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L e a r n i n g O b j e c t i v e s

C H A P T E R 9

L E A D I N G : T H E O R I E S A N D M O D E L S

The key to successful leadership today is influence, not authority.

Ken Blanchard, management author,

speaker, and consultant

Studying this chapter will help you to

➤ define leading and explain its relation to other management functions;

➤ examine, compare, and contrast leadership theories and models;

➤ identify practical tools and approaches for leading workers in organizations; and

➤ describe methods for leading physicians.

C o p y r i g h t 2 0 1 9 . H e a l t h A d m i n i s t r a t i o n P r e s s .

A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .

EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 11/2/2021 10:56 AM via UNIVERSITY OF MARYLAND GLOBAL CAMPUS AN: 2144509 ; Peter Olden.; Management of Healthcare Organizations: An Introduction, Third Edition Account: s4264928.main.eds

M a n a g e m e n t o f H e a l t h c a r e O r g a n i z a t i o n s2 1 6

Here’s WHat HaPPeneD The Partners HealthCare board of directors hired a CEO to lead the organization. The board looked for someone with the necessary leadership traits, skills, and behaviors. The CEO then led thousands of employees to achieve the organization’s vision and mission. Yet, the CEO was not the only manager who led. People in other top manage- ment jobs, such as executive vice president and chief information officer, also were leaders who used leadership theories, models, and methods to lead employees. So, too, did managers in middle and lower levels of the organization who led their own departments and workers. Throughout the organization—at all levels—managers influenced people to accomplish work, tasks, goals, mission, and vision. For example, achievement of one goal required staff to implement telehealth technology to monitor discharged hospital patients at home. Telehealth would help patients stay healthy and not have to be readmitted to the hospital. But some nurses resisted the “high- tech” approach because they favored their “high-touch” approach to patient care. Managers used leadership methods to influence the nurses and gain their support for telehealth. Leading was an essential part of what managers at all levels of Partners HealthCare did to achieve the organization’s goals.

T he opening Here’s What Happened presents an example of leading in a healthcare organization (HCO). You know there are leaders at the top of an HCO, such as the CEO at Partners HealthCare. But did you know there are leaders in middle

and lower levels of an HCO? As we learned in chapter 2, directing (also called leading) is one of the five main management functions, so it is something that all managers do. Management is the process of getting things done through and with people, and leading is part of that process. In chapter 2, we also learned about ten roles performed by manag- ers. One of the roles is leader, in which the manager creates a vision and motivates others to work toward it.

Leading is part of being a manager, and all managers lead—that is the view this book takes. However, there are other points of view. Scholars, managers, and leaders have debated what leadership and management mean, how they are related, and who leads and manages. Considering many writings about leading and leadership, this book defines leading to be a process by which a person tries to influence someone else to voluntarily accomplish a task, goal, or vision.

Managers lead, and other people sometimes do, too. An occupational therapist may lead a nervous client in trying adaptive equipment after an accident. A health administra- tion student may lead several other students to complete their group project.

This chapter is the first of three chapters on leading. It focuses on leading as part of management. Leading is defined and related to other management functions. We examine

leading

A process by which

a person tries to

influence someone

else to voluntarily

accomplish a task,

goal, or vision.

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C h a p t e r 9 : L e a d i n g : T h e o r i e s a n d M o d e l s 2 1 7

various perspectives of leading, including trait theory; skill theory; behavior theory; contingency and situational theory; and theories X, Y, and Z. The chapter also explains how managers use other practical leadership theories and methods, including transactional, transformational, servant, collaborative, and competency-based leadership. Managers should lead physicians somewhat differently from the way they lead many other workers; this chapter suggests how to do that. In chapter 10, we will examine how managers motivate people, which is essential for leading. Then, in chapter 11, we will study how managers use organization culture and ethics to lead people in HCOs. Together, these three chapters will help you learn to lead others in HCOs. You can add the leadership tools from these chapters to your healthcare management toolbox.

How does leading connect to what we have already learned in this book? To sum up the book so far in 50 words or less: First, managers plan the HCO’s mission, vision, and goals. Second, they organize the HCO’s tasks, jobs, and resources to achieve the plans. Third, they staff the HCO with people to do the jobs to achieve the plans. Fourth, they lead the people who staff the jobs to achieve the plans. We see how the fourth management function—leading—connects to three other management functions. (Stay tuned, because in chapter 12 we will connect those to the fifth and final management function.)

tH e o r I e s a n D mo D e L s f o r Le a D I n g Scholars and managers have developed useful theories and models of leadership and leading. These help us understand how managers lead people. Consider some leaders throughout world history, business, government, sports, and society. No single theory fully explains all leaders or all aspects of leading. By examining multiple theories, we can more fully learn how to lead in organizations.

t r a I t t H e o r y a n D s k I L L t H e o r y

Research in the early part of the twentieth century examined traits and characteristics of leaders. Think about effective leaders you know from a job, club, sports team, or other activities. Which personal traits do you think enabled these people to lead? Early leadership trait theory suggested that effective leadership was associated with traits such as intelligence, extroversion, confidence, and energy (Griffin, Phillips, and Gully 2017). Later studies

CHECK IT OUT ONLINE

Many ideas exist about what leadership is. Try Googling “what

is leadership” and you’ll get millions of results! You can find

leadership definitions from leaders, scholars, famous people,

and many others. Perhaps you will want to form your own defini-

tion. Check it out online and see what you discover.

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M a n a g e m e n t o f H e a l t h c a r e O r g a n i z a t i o n s2 1 8

emphasized ambition, sociability, assertiveness, and adaptability. Hundreds of studies were done, but that research revealed inconsistent results and identified so many traits that little practical advice on leading could be found. Research shifted to other aspects of leader- ship. However, in recent years, leadership trait studies have reemerged, now focusing on emotional intelligence, integrity, self-confidence, and other traits.

Some traits (e.g., “Justine is decisive”) can also be viewed from a skills perspective (e.g., “Justine has good decision-making skills”). Thus, skill theory emerged from trait theory to study skills and abilities for leading. Which skills do you think leaders need to influence others? Robert Katz determined that leaders need three types of skills (Dunn 2016):

1. Technical skills for working with things (e.g., making health products and services)

2. Conceptual skills for working with ideas (e.g., thinking of new goals)

3. Human skills for working with people (e.g., mentoring employees)

Do some leaders rely on one kind of skill more than another? Katz found that leading in high-level management positions requires more use of conceptual skills than technical skills. The opposite is true for leading in low-level positions. For leading in middle-level management jobs, both technical and conceptual skills are moderately important. Human skills (i.e., “people skills”), needed to influence others to achieve goals, are important for leading at all levels of management. In the Partners HealthCare case, conceptual skills would be especially important for the new CEO to conceive mission, vision, values, and long-range goals for the system. Technical, hands-on skills would be especially important for lower-level leaders, such as a pharmacy shift supervisor, to ensure that technical tasks are properly done. Human skills would be important at all levels of Partners HealthCare to influence others.

b e H av I o r t H e o r y

Researchers next looked beyond leaders’ traits and skills and studied their behaviors, actions, and conduct. Behavior theory examines leadership behavior (sometimes called leadership style) and how it influences leadership effectiveness. Rather than study the traits and skills a leader has, this theory looks at what a leader does—how she behaves or how she conducts herself. When you are a leader in healthcare, which behaviors will you use? How will you conduct yourself? Suppose you are a middle-level manager at a health information tech- nology company in St. Paul. Your management team decides it must relocate to a bigger office building. Which behaviors would you use to lead (influence) your employees to support relocation?

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C h a p t e r 9 : L e a d i n g : T h e o r i e s a n d M o d e l s 2 1 9

Leadership studies at Ohio State in the mid-1900s helped to develop behavior theory (Griffin, Phillips, and Gully 2017). This research examined two dimensions of leader behavior:

1. Consideration behavior: A leader considers the workers and their concerns, ideas, and feelings. The leader–worker relationship is characterized by mutual trust, communication, and respect.

2. Initiating structure behavior: A leader initiates work, tasks, and structure to complete jobs and achieve goals. The leader establishes clear roles, expectations, and communication channels for the leader and the workers.

The Ohio State studies rated leaders as high or low for each dimension, which created four types of leaders:

◆ Low initiating structure / Low consideration

◆ Low initiating structure / High consideration

◆ High initiating structure / Low consideration

◆ High initiating structure / High consideration

Behavior theory was further developed by similar studies that investigated which leadership behaviors were associated with the greatest employee satisfaction, job perfor- mance, goal achievement, and other effectiveness outcomes.

Pop quiz: In leadership behavior studies, which leadership style do you think was most effective?

a. Low initiating structure / Low consideration

b. Low initiating structure / High consideration

c. High initiating structure / Low consideration

d. High initiating structure / High consideration

It seems like High initiating structure / High consideration would be a good approach. But recall contingency theory from chapter 2. Maybe we need to add another answer choice: “It depends”!

Further research on leaders’ behavior was done by Blake and Mouton (1964). This research, like the Ohio State studies, used two dimensions: production orientation and

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M a n a g e m e n t o f H e a l t h c a r e O r g a n i z a t i o n s2 2 0

people orientation (Griffin, Phillips, and Gully 2017). Leaders were rated from 1 (low) to 9 (high) for each dimension. These orientations (leadership styles) created a managerial (or leadership) grid as shown in exhibit 9.1.

The researchers who developed the managerial grid conceived the same four leader- ship styles as the Ohio State studies, and they added a fifth style in the middle:

◆ Low production orientation / Low people orientation (1,1): Impoverished style

◆ Low production orientation / High people orientation (1,9): Country club style

◆ High production orientation / Low people orientation (9,1): Authoritarian style

exHIbIt 9.1 The Managerial

Grid 9,9

5,5

1,9

9,11,1

1

1

2

2

3

3

4

P r o d u c t i o n O r i e n t a t i o n

P e

o p

le O

ri e

n ta

ti o

n

4

5

5

6

6

7

8

9

7 8 9

Source: Adapted from Blake and Mouton (1964).

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C h a p t e r 9 : L e a d i n g : T h e o r i e s a n d M o d e l s 2 2 1

◆ High production orientation / High people orientation (9,9): Team leader style

◆ Middle production orientation / Middle people orientation (5,5): Middle-of- the-road style

Leaders who use one of the four corner styles in exhibit 9.1 would lead as follows (Esparza and Rubino 2014, 10):

◆ (1,1) Impoverished style—is detached and uncommitted to work or workers, lets workers do whatever, “delegates and disappears”

◆ (1,9) Country club style—uses rewards and recognition to encourage workers, avoids authority and discipline, maintains positive relationships with workers

◆ (9,1) Authoritarian style—is tough on workers, expects workers to get work done no matter what, not interested in workers’ input, doesn’t want dissent, expects loyalty

◆ (9,9) Team leader style—leads by example, helps workers achieve their highest potential, promotes goal achievement, develops close relationships among workers

The (5,5) middle-of-the-road style is in between the four corner styles—it includes some characteristics of each.

The managerial grid model was developed long ago, and organizations today still use it to guide leaders’ behavior. Many managers seem to like it and think it works well. Lead- ers do not have to exactly fit one of the five styles—they can be anywhere on the grid. The team leader style is often considered to be the best way to lead. However, while behavioral studies show the importance of leaders’ behaviors, the studies are not complete enough to provide universal recommendations for how to lead (Griffin, Phillips, and Gully 2017). As is true for the Ohio State studies, no single style always leads to the best outcomes. Appar- ently, something else affects the results. What could it be? Read on.

s I t u at I o n a L t H e o r y

By the early 1960s, scholars and leaders realized that the trait, skill, and behavior theories of leadership did not fully explain leadership effectiveness (Griffin, Phillips, and Gully 2017). Furthermore, they realized there was no universal best way to lead. Organizations and people are too complicated for that. The best leadership approach seemed to vary from situation to situation and from person to person. That is, the best approach was contingent—it depended on something.

contingent

Dependent on

something.

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This realization led to situational leadership research and a variety of situational theories of leadership. Different situations (contingencies) need different leadership styles. According to researchers, these contingencies included the following (Dye 2017; Griffin, Phillips, and Gully 2017; Walston 2017):

1. Characteristics of the leader (e.g., skills, traits, behaviors, earned trust, power to reward)

2. Characteristics of the followers (e.g., skills, traits, behaviors, motivation, relationship with leader)

3. Characteristics of the situation (e.g., clarity of goals, work to be done, urgency)

As an example, imagine an extroverted leader in a primary care patient-centered medical home in Aurora. The leader likes to chat with the employees (followers). This sounds like a good idea; after all, leaders should be friendly and get to know their employees (followers). However, such a style might not work equally well with all employees. Why? Because the best style is contingent on characteristics of the followers. An extroverted style would likely work well with extroverted followers. It would not work as well with introverted followers; with them, the leader could adjust to a less chatty style.

How about a contingency example based on the situation? A personal care home leader might ordinarily prefer thoughtful group discussions to lead staff to collaboratively make team decisions. However, if the building is on fire and the fire alarm is blaring, the leader will likely use a more direct, take-charge style.

Several situational leadership models are available to guide managers when they lead employees. One is the Hersey and Blanchard situational model. It was created as a consulting tool and is popular with practicing managers (Griffin, Phillips, and Gully 2017). The model calls for a leader to adjust behavior to fit with a subordinate worker’s readiness to work. “Readiness refers to the subordinate’s degree of motivation, compe- tence, experience, and interest in accepting responsibility” (Griffin, Phillips, and Gully 2017, 437). Readiness can also be described as “the ability and willingness to accom- plish a specific task” (Ledlow and Johnson 2019, 69). As a worker’s readiness for a task increases, the manager should adjust the leadership style. If a subordinate worker has low readiness for a task, then the manager’s task-oriented behavior (i.e., task direction, production orientation) should start high. As the worker’s readiness increases, the leader can reduce task behavior and follow an inverse relationship with readiness. Simultane- ously, the manager should adjust relationship behavior (i.e., support, people orientation) toward the subordinate as readiness to perform the task increases (Dye 2017; Griffin, Phillips, and Gully 2017):

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◆ If a subordinate has low readiness, the manager uses a “telling style” of high task emphasis and low relationship emphasis, stating a clear, firm direction and defined roles.

◆ If a subordinate has low to moderate readiness, the manager uses a “selling style” of high task emphasis and high relationship emphasis, giving the subordinate direction and identifying roles, plus offering information and explanation for persuasion.

◆ If a subordinate has moderate to high readiness, the manager uses a “participating style” of low task emphasis and high relationship emphasis, giving little direction and allowing the subordinate to join in making decisions.

◆ If a subordinate has high readiness, the manager uses a “delegating style” of low task emphasis and low relationship emphasis, enabling the subordinate to work independently without much supervision.

The bottom line: “People in leadership and management positions become more effective when they use a leadership style that is appropriate to the developmental level of the individual or group they want to influence” (Ledlow and Johnson 2019, 70). One size does not fit all! Each of the four styles is useful and appropriate for a particular set of contingencies.

Research and practice indicate that man- agers should develop a mix of leadership styles, such as those in the managerial (leadership) grid and those in the Hersey and Blanchard situational model. You can also develop the ability to assess yourself, your followers, and situations. Emotional intelligence will help with that; it is discussed in chapter 15. Based on those assessments, you can decide which style of leading to use with specific followers and situations. Returning to the grid in exhibit 9.1, perhaps leaders like this tool because it helps them deliberately ask themselves, For the leadership situation I now face, where should I be on the grid? How much should I use a people orientation and how much should I use a production orientation? This approach to leading cannot be developed in a semester of study or a year of work. Experience and trial-and-error are necessary. Everyone makes mistakes,

CHECK IT OUT ONLINE

Employers sometimes use personality tests to learn more about

their employees. These tests also can help you assess yourself,

which is needed for the situational theory approach to lead-

ing. A commonly used assessment is DiSC, which measures a

person’s levels of dominance, influence, steadiness, and con-

scientiousness. Another popular test is the Myers-Briggs Type

Indicator, which measures attitudes, functions, and lifestyles.

You can learn more about these assessments at www.discprofile

.com and www.myersbriggs.org. Check it out online and see

what you discover.

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M a n a g e m e n t o f H e a l t h c a r e O r g a n i z a t i o n s2 2 4

and we can learn from them. Good role models and mentors can help too, so choose role models and find mentors to help you develop your leadership styles.

t H e o r y x, t H e o r y y, a n D t H e o r y z

Research by Douglas McGregor led him to believe that leaders hold one of two differ- ent views of people and workers. These two contrasting views—known as Theory X and Theory Y—are summarized in exhibit 9.2.

These two views are important for contingencies, leadership, and how managers influence workers. A biotech genetics company manager who views people from a Theory X perspective would influence employees (followers) with an autocratic style of close oversight, distrust, coercion, monetary rewards, minimal communication, and unilateral decision making. In the same company (situation) with the same employees (followers), a manager with a Theory Y perspective would influence employees with a consultative/participative style of loose oversight, trust, open communication, shared decisions, freedom, self-direction, and personal development rewards. The two leadership styles depend on the leader’s view (Theory X or Theory Y) and are summarized in exhibit 9.3.

Theory Y managers assess contingencies that may affect how they manage, lead, and influence workers (Ledlow and Johnson 2019). Based on particular contingencies, these managers might alter their usual approach to influencing workers. For example, previously we learned that time urgency and a worker’s low readiness are contingencies that affect how managers influence workers. After considering contingencies, a Theory Y manager may shift to a more authoritarian style for a particular situation or worker. In contrast, Theory

Theory X

Leader assumes people

dislike work, are

lazy and stupid, are

motivated by rewards

from others, lack

self-discipline, want

security, and do not

want responsibility.

Theory Y

Leader assumes

people like meaningful

work, are creative and

capable, are motivated

by rewards from within

themselves, have

self-control, can direct

themselves, and want

responsibility.

Theory X assumes people Theory Y assumes people

• dislike work • like meaningful work

• are lazy and stupid • are creative and capable

• are motivated extrinsically (by rewards from other people)

• are motivated intrinsically (by rewards from within themselves)

• lack self-discipline and must be directed

• have self-control and can direct themselves

• want security and do not want change • want to contribute and participate

• do not want (and avoid) responsibility • want (and seek) responsibility

Sources: Dunn (2016); Ledlow and Johnson (2019); Walston (2017).

exHIbIt 9.2 Theory X

and Theory Y Assumptions

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C h a p t e r 9 : L e a d i n g : T h e o r i e s a n d M o d e l s 2 2 5

X managers are more rigid and thus are unlikely to consider contingencies or adjust their leadership style (Ledlow and Johnson 2019).

Theory Z emerged in the late 1970s and was further developed through the work of William Ouchi in the 1980s. This approach emphasizes concern for workers and strives to develop long-term, cooperative relationships among workers, peers, and the organization (Dunn 2016). It assumes that workers want close, supportive working relationships with other workers, including supervisors and subordinates. Supervisors influence workers using trust and teamwork while avoiding fear and reprisal. Growth opportunities for workers are important but are developed more slowly and deeply in Theory Z than in Theory Y. Individual responsibility is important, as is collective responsibility for coworkers and the organization. Theory Z seeks lasting employment and relationships with workers, which discourages the short-term job-hopping common among some workers and organizations.

t r a n s a c t I o n a L a n D t r a n s f o r m at I o n a L L e a D e r s H I P

Leadership has commonly been viewed from a transactional perspective, in which the leader transacts a deal with the followers: You perform tasks and comply with rules to help achieve the organization’s goals, and I will give you pay, benefits, and other rewards. That’s the deal, and it can be a win–win situation for everyone. Did you experience this type of leadership when you were young, with a parent transacting deals with you for home chores

Theory Z

Leader emphasizes

concern for workers,

develops long-

term cooperative

relationships,

provides slow yet

steady long-term

growth opportunities

for workers, and

promotes individual

and collective

responsibility.

Autocratic Leadership Based on Theory X

Consultative/Participative Leadership Based on Theory Y

• Tight supervision, close oversight • Loose general supervision, self-direction

• Distrust • Trust

• Decisions made unilaterally by manager

• Decisions shared by manager and workers

• Minimal involvement of workers • Extensive involvement of workers

• Limited, top-down communication • Open, frequent, two-way communication

• Coercion, externally controlled rewards

• Internal rewards from the work and job

Sources: Dunn (2016); Ledlow and Johnson (2019); Walston (2017).

exHIbIt 9.3 Leadership Style Based on Theory X and Theory Y

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M a n a g e m e n t o f H e a l t h c a r e O r g a n i z a t i o n s2 2 6

and compliance with rules? Managers often make these types of deals, influencing work- ers by giving or withholding rewards. Many organizations have transactional leadership, and followers go along with it. But the deals tend to maintain the status quo. This way of leading is not inspirational for achieving great change and excellence.

An alternative is transformational leadership, which was begun by James Burns in the late 1970s and further developed by Bernard Bass. Leaders who use this approach do not transact deals with followers (employees) based on self-interests. Instead, leaders strive to inspire and influence workers by appealing to higher-level human needs of self-actualization and fulfillment (Walston 2017). Whereas transactional leaders tend to maintain the exist- ing way of doing things, transformational leaders challenge the existing way and influence workers to change and revitalize the organization—sometimes radically!

Earlier, we learned about the trait, skill, and behavior theories of leadership. Which traits, skills, and behaviors do you think are needed for transformational leadership? What would a leader need to inspire others, challenge the status quo, and lead followers to trans- form an HCO to higher levels of performance? Take a few minutes to brainstorm and jot down your ideas. Then read what several writers emphasize (Elkins, Melton, and Hall 2014; Ledlow and Johnson 2019; Walston 2017):

◆ Charisma—provides a vision and purpose, develops pride, earns respect and trust

◆ Inspiration—clearly and simply communicates purpose and expectations, focuses efforts

◆ Intelligence—promotes rational thinking, careful problem solving, and use of intellect

◆ Individual consideration—coaches, advises, gives personal attention to each employee

Transformational leaders are guided by their organization’s mission, vision, and values, and they communicate those often to workers. Influence comes from a transformational leader’s charismatic emotional appeal, intellectual stimulation, and supportive concern for individual workers. Walston (2017) emphasizes that influence comes from creating a vision that inspires others. People who follow transformational leaders admire, respect, and trust the leader. As a result, the workers transcend their own self-interests in favor of their group’s interests, goals, and “the greater good.” Transformational leaders know their employees as unique individuals, interact with them in their work settings, teach and men- tor them individually, share the future vision with them and explain how to achieve it, and look for ways to enable each of them to become more self-fulfilled and satisfied. With so much support, workers develop loyalty, respect, and admiration for the transformational

transactional

leadership

Leadership based on

transactions; workers

perform tasks to

achieve goals and

then the leader gives

workers pay and other

rewards.

transformational

leadership

Leadership that

uses a compelling

vision, inspiration,

charisma, intelligence,

and attention to

employees’ individual

needs to revitalize

an organization with

change for the greater

good of all.

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C h a p t e r 9 : L e a d i n g : T h e o r i e s a n d M o d e l s 2 2 7

leaders and the organization. Workers want to help the organization succeed because they feel they are contributing to something important. All of this motivates employees to work hard to achieve the organization’s mission, vision, and values, which in turn leads them to feel more fulfilled.

Transformational leadership has the potential to influence each employee (and an entire HCO) to grow and achieve great (rather than merely good) performance. “Healthcare today requires strong transformational leaders” to advance HCOs amid rapid change and uncertainty (Walston 2017, 145). This kind of leading does not happen easily—it takes dedicated hard work!

s e r va n t L e a D e r s H I P

The servant leadership style emerged in the 1970s and has gained many advocates (Dye 2017). It is similar to transformational leadership because both are concerned with followers. However, servant leadership emphasizes that a leader should serve the followers (not just be concerned about them). A servant leader empowers workers (followers) by sharing power, information, and autonomy with them. Then the servant leader unselfishly respects, listens to, responds to, helps, reassures, teaches, supports, connects with, celebrates, and is a role model for the workers (followers). The servant leader serves followers by understanding and respecting their views, giving them necessary resources, meeting their needs, providing nonblaming performance feedback, and helping them grow with opportunities to succeed (Dye 2017; Ledlow and Johnson 2019; White and Griffith 2019). This approach requires humility, and many organizations are searching for humble leaders (Kaissi 2017). Servant leaders create a bottom-up approach that delegates more power and control to followers than top-down leaders would delegate. These leaders expect their approach to favorably influence workers’ morale, goal achievement, and development for future management positions.

Dye (2017) believes that servant leadership is needed in healthcare, which is sup- posed to be altruistic. Walston (2017), on the other hand, feels it may be hard to practice servant leadership because rewards and incentives (from traditional leadership styles) may motivate leaders toward self-interest and self-promotion instead of selfless service. Yet, servant leadership is in fact practiced in HCOs and can be effective, as shown in the Using Chapter 9 in the Real World sidebar. Both of the HCOs in the sidebar have earned the prestigious Malcolm Baldrige National Quality Award.

c o L L a b o r at I v e L e a D e r s H I P

Collaborative leadership is used to form alliances, partnerships, and other forms of inter- organization relationships. This type of leadership has become—and will continue to be— essential for healthcare managers. Recall from chapter 1 the trend of hospitals, medical

servant leadership

Leadership style

that emphasizes

that a leader should

serve the followers

by respecting,

empowering, hearing,

teaching, and

supporting workers

and helping them

succeed.

collaborative

leadership

Leadership used

to form alliances,

partnerships, and

other forms of

interorganization

relationships.

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M a n a g e m e n t o f H e a l t h c a r e O r g a n i z a t i o n s2 2 8

groups, insurers, ambulatory clinics, long-term care companies, community agencies, and other HCOs forming more mergers, alliances, networks, integrated delivery systems, account- able care organizations, patient-centered medical homes, and other collaborative structures.

Collaborative leadership is complex because it involves infl uencing people from multiple organizations toward a common purpose. For example, to improve population health in a community, many organizations (including public schools and government agencies) may try to form a community health alliance to work together to reduce health risks in the community. Someone who leads the formation of the alliance would not have direct control or authority over all the organizations and people. A collaborative leader must infl uence people from other organizations who are likely to have diff erent goals, cultures, management styles, attitudes, assumptions, knowledge, constraints, awareness of problems, and commitments (Borkowski and Deppman 2014). Some of these organizations may be competitors vying for each other’s resources, customers, market share, and revenue. Can somebody lead this group toward a common purpose?

USING CHAPTER 9 IN THE REAL WORLD

Senior leaders of Mercy Health System (now part of Mercy/Rockford Health System in

Wisconsin and Illinois) adopted a servant leadership philosophy. The leaders believe

that when they give excellent service to Mercy’s partners (workers), those partners give

excellent service to Mercy’s customers. The leaders inverted a top-down management

style and instead became facilitators, serving those who serve patients (White and

Griffi th 2019).

Jayne E. Pope, FACHE, a registered nurse and CEO of Hill Country Memorial Hospital

in Fredericksburg, Texas, leads by serving and empowering staff and patients. “We need

to remove any obstacles standing in the way of medical staff, nurses, and other care

providers so that those at the point of service can provide the highest-quality care,” she

says (Kash 2016, 308). “My mantra is to make heroes out of others” and “highlight the

work of team members” (Kash 2016, 308). She communicates with team members so

they have the information they need to make their own decisions. The hospital’s vision

is “empower others, create healthy,” and Pope does that as a leader. This leadership

approach has helped the hospital consistently deliver exceptional patient experience

that rated in the 97th percentile of the Hospital Consumer Assessment of Healthcare

Providers and Systems survey (Kash 2016).

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C h a p t e r 9 : L e a d i n g : T h e o r i e s a n d M o d e l s 2 2 9

Yes, it can be done—by using the collaborative leadership style. A leader needs spe- cific skills, traits, and competencies for collaborative leading. The transformational leader- ship and servant leadership styles are often equated with the collaborative leadership style because they use similar skills and behaviors. Additional competencies are also important for collaborative leadership. These leaders must be able to manage conflict, coordinate teams, create trust, share power, share credit, work with people over whom they do not have authority, apply political skills, and use emotional intelligence. Patience is a virtue because life in the collaboration lane is usually slow.

a u t H e n t I c L e a D e r s H I P a n D e t H I c a L L e a D e r s H I P

In the early part of the twenty-first century, two approaches to leading emerged that include much of transformational leadership and servant leadership. In these two new approaches— authentic leadership and ethical leadership—leading is based on values, morals, and the fair and trustworthy personal actions and interactions that leaders demonstrate (Walston 2017). Leaders, managers, and scholars are likely to continue developing these two approaches.

L e a D e r s H I P c o m P e t e n c y m o D e L s

A final approach to leading, based on competencies, also emerged early in the twenty- first century and has gained support. “Leadership competencies are a set of professional and personal skills, knowledge, values, and traits that guide a leader’s performance, behavior, interaction, and decisions” (Dye and Garman 2015, xiii). This approach may remind you of the earlier research on leadership traits, skills, and behaviors. Today, the healthcare management profession uses several competency models to lead healthcare organizations.

The Healthcare Leadership Alliance (HLA), comprising the American College of Healthcare Executives (ACHE) and several other healthcare professional associations, developed a competency model of leadership with five broad domains. “When it was first published in 2005, the HLA Competency Directory was a landmark effort to identify the competencies that were important across diverse professional roles within healthcare management. It contained 232 competencies that were common to all the professions participating in its development as well as another 68 competencies that were specific to certain disciplines within healthcare management” (HLA 2010).

From this, ACHE developed its Healthcare Executive Competencies Assessment Tool, which is used to assess expertise in a subset of common management and leadership competencies. This tool includes competencies in five domains: communication and relation- ship management, leadership, professionalism, knowledge of the healthcare environment, and business skills and knowledge (HLA and ACHE 2018).

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M a n a g e m e n t o f H e a l t h c a r e O r g a n i z a t i o n s2 3 0

Another healthcare management competency model is the Dye–Garman model. It uses 16 competencies in four domains—self-awareness, vision, execution, and people— that are essential for exceptional leadership (Dye and Garman 2015). Finally, the National Center for Healthcare Leadership (NCHL 2018) health leadership competency model 3.0 includes 28 core competencies. These are grouped into four action competency domains (transformation, execution, relations, and boundary spanning) and three enabling com- petency domains (health system awareness and business literacy, self-awareness and self- development, and values).

Le a D I n g PH y s I c I a n s Do you remember (from chapters 4 and 5) that managing physicians involves special considerations and approaches? Physicians, and some other highly professional workers, expect a great degree of autonomy without managerial oversight. Physicians expect manag- ers to respect and defer to their professional medical expertise. This expectation is one way physicians (and some other patient care professionals) think and behave differently from managers. These differences arise from differences in education, professional norms, job purpose, and other factors. Exhibit 9.4 examines managers and physicians in relation to several important factors. The information reflects broad generalities that do not apply to every manager, physician, and HCO. However, it does offer useful insights for managers who lead physicians.

As exhibit 9.4 shows, in general physicians think and behave differently than man- agers do. This understanding is important because physicians and HCO managers are interdependent. Contingency theory reminds us that the best style for leading depends on the leader, followers, and situation. When the followers are physicians, managers should adjust their style of leading to what works well with physicians. (This can be taken a step further by adjusting to specific physicians because they are not all alike.) Some managers

TRY IT, APPLY IT

Use what you have learned in this chapter to describe your usual leadership style (which

might change sometimes because of contingencies). Apply the leadership theories and

models to yourself while you reflect on your past experiences with leading. Think about

how you led a club, team, or group of students. Which skills, traits, and behaviors did you

use? Which theories and models of leadership did your leadership style seem to follow?

After some thought, write a paragraph or two describing your usual leadership style.

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C h a p t e r 9 : L e a d i n g : T h e o r i e s a n d M o d e l s 2 3 1

have created problems (and even derailed careers) by trying to lead physicians the same way they lead the general workforce. Here are suggestions for managers who are trying to lead physicians. (These ideas may also be useful when leading other types of professional healthcare workers.)

◆ Realize how your view of healthcare and your HCO may differ from that of physicians. Work to understand their views, concerns, language, culture, and behaviors.

Factor Managers Physicians

Authority Organizational, legitimate, expert; shared or individual

Professional, expert; individual

Responsibility Individual and group Mostly individual

Work relationships Hierarchical, bureaucratic, group

Peer, collegial

Allegiance, loyalty To the organization To patients and clients

Decisions Deliberative, uses input from others, based on consensus

Quick, based on own judgment

Resources Viewed as limited, must be used wisely

Assume resources will be available

Patient focus Groups and populations of patients

Usually one patient at a time

Time frame Ranges from now to years in the future

Now, today, this week, short-term

Dealing with uncertainty Accepted as part of the job Expects more certainty

Feedback received Sporadic, vague Specific, frequent

Responsiveness To patients, families, phy- sicians, board members, employees, accreditors, other stakeholders

To patients, families, phy- sicians, other patient care team members

Compensation Salary Shifting from pay per patient/procedure to value-based payment

Sources: Data from Dunn (2016); Dye (2017); Walston (2017); Welch (2010); White and Griffith (2019).

exHIbIt 9.4 Differences Between Managers and Physicians

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M a n a g e m e n t o f H e a l t h c a r e O r g a n i z a t i o n s2 3 2

◆ Create structures and opportunities for physicians to be heard (formally and informally). Be a good listener.

◆ Minimize the use of formal authority based on position, bureaucratic rules, and organization hierarchy.

◆ When appropriate, let physician leaders and the physician peer review process lead physicians.

◆ Develop and maintain contact with physicians. Be known by them and accessible to them.

◆ Understand and strive to meet physicians’ professional needs.

◆ Respect physicians’ time; avoid scheduling unnecessary meetings.

◆ Show how your ideas will help physicians and their patients, but avoid simply claiming everything you want is “good for patient care.”

◆ Develop trusting relationships with a few key physicians who can help you understand other physicians, explain your ideas to other physicians, and help you work with specific physicians.

◆ Use data that can be easily understood and easily judged as valid and reliable.

◆ Acknowledge and respect physicians’ medical expertise in medical matters; point out your managerial expertise in management matters.

◆ Explain yourself to physicians who may misinterpret your ideas and actions.

In recent years, healthcare systems and hospitals have increasingly hired physicians for high-level management and administrative leadership positions. Demand for them has greatly expanded and exceeds supply. This is a result of developments described in chapter 1, such as clinical integration, payment based on clinical outcomes, and population health. Although some of these jobs are directly responsible for medical affairs, others are more generally administrative—including CEO positions. After someone has studied, trained, and practiced as a physician for years, management development and executive coaching can help that person shift focus and prepare for a high-level management position such as CEO or chief operating officer. When physicians understand and embrace managerial thinking and behaviors, they can help managers and physicians throughout an HCO understand each other and collaborate toward the HCO’s goals. Physicians in management jobs help other managers understand physicians and vice versa.

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C h a p t e r 9 : L e a d i n g : T h e o r i e s a n d M o d e l s 2 3 3

Leading is influencing. It is a process by which a person tries to influence someone else to voluntarily accomplish a task, goal, or vision. Leading is one of the five management func- tions, and thus it is performed at all management levels in an HCO. It has been studied for more than a century by examining traits, skills, and behaviors of leaders.

A common behavioral approach to leading looks at how much leaders focus on getting tasks and goals done and how much they focus on employees and their needs. Managers may use a managerial grid to judge how much their leadership should focus on completing tasks and on employees’ needs. When managers have to lead, they may apply the Hersey and Blanchard situational model of leading to assess the situation and assess the people to be led (followers). Based on those contingencies, managers choose a style of leading that puts the appropriate amount of focus on tasks and on employees’ needs. Therefore, managers should develop a range of styles for leading, assess contingencies (people and situation), and then adjust their leadership style to fit the people and situation.

Other perspectives further explain how managers lead. Managers tend to use a style of leading that fits their assumptions about people—Theory X or Theory Y. Theory Z em- phasizes concern for workers and strives to develop long-term, cooperative relationships among workers, peers, and the organization. Transactional behavior by leaders tends to maintain the status quo. With healthcare in a constant state of change, healthcare manag- ers often must lead change. Transformational leadership is effective for leading change, and it is done through a compelling vision, inspiration, charisma, intelligence, and atten- tion to employees’ individual needs. This type of leadership enables leaders to revitalize an organization with change for the greater good of all. Managers may also use servant leadership, by which a leader serves workers by respecting, empowering, hearing, teach- ing, and supporting them and helping them succeed. Collaborative leadership is used to form alliances, partnerships, and other interorganization relationships. Authentic leader- ship, ethical leadership, and competency-based leadership have emerged in the twenty- first century as new approaches for leading people in healthcare and HCOs. When leading physicians, managers must realize they think differently from physicians about important work-related factors. Physicians expect professional autonomy based on their extensive medical education and training.

People can learn, develop, and improve their leadership. During their careers, leaders should develop a mix of leadership styles and be flexible. Then they can assess contingen- cies and use the style that is best for themselves, their followers, and their situations.

o n e m o r e t I m e

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M a n a g e m e n t o f H e a l t h c a r e O r g a n i z a t i o n s2 3 4

1. How did your understanding of leading and leadership evolve while reading this chapter?

2. This chapter explained trait theory, skill theory, behavior theory, situational (contingency) theory, Theory X, Theory Y, Theory Z, transactional leadership, transformational leadership, servant leadership, and collaborative leadership. Which of these theories and approaches do you think you will most likely use in your career? Why?

3. How do contingencies affect leading? Give examples to illustrate your answer.

4. Describe how physicians and managers differ in their work-related perspectives. Considering these differences, what steps could managers use to lead physicians?

These questions refer to the Integrative Case Studies at the back of this book.

1. Disparities in Care at Southern Regional Health System case: Mr. Hank wants to reduce disparities in care at Southern Regional. To do this, should he use situational

FOR YOUR TOOLBOX

• Trait theory

• Skills theory

• Behavior theory

• Managerial (leadership) grid

• Situational leadership

• Hersey Blanchard model

• Theory X and Theory Y

• Theory Z

• Transactional and transformational

leadership

• Servant leadership

• Collaborative leadership

• Leadership competency models

• Differences between managers and

physicians

f o r D I s c u s s I o n

c a s e s t u D y Q u e s t I o n s

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C h a p t e r 9 : L e a d i n g : T h e o r i e s a n d M o d e l s 2 3 5

theory, transformational theory, or some other approach to leading? Justify your answer using information from the case study and this chapter.

2. Hospice Goes Hollywood case: Using information from this chapter and the case study, explain how Ms. Thurmond should lead Dr. Frank to help achieve Joint Commission accreditation. Which leadership theories or models should she use?

3. I Can’t Do It All case: Use leadership theories, concepts, and models from this chapter to describe Mr. Brice’s leadership style.

4. Increasing the Focus on Patient Safety at First Medical Center case: Why might the transformational leadership approach be appropriate for Dr. Frame to use? Using information from this chapter and the case study, describe specifi c steps and actions she should take while using transformational leadership.

5. Rocky Road to Patient Satisfaction at Leonard-Griggs case: Ms. Ratcliff wants to implement patient satisfaction surveys at the fi ve physician practice sites. Refer to the managerial grid in exhibit 9.1. Where on the grid (i.e., how production oriented and how people oriented) should she be to lead the clinics’ employees to perform the survey work? Justify your answer.

RIVERBEND ORTHOPEDICS MINI CASE STUDY

Riverbend Orthopedics is a busy group practice with expanded services for orthopedic

care. It has seven physicians and a podiatrist, plus about 70 other employees. At its big,

new clinic building, Riverbend provides extensive orthopedic care. Several technicians

provide diagnostic medical imaging, from basic X-rays to magnetic resonance images.

The physicians perform surgery in their own outpatient surgery center with Riverbend’s

own operating nurses and technicians. Therapy is provided by three physical thera-

pists and one part-time contracted occupational therapist. In addition to staff provid-

ing actual patient care, the clinic has staff for fi nancial management, medical records,

human resources, information systems/technology, building maintenance, and other

administrative matters. Occasional marketing work is done by an advertising company.

Legal work is outsourced to a law fi rm. Riverbend is managed by a new president, Ms.

Garcia. She and Riverbend have set a goal of achieving “Excellent” ratings for patient

experience from at least 90 percent of Riverbend’s patients this year.

(continued)

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M a n a g e m e n t o f H e a l t h c a r e O r g a n i z a t i o n s2 3 6

Blake, R. R., and J. S. Mouton. 1964. The Managerial Grid: The Key to Leadership Excellence.

Houston, TX: Gulf Publishing.

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RIVERBEND ORTHOPEDICS MINI CASE STUDY (continued)

Ms. Garcia knows that merely setting the goal will not achieve it—she must lead the

staff to achieve it. The board has told her that funds will be available to support what

is needed to reach the goal. She begins to think about various leadership theories and

models.

mInI case stuDy QuestIon

1. Using information from this case and chapter, describe how Ms. Garcia should lead

to achieve the patient experience goal. How should she lead Dr. Barr, Dr. Chen, and

other physicians? How should she lead other staff? Which leadership theories and

models should she use? Why? You may make (and state) additional reasonable as-

sumptions about Riverbend Orthopedics.

r e f e r e n c e s

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ship for Today’s Health Care Professionals: Concepts and Cases, edited by L. G. Rubino,

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ple and Organizations, 12th ed. Boston: Cengage Learning.

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the%20HLA%20Competency%20Directory.pdf.

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Hospital.” Journal of Healthcare Management 61 (5): 307–10.

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nizations: Theory, Behavior, and Development, 2nd ed., edited by J. A. Johnson and C. C.

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spectives and Management Applications. Chicago: Health Administration Press.

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25 (3): 92–95.

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Chicago: Health Administration Press.

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L e a r n i n g O b j e c t i v e s

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