Hello EveryoneI need help on this assignment, and its due on Sunday, June 16th. Thank youConflict Resolution at the St. Clare HospitalThe St. Clare Hospital was founded in 1988. In the past few years,

5 Leadership Learning Objectives After reading this chapter, you should be able to: • Define leadership and identify key skills and competencies of leaders. • Examine the similarities and differences between leadership and management. • Recognize major leadership models and how they have changed over time. • Compare and contrast contemporary leadership styles and methodologies. • Evaluate health care leadership challenges. Marvin E. Newman/Sports Illustrated/Getty Images CN CT CO_LO CO_TX CO_BL CO_CRD fra81455_05_c05_121-150.indd 121 4/23/14 9:22 AM Vince Lombardi: The Man Who Showed Us What It Takes To Be Number One Few American figures embody leadership more than the venerable Vince Lombardi, deemed the greatest National Football League (NFL) coach of all time. As coach of the Green Bay Packers from 1959 to 1967, Lombardi turned a team that was mired in losses into one of the best NFL teams in history. The team won NFL titles in 1961, 1962, and 1965 in addition to Super Bowl titles in 1966 and 1967. Just 2 years into his tenure as coach, Lombardi took a group of underperforming under - achievers and rebranded them as champions (Lombardi, 2003). Often referred to as the “Greatest Coach in History,” Lombardi said, “Coaches who can outline plays on a blackboard are a dime a dozen. The ones who win get inside their player and motivate” (as cited in Vecchi - one, 1991, p. 166). Lombardi recognized that before he could motivate his players, he would first have to change their thought processes. He led by example, and soon his players began to mimic his style and profes - sionalism. Lombardi challenged his players to give their best and then some. He encouraged them to think on their toes and change the playbooks when appro - priate. Lombardi was not concerned with being liked:

Those who did not agree with what he was trying to achieve were encouraged to leave. He had a no-holds- barred approach to winning and only wanted to work with those who believed that the impossible was not only possible, but firmly within reach.

Lombardi’s determination to succeed and excel made him a model for all kinds of leaders, in sports and in business. In the process, he helped inspire people every - where to defy the odds and “get in the game,” not just physically but also mentally. “Leaders are made, they are not born,” he once said. “They are made by hard effort, which is the price which all of us must pay to achieve any goal that is worthwhile ” (Lombardi, 2003, p. 3). Lombardi’s legacy as one of the great - est major league football coaches is surpassed only by his legacy as one of the greatest masters of effective leadership.

Critical Thinking and Discussion Questions 1. Both “Chainsaw Al” Dunlap (featured in the opening vignette of Chapter 3) and Vince Lombardi effected dramatic changes in the organizations they led. Compare and contrast their approaches and results. 2. Lombardi focused intently on winning. Is this intensive focus applicable to health organi - zations? Why or why not? Marty Zimmerman/Associated Press Vince Lombardi is revered for know- ing how to motivate and lead his team. H1 KT SN ST fra81455_05_c05_121-150.indd 122 4/23/14 9:22 AM Section 5.2 Leaders and Followers 5.1 Introduction to Leadership For centuries, historians, researchers, and management experts have attempted both to define and understand leadership. From Confucius to Plato to Machiavelli, many of the world’s notable thinkers have analyzed and theorized about how humans lead and are led (Bass, 1990). Yet there is still a lack of consensus on what truly defines a leader, despite the important roles that leaders play in all types of organizations.

Hackman and Johnson (2000) suggest that the fascination with the subject of leadership has much to do with the nature of the human experience, given that leadership is an element of many different types of organizations. Others argue that leadership actually has little to do with leading and more to do with managing others, which has been a frequent topic of debates about what constitutes true leadership (as opposed to operational administration).

For every study that negates the importance of leadership, just as many support the asser - tion that leaders indeed play significant roles in group dynamics and organizational per - formance outcomes (Bass, 1990). This chapter looks at differing opinions of leadership and examines major leadership models and their implications for health administration. 5.2 Leaders and Followers In its basic form, leadership is a process of social influence that maximizes the efforts of others to achieve a goal. Some management researchers believe that leadership stems from possessing a combination of preferred characteristics that allow certain individuals to be perceived and accepted as leaders. Others say that leaders must be able not only to transform and drive organizations, but also to transform followers into tomorrow’s lead - ers. As scholar Bernard Bass (1960) said, “An effort to influence others is attempted leader - ship and when others actually change, leadership is successful” (p. 90). As Peter Drucker put it, “An effective leader is not someone who is loved and admired. He or she is some - one whose followers do the right things. Popularity is not leadership. Results are” (as cited in Hesselbein, Goldsmith, & Beckhard, 1996, p. xii).

However one decides to define and categorize leadership, the study and mastery of leadership will con - tinue to be among the highest pri - orities of managers whose goal is to advance to the executive suite and who possess the drive and skill to push organizations to greater levels of success. From veteran executives to junior managers new to decision- making roles, leadership is a recur - rent concern for anyone who needs to empower, direct, and inspire oth - ers to achieve organizational goals.

Developing leadership competence allows managers the opportunity to David Spurdens/www.ExtremeSportsPhoto.com/Fuse/Thinkstock Leading by example inspires followers to overcome fears and obstacles to success. fra81455_05_c05_121-150.indd 123 4/23/14 9:23 AM Section 5.2 Leaders and Followers challenge themselves in new and empowering ways so that they can lead people to places they never thought possible.

Leadership Characteristics and Competencies Numerous leadership studies have focused on factors such as status, social skills, intel - ligence, appearance, and disposition in an attempt to correlate certain characteristics with effective leaders. While many researchers have been unable to prove that possessing a combination of traits or skills predispose individuals to great leadership, others have suc - cessfully argued that both competencies and situational factors have a larger role to play in the discussion.

Leadership Characteristics Ralph Stogdill (1948) conducted an analysis of 124 studies published in the first half of the 20th century that focused on traits and personal factors connected to leadership. This review exposed a number of conflicting findings. Leaders shared no distinguishing physi - cal characteristics but were of varying sizes, shapes, and appearances. The leaders were almost exclusively White and male, reflecting the social climate of the 1940s and the limited opportunities at that time for non-Whites and females to hold leadership positions. Stogdill concluded, “A person does not become a leader by virtue of the possession of some com - bination of traits, but the pattern of personal characteristics of the leader must bear some relevant relationship to the characteristics, activities and goals of the followers” (p. 64).

Certain abilities do seem to distinguish successful leaders from their less successful coun - terparts. These traits are not apparent among all successful leaders, nor are they distrib - uted equally among them; nevertheless, they are a foundation for the acquisition and further development of the leadership competencies previously noted. Three sets of traits described in Table 5.1 appear to be critical to leadership: interpersonal factors, cognitive factors, and administrative factors (Hackman & Johnson, 2000). Table 5.1: Examples of three critical leadership traits Trait Behavioral example Interpersonal factors Ability to give effective oral presentations and manage discord, possession of emo - tional steadiness and self-assurance Cognitive factors Superior intelligence and amplified creativity Administrative factors Good planning and organizational skills, broad integrated function of work to be executed Source: Hackman, M., & Johnson, C. (2000). Leadership: A communication perspective . Prospect Heights, IL: Waveland Press. While certain skills are likely to be advantageous, in today’s changing and complex busi - ness environments it is also likely that a mixture of experience, training, and personal fra81455_05_c05_121-150.indd 124 4/23/14 9:23 AM Section 5.2 Leaders and Followers development will produce successful leaders. Successful organizations will delineate what leadership competencies are central to their needs to generate competitive advan - tages. Therefore, while some people may be “natural leaders,” it takes time and experi - ence to acquire and refine the competencies of a highly successful leader.

Leadership Competencies Leadership competencies are leadership skills and behaviors that contribute to superior individual and organizational performance. A focus on leadership competencies and skill development improves leadership. Remarkable leaders develop an expansive range of knowledge and competencies that they use and apply in the field.

Academic Emphasis by Health Care–Management Accrediting Agencies Health organization employers and students pursuing degrees in health administration are paying increased attention to whether academic institutions are providing graduates with the knowledge and skills needed to be successful in the workforce. To address this concern, two accreditation bodies evaluate health management educational programs. The Association of University Programs in Health Administration (AUPHA) has established a strict and thorough peer review process for undergraduate academic program standards to ensure that the program adequately prepares health management graduates to enter the field. Successful evaluation of the educational institution leads to certification by the AUPHA for undergraduate (bachelor ’s degree) programs (AUPHA, 2013b). The Commis - sion on Accreditation of Healthcare Management Education (CAHME) focuses on gradu - ate programs in health care management, with explicit requirements for all programs to adopt a competency-based curriculum. In this way the CAHME ensures that accredited health management programs will possess the strict academic rigor to prepare their stu - dents adequately for the demanding world of health care management (CAHME, 2013).

Peter Drucker (2002) asserted that large health care organizations may be the most com - plex in human history and that even smaller organizations are barely manageable. Given the role that managers and leaders play in various types of highly sophisticated health sys - tems, competency verification is on the rise. The widespread acceptance of evidence-based medicine was a natural precursor to an evidence-based approach to health care manage - ment (Kovner & Rundall, 2006). Thus was born the Healthcare Leadership Alliance (HLA), a consortium of professional associations in the health care field that developed a set of criteria to ensure that graduates are provided with certain knowledge, skills, and abilities that future employers will likely demand (Stefl, 2008). The HLA educational task force identified five competency domains common among the membership: 1. Communication and relationship management 2. Leadership 3. Professionalism 4. Knowledge of health care environments 5. Business skills and knowledge Because leadership competencies are central to health care executives’ performance, the leadership domain anchors the HLA model. The HLA went on to create a detailed compe - tency directory that lists a total of several hundred specific administrative competencies in fra81455_05_c05_121-150.indd 125 4/23/14 9:23 AM Section 5.2 Leaders and Followers the various domains. Originally developed for academic programs, the directory provides a framework for students and managers through identification of knowledge, skills, and abilities that are beneficial in clarifying job descriptions or in forming work teams with complementary skills and knowledge (Stefl, 2008).

Human Resources Efforts to Define and Recruit for Leadership Competencies When selecting and developing leaders, human resources professionals consider an indi - vidual’s competencies and identify qualities that need further development for success in a leadership role. By looking at competencies and comparing them with the skills neces - sary to fill a leadership position, organizations can make better informed decisions in hir - ing, developing, and promoting leaders.

Highly valued and sought-after health care leadership competencies include strong busi - ness acumen, effective communication and oral presentation skills, and superior conflict resolution skills, to name just a few. Executive recruiters and human resources profes - sionals consider competencies as a predictor of success or failure for various positions.

By creating competency models that reflect the future strategy of the business and the important results to stakeholders (i.e., customers, shareholders, and investors), organiza - tions can successfully create a strong and distinctive leadership brand (Intagliata, Ulrich, & Smallwood, 2000). Web Field Trip: Leadership Competency Assessments, Standards, and Tools 1. Review the ACHE competency directory and complete the competency self-assessment and the development plan for each domain: http://www.ache.org/pdf/nonsecure /careers/competencies_booklet.pdf . a. For competencies where you rate yourself as a novice, select at least two that are most pertinent to your career goals and identify specific actions to improve your skills. b. For competencies where you rate yourself as competent or expert, list at least two most pertinent to your career goals and identify specific actions whereby you can build on these skill strengths to become a stellar performer. 2. Other web-based resources on leadership include:

a. Dr. Paul Schyve (2009), vice president of the Joint Commission, authored a detailed set of leadership standards for hospitals and health systems; see: http://www .jointcommission.org/assets/1/18/WP_Leadership_Standards.pdf . b. A free leadership style self-assessment for general business purposes is available at: http://testyourself.psychtests.com/testid/2152 . The home page of the same website features an emotional intelligence test: http://testyourself.psychtests.com . c. Franklin Covey offers a leadership profile self-assessment based on best-selling author Stephen Covey’s 7 Habits of Highly Effective People : http://www.franklincovey .com/tc/resources/view/self7 . fra81455_05_c05_121-150.indd 126 4/23/14 9:23 AM Section 5.2 Leaders and Followers Followership Followership , in its simplest form, means adherence to a leader. A more formal definition is the description of leaders and followers as relational partners who play complementary roles (Hollander, 1992). Each recognizes the benefits to be derived by working together harmoniously to achieve shared objectives. The typical dynamic in most organizations is one where managers play a parental role and employees adopt the role of children. A healthier dynamic is an adult-to-adult workplace relationship where autonomous part - ners make mature, consensus decisions (Adler, 2013). Leader and Follower Spotlight: Helen Keller and Anne Sullivan One of the most dramatic depictions of the leader-follower dynamic is the story of deaf and blind student Helen Keller and her teacher Anne Sullivan, who was later portrayed in a play and movie titled The Miracle Worker . Keller lost both her vision and hearing at age 19 months, and she spent nearly 5 years as a deaf mute with no real recognizable way of communicating.

When she was 7 years old, her parents hired Sullivan as a tutor to help her better adjust to her dual disabilities and live the best life possible. Sullivan worked diligently to teach Keller sign language to show her a form of communication she could use to express herself. Eventually, Sullivan’s perseverance and Keller ’s innate intelligence and drive to learn enabled them to connect and communicate, and Keller was able to excel beyond her parents’ wildest dreams.

Keller graduated with honors from Radcliffe College, the women’s college affiliate of Harvard University, with Sullivan to take notes and interpret the professors’ lectures. She wrote 11 books and toured the country for myriad speaking engagements, particularly those where she could advocate for the rights of the blind. Her life story inspired two Oscar-winning movies, and she received the Presidential Medal of Freedom, the nation’s highest civilian honor. One of her stellar achievements was the Talking Books project, which made recordings of thousands of books available to blind people through the nation’s public libraries (Biography.com, n.d.) Keller began as a follower and developed into an inspiring leader because she overcame seemingly insurmountable odds. Sullivan and Keller ’s joint efforts and accomplishments demonstrate how outstanding leaders enable followers to grow and develop to become exceptional leaders themselves. Many of today’s health care leaders credit their success to mentors , more experienced individuals who provide guidance and advice to younger colleagues. For this reason the American College of Healthcare Executives (ACHE) has developed a series of informational resources on mentoring and encourages its regional chapters to establish mentoring programs for their members (ACHE, 2013b). Defining Followership The distinction between leading and following is not always clear. Many of the qualities of effective leaders—such as independent thought, commitment, competence, depend - ability, and honesty—also mark effective followers. Compounding the confusion is the fact that some scholars are reluctant to use the follower label (Hackman & Johnson, 2000).

Gardener and Rost (1990) contend that the term follower mirrors a hierarchical rather than a collaborative view of leadership and downgrades those who do not embrace a submissive fra81455_05_c05_121-150.indd 127 4/23/14 9:23 AM Section 5.2 Leaders and Followers and subservient role. They propose using other identifiers such as “constituents,” “stake - holders,” or “collaborators”; many organizations today refer to nonmanagement staff as “associates.” Others disagree, believing that followers play an essential role in the success of any group, organization, or society and that effective leadership is based on service, not hierarchy (Hackman & Johnson, 2000). Regardless of the term used to describe them, the most valued followers are independent thinkers who are go-getters yet also respect authority. Problematic followers are those who need constant direction and oversight, draining the energies of everyone they work with, particularly those leaders responsible for them.

Follower Styles Leaders need to understand how to work with followers who have varying skills and char - acteristics. Followership expert Robert Kelley (1992) developed five follower categories: • Alienated followers are often highly independent thinkers who tend to feel deval - ued by their organizations. They focus on bucking the system rather than attempt - ing to contribute in meaningful ways. • Conformists are in sync with organizational goals and directives but tend to be reserved, aloof, and indifferent when offering individual opinions, out of defer - ence for the powers that be. • Pragmatists will do enough to hold on to their jobs but are not likely to stand out one way or the other. • Passive followers demonstrate minimal individual thought or personal alle - giance and tend to wait for instruction from the leader before they attempt tasks.

This type of follower may have low-skill sets and nominal abilities or desires to carry out tasks without detailed and specific direction. • Exemplary followers are highly interactive participants capable of independent thought and follow-through who tend to go above and beyond what is expected of them. These employees are the cream of the crop. Similar to Kelley’s exemplary followers are those defined by Ira Chaleff as courageous followers , who are highly supportive of their leaders yet will also challenge and question their actions, decisions, and policies (Spalding, 2014). Gibbons and Bryant (2014) note that when exemplary followers become leaders, they are better able to appreciate followers’ concerns. Since physicians will be both leaders and followers throughout their careers, understanding both roles will enable them to be more effective in each one.

In order to gain followers’ trust and commitment to achieving organizational goals, lead - ers need to understand what drives and inspires followers. Management professors Henry Sims and Charles Manz (1989) suggest that the ultimate goal of leadership is empower - ing followers to take charge of their own thoughts and behaviors. Followers can learn to direct themselves with minimal guidance from the leader if they focus on the work at hand, find intrinsic value in the task, and adopt a positive attitude about their jobs (Manz & Sims, 1989). Steering followers from dependence to independence is a process that begins with the leader modeling the ideal behavior. Followers then work under the direction of the leader, who supports and rewards inventiveness and provides the needed resources and training. In the last stage followers act independently, with nominal direc - tion from the leader. fra81455_05_c05_121-150.indd 128 4/23/14 9:23 AM Section 5.2 Leaders and Followers Leadership Versus Management Leadership and management are neither synonymous nor mutually exclusive concepts.

Management is often associated with leadership, but there are some important differ - ences. While the manager is often more focused on the status quo, the leader is more engrossed with the final end goal of the group. Leadership focuses on doing the right things; management focuses on doing things right. Leadership makes sure the ladders we are climbing are leaning up against the right wall; management makes sure we are climbing the ladders in the most efficient way possible. (Covey, 1996, p. 154) A more nuanced view of the difference between managers and leaders considers manag - ers as organizers and mobilizers of people, whereas leaders align employees’ goals with organizational goals. When managers help shift employees forward, leaders in turn can further motivate them to achieve collective goals, resulting in greater fulfillment through work that becomes intrinsically motivating and gratifying (Kotter, 1990). Hackman and Johnson (2000) echoed Kotter ’s theme by stating that managers mobilize others though organizing and staffing, whereas leaders do so by aligning people, which emphasizes integration, teamwork, and commitment. Without the proper alignment, employees’ goals can be mismatched with organizational goals, and both can fall short of expectations.

Kotter (1990) also believed that managers and leaders strive for different outcomes.

Managers are more concerned with producing orderly results and changing processes to achieve goals, whereas leaders want to make substantive changes in organizational goals and strategies. Neither set of objectives is sufficient; a combination of both is what can propel organizations to continuously improved levels of accomplishment. Kotter pro - posed that the key to organizational success is a balance of leadership and management and that organizations have a duty to cultivate both to help ensure success. The ideal is strong leadership paired with strong management.

In today’s dynamic health care industry, both leaders and managers are critical to organi - zational viability and success. Health care administrators can be both leaders and manag - ers, depending on the context of their roles and positions. Although leaders and managers may have different perspectives and responsibilities, their coordinated efforts will deter - mine the organization’s performance.

Managerial Issues at Varying Organizational Levels Although much of the management literature seems to focus on executive-level leader - ship, there are both leadership and management challenges whenever one supervises oth - ers. Each management level has its own set of issues.

First-Line Supervisors It has long been recognized that the first-line supervisor is a key factor in positive employer- employee relations. Yet senior managers often ignore the importance of this position when implementing new technology and engaging frontline workers in group planning and problem solving to accomplish the work of the business unit. Since many first-line fra81455_05_c05_121-150.indd 129 4/23/14 9:23 AM Section 5.2 Leaders and Followers supervisors are promoted from line-worker positions, there is also the question of whether first-line supervisors identify more with managers or with workers. First-line supervisors are often at risk of feeling caught in the middle between management and the rank-and- file workers, which can be an uncomfortable position (Schlesinger & Klein, 1987).

In health organizations, first-line supervisors such as nursing unit leaders, chief laboratory technologists, and claims unit supervisors are principal links between line staff employees and higher level administrators. For this reason it is vital to prepare them for the major areas of supervisorial responsibility: 1. running the department smoothly and ensuring that employees successfully complete their assignments, 2. serving as a competent subordinate to their manager, 3. serving as a communications conduit between the administration and the employees, and 4. maintaining positive working relationships with the heads of all other depart - ments and services in the organization (Dunn, 2010). Middle Managers In large organizations, there are often several layers of management (e.g., associate hospi - tal administrators, service and functional directors, department managers, and assistant managers) between the executive-level leaders and first-line supervisors. These manag - ers are removed by at least one level from the people who do the actual work of the organization; their work involves responsibility for the work of many people over whom they have no direct control and whom they may not even know by name. Although the traditional functions of managerial work stressed planning, organizing, staffing, direct - ing, coordinating, reporting, and budgeting (per Luther Gulick’s POSDCORB acronym discussed in Chapter 1), several studies indicate that managers have limited control over how they spend their time. Rather, they spend much of their days attending meetings and responding to people and situations as they occur, often rapidly switching attention from one problem to another every few minutes. In addition, they are highly dependent on people in other departments and business units for information and assistance to fulfill their functional responsibilities. In some positions they may spend considerable time with stakeholders such as physicians, vendors, advocacy groups, community organizations, regulators, and government officials.

Stewart (1987) noted that middle management jobs are highly variable with respect to the kinds of contacts and relationships these managers must make and maintain, as well as how difficult it is to establish and nurture these relationships. These variations within middle management jobs need to be understood for successful selection, training, career development, and management succession planning. Stewart also cautions that manag - ers will still have their own individual and sectional interests and will differ in what they consider important; thus, they may make decisions and act in ways that top management does not expect and may not want.

Executive or General Managers Top executives are also in constant interaction with others, often on a far greater scale than middle managers. Even those with elaborately structured schedules face many fra81455_05_c05_121-150.indd 130 4/23/14 9:23 AM Section 5.2 Leaders and Followers unexpected and urgent events and encounters. Conger and Kotter (1987) observed that executives with multifunctional responsibilities for a large organization or several related organizations (such as a health system) use two primary techniques to manage their myriad responsibilities. The first is agenda setting , which involves developing a formal plan to guide their decisions. Without such a plan, they are at risk of making inconsistent decisions in response to immediate pressures and losing sight of long-term responsibili - ties and objectives. To deal with unanticipated events, in the form of both problems and opportunities, the agenda must be somewhat flexible. Kotter (1990) found that more effec - tive executives developed more comprehensive and longer range agendas, with strategies that allowed them to accomplish multiple goals at one time; they were also more aggres - sive in seeking information, both negative and positive.

The second executive management technique identified by Conger and Kotter (1987) is network building to establish a web of mutually beneficial cooperative relationship with people inside and outside the organization. Mintzberg (1973, 1989) found that leaders spent 44% of their time interacting with external stakeholders and the remainder deal - ing with internal individuals and groups. These networks enable executives to gather timely pieces of information from a wide variety of sources that, when put together and evaluated, yield insights into the decisions that must be made and the issues that must be addressed. They also help executives implement and update their agendas. Given that their role involves a perpetual series of dilemmas, choices, and challenges, both analyti - cal and social/relationship-building management skills are essential characteristics of effective executives. For this reason, Conger and Kotter recommend that an organization “should strive to develop in its younger managers the agenda and network building skills they need to cope with the uncertainty, complexity, and dependency of their jobs” (p. 402). Case Study: Inflated Performance Evaluations Shortly after reporting for her new position as director of the Human Resources Department at Mount Matterhorn Medical Center, Mary Brannen began to notice inconsistencies between the employee performance evaluations completed by her predecessor and her employees’ actual performance levels. Brannen’s staff of 10 ranged from entry-level interns to mid-level supervisors. Organizational policy required Brannen to evaluate her employees’ performance twice a year based on the following core competencies: • Applied job knowledge and skills • Leadership • Teamwork • Customer service • Communication • Quality of work • Timeliness of work Each core competency was measured against specific performance standards, and the employees’ performance was rated as “exceeds,” “meets,” or “fails to meet” in relation to those standards. On their previous performance evaluations, all employees received “exceeds” ratings on all seven core competencies, a promising indicator that the Human Resources Department employees were highly knowledgeable and proficient. (continued) fra81455_05_c05_121-150.indd 131 4/23/14 9:23 AM Section 5.2 Leaders and Followers Case Study: Inflated Performance Evaluations (continued) After approximately 3 months in her role as director, Brannen began to question the accuracy and reliability of the previous performance evaluations. Based on her observations, the majority of the staff members did not exceed the performance standards outlined in the evaluation and, in some instances, actually failed to meet the standards. For example, many of her employees failed to complete tasks on time, and their submitted work required extensive corrections to grammar and content. Brannen realized that drastic changes needed to occur within her department in order to meet organizational goals and properly manage her staff. With only 3 months remaining in the current evaluation period, Brannen had to quickly develop a plan to more effectively and accurately assess her employees’ performance, communicate performance expectations, document performance deficiencies, and hold employees accountable.

Reflection Questions : 1. Why do you think that the previous director rated the entire staff as “exceeds” when the employees were clearly not performing at that level? Do you think this is a com - mon practice in employee evaluations? What if inflated evaluations were the norm throughout the organization? 2. As the new director, what challenges does Brannen face in dealing with the incon - sistencies noted between her employees’ evaluations and their actual performance?

Would the resolution be different in a union environment? 3. How can Brannen address her employees’ inflated evaluations and performance defi - ciencies in a way that results in her staff trusting and supporting her as a leader? 4. Brannen apparently did not discuss her findings or her plans with her boss. Should she have done so? Explain your response. Resolution Brannen implemented the following changes within the Human Resources Department to address the inconsistencies she noted between her employees’ evaluations and their actual performance levels: 1. Brannen scheduled individual meetings with each employee to review their job descriptions and primary duties. She shared her performance expectations and leadership philosophy, as well as the corrective actions that would be taken if the employees did not sufficiently perform in their job roles. 2. In addition to the two required semiannual performance evaluations each year, Brannen initiated two individual mid-period counseling sessions so that each employee was meeting one-on-one with the director every 3 months. The purpose of the mid-period counseling sessions was to discuss performance expectations and how the employee was performing against those standards. This practice ensured that all employees were fully aware of the director ’s expectations and had the opportunity to correct any deficiencies prior to the end of their evaluation periods. Brannen developed a protocol for documenting performance deficiencies and holding members accountable for their performance. When an employee was not meeting the performance standard, Brannen drafted a letter of warning to the employee outlining how they were not meeting expectations and what actions were needed to correct the problem. Brannen would personally deliver this letter and discuss its contents with the employee. Employees who received three letters of warning in a particular performance dimension would be rated “fails to meet” for that core competency on their next performance evaluation. Employees rated “fails to meet” in more than five of the seven core competencies would be terminated.

Author: Lori Tillman, MBA, Health, Safety, & Work Life Department Head Work Life Supervisor, U.S. Coast Guard. fra81455_05_c05_121-150.indd 132 4/23/14 9:23 AM Section 5.3 Foundational Leadership Theories 5.3 Foundational Leadership Theories As with any body of knowledge grounded in research literature, the historical study of leadership is useful. It allows health care leaders to understand how the theories and mod - els of leadership have built upon each other over time and why some ideas have with - stood the test of time but others are no longer considered relevant in today’s environment.

Studying history also helps one avoid repeating past mistakes (Ledlow & Coppola, 2014).

In the early 20th century, the prevailing opinion was that leaders possessed inherent phys - ical and psychological characteristics that predisposed them to positions of authority and power. Most ideas about leadership were formulated from observation, commentary, and moralization. The rising use of scientific methods to assess human behavior altered the way that scholars looked at leadership (Hackman & Johnson, 2000). Although neither the great man theory nor situational approaches to leadership can fully explain leadership behavior, the study of each allows leaders to better understand leadership from a histori - cal perspective.

Great Man Theory In the 1840s Scottish philosopher Thomas Carlyle proposed what became known as the great man theory —the idea that great men or heroes help shape history through a com - bination of their individual qualities and divine inspiration. He also considered the study of great men an inherently noble endeavor as a means to discover more about one’s own character (Carlyle, 1849, 1888). Sir Francis Galton’s 1869 book, Hereditary Genius , proposed that exceptional talent is genetically determined. As evidence, he traced the relatives of famous people in law, politics, science, sport, music, and so on to see how many were prominent enough to have obituaries written about them. He then calculated the ratio of people meriting obituaries in various degrees of kinship to the initial men of genius. From this research Galton concluded that nature was far more important than nurture when it came to exceptional talent (Gela, 2000). One of the most vocal critics of the great man theory was British philosopher and pioneer sociologist Herbert Spencer (1873/1884), who contended that great men were products of where they grew up and the societal environ - ments in which they operated (Segal, 2000). Debate continues over Carlyle’s view that his - tory is basically the story of heroic leaders versus Spencer ’s contention that no one indi - vidual or leader is capable of changing the evolutionary development of history. Today’s scholars can likely agree that an individual can be recognized as a great man or woman if he or she made significant contributions to society during his or her lifetime. Furthermore, health care organizations that have enjoyed the benefits of stellar leadership will seek to replicate that experience by searching for a great man or woman as a successor.

Democratic Leadership Psychologist Kurt Lewin and colleagues were among the first to study business lead - ership. From a series of leadership decision-making experiments, they identified three fra81455_05_c05_121-150.indd 133 4/23/14 9:23 AM Section 5.3 Foundational Leadership Theories different types of leadership: authoritarian, democratic, and laissez-faire (Lewin, Lippit, & White, 1939). Authoritarian leaders generally believe that people will not successfully undertake work on their own. Examples of this type of leader behavior include engag - ing primarily in one-way downward communication, exerting tight control over follow - ers, and providing mostly negative or inadequate positive feedback. Democratic leaders believe that followers are capable of making informed decisions as competent members of the team and encourage follower contributions and involvement in every facet of the work. They engage followers in joint and transparent communication and ensure that followers have a voice in goal setting and decision making. Laissez-faire leaders adopt a leadership avoidance style (Bass, 1990). They resist making decisions, provide very lit - tle guidance or direction even when asked to do so, and generally acquiesce to follower wishes. While leaders tend to use a blend of leadership styles, Lewin and his colleagues’ (1939) experiments revealed that the most effective leadership style was democratic since it provided both opportunities for participation and some direction.

Situational Approaches Situational approaches , often called contingency leadership , posits that there is no single perfect style of leadership. Rather, certain qualities, talents, and behaviors necessary for leaders to be effective vary according to circumstance. A leader ’s effectiveness depends on his or her individual persona, the competency and activities of followers, the task itself, and countless other situational factors (Hackman & Johnson, 2000). Five of the most researched situational approaches are Blake and Mouton’s managerial grid, Fiedler ’s con - tingency model of leadership, path-goal theory, Hersey and Blanchard’s situational lead - ership theory, and leader-member exchange theory.

Managerial Grid Blake and Mouton’s 1964 managerial grid is a behavioral leadership–style model with two primary constructs: concern for production and concern for people. It incorporates two modes of motivation: positive (by rewards and/or encouragement) or negative (by fear).

Using a 9-point scale to measure the strength of the priority a leader places on production versus people, Blake and Mouton identified five distinct managerial styles, as depicted in Figure 5.1. With the exception of the impoverished style, each leadership approach is useful in certain situations. Although no research has validated the efficacy of the model, Blake and Mouton’s managerial grid is considered the foundation of situational leader - ship (Ledlow & Coppola, 2014). fra81455_05_c05_121-150.indd 134 4/23/14 9:23 AM Section 5.3 Foundational Leadership Theories Figure 5.1: Blake and Mouton’s managerial grid Blake and Mouton’s behavioral leadership–style model measures the strength of the priority a leader places on production versus people.

Source: Coaching Cosmos. (2014). Blake and Mouton’s managerial grid balancing task—and people-oriented leadership. Retrieved March 21, 2014, from http://coachingcosmos.com/34.html Contingency Theory In his theory of contingency leadership, Fiedler (1970) proposed that a group’s perfor - mance depends on proper alignment between a leader ’s style and the favorableness of the situation. Observing how workers regarded one another, Fiedler developed a sys - tem for rating the leaders’ least preferred coworkers (LPCs). Situational favorableness is a measure of how much a particular situation allows the leader to influence others.

Fiedler contended that leaders with high LPC ratings favor deeper relationship connec - tions with coworkers, whereas leaders with low LPC ratings are more inclined to hone in on task completion. Detractors of Fiedler ’s contingency theory, such as Schriesheim and Kerr (1977), have argued that the LPC tool is not a true gauge of leadership effectiveness, since situations must be modified to fit leaders versus leaders modifying their behavior to fit situations. Country Club Management Thoughtful attention to the needs of people for satisfying relationships leads to a comfortable, friendly organization atmosphere and work tempo. Team Management Work accomplishment is from committed people; interdependence through a “common stake” in organization purpose leads to relationships of trust and respect. Middle-of-the-Road Management Adequate organization performance is possible through balancing the necessity to produce while maintaining morale of people at a satisfactory level. Impoverished Management Exertion of minimum effort to get required work done is appropriate to sustain orangization membership. Authority-Compliance Management Efficiency in operations results from arranging conditions of work in such a way that human elements interfere to a minimum degreee. 9.1 1. 1 9.9 1. 9 5.5 Low 1 2 3 4 5 6 7 8 9 High Low 1 2 3 4 5 6 7 8 9 High Concern for people Concern for production fra81455_05_c05_121-150.indd 135 4/23/14 9:23 AM Section 5.3 Foundational Leadership Theories Path-Goal Theory Path-goal theory is based on expectancy theory (see Chapter 3), which proposes that employees are increasingly motivated to be exemplary followers if they believe under - taking or completing a task will lead to an outcome they find satisfying. In path-goal theory, two situational variables influence leadership style: the makeup of the follow - ers and the nature of the task. Supportive leadership takes the followers’ needs into account as the leader strives to provide an environment that is supportive and friendly.

In directive leadership , followers are told what to do and instructed on how to carry out the task. Participative leadership emphasizes actively involving followers in deci - sion making and giving their ideas full credence. In achievement-oriented leadership , the leader believes followers have the skill sets to achieve desired results and sets chal - lenging goals based on their ability to effectively carry out tasks (House, 1971; House & Mitchell, 1974).

Hersey and Blanchard’s Situational Leadership Paul Hersey and Kenneth Blanchard (1988) suggest that the maturity of followers plays a significant role in choosing an appropriate leadership style. Follower maturity involves two components that can be charted along a continuum: job maturity and psychological maturity. Job maturity refers to demonstrated task-related knowledge, skills, and abili - ties. Psychological maturity relates to feelings of self-assurance, readiness to grow, and motivation. In situational leadership theory the readiness level of followers determines the behavior of leaders. The varying combinations of these components are displayed in Table 5.2 and Figure 5.2.

Table 5.2: Follower readiness to grow and maturity levels Readiness level Combination of job maturity and psychological maturity levels Readiness level 1 Low job maturity/low psychological maturity; follower lacks skills and willingness Readiness level 2 Low job maturity/high psychological maturity; follower lacks skills but is willing Readiness level 3 High job maturity/low psychological maturity; follower is skilled but lacks willingness Readiness level 4 High job maturity/high psychological maturity; follower is skilled and willing Source: Hersey, P., & Blanchard, K. H. (1988). Management of organizational behavior: Utilizing human resources (5th ed.). Englewood Cliffs, NJ: Prentice Hall. fra81455_05_c05_121-150.indd 136 4/23/14 9:23 AM Section 5.3 Foundational Leadership Theories Figure 5.2: Hersey and Blanchard’s situational leadership curve In Hersey and Blanchard’s situational leadership curve model, follower readiness is the key variable that determines a leader ’s communication style.

Source: MLM Leadership NOW. (n.d.). Situational leadership. Retrieved March 21, 2014, from www.mlm-leadership-now.com/mlm -leadership-administration-situational-leadership SELLING Moderate Readiness High Task High Relationship Explaining Persuading Guiding Directing Observing Monitoring Encouraging Problem Solving Moderate Readiness Low Task High Relationship Low Readiness High Task Low Relationship High Readiness Low Task Low Relationship Unable and Unwilling or Insecure Unable but Willing or Confident Able but Unwilling or Insecure Able, Willing, and Confident LOW HIGH DELEGATING TELLING PARTICIPATING S4 S3 S2 S1 (LOW) (HIGH) TASK Behavior R2 R3 R4 R1 READINESS OF FOLLOWERS RELATIONSHIP Behavior (HIGH) MODERATE fra81455_05_c05_121-150.indd 137 4/23/14 9:23 AM Section 5.4 Contemporary Leadership Ideas and Approaches For each type of follower, Hersey and Blanchard (1988) prescribe and label specific leader behaviors. Underdeveloped R1 followers need clear direction and instructions in what is termed telling . Close oversight of their performance is vital. Moderately developed R2 followers need leaders to clarify decisions plainly and precisely in a personalized manner, an approach Hersey and Blanchard call selling . Moderately developed R3 followers need leaders to impart ideas and facilitate decision making, which falls under participating . They possess strong skill sets but lack the drive to engage in the process. Lastly, highly developed R4 followers need leaders to delegate responsibilities for decisions and imple - mentation to them. They possess strong self-confidence and dedication and are often seen as exemplary followers.

Hersey and Blanchard (1988) suggest that leaders can and should act to influence follow - ers’ behavior. The manipulation of task and relationship behaviors in accordance with follower maturity can facilitate growth and development among followers (Hackman & Johnson, 2000). 5.4 Contemporary Leadership Ideas and Approaches Today’s leadership thinkers focus less on the possible presence of innate leadership char - acteristics and more on learned approaches that allow leaders to fine-tune their styles as appropriate and apply them suitably as situations arise. Contemporary health care lead - ership ideas incorporate a broader perspective on emotional intelligence, servant, trans - forming, and global leadership.

Emotional Intelligence Daniel Goleman (Goleman, Boyatzis, & McKee, 2002), the pioneer and field leader in the study of emotional intelligence, focuses on how leaders conduct themselves and manage their relationships. Emotional intelligence (EI) is defined as a learned ability to distin - guish, comprehend, and communicate feelings accurately and to manage emotions so that they work for and not against the individual experiencing them. A person with a high EI level possesses both strong self-awareness and a keen ability to discern the needs of other people (Warner, 2012). Some insist that possessing EI is a skill set to be learned through engaging in flexible and open communication and focusing on, acknowledging, and appreciating others’ feelings. Others maintain that EI is instinctual; leaders will innately know what is needed of them in the same way that mothers know how to care for their newborn children (Hackman & Johnson, 2000). fra81455_05_c05_121-150.indd 138 4/23/14 9:23 AM Section 5.4 Contemporary Leadership Ideas and Approaches Goleman distinguishes four style types of EI, as shown in Figure 5.3.

Individuals with a reflective style are task-focused, highly results-driven people who prefer to fulfill their goals privately and in systematic and orga - nized ways. Those with a conceptual style are also task focused and highly results driven; they seek to fulfill their goals in ways that stretch them and provide greater opportunity for growth. Organized individuals value structured environments where oth - ers can interact seamlessly; they thrive where expectations and pro - cesses are clear and concise; and they are not likely to challenge existing assumptions or seek change in cur - rent practices. Empathetic individu - als are highly relationship driven, seeking personal connections with others and to be in touch with their own and others’ inner feelings. Theory in Action: Emotional Intelligence Applications in Health Organizations Awareness of the different EI styles enhances self-awareness of one’s leadership abilities, which in itself is a key EI characteristic. The others are self-management or regulation, self-motivation, empathy or social awareness, and social skills (Deckard, 2011). Freshman and Rubino (2002) argue that EI is a core leadership competency for health care professionals, who must possess the sensitivity to recognize and deal effectively with very sensitive human issues. Table 5.3 presents examples of how health care leaders can use EI to handle specific challenges. (continued) Figure 5.3: The four emotional intelligence styles The four emotional intelligence styles incorporate variables for structure and outcomes.

Source: Ready to Manage. (2013). Using different emotional intelligence styles. Retrieved March 21, 2014, from http://blog.readytomanage.com /using-different-emotional-intelligence-styles REFLECTIVE High Structure and High Outcomes CONCEPTUAL Highly Experimental and High Outcomes ORGANIZED High Structure and Highly Beliefs Driven EMPATHETIC Highly Experimental and Highly Beliefs Driven fra81455_05_c05_121-150.indd 139 4/23/14 9:23 AM Section 5.4 Contemporary Leadership Ideas and Approaches Theory in Action: Emotional Intelligence Applications in Health Organizations (continued) Table 5.3: Emotional intelligence (EI) characteristics, descriptions, and applications EI characteristic Description Application Self-awareness Knowledge of one’s true feelings, needs and drives, abilities, and vulnerabilities Recognizing that your inherently cautious nature may color your assessment of the fea - sibility of developing a new service line Self-regulation Ability to control one’s emotions without repressing them Scheduling time-limited periodic meetings with a subordinate whom you consider needy and annoying Self-motivation Taking initiative, seeking challenges and growth Stepping up to create a culture of regulatory compliance throughout your organization Social awareness Sensitivity to others’ needs and feelings Learning and asking about diverse patient populations’ care prefer - ences and concerns Social skills Ability to guide and influence others’ behavior Choosing the right time to propose adopting a new billing system Source: Freshman, B., & Rubino, L. (2002). Emotional intelligence: A core competency for health care administrators. Health Care Manager, 20 , 1–9. Servant Leadership The phrase servant leadership was coined by Robert Greenleaf (1970), who considered leadership an outgrowth of a calling to serve others. Both a leadership philosophy and a set of leadership practices, servant leadership is particularly relevant and desirable in health organizations with a strong community service or faith-based mission. Servant leaders put followers’ needs before their own in efforts to help followers develop, grow, and perform at increasingly high levels. Servant leadership accentuates cooperative part - nerships, interdependence, empathy, and the principled use of control and influence. fra81455_05_c05_121-150.indd 140 4/23/14 9:23 AM Section 5.4 Contemporary Leadership Ideas and Approaches Servant leaders make purposeful decisions to be in the service of others, rather than seek - ing to amplify their own authority and influence (Gillet, Cartwright, & Van Vugt, 2010).

Research on servant leadership in health organizations, while limited, has found some posi - tive associations between servant leadership and organizational performance. Anderson (2003) noted the usefulness of servant leadership in developing strong hospital-physician relationships. Pelote and Route (2007) observed that the most successful health care leaders displayed characteristics of servant leaders. By adopting a view of themselves primarily as coaches rather than experts, servant leaders function very effectively in the health care arena.

Transactional, Transforming, and Transformational Leadership Historian and leadership expert James MacGregor Burns (1978) defined transforming leadership as a process in which leaders and followers assist one another in advancing to increased levels of morale and incentive. In contrast to transactional leadership , where leaders exchange rewards of importance and value to the follower to drive preferred out - comes, transformational leaders offer followers a heightened enlightenment of satisfac - tion, stimulation, and a sense of purpose (Turan & Sny, 1996). Bass built on Burns’s work to argue that transactional and transformational leadership were not mutually exclusive concepts; instead, he proposed a linear progression from transactional to transformational leadership (Ledlow & Coppola, 2014). The end result of transformational leadership is relationships of mutual inspiration and motivation that change followers into leaders and may change leaders into moral agents (Bass, 1990).Transformational leaders are empower - ing, visionary, passionate, and creative. They are constantly looking for ways to innovate and improve the organization’s products or services. Ledlow and Coppola (2014) note that successful leaders of health organizations employ both transactional and transforma - tional leadership styles, sometimes simultaneously, based on the situation, and conclude that transformational leadership is a style associated with success in health organizations.

Global Leadership A more recently recognized managerial skill set characterizes leaders who cultivate business in foreign markets, set business strategy at a global level, and manage glob - ally diverse and dispersed staff (Society for Human Resource Management, 2008). As the world becomes increasingly interconnected and technologically astute, global leadership is likely to play a more vital role in all types of business, including health organizations.

Leaders from different cultures and disciplines working together toward common goals help shape the discussion and outcomes. Global leadership occurs when an individual or group organizes collaborative efforts among different stakeholders with a global business perspective (Hayes, 2011). The rise in the growth of medical tourism, where people travel outside their home countries to obtain less costly medical treatment, offers an example of global health care leadership. A German corporation has built a niche business, Holiday Dialysis International, by arranging cruises and other travel experiences to accommodate people on dialysis (Sheahan & Kroner, 2013).

Global leadership is important for health organizations in the United States engaged in international development and commerce. Morgan McCall and George Hollenbeck (2002) fra81455_05_c05_121-150.indd 141 4/23/14 9:23 AM Section 5.5 Health Care Leadership Challenges studied successful global leaders and developed a list of common competencies specific to them. They include open-mindedness and flexibility in thought and tactics, cultural inter - est and sensitivity, ability to deal with complexity, resilience, resourcefulness, optimism, energy, honesty, integrity, personal stability, and value-added technical or business skills.

As countries throughout the world become more interconnected through e-commerce and communication, international provision of health care services will further intensify.

Health professionals in the United States have a pivotal role to play in improving popula - tion health outcomes in developing countries. Additionally, there are many lessons that U.S. health care leaders can learn from their more successful global counterparts. The International Hospital Federation and the Commonwealth Fund recommend that U.S.

health care system leaders apply the following lessons learned from the study of other developed countries’ health systems: 1. Develop robust primary care systems to achieve better health outcomes at lower costs. 2. Redesign medical liability to eliminate incentives for litigation and defensive medicine. 3. Create disease registries to improve treatment effectiveness and lower costs asso - ciated with conditions. 4. Allow hospitals to employ physicians to increase efficiency and align financial incentives for both types of providers. 5. Formalize mentorships between senior executives and junior managers to develop future health leaders (May, 2013b). All of these ideas have been debated, and some have been partially adopted in the United States. For example, a growing number of community health centers and primary care practices are seeking formal accreditation from the National Committee for Quality Assurance as Primary Care Medical Homes. Some states have passed tort reform legisla - tion limiting malpractice awards, allow hospitals to employ physicians, and have created registries for diseases such as cancer. Encouraged by the ACHE, some large organizations have created formal leadership-mentoring programs. Because the United States does not have a national health care system, these practices that have helped other countries pro - vide better quality care at lower cost have not been consistently nor comprehensively adopted in the United States. 5.5 Health Care Leadership Challenges The delivery of health care in the United States is in a constant state of change as new tech - nological advances, demographic shifts, and increased competition all challenge health organization leaders to do more with less and respond effectively to myriad changes that influence delivery of care. Physician and health care consultant Dr. Kent Bottles (2010) listed the top health care leadership challenges of today: 1. Making effective use of health information technology, particularly at the community level and across traditional organizational boundaries. 2. Improving coordination of care and developing effective medical home models. fra81455_05_c05_121-150.indd 142 4/23/14 9:23 AM Section 5.5 Health Care Leadership Challenges 3. Pursuing more efficient and effective chronic disease management approaches. 4. Adopting cutting edge clinical quality, outcomes and patient safety initiatives. 5. Developing more effective ways of interacting with engaged patients and disease specific patient groups. 6. Integrating comparative effectiveness and research and evidence- based best practices into clinical care more quickly, effectively, and consistently. 7. Adapting clinical delivery system structure and processes to the con - tinuing emergence of genomic medicine/personalized medicine. 8. Expanding the use of inter-disciplinary health care teams. 9. Developing focused initiatives to eliminate health disparities. 10. Bringing about demonstrable improvements in population health sta - tus, rather than merely treating disease. 11. Developing the capacity to assume and manage financial and clinical risk for defined populations. 12. Developing innovative approaches to medical and health profession - als’ education that incorporate all of the above mentioned elements. Meeting the Challenges Los Angeles–based COPE Health Solutions is a leading health care corporation that part - ners with hospitals, physician groups, health plans, clinics, and other health care organiza - tions to help them achieve visionary, market-relevant health care solutions. Most recently, as health reform has become a major agenda item at the state and federal level, COPE Health Solutions has emerged as a thought leader in the areas of clinical integration, care coordination, and workforce planning and development. COPE CEO Allen Miller ’s Janu - ary 2014 briefing message articulates strategies for health organizations to provide better health and better care at lower cost ( The Triple Aim ). Across the country, physicians, hospitals, clinics, health plans, skilled nursing facilities and others are working to better understand how we can transform care delivery and payment incentives to achieve The Triple Aim [better health and better care, at lower cost]. Moreover, hospitals and health systems; physicians, nurses, pharmacists and providers of all types; patients and consumers; policy-makers and elected leaders are blazing a path to best leverage the impacts of emerging market changes. Major transformations in payment and the constitution of the health care mar - ket include Exchanges, expanded Medicaid eligibility, cuts in commercial reimbursement rates, demographic shifts, Medicaid and DSH budget cuts and the growth of Medicare Advantage.

While a few definitive national trends are beginning to emerge, such as the continued transition of fee-for-service Medicare into Medicare Advantage, other trends such as Medicaid expansion, the rate of membership growth in state exchanges and the adaptation of care coordination vary significantly by state and by community. Make no mistake though, change is no longer something that may be coming; rather, it is our new reality - throughout the United States. The pace of change will only continue to increase as enhanced fra81455_05_c05_121-150.indd 143 4/23/14 9:23 AM Section 5.5 Health Care Leadership Challenges reporting and transparency, coupled with a growing demand for value, force increasingly significant changes in how care is both paid for and delivered.

That said, health care is still very much local players, politics and realities.

Success in any community depends upon the ability of the various stake - holders to develop a vision for their future coupled with evidence-based strategies that are adapted to local realities and local community needs.

Providers require a vision beyond painful and blunt budget decisions.

They must partner with insurers and patients to offer their communities a clear vision that includes the ongoing development of trusting and mis - sion-based partnerships, enhanced clinical and financial integration mod - els and improved care coordination that optimize resource consumption while improving our population health status.

Today, the majority of providers and insurers recognize the need to create a more cost-effective delivery system that will be more competitive in an increasingly managed care market. This can only be accomplished by also ensuring that organizations remain or become more nimble and respon - sive so that they can flex to match the new health care landscape and needs of the community. Along with the communities they serve, stewards of critical health care resources find themselves at a crossroads of exciting opportunities and decisions that can mean the difference between failure and a thriving future.

Also critical to the success of any strategic effort will be the development and implementation of a strategic management framework, which will guide performance across each organization and instill a culture of advanced per - formance improvement (Lean management), problem-solving, value-based decision making and renewed customer focus. This framework provides the foundation for planning and execution, enabling leadership and staff to directly tie daily operations and performance to initiatives, measures and metrics informed by the organization’s vision and strategy.

The key to success in every community across our nation will be our suc - cess at producing a measurable reduction in health care cost inflation while improving the quality of care provided to all Americans. (Miller, 2014, p. 1) Adaptive Leadership With the implementation of the Patient Protection and Affordable Care Act of 2010, health organizations face myriad new and surprising challenges to serve more patients and deal with changes in Medicare and Medicaid reimbursements. Strong leadership will be vital in ensuring that organizations successfully navigate the murky waters of this major health reform legislation. Followers and patients alike will be looking to leaders of organizations for greater levels of transparency and solid solutions on delivering care that maximizes benefits to the patient. fra81455_05_c05_121-150.indd 144 4/23/14 9:23 AM Section 5.5 Health Care Leadership Challenges Adaptive leadership is a set of strategies and practices that can aid organizations and their people to penetrate gridlocks, realize profound change, and thrive in complex, intense, and demanding environments (Heifetz, 1998). In popular terms, adaptive leader - ship is often referred to as “thinking on your toes.” The adaptive leader explains the fun - damental issues and discusses with the group their roles and function in finding adequate solutions to problems. It is a rational and composed leadership framework that helps individuals and organizations thrive and flourish in difficult and ambiguous environ - ments. It is commonly used when organizations have high aspirations for growth and call for responses outside the existing set of capabilities. Adaptive leadership helps make organizational aspirations a reality (National Conservation Leadership Institute, 2013).

Understanding the theories and tools of leadership and applying them appropriately can greatly help leaders adapt their styles and practices to be successful in their roles in the often volatile environments of health care. It is also useful to learn from the career experi - ences of exemplary leaders in health organizations. Leader Spotlight: Sheila Rankin, Vice President of National Medicare Administration at Kaiser Foundation Health Plan Kaiser Permanente is the country’s leading health care provider and not-for-profit health plan.

Founded in 1945, the company has grown from a 12-bed hospital into a leading integrated health delivery system serving more than 9.1 million members in nine states and the District of Columbia and is recognized worldwide for providing innovative, high-quality, evidence-based health care.

As a vice president of National Medicare Administration, Sheila Rankin oversees operational processes for nearly 1.2 million–plus Kaiser Permanente Medicare members. She partners with colleagues throughout the organization to implement compliance and operational improvement initiatives to maintain Kaiser Permanente’s industry-leading reputation with federal regulators, ensure an excellent service experience for members, and achieve membership and revenue growth for the Medicare line of business.

Rankin began her career at Kaiser Permanente in 1996. She has worked in various administrative and implementation roles in the areas of product development, claims administration, and Health Insurance Portability and Accountability Act (HIPAA) compliance, and she has supported the launch of the Kaiser Permanente HealthConnect electronic health record system.

She joined the Medicare business line in 2005 to lead Kaiser Permanente’s implementation of the Medicare Modernization Act. Rankin previously worked with other national health care insurance providers in various operational roles. She holds a master ’s degree in occupational health and safety from the University of Southern California.

The author interviewed Rankin about her leadership style and practices at Kaiser Permanente in July 2013.

What are the major cultural differences between Kaiser Permanente and the organizations where you previously worked? How did these experiences shape your management knowledge and leadership style?

Kaiser Permanente has a strong mission: to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve. It shapes everything we do. This makes it much easier to make decisions. Whenever we get stuck, we put the member in the center of the problem and that moves us forward. (continued) fra81455_05_c05_121-150.indd 145 4/23/14 9:23 AM Section 5.5 Health Care Leadership Challenges Leader Spotlight: Sheila Rankin, Vice President of National Medicare Administration at Kaiser Foundation Health Plan (continued) How has Kaiser Permanente changed in the 15 years you have worked there? What has stayed constant?

The core values and mission are the same, but there have been many changes in the way we do business. We have the largest private electronic medical record system in the nation and have to collect and report a lot more data to the government, employers, and regulators. Kaiser Permanente’s investments in providing our members with quality service and care have earned us recognition: For 2013, six out of seven of our Medicare health plans earned five out of five stars overall for quality and service in 2013 from the Centers for Medicare and Medicaid Services and the National Committee for Quality Assurance ranked Kaiser Permanente as the top Medicare plan in each of the states where we operate. That recognition is great and drives us to keep striving to maintain our position as an industry leader and high-quality and highly rated Medicare plan.

What advice do you have for someone who wants to succeed in a large and complex organization like Kaiser Permanente ? You have to be able to collaborate and be a strong team member. That means listening to and respecting the other person’s point of view but defending your own position if you feel it is right. You need to build a network of colleagues throughout the organization and keep those connections alive.

What are the most enjoyable and what are most challenging and/or stressful situations in your current position?

Every day I get to help make things better—with teams and initiatives to improve internal business processes, develop systems to resolve member issues and increase sales and revenue—and see the results of those efforts. We are always asking, “Is this the best we can do?” We look at the competition, of course, but it’s more important to set our own bar.

What’s stressful is the amount of regulations we have to follow. They are constantly changing, and it’s not always clear what value they provide. It’s a challenge to comply and keep costs manageable. For example, Medicare plans are required to send an EOB [explanation of benefits] report to members each month or quarter showing the services they used—even if there is no utilization. So we developed the option of an online EOB to reduce paper consumption and fulfillment costs. CMS approved the paperless option as long as the member can get a paper copy if they prefer.

What do you do to recharge and relax?

I like to do things that are really different from what I do at work. I belong to a watercolor painting group, and that is a nice contrast to the analytical work environment. And I play tennis every week on a United States Tennis Association team, which gives me an opportunity to be competitive. At work it’s all about building consensus. On the court I can be aggressive, and I am—I play to win!

What do you wish you had more time for?

Travel! It’s so stimulating to see how people in other countries live, and it makes you appreciate what you have at home. I’m really looking forward to my next vacation, in Italy with some people from my painting group.

What makes Kaiser Permanente a great place to work for you? How could it be even better?

My core values are authentically aligned at Kaiser Permanente: I can be who I am, and I work with great people who believe in the organization’s mission and bring it to life. To make Medicare better, I wish we as a society could figure out how to help people receive more services at home. (continued) fra81455_05_c05_121-150.indd 146 4/23/14 9:23 AM Section 5.6 Summary and Resources 5.6 Summary and Resources Chapter Summary Leadership is an essential component of organizational success, and leaders are expected to demonstrate not only the desire to lead others but also to foster organizational innova - tion, growth, and creativity. Leadership effectiveness depends on both leaders’ and fol - lowers’ willingness to become collaborative partners who can propel the organizations they serve to new heights of performance.

Managers organize business processes, and leaders lead people. Leaders have greater influence and power over the group. Managers, especially at the supervisory level, have a more hands-on role in carrying out the work. The difference between the two is critical to the organization’s success and continued development of followers.

Leadership is a recurrent concern for anyone who needs to empower, direct, and inspire others. Developing leadership prowess allows leaders to challenge themselves in new and strengthening ways that can further prepare them to lead people to places they never thought possible, through hard work, innovation, shared responsibilities, and an unend - ing search for excellence.

There are three major leadership styles: authoritarian leaders, democratic leaders, and laissez-faire leadership. There are five categories of followers: alienated followers, con - formist, pragmatist, passive followers, and exemplary followers. Contemporary leader - ship studies focus less on the possible presence of innate leadership characteristics and more on learned approaches that allow leaders to fine-tune their styles as appropriate and apply them suitably as situations arise. These approaches include emotional intelligence, servant, transforming, and global leadership.

However one decides to define and categorize leadership, the study and mastery of this topic will continue to be one of the highest priorities of leaders looking to drive their orga - nizations to greater levels of success. Leader Spotlight: Sheila Rankin, Vice President of National Medicare Administration at Kaiser Foundation Health Plan (continued) It would be ideal to help people age at home with more support—especially low-income people who struggle just to meet basic needs, and people who don’t have family or friends. That would be extraordinary.

Reflection Questions : 1. How does Rankin maintain a work-life balance? 2. What organizational values are important to you? 3. How are you developing a network of colleagues within your organization? fra81455_05_c05_121-150.indd 147 4/23/14 9:23 AM Section 5.6 Summary and Resources Critical Thinking and Discussion Questions 1. What is your definition of leadership? How does it differ from the chapter? 2. What are the essential competencies that today’s health care leaders must possess in order to lead organizations successfully in today’s volatile environment? 3. What are some of the theories and perspectives presented in this chapter that most resonate with you and your experiences? Explain your response. 4. Fiedler ’s model of leadership is one of the oldest leadership models around. Do you believe it is still applicable today? Why or why not? 5. Do you think Bottles got it right with the list of health care challenges in leader - ship? Choose the six challenges you think are most important, rank them, and explain your reasoning. Supplement your list with any other challenges you foresee that were not included in Bottles’s list. Key Terms achievement-oriented leadership (House—path-goal theory) A leadership style in which the leader believes in fol - lowers’ competence and sets challenging goals.

adaptive leadership A leadership approach of ad hoc, rapid responses to problems, often based on time pressures and limited availability of information and/or resources.

agenda setting A process in which a leader develops a formal plan to guide his or her decisions.

alienated follower (Kelley) A follower who feels devalued by the organization and lacks motivation to achieve organiza - tional goal.

authoritarian leader (Lewin) A leader who exerts a high degree of control over followers, emphasizes role distinctions, and motivates by fear.

competencies The physical and intellec - tual qualifications for a task, position, or role. conceptual (Goleman) An emotional intel - ligence style whose practitioners tend to be highly focused and results driven and who seek opportunities for growth as they fulfill goals.

conformists (Kelley) Followers who are willing to contribute to organizational goals and to accede to the demands of those in positions of authority.

contingency leadership (Fiedler) A lead - ership style in which the leader ’s style varies according to the situation.

courageous followers (Chaleff) Loyal fol - lowers who will also question the leader ’s behaviors and decisions.

delegate (Hersey and Blanchard) To turn over responsibilities for making and implementing decisions to highly devel - oped followers.

democratic leader (Lewin) A leader who engages in supportive communication that facilitates interaction between leaders and followers.

directive leadership (House—path-goal theory) A leadership style in which the leader tells followers exactly what to do and precisely how to do it. fra81455_05_c05_121-150.indd 148 4/23/14 9:23 AM Section 5.6 Summary and Resources emotional intelligence (EI) (Goleman) The ability to monitor one’s own and oth - ers’ feelings and emotions and to use this information to manage oneself and others.

empathetic (Goleman) An emotional intelligence style characteristic of highly relationship-driven individuals.

exemplary followers Highly competent, engaged, and interactive employees who display initiative in attempting tasks, fol - low through on their commitments, and strive for excellence in all that they do.

followership A complementary role to leadership based on voluntary adherence to a leader.

global leadership A type of leadership in which leaders of a global community work together synergistically toward a common vision and common goals.

great man theory (Carlyle) The theory that great leaders possess characteris - tics or traits not found in the rest of the population.

job maturity (Hersey and Blanchard) Demonstrated task-related abilities, skills, and knowledge.

laissez-faire leaders A type of leader who abdicates responsibility and allows follow - ers to set their own goals.

leadership A process of social influence that maximizes the efforts of others to achieve a goal.

managerial grid (Blake and Mouton) Also known as the leadership grid; a behav - ioral leadership model that identified five distinct leadership styles based on concern for people versus concern for production and positive or negative motivational approaches. mentor An experienced manager who offers a younger professional career guidance.

network building An executive manage - ment technique of establishing mutually beneficial cooperative relationships with a variety of internal and external organiza - tional colleagues and stakeholders.

organized (Goleman) An emotional intel - ligence style practiced by individuals who value structured environments with clear expectations and processes.

participating (Hersey and Blanchard) A leadership style, most appropriate for skilled followers who lack motivation, in which the leader imparts ideas and facili - tates group decision making.

participative leadership (House— path-goal theory) A leadership style in which the leader seeks input from and engages followers in decision making.

passive followers (Kelley) Employees who will do what they are told but not take the initiative in attempting tasks.

path-goal theory (House) A leader ’s behavior varies according to the satisfac - tion, motivation, and performance of his or her followers.

pragmatists (Kelley) Followers who will do what is necessary to keep their jobs.

psychological maturity (Hersey and Blanchard) Feelings of self-assurance, readiness, and motivation.

reflective (Goleman) An emotional intel - ligence style used by task-focused, results- driven leaders.

selling (Hersey and Blanchard) A leader behavior in which the leader makes a deci - sion and persuades followers to accept it. fra81455_05_c05_121-150.indd 149 4/23/14 9:23 AM Section 5.6 Summary and Resources servant leadership (Greenleaf) A leader - ship style in which the leader considers his or her position an honor, places the needs of followers first, and helps followers achieve superior performance.

situational approach A leadership style in which the traits, skills, and behaviors necessary for effective leadership vary from situation to situation.

supportive leadership (House—path-goal theory) A leadership style in which the leader considers followers’ needs and seeks to create a nurturing and friendly work environment.

telling (Hersey and Blanchard) A leader behavior most appropriate for underdevel - oped followers: The leader tells followers of decisions and gives close directions on how to do assigned tasks. transactional leadership (Burns) A lead - ership style in which leaders exchange rewards of value to followers to drive preferred outcomes.

transformational leadership (Bass) A leadership style in which charismatic, innovative, big-picture leaders inspire and develop followers to achieve great things.

transforming leadership (Burns) A style of leadership in which the leader empow - ers and inspires followers to carry out work goals and creates a high-morale workplace climate. fra81455_05_c05_121-150.indd 150 4/23/14 9:23 AM