Health Deliver- Lead

CHAPTER 13 Complexity, Speed, and Change: Leadership Challenges for the Next Decade

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Great necessity elevates man; petty necessity casts him down.

Goethe, Wisdom and Experience

This chapter discusses the globalization of leadership, taking into account that many leadership theories and practices presented in many texts are based on Western ideologies. The need to leverage technology, lead through followership, and understand the basics of influence and power are addressed in respect to climate, culture change, and environment, along with suggested strategies for utilization by the health leader.

What kind of leader do you want to become and be? Leaders have an obligation to stay current and relevant in the field of leadership practice. This chapter presents issues and strategies to help leaders maintain their relevancy and creditability in the organization. In addition, the humble leader can admit to not knowing everything that occurs in a health organization; this chapter emphasizes that it is okay to say, “I don’t know,” when leading complex health entities.

LEARNING OBJECTIVES

· 1. Describe and outline issues related to globalization, power, followership, and culture change from a health leader’s perspective.

· 2. Give examples of tools that a health leader can use to change and adapt culture in the health organization.

· 3. Relate global leadership style differences and similarities using appropriate constructs to transformational leadership practices.

· 4. Analyze a health leader’s use of power as it relates to followership, culture change, and knowledge management.

· 5. Categorize global leadership differences according to a leader’s use of power, technology, and knowledge management.

· 6. Evaluate approaches to knowledge management, organizational learning, and transformational leadership with health organization culture change.

CULTURAL DIFFERENCES IN LEADERSHIP

As globalization increases, health leaders need to be culturally aware, understanding, and capable of leading people from diverse backgrounds, diverse educational portfolios, and diverse outlooks. In today’s global economy, it is commonplace for subordinates, peers, and superiors to be from different geographic, national, and cultural backgrounds. Likewise, patients, customers, and their families are growing more diverse. This trend requires a culturally competent and adaptive perspective for both the health leader and the health organizational culture the leader maintains. It adds complexity to the health leader’s landscape from both internal and external environmental perspectives. In turn, this complexity lends credence to demands for a dynamic culture leadership mentality and process to create a robust organizational culture amid an environment of change—the speed of change is also increasing.

Globalization causes concern when discussing differing perceptions across cultures:

· • Individualist (self oriented) and collectivist (team oriented) cultures will have significantly different perceptions of work and performance.

· • Power distance (higher power means more physical space): High-power cultures tend to be authoritarian, whereas power is more equally distributed in low-power cultures.

· • Uncertainty avoidance (risk taking and plan implementation without all information and organizational coupling) is thick with rules and guidelines.

· • Gender equality: Assertive, material, and competitive cultures tend to be masculine, whereas collaborative, harmonious, and nurturing cultures take on a feminine persona.

· • High-context communication cultures transfer meaning with more emphasis on the situation, whereas low-context communication cultures emphasize the sender’s responsibility to transfer communication meaning more than the situation. 1

Situational leadership applications fit nicely in the paradigm of a culturally competent leader considering the complexity of globalization. Leadership expectations differ depending on the culture, society, nation, or ethnic group to which leaders belong (and reside and practice). It is difficult to find much in the literature on leadership outside the “Western” perspective, for example. The Western perspective in the literature is predominately based on research conducted in the United States, the United Kingdom, Australia, or Europe. “To date [as of 2004] more than 90% of the organizational behavior [including leadership] literature reflects U.S.-based research and theory.” 2

In an attempt to bridge Western and Eastern thought on leadership, the new paradigm of “thinkers” in an interconnected world has evolved. Health leaders who are successful have many of the characteristics encompassed by this new paradigm:

· • Thinking in open systems in contrast with fixed, ideal states

· • Integration of multicultural characteristics into decision making

· • Viewing things globally (acting locally)

· • Global distribution

· • Use of technology to scan the environment

· • A full toolbox and knowledge of how to use all of the tools

· • Personal characteristics of resourcefulness, fearlessness, toughness, competence, humor, and playfulness 3

With this introduction, the most recent worldwide study on leadership, the GLOBE Study, is presented.

GLOBE LEADERSHIP STUDY 4 ,5

The most comprehensive global assessment of leadership styles, propensities, and expectations is an ongoing project called the GLOBE Study; to date, 170 researchers from 62 cultures have worked on this project. 6 Much of the GLOBE Study cultural constructs were derived from the previous work of Hofstede. 7 The following constructs used in the study pertain to cultural variation:

· • Performance orientation (How aggressive is task accomplishment?)

· • Assertiveness (How forceful and firm is the leader?)

· • Future orientation (Is tomorrow more important than yesterday or today?)

· • Humane orientation (People oriented, compassionate, and empathetic?)

· • Institutional collectivism (Is the total organization a “team”?)

· • In-group collectivism (Is there a small-group orientation?)

· • Gender egalitarianism (Are males and females equal in respect, reward, and punishment?)

· • Power distance (How much physical space is normal based on the leader’s or person’s perceived power?)

· • Uncertainty avoidance (How risk averse is the leader? Does implementation of a plan or task proceed without all information? How intuitive is the leader?) 8

In the study, each construct embodied a set of variables pertinent to the construct. Findings were based on each construct. Although a summary and highlights are presented in this chapter, it is recommended that health leaders read and study the findings of the entire GLOBE Study 9 ; the research can be found at the webpage cited in the references.

The cultural dimension named performance orientation emerged from the research as exceptionally important. It “reflects the extent to which a community encourages and rewards innovation, high standards, excellence, and performance improvement.” 10 High performance orientation societies value the following:

· • Training

· • Competitiveness and materialism

· • Direct communication and formal feedback

High performance orientation societies place emphasis on what a person does rather than who that person is. In contrast, low performance orientation societies emphasize who a person is rather than what that person does, and in general these societies favor the following:

· • Societal and family relationships

· • Environmental harmony

· • Indirect communication and informal feedback

The cultural dimension named uncertainty avoidance also emerged from the research as very important; it is “the extent to which a society, organization, or group relies on social norms, rules, and procedures to alleviate the unpredictability of future events.” 11 “An alternative way of thinking about uncertainty avoidance is that it’s about the extent to which ambiguous situations are felt as threatening (about the extent to which deliberate measures such as making and enforcing rules and procedures are taken to reduce ambiguity).” 12 Societies that avoid high uncertainty feature the following characteristics:

· • Resist change

· • Depend on clear policies and procedures

· • Take only deliberate risks

· • Are orderly and keep meticulous records

· • Emphasize formality in interactions

In contrast, societies with low uncertainty avoidance behave in the following ways:

· • Display only moderate resistance to change

· • Utilize informal norms in most situations

· • Take risks with less premeditation

· • Are less orderly and maintain fewer records

· • Allow greater informality in interactions

As for leadership styles, 21 constructs, each having a set of variables that were measured, were found valid in interpreting leadership style and performance across all 62 societies, which were clustered in 10 societal groups. Leadership styles were categorized and measured by 6 groupings of the 21 constructs:

· • Charismatic/value based

· • Team oriented

· • Participative

· • Autonomous

· • Humane

· • Self-protective 13

From the associated constructs or traits ( Table 13-1 ), each leadership grouping or style can be “defined” for the purpose of making comparisons between the styles. There is considerable overlap in some of the styles. Can you develop a continuum of preferred/desirable to less preferred/undesirable leadership styles based on the constructs?

· Much of the analysis in the book [and webpage] is focused on explaining how the nine cultural dimensions (e.g., “performance orientation,” “assertiveness,” and seven others) as independent variables relate to the six culturally endorsed leadership theory dimensions (e.g., “charismatic/value based,” “team oriented,” and four others) as dependent variables across the 10 societal clusters. 15

A summary of each style used in the GLOBE study is provided in Table 13-2 ; the cultural constructs are listed in priority for each style as either positively related (+) or negatively related (–). Can you relate this aspect of the GLOBE Leadership Study to other leadership behavior-based studies such as the Michigan or Ohio State leadership studies? Which other leadership theories or models can be integrated with the GLOBE Study? How do the constructs or traits that define or describe each leadership style in Table 13-1 connect to the cultural constructs?

Table 13-1 The Six Global Leadership Groupings/Styles and Associated Constructs in the GLOBE Study 14

Charismatic/Value Based	Team Oriented
Participative	Humane Oriented
Self-Protective	Autonomous

Sources: Adapted from House, R. J., Hanges, P. J., Javidan, M., Dorfman, P. W., & Gupta, V. (Eds.). (2004). Culture, leadership and organizations: The GLOBE Study of 62 societies. Thousand Oaks, CA: Sage, p. 676, Table 21.1; and Grovewell, LLC. Retrieved June 6, 2009, from http://www.grovewell.com/pub-GLOBE-dimensions.html . Reprinted with permission.

Table 13-2: GLOBE Study Cultural Constructs Associated with Leadership Style

	Charismatic/Value-Based	Team-Oriented	Participative	Humane-Oriented	Autonomous	Self-Protective
Performance Orientation	+	+	+	+	+	−
Uncertainty Avoidance		+	−	+		+
Humane Orientation	+	+	+	+	−
Power Distance	−		−			+
In-group collectivism	+	+				−
Gender egalitarianism	+		+			−
Assertiveness			−	+
Future Orientation	+	+		+
Institutional collectivism					−

Key:

+ = Positively associated with Leadership Style

− = Negatively associated with Leadership Style

Sources: Adapted from House, R. J., Hanges, P. J., Javidan, M., Dorfman, P. W., & Gupta, V. (Eds.). (2004). Culture, leadership and organizations: The GLOBE Study of 62 societies. Thousand Oaks, CA: Sage, pp. 47–48.

This charismatic/value–based style, which is employed by leaders who are inspiring, visionary, self-sacrificing, and performance oriented, was universally considered the most desirable style. 16 The team-oriented leadership style and the participative leadership style were nearly universally desirable as styles, albeit not in all societal clusters. 17 Autonomous and humane-oriented (modest and compassionate) leadership styles were neither desirable nor undesirable in most societal cultures and clusters. 18 The self-protective leadership style (self-centered, status conscious, and conflict inducer) was undesirable. 19 “Attributes that facilitate, such as decisiveness, and inhibit, such as irritability, outstanding leadership” 20 were consistent across the study.

Highlights of the GLOBE study by societal groups show the diversity in leadership style preferences, expectations, and societal norms. Ten societal clusters were identified in the study, but some of these clusters will be combined for purposes of their review in this chapter.

CULTURAL COMPETENCE

There is a strong connection among leadership, organizational culture, and organizational success. As we discussed earlier, competencies for health leaders are of utmost importance. Given opportunities for education and development, certain competencies will be strengthened whereas others will be less focused on. These competencies will greatly mold the role each healthcare administrator fills within their organization. Paramount to understanding all of this first is to be aware of cultural competence. Cultural competency in healthcare administration is critical to achieving better health outcomes for the multicultural and vulnerable populations being served. Creating a culture of leadership throughout the organization goes hand in hand with developing values, norms, and practices that exemplify leadership and forward thinking in line with the organization’s mission and goals.

Recently, cultural competence has gained attention from healthcare policy makers, providers, insurers, and educators as a strategy to improve quality and eliminate racial/ethnic disparities in health care. The goal of cultural competence, however, is to create a healthcare system and workforce that are capable of delivering the highest-quality care to every patient regardless of race, ethnicity, culture, or language proficiency. Cultural competence has emerged as an important issue for three practical reasons. First, as the United States becomes more diverse, clinicians will increasingly see patients with a broad range of perspectives regarding health, often influenced by their social or cultural backgrounds. For instance, patients may present their symptoms quite differently from the way they are presented in medical textbooks. They may have limited English proficiency, different thresholds for seeking care or expectations about their care, and unfamiliar beliefs that influence whether they adhere to providers’ recommendations. Second, research has shown that provider–patient communication is linked to patient satisfaction, adherence to medical instructions, and health outcomes. Thus, poorer health outcomes may result when sociocultural differences between patients and providers are not reconciled in the clinical encounter. Third, cultural competence is a tangible expression of “concern for people,” or empathy for others, and assists in building relationships. Ultimately, these barriers do not apply only to minority groups but may simply be more pronounced in all areas of health care. 21 ,22

Western Perspective 23

The Western perspective of leadership styles, for this summary, includes Germanic Europe, Anglo, and Nordic Europe clusters. For these Western clusters, charismatic/value–based leadership was the most preferred and desirable leadership style, followed by the team-oriented leadership style. Very close in preference to the team-oriented style was the participative leadership style. Significantly less preferred and less desirable was the human-oriented leadership style. The autonomous and self-protective leadership styles were not preferred and not desired for this perspective. Thus, in priority of preference, the Western perspective favored the charismatic/value–based style, team-oriented style, and participative style of leadership. The humane-oriented style was preferred or desired to only a minor degree, whereas the autonomous and self-protected styles were not preferred or desired.

Translating the Western perspective into modern leadership theories and models, transformational leadership, the omnibus leadership model, and the dynamic culture leadership model are readily integrated into this perspective. In balancing leadership emphasis among performance (mission accomplishment) and concern for people, having a team orientation, looking toward the future (vision achievement), and understanding a dynamic environment, there is considerable congruence between these models and the Western perspective of leadership style preference. Are there other leadership theories, models, principles, or competencies that integrate well with, or support, this perspective?

Asian Perspective 24

The Asian perspective of leadership styles includes the Confucian Asia (China, close neighbors of China, Japan, and close neighbors of Japan) and Southern Asia (from Afghanistan to Vietnam, including the southern belt of Asian countries) clusters. For these Asian clusters, charismatic/value–based leadership was the most preferred and desirable leadership style, followed by the team-oriented leadership style. Next in preference to the team-oriented style was the humane-oriented leadership style. Significantly less preferred and less desirable was the participative leadership style. The autonomous and self-protective leadership styles were not preferred and not desired for this perspective, yet were more readily tolerated than in the Western perspective. Thus, in priority of preference, the Asian perspective favored the charismatic/value–based style, team-oriented style, and humane-oriented style of leadership. The participative style was preferred or desired to only a moderate degree. The autonomous and self-protected styles were not preferred or desired, but were more readily tolerated by the Asian perspective than by the Western perspective.

Modern leadership theories and models salient for the Asian perspective could include transformational leadership, the “reframing organizational leadership” model, the omnibus leadership model, the dynamic culture leadership model, and an older theory, Theory Y (from behavioral leadership models). Can you match and integrate these contemporary leadership theories and models to the Asian perspective based on the GLOBE Study findings?

Middle Eastern Perspective 25

For the Middle Eastern perspective of preferred leadership styles, the cluster includes the land mass from southern Turkey to Iran to northwest Africa to the Mediterranean Sea. In this societal cluster, team-oriented leadership, and then charismatic/value–based leadership, were the most preferred styles. Participative and humane-oriented leadership styles were moderately preferred, whereas self-protective and autonomous leadership styles were least preferred. Tolerance for the self-protective leadership style mimicked the Asian perspective, whereas autonomous leadership was the least desired leadership style.

Modern leadership theories and models that integrate well with the Middle Eastern perspective would include the dynamic culture leadership model, transformational leadership, and the omnibus leadership model. Can you match and integrate these contemporary leadership theories and models to the Middle Eastern perspective based on the GLOBE Study findings?

Latin Perspective 26

In terms of the Latin perspective of preferred leadership styles, the cluster includes Latin America and Latin Europe (southern Europe bordering the Mediterranean Sea). In this group, charismatic/value–based leadership was the most preferred and desirable leadership style, followed by the team-oriented leadership style. Next in preference to the team oriented style was the participative leadership style. Significantly less preferred and less desirable was the human-oriented leadership style. The autonomous and self-protective leadership styles were not preferred and not desired for this perspective. The Latin and Western perspectives are very similar based on the results of this study.

Which leadership theories and models can you relate to the Latin leadership perspective? Can you list the characteristics of the theories and models in terms of the preferred leadership styles of the Latin societal cluster?

African Perspective 27

The African perspective covers sub-Saharan Africa. It is similar to the Western and Latin perspectives, although the humane-oriented leadership style was more preferred in African cultures than in Western or Latin cultures. Charismatic/value–based leadership was the most preferred and desirable leadership style, followed by the team-oriented leadership style. Next in preference to the team-oriented style was the participative leadership style. Slightly less preferred and less desirable was the human-oriented leadership style. The autonomous and self-protective leadership styles were not preferred and not desired for this perspective.

Eastern European Perspective 28

The Eastern European perspective includes eastern Germany (former East Germany) to Russia and south to the Balkans (in essence, countries in the former Eastern European Bloc or Communist Bloc). This perspective is similar to the Middle Eastern perspective, where team-oriented leadership, and then charismatic/value–based leadership, were the most preferred styles. Participative and humane-oriented leadership styles were moderately preferred, whereas the self-protective leadership style was least preferred. Tolerance for the autonomous leadership style was the greatest in the Eastern European perspective as compared to all other societal groups; this style was not preferred but would be considered a more neutral style.

GLOBE Summary

The major theme that health leaders need to understand, apply, and synthesize from the international research on leadership is that charisma, values, team orientation, and performance matter. Health leaders should focus on accomplishing the mission, striving for the vision of the organization, leading people and managing resources, and mastering and applying sound practices of leadership (leadership competencies); these demands are vitally important for leaders across the globe.

This section reviews the constructs or traits that are highly prized and accepted across the world. Culturally sensitive health leaders should strive to have the following characteristics:

· • Charismatic and visionary

· • Charismatic and inspirational

· • Charismatic and self-sacrificing

· • Consistently able to lead with integrity

· • Decisive

· • Performance oriented

· • Team collaborative

· • Team integrative

· • Diplomatic

· • Benevolent

· • Administratively competent

As a health leader, it is inevitable that you will lead and work with people from different countries, from different societies, and from different backgrounds. To demonstrate cultural competence, respect and understanding of different ways of doing things, different expectations, and different perspectives is essential. The leadership challenge is to integrate these differences into the group and organization while focusing on the mission (performance orientation), striving for the vision (future orientation), communicating well (visionary and integrating people into the mission and vision), leading people well and genuinely (charisma and humane orientation), managing resources effectively (administrative competence), building teams (team orientation), and being diplomatic, yet decisive.

The health leader needs to accomplish these tasks—a big set of tasks—within a solid moral framework built on truth, honesty, and integrity. Without morality, integrity, and honesty, regardless of cultural perspective, the leader’s work is meaningless. In simple terms, the health leader must develop and maintain an organizational culture that fulfills the mission and vision while incorporating the vast diversity and complexity that the world holds within a sound ethical framework. The health leader must accomplish this feat in an environment of dynamic change while meeting and exceeding the professional standards of care and health administration.

LEVERAGING TECHNOLOGY

Leveraging technology in a health organization, like the practice of leadership itself, creates competitive advantage—that is, more effectiveness, efficiency, and efficacy—in the practice of medicine, in the clinical environment of care, in patient outcomes, and in the administration of the enterprise. In the health context, technology is anything that is utilized in the practice of medicine, in patient care processes, and in the leading of people and management of resources. Examples of technology, in an attempt to cover the enormity of the term, include chairs, computers, harmonic scalpels, MRIs, patient beds, knowledge of and the process of budgeting, computer software, a forklift, an intercom system, pagers, cell phones, knowledge of and the process of diagnosing disease, and utilization of media richness theory for improved communication. Technology is encompassed in the following definitions: the practical application of knowledge, especially in a particular area; a manner of accomplishing a task, especially using technical processes, methods, or knowledge; and a capability given by the practical application of knowledge. 29

Technology, especially networked computer technology, can be leveraged by the health leader and the leadership team to facilitate communication so as to better lead people; to scan and monitor the efficiency, effectiveness, and efficacy of the organization; and to manage resources. True individual health leader technology leverage comes when the leader can allocate more time to interpersonal relationship building, both internal and external to the organization; “leadership by purposefully walking” around and talking to subordinates, peers, and superiors; and establishing a balance in the leader’s religious, professional, social, and personal life.

Technology is constantly evolving, increasing the complexity and speed of change. “The nature of the work or technology is changing and subordinates need to learn new skills and procedures.” 30 Yukl and Fiedler consider technology to be an important situational variable in their respective leadership models, the multiple linkage model 31 and the contingency leadership model. 32 Likewise, technology is a critical situational variable—one that affects ambiguity—in the garbage can model of decision making. 33 Schein identifies technology as an element in the category of artifact and creation of culture (a Level 1 element). 34

Health leaders should be cognizant of putting sound clinical and business practices into place, focusing on both the human and technological elements, to leverage technology most effectively.

· Exercising leadership requires distinguishing between leadership and authority and between technical and adaptive/operational work. Clarifying these two distinctions enables us to understand why so many people in top authority positions fail to lead: they commit the classic error of treating adaptive challenges as if they were technical problems. 35

Simply put, fixing a problem by changing or increasing the technology most likely will not work, but rather will further confound the problem. Human adaption to quality clinical and business processes, linked to organizational culture, needs to be effective, efficient, and efficacious such that technology can be leveraged to complement and merge as seamlessly as possible with the people the health leader leads.

· Health organization structure and control systems can no longer be depicted as tools that mechanically determine subordinates’ and team members’ behaviors. Health leaders must shift their thinking about organizations away from the organization as an entity, to subordinates’ choice and understanding. 36

How subordinates and team members fit into the processes and work with the technology needs to be communicated, documented, trained for, and continuously improved. Health leaders in this environment cannot assume that “cookie-cutter” methods will suffice, but instead must learn and become effective in developing teams of professionals within dynamic cultures. To appreciate the dynamic nature of organizations today, one need simply consider the realities of human diversity, information overload, the evolution of technology, the sophistication of the consumer, and e-commerce; many of these changes are rooted in technological advances.

Creating a health organization culture in which subordinates, team members, and leaders alike keep current with technological advances and best practices in clinical and administrative arenas is paramount. In their assessment of great groups or teams, Bennis and Biederman suggest that teams whose members want to excel desire new technology. Technology is embraced—the newer and the better—because creating the future is exciting. 37 Health leaders can leverage this excitement and enthusiasm by creating a conducive culture aligned with the organization’s mission and vision, communicating how people fit in with the technology employed, fostering a continuous learning emphasis, and developing systems of learning and knowledge management.

LEADERS AS FOLLOWERS

Every health leader was, most likely, a follower at some point. In fact, a health leader is likely to be simultaneously both a leader and a follower. Knowing what role you are in within a given situation and context is clearly important. The most successful health leaders were, and are, great followers. As a health leader, which traits, attitudes, and characteristics do you like to see in a follower? Good followers have a great attitude; commit to their responsibilities; complete their assigned (and at times unassigned) tasks; communicate to superiors, peers, and subordinates well and often; are loyal; and focus on the mission and vision of the organization within the appropriate strategies, goals, objectives, and action steps in their purview. Great followers are honest, are moral, and put the organization’s success ahead of their own interests. In many ways, great followers have attributes of great leaders.

Being a “transformational follower” means you are positively contagious to others as a role model. Transformational followers have a service “charisma,” focus on the leader or leadership’s organizational agenda and work to achieve it, communicate and follow up with all connected to their responsibilities and work, are loyal to leadership and the organization, stay appropriately coupled to the organizational norms and expectations, and deliver quality performance within a moral foundation.

The best method to understand how a health leader can be a great follower is to ask your superior, your leader, what his or her expectations for you are regarding followership. Leadership requires followership; followership requires leadership. Many of the same attributes of leadership pertain to followership, except that the leader sets the agenda and tempo for the follower’s work and work environment. Being a great health follower goes hand in hand with being a great health leader.

POWER, INFLUENCE, AND THE BASIS OF POWER

Power is a leader’s or agent’s capacity to influence another person’s, group’s, or organization’s values, beliefs, attitudes, and behaviors. Using power to influence a change of behaviors is less difficult than changing attitudes; attitudes are less difficult to change than either beliefs or values. Power and influence can be characterized in several ways; the two methods presented here are the most universal.

Power can be discussed in terms of Kelman’s social influence theory 38 ,39 and the process of social influence. Power and influence, serving as a catalyst, prompt three responses to varying degrees; that is, the subordinate or target of a leader’s power- and influence-based request or requirement may demonstrate instrumental compliance, internalization, and/or identification.

· • Instrumental compliance is defined as a subordinate’s or target person’s fulfillment of the leader’s requested action for the purpose of obtaining a tangible reward or avoiding a punishment controlled by the agent. This is an example of transactional leadership in action from a foundation of the social exchange theory.

· • Internalization is defined as a subordinate or target person’s commitment to support and implement requests (and actions required to fulfill the requests) made by the leader because they are perceived to be intrinsically desirable and correct in relation to the target’s values, beliefs, attitudes, and self-image. In this response, the request or proposal becomes integrated with the target person’s underlying values and beliefs. It is an example of transformational leadership in action.

· • Identification is defined as a subordinate’s or target person’s imitation of the leader’s behavior and/or adoption of the same attitudes to please the leader. This is an example of social learning theory in action, closely linked to role modeling.

Another way of thinking, or to consider in terms of the use of power and influence on subordinates, peers, stakeholders, and possibly superiors, results in three possibilities: commitment, compliance, or resistance.

· • Commitment occurs when the person, group members, or organizational members who are the focus of power and influence from the leader internally agree with a decision or request from the leader; they then implement an approach to fulfill the request or implement the decision effectively, efficiently, and efficaciously. Commitment implies attitude change in the subordinates.

· • Compliance occurs when the person, group members, or organizational members are willing to do what the leader desires but in a mechanical or apathetic manner, applying only moderate to minimal effort. Compliance implies that the subordinate’s behavior, but not his or her attitude, has changed due to the leader’s influence.

· • Resistance happens when organizational members are opposed to the leader’s request and actively avoid carrying it out, perhaps even taking steps to block actions to fulfill the leader’s request.

Of course, there are varying degrees of commitment, compliance, and resistance. When using power and influence, health leaders should assess the organizational culture and the individual team member’s personal impact and perception, such as with the coordinated management of meaning model, and should plan accordingly. Obviously, health leaders want commitment and at least compliance, while eliminating resistance.

The most recognized basis of power and influence comes from French and Raven’s Power Taxonomy. Table 13-3 is presented in tandem with Kelman’s model for purposes of synthesis and comparison.

Table 13-3 French and Raven’s Power Taxonomy and Kelman’s Power and Influence Outcomes

French and Raven’s Power Taxonomy	Description	Kelman’s Influence Processes
Reward	Person complies to obtain rewards controlled by the agent	Instrumental compliance
Coercive	Person complies to avoid punishment by the agent	Instrumental compliance
Legitimate (also called formal)	Person complies because the agent has the right to make the request; person is under the chain of authority	Instrumental compliance, internalization, and identification
Expert	Person complies because the agent has special knowledge	Internalization
Referent	Person complies because he or she admires or identifies with the agent and wants the agent’s approval	Identification
Information *	Control of information by agent is source of power

*Added by Yukl.

Sources: Data from French, J. R. P., & Raven, B. H. (1959). The bases of social power. In D. Cartwright (Ed.), Studies of social power (pp. 150–167). Ann Arbor, MI: Institute for Social Research; Kelman, H. C. (1958). Compliance, identification and internalization: Three processes of attitude change. Journal of Conflict Resolution, 2, 51–56; Kelman, H. C. (1974). Further thoughts on the process of compliance, identification, and internalization. In J. T. Tedeschi (Ed.), Perspectives on social power (pp. 125–171). Chicago: Aldine; Yukl, G. (1994) . Leadership in organizations(3rd ed.). Englewood Cliffs, NJ: Prentice Hall, p. 202 .

Agenda power—the authority and control of agenda items—is similar to information power but can be recognized as a source of power as well: Consider the secretary’s or assistant’s control of meeting agenda items on behalf of the leader (superior). Moreover, health leaders have power from legitimate or formal power, also called position power: “Position power includes potential influence derived from legitimate authority, control over resources and rewards, control over punishments, control over information, and control over the organization of the work and the physical work environment.” 40

Power is maintained, if not increased, by wise use of power. The use of power is particularly important in organizational culture; who controls resources, who receives those resources, and how resources are used contribute to the cultural disposition of the organization. Bolman and Deal, in their reframing organizational leadership model (specifically, under the “political” construct), overtly suggest that leaders must use power and resource distribution wisely. Again, consistent and predetermined leadership actions, when using power and distributing resources, are paramount to ensure leader success.

Power and influence, and the basis of power, change in all organizations. “Power is not static; it changes over time due to changing conditions and the actions of individuals and coalitions.” 41 Subcultures in health organizations have also been shown to create and build resistance to power, influence, and change. 42 Controlling your emotions is “power’s crucial foundation” 43 across all professional situations. Health leaders who control their emotional “self,” are cognizant of their sources and level of power, and are sensitive to subcultures in the organization and to sources and level of power in others, will best navigate amid coalitions and groups in moving the health organization forward in a positive direction.

Empowerment and Power

Empowerment is, in essence, the delegation of power, influence, and authority to another person—usually to a subordinate from a superior. Empowerment does not mean delegation of responsibility, although some responsibility rests in the subordinate that has delegated authority.

· All the [leadership] models suggest that these leaders use empowerment rather than control strategies in order to achieve transformational influence over their followers. They in essence advocate the transformational influence of leaders where the main goal is to change followers’ core attitudes, beliefs, and values rather than to induce only compliance behavior in them. Again they all agree that these forms of leadership lead to attitudinal changes among followers characterized by identification with the leader and internalization of values embedded in the leader’s vision and ideology. 44

Empowerment involves the matching of an employee’s knowledge, skills, and abilities to appropriate tasks, levels of authority, and levels of power and influence. Once the assignment is made, the health leader forgoes command over that task or authority until it is completed; again, this statement does not mean that responsibility is delegated. Oversight, mentoring, and guidance are advised in accordance to the capabilities of the subordinate employee. Empowering subordinates and team members conveys trust and individualized consideration, which fosters ownership. This practice encourages employees to achieve their maximum potential throughout their careers, allowing an organization to develop leadership from within.

Empowerment is about providing motivation, developing subordinates, and appropriately aligning the decision-making processes in the health organization. Health leaders and leadership teams that understand what motivates subordinates and team members will know how to keep them satisfied, productive, and fulfilled in the workplace.

In 1959, psychologist Fredric Herzberg described a two-factor theory of motivation that aligns well with empowerment. Herzberg’s theory distinguished between intrinsic (from the work itself) and extrinsic (outside of the actual work) motivators. Essentially, intrinsic factors are needed to motivate an employee to higher performance, and extrinsic motivators are needed to ensure an employee is not dissatisfied. Intrinsic and extrinsic motivational constructs are called “satisfiers” and “dis-satisfiers,” respectively. In summary, the two-factor theory of motivation consists of intrinsic motivators—challenging work, recognition, responsibility, effectiveness, personal growth, and achievement—and extrinsic motivators—salary, work conditions, company policies, job security, status, and administration. Health leaders who appropriately (with regard to individualized consideration of the subordinates they lead) enhance and increase intrinsic factors and maintain or enhance extrinsic factors, according to the industry market norms, will most likely have motivated subordinates. Empowerment is a large key to this positive situation.

ENDURING ORGANIZATIONAL VALUES AND BELIEFS

Every health organization has a foundation of values and beliefs that its holds dear and that form the essence of the organizational culture. The values and beliefs of health organizations focus on the relationship with patient care amid the pressures of the external environment, business expectations, and survival/longevity of the organization. These values and beliefs cause health leaders to decide on a strategy that may be less efficient but is more efficacious for the patients and communities they serve. Both values and beliefs are closely linked to societal norms and mores, although increased globalization can loosen these attachments and open up new possibilities to the society. Values tend to remain very stable over time and help organizations make sense of where they are and how they serve their purpose in the community. Beliefs are stable as well, and should focus on excellent patient care, effective and efficient operations, and teamwork in the health organization. How health leaders influence values and beliefs that foster attitudes and behaviors is the focus of this section.

Values, Beliefs, Attitudes, and Behaviors

Transformational health leaders have an advantage in solidifying or changing values, beliefs, attitudes, and behaviors in the organization. “Charismatic leaders have insight into the needs, hopes, and values of followers and are able to motivate commitment to proposals and strategies for change.” 45 Values and beliefs are expressed in strategic plans, organizational charters, and statements. Attitudes are the perceptions and opinions of members of the health organization that describe how they perceive the world around them. Behaviors are observed in actions. Health leaders should frequently express expectations about values, beliefs, attitudes, and behaviors to subordinates and other organizational stakeholders. Knowing your team members and subordinates also assists in knowing which values, beliefs, attitudes, and behaviors are consistent or inconsistent with the organization’s expressed values, mission, and vision.

Health leadership styles can influence followers’ values, beliefs, attitudes, and behaviors. Transactional leadership focuses on behaviors: Changing, motivating, and directing the behaviors and actions of subordinates based on social exchange is the essence of transaction-based leadership. It is possible that transactional leadership can alter attitudes; once the social exchange catalyst is removed or changed, however, it is highly likely that attitudes will return, at least somewhat, to their original state. Transformational leadership focuses on attitudes that lead to desired behaviors by changing the individual subordinate’s or subordinate group’s understanding, feeling, and connectedness with the health organization’s mission, vision, or task at hand. Indirectly, transformational leadership can influence subordinates’ beliefs over time and again, over time, shape the health organization’s culture. Transformational leadership can also influence subordinate values, although such changes tend to occur only over a longer time horizon and are linked to the intensity and capabilities of the leader and the level of leader loyalty from subordinates.

Change means adjusting, revising, and redirecting effort and actions (behaviors), including how subordinates envision and feel about their place in the organization (attitudes), to a new course. This type of change is more typical of organizational change. Less frequently, change may modify the beliefs and values of subordinates in the health organization.

For the health leader, it is important to reflect on the interconnected nature of values, beliefs, attitudes, and behaviors of individuals in the organization with organizational culture and the collective values, beliefs, attitudes, and behaviors with organizational culture; these constructs may either reinforce or conflict with one another in a dynamic way. Temporal (one point in time) assessment of these constructs can be accomplished much like organizational climate can be assessed. Over time (many temporal points in time in a sequence), values, beliefs, attitudes, and behaviors influence the organizational culture. Health leaders with consistent focus and direction can change, modify, and redirect individual and collective values, beliefs, attitudes, and behaviors as part of the macro-organizational culture development process. Edgar Schein’s primary embedding and secondary reinforcement mechanisms are an excellent approach to accomplish this aspect of organizational culture development for health leaders. Transformational leadership principles in practice are likewise both important and productive.

Leadership and Change

Health leaders who understand and are competent in applying transformational leadership principles (charisma is a component of transformational leadership) are best poised to create positive change in the health organization. Those who master transformational leadership principles and applications are best suited for initiating positive change.

To accomplish this goal, the transformational leader must be a competent communicator. Transformational leadership in action is best seen when several elements synergize to change the culture and improve the organization. “Transformational leadership refers to the process of building commitment to the organization’s [mission, vision, strategies, goals and] objectives and empowering followers to accomplish these objectives.” 46

An early conception of transformational leadership was developed by Burns in 1978 from descriptive research on political leaders; “leaders and followers raise one another to higher levels of morality and motivation.” 47 Expectation and goal setting, empowerment, and increased use of appropriate media channels for communication can combine to focus a team, thereby enabling its members to accomplish significant tasks in system improvement. 48

Transformational leadership is different from simple charismatic leadership in several respects (an idea attributed to Bernard Bass). Although charisma is a necessary component for transformational leadership, by itself it is not sufficient to account for transformation:

· Transformational leaders influence followers by arousing strong emotions and identification with the leader, but they may also transform followers by serving as a coach, teacher, and mentor. Transformational leaders seek to empower and elevate followers, whereas in charismatic leadership the opposite sometimes occurs. That is, many charismatic leaders seek to keep followers weak and dependent and to instill personal loyalty rather than commitment to ideals. 49

Schein’s primary embedding mechanisms and secondary reinforcement mechanisms to develop and maintain culture are salient within the context of change; transformational health leaders who use these mechanisms with a conscious and predetermined vision for a health organizational culture are best equipped to effect positive change. When this synthesized strategy is used consistently and morally, change can be accomplished more quickly, deliver greater benefits, and enhance the health leader’s status within the organization.

Strategies in Creating A Culture of Change

Health leaders can use transformational leadership strategies, 50 primary embedding and secondary reinforcement mechanisms, 51 and the dynamic culture leadership (DCL) model 52 processes to develop and synthesize a model to serve as a strategy for creating a culture of change in the health organization. A review of transformational leadership is presented here, followed by a discussion of the various culture change mechanisms and the DCL process.

Bernard Bass, building on work by Burns, developed the theory of transformational leadership. 53 This model measures the leader’s influence on followers. A health transformation leader would create trust, admiration, loyalty, and respect in the followers through the leader’s actions, behaviors, and persona. 54 Followers are motivated by the leader to do more than expected, as the leader makes followers more aware of the importance of task outcomes, induces them to transcend their own self-interest for the sake of the team, and activates their higher-order needs. 55 To do so, the leader uses the following transformational behaviors and actions:

· • Charisma: Leader influences followers by arousing strong emotions and identification with the leader.

· • Intellectual stimulation: Leaders increase follower awareness of problems and influence followers’ view of problems from a new perspective.

· • Individualized consideration: Leader provides support, encouragement, and developmental experiences for followers

· • Inspirational motivation: The extent to which the leader communicates an appealing vision using symbols to focus subordinate effort and model (role modeling; Bandura’s social learning theory) appropriate behavior. 56

Primary embedding mechanisms 57 are a set of powerful tools, behaviors, and mechanisms that a health leader can use to develop, refine, maintain, or change organizational culture:

· • What leaders pay attention to, measure, and control

· • Leader reactions to critical incidents and organizational crises

· • Deliberate role modeling, teaching, and coaching by leaders

· • Criteria for allocation of rewards and status

· • Criteria for recruitment, selection, promotion, retirement, and excommunication

Schein strongly states that leaders communicate both explicitly and implicitly the assumptions they really hold. If they are conflicted, their conflicts and inconsistencies are also communicated and become part of the culture. Consistency is the key: Health leaders must predetermine where and how to guide the organization and stay on task.

Another set of mechanisms support the primary set and are called secondary reinforcement mechanisms. 58 The secondary articulation and reinforcement mechanisms reinforce the primary embedding mechanisms. The following are of greatest importance to the health leader:

· • The organization’s design and structure

· • Organizational systems and procedures

· • Design of physical space, facades, and buildings

· • Stories, legends, myths, and parables about important events and people

· • Formal statements of organizational philosophy, creeds, and charters

Schein calls these “secondary” because they work only if they are consistent with the primary mechanisms. The secondary mechanisms are less powerful than primary mechanisms, more ambiguous, and more difficult to control, yet can be powerful reinforcements of the primary messages if the leader is able to control them.

The important point is that all of these mechanisms communicate culture content to newcomers and current staff. Together, they represent a rich set of tools, behaviors, decisions, and mechanisms a health leader can use to develop and maintain organizational culture. Health leaders must be consistent and conscious of how and when they utilize these mechanisms.

The DCL model 59 process suggests prescriptive elements that include assessing and aligning a robust leadership and management team to ensure that all of these individuals can utilize a broad range of knowledge, skills, abilities, and perspectives while being consistent in developing and maintaining an appropriate organizational culture. The leader’s use of the sequential and building elements of the model’s process constructs facilitates the development of the predetermined organizational culture desired. Process constructs include the following elements:

· • Communication improvement is the leadership’s and management team’s predetermined modeling, training, rewarding, and assimilation of the communication environment into the organization in the manner that best contributes to an effective organizational culture. In health organizations, a confirming and supportive communication environment that is cognizant of media richness of communication channels and competent in conflict management should be the most effective, efficient, and efficacious.

· • Strategic planning (which includes operational planning) is the structured inclusive process of planning to determine mission, vision, strategies, goals, objectives, and action steps that are consistent with organizational values and that meet the external environment’s expectations of the organization. Subordinate, internal, and external stakeholders should be included, as appropriate to their level and responsibilities, in the planning process. Continuous, “living” planning is a cultural imperative in dynamic environments.

· • Decision-making alignment involves aligning decisions with the strategic and operational plan while understanding reality-based decision making (pushing down decisions appropriately and using policies and standard operating procedures for routine and consistent decisions).

· • Employee enhancement is the assessment of employee knowledge, skills, abilities, experience, and trustworthiness and the practice of increasing or reducing responsibilities (such as making decisions) appropriately to the unit, group, and individual, in line with the organizational culture in development and the strategic and operational plans.

· • Knowledge management and organizational learning involves capturing what the organization knows and what it has learned, so that improvements to effectiveness, efficiency, and efficacy can be achieved.

· • Evaluating, reflecting, and retooling is the leadership and management team’s honest assessment of the DCL model cycle and understanding of how to perform the cycle better in the next repetition.

Using this process consistently will not only improve the organization’s ability to use these processes and lead to the development of an organizational culture that reflects the leadership’s vision, but also enable the organization to maneuver effectively in dynamic situations. Process repetition and consistency are foundational to success in this model.

From these three integrated aspects of leadership, a strategy for creating positive change in the organization can be realized. By scanning, monitoring, forecasting (for the external environment), and assessing the health organization (internal) and its setting, context, and location in the environment (external), the health leader and/or leadership team needs to develop a predetermined direction, a preliminary vision, and a picture of the best organizational culture that can achieve that direction and vision while attending to the health organization’s current mission. This process and the decisions it produces should be documented and planned over time. Health leader actions must then be planned to achieve the better future envisioned for the health organization. Health leaders must plan, practice, and hold themselves and other leaders accountable for consistency to realize the desired outcomes of the plan.

To turn the desired future into reality, change will most likely be required in the health organization and among its stakeholders. Active situational leadership—that is, selecting the appropriate mix of transformational and transactional leadership, frequent quality communication to subordinates and stakeholders, appropriately inclusive planning, decision-making alignment, empowerment, and organizational learning and knowledge management—should merge with an appealing vision of the future of the health organization so that the organization can achieve success. Can you integrate the concepts, actions, behaviors, and aspects from this section to develop an initial model of leading change? Are some elements particularly important in this respect? Table 13-4 summarizes one model for leader-facilitated positive health organization change.

Change, Conflict, and Transition Planning

Table 13-4 Leadership-Facilitated Organizational Change: Application of Theories and Models

Predetermined Organizational Culture to Develop	Individual Leader Actions and Behaviors	Leadership Team Actions and Behaviors	Organizational Actions and Behaviors by Leaders and Subordinates	Organizational Outcomes
Vision predetermined and culture changes predetermined by leadership team	Transformational leadership characteristics: · • Charisma · • Intellectual stimulation · • Individualized consideration · • Inspirational motivation · • Performance orientation · • Decisiveness · • Team integration and collaboration · • Being diplomatic · • Being benevolent · • Being administratively competent · • Transactional leadership (reward for performance) where appropriate	Primary embedding mechanisms: · • What leaders pay attention to, measure, and control · • Leader reactions to critical incidents and organizational crises · • Deliberate role modeling, teaching, and coaching by leaders · • Criteria for allocation of rewards and status · • Criteria for recruitment, selection, promotion, retirement, and excommunication Secondary reinforcement and articulation mechanisms: · • Design and creation of the organization’s design and structure · • Design and creation of the organizational systems and procedures · • Design of physical space, facades, and buildings · • Creating and telling of stories, legends, myths, and parables about important events and people · • Developing and publishing formal statements of organizational philosophy, creeds, and charters	Dynamic culture leadership process: · • Leadership alignment · • Communication improvement · • Strategic and operational planning · • Decision-making alignment · • Employee enhancement · • Knowledge management and organizational learning · • Evaluation, reflecting and retooling, and repeating the process	Predetermined vision and organizational culture incrementally transformed and realized

At the macro level of analysis, transformational leadership involves shaping, expressing, and mediating conflict among groups of people in addition to motivating individuals. 60 Anytime there is change, there is conflict. Managing this conflict is necessary for two reasons: (1) Conflict is inevitable and (2) it can create positive results. By being consistent in their delivery of the message of change and the organizational vision, health leaders can continuously reinforce the change while calming nervous tension or anxiety in the organization. Each step of the transition through change should be planned, with subordinates and team members being included, as appropriate, in developing aspects of the change and transition plan. Including internal and external stakeholders in organizational changes that will affect them is a great method for moving through the transitions and changes with less turbulence. Nevertheless, smooth change is rare—so expect some turbulence and resistance. Frequent supportive, descriptive, yet firm communication is a great tool for health leaders; media-rich channels of communication (e.g., face-to-face with individuals and groups) are recommended for communicating change.

Another change in health organizations that is inevitable involves leadership position changes. If transitional planning and succession planning has occurred, this transition tends to go more smoothly. Succession planning—the deliberate development and placement of internal leadership and management over time—should be a part of every health organization’s culture.

Maintaining A Culture of Adaptive Change

Once a culture of change is established in a health organization, it is important to nourish and maintain that culture:

· The organizational culture is a learned pattern of behavior, shared from one generation to the next. It includes the values and an assumption shared by members about what is right, what is good and what is important. Since demands on most organizations are unlikely to be steady and stable, only cultures that can adapt and change will be associated with superior performance over long periods of time. 61

Health leaders can and should develop a predetermined organizational culture focused on transformation, con-tinuous improvement, and the ability to thrive in a dynamic environment. A transformational culture for health organizations facilitates adaption and change over time.

Transactional cultures exhibit the following attributes:

· • Concentrate on explicit and implicit contractual relationships.

· • Job assignments include statements about rules, benefits, and disciplinary codes.

· • Jargon/values/assumptions usually set or imply a price or reward for doing anything.

· • Rewards are contingent on performance.

· • Management by exception is commonly practiced.

· • Employees work individually.

· • Employees do not identify with the organization, its vision, or its mission.

· • Leaders are negotiators and resource allocators.

· • Innovation and risk taking are discouraged.

Transformational cultures exhibit the following attributes:

· • Express a sincere sense of purpose and feeling of family.

· • Commitments are long-term.

· • Mutual interests are shared along with a sense of shared fates and interdependence.

· • Leaders serve as role models, mentors, and coaches.

· • Leaders work to socialize new members into the organization.

· • Shared norms are adaptive.

· • Organizational purposes, visions, and missions are emphasized; not threats.

· • Norms change with changes in the organization’s environment. 62

In thinking about the concepts covered in this chapter, can you incorporate leadership competencies regarding diversity, power, and changing and transforming organizations into an initial application model? After engaging in reflection, can you construct a leadership model that you can use in leading people and managing resources in a health organization? To assist in this effort of developing a leadership model to positively change a health organization, reflect on the following suggestions:

· • Model the behavior you expect yourself.

· • Communicate expectations and train other leaders and managers and staff.

· • Revise structures and reporting relationships.

· • Conduct team-based planning and policy development.

· • Use primary embedding and secondary reinforcement mechanisms.

· • Utilize the DCL model sequential processes.

· • Be consistent and communicate often to the organization.

· • Continue to scan, monitor, and assess the internal health organization environment while you scan, monitor, forecast, and assess the external environment to guide the health organization appropriately.

Which elements are clearest to you? Can you list the leadership elements that are important to realize change in a health organization?

KNOWLEDGE MANAGEMENT AND A LEARNING ORGANIZATION *

Learning organizations are living, open, robust systems. 63 Knowledge management in and of itself is an innovative strategy of change, adaption, and evolution. This process involves accumulating and creating knowledge and facilitating the sharing of knowledge throughout the organization. “The ability for a healthcare organization to develop systems to manage knowledge directly impacts the level of institutional knowledge and organizational learning.” 64 Knowledge management empowers the organization to fulfill its mission and vision. The ability to reach the vision of the organization, in turn, provides a greater ability to compete in a dynamic environment. If knowledge is created, captured, and managed appropriately in a consistent manner over time, a culture of learning is created. To manage knowledge effectively within the organization, it is first important to create a working definition of knowledge and to define what knowledge is not.

Clear distinctions can be made among data, information, and knowledge. Data comprise a set of objective facts about certain objects, events, people, or observations. Data become information when these facts are used to inform or convey a relevant message to the receiver. Information is capable of yielding knowledge, but is not synonymous with knowledge. Information becomes knowledge when decision makers determine how to take advantage of the information to further health organizational goals or as part of the decision-making process. Knowledge is “actionable” information. It conveys understanding as it applies to a particular problem.

In creating a practical working definition of knowledge, the organization should understand and emphasize these differences. A working definition of knowledge offered by Davenport and Prusak states that knowledge is a dynamic mix of contextually based experiences, values, contextual information, and insights that provide a framework for evaluating and incorporating new experiences and information. 65 In creating a system of knowledge management for the health organization, there are three processes of importance: knowledge accumulation, knowledge creation, and knowledge sharing.

Accumulating Knowledge

To learn, a health organization must have data, information, and knowledge to draw from. Essential data and information that are critical to the mission and core systems and processes of the health organization must be identified. Because knowledge management is an organizational phenomenon, the health organization should first identify and clarify the organization’s mission, vision, and core values. Identifying these organizational concepts provides an understanding of the current state of the organization, which will influence how priorities and boundaries for capturing and creating knowledge are set. The next step in accumulating knowledge is to discover existing knowledge and put it into a health organizational context. This step involves gathering and organizing knowledge to make it useful to others. If the intent of knowledge is to inform and influence decision making, then its focus must be on the future. Allowing for discussion and frequent debate is a vehicle to accumulate existing knowledge.

Creating Knowledge

Knowledge generation and usage is a never-ending work in progress. The health organization must continually acquire and create new knowledge. Experiments are crucial to the creation of new knowledge because they provide data and information; employees learn by taking chances and, sometimes, by making mistakes. Unintended mistakes should be viewed as opportunities to learn and improve patient care and business processes; they should be acceptable in the organization. At the same time, patient care should always strive to be error free (although mistakes do occur at times). People learn from mistakes and then push the answers out to others.

According to Nonaka, two types of knowledge—tacit and explicit—are important to the knowledge creation process. 66 Explicit knowledge is knowledge that is transferrable by the use of language. It is something that we can say or tell someone. Tacit knowledge is much more difficult to convey, because it is the result of subjective and experiential learning and, therefore, may not always be documented. Tacit knowledge is the means by which explicit knowledge is captured, assimilated, created, and disseminated.

* Much of this section was completed in collaboration with Kelley Chester, doctoral candidate, Georgia Southern University, 2007–2009.

Sharing Knowledge

Capturing and storing knowledge are the cornerstones of knowledge management. Although knowledge is stored in many ways in a health organization, the most popular approach combines a database form with the use of a technology-related platform. Once knowledge is stored properly, it can be disseminated throughout the organization and applied to specific situations and the decision-making process.

Knowledge databases should be broad in scope to provide for greater ease of usability. Leaders must be obsessive about noting and correcting errors in their stock of knowledge. What do they know or think they know? How does what they know or do not know affect specific decisions? Which errors reside in their knowledge and what are the consequences of those errors? Once errors are identified, a plan to rectify those errors must be developed.

For knowledge to be usable, the target audience of the knowledge database must be clear. Organizations today can deliver knowledge via a variety of technology platforms. Technology is a means to access information and knowledge but is no substitute for interaction. Put simply, communication and the learning process are inherently types of personal dialogue. 67

Summary of Knowledge Management and Organizational Learning

Based on the concepts of knowledge accumulation, knowledge creation, and knowledge sharing, a five-step approach to knowledge management is proposed † :

· 1. Identify what is critical to the organization.

· 2. Discover existing knowledge and put it into an organizational context.

· 3. Acquire or create new knowledge.

· 4. Establish knowledge databases.

· 5. Distribute knowledge to the appropriate audience.

Building a culture of learning within the health organization to foster the development and sharing of knowledge is an essential element in establishing and maintaining an effective, efficient, and efficacious knowledge management system. As the acceptance of evidence-based medicine and administrative practice grows, establishing and maintaining a knowledge management system within a culture of organizational learning will be critical to ensuring the success of both the health organization and its leadership team.

WHAT KIND OF LEADER DO YOU WANT TO BE?

This is a serious question: What kind of leader are you? For many people who are just starting their careers, this question may be rephrased: What kind of leader do you want to become? Armed with what was learned from the behavior phase and the situational phase of leadership thought, can you learn, practice, and develop leadership knowledge, skills, abilities, and competencies starting today, and continue that development throughout your lifetime? One definition of leadership is: Leadership is the dynamic and active creation and maintenance of an organizational culture and strategic systems that focus the collective energy of both leading people and managing resources toward meeting the needs of the external environment, while utilizing the most efficient, effective, and efficacious methods possible by moral means. To become the kind of leader you want to be, you will need to be active in your approach to the art and science of leadership. The process of “practicing the art of leadership” is discussed in more detail in this chapter. However, one characteristic you will have to embrace is the process of internalizing leadership as a continuous process if you want to be a leader who always gets better, always stays credible, and always wants to be the best.

The desire to be a great leader comes from within. For example, Fairholm summarizes several principles of “inner leadership.” Inner leadership is based on many of the principles of empowerment. Empowerment engages the inner leader in the kinds of actions necessary to internalize leadership as a constant process. By doing this, the leader becomes capable of assuming the following responsibilities:

· • Goal setting

· • Delegating to followers

· • Encouraging participation

· • Encouraging self-reliance

· • Challenging followers

· • Focusing on workers

· • Specifying followers’ roles 68

† This model is from the unpublished work of Kelley Chester, Dr. PH, Georgia Southern University, 2007–2009.

When looking at this series of inner leadership principles, how many theories and models come to mind that can be applied to them? How many could be put into practice? Which theories and models would work well together, and which ones might contradict one another? For purposes of synergy of theories and models, reflect on Table 13-5 , which shows a few of the linkages. Many more connections are also possible: Could more linkages to theories and models be listed?

A leader’s predisposition toward a certain mental hardwiring might lend itself to a natural tendency to emulate some of the many leadership styles discussed in this text. Looking at the Table 13-5 , which theories and leadership methods best fit with your experiences and natural talents? Although this process may seem somewhat mechanical and prescriptive, without an understanding of his or her own style and natural tendencies, a leader cannot emphasize strengths and work on weaknesses. With practice and over time, a leader should be able to seamlessly incorporate personal style and abilities into a blended practice of leadership.

You should be able to list other connections and links to theories and models. Again, it is important to create a vision for yourself of what kind of leader you want to be. Because it is important to communicate a clear and appealing vision to your subordinates, you need to develop a personal leadership vision. You will need to sell that vision of your leadership to potential employers in job interviews and by your performance in the job:

· Today, senior leaders of major organizations consistently rank leadership development as their number one concern. Leaders and the art they perfect is not bestowed on those, it is developed over time and with great effort; good leaders are not born but are produced over time and with great effort. 69

It’s Okay to Say, “I Don’t Know”

Table 13-5 Inner Leadership Principles Linked to Theories and Models

Inner Leadership Principle	Link to Other Leadership or Related Theory or Model (1)	Link to Other Leadership or Related Theory or Model (2)	Link to Other Leadership or Related Theory or Model (3)
Goal setting	Goal-setting theory (Locke and Latham)	Expectancy theory (Vroom) and path–goal model (House)	Dynamic culture leadership; planning, and specifically, objectives (Ledlow)
Delegating to followers	Garbage can model of decision making (March and Weisinger-Baylon)	Motivation by empowerment (several models: Bolman and Deal’s reframing organizations and Ledlow’s dynamic culture leadership)	Kaizen, total quality management, continuous quality management, and process improvement
Encouraging participation	Situational leadership model (Hersey and Blanchard)	Kelman’s model (instrumental) and the model of influence considering commitment, compliance, and resistance	Reframing leadership and management in organizations (Bolman and Deal)
Encouraging self-reliance	Transformational leadership model (Burns and Bass) and locus of control (Rotter)	Dynamic culture leadership (specifically, knowledge management and organizational learning)	Organizational culture primary and secondary mechanisms (Schein)
Challenging followers	Competency-based leadership (Bennis)	Transformational leadership (Burns and Bass)	Communication environment, conflict management, and media richness theory (Daft and Lengel)
Focusing on workers	Transformational leadership (Burns and Bass)	Cultural competence	Coordinated management of meaning (Pearce and Cronen)
Specifying followers’ roles	Shutz’s theory of affiliation	Communication clarity	Tuckman’s model of group dynamics

Leaders of health organizations are probably at a greater disadvantage than leaders of any other large organizations. Their unique challenges stem from the complexity of health organizations and the lack of understanding of what goes on in the health facility. To outsiders and less informed individuals, a physician is a physician, a nurse is a nurse, and any one administrator is equally as competent as the next. The complexities, competencies, skills, and specializations among administrators, physicians, nurses, and other allied health personnel and employees are lost on the layperson.

Leaders of health organizations not only have to be aware of the same accounting, marketing, logistical, human resources, and compliance regulations as their manufacturing and service industry peers, but also the challenges of managing Food and Drug Administration (FDA)–designated controlled substances, licensing and certification issues, innovation and technology, and the rapidly changing multispecialty best practices in areas of medicine or patient care. Moreover, this feat must be achieved in an environment of near-perfection when it comes to patient care.

In addition, the leader in a health organization may have absolutely no experience or professional education related to many of the daily activities that go on in the health facility. For example, in popular fast-food franchises, the list of menu items is finite and can be generalized. With few colloquial exceptions, the same items on the menu of one fast-food restaurant will be identical to the menu items at the same franchise restaurant across town. Managers of these local restaurants are required to be keenly aware of the ordering, processing, and delivery of all food items on the menu, as well as the intimate details of how everyone in that franchise does his or her job. This is never the case with the health leader, who will rely on the competence, honesty, and reporting of those who work for him or her in the organizational hierarchy over and above firsthand knowledge. 70 – 72

For example, in many manufacturing organizations, the leader must know the skills and duties of those persons who work underneath him or her in the organizational hierarchy. This is a difficult task for the leader of a health organization. A leader in a multispecialty, primary, secondary, or tertiary health organization will never be as competent at doing the individual tasks of any two individuals across specialties within the organization. In almost all cases with leaders who rise to positions of greater responsibility in health organizations, there will be dozens, even hundreds, of people in the organization who know more about their own jobs than the leader does. More so in health organizations than any other manufacturing- or service-driven organization, the leader must be comfortable with the prospect of not knowing the inner complexities of the organizing that he or she is running. At the same time, the health leader must be able to develop and employ systems and processes that create an efficient, effective, and efficacious healthcare environment. The leader must be comfortable with a personal and professional posture of admitting to him- or herself that he or she does not know everything that goes on in the organization. Leaders who try to know everything, manage everything, and control everything are destined for personal frustration, professional disappointment, and, ultimately, leader failure.

MAINTAINING RELEVANCY AND CREDIBILITY

In becoming comfortable stating, “I don’t know,” within a health organization, the next logical question a leader has to ask him- or herself is this: How do I maintain relevancy and credibility with my peers and colleagues? These critical self-assessment issues must be constantly addressed and evaluated by the leader, at least on an annual basis. Additionally, both relevancy and credibility are mutually exclusive issues the leader must pursue from individual strategies. 73 ,74

Credibility

Credibility is a complex construct that can be measured through experience, outcomes, and employee trust. A leader with little previous experience in the day-to-day operations of the health organization may not be perceived as credible. However, the defining of experience becomes even more complex when discussing the specific nature of the experience of the individual. For example, nurses may not be perceived as having credible experience in leading health organizations if their 20-year familiarity with leading people in health organizations has been restricted to leading only other nurses. Similarly, professional administrative leaders without clinical degrees may look at a physician leader with skepticism if the physician has risen to a position of authority based on his or her medical and clinical prowess rather than by taking on administrative and management developmental activities. The circle may continue if physicians view the administrator with only a master’s degree as an individual without experience to know enough about hands-on patient care to manage physicians.

As this discussion suggests, credibility is highly wedded to trust. Although professional rivalries and professional competition are part and parcel of leading complex health organizations, the leader should never lose focus on maintaining and instilling positive relationships with peers and staff. 75 Without gaining the trust of those in the organization, the leader will not be effective in his or her job. Consequently, trust is also highly wedded to outcomes all along the continuum and process of daily operations. 76 ,77 Likewise, building a trusting relationship with peers and colleagues is a key element in achieving credibility and positive outcomes.

Outcomes

Outcomes in regard to credibility are not restricted to financial, logistical, and morbidity/mortality metrics. Perhaps most importantly, they are related to outcomes with human resources. Organizational satisfaction, leader and employee development opportunities, and formation and maintenance of positive relationships with stakeholders are some of the most critical factors for a leader to consider. How a leader treats employees in regard to acknowledging input, respecting candor, protecting employee autonomy, and maintaining a positive leader climate are some of the most important factors that any leader can focus on in his or her organization. 78 The loss of trust of even a single person, considering that person’s influence in the organization, can begin a professional downturn for the leader. In fact, President Lyndon Johnson once said he had lost the trust of America because he lost the trust of one man: Walter Cronkite, the famous anchorman of CBS News. Cronkite said in 1968 during the evening newscast that he thought the Vietnam War could not be won. President Johnson was later quoted as saying, “If I’ve lost Cronkite, I’ve lost Middle America.”

Relevancy

Relevancy is an easier behavior trait for a leader to maintain. Relevancy is defined as a leader’s ability to maintain a position of continued and sustained contribution to the organization’s success. All other factors are antecedent to this ability. 79 Relevancy may be one of the most important hierarchal dispositions of the leader in any health organization. If the organization is growing its market share, increasing its local or national prominence, and improving in terms of other quality factors measured on a regular basis, these changes can be indicators of the relevance of the leader of the organization. However, an organization that achieves high outcomes while discounting employee satisfaction is a weak model of leader effectiveness. 80 ,81 As a result, creditability and relevancy are partnered elements of success. The path to achieving high outcomes in both of these areas is multifaceted and revolves around four key areas: joining professional organizations, service, continuing education, and personal professional development.

Professional Organizations

Membership in professional organizations is critical to establish a leader’s credibility and relevancy. For the sake of fairness, we will not identify any one organization in this chapter as the panacea for professional success. Rather, the selection of a professional organization in which to seek membership is a personal issue, and this decision should be tied to a leader’s current work environment. For example, a leader who was previously vested in a professional organization specializing in hospice care may no longer find the organization “relevant” if he or she decides to seek a leadership position within a multispecialty group practice. The goals of the two health organizations are not parallel. Outside stakeholders will clearly see that the leader has failed to maintain relevancy by not vesting him- or herself in a more creditable professional entity.

The greatest benefit offered by any professional organization is the opportunity to network and collaborate with peers from similar organizations. Despite the competitive nature of the business of health care, professional organizations seek to share best practices between and within similar organizations along the continuum of care. Professional organizations are also multidirectional warehouses where topical information from the environment is captured and then disseminated to leaders and organizational entities. For instance, professional organizations were seen as the leading entities for the dissemination of Health Insurance Portability and Accountability Act (HIPAA) information when these regulations and compliance standards were introduced in the latter part of the 1990s and early 2000s, over and above the information provided by governmental agencies. 82

Professional organizations also provide opportunities for mentoring and networking. Young leaders who become fully vested in professional organizations that are willing to share information and best practices will find the favor returned in later years when new policies, practices, or procedures need to be developed quickly with minimal resources. Many health leaders will freely share and contribute knowledge to peers within professional organizations out of professional courtesy and respect for the common organization they share. Failing to join, contribute to, and maintain a presence in a professional organization of choice will surely decrease opportunities for both organizational and personal growth.

Service

Professional service can be defined in a variety of ways. It is suggested that health professionals consider service from a volunteer perspective that involves contributing to their own organizational entity, their community, and their personal professional organization of choice.

Leading by example and volunteering are critical parts of any leader’s success. For instance, through his volunteer work as a reading tutor, which continued nearly up until the time of his death, Senator Edward Kennedy spent many hours around Washington, D.C., working with elementary school–aged children. 83 His leading by example resulted in the development of a district-wide volunteer initiative that resulted in hundreds of school-aged children in the nation’s capital having an adult mentor to read to them. Similarly, the health leader should be aware that if he or she wants the organization’s employees to demonstrate organizational citizenship behavior (OCB)—that is, doing extra work for the organization that benefits the organization, albeit without compensation—the leader must model this behavior him- or herself and lead by example.

Many organizations thrive on the OCB initiatives of their employees. Simple activities such as sponsoring the department’s annual Christmas party or starting a before-work exercise program demonstrate an individual’s potential to the organization beyond those things documented in annual performance reports. Likewise, service to the community by volunteering to sit on after-hours community boards or participating in charitable outreach programs not only establishes an individual as a leader outside the organization, but also provides positive marketing for the organization itself. Service to professional organizations can also be rewarding in many ways that benefit both the individual and the organizational entity if the professional is able to rise, or become elected, to a national position of prominence. As a result, the service to the organization, service to the community, and service to the profession will collectively result in increased opportunities for both personal growth and organizational success.

Continuing Education

A few years ago, the authors of this book participated in a seminar where the speaker was discussing strategies to pass a Joint Commission accreditation site visit. The speaker was very well known to the group and had achieved a level of national prominence and respect by his peers. However, this particular speaker had not worked in the practical world of health care for several years. After a very brief period of time, it became clear to a few members of the audience that the speaker was addressing old standards and procedures that were no longer applicable to more recent initiatives in accreditation site visits. Many in the audience were not aware of the subtle outdated information that was presented; however, a few people did get up and walk out of the room. It was clear that the speaker had not maintained creditability and relevancy in regard to his personal continuing education since he had left his CEO position in a major facility.

Continuing education (CE) will be different for practicing patient providers and administrators. The elements of CE are generally described as twofold: (1) continuing health education (CHE), or nonclinical education, and (2) continuing medical education (CME), or clinical education. Other variations exist; however, these two are the prevalent forms of CE in the health field.

For clinical professionals, the need for CME is immediately evident. New pharmaceuticals, procedures, and materials are constantly being introduced and changing in ways that may affect patient care. Medical professionals who do not keep abreast of these changes place both themselves and the organization in professional peril.

For nonclinical professionals, the need for CHE may be less mandated by state and national licensing agencies. Nevertheless, failure to seek out CHE is progressive, noticeable, and professionally and organizationally damaging for a professional. A leader who is unaware of how national policy affects billing, organizational strategy, and compliance issues can place the organization at risk or, as in the seminar speaker example, expose the organization to a loss of reputation.

CE opportunities are generally widely available to a leader in the modern era. Webcasts, podcasts, computer-based training, online seminars, and teleconferences have made CE readily available to those serving in both rural and urban communities. A leader who seeks to maintain both personal and organizational relevancy and legitimacy will seek out those CE opportunities best suited to the organizational needs on a continual basis.

Mentoring and Professional Development

No individual is ever too old or experienced for mentoring and additional professional development. Self-proclaiming that a level of personal success has been reached such that there is no one individual left to role-model best practices or act as a benchmark for achievement can be both a narcissistic act and a fatally flawed methodology for achieving personal and organizational success. It is incumbent upon the leader to become a mentor to the next generation of health leaders. 84 Often, a 30-year-old employee with 5 to 7 years of experience under his or her belt may be a more effective role model to a new employee than a more seasoned and (possibly) intimidating senior leader who is much older.

Seek out a mentor, ask questions, and follow examples of those leaders you find successful. You have a world of possible informal mentors to observe, including both those who perform well and those who do not; seek out those who perform at a high level and are moral leaders. If a mentor cannot be found in your current organization, seek a mentor (through a professional organization or association) from another organization; this is not a rare situation.

Professional development is a necessary component of staying relevant within the industry. Leaders all along the health continuum should seek opportunities to attend seminars and presentations on a continual basis. Additionally, staying current with the public and professional literature is important. Associations, topical publications, and toptier news organizations provide a myriad of material to enhance a leader’s knowledge base. A leader should allow for at least 30 to 60 minutes of professional reading each day to maintain a sense of relevancy with events in his or her environment. Quality books on leadership, management, systems, leading people, managing resources, and the like should be read as well.

Which book did you read last month and what are you reading this month? Try to finish a quality leadership and/or management book at least once a month.

DEVELOPMENT OF SYSTEMS TO LEAD PEOPLE AND MANAGE RESOURCES

As a health leader, you are responsible for leading people and managing resources. (Has that been said often enough?) To accomplish these essential and broad tasks, leaders must develop, refine, evaluate, and implement systems that facilitate leading people and managing resources. Nearly all of the theories and models in this book—and many of the applications of these theories and models—have provided a foundation for developing these systems. We encourage health leaders to put the dynamic culture leadership (DCL) model into practice as a basis of a system to lead people and manage resources. Yes, we are biased toward our model, but it is a solid starting point. (Other methods exist and can be used equally effectively, of course.) Personally, you as a health leader must plug into the systems you create. As a continuously developing situational and moral leader, your style, behaviors, and actions must be consistent with the organizational culture, values, strategies, and goals.

There are many systems in place in most health organizations, such as the human resources system, revenue management system, financial system, patient care system, and supply chain system. Considering these systems from a leadership perspective, are the systems and their associated processes aligned and consistent with the organizational culture required to succeed in the external environment? How do you keep these systems aligned and consistent? How would you use the DCL model to improve and integrate, with consistency, these systems? Remember—health leaders lead people and manage resources.

Take Care of People

The most important resources in any organization are the human resources. Individuals in any health organization will always be the most significant component of organizational success. Leaders will be wise to keep this fact close and personal. Without skilled, dedicated, and competent individuals to do the work of the organization in an ongoing manner, the organization is sure to fail. Always remember that the employees whom the leader directs will reflect the values and goals of the organization as well as communicate those goals and values to the customers whom the organization serves. Taking care of people is not only based on monetary and work environment factors, but also on moral grounds. 85

Leaders should also recognize the importance of taking advantage of the diversity in the workforce. It is a well-known fact that workforce diversity lends itself to achieving a higher degree of technical quality and organizational efficiency. Diversity increases the personnel resource pool available to the leader, which in turn tends to eliminate groupthink and increase differentiation. An increase in differentiation allows the organization to pursue new and innovative concepts that will increase its ability to survive—and thrive—over the long term. 86

Take Care of Resources

Resources are the materials and technologies that the leader needs to perform the business of the organization. Resources, in turn, are used as the inputs for the organization to process its outputs. This is true regardless of whether the organization has a service or manufacturing orientation. It is incumbent upon the leader to provide appropriate resources to the employees of the organization so that they can carry out the business of the entity. The leader must also stay abreast of emerging technologies that can aid employees in becoming more productive in the performance of their jobs. As a fiduciary agent of the health organization, the leader who can manage and take care of resources is better able to lead people. Managing resources tends to be easier than leading people; however, leaders must be competent at both aspects of leadership.

As a leader, you should develop and maintain a list of all resources under your management. This list should identify where the resource is housed, who uses it, how and when it is maintained (in-house, under warranty, or by contract), and, if appropriate, its calibration or performance quality assurance record. All resources (the tangible ones) should be on a maintenance schedule and checked according to the standards of practice for that resource; this is especially critical for resources that are used on, near, in, or with patients, providers, and staff. Also, all resources should be inventoried routinely (at least once a year) by you or your trusted representative; you should see and compare serial numbers for resources in use as compared to your list of resources. This inventory can be done with a quick check of 8% to 9% of resources on a monthly basis. During this inventory, verify if routine maintenance has been accomplished on the resource, if necessary supplies are available for use with the resource, and if the resource is in good working order.

As for intangible resources (such as dollars in a budget), leaders should keep track of committed and obligated funds. Leaders should meet routinely with the controller and/or financial officer of the health organization. It is suggested that young leaders meet with the financial officer once a month for the first 6 months of employment and then quarterly (at a minimum) thereafter to ensure fiscal responsibilities are being met and managed properly.

Pay Attention to Details

There is a careful balance in leadership between micromanagement and being detail oriented. In assessing the effectiveness of the work of the leader, the leader’s communication of vision, mission, values, and goal statements should be explicit. Implicit communication will be effective only if there are ingrained values and norms in the organization that clearly support ambiguity in direction and goal orientation. For example, a leader looking to relax dress standards for “casual Fridays” away from a coat and tie to something like khakis and three-button shirts would be incorrect in assuming that all employees consider casual dress to include polo shirts and items featured in GQ magazine. As the leader, ensure that you communicate your expectations explicitly. Additionally, attend to the details of the organization without micromanaging the process of work. Finally, if you are not predisposed to paying attention to details, you can develop that skill and learn by consistency and perseverance. Set a goal to be detail oriented.

Attend to the Communities Served by the Organization

Health leaders are expected to be knowledgeable about the community in which they operate. Even more importantly, health leaders are expected to become involved in the communities that their organizations serve. Community assessments to identify health improvement opportunities, as well as preparedness (consider the public health and healthcare/hospital preparedness programs) assessments and improvements, must be accomplished within the fabric of the community.

The reality of the modern business of health is that large organizations and individual populations of providers will tend to do business with the leaders of the organizations with which they have a personal relationship. 87 , 88 Although the Stark laws 89 prevent physicians from referring patients to only those facilities in which they have a financial interest, organizations, populations of physicians, and other entities will be more likely to do business with organizations with which they have an existing personal relationship. Without violating the parameters of ethics, the reality of the environment is that trust remains a major factor in doing business in the health field.

Leaders can establish and maintain trust with organizations, populations of providers, and outside stakeholders by becoming involved with and integrated into the community rather than isolating their personal and professional practices. To truly “live” in the community, the health leader will be expected to become a part of the process and participate in activities (or minimally support activities) along both horizontal and vertical community bridges. An effective leader will see being involved and becoming part of the community as a natural direction of organizational outreach. Those leaders who find this interaction to be too much of a chore might be advised to rethink whether the dynamic role of health leadership is truly their professional calling. 90 ,91

Share Your Knowledge

Health leaders are some of the most open, knowledge-sharing, and innovative industry leaders operating in the global community. The health community contains hundreds of health-related journals, industry trade publications, magazines, newspapers, and websites where best practices and innovative techniques are freely shared. Authors of these articles vigorously promote their ideas and personal success stories as benchmarks for success for peer organizations and affiliated professionals to adopt so that (often competing) organizations can improve their effectiveness. This behavior stands in stark contrast to that observed in nonhealth professions, such as the fast food and soft drink industries, where simple cola formulas and food recipes are regarded as top-secret property.

As a health leader, you have an obligation to contribute to the body of knowledge of the profession. 92 Leaders should personally author, or provide support and opportunity for those in the organization to author, descriptions of best practices and methods that increase outcomes along the continuum of care. Publishing, speaking at local and national conferences, and sharing information and knowledge not only will increase the leader’s personal credibility and relevancy in the community, but also act as a proxy for increasing the recognition of the organization.

Partner with Community Leaders

The “Henry Ford,” resource-dependent model of vertical integration, which attempts to control every aspect of production and throughput in an organization, has long since been cast aside. It is no longer possible to control every employee involved in sales and revenue generation connected to organizational survivability in the health industry. Joint ventures are becoming more common in the healthcare field as organizational entities try to achieve economies of scope and scale. Physician practice plans, sharing of administrative third-party entities, and contracting with part-time employees are models of success for future health organizations. As a result of these ventures, leaders will have to partner with other health leaders who are effective in their own specialty niche, such as technology or billing. In many cases, a leader may belong to an invisible network of suppliers, administrative personnel, record keepers, and human resources. Problems with simple one-item elements, such as a decrease in the availability of blood products from a single-source supplier, can threaten an organization’s creditability and survivability in this environment if backup plans and collegial networks of support are not in place to assist the organization when it faces lean, changing, and turbid environments. Today’s savvy health leader will be aware that the leader of a perceived rival organization today may be the organization’s rescuer tomorrow in resource-restricted environments if positive relationships have been maintained.

INTEGRITY

In this chapter, we have presented issues revolving around relevancy and creditability. The end result of consistency in practice and awareness by stakeholders of this genuine predisposition to care is a construct recognized by outside agents as integrity. ‡ 93 ,94

Integrity may be defined as the consistency of actions over time. 95 Lack of integrity is impossible to disguise for long periods. True integrity may be demonstrated through a leader’s ability to lead by example, becoming a “Do as I do” leader, and taking responsibility for actions. If an early careerist can embrace these life rules as a compass for daily activities, he or she certainly has a high chance of achieving enviable professional development and success.

RELATIONSHIP BUILDING AND COMMUNICATION

The ability to build and maintain relationships is critical for successful health leaders. Highly competent communication skills are also a health leader imperative for success. This section reiterates the foundations of relationships and communication. Read it while you keep all health organization stakeholders in mind, such as physicians, nurses, allied health staff, administrators, other leaders, community members, and patients. Can you visualize what you would do to build relationships and communicate with key stakeholder groups?

Factors to Strengthen Relationships

Relationships refer to the feelings, roles, norms, status, and trust that both affect and reflect the quality of communication between members of a group. 96 Relational communication theorists assert that every message has both a content and relationship dimension, where

· • Content contains specific information conveyed to someone.

· • Relationship messages cue or provide hints about whether the sender/receiver likes or dislikes the other person.

Communicating with someone in a manner that provides both content and positive relationship information is important. Language, tone, and nonverbal communication work together to provide communicative meaning that is interpreted by another person. In particular, care must be taken with nonverbal communication. 97 ,98

‡ On page 242 of Reference 93, Carter credits influence, to some extent, by the fine discussion of integrity in Martin Benjamin’s book, Splitting the Difference: Compromise and Integrity in Ethics and Politics(Lawrence, KS: Lawrence University Press of Kansas, 1990).

· • Nonverbal communication is more prevalent than verbal communication. It consists of

· • Eye contact

· • Facial expressions

· • Body posture

· • Movement

· • People believe nonverbal communication more than verbal communication: Sixty-five percent of meaning is derived from nonverbal communication.

· • People communicate emotions primarily through nonverbal communication: Ninety-three percent of emotions are communicated nonverbally.

Frequency of communication that is timely, useful, accurate, and in reasonable quantity must be considered to reinforce and validate the relationship. One important factor in this regard is quality communication of sufficient and desired frequency, which enhances the likelihood of developing quality interpersonal relationships.

Another key factor is disclosure. Disclosure relates to the type of information you and the other person in the relationship share with each other; disclosure is one factor that can help you “measure” or evaluate the depth and breadth of a relationship. The “deeper” the information disclosed, the closer the bond of the relationship. Broader topics of information and experience sharing (e.g., family activities, work, fishing together, or playing golf) suggest a closer bond within the relationship as well.

Self-disclosure can be categorized and measured. In the following model, level 5 illustrates a weak relationship bond whereas level 1 shows a strong relationship bond. Disclosure or self-disclosure is strongly and positively correlated with trust (i.e., connected such that more trust means more disclosure)—and trust starts with quality communication. Shown are Powell’s self-disclosure levels:99

· • Level 5: Cliché communication

· • Level 4: Facts and biographical information

· • Level 3: Personal attitudes and ideas

· • Level 2: Personal feelings

· • Level 1: Peak communication (rare; usually with family or close friends)

In summary, self-disclosure can be described as follows: 100

· • A function of ongoing relationships

· • Reciprocal

· • Timed to what is happening in the relationship (contextual/situational/relational)

· • Relevant to what is happening among people present

· • Usually moves by small increments

A third factor in establishing effective relationships is trust. Trust is built and earned over time through honest interaction (communication and experiences). Honesty, inclusion, and sincerity are directly linked to building trust. Trust is an essential component of a quality, positive relationship. Honesty is being truthful and open concerning important pieces of information that you share with another person. Inclusion focuses on including the other person in the relationship in activities and experiences that are important to both of you. Inclusion is also about making sure the other person is part of the “group” in the organization. Sincerity is meaning what you say, meaning what you do, and not keeping a record or account of the relationship (not keeping score). Over time, if honesty, inclusion, and sincerity are the basis of your interaction with others, positive and quality relationships will begin to grow.

The fourth factor in relationship building is cultural competence. This factor is based not only on ethnic or national dimensions, but also socioeconomic factors. For instance, consider the cultural differences in surgeons versus nurses versus facility technicians or linen staff or consultants. Every stakeholder group, and every individual, has a unique culture. Understanding those cultural issues, or “walking a mile in someone else’s shoes,” is a factor important to building solid interpersonal relationships. Understanding and modifying your approach to relationship building and enhancement based on cultural differences will serve you well in leadership positions.

HAVE FUN

Leaders of health organizations can endure only if they are having fun in pursuit of productive and results-driven efforts. Managing complex issues on a continuous problem-solving cycle 101 can lead to burnout and leader turnover. Those leaders who endure in the profession truly see the art and science of leading complex health organizations as a pseudo-hobby and as an extension of their own personality. If this is you, you have the potential to have a long and productive career in the health field.

SUMMARY

This chapter discussed the globalization of leadership, taking into account that many of the leadership theories and practices presented in this book are based on Western ideologies. The need to leverage technology, lead through followership, and understand the basics of influence and power are important with respect to climate, culture change, and environment. Knowledge management and organizational learning are also keys to keeping the health organization attuned to its dynamic environment and flexible enough to embrace change when necessary. As part of this effort, the health leader may use a variety of integrative models as the basis for fostering change—including change in the culture—within the organization. Lastly, what kind of leader do you want to be? What kind of leader will you be? What will your organization accomplish because of your efforts, initiatives, motivation, and leadership ability?