Changing healthcare landscape demands transformational leaders

Training required beyond traditional development plans – and tough decisions when training isn't enough

Rapid pace of change demands transformational leadership

Our nation's health care system continues to experience significant, and at times, dramatic change. The operational, relational, and analytical challenges characteristic of change can only be met with effective leadership at all levels. Transformational leaders must demonstrate capabilities beyond general management skills and supervisor competencies. These leaders must be able to:

• Serve as a role models by "walking the talk"
• Inspire and motivate others
• Demonstrate genuine concerns for the needs and feelings of others
• Challenge others to be innovative and creative

Compared to traditional management skills, these capabilities are more difficult to address in development plans. Therefore, organizations can face difficult situations when promoting key leaders from within who may not be capable of demonstrating the leadership required of their new roles.

Promoting from within demands thoughtful leadership development

In health care, promoting from within is typical: and often an effective method for engagement and development. It may however, assume advanced skills that are not present in the individual being promoted. As a result, appropriate training may not be offered, leading to ineffective leadership at critical service line and departmental levels. Skills that contributed to success as an individual contributor or lower level supervisor are no longer sufficient.

It's understandable that training in the form of leadership development may be overlooked. Advancements in technology; new approaches to performance management (i.e. process improvement systems, analytics); and the rapid pace of regulatory and reimbursement change can prioritize skills training over leader development resulting in ineffective leader competencies.

As a result, recently promoted managers are able to organize and supervise the tasks of the department, but do not possess the high level leadership skills that are required to foresee change and take people through it. Leaders in this scenario are able to manage work but may have trouble leading people.

Closing the gap between management and leadership

Management is the ability to design, develop, implement, and maintain work (tasks and processes). These competencies are frequently not enough to support the vision and strategies of the organization. Without strong leadership to foresee change and effectively take people through strategies will fail.

Competencies associated with transformational leadership are challenging to teach through traditional development plans and performance reviews. The first step is to identify leadership characteristics essential to success for their particular organization, such as:

• Personal integrity/honesty
• Open, approachable style
• Confidence and optimism
• Clear and effective communication
• Great listening skills
• Capacity to engage individuals at all levels
• Ability to "manage up" to engage superiors and peers
• Ability to articulate vision/values and translate to day-to-day operations and individual goals
• Accountability: holds self and team to outcomes and timelines

When organizations retain weak leaders

There is a paradox for promoting from within versus external recruitment. Organizations demand these leadership skills when recruiting. Yet, these capabilities are infrequently used to evaluate the effectiveness, and subsequent retention of existing leaders. As a result, organizations may retain weak leaders. Rationale may include length of service and mastery of the clinical/technical aspects of roles.

Clearly, coaching and development are crucial steps when a leader, promoted from within, lacks critical competencies. When coaching doesn't work, though, organizations are faced with a conundrum. Demoting or dismissing an ineffective leader may seem inconsistent with the leader's self-image and may not seem to support the organization's values and philosophy.

Organizations must examine these situations from a "greater good" perspective, noting the negative impact of retaining an ineffective leader. Often, decision-makers have not undertaken an honest and thorough inventory of the ramifications of poor leadership, such as:

• Culture of mistrust and disrespect
• Poor safety/quality performance
• Consistent failure to achieve goals
• Retention and recruitment challenges
• Inefficiency, high cost
• Damage to reputation
• Self-aggrandizement
• Misalignment of knowledge and perceived knowledge

The impact of ineffective leadership is too high to ignore. Organizations must resist the tendency to focus only on skills and competencies. Clear and well-defined personal characteristics for leadership must be presented as expectations for the role. Behaviors that represent these should be described in detail. An effective development plan in this area is a challenge to structure and to evaluate; and success is less likely than with traditional plans. This means that removal of a long tenured leader may ultimately need to occur.

Case Study

An outstanding critical care nurse with an excellent reputation and technical proficiency was respected by her peers and supervisors; and loved by her patients. She was promoted to Unit Director because of her outstanding performance in her direct care role.

During her four years as Director, she received two annual evaluations by the VP of Nursing, identifying key concerns:

• Timeliness on management tasks (employee evaluations and time schedules)
• Reliability in attending critical nursing management meetings
• Communications with physicians

During the same period, staff completed two employee engagement surveys, noting of the Director:

• Lack of feedback regarding major hospital strategies and initiatives
• Perception of being "put off" when requesting discussions with Director who seemed "too busy"
• Generally low scores for communication, feedback, and recognition
• Overall survey ranking in the lowest quartile

As a result, the VP requested a meeting to develop an improvement plan, and six subsequent monthly meetings to review progress. Upon completion of the improvement plan:

• The Director improved in

  • The organization and efficiency of management tasks
  • Reliable attendance at meetings

• The Director continued to struggle with

  • Effective communication with physicians
  • Ability to lead through difficult organization changes

Noting lack of improvement in vital areas of communication, engagement, and credibility; the VP came to the difficult and emotional conclusion to remove the Director from her role. When discussing this decision, the Director was tearful and attributed her low performance to others. She demonstrated little insight into the nature of the problems and offered no ideas for solution. After learning of the decision, she even rallied staff and peers to advocate for the decision to be overturned.

The Director was offered a role in the Quality Department as a clinical research and review nurse. The VP felt her methodical approach would be a good fit for the technical, detail-oriented nature of this role.

Three years later, the Director is in her role, has completed an advanced degree, and thanked the VP for moving her to a position more suited to her skills and interests. The Unit for which the director was previously responsible is performing well under the leadership of an individual recruited for excellent engagement and communication skills.

In the end, a leader's personal actions guide and sustain the organization. How she articulates and deploys its vision and values are critical to success. It is essential that a leader has a well-developed sense of self-awareness, and understands the effect of her presence and actions on others. Hard personnel decisions require that issues are faced objectively and realistically, while maintaining a fair and sensitive attitude towards those involved. Acceptance of a leader role implies an attitude of "what is best for my organization?" Answering this question in an informed and honest manner has proven to yield the most successful decisions and ultimate results.

Carrie Alexander
Carrie is a senior consultant with Findley Davies, helping clients integrate well-being within organizational culture and health care strategy. Carrie designs, develops, implements, and measures wellness initiatives for large employers in a variety of industries.

Patricia Ruflin, RN, MA
Patricia is a principal with SRM Consults, providing hospitals, health systems, physicians and long term care facilities with leadership and strategic planning. Ruflin is a former hospital CEO with more than 25 years of executive management experience

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.​


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