Leadership Development in Healthcare: A Qualitative Study Author(s): Ann Scheck McAlearney Source: Journal of Organizational Behavior, Vol. 27, No. 7, Special Issue: Healthcare: The Problems are Organizational not Clinical (Nov., 2006), pp. 967-982 Published by: Wiley Stable URL: http://www.jstor.org/stable/4093879 Accessed: 26-05-2015 08:44 UTC REFERENCES Linked references are available on JSTOR for this article: http://www.jstor.org/stable/4093879?seq=1&cid=pdf-reference#references_tab_contents You may need to log in to JSTOR to access the linked references.
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Journal of OrganizationalBehavior J. Organiz. Behav. 27, 967-982 (2006) Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/job.417
*WILEY
7
SInterScience@
DISCOVER SOMETHING GREAT
Leadership development in healthcare: A qualitative study ANN SCHECK McALEARNEY* Divisionof HealthServicesManagement andPolicy,Schoolof PublicHealth,TheOhioState Columbus, Ohio,U.S.A. University,
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 leadershipdevelopmentin healthcareorganizations.An extensive qualitativestudy comprised of 35 expert interviews and 55 organizational case studies included 160 in-depth, semistructuredinterviews and explored this issue. Across interviews, several themes emerged aroundleadershipdevelopmentchallenges that were particularlysalient to healthcareorganizations. Informantsdescribedhow the relative newness of leadershipdevelopmentpractices in a majority of healthcareorganizationscontributesto an overall perception of haphazard practices throughoutthe industry.In addition, respondentsnoted 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 development. Framed by these challenges, I propose a conceptual model of commitment to leadershipdevelopmentin healthcareorganizationsas influenced by three factors-strategy, culture, and structure.These, in turn, influence program design decisions and can impact organizationaleffectiveness. 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 considering the importance of organizational commitment to leadership development can help ensure that programsare 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 * Correspondence to:AnnS. McAlearney, Divisionof HealthServicesManagement andPolicy,TheOhioStateUniversity, Cunz @osu.edu Hall,Room476, 1841MillikinRoad,Columbus,OH43210-1229,U.S.A.E-mail:mcalearney.1
Copyright ? 2006 John Wiley & Sons, Ltd.
Received 30 January 2005 Revised 30 January 2006 Accepted 29 June 2006
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technologies (Benchmarks,2002), and addressingthe glaring inequities and disparitiesin both access to care and medical treatment(Kerr,McGlynn,Adams, Keesey, & Asch, 2004; McGlynn et al., 2003; Smedley, Instituteof Medicine, Stith, & Nelson, 2002). This article addressesthe gaps in leadership development within healthcareorganizationsand contextual factors that hamperclosing these gaps. Certain features of healthcare organizations are clearly unique to the industry (Ramanujam& Rousseau,2004). Althoughphysiciansplay a centralrole in the delivery of healthcareservices, they are rarely employed by providerorganizations,and are thus typically outside the purview of traditional humanresourcespractices and leadershipdevelopmentinitiatives.In addition,the professionalnorms and practice standardsexpected of physicians and other medical professionals create demands for continuedclinical education and developmentthat the organizationmust facilitate,but that are rarely linked to the education and developmentpriorities of the healthcareorganizationitself. Further,the multiple constituencies of healthcare organizations including patients, families, insurers, and regulatorsthat compete to influence healthcarehave varied perspectives about care delivery and its dynamics, and these divergent views contribute to considerable complexity around definitions of organizationaleffectiveness and impact for healthcareleaders to interpret.
Challengesfor 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 environmentaland organizational factors. Environmentally,healthcareorganizationsare faced with a myriad of regulatoryinfluences largely out of theircontrol.Forexample, most hospitalsreceive a majorityof theirreimbursementfrom public sources, includingthe Federally-sponsoredMedicareprogramandthe co-sponsoredFederaland State-fundedMedicaidprogram.Yet these providerorganizationsrarelyhave much power or influence over reimbursementrates, and reimbursementfor 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 reimbursementrates, while needing to deliver high-quality care regardlessof 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 administratorsand 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 organizationalpriorities create constant challenges for healthcare leaders charged to direct and appropriatelyutilize financialand humanresourcesto best serve patients,communities,and other stakeholdersand constituents. The needs of multiple internal and external stakeholdersoften conflict. An oft-repeatedphrase is the notion of "no mission, no margin,"reflectingthe fundamental importanceof maintainingthe healthcareorganization'sfinancialviability in orderto serve the needs of patients and the community.Though goals may be clearerin for-profithospitals or healthcaresystems in which shareholderdemands mandatea focus on financials, such settings still requireprofessional 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 JohnWiley& Sons,Ltd.
J. Organiz.Behav.27, 967-982 (2006) DOI:10.1002/job
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IN HEALTHCARE 969 DEVELOPMENT LEADERSHIP
& 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 healthcarespecific management literature, yet several years and millions of dollars later, the two systems separatedto 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 organizationalchallenges combined increasethe need for strongleadershipat 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 healthcareorganizations,the impact of leadersextends to the lives and well-being of patientsand their communities. Featuresof healthcaredelivery make these effects distinct. For example, in contrastto other customers and consumers, the vulnerability of patients and the problem of asymmetric information in healthcare delivery choices are frequently mentioned as contributorsto patients' position as a unique category of customers(Newhouse, 2002). The typically dual role of physicians as both consumers of healthcareresources and controllersof organizationalrevenues in their ability to direct patients and prescribe care, makes leader relationships with physicians fairly atypical in comparisonwith key stakeholderrelationshipsin other industries. Further, researchers and authors have recently emphasized that great leadership must be transformational,requiringleaders to be able to empower and motivate their workforce, define and articulatea vision, build andfoster trustandrelationships,adhereto acceptedvalues and standards,and inspire their followers to accept change and meet organizationalgoals 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,transformationalleaders is far from established, especially in healthcareorganizations.
Leadershipdevelopmentpractices Leadership development practices are defined as educational processes designed to improve the leadershipcapabilitiesof individuals.These practicesarerootedin the traditionsof managementtraining programsdesigned to improve both individualmanagerialskills and job performance(Burke & Day, 1986), and can have importanteffects on both organizationalclimate (Moxnes & Eilertsen, 1991) and organizationalculture(Schein, 1985). Practicesin leadershipdevelopmentare a variantof management developmentpracticeswhich are defined as interventionsthat are intendedto enhance effectiveness or improve organizationalcultureby facilitatingmanagers'learning (Gray & Snell, 1985). CongerandBenjamin(1999) outline four generalapproachesto leadershipdevelopmentthatinclude developing the individual leader, socializing company vision and values, strategic leadership initiatives, and action learning (Conger & Benjamin, 1999). Within organizations, leadership developmentpracticescommonly include activities such as 360-degree feedback, skill-basedtraining, job assignments,developmentalrelationships(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 JohnWiley& Sons,Ltd.
J. Organiz.Behav.27, 967-982 (2006) DOI:10.1002/job
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content of leadershipdevelopmentprograms,programdesigns 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,ratherthan focus on programfeatures and details.
Leadership developmentin healthcare Anecdotal evidence suggests the healthcare industry lags behind other industries with respect to leadershipdevelopmentpractices and other humanresourcesfunctions,but these issues have not been systematically investigated. This exploratory study is designed to improve our understandingof leadership development practices in healthcare organizationsby asking experts and organizational representativesto describe their views of leadershipdevelopmentin healthcare,and to propose future directions for healthcareleadershipdevelopment.
OrganizationalContext
External Environment The $1.7 trillionU.S. healthcareindustryis bothextensiveandcompetitive,with nearly5,000 hospitals and 700,000 physiciansnationwide.Most marketsaredominatedby not-for-profithospitalsandhealth systems,yet these healthcareorganizationsaresubjectto strongpressureto adhereto rigorousbusiness principlesin orderto remainviable and realize their organizationalmissions. Industry Factors Severalfeaturesof the healthcareindustryareclearlyunique.Forinstance,while physiciansarerarely employed by hospitals or health systems, they play a central role in directing and utilizing organizationalresources,creatingchallengesfor organizationalleaders.Similarly,externalinfluences from thirdpartiesincludinginsurancecompanies,employers,and governmentpayersdrive strategic organizationalprioritiesaroundissues such as cost containmentand quality improvement. Organizational Factors Inside healthcareorganizations,internalcoordinationis often reportedlypoor, leading to avoidable, expensive, and often devastatingmedical and managerialmistakes. The cultural chasm between administratorsand clinicians contributesto a sense of chaos, with workersoften identifying more with their professional peers than with the organization.Further,human resources functions in healthcareorganizationshave historicallybeen limited in scope, and rarelyvalued for any strategic role in contributingto organizationalsuccess. Current Problems Faced Enhanced focus on strategic prioritiesin healthcarehas increased organizations' attentionto the need to develop and improve their humanresourcescapabilities. Yet, despite evidence from other industries about the roles and opportunities for leadership development in organizations, our understandingof leadership development practices in healthcareorganizationswas 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 prepareleaders at all levels in healthcareorganizations.
Copyright? 2006 JohnWiley& Sons,Ltd.
J. Organiz.Behav.27, 967-982 (2006) DOI:10.1002/job
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IN HEALTHCARE 971 DEVELOPMENT LEADERSHIP
Methods Study design I conducted 35 key informantinterviews with individualsconsidered experts in healthcareleadership on the basis of their nationalreputation,and studied 55 organizationsreportedto provide healthcare leadership development trainingeither in-house or as a vendor to healthcareproviderorganizations. The combinationof expertinterviewsand organizationalcase studiesincluded a total of 160 interviews conducted between September2003 and December 2004. Table 1 shows the characteristicsof study participantsacross expert interviews and case studies. I used standard,semi-structuredinterview guides including open-endedquestions to both frame the interviews and permit probing for additional information (Miles & Huberman, 1994) in the expert interviewsand case studies.The originalinterviewguides were pilot tested with healthcareleadersand provider organizationsin the local area. This qualitative design (Maxwell, 1996) enabled me to meet the objectives of my research, permittingexplorationof the differentissues that emerged aroundthe topic of leadershipdevelopment in healthcare.A qualitativeapproachwas appropriatefor this study because of the exploratorynature of my research,and because I suspectedthat experts' and organizations'perspectivesaboutleadership development were multidimensional, making them difficult to examine quantitatively (Miles & Huberman,1994). In addition,my use of qualitativemethods enabled me to explore both experiences and predictionsof experts and organizationalrepresentatives,and providedrich informationaboutthe multiple facets of leadershipdevelopmentchallenges in healthcare(Crabtree& Miller, 1999; Miles & Huberman,1994). No potentialinformantcontactedrefusedto participatein the study.All participants were assured that their voluntaryparticipationwould remain anonymous.
Expert interviews Expert key informantswere purposely selected based on their reputationin the healthcareindustry using a snowball sampling technique. The original sample of key informantswas generated by the industry and academic members of the national Center for Health Management Research (Seattle, WA), and the sample was extendedby study informantswho were asked to suggest additionalexperts Table1. Studyparticipants Number(%)
Description
15 (43%) 12 (34%) 8 (23%)
Expertsinterviewed
Associationleaders Universityfaculty Industryconsultants
case studies Organizational
Healthcareproviderorganizations Leadershipdevelopmentprogramvendors
35
Total
Total
case study Organizational informants
43 (78%) 12 (22%) 55
Executive-levelInformant Director-levelInformant
39 (31%) 51 (41%)
Manager-level Informant
23 (18%)
12 (10%)
Programparticipant
125 160
Total Total key informants
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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 saturationwas judged to be reached when informants'suggestions about key informantswere repetitive, and when no new insights were emerging from the ongoing data analysis (Morse, 2000). Interviewswere conductedboth in-personand telephonically,using rigorousethnographicinterview techniques (Spradley, 1979). Interviews lasted 45-90 minutes, with an average durationof 1 hour, consistentwith the methodssuggestedfor in-depthinterviews(McCracken,1988). Expertswere askedto describetheirown healthcareleadershipandleadershipdevelopmentexperiences,andto commenton both the currentstatus of and programdevelopmentopportunitiesfor leadershipdevelopmentin healthcare.
Organizationalcase studies Similar to expertinformants,organizationswere purposelysampledbased on theirreportedexperience and reputationwith leadershipdevelopmentin healthcare.The original sample was again producedby the membersof the Centerfor Health ManagementResearch,and extended based upon conversations with experts and other organizational informants. Fifty-five organizations were studied between September2003 and December 2004. Five organizationswere studiedin personin orderto efficiently complete multiple key informantinterviews, while the remaining organizationswere studied using numerous telephone interviews. One hundred twenty-five interviews were held as part of the organizationalcase studies.These case studies(Yin, 1984) consisted of interviewswith key informants, in additionto collection and studyof documentsassociatedwith the leadershipdevelopmentprograms, and a review of publicly available programinformationaccessible throughformal publicationor 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 developmentactivities and externalorganizationswhich provide leadershipdevelopmentprogramsto individualsand institutionsin the health services industry.Internalcase study organizationsconsisted of 43 healthcare systems and individual hospitals which had reportedlydesigned 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 healthcareleadership development programs. Questions addressed the structure and format of leadership development program activities, including approachesto identifying and targetingindividualsand groups for leadershipdevelopment opportunities.Similar to the expert interviews, an open-ended list of questions was used, including questions probing for more information.
Analyses A majorityof the interviewswere audiotapedand professionallytranscribed,with extensive field notes used in the small numberof cases (3) where taping was infeasible. This process yielded 160 transcripts and over 1,000 single-spaced pages for analysis. My analysesused the constantcomparativemethodof qualitativedataanalysis(Glaser& Strauss,1967), and common techniquesto code the data (Constas, 1992; Miles & Huberman,1994). Using a grounded theoryapproach(Glaser& Strauss,1967;Strauss& Corbin,1998),I readtranscriptsanddiscussedfindings with my researchassociatesand professionalcolleagues as the study progressed.This iterativeprocess enabledme to explore new themes that emergedin subsequentinterviewsand case studies. Copyright? 2006 JohnWiley& Sons,Ltd.
J. Organiz.Behav.27, 967-982 (2006) DOI:10.1002/job
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I applied a combinationof deductiveand inductivemethodsin my analyses. Priorto coding the data, I producedideas aboutthe themes I expected to find, andthen closely readthe transcriptsto inductively advance code development.This coding process permittedme 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 categoryof responses, found across expertsand/or across organizations,that aggregatespatternsobserved in the data. In addition, throughoutthe study, periodic discussions with professionalcolleagues andmy researchassociates and an ongoing review of the literaturehelped me to validate, compare, and extend my findings, where appropriate(Glaser & Strauss, 1967). I used the qualitativedata analysis software Atlas.ti (version 4.2) (Scientific Software Development, 1998) to supportthese 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, supportingthe validity of these findings. A summaryof these leadership development challenges is presentedin Table 2, and below I discuss each theme in greaterdetail. Second, I propose a conceptual model for organizationalcommitmentto leadershipdevelopmentin healthcareorganizations.I present this model and three propositionsin the following pages. Verbatimquotationshave been selected that are representativeof the data.
Table2. Challengethemesin healthcareleadershipdevelopment
Theme 1: Theme 2:
Challenge
comments Representative
Industrylag: The healthcare industryis very behind Representativeness:Need to make organization representativeof community
"We're15 years behind" "I don't think we are doing very well at all." "Hospital leadership should be a reflection of the demographics of the communitythat the hospital serves."
Professional conflicts: Pressureto segregate different professional groups for
"I do think it divides the organizationand so I don't know that that's a good thing to have your managers divided."
andpatientpopulation
Theme 3:
leadershipdevelopment Theme 4:
Theme 5:
Theme 6:
Time constraints: Challenge of freeing time for programparticipation Technicalhurdles: Challenges of the organization'stechnical capabilities Financial constraints: Challenges associated with
"That'san hour or two...that's being spent away from patient care in a learning environment." "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." "It's something that's the first thing that people cut in a tight budget situation."
type budgets,organization
Copyright(
2006 John Wiley & Sons, Ltd.
J. Organiz. Behav. 27, 967-982 (2006)
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Challenges of leadership developmentin healthcare Theme 1: IndustryLag-The healthcareindustryis very behind. Across informants,many respondentsnoted that "healthcareorganizationsare 10-15 years behind otherindustriesin the areaof leadershipdevelopment."This characterizationof the industryas a whole was consistent, and perhaps reflective of the trouble and delays healthcareorganizationshave had translating other industry practices (e.g., quality improvement techniques) into their own environments.As one respondentexplained: "I thinkthey'relearningwhat industrylearned 15 years ago. You've got to develop your own people and you've got to fully pursueit. You'vegot to invest to do it andyou might as well make it a rational decision that'smatchedto the business strategiesratherthanhavingthese segmentedareaswherewe have OD [OrganizationalDevelopment] doing some things here, we have nursing development rolling out God knows what over there. I think they're really learning what industrylearned. You know, it's a classic curve. We're 15 years behindin qualityand we're aboutthe same amountof time behind in training." In addition,therewas a sense thatcommitmentsto leadershipdevelopmentby healthcareorganizations were generallyrare,andoften insufficient.As one individualreported,"I thinka lot people who get intoit are just going throughmotions." Anotherrespondentsimilarly noted, "I think that healthcaredoesn't mandate enough leadership development from their managerialranks in general." In contrast, the importanceof senior leadershipcommitment,the designationof a highly visible and powerfulprogram director,and the need to align leadershipdevelopmentactivities with other organizationalgoals and strategiesmay be standardin other industrieswhich have a longer history of incorporatingleadership developmentpractices,but are only beginning to be recognized in healthcare. Theme2: Representativeness-Need to make the organizationrepresentativeof the communityand the patient population. A second theme thatemergedinvolved the reportedchallenge of healthcareorganizationsto develop a diverse group of leaders that was representativeof both the patient population and the surrounding community.As one informantexplained, "As you develop your managementstaff I thinkyou have to look for an opportunityto bring the kind of diversity that's necessary for your organizationto be responsiveto the needs of the communitythatyou serve." Commentssuch as this were frequentacross respondents,and reflectedthe growing industrysensitivity to the needs of diverse populations,andthe critical issue of disparatehealthcareprovision in U.S. hospitals (Kerr,McGlynn, Adams, Keesey, & Asch, 2004; McGlynn et al., 2003; Smedley, Institute of Medicine, Stith, & Nelson, 2002). Theme3: ProfessionalConflicts-Pressure to segregatedifferentprofessionalgroupsfor leadership development. Anothertheme emerged aroundthe issue of bridgingthe gap that exists between administrativeand clinical leadership in healthcare organizations. Across the internal programs I studied, there was considerabledebate about the best way to develop clinician leaders, with a numberof the proposed approacheshaving only recentlybeen implemented.Forexample, manyorganizationsreportedtension aroundthe issue of nursingleadershipdevelopment.Opportunitiesaregrowingfor nursesto participate in leadership development programsthat are separatefrom both organizationalprogramsand other clinical leadershipprograms(e.g., the Health Care Advisory Board's Nursing LeadershipAcademy), yet not all respondentsbelieve this approachis best for the organizationas a whole. As one respondent Copyright? 2006 JohnWiley& Sons,Ltd.
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explained, "there'sbeen some resistancein termsof sendingnursingmanagersbecause I think [nursing leadership]feels they are responsiblefor the nursingmanagementdevelopmentso why shouldthey go to the LeadershipInstitutewhen [nursingleadership] can give them everything they need." Specific concernsalso emerged aboutthe best way to develop physician leaders. Consistentwith the oft-reported"cultureclash" between physicians and administrators,many informantscommented on the special challenge of physician leadership development. As one respondent summarized, "Administratorsare from Venus, physicians are from Mars,because you've got a clash of cultures and a clash of different perspectives. So I think leadership development in this setting requires more-because it's a mix of differentcultures-requires more competencyin what would be crossculturalcommunication.So I think it is a little bit different. I'm sure there's other settings where those issues come up, but that strikesme because there'sclearly two very differentways of looking at the world." Reportedchallenges of physician leadershipdevelopmentranged from basic issues such as getting physicians to participate to philosophical issues surrounding physicians' different training and orientationtowardschange, decision-making,and focus. Across settings, organizationswere as likely to incorporatephysicians in theirleadershipdevelopmentprogramsas not, and there appearedno clear consensus about which approachwould ultimately be best. Theme 4: Time Constraints-Challenges of freeing time for programparticipation. A fourth theme that emerged across study participantswas the difficulty for organizationsto free people's time to participate in leadership development activities. Although this challenge was admittedly not unique to healthcareorganizations,the nature of work being "missed" by program participantswas noted as "different."As one organizationalinformantexplained, "If you have a class of 20 people, all nursingstaff, you know, that's an hour or two of their salary that's being spent away from patient care in a learning environment."Where such developmental activities were reportedly more accepted organizationally,this challenge was less acute, but respondents still noted issues associated with participation. Several organizations recognized these issues, but solutions or suggestions to manage the problem were absent. Parallelingorganizationalconcerns,individualsalso commentedabouthow hardit was to find time to participate.Rarely were developmentalexperiences and opportunitiesbuilt into existing jobs. Most respondents,instead,describedleadershipdevelopmentactivitiesas somethingtheyhad to maketime for in additionto theirregularresponsibilities.Many reportedthat,if they participatedin a program,short-term disadvantagessuchas fallingbehindin workor learningthingsthatseemedminimallyrelevantoverwhelmed anylong-termpotentialto be gainedfromdevelopment.Further,non-hospital-employed physicianschoosing to attenda programtypicallylost revenuebecause they were not using theirtime to see patients. Theme 5: Technical Hurdles--Challenges of the organization'stechnical capabilities. Additional challenges associated with leadership development in healthcare organizations were reportedin the context of organizations'technical capacities. The ability to deliver web-based training was typically limited by non-universalaccess of employees to computers,much less the Internet.As an informantpondered, "Do we need computerkiosks thatare dedicatedto this kind of thing?How arewe going to structure it to bringthe productcloser to the staff so they don't have to leave the unit?Do we do somethingin a breakroom?Do we have a mobile computerthatwe can move around?We'rejust not sure.And it all looks differentdependingon the site. So partof our next year is doing that kind of inventoryso we can have a handle on what kind of capital investment we might need to make." Copyright? 2006 JohnWiley& Sons,Ltd.
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Further,even in hospitals where therewere sufficientnumbersof computersavailable,therewere no guaranteesthat the informationsystems capabilitieswere sufficientlyadvancedto permitoptions such as audio content delivery or video-conferences. Technicalissues appearedespecially challenging for some of the smaller,non-system-basedhospitals, and this was likely relatedto the financialchallenges reportedby many organizations,and described next. Theme 6: Financial Constraints-Challenges associated with budgets, organizationtype. A sixth theme emergedaroundthe challenges associatedwith tight budgets and financialconstraints in healthcare organizations. Although healthcare organizations may not be the only type of organizationstrugglingwith this issue, organizationalrespondentsfrequentlymade comments such as, "You know we're working on these paper-thinmargins."In the context of leadershipdevelopment, these thin marginsoften put programactivities at risk. One informantexplained how, "The money is getting tighterand tighterand our workloadis getting largerand largerand so often educationis one of the ones that is cut back or even cut out." Across organizationsstudied, a majority of respondents reporteda sense that leadershipdevelopment programswere perpetuallyat risk, and noted that this inability to count on the future of the programscontributedto skepticism about the organizations' commitments to development, as well as job insecurityfor those tasked with designing or delivering leadership development programs.Finances appearedmore problematicin healthcareorganizations owned independently as opposed to system-owned. Hospitals that were part of a healthcaresystem were reportedlymorelikely to be able to build and sustainleadershipdevelopmentcapacitiesthantheir free-standing counterparts,and often promoted leadership development activities as part of the corporatesupportfunction.
Conceptual Model of Organizational Commitment to Leadership Development Considering these data, I propose a conceptual model of commitment to leadership developmentin healthcare organizations as being influenced by three factors: (1) organizational strategy; (2) organizationalculture;and (3) organizationalstructure(Figure 1). In turn,this commitmentinfluences the program design decision process, resulting in broader or narrower leadership development opportunities for individuals. Further, these program design decisions correspondingly affect organizationaleffectiveness, depending on programscope, reach, and impact. Changes in any of the three factors can shift organizationalcommitmentto leadershipdevelopment, potentially influencing both the design decision process and overall organizationaleffectiveness. In the following section, I discuss threeaspects of the model in greaterdepth:(A) the perceivedvalue of learning and growth;(B) the dynamic natureof the programdesign decision process; and (C) how leadership development may promote organizationaleffectiveness.
A. Perceived value of learning and growth Proposition A: The more the organization's senior leaders value learning and growth, both of individual employees and of the organization, the more likely leadership development is to be supportedand sustained within that organization. Copyright? 2006 JohnWiley& Sons,Ltd.
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LEADERSHIPDEVELOPMENTIN HEALTHCARE
OrganizationalStrategy * Competingstrategic priorities * Need to focus on financialsustainability * Timehorizonfor organizationaldecisions * Linkbetween developmentandother strategicorganizational priorities
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Organizational Culture * Orientationtowards learningand growth * Seniorleadership support * Value of developmentrelative to otherpriorities * Supporters,resistors, otherforcespro and con
Organizational Structure * Placementof leadership developmentfunction * Linkageto human resources,other organizational developmentfunctions * Centralizationof decisionmakingabout developmentresource allocation
OrganizationalCommitment to Leadership Development * Resourceavailabilityfor leadershipdevelopment * Positionandpowerof programdirector * Expectationsfor leadershipdevelopmentprogram * Sustainabilityof commitmentto leadershipdevelopment
* * * *
Leadership Development Program Design Decisions Targetpopulationfor leadershipdevelopment Balanceof internalversus externalprogramopportunities Involvementin clinical leadershipdevelopment Metricsto assess program
* * * *
Organizational Effectiveness Improvedemployeemotivation Reducedemployeeturnover Increasedorganizationalresilience Enhancedabilityto succeedin market
commitmentto leadership Figure1. Conceptualmodeldepictinginfluenceson and impactsof organizational developmentin healthcareorganizations
Organizationalleaderswho believe in the value of learningand growthare likely to invest heavily in leadershipdevelopment activities and commit to sustainingthe programover time. For instance, one executive describinga strongprogramdeclared, "we would never shutthis down." Anotherrespondent summarizedthe importanceof this perception:"The organizationhas to value developmentin general. Whetherit's developingtheirstaff for clinical competence or leadersfor theirleadershipcompetencies, you have to have an organizationthat values development.And ongoing development. You can't stop and say, "okay,we're there,"because you're never there."In severalhealth care organizationsstudied, the hiringof a Chief LearningOfficerprovidesevidence of this organizationalvalue, and demonstrates commitment to leadershipdevelopment within the organization. Copyright? 2006 JohnWiley& Sons,Ltd.
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In contrast,leaderswhose interestsin learningand growtharemorereactionaryareunlikely to invest in long-termleadershipdevelopmentinitiatives or senior hires. Withinthese organizations,leadership development activities are assigned to lower-status directors within the larger human resources function, and budgets are typically limited and at constant risk of future cuts.
B. Dynamics of program design decision process Proposition B: The natureand conceptualizationof leadershipdevelopment programswill affect how organizationssupportsuch programsbecause of how the design decision process is viewed. In several organizations with strong commitment to leadership development programs, such programswere well integratedwithin the organization,reflectedby comments associating leadership developmentwith strategy,culture,or structure.One intervieweedescribedleadershipdevelopmentas, "really a culturequestion. If you have a culturethat has a history of valuing these kinds of things, the uphill battle is long gone." In another organization, a leadership development program director describedthe need to "[make] sure that I'm aligned with the strategicplan." However,shifts in any of the three factors, strategy, culture, or structure,may affect program commitment. For example, a change in leadershipinvolving hiringa new CEO could affect all threefactorsas the new leadermakes organizationaldecisions thathave a correspondingimpact on commitmentto leadershipdevelopment. Similarly, a strategic decision to invest more in information technologies may restrict resources available for development, thereby affecting programcommitment, design, and potential impact.
C. Leadership developmentaffecting organizational effectiveness Proposition C: Organizational decisions to invest in leadership development can affect the organization's overall effectiveness by improving employee motivation, reducing turnover,and building organizationalresilience to change. Organizations heavily committed to leadership development tend not to differentiate between leadership effectiveness and leadership development programsuccess. As one executive explained, "You'reinvestingin the people, the managerswho makeyou successful."Insteadof using metrics such as program attendance, employee satisfaction with programs, and credit hours accumulated, these organizations measure success on the basis of organization-wide metrics including employee satisfaction,employee turnover,physician satisfaction,financialperformance,and so forth. The move beyond programprocess evaluationto acceptance that leadershipaffects the organization'sability to realize its strategic goals is reflective of a broader view of leadership impact and underlying assumptions. In several organizations, this was described as "a development mindset," where the committed organizationviewed leadership development as critical for organizationalsuccess.
Discussion This exploratory investigation finds evidence that healthcare organizations experience major challenges in designing and delivering leadership development programs.Given the circumstances Copyright? 2006 JohnWiley& Sons,Ltd.
J. Organiz.Behav.27, 967-982 (2006) DOI: 10.1002/job
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IN HEALTHCARE 979 LEADERSHIP DEVELOPMENT
associated with a complex external environment and time-pressuredemployees, it is perhaps not surprisingthatdevelopmentalconcerns and opportunitiesseemed absentfrom the strategicprioritylist of manyhealthcareorganizations.Yet the challenges to improvehealthcareleadershipdevelopmentare not insurmountable.Recent literatureemphasizes the importanceof strong leadership development practices (Conger & Benjamin, 1999; Day, Zaccaro, & Halpin, 2004; Fulmer & Goldsmith, 2001; Giber,Carter,& Goldsmith,2000; McAlearney,2005; McCauley,Moxley, & VanVelson,1998; Tichy, 1999), and healthcare organizations can incorporatemany evidence-based practices such as using developmentalassignments,creatingjob rotations,and tying developmentto performanceevaluations that have strengthenedorganizations'leadership across industries. Although many individualsin healthcarecontinue to emphasize the uniqueness of the industry,this insular thinking has tended to limit healthcareorganizations'abilities to improve their management capabilities. Looking outside healthcarecan provide examples of programdesign decisions and best practicesthatcan be adoptedwithin healthcareorganizations.For instance, universitysettings provide environmentswhere faculty often have more clout than administratorsin determining strategy and defining organizational mission, similar to the disproportionateinfluence of many physicians on hospital direction. Study of university leadershipdevelopment programsmay provide insight that is transferableto healthcareorganizations.In addition,recruitingindividualswith relevantexperience in other industries into healthcare organizations may be an effective way to improve leadership developmenthealthcare.Thus despite healthcareorganizations'reluctanceto considerevidence-based management in the same favorable light as evidence-based medicine (Kovner & Rundall, 2006), healthcareorganizationscan apply lessons learned about leadership development to make important strides to accelerate leadershipdevelopment in healthcare,and to better position themselves for the future.
Limitationsof this study For this qualitativestudy,participationwas very high, but the use of a snowball samplingtechniqueto select interview targetslimited my ability to focus on organizationsthat might be considered to have best practices in leadership development a priori. Further, since the proliferation of leadership development programsis relatively new in many healthcare organizations, some of my interviews focused more on plans for the future ratherthan evidence from the past. Futureresearchtargetedto studymodel healthcareleadershipdevelopmentprogramsand theirprogramdesign decisions would be invaluable, as well as studies which incorporatedata collection to permit testing of my conceptual model, and formal comparisonof leadership development programsacross industries.
Conclusion In healthcareorganizations,as in other industries,the leadershipchallenges are immense. Similar to other organizationalleaders, healthcareexecutives are expected to lead their organizationsand their employees with integrity, honesty, energy, and enthusiasm. However, healthcare leaders must also respond to the distinct features of their industryas they attemptto promote excellence in quality of care, patientsatisfaction,andrelationshipswith physicians and communities.Consideringthe nuances of the different leadership development challenges and aspects of organizational commitment to Copyright? 2006 JohnWiley& Sons,Ltd.
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leadership development described in this paper can help healthcareorganizationsstriving to develop better leaders and attemptingto maximize overall organizationalperformance.
Acknowledgements The studyreportedin this paperhas been supportedby a grantfrom the Centerfor HealthManagement Research. I greatly appreciatethe help of all study participants,as well as the research assistance providedby KatrinaBuchholtz,SarahHoshaw,ViktoryaPelts, Mindy MarcumSlenn, Stacy Baker,and Diana Lau, all affiliatedwith The Ohio State University duringthe study.In addition,I am indebtedto both the editors of this journal special issue and to two anonymous reviewers for their invaluable suggestions to improve this manuscript.
Author biographies Ann Scheck McAlearney is an Associate Professorin the Division of Health Services Management and Policy in the School of Public Health at the Ohio State University. Her research focuses on organizationalchange and development;healthinformationtechnology innovations;populationhealth managementand improvement;and leadership in health care organizations.
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