themselves
Recognises that all department members are equally important
Enables contribution, without interruption, from all team members in meetings
Actively guards against gender bias, ethnicity bias and ageism
Supports staff requirement for non-clinical time to protect staff well-being
Informs themself and staff of bullying behaviours so these can be actively discouraged
Gives regular positive feedback to staff
Ensures adequate time for the role
Accepts others’ points of view
Welcomes constructive feedback and advice