Do healthcare leaders have a responsibility to be culturally competent? Why or why not?

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Leadership
Louis Rubino

CHAPTER
2
LEARNING OBJECTIVES

By the end of this chapter, the student will be able to:

…
Distinguish between leadership and management;

…
Define followership and why it’s as important as leadership;

…
Summarize the history of leadership in the United States from the 1920s to current

times;

…
Compare contemporary models of leadership;

…
Describe leadership domains and competencies;

…
Compare leadership styles;

…
Summarize old and new governance trends;

…
Discuss how culture plays a role in leadership; and

…
Provide a rationale for why healthcare leaders have a greater need for ethical

behavior.

LEADERSHIP VS. MANAGEMENT

In any business setting, there must be leaders as well as managers. But are these the same
people? Not necessarily. There are leaders who are good managers and there are managers
who are good leaders, but usually neither case is the norm. In health care, this is especially
important to recognize because of the need for both. Health care is unique in that it is a
service industry that depends on a large number of highly trained personnel as well as trade
workers. Whatever the setting, be it a hospital, a long-term care facility, an ambulatory
care center, a medical device company, an insurance company, or some other healthcare
CHAPTER 2 LEADERSHIP

sector, leaders as well as managers are needed to keep the organization moving in a forward
direction and, at the same time, maintain current operations. This is done by leading and
managing its people.

Leaders usually take a focus that is more external, whereas the focus of managers is
more internal. Even though they need to be sure their healthcare facility is operating
properly, leaders tend to spend the majority of their time communicating and aligning
with outside groups that can benefit their organizations (partners, community, vendors) or
influence them (government, public agencies, media). See Figure 2-1. There is crossover
between leaders and managers across the various areas, though a distinction remains for
certain duties and responsibilities.

Usually the top person in the organization (e.g., Chief Executive Officer, Administrator,
Director) has full and ultimate accountability. There are several managers reporting to
this person, all of whom have various functional responsibilities (e.g., Chief Nursing
Officer, Physician Director, Chief Information Officer). These managers can certainly

Media
External Stakeholders
Financial
Stakeholders
Government Vendors
Health Policy,
Laws, &
Regulations
Community
Groups
Strategic Partners
Internal Stakeholders
Administration
Professionals
Operations
Management Focus/
Internal
FIGURE 2-1 Leadership and Management Focus
Note: Arrows represent continual interactions between all elements of the model.

FOLLOWERSHIP

be leaders in their own areas, but their focus will be more internal within the organization’s
operations.

Leaders have a particular set of competencies that require more forward thinking than
those of managers. Leaders need to set a direction for the organization. They need to be
able to motivate their employees, as well as other stakeholders, so that the business continues
to exist and, hopefully, thrive in periods of change. No industry is as dynamic as
health care, with rapid change occurring due to the complexity of the system and government
regulations. Leaders are needed to keep the entity on course and to maneuver around
obstacles, like a captain commanding his ship at sea. Managers must tend to the business
at hand and make sure the staff is following proper procedures. They need a different set
of competencies. See Table 2-1.

FOLLOWERSHIP

For every leader, there must be followers. Leaders must have someone they can lead in
order to accomplish what they set out to do. Not everyone can or should be a leader.
Leaders should have certain recognizable traits that will help them take charge, while followers
must have a willingness to be led as well as the ability to do the task requested. True
leaders inspire commitment from dedicated people.

Atchison (2003) wrote about this process in his book Followership. He describes followership
as complementary to leadership and recommends that it be recognized as a
necessary component for an effective leader. A self-absorbed administrator will not make
a good leader. A true leader will recognize the importance of getting respect, not simply
compliance, from the people who follow. It is one thing to have people do what you say,
but to have someone want to do it is another thing. The leader who understands this
is on the way to greatness and will create a much more meaningful work environment.

TABLE 2-1 Leadership vs. Management Competencies
Leadership Competencies Management Competencies

Setting direction or mission Staffing personnel
Motivating stakeholders Controlling resources
Being an effective spokesperson Supervising the service provided
Determining strategies for the future Overseeing adherence to regulations
Transforming the organization Counseling employees
CHAPTER 2 LEADERSHIP

As Atchison says, “An executive title without followers has an illusion of power. These
titled executives create a workplace without a soul.”

HISTORY OF LEADERSHIP IN THE UNITED STATES

Leaders have been around since the beginning of man. We think of the strongest male
becoming the leader of a caveman clan. In Plato’s time, the Greeks began to talk about
the concept of leadership and acknowledged the political system as critical for leaders to
emerge in a society. In Germany during the late 19th century, Sigmund Freud described
leadership as unconscious exhibited behavior; later, Max Weber identified how leadership
is present in a bureaucracy through assigned roles. Formal leadership studies in the United
States, though, have only been around for the last 100 years (Sibbet, 1997).

We can look at the decades spanning the 20th century to see how leadership theories
evolved, placing their center of attention on certain key components at different times
(Northouse, 2010). These emphases often matched or were adapted from the changes
occurring in society.

With the industrialization of the United States in the 1920s, productivity was of paramount
importance. Scientific management was introduced, and researchers tried to determine
which characteristics were identified with the most effective leaders based on their
units having high productivity. The Great Man Theory was developed out of the idea
that certain traits determined good leadership. The traits that were recognized as necessary
for effective leaders were ones that were already inherent in the person, such as being male,
being tall, being strong, and even being Caucasian. Even the idea that “you either got it or
you don’t” was supported by this theory, the notion being that a good leader had charisma.
Behaviors were not considered important in determining what made a good leader. This
theory discouraged anyone who did not have the specified traits from aspiring to a leadership
position.

Fortunately, after two decades, businesses realized that leadership could be enhanced
through certain conscious acts, and researchers began to study which behaviors would
produce better results. Resources were in short supply due to World War II, and leaders
were needed who could truly produce good results. This was the beginning of the Style
Approach to Leadership. Rather than looking at only the characteristics of the leader,
researchers started to recognize the importance of two types of behaviors in successful leadership:
completing tasks and creating good relationships. This theory states that leaders
have differing degrees of concern over each of these behaviors, and the best leaders would
be fully attentive to both.

In the 1960s, American society had a renewed emphasis on helping all of its people
and began a series of social programs that still remain today. The two that impact
health care directly, by providing essential services, are Medicare for the elderly (age 65
and over) and the disabled and Medicaid for the indigent population. The Situational
Approach to Leadership then came into prominence and supported this national concern.
This set of theories focused on the leader changing his or her behavior in certain
situations in order to meet the needs of subordinates. This would imply a very fluid
leadership process whereby one can adapt one’s actions to an employee’s needs at any
given time.

Not much later, researchers believed that perhaps leaders should not have to change
how they behaved in a work setting, but instead the appropriate leaders should be
selected from the very beginning. This is the Contingency Theory of Leadership
and was very popular in the 1970s. Under this theory, the focus was on both the
leader’s style as well as the situation in which the leader worked, thus building upon
the two earlier theories. This approach was further developed by what is known as the
Path–Goal Theory of Leadership. This theory still placed its attention on the leader’s
style and the work situation (subordinate characteristics and work task structure) but
also recognized the importance of setting goals for employees. The leader was expected
to remove any obstacles in order to provide the support necessary for them to achieve
those goals.

In the later 1970s, the United States was coming out of the Vietnam War, in which
many of its citizens did not think the country should have been involved. More concern
was expressed over relationships as the society became more psychologically attuned to
how people felt. The Leader–Member Exchange Theory evolved over the concern that
leadership was being defined by the leader, the follower, and the context. This new way of
looking at leadership focused on the interactions that occur between the leaders and the
followers. This theory claimed that leaders could be more effective if they developed better
relationships with their subordinates through high-quality exchanges.

After Vietnam and a series of weak political leaders, Americans were looking for people
to take charge who could really make a difference. Charismatic leaders came back into
vogue, as demonstrated by the support shown to President Ronald Reagan, an actor turned
politician. Unlike the Great Man Theory earlier in the century, this time the leader had to
have certain skills to transform the organization through inspirational motivational efforts.
Leadership was not centered upon transactional processes that tied rewards or corrective
actions to performance. Rather, the transformational leader could significantly change
an organization through its people by raising their consciousness, empowering them, and
then providing the nurturing needed as they produced the results desired.

In the late 1980s, the United States started to look more globally for ways to have better
production. Total Quality Management became a popular concept and arose from
researchers studying Japanese principles of managing production lines. In the healthcare

HISTORY OF LEADERSHIP IN THE UNITED STATES
CHAPTER 2 LEADERSHIP

setting, this was embraced through a process still used today called Continuous Quality
Improvement or Performance Improvement. In the decade to follow, leaders assigned
subordinates to a series of work groups in order to focus on a particular area of production.
Attention was placed on developing the team for higher level functioning
and on how a leader could create a work environment that could improve the performance
of the team. Individual team members were expendable, and the team entity was
all important.

CONTEMPORARY MODELS

We have entered the 21st century with some of the greatest leadership challenges ever in
the healthcare field. Critical personnel shortages, limited resources, and increased governmental
regulations provide an environment that yearns for leaders who are attentive
to the organization and its people, yet can still address the big picture. Several of today’s
leadership models relate well to the dynamism of the healthcare field and are presented
here. Looking at these models, there seems to be a consistent pattern of self-aware leaders
who are concerned for their employees and understand the importance of meaningful
work. As we entered the 2000s, the Self-Actualized Leadership Theory, taking the term
from Maslow’s top level in his Hierarchy of Needs (Maslow, 1943), defines this type of
leader. Today requires leaders to use Adaptive Leadership to create flexible organizations
able to meet the relentless succession of challenges faced (Heifetz, Grashow, & Linsky,
2009). Plus, today’s astute healthcare leaders recognize the importance of considering
the global environment, as health care wrestles with international issues that impact us
locally, such as outsourcing services, medical tourism, and over-the-border drug purchases.
See Table 2-2.

Emotional Intelligence (EI)

Emotional Intelligence (EI) is a concept made famous by Daniel Goleman in the late
1990s. It suggests that there are certain skills (intrapersonal and interpersonal) that a
person needs to be well adjusted in today’s world. These skills include self-awareness
(having a deep understanding of one’s emotions, strengths, weaknesses, needs, and drives),
self-regulation (a propensity for reflection, an ability to adapt to changes, the power to say
no to impulsive urges), motivation (being driven to achieve, being passionate about one’s
profession, enjoying challenges), empathy (thoughtfully considering others’ feelings when
interacting), and social skills (moving people in the direction you desire by your ability to
interact effectively) (Freshman & Rubino, 2002).

Since September 11, 2001, leaders have needed to be more understanding of their subordinates’
world outside of the work environment. EI, when applied to leadership, suggests
CONTEMPORARY
MODELS

TABLE 2-2 Leadership Theories in the United States
Period of Time Leadership Theory Leadership Focus

1920s and 1930s Great Man Having certain inherent traits
1940s and 1950s Style Approach Task completion and developing relationships
1960s Situational Approach Needs of the subordinates
Early 1970s Contingency and Path–Goal Both style and situation
Late 1970s Leader–Member Exchange Interactions between leader and subordinate
1980s Transformational Approach Raise consciousness and empower followers
1990s Team Leadership Team performance and development
2000s Self-Actualized Leadership Introspection and concern for meaningfulness
2010s Adaptive Leadership Build capacity to thrive in a new reality
2010s Global Leader Recognizing the impact of globalization for

their industry

a more caring, confident, enthusiastic boss who can establish good relations with workers.
Researchers have shown that EI can distinguish outstanding leaders and strong organizational
performance (Goleman, 1998). For health care as an industry and for healthcare
managers, this seems like a good fit. See Table 2-3.

Authentic Leadership

The central focus of authentic leadership is that people will want to naturally associate
with someone who is following their internal compass of true purpose (George &

TABLE 2-3 Emotional Intelligence’s Application to Healthcare Leadership
EI Dimension Definition
Leadership Application

Self-Awareness
A deep understanding of one’s emotions
and drives

Self-Regulation
Adaptability to changes and control over
impulses

Motivation
Ability to enjoy challenges and being
passionate toward work

Empathy
Social awareness skill, putting yourself in
another’s shoes

Social Skills
Supportive communication skills, abilities
to influence and inspire

Knowing if your values are congruent

with the organization’s
Considering ethics of giving bribes to
doctors

Being optimistic even when

census is low
Setting a patient-centered vision for
the organization

Having an excellent rapport
with the board
Sims, 2007). Leaders who follow this model are ones who know their authentic selves,
define their values and leadership principles, understand what motivates them, build a
strong support team, and stay grounded by integrating all aspects of their lives. Authentic
leaders have attributes such as confidence, hope, optimism, resilience, high levels of integrity,
and positive values (Brown & Gardner, 2007). Assessments given to leaders in a variety
of international locations have provided the evidence-based knowledge that there is a
correlation between authentic leadership and positive outcomes based on supervisor-rated
performance (Walumbwa , Avolio, Gardner, Wernsing, & Peterson, 2008).

Inspirational Leadership

This model’s focus is on leaders who inspire by giving people what they need. This
can be very different from what they want. Inspirational leaders are not perfect and in
fact expose their weaknesses so people can relate to them better. As with emotional intelligence,
empathy is recognized as important. Inspirational leadership supports the concept
known as “tough empathy,” which is the quality of leaders caring passionately about their
employees and their work yet being prudent in what they provide in the way of support.
Inspirational leaders will rely on intuition to act and use their uniqueness (e.g., expertise,
personality, or even something as simple as a greeting) as a way to distinguish themselves
in the leadership role (Goffee & Jones, 2000).

Diversity Leadership

Our new global society forces healthcare leaders to address matters of diversity, whether
with their patient base or with their employees. This commitment to diversity is necessary
for today’s leader to be successful. The environment must be assessed so that goals can
be set that embrace the concept of diversity in matters such as employee hiring and promotional
practices, patient communication, and governing board composition, to name
a few. Strategies have to be developed that will make diversity work for the organization.
The leader who recognizes the importance of diversity and designs its acceptance into
the organizational culture will be most successful (Warden, 1999). Healthcare leaders are
called to be role models for cultural competency (see Chapter 14 for more on this important
topic) and to be able to attract, mentor, and coach those of different, as well as similar,
backgrounds (Dolan, 2009).

Servant Leadership

Many people view health care as a very special type of work. Individuals usually work in this
setting because they want to help people. Servant leadership applies this concept to top

CHAPTER 2 LEADERSHIP
CONTEMPORARY MODELS

administration’s ability to lead, acknowledging that a healthcare leader is largely motivated
by a desire to serve others. This leadership model breaks down the typical organizational
hierarchy and professes the belief of building a community within an organization in
which everyone contributes to the greater whole. A servant leader is highly collaborative
and gives credit to others generously. This leader is sensitive to what motivates others and
empowers all to win with shared goals and vision. Servant leaders use personal trust and
respect to build bridges and use persuasion rather than positional authority to foster cooperation.
This model works especially well in a not-for-profit setting, since it continues the
mission of fulfilling the community’s needs rather than the organization’s (Swearingen &
Liberman, 2004).

Spirituality Leadership

Recently, the United States has experienced some very serious misrepresentations and
misreporting by major healthcare companies, as reported by U.S. governmental agencies
(e.g., HealthSouth, Tenet, and Paracelsus Healthcare). Trying to claim a renewed sense of
confidence in the system, a model of leadership has emerged that focuses on spirituality.
This spiritual focus does not imply a certain set of religious beliefs but emphasizes ethics,
values, relationship skills, and the promotion of balance between work and self (Wolf,
2004). The goal under this model is to define our own uniqueness as human beings and
to appreciate our spiritual depth. In this way, leaders can deepen their understanding and
at the same time be more productive. These leaders have a positive impact on their workers
and create a working environment that supports all individuals in finding meaning in
what they do (see Table 2-4). They practice five common behaviors of effective leaders as
described by Kouzes and Posner (1995): (1) Challenge the process, (2) Inspire a shared
vision, (3) Enable others to act, (4) Model the way, and (5) Encourage the heart, thus taking
leadership to a new level (Strack & Fottler, 2002).

TABLE 2-4 Spirituality Leadership’s Application
Behavior Definition Leadership Application
Challenge the process Always striving to do better Change management
Inspire a shared vision Collective sense of purpose Strategic orientation
Enable others to act Meeting needs of followers to Gaining trust and confidence to
get results achieve goals
Model the way Setting a personal example Coaching to motivate
Encourage the heart Developing others to find meaning Encouraging personal
in work development of followers
CHAPTER 2 LEADERSHIP

LEADERSHIP STYLES

Models give us a broad understanding of someone’s leadership philosophy. Styles demonstrate
a particular type of leadership behavior that is consistently used. Various authors
have attempted to explain different leadership styles (McConnell, 2003; Northouse, 2009;
Studer, 2008). Some styles are more appropriate to use with certain healthcare workers,
depending on their education, training, competence, motivation, experience, and personal
needs. The environment must also be considered when deciding which style is the
best fit.

In a coercive leadership style power is used inappropriately to get a desired response
from a follower. This very directive format should probably not be used unless the
leader is dealing with a very problematic subordinate or is in an emergency situation
and needs immediate action. In healthcare settings over longer periods of time,
three other leadership styles could be used more effectively: participative, pacesetting,
and coaching.

Many healthcare workers are highly trained, specialized individuals who know much
more about their area of expertise than their supervisor. Take the generally trained chief
operating officer of a hospital who has several department managers (e.g., Radiology,
Health Information Systems, Engineering) reporting to him or her. These managers will
respond better and be more productive if the leader is participative in his or her style.
Asking these managers for their input and giving them a voice in making decisions will let
them know they are respected and valued.

In a pacesetting style, a leader sets high performance standards for his or her
followers. This is very effective when the employees are self-motivated and highly
competent—e.g., research scientists or intensive care nurses. A coaching style is recommended
for the very top personnel in an organization. With this style, the leader
focuses on the personal development of his or her followers rather than the work tasks.
This should be reserved for followers the leader can trust and those who have proven
their competence. See Table 2-5.

TABLE 2-5 Leadership Styles for Healthcare Personnel
Style Definition Application
Coercive Demanding and power based Problematic employees
Participative Soliciting input and allowing decision making Most followers
Pacesetting Setting high performance standards Highly competent
Coaching Focus on personal development Top level
LEADERSHIP PROTOCOLS

LEADERSHIP COMPETENCIES

A leader needs certain skills, knowledge, and abilities to be successful. These are called
competencies. The pressures of the healthcare industry have initiated the examination
of a set of core competencies for a leader who works in a healthcare setting (Dye &
Garman, 2006; Shewchuk, O’Connor, & Fine, 2005). Criticism has been directed at
educational institutions for not producing administrators who can begin managing effectively
right out of school. Educational programs in health administration are working
with the national coalition groups (e.g., Health Leadership Alliance, National Center for
Healthcare Leadership, and American College of Healthcare Executives) and healthcare
administrative practitioners to come up with agreed upon competencies. Once identified,
the programs can attempt to have their students learn how to develop these traits
and behaviors.

Some of the competencies are technical—for example, having analytical skills, having
a full understanding of the law, and being able to market and write. Some of the competencies
are behavioral—for example, decisiveness, being entrepreneurial, and an ability
to achieve a good work/life balance. As people move up in organizations, their behavioral
competencies are a greater determinant of their success as leaders than their technical competencies
(Hutton & Moulton, 2004). Another way to examine leadership competencies
is under four main groupings or domains. The Functional and Technical Domain is
necessary but not sufficient for a competent leader. Three other domains provide competencies
that are behavioral and relate both to the individual (Self-Development and
Self-Understanding) and to other people (Interpersonal). A fourth set of competencies
falls under the heading Organizational and has a broader perspective. See Table 2-6 for a
full listing of the leadership competencies under the four domains.

LEADERSHIP PROTOCOLS

Healthcare administrators are expected to act a certain way. Leaders are role models for
their organizations’ employees, and they need to be aware that their actions are being
watched at all times. Sometimes people at the top of an organization get caught up
in what they are doing and do not realize the message they are sending throughout
the workplace by their inappropriate behavior. Specific ways of serving in the role of a
healthcare leader can be demonstrated and can provide the exemplary model needed to
send the correct message to employees. These appropriate ways in which a leader acts are
called protocols.

There is no shortage of information on what protocols should be followed by today’s
healthcare leader. Each year, researchers, teachers of health administration, practicing
CHAPTER 2 LEADERSHIP

TABLE 2-6 Leadership Domains and Competencies
Domain: Functional and Technical
Competencies:

Knowledge of business/business acumen
Strategic vision
Decision making and decision quality
Managerial ethics and values
Problem solving
Change management/dealing with ambiguity
Systems thinking
Governance

Domain: Interpersonal
Competencies:

Communication
Motivating
Empowerment of subordinates
Management of group process
Conflict management and resolution
Negotiation
Formal presentations
Social interaction
Domain: Self-Development and Self-Understanding
Competencies:

Self-awareness and self-confidence
Self-regulation and personal responsibility
Honesty and integrity
Lifelong learning
Motivation/drive to achieve
Empathy and compassion
Flexibility
Perseverance
Work/life balance
Domain: Organizational
Competencies:

Organizational design
Team building
Priority setting
Political savvy
Managing and measuring performance
Developing others
Human resources
Community and external resources
Managing culture/diversity
Source: Hilberman, Diana (Ed.), The 2004 ACHE-AUPHA Pedagogy Enhancement Work Group. June, 2005.

administrators, and consultants write books filled with their suggestions on how to be
a great leader (for some recent examples, see Dye, 2010; Ledlow & Coppola, 2011; and
Rath and Conchie, 2008). There are some key ways a person serving in a leadership role
should act. These are described here and summarized in Table 2-7.

Professionalism is essential to good leadership. This can be manifested not only in the
way people act but also in their mannerisms and their dress. A leader who comes to work
in sloppy attire or exhibits obnoxious behavior will not gain respect from followers. Trust
and respect are very important for a leader to acquire. Trust and respect must be a two-
way exchange if a leader is to get followers to respond. Employees who do not trust their
leader will consistently question certain aspects of their job. If they do not have respect for
the leader, they will not care about doing a good job. This could lead to low productivity
and bad service.
GOVERNANCE

TABLE 2-7 Key Leadership Protocols

1. Professionalism
2. Reciprocal trust and respect
3. Confident, optimistic, and passionate
4. Being visible
5. Open communicator
6. Risk taker/entrepreneur
7. Admitting fault
Even a leader’s mood can affect workers. A boss who is confident, optimistic, and
passionate about his or her work can instill the same qualities in the workers. Such enthusiasm
is almost always infectious and is passed on to others within the organization. The
same can be said of a leader who is weak, negative, and obviously unenthusiastic about his
or her work—these poor qualities can be acquired by others.

Leaders must be very visible throughout the organization. Having a presence can assure
workers that the top people are “at the helm” and give a sense of stability and confidence
in the business. Quint Studer (2009), founder and CEO of Studer Group, states
how “rounding” can help leaders meet certain standard goals: making sure that the staff
know they are cared about, know what is going on (what is working well, who should be
recognized, which systems need to work better, which tools and equipment need attention),
and know that proper follow-up actions are taking place. Leaders must be open
communicators. Holding back information that could have been shared with followers
will cause ill feelings and a concern that other important matters are not being disclosed.
Leaders also need to take calculated risks. They should be cautious, but not overly so, or
they might lose an opportunity for the organization. And finally, leaders in today’s world
need to recognize that they are not perfect. Sometimes there will be errors in what is said
or done. These must be acknowledged so they can be put aside and the leader can move
on to more pressing current issues.

GOVERNANCE

Individuals are not the only ones to consider in leadership roles. There can be a group of
people who collectively assume the responsibility for strategic oversight of a healthcare
organization. The term governance describes this important function. Governing bodies
can be organized in a variety of forms. In a hospital, this top accountable body is called a
board of trustees in a not-for-profit setting and a board of directors in a proprietary, or for-
profit, setting. Since many physician offices, long-term care facilities, and other healthcare
CHAPTER 2 LEADERSHIP

entities are set up as professional corporations, these organizations would also have a board
of directors.

Governing boards are facing heightened scrutiny due to the failure of many large corporations
in the last decade. The U.S. government recognizes the importance of a group of
people who oversee corporate operations and give assurances for the fair and honest functioning
of the business. Sarbanes-Oxley is a federal law enacted in 2002 that set new or
enhanced standards for proprietary companies that are publicly traded. Financial records
must be appropriately audited and signed off by top leaders. Operations need to be discussed
more openly so as to remove any possibility of cover-up, fraud, or self-interest. Each
governing board member has fiduciary responsibility to forgo his or her own personal
interests and to make all decisions concerning the entity for the good of the organization.
Many believe the not-for-profits should have the same requirements and are applying pressure
for them to fall under similar rules of transparency.

Although healthcare boards are becoming smaller in size, they recognize the importance
of the composition of their members. A selection of people from within the organization
(e.g., system leaders, the management staff, physicians) should be balanced with outside
members from the community (see Table 2-8). The trend is to appoint members who
have certain expertise to assist the board in carrying out its duties. Also, having governing
board members who do not have ties to the healthcare operations will reduce the possibility
of conflicts of interests. Board meetings have gone from ones in which a large volume
of information is presented for a “rubber stamp” to meetings that are well prepared,
purposeful, and focused on truly important issues. A self-assessment should be taken
at least annually and any identified problem areas (including particular board members)
addressed. This way, the governing board can review where it stands in its ability to give

TABLE 2-8 Healthcare Governance Trends
Function Old Way New Trend
Size of board
Membership
Conflicts of interest
Meetings
Evaluations
Large (10 to 20 people)
Many members from within
the organization
Some present, not disclosed
Voluminous detailed information
presented
If done, not taken too seriously
Smaller (6 to 12 people)
More balance of members within and
outside the organization
Must be disclosed but prefer none
Strategic information and
trends presented
Taken seriously to identify issues
and correct
Leadership Fiduciary and strategic responsibilities Generative source
BARRIERS AND CHALLENGES

fair, open, and honest strategic oversight (Gautam, 2005). A new way of looking at governance
goes beyond fiduciary and strategic responsibility, whereby the board serves as the
generative source of leadership, espousing the meaning for the organization’s healthcare
delivery (Chait, Ryan, & Taylor, 2005).

BARRIERS AND CHALLENGES

Health care is one of the most dynamic industries in the world. The only constant is
change. Healthcare leaders are confronted with many situations that must be dealt with
as they lead their organizations. Some can be considered barriers that, if not managed
properly, will stymie the capacity to lead. Certain other areas are challenges that must be
addressed if the leader is to be successful. A few of the more critical ones in today’s healthcare
world are presented here. See Table 2-9.

Due to the complex healthcare system in the United States, many regulations and laws
are in place that sometimes can inhibit innovative and creative business practices. Leaders
must ensure that the strategies developed for their entity comply with the current laws, or else
they jeopardize its long-term survivability. Leaders are expected to sometimes think “outside
the box,” i.e., go beyond the usual responses to a situation, to provide new ideas for the
development of their business, but this can be challenging when many constraints must be
considered. Some examples are the government’s antitrust requirements, which can affect
developing partners; federal moratoriums on certain services, which can affect growing the
business; and safe harbor requirements, which can affect physician relations. These and other
laws and regulations can affect a healthcare leader’s ability to lead.

The healthcare industry is unique. Major players in the arena, physicians, are not always
easily controlled by the medical organizations where they work (e.g., hospitals, insurance
companies, long-term care facilities). Yet this very influential group of stakeholders has
substantial input over the volume of patients that a healthcare facility receives. This necessitates
that the healthcare leader find ways to include doctors in the process of setting a

TABLE 2-9 Key Healthcare Leadership Barriers and Challenges

1. Laws and regulations (Barrier)
2. Physicians (Challenge)
3. New technology (Barrier)
4. Culture of safety (Challenge)
5. Resource limitation (Barrier)
6. Economy (Challenge)

CHAPTER 2 LEADERSHIP

direction, monitoring the quality of care, and fulfilling other administrative functions. The
wise healthcare leader will include physicians early on in any planning process. Doctors
are usually busy with their own patients and practices, but if they are not looked to for
their expertise and advice on certain important matters in the facilities where they work,
then they will become disengaged. This could cause essential functions to be overlooked.
It could also cause physicians to alter the referral patterns for their patients. Everybody
would much rather work at a place where their opinions are requested and respected.

Technology is a costly requirement in any work setting. Information systems management
and new medical equipment are especially expensive for the modern healthcare
facility or practice due to the rapidly changing data collection requirements and medical
advances in the field. Healthcare leaders must assess the capabilities of their entities for
new technology and determine if their systems and equipment are a barrier to making
future progress. Healthcare leaders cannot be successful if their organizations have antiquated
systems and out-of-date support devices in today’s high-tech world. Computer
hardware and clinical software must be integrated to provide the quality and cost information
needed for an efficient medical organization. Electronic medical records, wireless
devices, and computerized order entry systems, as well as advanced medical equipment
and new pharmaceuticals, will be items the leader must have in place in order to lead his
or her healthcare organization into the 21st century.

Safety concerns have traditionally been a management responsibility. However, safety
has become such an important issue in today’s healthcare world that leaders must be
involved in its oversight. A top-down direction must be given throughout the organization
that mistakes will not be tolerated. Coordinated efforts must shift from following up
on errors to preventing their recurrence to developing systems and mechanisms to prevent
them from ever occurring. The Joint Commission has leadership standards for all sectors,
calling for the leaders in the healthcare entity to accept the responsibility for fostering a
culture of safety. The focus of attention is on the performance of systems and processes
instead of the individual, although reckless behavior and blatant disregard for safety are
not tolerated (The Joint Commission, 2010).

ETHICAL RESPONSIBILITY

Ethics are principles determining behavior and conduct appropriate to a certain setting. It
is a matter of doing right vs. wrong. Ethics are especially important for healthcare leadership
and require two areas of focus. One area is biomedical ethics and the actions a leader
needs to consider as he or she relates to a patient. Another is managerial ethics. This
involves business practices and doing things for the right reasons. A leader must ensure an
environment in which good ethical behavior is followed.
LEADERS LOOKING TO THE FUTURE

TABLE 2-10 American College of Healthcare Executives Code of Ethics
Responsible Area
Sample Guidelines

To the profession
Comply with laws
Avoid any conflicts of interest
Respect confidences

To the patients or others served
Prevent discrimination
Safeguard patient confidentiality
Have process to evaluate quality of care

To the organization
Proper resource allocation
Improve standards of management
Prevent fraud and abuse within

To the employees
Allow free expression
Ensure a safe workplace environment
Follow nondiscrimination policies

To the community and society
Work to meet the needs of the community
Provide appropriate access to services
Advocate for healthy society

To report violations of the code
Healthcare executive–supplier interactions
Decisions near the end of life
Impaired healthcare executives

The American College of Healthcare Executives (ACHE) does an excellent job
in educating its professional membership as to the ethical responsibilities of healthcare
leaders (American College of Healthcare Executives, 2009). Ethical responsibilities apply
to several different constituencies: to the profession itself, to the patients and others served,
to the organization, to the employees, and to the community and society at large (see
Table 2-10). A healthcare leader who is concerned about an ethical workplace will not
only model the appropriate behavior but will also have zero tolerance for any deviation by
a member of the organization. A Code of Ethics gives specific guidelines to be followed
by individual members. An Integrity Agreement would address a commitment to follow
ethical behavior by the organization.

LEADERS LOOKING TO THE FUTURE

Some people believe that leaders are born and that one cannot be taught how to be a good
leader. The growing trend, however, is that leaders can, in fact, be taught skills and behaviors
that will help them to lead an organization effectively (Parks, 2005). In health care,
many clinicians who do well at their jobs are promoted to supervisory positions. Yet they
do not have the management training that would help them in their new roles. For example,
physicians, laboratory technologists, physical therapists, and nurses are often pushed
into management positions with no administrative training. We are doing a disservice to
these clinicians and setting them up for failure.

Fortunately, this common occurrence has been recognized, and many new programs
have sprouted to address this need. Universities have developed executive programs to
attract medical personnel into a fast-track curriculum to attempt to give them the essential
skills they need to be successful. Some schools have developed majors in healthcare leadership,
and some healthcare systems have started internal leadership training programs. This
trend will continue into the future, since healthcare services are expected to grow due to
the aging population, and thus there will be a need for more people to be in charge. In
addition, leaders should continually be updated as to the qualities that make a good leader
in the current environment, and therefore, professional development, provided through
internal or external programs, should be encouraged. The Baldrige National Quality
Program recognizes in its most recent criteria for performance excellence the need for
senior leaders to create a sustainable environment for their organizations through the continual
development of future leaders by enhancing their personal leadership skills (Baldrige
National Quality Program, 2009). Yet Garman and Dye (2009) caution us to distinguish
leader development from leadership development. They call for the need to bind leadership
development activities into a collective network of leaders who are linked to organizational
level goals rather than each leader’s individual performance. Further understanding
of the difference can be explained through decision making. A leader collaborating with
his or her superior would be considered leader development, but in leadership development,
the process would be team based.

Each of the different sectors in health care has a professional association that will support
many aspects of its particular career path. These groups provide ongoing educational
efforts to help their members lead their organizations. Another benefit for leaders is that
these groups provide up-to-date information about their particular field. Professional
associations are a good way to network with people in similar roles, a highly desirable
process for healthcare leaders. Also, ethnic professional associations link healthcare leaders
from representative minority groups as they attempt to increase diversity in the healthcare
profession and improve health status, economic opportunities, and educational advancement
for their communities. Most of these various professional groups have student chapters,
and early involvement in these organizations is highly recommended for any future
healthcare leader. Table 2-11 lists some of these associations.

To prepare an organization for the future, its leader needs to be looking out for opportunities
to partner with other entities. Health care in the United States is fragmented, and
to be successful, different services need to be aligned and networks need to be created that
will allow patients to flow easily through the continuum of care. It is the astute leader who
can determine who are the best partners and negotiate a way to have a win–win situation.

CHAPTER 2 LEADERSHIP
LEADERS LOOKING TO THE FUTURE

TABLE 2-11 Professional Associations
Name Acronym Targeted Career Website
American College of ACHE Health administrators www.ache.org
Healthcare Executives
Healthcare Financial HFMA Healthcare chief financial www.hfma.org
Management Association officers
Association for University AUPHA Health administration www.aupha.org
Programs in Health education
Administration Program directors
Medical Group Management MGMA Medical groups www.mgma.org
Association administrators
American College of Health ACHCA Long-term care www.achca.org
Care Administrators administrators
American Academy of Nursing AAN Nurse leaders www.aannet.org
American College of Physician ACPE Physician leaders www.acpe.org
Executives
National Association of Health NAHSE Black healthcare leaders www.nahse.org
Services Executives
National Forum for Latino NFLHE Latino healthcare leaders www.nflhe.org
Healthcare Executives
Asian Health Care Leaders AHCLA Asian healthcare leaders www.asianhealthcareleaders
Association .org

Of course, these efforts to develop partnerships must be in line with the organization’s
mission and vision, or the strategic direction will have to be reexamined.

A leader who is concerned about the future will stay on top of things in the healthcare
industry. Reading newspapers, industry journals, and Web reports, as well as attending
industry conferences, helps to keep leaders in the know and allow them to determine how
changes in the field could impact their organization. Leaders who remain current will be
better positioned to act proactively and to provide the best chance for their organizations
to seize a fresh opportunity.

The healthcare leader who is concerned about the future, as well as today’s business,
must continuously reassess how he or she fits in the organization. Nothing could be worse
than a disenchanted person trying to lead a group of followers without the motivation and
enthusiasm needed by great leaders. A leader should consider his or her own succession
planning so that the organization is not left at any time without a person to lead. Truly
unselfish leaders think about their commitment to their followers and do their best to
ensure that consistent formidable leadership will be in place in the event of their departure.
CHAPTER 2 LEADERSHIP

This final act will allow adequate time for a smooth transition and ensure the passage of
accountability so that the followers can realign themselves with the new leader.

Finally, the recently enacted Patient Protection and Affordable Care Act may not yet
provide us full healthcare reform, but it will dramatically alter the way health insurance
is administered. A call is made for a new breed of leaders at every level to tame the chaos
associated with this dynamic industry (Lee, 2010). These will certainly be challenging
times for healthcare leaders, and some of the key elements identified for success will be perspective,
adaptability, and finding their inner passion as a personal driving force (Sukin,
2009). There is no doubt there will be opportunities for leaders in all disciplines to make
a difference for their organizations and their communities as we enter this exciting new
phase of American healthcare delivery.

DISCUSSION QUESTIONS

1.
What is the difference between leadership and management?
2.
Are leaders born, or are they trained? How has the history of leadership in the United
States evolved to reflect this question?
3.
List and describe the contemporary models of leadership. What distinguishes them
from past models?
4.
What are the leadership domains and competencies? Can you be a good leader and
not have all the competencies listed in this model?
5.
Why do healthcare leaders have a higher need for ethical behavior than might be
expected in other settings?
6.
Do healthcare leaders have a responsibility to be culturally competent? Why or
why not?
7.
Why is emotional intelligence important for healthcare managers? Identify three
ways someone who is new to the field can assess and develop his or her EI quotient.
Cases in Chapter 17 that are related to this chapter include:
Choosing a Successor—see p. 444….
Emotional Intelligence in Labor and Delivery—see p. 434….
The Merger of Two Competing Hospitals—see p. 406….
Additional cases, role-play scenarios, video links, websites, and other information
sources are also available in the online Instructor’s Materials.

REFERENCES

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CHAPTER 2 LEADERSHIP

Additional Websites to Explore
National Center for Healthcare
Leadership: www.nchl.org
Health Leadership Council: www.hlc.org
National Public Health Leadership
Institute: www.phli.org
World Health Organization
Leadership Service: www.who.int/health_leadership
Health Leaders Media: www.healthleaders.com
Institute for Diversity of Health
Management: www.diversityconnection.org
Healthcare Leadership Alliance
Competency Directory: www.healthcareleadershipalliance.org/
Coach John Wooden’s Pyramid of Success: www.coachwooden.com

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