The successful department chief: Essential skills, considerations in a changing landscape

As new chiefs and chairs start to take on their new jobs during this dynamic era, it’s clear that the role of the chief has changed dramatically over time.

Decades ago, chiefs were usually responsible for small departments, overseeing the research, clinical and educational mission of an academic medical center. Now, they often lead large clinical enterprises that expand to an entire healthcare network. Much has been written about the increasing need for management experience to ensure success in these important roles, and that urgency has increased as new clinical imperatives continue to expand. 

With these changes in mind, what should we be looking for in chiefs? What skills do they need to be successful? And how can we align incentives to further their success?

What to look for in a chief

The ideal chief would not only have expertise in the tripartite mission, but also some advanced management training or experience. Notably, this requirement could work against some candidates, so it needs to be applied carefully. For example, people who have been doing challenging jobs in a more matrixed support role, such as residency director or medical director, may have developed very robust skills that aren’t recognized by our traditional criteria. In many cases, providing augmented, deliberate training and personnel in areas where a chief may need time to develop skills is a great way to onboard a highly emotionally intelligent and adaptable chief who has all the skills of a great leader but may not have traditional managerial experience. 

What skills do chiefs need to acquire for success?

The two biggest gaps I usually see in new chiefs' experience are basic budgeting or fiscal vocabulary, and managing disruptive faculty. Much of basic finance is intuitive and straightforward addition, subtraction and division, but the vocabulary and syntax may not be obvious without a little training. Just as a nonmedical professional might not understand or be able to put into context what a normal sodium level is, some of the data, such as what is the recommended days cash on hand, may not make sense unless you have some experience.

The gap in managing faculty is twofold: lack of experience in handling disruptive physicians and the panic that there will be a patient care gap or an unmanageable research consequence if someone is put on leave or terminated. In my experience, however, no one ever says, "we broke up too early." While most situations can be improved with a matter of fact conversation, it's also not uncommon for reported issues to be the tip of the iceberg and in those cases more definitive approaches are required. Better to break up in many of the cases as challenging situations often only get worse with time. Having experience, or a human resources expert to help, can assist in identifying which problems are terminal and which can be changed with rehabilitation and communication, or creative solutions.

How do we align incentives to further success?

Obviously there are a number of compensation levers that can be used to incentivize chiefs toward certain types of performance. However, serious challenges can arise when the chief prioritizes performance indicators that he or she delegates to other team members who don't stand to benefit personally from that success, instead of working on them directly. A novel idea proposed by some is to incentivize chiefs to achieve certain goals by giving money back to their department for initiatives. This aligns nicely with the concept that chiefs often view their primary role as stewards of their faculty and department.

In conclusion, it's important to recognize that a lack of managerial experience should not be fatal to a good candidate for department chief. He or she can often learn those fiscal, HR or other managerial skills, while delegating them to experts at the start. Excellent communication skills, confidence in decision-making, deft "people skills" and emotional intelligence are essential attributes to look for in a chief. 

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