Leadership Development in Healthcare: A Qualitative Study

Author(s): Ann Scheck McAlearney

Source: Journal of Organizational Behavior, Vol. 27, No. 7, Special Issue: Healthcare: The
Problems are Organizational not Clinical (Nov., 2006), pp. 967-982
Published by: Wiley
Stable URL: http://www.jstor.org/stable/4093879
Accessed: 26-05-2015 08:44 UTC
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Journal of OrganizationalBehavior
J. Organiz. Behav. 27, 967-982 (2006)
Published online in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/job.417

*WILEY

SInterScience@

DISCOVER
SOMETHING
GREAT

Leadership development in healthcare:

A qualitative study
ANN SCHECK McALEARNEY*
Divisionof HealthServicesManagement
andPolicy,Schoolof PublicHealth,TheOhioState
Columbus,
Ohio,U.S.A.
University,

Summary

Challenges associated with leading a $1.7 trillion industry have created a need for strong
leaders at all levels in healthcare organizations.However, despite growing support for the
importance of leadership development practices across industries, little is known about
leadershipdevelopmentin healthcareorganizations.An extensive qualitativestudy comprised
of 35 expert interviews and 55 organizational case studies included 160 in-depth, semistructuredinterviews and explored this issue. Across interviews, several themes emerged
aroundleadershipdevelopmentchallenges that were particularlysalient to healthcareorganizations. Informantsdescribedhow the relative newness of leadershipdevelopmentpractices
in a majority of healthcareorganizationscontributesto an overall perception of haphazard
practices throughoutthe industry.In addition, respondentsnoted challenges associated with
developing leaders who would be representative of the patient community served, and
commented on the pressure to segregate different professional groups for leadership development. Framed by these challenges, I propose a conceptual model of commitment to
leadershipdevelopmentin healthcareorganizationsas influenced by three factors-strategy,
culture, and structure.These, in turn, influence program design decisions and can impact
organizationaleffectiveness. In the context of inherently complex healthcare organizations
where leaders must respond to multiple stakeholders and meet performance goals across
multiple dimensions of effectiveness, addressing these reported challenges and considering the importance of organizational commitment to leadership development can help
ensure that programsare effectively designed, delivered, and sustained. Copyright ? 2006
John Wiley & Sons, Ltd.

Introduction
A sense of crisis is building about how healthcare organizations will meet their leadership needs in the
future (Institute for the Future, 2000; Mecklenburg, 2001; Schneller, 1997). Yet few healthcare
organizations have made substantial investments in developing their leaders. Although bombarded by
constant and rapid change within the $1.7 trillion industry (Smith, Cowan, Sensenig, Catlin, & Health
Accounts Team, 2005), healthcare organizations are frequently slow to adopt best practices from other
industries. Instead, the industry struggles to respond to crucial needs including reducing unnecessary
medical errors (Kohn, Corrigan, & Donaldson, 1999), increasing investments in information
* Correspondence
to:AnnS. McAlearney,
Divisionof HealthServicesManagement
andPolicy,TheOhioStateUniversity,
Cunz
@osu.edu
Hall,Room476, 1841MillikinRoad,Columbus,OH43210-1229,U.S.A.E-mail:mcalearney.1

Copyright ? 2006 John Wiley & Sons, Ltd.

Received 30 January 2005

Revised 30 January 2006
Accepted 29 June 2006

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968

A. S. McALEARNEY

technologies (Benchmarks,2002), and addressingthe glaring inequities and disparitiesin both access
to care and medical treatment(Kerr,McGlynn,Adams, Keesey, & Asch, 2004; McGlynn et al., 2003;
Smedley, Instituteof Medicine, Stith, & Nelson, 2002). This article addressesthe gaps in leadership
development within healthcareorganizationsand contextual factors that hamperclosing these gaps.
Certain features of healthcare organizations are clearly unique to the industry (Ramanujam&
Rousseau,2004). Althoughphysiciansplay a centralrole in the delivery of healthcareservices, they are
rarely employed by providerorganizations,and are thus typically outside the purview of traditional
humanresourcespractices and leadershipdevelopmentinitiatives.In addition,the professionalnorms
and practice standardsexpected of physicians and other medical professionals create demands for
continuedclinical education and developmentthat the organizationmust facilitate,but that are rarely
linked to the education and developmentpriorities of the healthcareorganizationitself. Further,the
multiple constituencies of healthcare organizations including patients, families, insurers, and
regulatorsthat compete to influence healthcarehave varied perspectives about care delivery and its
dynamics, and these divergent views contribute to considerable complexity around definitions of
organizationaleffectiveness and impact for healthcareleaders to interpret.

Challengesfor leadership in the healthcare industry

Complexity in the healthcare industry undoubtedly creates special challenges for leadership and
leadership development, stemming from a combination of both environmentaland organizational
factors. Environmentally,healthcareorganizationsare faced with a myriad of regulatoryinfluences
largely out of theircontrol.Forexample, most hospitalsreceive a majorityof theirreimbursementfrom
public sources, includingthe Federally-sponsoredMedicareprogramandthe co-sponsoredFederaland
State-fundedMedicaidprogram.Yet these providerorganizationsrarelyhave much power or influence
over reimbursementrates, and reimbursementfor both hospital and physician services may be below
the actual cost of providing care. As a result, hospitals are challenged to manage fragile budgets and
often shifting reimbursementrates, while needing to deliver high-quality care regardlessof payment
source or adequacy.
Organizationally, healthcare organizations are notorious for seemingly chaotic internal
coordination. Multiple hierarchies of professionals, on both the clinical and administrative sides
of the organization, generate special challenges for directing the organization and coordination of
work in healthcare. Often noted is the cultural chasm between administratorsand clinicians (e.g.,
Friedson, 1972; McAlearney, Fisher, Heiser, Robbins, & Kelleher, 2005; Shortell, 1992). Even
within clinical ranks, divisions exist associated with professional distinctions such as between
physicians and nurses, pharmacists and physicians, and so forth. Such differences create
considerable challenges for leadership as organizations struggle to manage their varied employed
and contracted worker populations.
Competing organizationalpriorities create constant challenges for healthcare leaders charged to
direct and appropriatelyutilize financialand humanresourcesto best serve patients,communities,and
other stakeholdersand constituents. The needs of multiple internal and external stakeholdersoften
conflict. An oft-repeatedphrase is the notion of "no mission, no margin,"reflectingthe fundamental
importanceof maintainingthe healthcareorganization'sfinancialviability in orderto serve the needs of
patients and the community.Though goals may be clearerin for-profithospitals or healthcaresystems
in which shareholderdemands mandatea focus on financials, such settings still requireprofessional
commitments and face ethical concerns.
Managerial and organizational learning receive relatively little attention in health care
organizations. Management mistakes in healthcare are rarely acknowledged or examined as useful
sources of organizational learning (Hofmann, 2005; Hofmann & Perry, 2005; Jones, 2005; Kovner
Copyright? 2006 JohnWiley& Sons,Ltd.

J. Organiz.Behav.27, 967-982 (2006)

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IN HEALTHCARE 969
DEVELOPMENT
LEADERSHIP

& Rundall, 2006; Russell & Greenspan, 2005). For example, the failed merger between Stanford
and UCSF Medical Center could have been predicted by a review of both general and healthcarespecific management literature, yet several years and millions of dollars later, the two systems
separatedto become independent systems once again (Russell, 2000). In healthcare settings, there
is often little attention given to how to improve management practice, increasing the likelihood that
previous mistakes will be repeated.

Conceptual Background
Healthcare leadership needs
Clinical and organizationalchallenges combined increasethe need for strongleadershipat all levels of
healthcare organizations. Considerable evidence supports the notion that leaders and their actions
affect organizational results (Fuller, Paterson, Hester, & Stringer, 1996; Lowe, Kroeck, &
Sivasubramaniam,1996; Sashkin & Rosenbach, 2001; Smith, Carson, & Alexander, 1984). In
healthcareorganizations,the impact of leadersextends to the lives and well-being of patientsand their
communities. Featuresof healthcaredelivery make these effects distinct. For example, in contrastto
other customers and consumers, the vulnerability of patients and the problem of asymmetric
information in healthcare delivery choices are frequently mentioned as contributorsto patients'
position as a unique category of customers(Newhouse, 2002). The typically dual role of physicians as
both consumers of healthcareresources and controllersof organizationalrevenues in their ability to
direct patients and prescribe care, makes leader relationships with physicians fairly atypical in
comparisonwith key stakeholderrelationshipsin other industries.
Further, researchers and authors have recently emphasized that great leadership must be
transformational,requiringleaders to be able to empower and motivate their workforce, define and
articulatea vision, build andfoster trustandrelationships,adhereto acceptedvalues and standards,and
inspire their followers to accept change and meet organizationalgoals on multiple levels (Bass, 1985;
Bennis, 1989; Bono & Judge,2003; Burns, 1978; Gardner,1990; House, 1977; House & Shamir,1993;
Kouzes & Posner, 1993, 1995). Yet a sense of how to best develop these great,transformationalleaders
is far from established, especially in healthcareorganizations.

Leadershipdevelopmentpractices
Leadership development practices are defined as educational processes designed to improve the
leadershipcapabilitiesof individuals.These practicesarerootedin the traditionsof managementtraining
programsdesigned to improve both individualmanagerialskills and job performance(Burke & Day,
1986), and can have importanteffects on both organizationalclimate (Moxnes & Eilertsen, 1991) and
organizationalculture(Schein, 1985). Practicesin leadershipdevelopmentare a variantof management
developmentpracticeswhich are defined as interventionsthat are intendedto enhance effectiveness or
improve organizationalcultureby facilitatingmanagers'learning (Gray & Snell, 1985).
CongerandBenjamin(1999) outline four generalapproachesto leadershipdevelopmentthatinclude
developing the individual leader, socializing company vision and values, strategic leadership
initiatives, and action learning (Conger & Benjamin, 1999). Within organizations, leadership
developmentpracticescommonly include activities such as 360-degree feedback, skill-basedtraining,
job assignments,developmentalrelationships(e.g., mentoring,coaching), and action learning(McCall,
Lombardo, & Morrison, 1998; McCauley, Moxley, & VanVelson, 1998; Revans, 1980). Although
considerable variability exists across organizations and industries with respect to the balance and
Copyright? 2006 JohnWiley& Sons,Ltd.

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970

A. S. McALEARNEY

content of leadershipdevelopmentprograms,programdesigns are generally consistent with the four

basic frameworks outlined above. This consistency presents opportunities to explore program
development challenges and decisions in a particular set of organizations, such as healthcare
organizations,ratherthan focus on programfeatures and details.

Leadership developmentin healthcare

Anecdotal evidence suggests the healthcare industry lags behind other industries with respect to
leadershipdevelopmentpractices and other humanresourcesfunctions,but these issues have not been
systematically investigated. This exploratory study is designed to improve our understandingof
leadership development practices in healthcare organizationsby asking experts and organizational
representativesto describe their views of leadershipdevelopmentin healthcare,and to propose future
directions for healthcareleadershipdevelopment.

OrganizationalContext

External Environment
The $1.7 trillionU.S. healthcareindustryis bothextensiveandcompetitive,with nearly5,000 hospitals
and 700,000 physiciansnationwide.Most marketsaredominatedby not-for-profithospitalsandhealth
systems,yet these healthcareorganizationsaresubjectto strongpressureto adhereto rigorousbusiness
principlesin orderto remainviable and realize their organizationalmissions.
Industry Factors
Severalfeaturesof the healthcareindustryareclearlyunique.Forinstance,while physiciansarerarely
employed by hospitals or health systems, they play a central role in directing and utilizing
organizationalresources,creatingchallengesfor organizationalleaders.Similarly,externalinfluences
from thirdpartiesincludinginsurancecompanies,employers,and governmentpayersdrive strategic
organizationalprioritiesaroundissues such as cost containmentand quality improvement.
Organizational Factors
Inside healthcareorganizations,internalcoordinationis often reportedlypoor, leading to avoidable,
expensive, and often devastatingmedical and managerialmistakes. The cultural chasm between
administratorsand clinicians contributesto a sense of chaos, with workersoften identifying more
with their professional peers than with the organization.Further,human resources functions in
healthcareorganizationshave historicallybeen limited in scope, and rarelyvalued for any strategic
role in contributingto organizationalsuccess.
Current Problems Faced
Enhanced focus on strategic prioritiesin healthcarehas increased organizations' attentionto the
need to develop and improve their humanresourcescapabilities. Yet, despite evidence from other
industries about the roles and opportunities for leadership development in organizations, our
understandingof leadership development practices in healthcareorganizationswas limited.
Time
This study was conducted in 2003 and 2004, during a period of rapid change in the healthcare
industry. Intensifying demands for new information technologies in clinical practice, error
reduction in medicine, and new capabilities among healthcare knowledge workers increased
pressure to better prepareleaders at all levels in healthcareorganizations.

Copyright? 2006 JohnWiley& Sons,Ltd.

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IN HEALTHCARE 971
DEVELOPMENT
LEADERSHIP

Methods
Study design
I conducted 35 key informantinterviews with individualsconsidered experts in healthcareleadership
on the basis of their nationalreputation,and studied 55 organizationsreportedto provide healthcare
leadership development trainingeither in-house or as a vendor to healthcareproviderorganizations.
The combinationof expertinterviewsand organizationalcase studiesincluded a total of 160 interviews
conducted between September2003 and December 2004. Table 1 shows the characteristicsof study
participantsacross expert interviews and case studies.
I used standard,semi-structuredinterview guides including open-endedquestions to both frame the
interviews and permit probing for additional information (Miles & Huberman, 1994) in the expert
interviewsand case studies.The originalinterviewguides were pilot tested with healthcareleadersand
provider organizationsin the local area.
This qualitative design (Maxwell, 1996) enabled me to meet the objectives of my research,
permittingexplorationof the differentissues that emerged aroundthe topic of leadershipdevelopment
in healthcare.A qualitativeapproachwas appropriatefor this study because of the exploratorynature
of my research,and because I suspectedthat experts' and organizations'perspectivesaboutleadership
development were multidimensional, making them difficult to examine quantitatively (Miles &
Huberman,1994). In addition,my use of qualitativemethods enabled me to explore both experiences
and predictionsof experts and organizationalrepresentatives,and providedrich informationaboutthe
multiple facets of leadershipdevelopmentchallenges in healthcare(Crabtree& Miller, 1999; Miles &
Huberman,1994). No potentialinformantcontactedrefusedto participatein the study.All participants
were assured that their voluntaryparticipationwould remain anonymous.

Expert interviews
Expert key informantswere purposely selected based on their reputationin the healthcareindustry
using a snowball sampling technique. The original sample of key informantswas generated by the
industry and academic members of the national Center for Health Management Research (Seattle,
WA), and the sample was extendedby study informantswho were asked to suggest additionalexperts
Table1. Studyparticipants
Number(%)

Description

15 (43%)
12 (34%)
8 (23%)

Expertsinterviewed

Associationleaders
Universityfaculty
Industryconsultants

case studies
Organizational

Healthcareproviderorganizations
Leadershipdevelopmentprogramvendors

35

Total

Total

case study
Organizational
informants

43 (78%)
12 (22%)
55

Executive-levelInformant
Director-levelInformant

39 (31%)
51 (41%)

Manager-level Informant

23 (18%)

12 (10%)

Programparticipant

125
160

Total
Total key informants

Copyright? 2006 JohnWiley& Sons,Ltd.

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972

A. S. McALEARNEY

for the study interviews. Experts had a variety of current and former affiliations, including with
healthcare industry associations, universities, consulting organizations, and provider organizations.
Data saturationwas judged to be reached when informants'suggestions about key informantswere
repetitive, and when no new insights were emerging from the ongoing data analysis (Morse, 2000).
Interviewswere conductedboth in-personand telephonically,using rigorousethnographicinterview
techniques (Spradley, 1979). Interviews lasted 45-90 minutes, with an average durationof 1 hour,
consistentwith the methodssuggestedfor in-depthinterviews(McCracken,1988). Expertswere askedto
describetheirown healthcareleadershipandleadershipdevelopmentexperiences,andto commenton both
the currentstatus of and programdevelopmentopportunitiesfor leadershipdevelopmentin healthcare.

Organizationalcase studies
Similar to expertinformants,organizationswere purposelysampledbased on theirreportedexperience
and reputationwith leadershipdevelopmentin healthcare.The original sample was again producedby
the membersof the Centerfor Health ManagementResearch,and extended based upon conversations
with experts and other organizational informants. Fifty-five organizations were studied between
September2003 and December 2004. Five organizationswere studiedin personin orderto efficiently
complete multiple key informantinterviews, while the remaining organizationswere studied using
numerous telephone interviews. One hundred twenty-five interviews were held as part of the
organizationalcase studies.These case studies(Yin, 1984) consisted of interviewswith key informants,
in additionto collection and studyof documentsassociatedwith the leadershipdevelopmentprograms,
and a review of publicly available programinformationaccessible throughformal publicationor the
Internet.Interviews lasted 30-90 minutes, with an average of 45 minutes for each interview.
Organizations studied included both healthcare provider organizations with internal leadership
developmentactivities and externalorganizationswhich provide leadershipdevelopmentprogramsto
individualsand institutionsin the health services industry.Internalcase study organizationsconsisted
of 43 healthcare systems and individual hospitals which had reportedlydesigned and implemented
healthcare leadership development programs, and respondents included executives, directors,
managers, and program participants. Twelve external case study organizations included both
healthcare associations and other vendors of healthcare leadership development programs, with
respondents including individuals leading the organizations and those developing and delivering
healthcareleadership development programs.
Questions addressed the structure and format of leadership development program activities,
including approachesto identifying and targetingindividualsand groups for leadershipdevelopment
opportunities.Similar to the expert interviews, an open-ended list of questions was used, including
questions probing for more information.

Analyses
A majorityof the interviewswere audiotapedand professionallytranscribed,with extensive field notes
used in the small numberof cases (3) where taping was infeasible. This process yielded 160 transcripts
and over 1,000 single-spaced pages for analysis.
My analysesused the constantcomparativemethodof qualitativedataanalysis(Glaser& Strauss,1967),
and common techniquesto code the data (Constas, 1992; Miles & Huberman,1994). Using a grounded
theoryapproach(Glaser& Strauss,1967;Strauss& Corbin,1998),I readtranscriptsanddiscussedfindings
with my researchassociatesand professionalcolleagues as the study progressed.This iterativeprocess
enabledme to explore new themes that emergedin subsequentinterviewsand case studies.
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LEADERSHIPDEVELOPMENTIN HEALTHCARE

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I applied a combinationof deductiveand inductivemethodsin my analyses. Priorto coding the data,

I producedideas aboutthe themes I expected to find, andthen closely readthe transcriptsto inductively
advance code development.This coding process permittedme to organize the data into categories of
findings, and allowed me to identify broad themes that emerged from the data (Miles & Huberman,
1994). I use the term "theme" to identify a cohesive categoryof responses, found across expertsand/or
across organizations,that aggregatespatternsobserved in the data. In addition, throughoutthe study,
periodic discussions with professionalcolleagues andmy researchassociates and an ongoing review of
the literaturehelped me to validate, compare, and extend my findings, where appropriate(Glaser &
Strauss, 1967). I used the qualitativedata analysis software Atlas.ti (version 4.2) (Scientific Software
Development, 1998) to supportthese analyses.

Results
First, six distinct themes emerged from the data concerning the specific leadership development
challenges for healthcare organizations. Each of the themes was discussed across informants,
supportingthe validity of these findings. A summaryof these leadership development challenges is
presentedin Table 2, and below I discuss each theme in greaterdetail. Second, I propose a conceptual
model for organizationalcommitmentto leadershipdevelopmentin healthcareorganizations.I present
this model and three propositionsin the following pages. Verbatimquotationshave been selected that
are representativeof the data.

Table2. Challengethemesin healthcareleadershipdevelopment

Theme 1:
Theme 2:

Challenge

comments
Representative

Industrylag: The healthcare

industryis very behind
Representativeness:Need to
make organization
representativeof community

"We're15 years behind"

"I don't think we are doing very well at all."
"Hospital leadership should be a reflection
of the demographics of the communitythat
the hospital serves."

Professional conflicts:
Pressureto segregate different
professional groups for

"I do think it divides the organizationand

so I don't know that that's a good thing to
have your managers divided."

andpatientpopulation

Theme 3:

leadershipdevelopment
Theme 4:

Theme 5:

Theme 6:

Time constraints: Challenge of

freeing time for
programparticipation
Technicalhurdles:
Challenges of the
organization'stechnical
capabilities
Financial constraints:
Challenges associated with

"That'san hour or two...that's being spent

away from patient care in
a learning environment."
"If I don't have a sound card then what's the
use of getting a teleconference or a
videoconference?Because then
I can't even hear it."
"It's something that's the first thing that
people cut in a tight budget situation."

type
budgets,organization

Copyright(

2006 John Wiley & Sons, Ltd.

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974

A. S. McALEARNEY

Challenges of leadership developmentin healthcare

Theme 1: IndustryLag-The healthcareindustryis very behind.
Across informants,many respondentsnoted that "healthcareorganizationsare 10-15 years behind
otherindustriesin the areaof leadershipdevelopment."This characterizationof the industryas a whole
was consistent, and perhaps reflective of the trouble and delays healthcareorganizationshave had
translating other industry practices (e.g., quality improvement techniques) into their own
environments.As one respondentexplained:
"I thinkthey'relearningwhat industrylearned 15 years ago. You've got to develop your own people
and you've got to fully pursueit. You'vegot to invest to do it andyou might as well make it a rational
decision that'smatchedto the business strategiesratherthanhavingthese segmentedareaswherewe
have OD [OrganizationalDevelopment] doing some things here, we have nursing development
rolling out God knows what over there. I think they're really learning what industrylearned. You
know, it's a classic curve. We're 15 years behindin qualityand we're aboutthe same amountof time
behind in training."
In addition,therewas a sense thatcommitmentsto leadershipdevelopmentby healthcareorganizations
were generallyrare,andoften insufficient.As one individualreported,"I thinka lot people who get intoit
are just going throughmotions." Anotherrespondentsimilarly noted, "I think that healthcaredoesn't
mandate enough leadership development from their managerialranks in general." In contrast, the
importanceof senior leadershipcommitment,the designationof a highly visible and powerfulprogram
director,and the need to align leadershipdevelopmentactivities with other organizationalgoals and
strategiesmay be standardin other industrieswhich have a longer history of incorporatingleadership
developmentpractices,but are only beginning to be recognized in healthcare.
Theme2: Representativeness-Need to make the organizationrepresentativeof the communityand
the patient population.
A second theme thatemergedinvolved the reportedchallenge of healthcareorganizationsto develop
a diverse group of leaders that was representativeof both the patient population and the surrounding
community.As one informantexplained, "As you develop your managementstaff I thinkyou have to
look for an opportunityto bring the kind of diversity that's necessary for your organizationto be
responsiveto the needs of the communitythatyou serve." Commentssuch as this were frequentacross
respondents,and reflectedthe growing industrysensitivity to the needs of diverse populations,andthe
critical issue of disparatehealthcareprovision in U.S. hospitals (Kerr,McGlynn, Adams, Keesey, &
Asch, 2004; McGlynn et al., 2003; Smedley, Institute of Medicine, Stith, & Nelson, 2002).
Theme3: ProfessionalConflicts-Pressure to segregatedifferentprofessionalgroupsfor leadership
development.
Anothertheme emerged aroundthe issue of bridgingthe gap that exists between administrativeand
clinical leadership in healthcare organizations. Across the internal programs I studied, there was
considerabledebate about the best way to develop clinician leaders, with a numberof the proposed
approacheshaving only recentlybeen implemented.Forexample, manyorganizationsreportedtension
aroundthe issue of nursingleadershipdevelopment.Opportunitiesaregrowingfor nursesto participate
in leadership development programsthat are separatefrom both organizationalprogramsand other
clinical leadershipprograms(e.g., the Health Care Advisory Board's Nursing LeadershipAcademy),
yet not all respondentsbelieve this approachis best for the organizationas a whole. As one respondent
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LEADERSHIPDEVELOPMENTIN HEALTHCARE

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explained, "there'sbeen some resistancein termsof sendingnursingmanagersbecause I think [nursing

leadership]feels they are responsiblefor the nursingmanagementdevelopmentso why shouldthey go
to the LeadershipInstitutewhen [nursingleadership] can give them everything they need."
Specific concernsalso emerged aboutthe best way to develop physician leaders. Consistentwith the
oft-reported"cultureclash" between physicians and administrators,many informantscommented on
the special challenge of physician leadership development. As one respondent summarized,
"Administratorsare from Venus, physicians are from Mars,because you've got a clash of cultures
and a clash of different perspectives. So I think leadership development in this setting requires
more-because it's a mix of differentcultures-requires more competencyin what would be crossculturalcommunication.So I think it is a little bit different. I'm sure there's other settings where
those issues come up, but that strikesme because there'sclearly two very differentways of looking
at the world."
Reportedchallenges of physician leadershipdevelopmentranged from basic issues such as getting
physicians to participate to philosophical issues surrounding physicians' different training and
orientationtowardschange, decision-making,and focus. Across settings, organizationswere as likely
to incorporatephysicians in theirleadershipdevelopmentprogramsas not, and there appearedno clear
consensus about which approachwould ultimately be best.
Theme 4: Time Constraints-Challenges of freeing time for programparticipation.
A fourth theme that emerged across study participantswas the difficulty for organizationsto free
people's time to participate in leadership development activities. Although this challenge was
admittedly not unique to healthcareorganizations,the nature of work being "missed" by program
participantswas noted as "different."As one organizationalinformantexplained, "If you have a class
of 20 people, all nursingstaff, you know, that's an hour or two of their salary that's being spent away
from patient care in a learning environment."Where such developmental activities were reportedly
more accepted organizationally,this challenge was less acute, but respondents still noted issues
associated with participation. Several organizations recognized these issues, but solutions or
suggestions to manage the problem were absent.
Parallelingorganizationalconcerns,individualsalso commentedabouthow hardit was to find time to
participate.Rarely were developmentalexperiences and opportunitiesbuilt into existing jobs. Most
respondents,instead,describedleadershipdevelopmentactivitiesas somethingtheyhad to maketime for in
additionto theirregularresponsibilities.Many reportedthat,if they participatedin a program,short-term
disadvantagessuchas fallingbehindin workor learningthingsthatseemedminimallyrelevantoverwhelmed
anylong-termpotentialto be gainedfromdevelopment.Further,non-hospital-employed
physicianschoosing
to attenda programtypicallylost revenuebecause they were not using theirtime to see patients.
Theme 5: Technical Hurdles--Challenges of the organization'stechnical capabilities.
Additional challenges associated with leadership development in healthcare organizations were
reportedin the context of organizations'technical capacities. The ability to deliver web-based training
was typically limited by non-universalaccess of employees to computers,much less the Internet.As an
informantpondered,
"Do we need computerkiosks thatare dedicatedto this kind of thing?How arewe going to structure
it to bringthe productcloser to the staff so they don't have to leave the unit?Do we do somethingin a
breakroom?Do we have a mobile computerthatwe can move around?We'rejust not sure.And it all
looks differentdependingon the site. So partof our next year is doing that kind of inventoryso we
can have a handle on what kind of capital investment we might need to make."
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976

A. S. McALEARNEY

Further,even in hospitals where therewere sufficientnumbersof computersavailable,therewere no

guaranteesthat the informationsystems capabilitieswere sufficientlyadvancedto permitoptions such
as audio content delivery or video-conferences. Technicalissues appearedespecially challenging for
some of the smaller,non-system-basedhospitals, and this was likely relatedto the financialchallenges
reportedby many organizations,and described next.
Theme 6: Financial Constraints-Challenges associated with budgets, organizationtype.
A sixth theme emergedaroundthe challenges associatedwith tight budgets and financialconstraints
in healthcare organizations. Although healthcare organizations may not be the only type of
organizationstrugglingwith this issue, organizationalrespondentsfrequentlymade comments such as,
"You know we're working on these paper-thinmargins."In the context of leadershipdevelopment,
these thin marginsoften put programactivities at risk. One informantexplained how, "The money is
getting tighterand tighterand our workloadis getting largerand largerand so often educationis one of
the ones that is cut back or even cut out." Across organizationsstudied, a majority of respondents
reporteda sense that leadershipdevelopment programswere perpetuallyat risk, and noted that this
inability to count on the future of the programscontributedto skepticism about the organizations'
commitments to development, as well as job insecurityfor those tasked with designing or delivering
leadership development programs.Finances appearedmore problematicin healthcareorganizations
owned independently as opposed to system-owned. Hospitals that were part of a healthcaresystem
were reportedlymorelikely to be able to build and sustainleadershipdevelopmentcapacitiesthantheir
free-standing counterparts,and often promoted leadership development activities as part of the
corporatesupportfunction.

Conceptual Model of Organizational Commitment to

Leadership Development
Considering these data, I propose a conceptual model of commitment to leadership developmentin
healthcare organizations as being influenced by three factors: (1) organizational strategy; (2)
organizationalculture;and (3) organizationalstructure(Figure 1). In turn,this commitmentinfluences
the program design decision process, resulting in broader or narrower leadership development
opportunities for individuals. Further, these program design decisions correspondingly affect
organizationaleffectiveness, depending on programscope, reach, and impact. Changes in any of the
three factors can shift organizationalcommitmentto leadershipdevelopment, potentially influencing
both the design decision process and overall organizationaleffectiveness.
In the following section, I discuss threeaspects of the model in greaterdepth:(A) the perceivedvalue
of learning and growth;(B) the dynamic natureof the programdesign decision process; and (C) how
leadership development may promote organizationaleffectiveness.

A. Perceived value of learning and growth

Proposition A: The more the organization's senior leaders value learning and growth, both of
individual employees and of the organization, the more likely leadership development is to be
supportedand sustained within that organization.
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LEADERSHIPDEVELOPMENTIN HEALTHCARE

OrganizationalStrategy
* Competingstrategic
priorities
* Need to focus on
financialsustainability
* Timehorizonfor
organizationaldecisions
* Linkbetween
developmentandother
strategicorganizational
priorities

977

Organizational
Culture
* Orientationtowards
learningand growth
* Seniorleadership
support
* Value of
developmentrelative
to otherpriorities
*
Supporters,resistors,
otherforcespro and
con

Organizational
Structure
* Placementof leadership
developmentfunction
* Linkageto human
resources,other
organizational
developmentfunctions
* Centralizationof
decisionmakingabout
developmentresource
allocation

OrganizationalCommitment to Leadership Development

* Resourceavailabilityfor leadershipdevelopment
* Positionandpowerof programdirector
* Expectationsfor leadershipdevelopmentprogram
* Sustainabilityof commitmentto leadershipdevelopment

*
*
*
*

Leadership Development Program Design Decisions

Targetpopulationfor leadershipdevelopment
Balanceof internalversus externalprogramopportunities
Involvementin clinical leadershipdevelopment
Metricsto assess program

*
*
*
*

Organizational Effectiveness
Improvedemployeemotivation
Reducedemployeeturnover
Increasedorganizationalresilience
Enhancedabilityto succeedin market

commitmentto leadership
Figure1. Conceptualmodeldepictinginfluenceson and impactsof organizational
developmentin healthcareorganizations

Organizationalleaderswho believe in the value of learningand growthare likely to invest heavily in

leadershipdevelopment activities and commit to sustainingthe programover time. For instance, one
executive describinga strongprogramdeclared, "we would never shutthis down." Anotherrespondent
summarizedthe importanceof this perception:"The organizationhas to value developmentin general.
Whetherit's developingtheirstaff for clinical competence or leadersfor theirleadershipcompetencies,
you have to have an organizationthat values development.And ongoing development. You can't stop
and say, "okay,we're there,"because you're never there."In severalhealth care organizationsstudied,
the hiringof a Chief LearningOfficerprovidesevidence of this organizationalvalue, and demonstrates
commitment to leadershipdevelopment within the organization.
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978

A. S. McALEARNEY

In contrast,leaderswhose interestsin learningand growtharemorereactionaryareunlikely to invest

in long-termleadershipdevelopmentinitiatives or senior hires. Withinthese organizations,leadership
development activities are assigned to lower-status directors within the larger human resources
function, and budgets are typically limited and at constant risk of future cuts.

B. Dynamics of program design decision process

Proposition B: The natureand conceptualizationof leadershipdevelopment programswill affect
how organizationssupportsuch programsbecause of how the design decision process is viewed.
In several organizations with strong commitment to leadership development programs, such
programswere well integratedwithin the organization,reflectedby comments associating leadership
developmentwith strategy,culture,or structure.One intervieweedescribedleadershipdevelopmentas,
"really a culturequestion. If you have a culturethat has a history of valuing these kinds of things, the
uphill battle is long gone." In another organization, a leadership development program director
describedthe need to "[make] sure that I'm aligned with the strategicplan." However,shifts in any of
the three factors, strategy, culture, or structure,may affect program commitment. For example, a
change in leadershipinvolving hiringa new CEO could affect all threefactorsas the new leadermakes
organizationaldecisions thathave a correspondingimpact on commitmentto leadershipdevelopment.
Similarly, a strategic decision to invest more in information technologies may restrict resources
available for development, thereby affecting programcommitment, design, and potential impact.

C. Leadership developmentaffecting organizational effectiveness

Proposition C: Organizational decisions to invest in leadership development can affect the
organization's overall effectiveness by improving employee motivation, reducing turnover,and
building organizationalresilience to change.
Organizations heavily committed to leadership development tend not to differentiate between
leadership effectiveness and leadership development programsuccess. As one executive explained,
"You'reinvestingin the people, the managerswho makeyou successful."Insteadof using metrics such
as program attendance, employee satisfaction with programs, and credit hours accumulated, these
organizations measure success on the basis of organization-wide metrics including employee
satisfaction,employee turnover,physician satisfaction,financialperformance,and so forth. The move
beyond programprocess evaluationto acceptance that leadershipaffects the organization'sability to
realize its strategic goals is reflective of a broader view of leadership impact and underlying
assumptions. In several organizations, this was described as "a development mindset," where the
committed organizationviewed leadership development as critical for organizationalsuccess.

Discussion
This exploratory investigation finds evidence that healthcare organizations experience major
challenges in designing and delivering leadership development programs.Given the circumstances
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IN HEALTHCARE 979
LEADERSHIP
DEVELOPMENT

associated with a complex external environment and time-pressuredemployees, it is perhaps not

surprisingthatdevelopmentalconcerns and opportunitiesseemed absentfrom the strategicprioritylist
of manyhealthcareorganizations.Yet the challenges to improvehealthcareleadershipdevelopmentare
not insurmountable.Recent literatureemphasizes the importanceof strong leadership development
practices (Conger & Benjamin, 1999; Day, Zaccaro, & Halpin, 2004; Fulmer & Goldsmith, 2001;
Giber,Carter,& Goldsmith,2000; McAlearney,2005; McCauley,Moxley, & VanVelson,1998; Tichy,
1999), and healthcare organizations can incorporatemany evidence-based practices such as using
developmentalassignments,creatingjob rotations,and tying developmentto performanceevaluations
that have strengthenedorganizations'leadership across industries.
Although many individualsin healthcarecontinue to emphasize the uniqueness of the industry,this
insular thinking has tended to limit healthcareorganizations'abilities to improve their management
capabilities. Looking outside healthcarecan provide examples of programdesign decisions and best
practicesthatcan be adoptedwithin healthcareorganizations.For instance, universitysettings provide
environmentswhere faculty often have more clout than administratorsin determining strategy and
defining organizational mission, similar to the disproportionateinfluence of many physicians on
hospital direction. Study of university leadershipdevelopment programsmay provide insight that is
transferableto healthcareorganizations.In addition,recruitingindividualswith relevantexperience in
other industries into healthcare organizations may be an effective way to improve leadership
developmenthealthcare.Thus despite healthcareorganizations'reluctanceto considerevidence-based
management in the same favorable light as evidence-based medicine (Kovner & Rundall, 2006),
healthcareorganizationscan apply lessons learned about leadership development to make important
strides to accelerate leadershipdevelopment in healthcare,and to better position themselves for the
future.

Limitationsof this study

For this qualitativestudy,participationwas very high, but the use of a snowball samplingtechniqueto
select interview targetslimited my ability to focus on organizationsthat might be considered to have
best practices in leadership development a priori. Further, since the proliferation of leadership
development programsis relatively new in many healthcare organizations, some of my interviews
focused more on plans for the future ratherthan evidence from the past. Futureresearchtargetedto
studymodel healthcareleadershipdevelopmentprogramsand theirprogramdesign decisions would be
invaluable, as well as studies which incorporatedata collection to permit testing of my conceptual
model, and formal comparisonof leadership development programsacross industries.

Conclusion
In healthcareorganizations,as in other industries,the leadershipchallenges are immense. Similar to
other organizationalleaders, healthcareexecutives are expected to lead their organizationsand their
employees with integrity, honesty, energy, and enthusiasm. However, healthcare leaders must also
respond to the distinct features of their industryas they attemptto promote excellence in quality of
care, patientsatisfaction,andrelationshipswith physicians and communities.Consideringthe nuances
of the different leadership development challenges and aspects of organizational commitment to
Copyright? 2006 JohnWiley& Sons,Ltd.

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980

A. S. McALEARNEY

leadership development described in this paper can help healthcareorganizationsstriving to develop

better leaders and attemptingto maximize overall organizationalperformance.

Acknowledgements
The studyreportedin this paperhas been supportedby a grantfrom the Centerfor HealthManagement
Research. I greatly appreciatethe help of all study participants,as well as the research assistance
providedby KatrinaBuchholtz,SarahHoshaw,ViktoryaPelts, Mindy MarcumSlenn, Stacy Baker,and
Diana Lau, all affiliatedwith The Ohio State University duringthe study.In addition,I am indebtedto
both the editors of this journal special issue and to two anonymous reviewers for their invaluable
suggestions to improve this manuscript.

Author biographies
Ann Scheck McAlearney is an Associate Professorin the Division of Health Services Management
and Policy in the School of Public Health at the Ohio State University. Her research focuses on
organizationalchange and development;healthinformationtechnology innovations;populationhealth
managementand improvement;and leadership in health care organizations.

References
Bass, B. M. (1985). Leadershipand performancebeyond expectations. New York:Free Press.
Benchmarks, M. S. (2002). IT Spending Benchmarks.Retrieved January 20, 2005, from www.itmweb.com/
bench.htm
Bennis, W. (1989). On becoming a leader. Reading, MA: Addison-Wesley.
Bono, J. E., & Judge, T. A. (2003). Self-concordanceat work: Towardunderstandingthe motivationaleffects of
transformationalleaders. Academy of ManagementJournal, 46, 554-571.
Burke, J. M., & Day, R. R. (1986). A cumulative study of the effectiveness of managerialtraining.Journal of
Applied Psychology, 71, 232-245.
Burns, J. M. (1978). Leadership.New York:Harper& Row.
Conger,J., & Benjamin,B. (1999). Building leaders: How successful companiesdevelop the next generation.San
Francisco:Jossey-Bass.
Constas, M. (1992). Qualitative analysis as a public event: The documentation of category development
procedures.American Education Research Journal, 29, 253-266.
Crabtree,F. & Miller, W. (1999). Doing qualitative research. ThousandOaks, CA: Sage.
Day, D. V., Zaccaro, S. J., & Halpin, S. M. (2004). Leader developmentfor transformingorganizations.Growing
leaders for tomorrow.Mahwah, New Jersey: Lawrence ErlbaumAssociates.
Friedson, E. (1972). Profession of medicine: A study of sociology of applied knowledge.New York, NY: Dodd/

Mead.

Fuller,J. B., Paterson,C. E., Hester,K., & Stringer,D. Y. (1996). A quantitativereview of researchon charismatic
leadership.Psychological Reports, 78, 271-287.
Copyright ? 2006 John Wiley & Sons, Ltd.

J. Organiz. Behav. 27, 967-982 (2006)

DOI: 10.1002/job

This content downloaded from 175.111.91.19 on Tue, 26 May 2015 08:44:01 UTC
All use subject to JSTOR Terms and Conditions

IN HEALTHCARE 981
DEVELOPMENT
LEADERSHIP
Fulmer, R. M., & Goldsmith, M. (2001). The leadership investment:How the world's best organizations gain
strategic advantage throughleadership development.New York:AMACOM.
Gardner,J. (1990). On Leadership.New York:Free Press.
Giber,D., Carter,L., & Goldsmith,M. (2000). Best practices in leadershipdevelopmenthandbook:Case studies,
instruments,training. San Francisco:Jossey-Bass/Pfeiffer.
Glaser,B., & Strauss,A. (1967). Thediscovery of groundedtheory:Strategiesfor qualitative research.New York:
Aldine de Gruyter.
Gray, H., & Snell, R. (1985). Towardseffective practice where managementdevelopment is a recent concern.
Leadership and OrganizationalDevelopmentJournal, 7, 21-26.
Hofmann,P. B. (2005). Acknowledging and examining managementmistakes. Chapter1. In P. B. Hofmann,& F.
Perry (Eds.), Management mistakes in healthcare: Identification, correction, and prevention (pp. 3-27).
Cambridge:CambridgeUniversity Press.
Hofmann, P. B., & Perry,F. (Eds). (2005). Managementmistakes in healthcare: Identification,correction, and
prevention. Cambridge:CambridgeUniversity Press.
House, R. J. (1977). A 1976 theory of charismaticleadership.In J. G. Hunt, & L. Larsen (Eds.), Leadership:The
cutting edge. Illinois: SouthernIllinois University Press.
House, R. J., & Shamir,B. (1993). Towardthe integrationof transformational,charismatic,and visionarytheories.
In M. M. Chemers & R. Ayman (Eds.), Leadership theory and research: Perspectives and directions
(pp. 81-107). New York:Academic Press.
Institutefor the Future. (2000). Health and Health care 2010: Theforecast, the challenge. San Francisco, CA:
Jossey-Bass Publishers.
Jones, W. J. (2005). Identifying, classifying, and disclosing mistakes. Chapter3. In P. B. Hofmann, & F. Perry
(Eds.), Managementmistakesin healthcare:Identification,correction,andprevention(pp. 40-73). Cambridge:
CambridgeUniversity Press, 40-73.
Kerr,E. A., McGlynn, E. A., Adams, J., Keesey, J., & Asch, S. M. (2004). Profilingthe quality of care in twelve
communities: Results from the CQI study. Health Affairs, 23, 247-256.
Kohn, L., Corrigan, J., & Donaldson, M. (Eds). (1999). To err is human: Building a safer health system.
Washington,D.C.: National Academies Press.
Kovner,A. R., & Rundall,T. G. (2006). Evidence-basedmanagementreconsidered.Frontiersof Health Services
Management,22, 3-22.
Kouzes, J. M., & Posner, B. Z. (1993). Credibility:How leaders gain and lose it, why people demand it. San
Francisco: Jossey-Bass.
Kouzes, J. M., & Posner, B. Z. (1995). The leadership challenge (2nd ed.). San Francisco: Jossey-Bass.
Lowe, K. B., Kroeck, K. G., & Sivasubramaniam,N. (1996). Effectiveness correlates of transformational
and transactionalleadership:A meta-analytic review of the MLQ literature.Leadership Quarterly,7, 385425.
Maxwell, J. (1996). Qualitative research design. Thousand Oaks, CA: Sage.
McAlearney, A. S. (2005). Exploring mentoring and leadership development in health care organizations:
Experience and opportunities.Career Development International, 10, 493-511.
McAlearney,A. S., Fisher, D., Heiser, K., Robbins, D., & Kelleher, K. (2005). Developing effective physician
leaders: Building skills and changing cultures. Hospital Topics, 83, 11-18.
McCall, M. W., Lombardo, M. M., & Morrison, A. M. (1998). The lessons of experience: How successful
executives develop on the job. Lexington, MA: Lexington Press.
McCauley, C. D., Moxley, R. S., & VanVelson, E. (1998). The center for creative leadership handbook of
leadership development.San Francisco:Jossey-Bass.
McCracken,G. (1988). The long interview.Thousand Oaks, CA: Sage.
McGlynn,E. A., Asch, S. M., Adams, J., Keesey, J., Hicks, J., DeCristofaro,A., et al. (2003). The qualityof health
care delivered to adults in the United States. New England Journal of Medicine, 348, 2635-2645.
Mecklenburg,G. (2001). CareerPerformance:How Are We Doing? Journalof HealthcareManagement,46, 8-13.
Miles, M., & Huberman,A. (1994). Qualitative data analysis. Thousand Oaks, CA: Sage.
Morse, J. M. (2000). Determining sample size. Qualitative Health Research, 10, 3-5.
Moxnes, P., & Eilertsen, D. (1991). The influence of management training upon organizational climate: An
exploratorystudy. Journal of OrganizationalBehavior, 12, 399-411.
Newhouse, J. (2002). Why is there a quality chasm? Health Affairs, 21, 13-25.
Ramanujam, R., & Rousseau, D. M. (2004). Organizational behavior in healthcare-The challenges are
organizational,not just clinical. Journal of OrganizationalBehavior, 25, 667-669.
Revans, R. W. (1980). Action learning. London: Blond and Briggs.

Copyright ? 2006 John Wiley & Sons, Ltd.

J. Organiz. Behav. 27, 967-982 (2006)

DOI: 10.1002/job

This content downloaded from 175.111.91.19 on Tue, 26 May 2015 08:44:01 UTC
All use subject to JSTOR Terms and Conditions

982

A. S. McALEARNEY

Russell, J. A., & Greenspan,B. (2005). Correcting and preventing managementmistakes. Chapter5. In P. B.
Hofmann, & F. Perry (Eds.), Managementmistakes in healthcare: Identification,correction, and prevention
(pp. 84-102). Cambridge:CambridgeUniversity Press.
Russell, S. (2000). $176 Million tab on failed hospital merger.San Francisco Chronicle, December 14.
Sashkin, M., & Rosenbach,W. E. (2001). A new vision of leadership.In W. E. Rosenbach,& R. L. Taylor(Eds.),
Contemporaryissues in leadership (5th ed.). Boulder, CO: Westview Press.
Schein, E. (1985). Organizationalculture and leadership. A dynamic view. San Francisco: Jossey-Bass.
Schneller,E. S. (1997). Accountabilityfor health care: A white paperon leadershipand managementfor the U.S.
Health Care System. Health Care ManagementReview, 22, 38-48.
Scientific Software Development. (1998). Atlas.ti. 4.2 ed. Berlin: Scientific Software Development.
Shortell, S. M. (1992). Effective hospital-physicianrelationships.Ann Arbor,MI: Health AdministrationPress.
Smedley, B., Instituteof Medicine, Stith, A. Y., & Nelson, A. R. (2002). Unequal treatment:Confrontingracial
and ethnic disparities in health. Washington,DC: National Academies Press.
Smith, D., Cowan, C., Sensenig, A., Catlin,A., & Health AccountsTeam. (2005). Health spendinggrowthslows in
2003. Health Affairs, 24, 185-194.
Smith, J. E., Carson, K. P., & Alexander, R. A. (1984). Leadership:It can make a difference. Academy of
ManagementJournal, 27, 765-776.
Spradley,J. P. (1979). The ethnographicinterview.Fort Worth,TX: HarcourtPublishers.
Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniquesand procedures for developing
grounded theory.Thousand Oaks, CA: Sage.
Tichy, N. M. (1999). The leadership engine. How winning companies build leaders at every level. New York:
HarperBusiness.
Yin, R. (1984). Case study research: Design and Methods. Newbury Park, CA: Sage.

Copyright ) 2006 John Wiley & Sons, Ltd.

J. Organiz.Behav. 27, 967-982 (2006)

DOI: 10.1002/job

This content downloaded from 175.111.91.19 on Tue, 26 May 2015 08:44:01 UTC
All use subject to JSTOR Terms and Conditions