From Management to Leadership: Strategies for Transforming Health, Third Edition by Jo Manion

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Chapter 1: Leadership: An Elusive Concept

Chapter Objectives

Define leadership.

Differentiate between leadership and management.

Identify reasons that leadership is especially important today.

Discuss challenges that health care leaders face today.

Distinguish between a challenge and an excuse.

Leadership has to take place every day. It cannot be the responsibility of the few, a rare event, or a once-in-a- lifetime opportunity.

R. A. HEIFETZ AND D. L. LAURIE, “THE WORK OF LEADERSHIP”

No other issue is as important in health care today as the development and continual evolution of leaders. “Leadership is the pivotal force behind successful organizations…. To create vital and viable organizations, leadership is necessary to help organizations develop a new vision of what they can be, then mobilize the organization to change toward the new vision” (Bennis and Nanus, 1985, p. 12). An organization's success is directly correlated to its leaders’ strengths and the depth of internal leadership capacity. The failure of an organization to develop leaders at all levels, relying instead on a few strong leaders at the top, results in dismal outcomes. In the foreword to Gifford and Elizabeth Pinchot's book The Intelligent Organization (1996b, p. x), Warren Bennis notes that “traditional bureaucratic organizations have failed and continue to fail, in large part, because they tend to rely exclusively on the intelligence of those at the very top of the pyramid.”

In the same way, relying on only formal managers for leadership limits the tremendous possibilities that exist when leaders are acknowledged from within any part or level of the organization. “Solutions… reside not in the executive suite but in the collective intelligence of employees at all levels, who need to use one another as resources, often across boundaries, and learn their way to those solutions” (Heifetz and Laurie, 1997, p. 124). Health care is facing a daunting challenge: the development of leaders. “The leadership pool in health care is shrinking in part because companies continue to ruthlessly excise management positions—formerly training grounds for aspiring executives—in the race to become leaner and meaner” (Grossman, 1999, p. 18). And although these tactics may have saved money in the short term, the long-term consequences to health care were significant in the absence of qualified individuals to move into executive and leadership roles. This past decade has seen the further decimation of ranks of managers as older workers are beginning to retire. The tremendous challenges of leadership positions today have resulted in situations in many organizations where the time required to recruit to frontline management positions has extended. The work is less appealing to potential candidates than it was in the past.

Many people fail to understand clearly the distinction between leadership and management; as a result, this narrows the field from which organizational leaders might emerge. In some instances, organizations do not recognize leaders who, without formal positional authority, emerge from the ranks; they sometimes resist them and label them as troublemakers or dissatisfied employees. “It is an illusion to expect that an executive team on its own will find the best way into the future. So you must use leadership to generate more leadership deep in the organization” (Heifetz, Grashow, and Linsky, 2009, p. 68).

This chapter explores the concept of leadership, differentiates it from management, identifies reasons that leadership is so critical in today's health care organizations, and illuminates several major challenges facing health care leaders.

Defining Leadership

Defining leadership is the first step. It is a much more elusive concept than is management. Most authorities on the topic define leadership as influencing others to do what needs to be done, especially those things organizational leadership believes need to be accomplished. The term transformational leadership has become repopularized as a result of the Magnet recognition program that identifies organizations with internal cultures strongly supportive of excellence in professional practice. The new model for Magnet has five identified components, one of which is transformational leadership. Leading people where they want to go is easy; in some instances, the biggest challenge is getting out of their way. However, the transformational leader “must lead people to where they need to be to meet the demands of the future” (Wolf, Triolo, and Ponte, 2008, p. 202). It's important to note here that the goal of the transformational leader is to transform the organization or department, not necessarily the people within it.

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Kouzes and Posner (2002, p. xvii) identify the leadership challenge as “how leaders mobilize others to want to get extraordinary things done in organizations.” Max DePree (1989, p. xx) believes the art of leadership is “liberating people to do what is required of them in the most effective and humane way possible.” This definition implies that leadership is not something one does to or for the follower but is instead a process of releasing the potential already present within an individual. The leader sets the stage and then steps out of the way to let others perform. True leadership enables followers to realize their full potential—potential that the followers perhaps did not suspect.

Also implied in any definition is that leadership is work. It is about performance: achieving outcomes, getting needed results. Peter Drucker (1992, p. 199) says that “it has little to do with ‘leadership qualities’ and even less to do with ‘charisma.’ It is mundane, unromantic, and boring. Its essence is performance.” Kouzes and Posner (2002, p. 13) reinforce this message: “Leadership is not at all about personality; it's about practice.”

Leadership is mobilizing the interest, energy, and commitment of all people at all levels of the organization. It is a means to an end. “An effective leader knows that the ultimate task of leadership is to create human energies and human vision” (Drucker, 1992, p. 122). Bardwick (1996) clearly states that leadership is not intellectual or cognitive but emotional. She points out that at the emotional level, leaders create followers because they generate “confidence in people who are frightened, certainty in people who were vacillating, action where there was hesitation, strength where there was weakness, expertise where there was floundering, courage where there were cowards, optimism where there was cynicism, and a conviction that the future will be better” (p. 14).

Noted leadership scholar and author Warren Bennis, who has spent four decades studying leaders, describes the leader as “one who manifests direction, integrity, hardiness, and courage in a consistent pattern of behavior that inspires trust, motivation, and responsibility on the part of the followers who in turn become leaders themselves” (Johnson, 1998, p. 293). He concludes that in addition to passion and an intense level of personal commitment, virtually every great leader has four competencies (O'Connell, 2009):

The ability to manage others’ attention, through a clear vision of what needs to be accomplished

The knack for managing meaning by communicating well

The skill of managing others’ trust through being a person of integrity and good character

The self-knowledge that allows the leader to deploy his or her skills effectively

None of these is easily teachable by the methods often used for leadership development, such as reading widely or attending seminars and formal academic programs. However, all three can be learned or perfected through life's experiences. For most people, the development of leadership capacity is lifelong work—a trial-and-error method of perfecting techniques and approaches and the evolution of personality and individual beliefs. Often the leader is not even aware of exactly how he or she influenced a follower. An opportunity or need to lead appeared, and the leader stepped forward to meet the challenge.

Harry Kraemer (2003, p. 18), chairman and CEO of Baxter Healthcare, believes that the best leaders are “people who have a very delicate balance between self-confidence and humility.” They are both self-confident and comfortable expressing their ideas and opinions, but they balance this expression with a healthy dose of humility and an understanding that other people may have better ideas and more insight on any given issue.

And perhaps most telling are the results of research conducted by Jim Collins and his associates (2001). They studied extensively the difference between good companies and compared them to similar companies that had achieved greatness. Although Collins told his research team specifically not to focus on leadership at the top, their final analysis revealed that leadership was a key factor for those companies with extraordinary success. The type of leadership the study revealed was a shocking surprise to the researchers. They found that the characteristics of these successful leaders did not include high- profile personalities and celebrity status but just the opposite: “Self-effacing, quiet, reserved, even shy—these leaders are a paradoxical blend of personal humility and professional will. They are more like Lincoln and Socrates than Patton or Caesar” (p. 12). Their ambition is first and foremost for their organization, not for themselves.

Several years later, Collins (2005) examined leadership in social sector organizations and found a striking difference between the social and business sectors. He described social sector leadership as a “legislative” type of leader. In other words, these leaders do not have the power of decision. Frances Hesselbein, CEO of the Girl Scouts of the USA, was asked how she accomplished her results without the concentrated executive power seen in the business sector. She replied, “Oh, you always have power, if you just know where to find it. There is the power of inclusion, and the power of language, and the power of shared interests, and the power of coalition. Power is all around you to draw upon, but it is rarely raw, rarely visible” (Collins, 2005, p. 10).

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The complex and diffuse power structures common in health care organizations means that no executive has enough structural power to make the most important decisions alone. To those from other sectors, the leader may look weak and indecisive when in fact successful leaders in social sector organizations develop incredible skills of persuasion, political currency, and coalition building. Collins 2005 notes that the irony here is that those of us in the social sector “increasingly look to business for leadership models and talent, yet I suspect we will find more true leadership in the social sectors than the business sector” (p. 12). True leadership, says Collins, exists only if people follow when they have the freedom not to.

Distinguishing Between Management and Leadership

How does leadership differ from management? Most would agree that not all managers are good leaders and not all leaders are good managers. However, differentiating between these two concepts concisely and concretely is difficult. A common misconception is that the legitimate authority of a position, such as holding a management job or an elected office, automatically confers leadership skills on the person holding that position. Nothing is further from the truth. In the same way, simply being able to biologically reproduce does not make a person a good parent. Leadership and management are two separate and distinct concepts, although they may exist simultaneously in the same person. In an interview (Flower, 1990), Bennis compares management and leadership on several key points. His viewpoint greatly increases clarity about these two concepts.

Efficiency Versus Effectiveness

The first differentiating point is related to the essential focus of the individual. A manager is concerned with efficiency—getting things done right, better, and faster. Increasing productivity and streamlining current operations are important, and managers often exhort employees to work smarter, not harder. Productivity reports and statistics are crucial for evaluating success. In contrast, a leader is more concerned with effectiveness, asking: “Are we doing the right thing?” The initial question is not, “How can we do this faster?” but, “Should we be doing this at all?” To answer the latter question, a key deciding factor is whether the activity in question directly supports the organization's overall purpose and mission. Is the activity in alignment with the stated values and beliefs of the organization and the people within it? Will it produce desirable outcomes?

A classic example of this difference occurred some years ago in a 480-bed midwestern medical center. As the hospital's volume increased over the years, traffic flow on the elevators became a major problem. Several process improvement teams attacked the problem at various times but came up with no lasting or truly effective solution. After years of frustration, a team assigned to this issue finally came up with a solution: building a new set of elevators for patients only. The intent was to move patients faster and more efficiently, a goal the medical center attempted to accomplish for several hundred thousand dollars.

A couple of years later, the organization went through a major reengineering and work redesign effort. The first questions were: Why are we transporting patients all over the organization? Can we deploy any services to the patient care unit to reduce the distance that patients travel? These are leadership questions; instead of asking how to move patients faster, the project team asked: Should patients be moved at all? How can we reduce movement of patients? This kind of thinking has led to the concept of the universal room: the patient is admitted to a room and remains assigned to that room throughout the entire hospital stay. The level of care may change depending on the patient's needs, but the location of the patient does not.

How Versus What and Why

A second differentiating characteristic is that management is about how, whereas leadership is about what and why. A good manager usually understands the work processes and can demonstrate and explain to an employee how to accomplish the work. Health care, which has a history of promoting people with job or technical expertise to management and supervisory roles, clearly values these characteristics. The highly skilled worker or practitioner becomes a manager, and overall this is the typical pattern regardless of the department or discipline in question. Healthcare workers tend to highly value job expertise in their managers and, in fact, often show disdain for managers who cannot perform at a highly competent level the work of the employees they manage. This is understandable when we examine health care's history. Early hospitals were led and managed by individuals with a high level of technical clinical expertise (physicians and nurses). Only in recent decades have a significant number of executives and managers with nonclinical backgrounds entered health care administration. Some clinical health care workers today still doubt that individuals with nonclinical backgrounds can possibly understand enough to be effective leaders in health care organizations.

Knowing and controlling work processes are essential components of the managerial role—and rightly so. Management's origins were in the factories of the industrial age. The workforce of the late 1800s was very different from today's workforce. Most early factory workers were newly arrived immigrants, women, and children—poorly informed, uneducated, non-English- speaking, and uninvolved employees—working for survival wages. The work was compartmentalized, broken down into small, manageable pieces that one person could easily teach to these early workers. The manager was responsible for ensuring that employees did the work correctly and was often the only person who understood the entire piece of work. The workforce is

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remarkably different today, where most are considered knowledge workers.

In contrast to a manager, a leader focuses on what needs to be done and why. He or she spends more time explaining the general direction and purpose of the work, and then the leader gets out of the way so that the follower can do it. Someone once characterized a leader as an individual who describes what needs to be done and then says, “It's up to you to impress me with how you do it.”

This implies several points. First, the leader knows what needs to be done and can clearly articulate this to others in a way that convinces the followers that it is an appropriate direction. Second, the leader has the patience to share the reasons this course has been chosen and ensures that those reasons are acceptable and valid to the follower. Finally, the leader accepts that the follower may find a new and possibly better way to accomplish the goals. The leader is not wedded to his or her way of performing a task or carrying out a responsibility.

There are many examples of this leadership approach in health care organizations today. When a health care organization is undertaking a major cultural change initiative, executives often present it in a way that first explains the organization's current status, the external environment, and the reasons the board of trustees and executive team believe this initiative is necessary for the organization's future viability. When the case is made well and the reasons are clear, employees in most instances view them as important and valued. When the reasons for the change align with important values and beliefs that frontline employees hold, positive results are much more likely.

Structure Versus People

In contrast, Bennis (Flower, 1990) points out that management is about systems, controls, procedures, and policies—all of which create structure—whereas leadership is about people. Managers spend much of their time dealing with organizational structure. Anyone who has successfully participated in an accreditation visit by an outside agency has a sense of the number of policies and procedures that the average health care institution generates. There is usually a policy or procedure for every aspect of organizational and professional life. Infection control monitoring, risk management reporting, corporate compliance protocols, and patient-complaint resolution are only a few among the multitude of control systems designed to oversee organizational processes. These systems ensure that work is progressing as expected; they are designed to alert the manager to any deviation so that it can be investigated and corrected. Extensive policies and procedures, however, can sometimes be used to substitute for employees’ good judgment and initiative in decision making. Relying heavily on the use of written policies and procedures can inadvertently weaken the development of individual decision making in the organization.

Although control is really the essence of management, it shouldn't be construed as a negative. There need to be organizing structures and processes in the most complex organizations. There is continual pressure to reduce variation and increase quality, and this is often accomplished by meeting established standards and expectations. The manager's role is to control processes and structures to ensure that certain outcomes result. “This is managerial control. Managers must have many checks and balances to ensure timely, cost-effective, and high-quality results” (Vestal, 2009c, p. 6).

Leadership is about people and relationships. Leadership exists only within the context of a relationship. If there are no followers, there is no need for leadership, just independent action. Leadership occurs when leader behavior influences someone else to act in a certain manner, and at the core of such a connection between people is trust. Chapter 2 explores these concepts in depth. Leadership as primarily a relationship may be disturbing news for managers who have limited people or interpersonal skills, for an individual who has difficulty in working with others will find it virtually impossible to become a transformational leader. A book on policies and procedures cannot replace this key relationship. Fortunately, an aspiring leader can develop and hone people skills, but maintaining them takes more energy if they are not part of the individual's natural talent base.

Status Quo Versus Innovation

Whereas maintaining and managing the status quo are appropriate managerial behaviors (Bennis, 1989), leaders are more concerned with innovation and implementing new processes to create a desired future. This is a difficult area for many health care leaders because most health care organizations have not customarily encouraged or highly valued either creativity or innovation. The words are frequently used and can even appear in the mission statement, but only rarely are health care organizations flexible and fluid enough to encourage true innovation. Most are bureaucratic structures that respond to any deviation from standard practice as something to stamp out, control, or at least limit in some manner.

Punitive responses to mistakes are common, and many managers have learned not to rock the boat or deviate in any significant way. The incident-reporting mechanism is a common example. If an employee reports making a mistake, a familiar response is for the manager to determine what went wrong and how the employee needs to change so that the mistake never occurs again—a return to the status quo. Less frequent is a response that investigates the mistake in partnership with

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employees to determine why the mistake occurred and what needs to change in the system so that the problem does not occur again. Recent emphasis on patient safety and quality has stimulated a move toward more creative problem solving and resolution without placing blame. Often referred to as a just culture, errors and mistakes are seen as an opportunity for improvement. Investigation is thorough, but responses to these situations are deliberate and based on many factors.

Leaders are always looking for ways to improve the current situation; they are never satisfied with the status quo. A leader's automatic response to a problem or mistake is to consider ways to capitalize on the opportunity that the mistake has created. For this reason, Bennis points out, “bureaucracies tend to suppress real leadership because real leaders disequilibrate systems; they create disorder and instability, even chaos” (Flower, 1990, p. 62).

Because a leader trusts people, he or she knows that the follower can always find a way to improve on the current situation. DePree (1989) describes highly effective leaders as those who are comfortable abandoning themselves to others’ strengths and admitting that they themselves cannot know or do everything. This can be frightening to those who are not up to the challenge of continually questioning their own performance or established practices. Fearful individuals may react to this drive for continual improvement as implied criticism: “It was not good enough, and now we have to change it.”

Bottom Line Versus Horizon

Managers keep their eyes on the bottom line; leaders focus on the horizon. “With leaders, the future calls to them in a voice they can't drown out. The future is more real than the present; it compels them to act” (Breen, 2005, p. 66). Managers ask: Are we within budget? Are we meeting our goals? What's the deadline? How can we improve our productivity? The manager's emphasis is on counting, recording, and measuring to ensure that everything is on target. It is easy to forget that many things that count—that are important—cannot be counted. By its very nature, leadership and its results are difficult to measure. How do you measure a relationship? What are the concrete, observable outcomes of a healthy working relationship? How do you evaluate the success of an inspiring vision? Good leaders see beyond the bottom line to the horizon, where a vision of a different future for themselves and their followers guides their day-to-day decision making. This vision inspires them as they make difficult decisions on behalf of the organization and the people within it.

A leader with a vision of the future that includes highly engaged and passionate employees who feel ownership of their jobs, make decisions affecting work in their span of control, and work in partnership with the organization's managers knows that in order to attain this vision, the organization will need to continually invest in employee learning and development opportunities. In many organizations today, employees are being asked to contribute more, learn additional skills, and take on more responsibility at the same time that their organizations have severely reduced education departments and learning resources. Leadership decisions to invest in employee education may not look good on the bottom line, but they often are required in order to attain an alternative future. Exemplary leaders recognize that organizations that do not invest in the development of internal staff resources now will have to pay a much higher price in the future.

Another simple example of the difference between focusing on results and paying attention to the future payoff is evident when we observe leaders who become actively involved in coaching their employees for improved performance. If an employee is having difficulty with a key vendor, people in another department, or perhaps a physician, it is relatively easy for a manager to use his or her legitimate authority and step in to solve the problem. Coaching and supporting the employee in solving the problem directly may be more time-consuming and riskier. However, this leadership approach creates stronger, more effective employees, and the payoff is in the future because employees learn how to handle their own problems.

Management and Leadership: A Final Word

That there is a difference between management and leadership is clear. However, it is more of a both-and choice rather than an either-or choice. None of this discussion is to imply that there is not a need for exemplary managers in today's health care organizations, and often the best leaders have strong management skills. Managers will always be needed, and the role is so crucial that everyone in the organization must share managerial responsibilities. Highly efficient employees who understand their work, are able to organize and structure it, and can measure outcomes and take corrective action will always be in high demand. With a greater number of experienced and mature workers in health care today, organizations place higher expectations on employees than ever before. As more employees become self-managing, organizations may reduce the number of formal managers. At the same time, however, there is an increasing need for leaders. According to many scholars, organizations in this country have been overmanaged and underled (Bennis and Nanus, 1985; Kouzes and Posner, 2002; Peters, 1987).

Why Leadership Is in Demand Today

During the 1970s, health care organizations had a burgeoning interest in management development programs. It was recognized that promoting technically competent employees into management positions produced a responsibility on the part of

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