Proposal

Introduction to the Problem 1

Background of the Study 5

Statement of the Problem 8

Purpose of the Study 9

Rationale 10

Research Questions 11

Significance of the Study 11

Definition of Terms 13

Assumptions and Limitations 14

Nature of the Study 15

Organization of the Remainder of the Study 17

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CHAPTER 1. INTRODUCTION

Introduction to the Problem

Physician engagement is one of the foremost health care administration topics of the

decade. The recent literature is filled with calls for action and descriptions of current engagement

initiatives (Clark, 2012; Daly, 2013; Denis, Baker, Black, Langley, & Lawless, 2013; Dickson,

2012, Frattaroli, Webster, & Wintemute, 2013; Grimes, & Swettenham, 2012; Johnson, 2014;

Kaissi, 2012aa; Milliken, 2014). Despite over three decades of discussion and action, physician

engagement issues continue to headline at health care conferences (Beckman, 2014; Dickson,

Reid, Van Aerde, 2014; Marino, & Faber, 2014; Riskind; 2014). Improving the relationships

between hospital physicians and front-line managers represents and unexplored opportunity for

meaningful improvement in physician engagement.

The concept of physician engagement developed out of the body of evidence surrounding

employee engagement. Employee engagement has been widely discussed in human resources

literature for years and has long been considered critical in improving organizational

performance (Attridge, 2009; Gruman, & Saks, 2011; Kular, Gatenby, Rees, Soane, & Truss,

2008; Macey, & Schneider, 2008; Robinson, Perryman, & Hayday, 2004; Schaufeli, Salanova,

Gonzalez-Romá, & Bakker, 2002; Saks, & Gruman, 2011). Although physicians typically are

not hospital employees, the increasingly intertwined fortunes of hospitals and physicians have

resulted in growing interest in physician engagement as a means to improve hospital

performance.

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Physician engagement is important because, where physicians are actively and

collaboratively engaged in hospital operations and performance improvement, their organizations

perform better financially and have higher patient satisfaction, better overall quality, higher

staff/physician satisfaction rates and lower staff/physician turnover (Gosfield, 2010; Kaissi,

2012aa; Rice,, & Sagin, 2010). Physicians have been shown to hold greater influence on hospital

operations than either administrators or other paramedical and allied health professions

(Hamilton, Spurgeon, Clark, Dent, & Armit, 2008). Ultimately, physicians attract patients to

hospitals and physicians drive utilization and cost (Armour et al., 2001; Halpert, Pearson,

LeWine, & McKean, 2000; Paller, 2005).

For decades, the relationship between physicians, hospital administrators and front-line

managers has been characterized by conflict, suspicion, lack of collaboration and sometimes

outright hostility (Bettner, & Collins, 1987; Robinson, 2001). Over the last few years the health

care system has been suffering from further deteriorating relationships (Burns, Goldsmith, &

Muller, 2010; New Jersey Department of Health, 2008; Payton, 2012), fueled by stronger

competition, demographic shifts, reimbursement cuts and public demands for accountability and

quality improvement (Carlson, & Greeley, 2010). Greater regulation and escalating financial

pressures on both hospitals and physicians from the Affordable Care Act has further increased

tensions (Beckman, 2011; Harbeck, 2011; Payton, 2012). This continuing system pressure to

decrease costs and improve quality has highlighted the importance of a positive relationship

between management and physicians and emphasized the need for collaboration.

Despite discussions and interventions to increase physician engagement that go back

more than twenty-five years (Bettner, & Collins, 1987), there is still abundant recent literature

describing the ongoing crisis and the need for greater physician engagement (Clark, 2012; Daly,

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2013; Denis et al., 2013; Dickson, 2012, Frattaroli et al., 2013; Grimes, & Swettenham, 2012;

Johnson, 2014; Kaissi, 2012aa; Milliken, 2014; Payton, 2012; Sears, 2012), Past initiatives have

had variable and only limited effectiveness (Baker, & Denis, 2011); some efforts at physicianhospital

integration have worked in the short term, but there have also been some spectacular

failures (Fraschetti, & Sugarman, 2009). It is clear there is still considerable opportunity for new

and innovative ways of engaging physicians.

Most existing/published efforts aimed at improving physician engagement have been

focused on building broad alignment between key physician groups and the hospital, as well as

engaging physician leaders in the process of hospital administration (Shortell et al., 2001). These

types of initiatives are most often high level, structural and strategic, including system outreach,

monetary incentives, hospital-physician integration, physician participation on strategic

committees, and stronger medical leadership infrastructure (Buller, 2003; Carlson, & Greeley,

2010; Fralicx, 2012; Gosfield, 2010; Kaissi, 2012aa). People most closely involved in these

initiatives are typically hospital board members, hospital executives and senior medical

leadership representatives.

While strategic alignment is important, most of a hospital physician’s daily interactions

occur with other direct care providers and front-line managers, not with hospital board members,

hospital executives or even physician leaders. It is the behavior of individual physicians that has

the major impact on quality and utilization for hospitals (Hamilton et al., 2008; Paller, 2005) and

the role of the front-line nurse manager is pivotal in creating enabling environments for building

effective, productive and influential ongoing relationships with medical staff (Kaissi, 2005;

McSherry, Pearce, Grimwood, & McSherry, 2012; Whiley, 2001). Improving physician-front4

line manager relationships represents an excellent opportunity to further enhance physician

engagement.

There is considerable support in the literature about the importance of front-line

managers in building collaboration and improving outcomes. They bring organizational goals

and objectives to the front-line caregivers, shape behavior, build engagement and remove

barriers (Cipriano, 2011; Grimes, & Swettenham, 2012). Front-line managers are most often the

individuals responsible for enforcing hospital policies and managing physician behavior on a

day-to-day basis. They must be able to engage physicians to become willing “followers” who

support organizational goals as, in most cases, physicians are not employees of the hospital and

cannot be forced into participation or compliance.

Leaders cannot lead unless they have willing and engaged followers (Chaleff (2003).

Followers have specific expectations about how leaders should behave and will typically choose

whether or not to accept leadership based on conformity to their expectations, trust, perceived

leadership competence and believed worthiness of role and power (Kenney, Schwartz-Kenney,

& Blascovich, 1996; Kaissi, 2012aa; Suderman, 2011). Followership also increases in

proportion to the number of interpersonal interactions that are seen as being positive and

meaningful (Bujak, 2003). Increasing positive interactions and improving alignment between

physician expectations and leadership behavior could increase physician engagement and

collaboration between physicians and managers.

Therefore it would be helpful to better understand what physicians expect from front-line

managers, specifically, how they determine leadership competence and what factors contribute to

their conscious and sub-conscious decisions to accept manager influence. Then, if physician

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expectations differ from organizational role definitions and expectations of management

performance, efforts could be made to bridge that gap

Background of the Study

The fractured relationship between hospital administration and physicians has had many

unfortunate consequences. Physicians are asking to be paid for nonclinical duties they previously

did voluntarily; some are refusing to serve on hospital committees, service the emergency

department or take call; some are limiting the number of patients they will visit in a day; others

lie for patients on insurance and hospital billing claims; still others are opening physician-owned

practices that directly compete with hospitals for market share – all symptoms of lack of

physician engagement (Brown, 1983; Carlson, & Greeley, 2010; Holm, 2008; Hunter, 2001;

Sade, 2012). Aside from the obvious financial and quality implications of this behavior,

declining physician engagement across the broader health care system has also been identified as

a key contributor to more physicians opting for early retirement or reduced practice hours,

leading to increasing concerns over shortages of primary care practitioners, surgical specialists

and hospitalists (Fraser, 2010; Sheldon, 2011; Voelker, 2009). Without addressing the issue of

physician engagement, hospitals will not be able to meet current and future performance

expectations.

Despite the conflicts, hospitals need physicians as they attract patients to the hospital and

the physician is typically the only provider who can admit and discharge patients, order tests,

dictate treatment and document the course of medical care for many coding/billing purposes

(Kaissi, 2012a). Physicians may have obligations around administrative/committee work,

teaching, and on-call coverage but ultimately do not pay to use hospital facilities. They must

voluntarily comply with hospital policies and procedures. At the same time, increased threat of

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litigation/malpractice claims often result in higher costs from defensive workups, more lab tests

and redundant diagnostic procedures (Baicker, Fisher, & Chandra, 2007).

Hospitals have tried to break their dependence on physician goodwill, by strengthening

utilization management policies, procedures and restricting access to specific resources.

However, physicians then find ways to sabotage these rules and regulations, increasing “stat”

orders and insisting on critical or defensive interventions (Pfifferling, 2008). Managers,

following organizational direction, try to improve compliance, but find themselves cajoling,

threatening and negotiating behavior changes and compliance (Harris, 1977).These kinds of

behaviors are intrinsically dissatisfying and do not build positive relationships.

In theory, good managers, as defined by the typical competency-based frameworks used

in hospitals (NHCL, 2012) should be able to drive better performance and greater compliance

from physicians. However, there is ongoing evidence that experiences and personal connections

affect physician engagement (Kaissi, 2012aa) and that willingness to follow a leader is ultimately

based on subjective world view (Bujak, 2003; Chaleff, 2003; Kenney et al., 1996; Kaissi,

2012aa; Suderman, 2011) rather than traditional leadership competencies.

“Good” Leadership and Physician Perspectives

“Good” leadership means different things to different people. At the broadest level,

leadership is a process if influencing others to achieving organizational goals and objectives

(Kruse, 2013). In addition to the virtually infinite different subjective views on good leadership,

there are a multitude of formal definitions, theories and models, including transformational

leadership, servant leadership, wise leadership, transactional leadership and many more

(Kellerman, 2007; Mazyck, 2008; Nonaka, & Takeuchi, 2011; Ramsey, 2003; Rolfe, 2011). In

health care, most organizations today have adopted the widely supported National Center for

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Healthcare Leadership (NCHL) model for assessing leadership competencies (NCHL, 2012) and

use this, or some similar/related model, to guide and evaluate leadership performance in

managers. The NCHL Model defines twenty-six competencies, including communication,

financial management and human resources management, grouped into the three domains of

transformation, execution and people.

While these usually accepted measures of front-line manager effectiveness focus on

traditional leadership competencies including transformation, execution and people skills

(DeOnna, 2006; NCHL, 2012; Ten Haaf, 2007), and the extent to which managers can influence

employees and other stakeholders to work towards organizational objectives (Cooper, &

Nirenberg, 2004), senior leaders throughout the health care system suggest that physicians

appear to judge competence by a different measures than the traditional leadership competencies.

Even physician executives, who are most likely to have recognized leadership and management

training, have usually been through physician leadership programs that heavily favor traditional

management skills such as financial management, conflict resolution, business strategy, and

organizational behavior rather than soft skills and relationship-building (Physician Leadership

Program. 2013; Preparing Physicians to Lead, 2013). Since most physicians have no formal

education on the topics of leadership assessment and management skills and interact with frontline

hospital managers and other administrators intermittently, often transactionally, they make

their judgments about leader effectiveness based on incomplete information and perception

rather than through any formal or validated performance assessment tools.

Differing perceptions are significant because perception is the process by which we

interpret and make meaning the world around us (Lindsay, & Norman, 1977). Perceptions are

often subconscious, based on past experiences, values, prejudices, self-interest and other

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attitudes, and have been shown to be more important than reality in the decision-making process

(Potgieter, 2011). In the absence of conflicting information, and sometimes despite conflicting

information, perception invariably becomes reality in the mind of the perceiver. Furthermore,

these perceptions and expectations may actually affect actual manager performance (Inamori, &

Analoui, 2010; Livingston, 2009). Perceptions eventually create their own reality.

With each manager-physician interaction, physicians accumulate information that is

filtered through their perceptions about the manager/organization and that affects the probability

of engagement and compliance with organizational goals and objectives. If the factors

influencing physician perceptions differ from the traditional leadership competencies, and/or

from the competencies that are encouraged and rewarded by the organization, dissonance and

conflict may result (Kissick, 1995; Reay, & Hinings, 2009; Waldman, & Cohn, 2007). Therefore,

understanding the factors that influence physician perceptions of manager competence, and

hence physician engagement, could allow managers to modify behavior to more effectively

influence physician engagement

Statement of the Problem

Hospitals today have an urgent need to find innovative approaches to building physician

engagement. Existing efforts have not yielded sustainable results and none address the essential

issue of daily physician-manager interactions at the front line and the effectiveness of

physicians’ relationship with the front-line manager of the patient care unit (Baker, & Denis,

2011; Fraschetti, & Sugarman, 2009). Better physician-manager collaboration will improve

physician engagement and enhance organizational performance.

In the daily work on patient care units, physician compliance and willingness to

acknowledge leadership and direction of management is related to the extent that they

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trust/respect manager leadership skills (Chaleff, 2003; Kenney et al., 1996; Kaissi, 2012a;

Suderman, 2011). However, manager behaviors and performance expectations are based on

competency frameworks that may not align with expectations of physicians, whose world views

differ from those of administrators (Kaissi, 2012a; Klopper-Kes, Meerdink, Van Harten, &

Wilderom, 2009; von Knorring, de Rijk, & Alexanderson, 2010; Waldman, & Cohn, 2007).

Differing expectations lead to conflict and distrust (Kissick, 1995; Reay, & Hinings, 2009;

Waldman, & Cohn, 2007), minimizing physician engagement and potentially manager

effectiveness. Although it has been shown that physicians and administrators have different

world views and that they have different priorities at the front line of patient care, there is little

evidence or research about what exactly they do view positively in terms of manager behaviors

and activities. Gaining a better understanding of what manager behaviors and activities

physicians value, will create an opportunity to improve alignment between formal organizational

manager role expectations and physician perspectives.

Purpose of the Study

The purpose of this action research project was to determine what factors influence

physician perceptions of leadership effectiveness in front-line managers, which affected how

physicians decided whether or not to trust, accept leadership from and collaborate with, frontline

managers. This purpose was relevant to current health care system challenges because

physician perceptions of leadership effectiveness can be linked to physician engagement and

subsequently to organizational efficiency and effectiveness.

First, an initial qualitative study, consisting of face-to-face interviews of a sample group

of physicians was used to collect data on how physicians judge effective leadership performance

in front-line managers in hospitals. Then, the results of these interviews were compared against a

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typical leadership competency model used by hospital administrators to judge effective

leadership performance in front-line managers and analyzed using a complexity theory lens.

Finally, based on the results of the above research, and using an adaptive leadership model

suggested by complexity theory (Avolio et al., 2009, Uhl-Bien, Marion, & McKelvey, 2007), a

specific intervention with leadership behavior changes was proposed to help improve alignment

between physician and administrator perspectives.

Rationale

This action research was undertaken to find ways of improving physician engagement at

the study site, a hospital in Ontario, Canada. The research results were used to design an

intervention aimed at creating an enabling environment for increasing alignment between

physician and administration expectations of leadership behavior in front-line management, on

the premise that increased alignment would decrease physician disengagement and improve

collaboration.

Since the target organization is facing massive system change and incremental funding

reduction over the next three years (Ontario Health Coalition, 2012; Ontario Ministry of Health,

2012), improved collaboration and efficiency is critical to organizational survival. In addition,

both the local health care region and Ontario as a whole are suffering from ongoing and

potentially crippling physician shortages in many specialties (Singh et al., 2010). Recruitment

and retention of internists, hospitalists and physician assistants are all persistent challenges and

any initiative that improves competitiveness in this area is helpful. Improved alignment in

perspectives should enable increased efficiency, better outcomes and improved satisfaction for

staff and physicians (Accreditation Canada, 2010).

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If successful, the project results should be transferable to other hospitals in the region and

province, since they are all facing similar challenges with physician engagement and funding

reductions (Hutchinson, 2010; Ontario Health Coalition, 2012). These types of pressures are also

being experienced elsewhere in Canada and the United States (Carlson, & Greeley, 2010;

Dickson, 2012; Kaissi, 2011; Robinson, 2001) and so the project has the potential to make a

broader contribution to health care administration.

Research Questions

Primary Research Question: How do hospital physicians judge leadership effectiveness

of front-line managers?

Secondary Research Question 1: How do physician perspectives differ from those in a

current competency-based leadership effectiveness evaluation model used by administrators?

Secondary Research Question 2: What intervention(s) could improve alignment between

administrator and physician perceptions of leadership effectiveness?

Significance of the Study

This action research study was pursued in order to find a new opportunity for enhancing

organizational performance at the study site hospital, which operates in an increasingly complex,

challenging and competitive environment. Managers at the target organization, and in other

hospitals around the country, have being asked to provide ongoing patient care services out of

shrinking budgets while meeting increasingly stringent quality and reporting requirements. They

enforce hospital utilization policies and communicate performance targets, mediating between

increasingly unhappy physicians and often disenfranchised employees. But ultimately

physicians, not managers, drive utilization and demand, and managers have no formal authority

over physician behavior.

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Existing/published efforts to improve physician engagement in supporting hospital goals

and objectives have focused on high level, strategic and structural interventions (Bettner, &

Collins, 1987; Buller, 2003; Carlson, & Greeley, 2010; Fralicx, 2012; Gosfield, 2010; Kaissi,

2011). People involved in these initiatives are typically hospital board members, hospital

executives and senior medical leadership. While strategic alignment is important, most of a

hospital physician’s daily interactions occur with other direct care providers and front-line

managers, not with hospital board members and executives. The role of the front-line manager is

central in creating enabling environments and in building effective ongoing and mutually

beneficial relationships with medical staff (McSherry et al., 2012; Whiley, 2001).

Front-line manager complain about lack of physician responsiveness, excessive physician

resource utilization, inadequate physician presence on inpatient units and poor physician

communication with patient family members. Physicians, in turn, chafe against what they see as

increasing regulation and obstructive bureaucracy, while complaining about poor care

coordination, lack of communication restrictive policies and excessive focus on money and

efficiency. Conversely, physicians are more visible on units where they have positive

relationships with the coordinating front-line manager. They are also more easily engaged in

supporting hospital targets and more willing to attend meetings where they respect the

organizing manager, while allegedly ignoring meeting invitations from others.

Gaining a better understanding of physician expectations of front-line manager leadership

roles helped identify the gap between physician and organizational expectations and evaluate if it

could be bridged by one or more of physician education, improved communication,

modifications to manager role or more specialized manager training. In addition to increasing

engagement, improved relationships between managers and physicians will increase quality of

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work life for both groups and improve collaboration, which in turn will increase productivity and

enhance outcomes, customer satisfaction and patient safety (Accreditation Canada, 2010;

Amabile, & Kramer, 2012).

Definition of Terms

Bundled payments set a reimbursement rate for an episode of care rather than for

individual interventions (Burns, 2013; Draper, 2011).

Employee engagement means that employees exert discretionary effort beyond the basic

requirements of the job and work to create additional value without being asked (Kruse, 2012).

Followership means that leaders cannot lead without followers and that leadership is a

relationship created actively by both the leader and followers (Oc, & Bashshur, 2013).

Hospitalists are physicians who specialize in inpatient medicine rather than in the typical

service lines of surgery, medicine, cardiology etc. (Wachter, & Goldman, 1996).

Leadership Competencies: When a person is described as having competency in a

specific field, they are stated to have the all of the required knowledge, skill and judgment to

perform effectively in that field (Hollenbeck, McCall, & Silzer, 2006).

Physician Engagement means that physicians are actively involved in the planning and

delivery of care and also in supporting the pursuit of organizational objectives.

Physician-hospital integration refers to the process of devising more formal and mutually

beneficial relationships between physicians and hospitals, such as expanded hospitalist programs

or partnership agreements and professional service agreements.

Utilization management refers to the deliberate control of resource consumption in

hospitals.

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Value-based purchasing (or pay-for-performance) is an effort to increase health care

system efficiency where hospitals are reimbursed based on how well they meet predetermined

performance targets rather than by fee-for-service.

Assumptions and Limitations

This research was premised on a series of logical conclusions which, while founded in

comprehensive literature review, still ultimately led to an assumption about the validity of this

series of conclusions. This sequence began with evidence that 1) physician satisfaction was a

critical issue in health care today 2) that it was declining 3) that existing engagement efforts have

had limited success and there was a need for novel approach 4) that manager actions at the front

line were important in communicating organizational objectives 5) That physician attitudes

towards managers affected the extent to which physicians were willing to listen to managers and

engage in activities related to organizational objectives 6) That while there was evidence that

physician attitudes were based on different world view and socialization from traditional

administrative views, there was little evidence about what actual factors influence their

perceptions.

This researcher assumed that the factors influencing physician perceptions of leadership

effectiveness of front-line managers were different from those in traditional leadership

competency models and that these factors could be described, measured and compared. The

study also assumed that a sufficient number of physicians would volunteer to be interviewed and

that they would be truthful in their interviews.

Because of the subjective nature of qualitative research, this project was subject several

limitations. Interviewees may not have been aware of their own biases, prejudices and

perceptions about what constitutes leadership effectiveness. Past and existing relationships

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researcher / interviewee relationships and organizational position may have influenced interview

responses and discussion. Despite assurances of anonymity, interviewees may have felt inhibited

by concerns over confidentiality. Finally, this was an action research project in which

organizational context is relevant and influential in interviewee responses, which could be seen

as a limitation on the generalizability of the work.

Nature of the Study

This study was based on the conceptual framework provided by complexity theory. In

complexity science scholars suggest that interdependence and independent action exist

simultaneously and both rational and irrational behavior can coexist (Cooksey, 2001). Through

the combination of many simple patterns and relationships, there are infinite outcomes and

possible actions. Complexity science borrows from many other disciplines, including biology,

sociology, computer science, economics, anthropology (Zimmerman, Lindberg, & Plsek, 2009),

and studies how systems actually behave rather than how they are expected to behave.

Complexity theory provided a relevant and helpful framework for thinking about the

relationship between front-line managers and hospital physicians. In complexity theory, the

hospital is viewed as a complex adaptive system (CAS) and described as a set of relationships

between autonomous agents, with infinite interconnections and the capacity to learn from

experience and alter behavior (Zimmerman et al., 2009). All of these independent agents (such as

physicians and managers) act locally and independently, according to their own plan and agenda.

In general, people do not all behave the same way when faced with similar circumstances and

much of human behavior is not predictable or even explainable. Even with many shared

experiences and agreed upon goals, people may choose different actions.

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Historically, leaders have been encouraged to try to influence and control in order to

drive alignment towards a common vision (Marion, & Uhl-Bien, 2001). Complexity theory

holds that human behavior does not respond well to such efforts at control because of the reality

of free choice/human agency and unexplained actions and responses (Heylighen, 2006). When

faced with traditional efforts to drive alignment, these stakeholders may respond by developing

coalitions to protect their own interests and visions however, given the right set of enabling

circumstances, they can also act collaboratively, co-dependently and supportively (Marion, &

Uhl-Bien, 2001).

Instead of aiming to control or direct, the role of an adaptive leader is to support and

enable learning, creativity, and desired behavior in the complex organizational system,

particularly in those functioning predominantly with knowledge workers such as physicians

(Uhl-Bien et al., 2007). Adaptive leadership embraces the evolutionary, creative and learning

activities that leaders must facilitate to stimulate collaboration. Rather than being directive or

manipulative, adaptive leadership supports and coaches the activities of the many free agents

comprising the system (Avolio et al., 2009; Uhl-Bien et al., 2007).

Complexity theory has been used to describe and explain many phenomena in health care

systems and hospitals, including unexpected consequences of government interventions (Reece,

2008), differential leadership success in hospitals (Ford, 2009), adaptive interventions in primary

care (Litaker, Tomolo, Liberatore, Stange, & Aron, 2006), planning physician governance

(Lindberg, Herzog, Merry, & Goldstein, 1998) and hospital change management (Dattée, &

Barlow, 2010). It has also been used in dissertation research to look at the impact of

environmental change on hospitals (Penprase, 2007). In the case of front-line leadership in

hospitals, complexity theory suggests that an adaptive leader could facilitate alignment of goals

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and that the organization could create enabling structures that also support collaboration among

free agents (Uhl-Bien et al., 2007; Zimmerman et al., 2009).

In summary, complexity theory is founded on a viewpoint that reality is subjective,

changing and relational. Meaning is created out of the complex relationships among people and

between people and the environment. As such, complexity theory will well support dissertation

research that is aimed at better understanding the perceived reality of physicians and managers as

it relates to the leadership effectiveness of front-line managers in hospitals.

Organization of the Remainder of the Study

The remainder of this research study includes sections on the literature, methods, analysis

and discussion. Chapter 2 presents an aggregation of the relevant current literature related to the

research and theoretical framework. Chapter 3 provides details of the qualitative research

methodology and study design. Chapter 4 describes the results of the study and the analysis of

the data. Finally, chapter 5 includes discussion of the results, limitations, conclusions, and

recommendations for future research.