11 Feb Summary Challenges associated with leading a $1.7 trillion industry have created a need for strong leaders at all levels in healthcare organizations.
formal analysis and critique of the attachment. Additional references must be used to support the critique position. The narrated power point presentation must be no more than 10 slides in length, excluding title page, reference page and appendix. Create a slide for each heading in bold.must have title page and reference page.
Journal of Organizational Behavior
J. Organiz. Behav. 27, 967–982 (2006)
Published online in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/job.417
*Correspondence to: A Hall, Room 476, 1841
Copyright # 2006
Leadership development in healthcare: A qualitative study
ANN SCHECK McALEARNEY*
Division of Health Services Management and Policy, School of Public Health, The Ohio State University, Columbus, Ohio, U.S.A.
Summary Challenges associated with leading a $1.7 trillion industry have created a need for strong leaders at all levels in healthcare organizations. However, despite growing support for the importance of leadership development practices across industries, little is known about leadership development in healthcare organizations. An extensive qualitative study comprised of 35 expert interviews and 55 organizational case studies included 160 in-depth, semi- structured interviews and explored this issue. Across interviews, several themes emerged around leadership development challenges that were particularly salient to healthcare organ- izations. Informants described how the relative newness of leadership development practices in a majority of healthcare organizations contributes to an overall perception of haphazard practices throughout the industry. In addition, respondents noted challenges associated with developing leaders who would be representative of the patient community served, and commented on the pressure to segregate different professional groups for leadership devel- opment. Framed by these challenges, I propose a conceptual model of commitment to leadership development in healthcare organizations as influenced by three factors—strategy, culture, and structure. These, in turn, influence program design decisions and can impact organizational effectiveness. In the context of inherently complex healthcare organizations where leaders must respond to multiple stakeholders and meet performance goals across multiple dimensions of effectiveness, addressing these reported challenges and consider- ing the importance of organizational commitment to leadership development can help ensure that programs are effectively designed, delivered, and sustained. Copyright # 2006 John Wiley & Sons, Ltd.
Introduction
A sense of crisis is building about how healthcare organizations will meet their leadership needs in the
future (Institute for the Future, 2000; Mecklenburg, 2001; Schneller, 1997). Yet few healthcare
organizations have made substantial investments in developing their leaders. Although bombarded by
constant and rapid change within the $1.7 trillion industry (Smith, Cowan, Sensenig, Catlin, & Health
Accounts Team, 2005), healthcare organizations are frequently slow to adopt best practices from other
industries. Instead, the industry struggles to respond to crucial needs including reducing unnecessary
medical errors (Kohn, Corrigan, & Donaldson, 1999), increasing investments in information
nn S. McAlearney, Division of Health Services Management and Policy, The Ohio State University, Cunz Millikin Road, Columbus, OH 43210-1229, U.S.A. E-mail: [email protected]
John Wiley & Sons, Ltd.
Received 30 January 2005 Revised 30 January 2006
Accepted 29 June 2006
968 A. S. McALEARNEY
technologies (Benchmarks, 2002), and addressing the glaring inequities and disparities in both access
to care and medical treatment (Kerr, McGlynn, Adams, Keesey, & Asch, 2004; McGlynn et al., 2003;
Smedley, Institute of Medicine, Stith, & Nelson, 2002). This article addresses the gaps in leadership
development within healthcare organizations and contextual factors that hamper closing these gaps.
Certain features of healthcare organizations are clearly unique to the industry (Ramanujam &
Rousseau, 2004). Although physicians play a central role in the delivery of healthcare services, they are
rarely employed by provider organizations, and are thus typically outside the purview of traditional
human resources practices and leadership development initiatives. In addition, the professional norms
and practice standards expected of physicians and other medical professionals create demands for
continued clinical education and development that the organization must facilitate, but that are rarely
linked to the education and development priorities of the healthcare organization itself. Further, the
multiple constituencies of healthcare organizations including patients, families, insurers, and
regulators that compete to influence healthcare have varied perspectives about care delivery and its
dynamics, and these divergent views contribute to considerable complexity around definitions of
organizational effectiveness and impact for healthcare leaders to interpret.
Challenges for leadership in the healthcare industry
Complexity in the healthcare industry undoubtedly creates special challenges for leadership and
leadership development, stemming from a combination of both environmental and organizational
factors. Environmentally, healthcare organizations are faced with a myriad of regulatory influences
largely out of their control. For example, most hospitals receive a majority of their reimbursement from
public sources, including the Federally-sponsoredMedicare program and the co-sponsored Federal and
State-funded Medicaid program. Yet these provider organizations rarely have much power or influence
over reimbursement rates, and reimbursement for both hospital and physician services may be below
the actual cost of providing care. As a result, hospitals are challenged to manage fragile budgets and
often shifting reimbursement rates, while needing to deliver high-quality care regardless of payment
source or adequacy.
Organizationally, healthcare organizations are notorious for seemingly chaotic internal
coordination. Multiple hierarchies of professionals, on both the clinical and administrative sides
of the organization, generate special challenges for directing the organization and coordination of
work in healthcare. Often noted is the cultural chasm between administrators and clinicians (e.g.,
Friedson, 1972; McAlearney, Fisher, Heiser, Robbins, & Kelleher, 2005; Shortell, 1992). Even
within clinical ranks, divisions exist associated with professional distinctions such as between
physicians and nurses, pharmacists and physicians, and so forth. Such differences create
considerable challenges for leadership as organizations struggle to manage their varied employed
and contracted worker populations.
Competing organizational priorities create constant challenges for healthcare leaders charged to
direct and appropriately utilize financial and human resources to best serve patients, communities, and
other stakeholders and constituents. The needs of multiple internal and external stakeholders often
conflict. An oft-repeated phrase is the notion of ‘‘no mission, no margin,’’ reflecting the fundamental
importance of maintaining the healthcare organization’s financial viability in order to serve the needs of
patients and the community. Though goals may be clearer in for-profit hospitals or healthcare systems
in which shareholder demands mandate a focus on financials, such settings still require professional
commitments and face ethical concerns.
Managerial and organizational learning receive relatively little attention in health care
organizations. Management mistakes in healthcare are rarely acknowledged or examined as useful
sources of organizational learning (Hofmann, 2005; Hofmann & Perry, 2005; Jones, 2005; Kovner
Copyright # 2006 John Wiley & Sons, Ltd. J. Organiz. Behav. 27, 967–982 (2006)
DOI: 10.1002/job
LEADERSHIP DEVELOPMENT IN HEALTHCARE 969
& Rundall, 2006; Russell & Greenspan, 2005). For example, the failed merger between Stanford
and UCSF Medical Center could have been predicted by a review of both general and healthcare-
specific management literature, yet several years and millions of dollars later, the two systems
separated to become independent systems once again (Russell, 2000). In healthcare settings, there
is often little attention given to how to improve management practice, increasing the likelihood that
previous mistakes will be repeated.
Conceptual Background
Healthcare leadership needs
Clinical and organizational challenges combined increase the need for strong leadership at all levels of
healthcare organizations. Considerable evidence supports the notion that leaders and their actions
affect organizational results (Fuller, Paterson, Hester, & Stringer, 1996; Lowe, Kroeck, &
Sivasubramaniam, 1996; Sashkin & Rosenbach, 2001; Smith, Carson, & Alexander, 1984). In
healthcare organizations, the impact of leaders extends to the lives and well-being of patients and their
communities. Features of healthcare delivery make these effects distinct. For example, in contrast to
other customers and consumers, the vulnerability of patients and the problem of asymmetric
information in healthcare delivery choices are frequently mentioned as contributors to patients’
position as a unique category of customers (Newhouse, 2002). The typically dual role of physicians as
both consumers of healthcare resources and controllers of organizational revenues in their ability to
direct patients and prescribe care, makes leader relationships with physicians fairly atypical in
comparison with key stakeholder relationships in other industries.
Further, researchers and authors have recently emphasized that great leadership must be
transformational, requiring leaders to be able to empower and motivate their workforce, define and
articulate a vision, build and foster trust and relationships, adhere to accepted values and standards, and
inspire their followers to accept change and meet organizational goals on multiple levels (Bass, 1985;
Bennis, 1989; Bono & Judge, 2003; Burns, 1978; Gardner, 1990; House, 1977; House & Shamir, 1993;
Kouzes & Posner, 1993, 1995). Yet a sense of how to best develop these great, transformational leaders
is far from established, especially in healthcare organizations.
Leadership development practices
Leadership development practices are defined as educational processes designed to improve the
leadership capabilities of individuals. These practices are rooted in the traditions of management training
programs designed to improve both individual managerial skills and job performance (Burke & Day,
1986), and can have important effects on both organizational climate (Moxnes & Eilertsen, 1991) and
organizational culture (Schein, 1985). Practices in leadership development are a variant of management
development practices which are defined as interventions that are intended to enhance effectiveness or
improve organizational culture by facilitating managers’ learning (Gray & Snell, 1985).
Conger and Benjamin (1999) outline four general approaches to leadership development that include
developing the individual leader, socializing company vision and values, strategic leadership
initiatives, and action learning (Conger & Benjamin, 1999). Within organizations, leadership
development practices commonly include activities such as 360-degree feedback, skill-based training,
job assignments, developmental relationships (e.g., mentoring, coaching), and action learning (McCall,
Lombardo, & Morrison, 1998; McCauley, Moxley, & VanVelson, 1998; Revans, 1980). Although
considerable variability exists across organizations and industries with respect to the balance and
Copyright # 2006 John Wiley & Sons, Ltd. J. Organiz. Behav. 27, 967–982 (2006)
DOI: 10.1002/job
970 A. S. McALEARNEY
content of leadership development programs, program designs are generally consistent with the four
basic frameworks outlined above. This consistency presents opportunities to explore program
development challenges and decisions in a particular set of organizations, such as healthcare
organizations, rather than focus on program features and details.
Leadership development in healthcare
Anecdotal evidence suggests the healthcare industry lags behind other industries with respect to
leadership development practices and other human resources functions, but these issues have not been
systematically investigated. This exploratory study is designed to improve our understanding of
leadership development practices in healthcare organizations by asking experts and organizational
representatives to describe their views of leadership development in healthcare, and to propose future
directions for healthcare leadership development.
Organizational Context
External Environment
The $1.7 trillion U.S. healthcare industry is both extensive and competitive, with nearly 5,000 hospitals
and 700,000 physicians nationwide. Most markets are dominated by not-for-profit hospitals and health
systems, yet these healthcare organizations are subject to strong pressure to adhere to rigorous business
principles in order to remain viable and realize their organizational missions.
Industry Factors
Several features of the healthcare industry are clearly unique. For instance, while physicians are rarely
employed by hospitals or health systems, they play a central role in directing and utilizing
organizational resources, creating challenges for organizational leaders. Similarly, external influences
from third parties including insurance companies, employers, and government payers drive strategic
organizational priorities around issues such as cost containment and quality improvement.
Organizational Factors
Inside healthcare organizations, internal coordination is often reportedly poor, leading to avoidable,
expensive, and often devastating medical and managerial mistakes. The cultural chasm between
administrators and clinicians contributes to a sense of chaos, with workers often identifying more
with their professional peers than with the organization. Further, human resources functions in
healthcare organizations have historically been limited in scope, and rarely valued for any strategic
role in contributing to organizational success.
Current Problems Faced
Enhanced focus on strategic priorities in healthcare has increased organizations’ attention to the
need to develop and improve their human resources capabilities. Yet, despite evidence from other
industries about the roles and opportunities for leadership development in organizations, our
understanding of leadership development practices in healthcare organizations was limited.
Time
This study was conducted in 2003 and 2004, during a period of rapid change in the healthcare
industry. Intensifying demands for new information technologies in clinical practice, error
reduction in medicine, and new capabilities among healthcare knowledge workers increased
pressure to better prepare leaders at all levels in healthcare organizations.
Copyright # 2006 John Wiley & Sons, Ltd. J. Organiz. Behav. 27, 967–982 (2006)
DOI: 10.1002/job
LEADERSHIP DEVELOPMENT IN HEALTHCARE 971
Methods
Study design
I conducted 35 key informant interviews with individuals considered experts in healthcare leadership
on the basis of their national reputation, and studied 55 organizations reported to provide healthcare
leadership development training either in-house or as a vendor to healthcare provider organizations.
The combination of expert interviews and organizational case studies included a total of 160 interviews
conducted between September 2003 and December 2004. Table 1 shows the characteristics of study
participants across expert interviews and case studies.
I used standard, semi-structured interview guides including open-ended questions to both frame the
interviews and permit probing for additional information (Miles & Huberman, 1994) in the expert
interviews and case studies. The original interview guides were pilot tested with healthcare leaders and
provider organizations in the local area.
This qualitative design (Maxwell, 1996) enabled me to meet the objectives of my research,
permitting exploration of the different issues that emerged around the topic of leadership development
in healthcare. A qualitative approach was appropriate for this study because of the exploratory nature
of my research, and because I suspected that experts’ and organizations’ perspectives about leadership
development were multidimensional, making them difficult to examine quantitatively (Miles &
Huberman, 1994). In addition, my use of qualitative methods enabled me to explore both experiences
and predictions of experts and organizational representatives, and provided rich information about the
multiple facets of leadership development challenges in healthcare (Crabtree & Miller, 1999; Miles &
Huberman, 1994). No potential informant contacted refused to participate in the study. All participants
were assured that their voluntary participation would remain anonymous.
Expert interviews
Expert key informants were purposely selected based on their reputation in the healthcare industry
using a snowball sampling technique. The original sample of key informants was generated by the
industry and academic members of the national Center for Health Management Research (Seattle,
WA), and the sample was extended by study informants who were asked to suggest additional experts
Table 1. Study participants
Description Number (%)
Experts interviewed Association leaders 15 (43%) University faculty 12 (34%) Industry consultants 8 (23%) Total 35
Organizational case studies Healthcare provider organizations 43 (78%) Leadership development program vendors 12 (22%) Total 55
Organizational case study Executive-level Informant 39 (31%) informants Director-level Informant 51 (41%)
Manager-level Informant 23 (18%) Program participant 12 (10%) Total 125
Total key informants 160
Copyright # 2006 John Wiley & Sons, Ltd. J. Organiz. Behav. 27, 967–982 (2006)
DOI: 10.1002/job
972 A. S. McALEARNEY
for the study interviews. Experts had a variety of current and former affiliations, including with
healthcare industry associations, universities, consulting organizations, and provider organizations.
Data saturation was judged to be reached when informants’ suggestions about key informants were
repetitive, and when no new insights were emerging from the ongoing data analysis (Morse, 2000).
Interviews were conducted both in-person and telephonically, using rigorous ethnographic interview
techniques (Spradley, 1979). Interviews lasted 45–90 minutes, with an average duration of 1 hour,
consistent with the methods suggested for in-depth interviews (McCracken, 1988). Experts were asked to
describe their own healthcare leadership and leadership development experiences, and to comment on both
the current status of and program development opportunities for leadership development in healthcare.
Organizational case studies
Similar to expert informants, organizations were purposely sampled based on their reported experience
and reputation with leadership development in healthcare. The original sample was again produced by
the members of the Center for Health Management Research, and extended based upon conversations
with experts and other organizational informants. Fifty-five organizations were studied between
September 2003 and December 2004. Five organizations were studied in person in order to efficiently
complete multiple key informant interviews, while the remaining organizations were studied using
numerous telephone interviews. One hundred twenty-five interviews were held as part of the
organizational case studies. These case studies (Yin, 1984) consisted of interviews with key informants,
in addition to collection and study of documents associated with the leadership development programs,
and a review of publicly available program information accessible through formal publication or the
Internet. Interviews lasted 30–90 minutes, with an average of 45 minutes for each interview.
Organizations studied included both healthcare provider organizations with internal leadership
development activities and external organizations which provide leadership development programs to
individuals and institutions in the health services industry. Internal case study organizations consisted
of 43 healthcare systems and individual hospitals which had reportedly designed and implemented
healthcare leadership development programs, and respondents included executives, directors,
managers, and program participants. Twelve external case study organizations included both
healthcare associations and other vendors of healthcare leadership development programs, with
respondents including individuals leading the organizations and those developing and delivering
healthcare leadership development programs.
Questions addressed the structure and format of leadership development program activities,
including approaches to identifying and targeting individuals and groups for leadership development
opportunities. Similar to the expert interviews, an open-ended list of questions was used, including
questions probing for more information.
Analyses
Amajority of the interviews were audiotaped and professionally transcribed, with extensive field notes
used in the small number of cases (3) where taping was infeasible. This process yielded 160 transcripts
and over 1,000 single-spaced pages for analysis.
My analyses used the constant comparative method of qualitative data analysis (Glaser & Strauss, 1967),
and common techniques to code the data (Constas, 1992; Miles & Huberman, 1994). Using a grounded
theory approach (Glaser & Strauss, 1967; Strauss &Corbin, 1998), I read transcripts and discussed findings
with my research associates and professional colleagues as the study progressed. This iterative process
enabled me to explore new themes that emerged in subsequent interviews and case studies.
Copyright # 2006 John Wiley & Sons, Ltd. J. Organiz. Behav. 27, 967–982 (2006)
DOI: 10.1002/job
LEADERSHIP DEVELOPMENT IN HEALTHCARE 973
I applied a combination of deductive and inductive methods in my analyses. Prior to coding the data,
I produced ideas about the themes I expected to find, and then closely read the transcripts to inductively
advance code development. This coding process permitted me to organize the data into categories of
findings, and allowed me to identify broad themes that emerged from the data (Miles & Huberman,
1994). I use the term ‘‘theme’’ to identify a cohesive category of responses, found across experts and/or
across organizations, that aggregates patterns observed in the data. In addition, throughout the study,
periodic discussions with professional colleagues and my research associates and an ongoing review of
the literature helped me to validate, compare, and extend my findings, where appropriate (Glaser &
Strauss, 1967). I used the qualitative data analysis software Atlas.ti (version 4.2) (Scientific Software
Development, 1998) to support these analyses.
Results
First, six distinct themes emerged from the data concerning the specific leadership development
challenges for healthcare organizations. Each of the themes was discussed across informants,
supporting the validity of these findings. A summary of these leadership development challenges is
presented in Table 2, and below I discuss each theme in greater detail. Second, I propose a conceptual
model for organizational commitment to leadership development in healthcare organizations. I present
this model and three propositions in the following pages. Verbatim quotations have been selected that
are representative of the data.
Table 2. Challenge themes in healthcare leadership development
Challenge Representative comments
Theme 1: Industry lag: The healthcare industry is very behind
‘‘We’re 15 years behind’’ ‘‘I don’t think we are doing very well at all.’’
Theme 2: Representativeness: Need to make organization representative of community and patient population
‘‘Hospital leadership should be a reflection of the demographics of the community that the hospital serves.’’
Theme 3: Professional conflicts: Pressure to segregate different professional groups for leadership development
‘‘I do think it divides the organization and so I don’t know that that’s a good thing to have your managers divided.’’
Theme 4: Time constraints: Challenge of freeing time for program participation
‘‘That’s an hour or two. . .that’s being spent away from patient care in a learning environment.’’
Theme 5: Technical hurdles: Challenges of the organization’s technical capabilities
‘‘If I don’t have a sound card then what’s the use of getting a teleconference or a videoconference? Because then I can’t even hear it.’’
Theme 6: Financial constraints: Challenges associated with budgets, organization type
‘‘It’s something that’s the first thing that people cut in a tight budget situation.’’
Copyright # 2006 John Wiley & Sons, Ltd. J. Organiz. Behav. 27, 967–982 (2006)
DOI: 10.1002/job
974 A. S. McALEARNEY
Challenges of leadership development in healthcare
Theme 1: Industry Lag—The healthcare industry is very behind.
Across informants, many respondents noted that ‘‘healthcare organizations are 10–15 years behind
other industries in the area of leadership development.’’ This characterization of the industry as a whole
was consistent, and perhaps reflective of the trouble and delays healthcare organizations have had
translating other industry practices (e.g., quality improvement techniques) into their own
environments. As one respondent explained:
‘‘I think they’re learning what industry learned 15 years ago
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