Running head: DRAFT – MIND THE GAP: THE LEADERSHIP GAP IN HEALTHCARE
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Mind the Gap: The Leadership Gap in Healthcare
Annette Baskin, Desiree Thompson, Danae Lawson, Michelle Saunders, Yvonne Sundberg
Group 3
Liberty University
BUSI 646-Managing Human Capital in Healthcare
September 21, 2022
Respectfully Submitted to Dr. Eric Richardson
DRAFT – MIND THE GAP: THE LEADERSHIP GAP IN HEALTHCARE
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Statement of the Topic
There has been a wealth of information shared regarding leadership in healthcare. From the
inadequacy of current leadership to what it takes to be an impactful leader, thoughts regarding
the roadmap to bridging the gap in healthcare leadership are everywhere. This topic is
particularly important because of the current shift in healthcare to a more value-based approach.
The objectives of the healthcare industry have shifted from acute care to preventative care with a
focus on outpatient treatments and minimizing as much as possible the need for inpatient care.
Though there has recently been an influx of people seeking healthcare services, due to the
creation of the Affordable Care Act and baby-boomers aging and hitting retirement age, the focus
has not only been on serving more people but also servicing them with improved quality. There
are three things that entire healthcare industry has made a focus increased which include patient
satisfaction, improved quality, and efficiency. To complete these objectives it is vital to have
adequate leadership in place to take on the task. There is an opportunity to not only explore the
gaps in leadership but also facilitate a conversation regarding why these gaps exist and the
current impact they are having on the industry. Though currently gaps in leadership include lack
of diversity, ineffective leadership styles, and lack of development for and from leaders, there is
promise that solutions are already available both within the industry as well as externally. By
highlighting the importance of leadership, acknowledging the gaps, and proposing practical
solutions, the hope is to facilitate continued growth in the healthcare industry and further the
conversation regarding healthcare leadership.
Keywords: Leadership, Healthcare, Development, Servant Leadership
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Essentials of Leadership
Knowledge and understanding of the essentials of leadership is the first step for closing
the leadership gap. Proper education on how to become a great leader should help create better
leaders. Before one becomes a leader in the healthcare field, she should attend a seminar or
workshop in leadership skills sponsored by the National Public Health Leadership Institute
(PHLI). The National Public Health Leadership Institute studied “the value and impact of
executive coaching as an integral part of the yearlong PHLI program. Scholars have consistently
rated the coaching experience as one of the most valuable if not the most valuable aspect of the
PHLI program” (Baker, 2012, p.100). The PHLI program enabled participants to gain a
perspective on such things such as “enhanced self-awareness, enhanced awareness of how others
perceive the leader, identification of areas of strength in leadership practice, and identification of
growth opportunities” (Baker, 2012, p.100). Unfortunately, those who are not able to attend
these programs often face numerous obstacles to experiencing a coaching experience. The cost of
these programs can often be a barrier to participation, and, for some, it may be insurmountable.
However, cost isn’t the only obstacle. Another obstacle that may arise is the difficulty in finding
a leadership coach or mentor in the healthcare field. Developing an ongoing relationship with a
coach or mentor can help guide new leaders throughout their careers.
Different Leadership Styles
Programs such as those sponsored by the National Public Health Leadership Institute can
facilitate the development of all types of leaders. There appear to be two major types of
leadership styles. The two styles are identified as “transactional” and “transformational.”
Transactional leadership “describes the relationship between leaders and employees as one in
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which employees exchange some form of compliance for reward” (Curtis, 2011, p.32).
Transformational leadership “is concerned with more than just compliant behavior from
employees” (Curtis, 2011, p.32). According to Curtis, the most attractive leadership style is
transformational leadership. According to Curtis, this style can achieve “greater performance by
stimulating innovative ways of thinking and transforming followers' beliefs and aspirations. They
can see the importance of organizational change, have a vision, and can marshal commitment to
that vision to support the changes required” (Curtis, 2011, p.32). The main value of
transformational leadership appears to be skilled communication. This factor facilitates the
ability of leaders to promote self-confidence and trust among the teams. This type of leadership
also demonstrates skills for those who are not in higher-ranking positions.
Transformational leadership can help decipher the differences between a leader and a
manager. It can help a leader develop a more creative leadership style that fosters better
performance by her employees. Good leadership seeks to influence those around us to follow and
move in a new direction. Whether we are in a leadership position or not, we are constantly trying
to influence other people to act. “Each of us influences at least ten thousand other people during
our lifetime, so the question is not whether you will influence someone, but how you will use
your influence” (Pohl, 2012, p 4). How a leader influences others is important. Both good and
bad influences can make or break a relationship with an employee.
There is a big difference between a leader and a manager. A major misunderstanding is
that leading and managing are one and the same.
The main difference between the two is that leadership is about influencing people to
follow while management focuses on maintaining systems and processes. Managers can
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maintain direction, but they can't change it to move people in a new direction, you need
influence” (Pohl, 2012, p 4).
A “leader” may not necessarily be in a formal “leadership” position. If employees are listening to
another employee who is not in a leadership position, they are still seen as a leader by their
coworkers.
Describing a Successful Leader
There are many words that can be used to define a successful leader, such as “flexible,
adaptable, agile, and versatile” (Yukl & Mahsud, 2010, p.81). To become a successful leader, it is
essential for the person to stay current with technology and evolving methods and procedures, to
know what is expected of them by managers, coworkers, and subordinates, and, if in a cross-
cultural situation, to learn about the cultural differences and proper attitudes (Yukl & Mahsud,
2010). In order to close any gaps, it is essential that leaders be able to analyze a situation and
identify and implement a strategy to change the behaviors that are not working in the
environment. Being able to skillfully bring about a change in behavior is an important skill.
Leaders need to appreciate and take advantage of opportunities to increase their self-
awareness of relevant traits, skills, and behaviors, and to develop necessary skills before
they are needed. Leaders should also recognize their responsibility for helping
subordinates develop and use the skills and behaviors required for flexible and adaptive
leadership (Yukl & Mahsud, 2010, p.91).
Being a leader in a field such as healthcare that is always evolving and changing can be a
difficult task. It is important to maintain flexibility and adaptability even though it can be
stressful. Leadership requires a high level of commitment to complete tasks effectively,
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efficiently, and ethically. Leaders are examples of those around them. They teach others and
should do so in an ethical manner. Change is inevitable. Leaders can help with transitions to
accommodate change go smoothly.
The Importance of Leadership in Healthcare
Leadership in healthcare is very important because it helps to improve patient outcomes
and improves the well-being of healthcare providers by promoting positive employee
engagement in the workplace which would also help to reduce burnout. Doing this would bring
about change in the healthcare organization hence, “healthcare leadership is the ability to
effectively and ethically influence others for the benefit of individual patients and populations”
(Hargett et al., 2017, p.70). Although the importance of effective leadership is widely known, the
understanding of the competence of effective leadership remains restricted which is why Hargett
and his colleagues used a concept mapping approach to help identify the stakeholders’ mental
model of effective healthcare leadership. This concept mapping approach involved a blend of
both qualitative and quantitative analysis of group processes that helped produce a visual
combination of the group’s ideas (Hargett et al., 2017). The study was conducted by using
literature reviews, focus groups of 92 individuals, and consensus meetings which were all used
as part of the method of study. The findings gathered from the study revealed that, when we use
mixed approaches (qualitative and quantitative analysis), we can develop a “graphical
representation of a shared leadership model derived in the healthcare setting” (Hargett et al.,
2017, p.69). This means that with this approach, healthcare leaders and managers can have a
sense of direction on how to achieve quality performance in their organizations because the
mapping approach has been proven to be useful for teaching effective leadership skills.
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Fixing the Gaps in Healthcare
Before we can fix the gaps in healthcare, we must first realize that there are gaps and
having knowledge of these gaps, is the beginning of success because leadership is about vision
and how to provide the needful change needed for an organization. The best way to fix these
gaps is through effective leadership. Leadership is not an easy task for healthcare leaders because
they constantly face several challenges in the society such as monetary challenges due to the
complex economics of healthcare, the constant change of patients’ expectations, new
technologies, and the demographics of the aging population. These challenges are the reason why
healthcare organizations must look within for answers on how to use effective methods and tools
to fix the gaps in healthcare. One opportunity to look within includes not overlooking poverty-
stricken individuals in society, because this group of people needs immediate access to
healthcare services. Healthcare providers who are committed to serving the poor also “face
daunting challenges, with the most obvious one pertaining to the provision of services with little
or no expectation of remuneration” (Elrod & Fortenberry, 2017, p.38) and these challenges are
often overlooked by the society who tend to think that when healthcare providers deliver
healthcare to the underserved population, that it is fully covered by health insurance. This is not
entirely true because when reimbursements “are provided, they often fall short of covering the
actual costs associated with rendering services” (Elrod & Fortenberry, 2017, p.38). So, therefore,
healthcare providers should try as much as possible to bridge the healthcare access gaps
experienced by the underserved in the societies (Elrod & Fortenberry, 2017) because this ensures
that the needs of the underserved populations are met.
Gaps Faced by Women in Healthcare
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Healthcare leaders should ensure that there is gender diversity in their organization
because gender gaps according to a research study done by academic researchers, have been
known to be “penetrating deep into the healthcare organizations” (Kalaitzi et al., 2019, p. 43)
which is known to have the largest source of employment.
Kalaitzi et al., stated:
75% of the global healthcare workforce is comprised of women in some countries, only
about 25% of those women hold leadership positions. In the healthcare provision sector,
women leaders represent only 18% of hospital CEOs and 14% of healthcare boards of
directors; in clinical leadership, only15.9% of women have reached top-level positions; in
academic medicine, Grade A has been achieved only by 14% of women pursuing a high-
level career in the field. (Kalaitzi et al., 2019, p.44)
Even though the healthcare force is comprised mostly of women, they continue to encounter
several societal and cultural challenges that tend to affect their careers. To solve this, a
conceptual framework has been proposed to be used in addressing evidence-based research
which would help advance women’s leadership in healthcare.
Balancing Healthcare Quality Services and Costs
In order for healthcare quality services and costs to be balanced, it must first be aligned
with effective leadership because healthcare organizations can attain quality through
collaborative leadership which will help improve patient healthcare quality and cost because
according to a quantitative study that was carried out to address healthcare costs, strategies for
managing healthcare cost, and the evaluation of collaborative leadership cost-reduction
strategies, the results from the study revealed that “adopting collaborative leadership strategies is
important to balance the cost of healthcare and the quality of services” (Okpala, 2018, p. 148)
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and also, a “patient-based collaboration strategy was associated with enhanced quality of
healthcare” (Okpala, 2018, p. 149). Healthcare leaders must be able to establish a cultural
environment that would help support the overall quality objectives of the healthcare organization
and adopt a patient-based collaboration strategy because “the patient-based collaborative strategy
offered significantly higher cost-reduction effectiveness” (Okpala, 2018, p. 149) which has been
linked not only with an improved quality of healthcare but also known to manage healthcare
costs.
Coaching and Development Gaps in Leadership
An important element that contributes to the leadership gap in healthcare is created by the
inability of current leadership to develop their frontline staff and the future leaders of the
industry. Even more specifically, coaching is a tool by which development can occur; however,
leaders in health care struggle with effectively utilizing that tool. Coaching is important to
leadership because it is the essence of a quality leader to create other leaders rather than to create
more followers. Developing more leaders not only secures the future of the industry but it also
creates a culture of growth and self-sufficiency.
The Importance of Coaching and Development
Coaching and development positively impact employees because it provides them with
ownership for their own growth. The benefits of an effective coaching relationship include the
development of trustful relationships that foster learning, professional growth, relationship
building, problem-solving, and goal setting (Cummings, Hewko, Wang, Wong, Laschinger &
Estabrooks, 2018). In an ever-evolving environment, such as the health care industry, it is
important that a culture of learning be developed among employees. Problem-solving is also a
needed skill in future leaders particularly in the health care industry because there are unique
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issues that present themselves in health care and without solutions those issues can become
detrimental. According to Jones, Woods, and Guillame (2016), other benefits of coaching are that
it improves outcomes in the workplace, creates more opportunities for growth professionally,
increases productivity, and increases active rather than passive learning. Productivity in health
care has been under the microscope as organizations strive to maximize outcomes and minimize
cost.
There are illustrations of coaching being used in healthcare. It is important to develop
coaching as a skill to be an effective nurse leader (Cummings, Hewko, Wang, Wong, Laschinger
& Estabrooks, 2018). Nurses thrive more in environments where there is better leadership,
empowering work environments, and open feedback regarding performance (Cummings, Hewko,
Wang, Wong, Laschinger & Estabrooks, 2018). Better patient outcomes and greater research use
are the result of impactful and professional coaching (Cummings, Hewko, Wang, Wong,
Laschinger & Estabrooks, 2018).
An illustration of a biblical coaching and development relationship can be found between
Paul and Timothy. In the first letter to Timothy Paul refers to him as a “true son” (1 Timothy 1:2,
NLT) which indicates genuine care for him which is necessary for any coaching environment.
Paul also gives him very specific instructions and says, “But you Timothy, are a man of God; so
run from all these evil things. Pursue righteousness and a godly life, along with faith, love,
perseverance, and gentleness” (1 Timothy 6:11), and it is necessary to create very specific
objectives during coaching sessions. The idea of Christianity is not only to focus on one’s own
salvation but to also share the good news with others. Likewise, professionally it is important to
pursue growth and training, but it is equally as important to share knowledge with others.
Defining Coaching
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Coaching, as a form of development, has a very distinct characteristic. Coaching is
defined as a “one-to-one learning and development intervention that uses a collaborative,
reflective, goal-focused relationship to achieve professional outcomes that are valued by the
coachee” (Jones, Woods & Guillame, 2016, p. 250). A deeper look into the coaching definition
reveals key elements including the fact that both the coach and the one being coached must work
together, utilize information provided by previous behavior and create plans goals and objectives
for the future. Another key element of coaching is that it functions best if there is a relationship
created and maintained between the coach and the person receiving the coaching (Jones, Woods
& Guillame, 2016). A genuine effort to create and facilitate a relationship with each team
member must be done well before coaching sessions begin because it increases the opportunity
for both coaches and team members to collaborate effectively. Coaching is not as impactful if the
person being coached doubts the sincerity of the coach. Other elements of coaching include a
formal and contractual agreement that outlines improvement, objectives, and also the fulfillment
of those objectives.
Coaching is different from other developmental techniques. Though there is a place for
both mentorship and coaching as it relates to professional development, it is important to
understand the differences between the two techniques. Relationship formation is essential for
both techniques; however, the extent of and motivation behind the relationship is different.
According to Jones, Woods, and Guillame (2016), coaching as a form of development is different
from mentorship because it is objective specific and not a long-term relationship. Coaching is
also different from performance management, because the relationship is more than just
supervisor and subordinate, and goals are established mutually rather than one-sided
communication of expectations. Coaching as a developmental tool is more personalized than
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previous techniques and navigates away from the mentality of one size fits all as it relates to
training (Jones, Woods & Guillame, 2016).
Reasons for the Coaching Gap in Healthcare
For multiple reasons, though it has been used in many other industries, coaching has not
fully been embraced by the leadership in healthcare. Discomfort is a key reason that leaders
avoid coaching. Cummings, Hewko, Wang, Wong, Laschinger, and Estabrooks (2018)
acknowledge that beginning to implement coaching can be difficult for employees to adjust if it
has not been performed in the past. According to Lloyd (2018), managers are fearful of
disgruntled employees that may deny or pass blame. A lack of knowledge about how to properly
offer to coach as a form of development is an additional reason that leaders do not offer
coaching. Managers seem to be fearful of making themselves vulnerable to legal ramifications
(Lloyd, 2018).
Another reason that coaching is often avoided is because of the many other items that
occupy the attention of clinicians in leadership. Clinician leaders are often trying to maintain
patient experience, employee workflow as wells as policies, rules, and regulations that have to be
followed, and unfortunately coaching and development often is not prioritized. Since the passing
of the Affordable Care Act there has been an influx in patients, and because the population is
aging more people need more medical care. With the current and progressing shortage of both
physicians and nurses in healthcare, there is a lot of pressure to complete administrative tasks
and see patients, and that leaves little time for development techniques.
Opportunities to Close the Coaching Gap
There are numerous opportunities to close the coaching gap in leadership. It is very
important to create a safe space in order to have coaching conversations. A manager’s support is
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necessary for coaching conversations. According to Jones, Woods, and Guillaume (2016), a safe
space for a coaching session is one without judgment, which is private and confidential, and
allows the person being coach to have a place to reflect.
It is also important to ensure to get the employee's contribution and buy-in regarding
coaching goals and objectives. Lloyd (2018) recommends finding out what motivates the
employee to change rather than attempting to incentivize them with inefficient motivation. This
can be done with more ease if a relationship is previously developed and the employee is
encouraged to make this a collaborative effort. One tip that has been confirmed to assist in
coaching conversations is the use of open-ended questions and practice good listening skills in
order to facilitate a good coaching conversation (Sherman & Cohn, 2016).
Impacts of recruiting on the gap in leadership
In preparation for filling the leadership gap, we must first figure out the best process in
which to do that and where to start. “Preparing health care managers for the complexity of the
health care industry poses a heavy challenge on health care organizations, chief executive
officers (CEOs), managers, and educational institutions” (Walter, 2017). With the always
evolving healthcare system we see that healthcare management is not simple and recruiting the
right leaders to handle this field is very important (Walter, 2017).
Qualities of Leaders
When looking for leaders there are characteristics that are needed in healthcare leaders
like honesty, ethical, dependable, and goal-oriented (Paul, 2011, p.655). The goal of finding the
difference in this success to help further the success of other leadership areas. Having leaders
that are diverse and will be able to guide healthcare employees of different ethnicities. The
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leaders that are being recruited need to be role models they are the people that other healthcare
workers want to be like. Pushing for the highest qualities is the goal, seeing the small
independent qualities are what make a strong leader. Leaders do not see these qualities the ones
that think this is normal are the ones that will last and stick around to the long term.
Transformational leadership is a high quality that is looked for in healthcare leaders. The
transformational leader is the type that pushes, stimulates and motivates the ones that they work
with (McDonagh, Bobrowski, Hoss, Paris, & Schulte, 2014). Galatians 6:9 says, “Let us not
become weary in doing good, for at the proper time we will reap a harvest if we do not give up.”
The greatest quality to look for when recruiting a leader is someone that will handle the bad and
keep working towards the good for the better of healthcare.
Leadership Framework
Streamlining the leaders that are brought in will aid the gap in the long run. “Similar to
the chef who focuses on being opportunistic with ingredients and streamlines kitchen systems
and processes to produce a meal of great value no matter what (Paul, 2011, p.655).” Focusing on
the purpose that the leader will need to fulfill is how you find the leaders that can fill the gap.
When zeroing in on having the leadership that will build an organization that will drive to the
solution. The framework for leadership is the foundation of how the leader will grow and
develop, thus if a good framework is created at the start then the gap wouldn’t be created.
“Leadership is included in most of the frameworks in implementation science that highlight
factors essential to implementation, such as the Consolidated Framework for Implementation
Research (CFIR) (cf. [1]) and the Preparation, Implementation, Sustainment (EPIS) framework”
(Richter, Thiele, Schwarz, Lornudd, Lundmark, Moson, & Hasson, 2016). Mending the
leadership gap can be solved if one knows the framework in which the kind of leader the
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healthcare organization is in need of. When creating the framework of leaders in healthcare the
focus should be on what is best for the care of the patients.
Improvement of Current Leaders
“There is a documented need for diverse leadership teams with transformational
leadership skills to successfully lead organizations, yet women who comprise three-fourths of the
healthcare workforce are sparsely represented in board rooms and in the senior executive suite”
(McDonagh, Bobrowski, Hoss, Paris, & Schulte, 2014, p.1). This expresses the need for diverse
leaders to mind the gap. The idea of what a leader is can get to some and cause others to lose
focus on the task at hand. The leaders of today need to maintain hope and need the support of
other coworkers. “Leadership has been defined and measured in different ways in the existing
empirical studies, which makes comparisons across studies difficult” (Richter, Schwarz,
Lornudd, Lundmark, Mosson, & Hasson, 2016). The transformation from a role model to a
leader is they have the vision for the healthcare plan of action (Richter…, 2016). Having the
drive towards what is best for the healthcare situation. Leaders in health care organizations and
health care management systems would benefit from assistance building innovative methods to
address these gaps of knowledge of key characteristics expected of advisors in the health care
industry (Walter, 2017).
Efforts to Bridge the Gaps in Healthcare
There are several options to close the gap in leadership that exists in healthcare
organizations. This can be accomplished by identifying breakdowns in communication, lack of
leadership skills with leaders, insufficient knowledge, resisting change, and staff not willing to
share their knowledge. In a realm of budget cuts and investments for lower-paying positions,
leadership must implement training and development opportunities with their current nursing
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staff. Training and development opportunities will yield great rewards in the healthcare industry
where experience and knowledge are lacking. Employers must be prepared to recognize the in-
house talent already available and the nature of it fully, by investing educational resources to
training and develop their current nursing staff. Embracing equality and diversity allows
additional room for talent to be noticed. Apprenticeships give current staff opportunities to
improve skills and increase loyalty while also creating an attractive investment for employers.
Understaffing and workplace dissatisfaction can be undone when proper measures are taken to
train and retain current employees, this will give them a sense of belonging and making a
difference in patient healthcare. Implementing the creative leadership skills of the current staff
will motivate people to be committed to their job and understand the meaningful goal of the
healthcare organization.
Middle Managers Bridge the Gap
Leadership gaps are bridged by middle managers, and the responsibilities of middle
managers show how they receive little attention in the workplace, however, they play a vital role
in the healthcare innovation implantation. Research has shown that teamwork designs have also
become popular in healthcare organizations. Team building is a necessity for a successful
organization. Teams can collaborate in effective ways to do business. Middle managers influence
the organizational leaders as well as the front-line employees working under them. The middle
managers oversee their initiatives, their potential to influence innovation and implementation.
One must have a comprehensive understanding of the middle manager’s role and the importance
of the gap between evidence of effective care and practice. The middle manager should be apt to
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continuous learning, adjust to change, and improvement processes. Most middle managers do not
receive the attention or recognition needed as their role grows more vital in innovation. As the
middle manager’s responsibilities in healthcare organizations increases, their potential influence
over innovation implementation continues to grow. Middle managers provide ideas that are
applied to the organization to further satisfy the needs and expectations of the organization.
Middle managers are often underrepresented in the healthcare innovation implementation
process.
Servant Leadership Bridges the Gap
Job satisfaction directly correlates with the concept of servant leadership in the healthcare
profession. It is largely impacted by the leadership styles of management. Servant leadership
style focuses on the strength of the management team, skilled communicator, compassionate, a
systems thinker, and develops trust while engaging in the serving needs of patient care.
Employees care for patients differently when job satisfaction is observed. When one enters the
healthcare profession, some view it as a calling and others consider the traditional calling
concept as the ethical basis for the profession. In the review of employee satisfaction, there is a
concern in healthcare as it is in other business sectors. High-quality service from management
results in high-quality service to clients and patients. If this type of service is not displayed, it
will create low morale. Weaknesses in management result in persistent low morale in healthcare
workers. When there is persistently low healthcare worker morale, it has been noted as a
weakness in the management of healthcare that contents the leadership style of managers. Job
satisfaction is an import aspect of ensuring high-quality healthcare and that dissatisfaction among
healthcare workers leads to poor quality and less efficient service delivery.
Nursing Leadership Bridges the Gap
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Nursing leadership is rapidly changing due to the roles and scope of practice and the
location of patient care settings. One factor to consider is the retirement of the baby boomers.
They are slowly retiring and not grooming the Generation X and Y fully for the nursing positions
in the workplace. This is viewed as most nursing leaders struggle to meet the change in
generations by differing expectations and tension by disagreement in views. Generational values
have shifted in the workplace for nurses. People are more focused on family or personal gain.
Generations X and Y place great value on work-life balance, they place a higher value on work-
life balance because they are less willing to sacrifice their home life for the organization.
Leadership roles are transitioning in a way that does not benefit the industry. Healthcare
leadership must have a vision for the future, due to the rapid changes in healthcare, because the
younger generation does not want to take the roles that were created in the past. Older nurses are
retiring without the tools to train upcoming nursing professionals for lasting careers. Chief
Nurses, officers, directors, and charge nurses are positions that are phasing out due to retirement
and leadership gaps.
Conclusion
Leadership in healthcare is a dense topic to address because there is a multitude of factors
to address and plenty of research behind each topic. The wealth of information available is
indicative of the importance of the topic. Healthcare and everything related to it is undergoing a
major shift, and in order to successfully navigate that shift leadership must be in place and the
gaps that currently exist need to be minimized. Gaps in healthcare-related to gender and ethnic
diversity, the skillset of current leaders, and the lack of coaching development are opportunities
for improvement. Being mindful of the solutions already available within the industry and
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striving toward leadership styles and characteristics that are useful during this time of transition
are vital for the continued improvement of the healthcare system.
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