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HC-BS415_Week4_PP2.pptxChapter 6
Leadership Competencies: Application of Skills, Tools, and Abilities
“Thinking always ahead, thinking always of trying to do more, brings a state of mind in which nothing seems impossible.”
Henry Ford
Learning Objectives
Describe planning, decision making, and training in health organizations and provide examples of each.
Summarize the planning process and the decision making process within the context of leadership.
Apply and relate at least two different decision making models to a leadership situation.
Differentiate the levels or components of the planning process and distinguish each level or component from the other.
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Learning Objectives
Plan and design a quality improvement program based on a system of rational decision making for a health organization.
Compare and contrast willful choice to garbage can models of decision making, training leaders to training staff, and cultural competence to ethics and morality.
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Application of Skills, Tools & Abilities
Planning
Planning is an essential leadership skill that requires knowledge about planning and the ability to structure and develop a system of planning.
Health leaders who can understand, apply and evaluate planning will have advantages over those who haphazardly plan or fail to plan.
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Application of Skills, Tools & Abilities
Planning
Planning occurs formally, informally, strategically (how the organization can best serve its purpose in the external environment) and operationally (how can the internal capabilities and resources of an organization be used effectively, efficiently and efficaciously to achieve the strategies and goals of the organization as documented in the strategic plan).
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Application of Skills, Tools & Abilities
Planning
Planning is a process that uses macro and micro environmental factors and internal information to engage stakeholders to create a framework, template and outline for section, branch or organizational success; planning can be strategic or operational or a combination of both
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Strategic Planning is concerned with finding the best future for your organization and determining how the organization will evolve to realize that future;
It is a stream of organizational decisions focused in a specific direction based on organizational values, strategies and goals.
The focus is on external considerations and how the organization can best serve the external markets’ expectations, demands and needs;
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Operational Planning is about finding the best methods, systems and processes to accomplish the mission/purpose, strategies, goals and objectives of the organization in the most effective, efficient and efficacious way possible.
The focus in operational planning concerns more internal resources, systems, processes, methods and considerations.
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Planning is a journey. The journey must have a destination. The journey must be planned. It is a planned journey forward in time. In that light, planning includes both a process (achieving goals and objectives) and an outcome (the plan).
The ultimate outcome of planning is a vision that is achieved.
The desired future state is the vision of the organization. The vision is what the combined staff of the organization strives to achieve.
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The strategic plan is a roadmap, the organizational vision is the final destination, describing “where the organization is going.”
The healthcare leader must energize followers to “buy-in” to the vision in order for the organization to begin its’ strategic journey.
Vision must be tested and re-tested to ensure “buy-in” from all stakeholders, including external and internal.
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Situational Assessment and Environmental Scanning
Situational assessment and continuous environmental scanning are crucial for organizations to survive in the dynamic health industry.
A health organization must understand the impact of the operating environment. The leader’s responsibility is to remain current and recognize situational and environmental changes that can impact the organization.
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Situational Assessment and Environmental Scanning
Forces that contribute to the health industry’s rapid and dynamic environment are varied but are cumulative and thus, have a cumulative impact on the industry.
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Macro-Environmental Forces
Legal, [regulatory, executive orders, case law, etc…] and Ethical forces;
Political (including government policy) forces;
Cultural and Sociological (including values [beliefs and attitudes]) forces;
Public Expectations (including community, interest groups and media);
Economic forces; and
Ecological forces.
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Health Care Environmental Forces [also called Micro-Environmental Forces]
Planning and Public Policy (regulation, licensure and accreditation) forces;
Competitive forces;
Health Care Financing (third-party payers, public and private, and financial risk);
Technology (equipment, material and supply entities) forces;
Health Research and Education;
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Health Status & Health Promotion (wellness & disease); and
[Integration with other health disciplines ] Public Health (sanitation, environmental protection, etc…) forces
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The Rand Corporation suggests that immense pressure of cost-containment and speed of change are the leading factors in the health industry at this time. Multiple forces cumulatively contribute to change in the health industry.
Rand Corporation, http://www.rand.org/cgi-bin/health/showab.cgi?key=1998_77&year=1998, retrieved May 11, 2009.
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The dynamic whirlwind, often called ‘white water change’ frames a picture of the world the health leader must navigate.
The health leader must continue to use the dynamic nature of the industry to challenge their organizations, groups, teams and individuals to become more efficient, effective and efficacious while under significant cost-containment pressure.
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Kotter suggests eight steps to transform organizations in dynamic situations:
Establish a Sense of Urgency by examining market and competitive realities and identifying and discussing crises, potential crises or major opportunities;
Form a Powerful Guiding Coalition by assembling a group with enough power to lead the change effect [from an level of the organization] and encourage the group to work together as a team;
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Kotter suggests eight steps to transform organizations in dynamic situations: (con’t)
Create a Vision to help direct the change effort and develop strategies for achieving that vision;
Communicating the Vision by using every vehicle possible to communicate the new vision and strategies and by teaching new behaviors by the example of the guiding coalition [at lower levels of the organization, the leader translates the senior leadership’s vision for their section, branch or unit into understandable and actionable tasks for that level and situation];
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Kotter suggests eight steps to transform organizations in dynamic situations: (con’t)
Empowering Others to Act on the Vision by getting rid of obstacles to change, changing systems or structures that seriously undermine the vision and encouraging risk taking and nontraditional ideas, activities and actions;
Planning for and Creating Short-Term Wins by planning for visible performance improvements, creating those improvements and recognizing and rewarding employees involved in the improvements;
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Kotter suggests eight steps to transform organizations in dynamic situations: (con’t)
Consolidating Improvements and Producing Still More Change by using increased credibility to change systems, structures and policies that don’t fit the vision, hiring, promoting and developing employees who can implement the vision, and reinvigorating the process with new projects, themes, and change agents; and
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Kotter suggests eight steps to transform organizations in dynamic situations: (con’t)
Institutionalizing New Approaches by articulating the connections between the new behaviors and corporate [organizational] success and developing the means to ensure leadership development and succession.
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Leaders of health organizations should consider the changes in the macro and micro environment against the cost, quality and access constructs for the community members they serve.
Also understand changes to the health organization concerning:
Operations
Workforce
Supply Chain
Revenue Management / Reimbursement
Community Health Status
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The Leader’s Role in Planning
People look for leaders who have a vision and someone who can direct them in the path of the mission.
Planning is the fundamental function of leadership from which all other outcomes are achieved.
The first step in planning is establishing the organizational situational assessment, then the vision, mission, strategies, goals, objectives and action steps are developed.
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The Leader’s Role in Planning
The vision provides the motivational guidance for the organization and typically is defined and promoted by senior leadership.
Vision is how the organization intends to achieve its goals while ‘mission’ defines why the organization pursues the goals it does.
Both vision and mission are ‘directional strategies.’
The mission statement is the organization's reason for being, its purpose.
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From the mission, strategies to achieve the mission and ultimately, the vision, are devised.
Goals are broad statements of direction that come from strategies. This multi-level approach focuses and narrows effort for each section within the health organization.
Goals further refine the strategies focused on the mission. They are expected to be general, observable, challenging, and untimed. Goals are general in nature; objectives are highly specific.
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Objectives, in pursuit of achieving goals, are very specific.
SMART, objectives must be ‘Specific, Measurable, Attainable, Rewarding, and Timed.’
Action steps or tactics represent a fifth level of planning and provide the most specific approach to describing who, what, when, where and how activities will take place to accomplish an objective.
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Application of Skills, Tools & Abilities
Planning can be described as an ongoing process of thinking and implementing at multiple levels.
At each level, health leaders are directing, staffing, organizing, and controlling.
Health leaders must remember that what is measured gets done; all planning objectives and action steps must be measureable, assigned to an accountable and responsible person and be set within a time period.
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Application of Skills, Tools & Abilities
Periodic progress reviews, monthly or quarterly, are essential to see the movement toward success.
In this effort of directing, staffing, organization and controlling, rewarding is also important. The five elements are crucial as leaders embrace the foundations and functions of planning.
Health leaders must publically praise success and reward those who achieved pre-determined action steps, objectives and goals.
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Decision Making and Decision Alignment
Decision making occurs in all organizations. Health organizations are faced with many decisions each day.
The decision making process begins with identifying a question, problem, an area needing improvement or an operational issue.
Problems, issues, questions, and operational challenges come to leaders and managers from many different people both within and outside the health organization.
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Decision Making and Decision Alignment
Leaders and managers usually are taught to utilize the rational decision making model using analytical (quantitative) methods and when necessary, couple with group methods (qualitative) such as normative group technique (brainstorming, alternative categorization, prioritizing alternatives and selecting an alternative based on group consensus) to triangulate (using both quantitative and qualitative methods) on an effective decision.
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In truth, decision making is not as sterile and ordered as most have been taught.
Willful choice or rational decision making models together with reality based, or garbage can models, are used in organizations along with a myriad of tools and techniques.
The major domains of decision making are:
Willful Choice or Rational Models;
Reality-based or Garbage Can Models; and
Combinations of willful choice and reality-based models.
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Methods of decision making are:
Quantitative methods: use tools such as multiple attribute value, probability based decision trees, analytical mathematical models, linear programming and similar tools;
Qualitative methods: use tools such as focus groups, interviews (formal and informal), normative group techniques and similar tools; and
Triangulation methods: combine both quantitative and qualitative methods where, classically, qualitative methods are ‘theory building’ and quantitative methods are ‘theory testing, validating or confirming.’
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Bounded Rationality in Decision Making
Decision Making must occur within the bounded rationality of the environmental context in which the problem must be solved
Willful Choice Decision Making Models
Decision making models and current understanding implies decisions are made by rational, intentional, and willful choice.
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Willful Choice Decision Making Models
Choice is guided by four basic principles:
1) unambiguous (you know what questions to ask) knowledge of alternatives,
2) probability and knowledge of consequences,
3) a rational and consistent priority system for alternative ordering, and
4) heuristics or decision rules to choose an alternative
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Willful Choice, six step model of decision making application:
1) Identify the problem,
2) Collect data,
3) List all possible solutions,
4) Test possible solutions,
5) Select the best course of action, and
6) Implement the solution based on the decision made.
The practical model assumes time and information are abundant, energy is available, and goal congruence of participants (everyone is focused on the same set of goals) has been achieved.
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The practical model assumes time and information are abundant, energy is available, and goal congruence of participants (everyone is focused on the same set of goals) has been achieved.
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Criticism of Willful Choice Models
Well known leadership and management concepts consider pre-planning (short and long-term) as the method to solve ambiguity (not knowing what to do) in business, but as task complexity increases and time availability decreases, the ability to plan and problem solve increasingly become more difficult.
The rapid pace of operations and change in health today makes traditionally based organizations less adaptive and flexible in complex environments.
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Criticism of Willful Choice Models
Information and time are assumed to be abundant and relatively free resources in rational and willful choice models, as well as, organizational participants in the decision making process are assumed to have similar (if not the same) goals.
These issues are the basis of willful choice model criticisms.
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Reality suggests that preferences of participants in the decision making process vary in, often, illogical and emotionally dependent ways. Although considered in the willful choice models, time and information are not considered as valuable or scarce as reality actually suggests.
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Reality Based Decision Making: Overview of the Garbage Can Model
Reality-based models, such as the garbage can model, are intended to extend the understanding of organizational decision making by emphasizing a temporal context (the situation at one point in time) and accepting chaos as reality.
Rational (willful choice) decision making models are a subset of reality-based models.
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Reality Based Decision Making: Overview of the Garbage Can Model
In ambiguous (do not know what to ask or do) situations where time and information are limited or constrained and ‘perfect information’ impossible to acquire, where organization structure/hierarchy is loosely coupled, and organized anarchy (chaos) seems to embody the organizational persona, analytical decision making models do not fit reality.
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Garbage Can Model Concepts
Garbage can models are attempts at finding logic and order in the mist of decision making chaos.
Garbage, defined as sets of problems, solutions, energy, and participants, are dumped into a can as they are produced (streams of ‘garbage’ in time) and when the can is full, a decision is made and removed from the scenario.
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Garbage Can Model Concepts
Many things seem to be happening at once, technologies are changing and poorly understood; alliances, preferences, and perceptions are changing; solutions, opportunities, ideas, people, and outcomes are mixed together in ways that make interpretation uncertain and leave connections unclear.”
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In management arenas, decision making load, speed required in decision making, uncertainty, and equivocality (equivocality is another word for ambiguity: not knowing what questions to ask or what to do) are commonplace.
The temporal nature of decision making processes, if taken as ‘snapshots’ in time, would show sequential arrival of problems, solutions, and information in a complex mix of participants, environmental factors, and consequences of prior decisions as reality in the ‘organized chaos’ of decision making in organizations.
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Since time is not static and multidimensionality is reality, the garbage can model depicts the chaotic nature of decision making.
Loose coupling in organizations foster a garbage can decision making approach.
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Loose coupling in an organization is defined as the more informal, differentiated, focus less on following the rules but still have structured connectivity of intra-organizational entities.
Loose coupling tends to allow a more flexible organization. Organizations that are loosely coupled, in the traditional sense, are more adaptive to change and environmental factors.
The strength of feedback loops determines organizational coupling; stronger feedback loops imply tighter coupling, whereas weaker loops suggest loose coupling.
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Four criteria for determining coupling status in organizations are:
formal rules where the closer the rules are followed the more tightly coupled (in entrepreneurial organizations, formal rules are not as important),
agreement on rules where the greater the employee congruence, the tighter the coupling (entrepreneurial firms agree on social norms rather than formal rules),
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Four criteria for determining coupling status in organizations are:
feedback where the closer the feedback, in time, the tighter the coupling, and
attention where empowered individuals allocate energy and time to prioritized areas in their ‘area’ (participation, competence, and empowerment foster focused attention to areas of responsibility).
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In the garbage can model the concept of loose coupling is required to understand decision making. As a thinking exercise, where should a health leader establish the level of coupling in a health organization; see figure on next slide.
Application of Skills, Tools & Abilities
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Application of Skills, Tools & Abilities
“The process is thoroughly and generally sensitive to load. An increase in the number of problems, relative to the energy available to work on them, makes problems less likely to be solved, decision makers more likely to shift from one arena to another more frequently, and choices longer to make and less likely to resolve problems.” Individuals in the decision making process, directly and indirectly, are interconnected and influence the context of the decision at hand.”
March, James G. & Weisinger-Baylon, Roger. (1986). Ambiguity and command: Organizational perspectives on military decision making. Pitman Publishing: Marshfield, Massachusetts. Page 18.
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Application of Skills, Tools & Abilities
Decision possibilities in the garbage can form the spectrum from willful choice models to garbage can based models.
Decisions by ‘flight,’ ‘resolution,’ and ‘oversight’ are prominent categories in the model.
‘Flight’ is defined as a decision maker’s intentional movement (attention shift) to another area of concern (problem).
‘Resolution’ is defined as a decision that uses classical decision making processes such as willful choice models.
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Application of Skills, Tools & Abilities
‘Oversight’ is defined as decision makers activating a process or procedure before a problem becomes apparent such as a standing operating procedure or using an established and documented process.
Much of the research shows that ‘flight’ was a significant result of many decision making decisions
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Application of Skills, Tools & Abilities
Optimization of Decision Making
Leaders in health organizations must develop a system of decision making understanding that decision making is not always orderly by:
Evaluating the situation and decisions that need to be made across the organization (or within your area of responsibility) and categorizing decisions by quantity, urgency, information needed to make the decision, and variance in decision outcomes;
Developing readily available information concerning core business functions;
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Application of Skills, Tools & Abilities
Optimization of Decision Making
Standardizing, documenting and training team members on decisions that need to be made routinely where the same or similar decision outcome is required and by ‘pushing’ those decisions to the lowest levels of the organization but requiring feedback loops;
Determining decision making load (quantity in a set time frame) and information available to make decisions (those not standardized);
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Application of Skills, Tools & Abilities
Optimization of Decision Making
Determining the importance of a decision to the organization by creating a system of risk determination, urgency and technological requirements for non-standardized decisions; and
Training team members on the decision making system and processes.
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Application of Skills, Tools & Abilities
When a decision or decisions need to be made, a health organization leader must:
Evaluate the priority and risk of the decision to be made and determine if this is a standardized decision or a decision that needs to be worked through.
Evaluate time available, resources available, participant attention, goals and incentives.
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Application of Skills, Tools & Abilities
When a decision or decisions need to be made, a health organization leader must:
Determine what decision making method to use, oversight based on established documented processes such as standing operating procedures, resolution using a willful choice model or by pushing the decision to the appropriate level, individual or group. It is also important to know when to make a decision, flight, based on the importance and risk level of the decision at hand.
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Application of Skills, Tools & Abilities
Understanding that decision making is not a sterile and orderly process in most cases it is the essential knowledge required for a leader and manager to develop a reality-based decision making system.
Importantly, organizational decision making should be aligned (decisions should be in accordance with) the organization’s mission and vision statements and strategic planning based goals and objectives.
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Application of Skills, Tools & Abilities
Tools of Decision Making
Quantitative methods include mathematical and computational analytical models to leaders understand the decision making situation (data turned to information to knowledge) and produce mathematical outcomes of solutions.
Some models are rather simple while others can be very complex. (Quantitative models assist in putting a ‘number’ on uncertainty)
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Application of Skills, Tools & Abilities
Tools of Decision Making
Models include multiple attribute value and multiple utility methods, linear programming, probability and decision trees based on Bayes Theorem, and can be as complex as discrete and dynamic simulation.
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Application of Skills, Tools & Abilities
Tools of Decision Making
Qualitative methods include a variety of tools from personal intuition, discussions with team members, informal interviews, formal interviews, focus groups, nominal group techniques and even voting.
Qualitative methods are very useful since experience, intuition and common sense are used to aid decision making by individuals as well as groups.
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Application of Skills, Tools & Abilities
Triangulation is a more thorough method to make decisions. Although triangulation takes time, it brings both quantitative and qualitative approaches into the decision making process.
It is common for a group to use nominal group techniques to come to a small set of possible solutions and then for each solution to be analyzed quantitatively.
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Application of Skills, Tools & Abilities
Decision Making in Quality Improvement
Where quality improvement systems exist, decision making systems are embedded throughout the system of continuous quality improvement. The Kaizen Theory and the Shewhart Cycle are examples of quality improvement systems with embedded decision systems.
One process which falls under the principles of the Kaizen Theory is the Shewhart cycle, also referred to as the Deming model and the plan-do-check-act cycle (PDCA).
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Application of Skills, Tools & Abilities
Training: Training is a responsibility of leadership and is usually housed in the human resources department .
Training is the main vehicle for human resource development (HRD).
Training as a key role of HRD that works to improve the organization’s effectiveness, efficiency and efficacy by providing employees with the learning needed to improve their current or future job performance based on the mission, vision, strategies and goals of the organization.
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Application of Skills, Tools & Abilities
Training is the main vehicle for human resource development (HRD).
Training is a planned set of activities that start with health organizational needs assessment, gap analysis (do current employees lack certain capabilities?), training module development, trainer identification, logistics of training, the training itself, and training evaluation and refinement.
Training in organizations should focus on the learning of organizationally required knowledge, skills, and abilities (KSAs).
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Training is the main vehicle for human resource development (HRD).
Training of staff and subordinates is, of course, essential for long-term success of the health organization.
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“To be successful, training must be designed to:
(1) develop and refine certain of the teachable skills,
(2) improve conceptual abilities,
(3) tap individuals' personal needs, interests, and self-esteem, and
(4) help leaders see and move beyond their interpersonal blocks.”
Maltby, Daniel E. (n.d.). Are Leaders Born, or Made? The State of Leadership Theory and Training Today. Biola University. Retrieved July 8, 2009 from http://www.biola.edu/academics/professional-studies/leadership/resources/leadership/bornormade
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Cultural and moral competencies are two of the more important health organization training efforts for leaders and their subordinates.
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Cultural competence provides the knowledge, skills and abilities that allow health leaders to increase their understanding and appreciation of cultural differences among groups of people.
Cultural competency focuses on behaviors, attitudes and policies. It is this foundation that enables exploration of different cultures, learning about cultural heritages and the effects of diversity on health care and the health industry.
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Application of Skills, Tools & Abilities
Ethics can be defined as a theory of moral values. There is a perception that all organizations are expected to work to the highest standards of integrity and ethics.
Ethical standards and values are not created by law or regulations but it is created by the board and trustees of an organization and carried out by the leadership.
Ethics is a framework for decision making and action whereas morality is the level to which the ethical framework is applied.
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Discussion Questions
Discuss the importance of and use of planning, decision making and training in health organizations and provide examples of each. How can planning, decision making and training aid in developing organizational culture in health organizations?
Explain the planning process within the context of leadership. Explain the decision making processes in health organizations. Predict how successful leaders can be when they master these tools of leadership; what if they do not master these tools?
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Discussion Questions
Use examples to apply and relate at least two different decision making models to a leadership situation in a health organization. How are the models different? When should each model be used in health organizations?
Illustrate the levels or components of the planning process and distinguish each level or component from the other. How does this structure help in planning and in progress review?
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Discussion Questions
Relate how a quality improvement program is based on a system of willful choice decision making in a health organization. Can a reality based decision making model work in quality improvement? Why or why not?
Compare and contrast willful choice to garbage can models of decision making, training leaders to training staff, and cultural competence to ethics and morality. Justify your positions.
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Exercises
Define the over all concepts of planning, decision making and training and give examples of each in your definition.
Generalize how a successful health leader prepares for: A) planning in a health organization; B) developing a decision making system in a health organization; and C) ensures all employees are culturally competent in a health organization. Complete this exercise in two (2) pages or less.
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Exercises
Prepare a list of internal and external stakeholders for a health organization in preparation of strategic planning categorizing each group.
Compare and contrast in two (2) pages, the willful choice and garbage can model of decision making within a health organization context.
Organize a planning effort in preparation for a Kaizen Theory or Shewhart Cycle Quality Improvement Project within a unit (keep it small) of a health organization in three (3) pages or less.
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Exercises
Appraise the concept of ‘coupling’ within the context of decision making, and ethics and morality in a health organization in two to three (2 – 3) pages.
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