From Management to Leadership E-Book

Jo Manion

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 656

Veröffentlichungsjahr: 2011

Beschreibung

From Management to Leadership identifies the fundamental interpersonal skills that every health care leader (and aspiring leader) needs to develop in order to be a successful executive or manager. The third edition of the classic text offers suggestions for developing and improving essential health care leadership skills. Written to be a practical guide, the book presents concepts and skills that can be immediately applied to everyday situations. Completely revised and updated, this edition includes new concepts and resources based on the latest research and practices.

Praise for the Third Edition of From Management to Leadership

"As leaders, we want engagement, commitment, ownership, teamwork, and results. Jo Manion illuminates the interpersonal skills that are pivotal. She provides the how in a way that's convincing, refreshing, mind-stretching, and practical."
—Wendy Leebov, EdD, president, Wendy Leebov and Associates

"This third edition continues the tradition of enumerating the incisive and articulate response of leaders to the complexities of the age and of the necessary recalibration of the leader's role. I encourage contemporary leaders to see this text as a must have in their leadership library: I certainly have it in mine!"
—Tim Porter-O'Grady, DM, EdD, ScD(h), APRN, FAAN, senior partner, Tim Porter-O'Grady Associates, Inc. and associate professor, College of Nursing and Health Innovation, Arizona State University

"Finally, a book that addresses the need for health care leaders and aspiring leaders to be much more than good managers. This book gives practical, concrete, and insightful strategies to becoming a great leader."
—Katherine W. Vestal, RN, PhD, FACHE, FAAN, president, Work Innovations LLC

Companion Web site: www.josseybass.com/go/manion

Leseprobe

CONTENTS

Preface

Acknowledgments

The Author

Chapter 1 : Leadership

Defining Leadership

Distinguishing Between Management and Leadership

Why Leadership Is in Demand Today

Challenges Facing Today’s Leaders

Conclusion

Chapter 2 : Cultivating the Leadership Relationship

Emotional Intelligence

Social Intelligence

The Leadership Relationship

Essential Elements of a Healthy Relationship

Creating a Trust-Based Organizational Climate

The Nature of the Leadership Relationship

Collective Responsibility and Accountability

Conclusion

Chapter 3 : Building Commitment

Compliance

Commitment

Organizational Commitment

Leadership Interventions

Mission

Vision

Common Pitfalls

Conclusion

Chapter 4 : Communicating with Clarity

Defining Communication

Common Problems

Communication and Leadership

Information

The Leader’s Primary Responsibilities: Information and Communication

Nonverbal Communication

Written Communication

Special Communication Issues

Conclusion

Chapter 5 : The Art of Effectively Facilitating Processes

The Key Tenets

Empowering Others

Resolving Conflict

Creating Teams

Facilitating the Processes of Change and Transition

Conclusion

Chapter 6 : Getting Results

Proactivity

Problem Solving

Decision Making

Appreciative Inquiry

Polarity Management

Conclusion

Chapter 7 : Coaching and Developing Others

The Leader’s Role

The Coaching Role

The Coaching Process

Teaching Others

Conclusion

Chapter 8 : Going Forward into Our Future

References

Index

To my father . . .

who first set me on my path and instilled in me a can-do belief with countless repetitions of The Little Engine That Could

To the countless leaders . . .

who have joined me on my journey and inspired me with their personal insights, stories of wisdom, shared disappointments, acts of courage, unbridled passion for their work, and unwavering faith

Copyright © 2011 by John Wiley & Sons, Inc. All rights reserved.

Published by Jossey-Bass

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Library of Congress Cataloging-in-Publication Data

Manion, Jo.

From management to leadership: strategies for transforming health care / Jo Manion.—3rd ed.

p. cm.

Includes bibliographical references and index.

ISBN 978-0-470-88629-8 (pbk.); 978-1-118-01553-7 (ebk); 978-1-118-01554-4 (ebk); 978-1-118-01555-1 (ebk)

1. Health services administration—Psychological aspects. 2. Leadership. 3. Interpersonal relations. I. Title.

[DNLM: 1. Health Facility Administrators. 2. Efficiency, Organizational. 3. Health Services Administration. 4. Interpersonal Relations. 5. Leadership. WX 155]

RA971.M3468 2011

362.1068—dc22

2010042998

PREFACE

Welcome to the journey! Whether you are already a transformational leader, an aspiring leader, or simply someone who is interested in a path of continual learning, this book was written for you. Strengthening leadership capacity is a critical challenge facing health care professionals and organizations today. The concepts and principles presented within these pages are essential for those facing the challenge of transforming our health care organizations.

Our world has always been complex; however, in every segment of our lives, the complexity is increasing. Tumultuous change is occurring at breakneck speed and with it comes an overpowering need for individuals who can lead others effectively during these demanding times. Strong and capable leaders are needed who create the direction, remain focused on important priorities amid great distractions, win the commitment of followers and other key stakeholders, and influence others to do what is necessary to achieve a future strategic vision. Unprecedented changes are occurring in executive and managerial health care roles, as well as the manner in which health care organizations function. Health care leaders are assuming nontraditional roles that demand mastery of new and different skills for which they may feel inadequately equipped. The uncertainty of health care reform and the increased presence of government in the health care sector lead to a stressful state of ambiguity. Leaders today face a tremendous challenge in balancing the demands of day-to-day organizational life while learning for the future.

Some organizations meet the challenge of leadership development by recruiting strong leaders from the outside. However, vibrant, dynamic, and flourishing organizations are also committed to developing leaders from within the existing ranks of their managers and employees. Working in partnership with employees to develop their leadership skills is in any organization’s best interests. By providing opportunities, active coaching, guidance, and solid experiential learning programs, the organization creates an ever-expanding source of new leaders to navigate amid the turmoil of this decade.

Leadership development is far more than simply an organizational issue, however; it is an intensely personal issue for all health care workers who are being asked to assume increasingly higher levels of responsibility, to be more involved in making decisions about issues that were previously solely the traditional manager’s domain, and to serve in leadership roles. Loren Ankario (quoted in “Know How to Lead,” 1993) noted that in the first decade of this new millennium, “anyone who is not a leader in his or her own way probably won’t have a job.” Those words, written almost twenty years ago, have proven to be prophetic. In today’s workplace, many employees are seeking—in some instances, demanding—opportunities to serve in roles that influence their work environment even more broadly. In models of shared decision making, organizations consciously develop leaders at all levels.

The concept of leaders at all levels corresponds to societal trends. Overall, the health care workforce is more mature and experienced than ever before in our history. Today’s successful health care manager understands that the old command-and-control methodology is no longer appropriate. The work relationship has evolved into a partnership model in which leadership roles are fluid and dynamic, with individuals moving in and out of these roles almost constantly. Facilitating the development of employees’ leadership skills makes strategic sense because the entire organization benefits. The organization’s foundation is stronger, its structure more resilient, and its future viability more likely in an organization filled with individuals who are leaders or are capable of moving into leadership roles.

To reiterate, this book is written for all health care leaders and aspiring leaders. Seasoned leaders will find that the concepts and skills presented here are essential as they reshape and redefine their roles. The book may also serve as a reference or reminder to which the master leader returns when facing a particular challenge. For new or aspiring leaders, this book can serve as a road map for developing interpersonal skills that enhance the leadership process.

In his book On Becoming a Leader, Warren Bennis (1989) notes that leadership courses can teach only skills, not character or vision. He believes character and vision develop in an individual over the course of time, most often as a result of life experiences—learning that occurs beyond traditional course work. However, Peter Drucker believes that all aspects of leadership can and must be learned (Hesselbein, Goldsmith, and Beckhard, 1996). Perhaps it is useful to differentiate between talent and skills, as Buckingham and Coffman (1999) suggest. First, they believe that talent is necessary, and when combined with education and training, determination, and practice, it leads to excellence in practice. In other words, all the determination, education, and training in the world will not help me become a great singer if I do not first have the necessary talent to excel (I am tone deaf and cannot carry a tune). Furthermore, talent cannot be taught; it is there, or it is not.

The presence of the right talent, more than experience, learning, or intelligence, is the prerequisite for excellence as a leader. Skills, however, can be taught and developed. The purpose of this book is to explore the essential interpersonal skills of effective leaders that can be taught and learned: skills that, with study and practice, can increase a leader’s effectiveness and strengthen his or her talent base. It is a substantial and in-depth source for the concepts covered. Recent and classic evidence is provided to support the conclusions and writings in this book.

There is an inherent difficulty in writing about leadership. The concepts presented here are most frequently presented in a linear fashion in order to explain them clearly. However, most of these concepts are nonlinear in actual application. Presenting them in a linear fashion can sometimes oversimplify the process and only inadequately give voice to the tremendous complexity that a nonlinear process represents. Only through applying and using these skills does the leader develop them. Yet as learners apply these concepts, they may become frustrated because of the vast number of factors that seem to bear on the outcome. Events and situations rarely unfold in predictable, orderly fashion. The inherent nature of organizations is a state of continual emergence. A particular approach may work well with one individual on a given day, and later the same day factors may have changed enough that the approach needs to be modified. The level of complexity in our environments is almost impossible to comprehend and certainly to describe adequately.

Prior to the publication of the first edition of this book, the American Hospital Association Press and the Center for Health Care Leadership of the American Hospital Association conducted market research on the nature of the leadership gap in health care. Focus groups of more than sixty well-known chief executive officers, board members, physician leaders, consultants, academicians, and community activists revealed five administrative pitfalls driving the emerging paradigm of health care leadership:

Little or no sense of shared vision and mission within health care organizationsIneffective communication skills, especially at the executive levelUnwillingness to abandon hierarchical control structures, particularly at the executive and board levelsRefusal to let go of the hospital mentality and traditional modes of serviceDenial of the inevitability of rapid evolution toward capitated reimbursement and managed care

I hope we have made progress in these areas since then. And, indeed, in many organizations, there is vibrancy and passion for the future, and employees work in enthusiastic partnership with executives and managers. Unfortunately, these pitfalls are still present in far too many health care organizations, with tremendous negative consequences as we rapidly move forward to a new future. To offset these weaknesses, leaders will need to take on some nontraditional roles and use innovative approaches for which they may feel unprepared. Mastery of new skills is critical to the successful transition into these roles, and the research shows that these nontraditional skills are clustered into two domains:

Systems thinking, including skills in collaborative visioning, strategic planning, broad-based decision making, innovative problem solving and process improvement, and stewardshipInterpersonal abilities, including communication skills, both verbal and nonverbal; coaching; giving constructive feedback; managing conflict; building consensus; delegating responsibility; building teams; and managing change

This book addresses these interpersonal skills, although in a somewhat unusual format. The premise of this book is that leadership exists only within a relationship: if there are no followers, there is no need for a leader. Interpersonal skills in leadership are critical success factors, yet few have written about developing these skills within the leadership context. This book identifies the fundamental interpersonal competencies every transformational leader needs, and it maps out suggestions for improving these skills. It shares examples from health care leaders at all levels to emphasize key points. The concepts in this book are immediately applicable in leadership practice at any level and in any setting where leadership is required and exists.

This third edition contains significantly updated and expanded content. I have added references that reflect current leadership writings and retained classic references and concepts when they are still of value. Some of the most crucial concepts have been around for years, and an older reference date does not necessarily mean the concept is outdated. Learner objectives have been added at the beginning of each chapter at the request of faculty who use this book as a text for their leadership programs. At the end of each chapter are discussion questions with suggested application activities. These can be used for personal reflection or as a basis of conversation with others. In some workplaces, the book is used as a journal selection, with participants reading a chapter and then engaging in dialogue with others about the content. This can serve as a transformational learning tool as it helps move beyond the book knowledge to a more experientially based process.

The first chapter sets the stage by exploring the difference between management and leadership, a concept that even experienced managers and leaders often have trouble grasping concretely. It provides multiple working definitions of leadership and identifies key interpersonal requirements. The chapter examines the reasons that leadership is more crucial today than ever before, as well as several major challenges that contemporary leaders face. Each of the remaining chapters fully examines a key leadership competency.

Chapter Two focuses on establishing the leader-follower relationship, a crucial foundation, for leadership exists only in the context of a relationship. If there are no followers, there is no need for a leader. The chapter addresses the four key elements of this relationship—trust, respect, support, and communication—and includes the nature of collaboration and aspects of forming a partnership. Contemporary leaders will be successful only if they are willing and able to work effectively in partnership with others.

Building commitment among followers is the theme of Chapter Three. A solid base of organizational development theory is presented to increase understanding of the concept of organizational commitment. Executives and managers who inform employees of decisions they have made are seeking compliance or conformance. Most organizational changes occurring today require full commitment from followers to be successful. Commitment is often described as buy-in, a feeling of ownership that goes well beyond mere compliance. Commitment engages the heart and emotions, not just the intellect. What can a leader do to increase the likelihood that key stakeholders—employees, physicians, community members—will commit to the direction the organization takes? The chapter examines both affective and normative organizational commitment. Building a sense of connection and community among all participants and clarifying shared values and a common purpose lead to the possibility of an energizing and inspiring shared vision. Case studies or examples are used to exemplify the power of vision.

Chapter Four deals with the leader’s role in communicating effectively, both operationally and strategically. Although seemingly the most simplistic of the interpersonal competencies, communication is central to establishing a healthy leader-follower relationship, and it can be enormously complex. This chapter thoroughly explores verbal and nonverbal communication within the context of contemporary leadership practice. It reexamines long-known principles and concepts in light of today’s workplaces and challenges. Several short case examples are shared. It addresses special communication issues such as communicating during times of rapid change, over geographical distances, and with teams.

Many leaders and managers learned their skills in work environments that emphasized outcomes rather than processes. Such organizations often rewarded and promoted the decisive get-it-done individual, whereas they may have seen as slow and plodding the individual who spent the time needed to ensure that the organization followed an appropriate process. Today’s leaders must be able to integrate these two approaches and achieve effective outcomes through constructive processes. Key principles of facilitating process are the focus of Chapter Five. The chapter scrutinizes critical processes such as empowering others, resolving conflict, creating effective teams, and leading change and transition. I have separated the critical processes of problem solving and decision making from this chapter and made them the basis of a new chapter focused on getting results. An extension of Chapter Five, the new Chapter Six now includes two alternatives to a traditional problem-solving approach: the action research methodology of appreciative inquiry and a presentation on recognizing polarities and managing them.

The major interpersonal competency, developing others, is the subject of Chapter Seven. Everyone agrees that leaders today must be coaches, and practical, concrete advice is becoming available on how to fill this role. Principles of coaching, teaching, motivating, and encouraging others are this chapter’s subject. Effective leaders are continual learners themselves, and they expect others around them to continually grow, develop, learn, and stretch. Good leaders are serious about tapping the potential within each person to expand his or her reach, grow, and increase personal leadership capacity. Systems thinking and collaborative learning are key characteristics of a leader-coach-teacher.

Although mastery of these key competencies does not guarantee immediately successful leadership, it can help those who have innate talents become more effective. Developing and refining leadership skills is a lifelong journey. Circumstances regularly alter, creating the need for new skill sets. I offer this book to stimulate thought and provoke creative action for those on the path to expanding personal leadership capacity. Enjoy the journey!

ACKNOWLEDGMENTS

I gratefully acknowledge the following people who were instrumental in helping to make this book a reality:

The countless leader colleagues who over the years have shared their experiences and stories with me while on their pathThe colleagues and research participants who willingly and generously gave of their time and wisdom in my pursuit of answersThose who have been instrumental in this book’s journey over the years: Winnie Schmeling, Richard Hill, and Andy Pasternack and Seth Schwartz at Jossey-BassMy husband and lifelong partner, Craig, who has been an unwavering source of support, love, and encouragement

THE AUTHOR

Jo Manion is the president of Manion & Associates, an organizational development consulting practice in Oviedo, Florida. A nationally recognized professional speaker, consultant, and author, she specializes in practical strategies focused on professional and organizational development. Her four decades of health care experience in a variety of organizations and positions have created expertise in the areas of leadership development, the creation of positive work environments, increasing organizational capacity, and the development of effective teams. Her research focuses on the area of the leadership role in creating positive workplaces. A fellow in the American Academy of Nursing, she holds both a master’s degree and a doctorate in human and organizational systems from the Fielding Graduate Institute. She is the author of The Engaged Workforce: Proven Strategies to Build a Positive Health Care Workplace (2009) and coauthor of Nature’s Wisdom in the Work Place: Managing Energy in Today’s Health Care Organization (2005). She is widely published on a variety of topics.

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.

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 accomplishedThe knack for managing meaning by communicating wellThe skill of managing others’ trust through being a person of integrity and good characterThe 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).

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 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 Two 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 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 the organization to provide management and supervisory training and education. In the 1990s, there was a shift in all sectors of society to emphasize the importance of leadership skills. The increased number of titles about leadership in a popular bookstore reflects this emphasis. A search on amazon.com produces over sixty-three thousand hits, and when the search is narrowed to health care leadership, there are still 883 titles. Why this focus on leadership? Why is this a compelling issue in today’s world? There are at least three major reasons:

The unrelenting crush of changeRapidly shifting paradigmsSurvival

Change

Change has been the byword for over twenty years. Never before has the pace of change been so fast or have the changes altered so deeply the way people live and work. “The change and upheaval of the past years have left us with no place to hide. We need anchors in our lives, something like a trim-tab factor, a guiding purpose. Leaders fill that need” (Bennis, 1989, p. 15). Fundamental changes in health care are occurring so rapidly that it is hard to keep pace. What we all believed to be significant organizational changes in the 1980s—revised job descriptions, new management positions, novel performance appraisal systems—pale by comparison to today’s changes, such as new locations for services, innovative business structures, specialty or niche hospitals, distance medicine, virtual patients, health care on the Internet, replacing employees by automation, outsourcing, cross-training of skills, forming partnerships within the community, simultaneously collaborating and competing with the same entity, and merging with other organizations or developing an entirely new system. Annison (1994, p. 1) states the case clearly: “During periods of stability we can be successful by doing more of what we already do; the focus is on management and maintaining the present. During periods of change, the emphasis is on changing what we do and the focus is on leadership.”

Shifting Paradigms

Paradigms, or the models through which we view the world, are rapidly shifting. Barker (1992, p. 37) describes it this way: “A paradigm shift, then, is a change to a new game, a new set of rules.” This shift creates confusion and unease as well as new possibilities. In some instances, a player in the health care sector changes the paradigm, whereas in other situations, the impetus comes from without. The rules and game plan may suddenly change, leaving those in the game to figure out the new rules.

Competition in health care is a good example of a paradigm that continues to shift. Not so long ago, the major competitor for a hospital was the other hospital in town, just down the road. Today competition comes from everywhere: stand-alone health care facilities, such as ambulatory care centers, specialty hospitals and services, and diagnostic centers in physician offices; hospitals from other communities that set up satellite or full-service facilities outside their originating communities; and even previous customers who decide to become providers on a limited basis. There are now destination health care countries where American citizens can go to receive their care in countries such as India or Thailand, often in hospitals or clinics run by American-educated and -trained individuals. The cost is much less than in the United States.

The lines and boundaries are no longer clear. As the business world has demonstrated, one must sometimes collaborate with close competitors (Annison, 1997). Consumers buying an Apple computer may be purchasing a machine manufactured by Toshiba; MasterCard and Visa collaborate on automatic teller machines and choose to compete on marketing and customer service. Similarly, in health care, two hospitals from competing systems have jointly built a wellness facility in their community, and a major medical center has partnered with a large clinic-based physician practice on several joint projects while competing with it on several others.

Times of great change and rapidly shifting paradigms call for leaders. As Barker (1992, p. 164) points out, “You manage within a paradigm. You lead between paradigms.” When times are stable and game rules remain consistent and known, structures, standards, and protocols enhance the manager’s ability to optimize the paradigm. In fact, this describes the manager’s job exactly. However, during a shift to new paradigms, leadership is required, as Barker explains: “Leaving one paradigm while it is still successful and going to a new paradigm that is as yet unproved looks very risky. But leaders, with their intuitive judgment, assess the seeming risk, determine that shifting paradigms is the correct thing to do, and, because they are leaders, instill the courage in others to follow them” (p. 164).

When paradigms shift and the rules change, everyone involved goes back to zero. Put simply in the words of a colleague, “What got you to the party won’t keep you there!” It is time to let go of past successes and look for new ways of doing things. There is no guarantee that the organization, group, or individual who was very good with the old game rules will be as good with the new ones. In fact, the more successful the individual or organization was with the old model, the more difficult it is for him or her to engage in a new way of thinking. A recently observed paradigm shift was seen in 2009 when health care reform was being hotly debated. Business owners and employers were seen as “the bad guy,” the ones with a hidden agenda that involved keeping the current system in place. As a result of this political climate, many of these voices were silent when the debate was held, although they certainly represented a tremendous source of knowledge about the system.

When paradigms shift, it is crucial to recognize the change, or your efforts will be fruitless. It is foolish to hold onto the belief that past or current success automatically leads to future success. When we hold to the old paradigm, we may be reluctant to make changes rapidly enough to adapt to the changing external environment. A common behavior is the overreliance on internal expertise and experience, resulting in an aversion to risk taking and a desire to dictate to others how things will be. None of these behaviors will lead to ultimate or enduring success.

The issue of changing paradigms is easy to talk about intellectually but difficult to deal with in its reality. What will it really take to become a fluid and flexible organization, capable of dealing with the enormously tumultuous external environment? How can we provide mobile health care services instead of being limited to an institution and its four walls? How can we shift from the old methods of communicating and move into the tremendous opportunities that new communication technology and the Internet present?

Survival

The final and perhaps most important reason that we need leadership today is survival. Bennis (1989) reported the work of a scientist at the University of Michigan who examined and listed what he considered to be the ten basic dangers to our society, factors that he believed were capable of destroying the human species. The top three are:

A nuclear war or accident, capable of destroying the human raceA worldwide epidemic, disease, famine, or financial depressionThe quality of management and leadership in our institutions

There was probably no clearer example of the importance of leadership as during the immediate aftermath of the devastating terrorist attacks on the United States on September 11, 2001. The actions and decisions of our national leaders were crucial. Hasty and reactive actions could have led to even more devastating results. The quality and importance of leaders who emerged was striking.

Leaders are responsible for an organization’s effectiveness. As an industry, health care is vulnerable as a result of regulatory changes, technological pressures, globalization, the litigious mind-set, changing demographics, and environmental challenges. Strong leadership is needed to take us into a very uncertain future. Pinchot and Pinchot (1996a, p. 18) eloquently describe the need for leaders: “The more machines take over routine work and the higher the percentage of knowledge workers, the more leaders are needed. The work left for humans involves innovation, seeing things in new ways, and responding to customers by changing the way things are done. We are reaching a time when every employee will take turns leading. Each will find circumstances when they see what must be done and must influence others to make their vision of a better way a reality.”

Finally, the role of leaders as it influences organizational integrity is crucial. “There is a pervasive, national concern about the integrity of our institutions. Wall Street was, not long ago, a place where a man’s word was his bond. The recent investigations, revelations, and indictments have forced the industry to change the way it conducted business for 150 years. Jim Bakker and Jimmy Swaggart have given a new meaning to the phrase ‘children of a lesser God’” (Bennis, 1989, pp. 15–16). Although Bennis wrote those words years ago, they seem prophetic. In the past few years, Americans have become almost inured to corporate scandal and wrongdoing. The collapse of Enron, Arthur Andersen, and WorldCom was just the beginning of what seems to be a never-ending parade of corporate corruption. Many Americans now fully expect that people in positions of power lack personal and professional integrity and can be counted on to lie and cheat. Political corruption and lack of faith in national leaders is at an all-time low.

Health care is not immune to the issue of integrity. Hospital executives indicted for Medicare fraud, home health agencies led by criminals previously convicted of fraud, a cardiovascular surgeon falsifying information and performing hundreds of clearly unnecessary surgeries, a pharmacist diluting chemotherapeutic agents to increase profit, executives at a well-known rehabilitation company indicted for illegal practices, or a community hospital’s senior executives convicted of embezzlement: all have made the headlines in recent years. Never before has the need for ethical, exemplary leaders been more crucial as we face the challenges of the next decade.

Challenges Facing Today’s Leaders

Today the opportunities and possibilities for leaders are endless, as are the challenges. Difficulties are not all bad. Strong leaders see difficult times as offering tremendous opportunities. Often the times and events that push us the most also have the capability of bringing forth our very best. It’s important to notice the difference between a challenge and an excuse. Every one of these challenges presented here can also be used as an excuse in the organization. “I couldn’t make a decision when things were so uncertain.” “You just can’t please everyone. I don’t know how you can motivate these young people today!” When we give up on the challenge, we are letting it become an excuse, a reason that we cannot accomplish the results we need. For every one who uses a challenge as an excuse, there is a leader somewhere who uses the same challenge to achieve stunning results.

Demands are different for today’s leaders and have ramifications for anyone aspiring to lead others. Recent dramatic upheavals have left no sector untouched. “The financial, political, environmental, and social challenges have affected us all in different ways and, in turn, have impacted our organizations and employees. It leaves us all wondering what will happen next that will change the world we live in and the places we work” (Vestal, 2009a, p. 6). The more a leader understands these issues, the more likely it is that he or she can find the strength and courage to meet the test that these challenges present. A handful of representative challenges include these:

Accelerating levels of ambiguity and uncertaintyWorkforce issuesDiversity in the workforceTurbulent business and regulatory environmentsThe leader’s energy drain

Accelerating Levels of Ambiguity and Uncertainty

Probably the most apt description of today’s world is uncertainty. Leaders today are dealing with a level of ambiguity and uncertainty almost unparalleled in our memories. Although uncertainty and ambiguity are not measurable, they are palpable in workplaces. Change continues to accelerate at a pace that makes it impossible to predict even the near-term future with any accuracy. And as change begets more change, the challenges become more complex and difficult to meet.

Today’s solution rapidly becomes tomorrow’s problem that must be dealt with. In no other area is this clearer than in technology. The advent of the electronic medical record (EMR) created visions of a health care environment where workers could be more productive, the electronic processing of medical information making their lives much easier. Nurses would spend more time at the bedside caring for patients. Members of various departments and different disciplines could communicate virtually through real-time computing technology. Errors would be reduced and patient quality increased.

The reality for many people today is quite different from the original vision and the promise implied, if not explicitly made. In many organizations, problems abound with the EMR. Decisions about hardware and software were made with limited or low-quality input from end users, and as a result, they are inadequate to meet practitioners’ needs. Organizations invested major portions of their financial resources into technology, only to find it seriously outdated within a few years. Years are spent waiting for upgrades, either because of their lack of availability or lack of resources on the part of the organization. Productivity for many has declined rather than improved. Caregivers navigate multiple screens to access pertinent information. Duplication continues to exist as practitioners are forced to complete screens of information that may not even apply to the individual for whom they are caring, such as a decubitus ulcer assessment on an ambulatory clinic patient. And the quality of patient care? Of course, in many ways it has improved because of the technology capabilities inherent in the EMR. However, the impact of a caregiver or physician sitting with his or her back to the patient busily inputting data into the computer was never considered as a serious consequence of the technology. Relationship-based care, the underlying foundation of an effective relationship between patient and health care worker, can be seriously and negatively affected when caregivers lose the high touch of person-centered care in our high-tech world of today.

Of course, the world is not worse off because of the invention of the computer. And no one would advocate stopping or even slowing the tremendous advances that have been made through technology of all kinds. Nanotechnology holds great hope for treating and curing diseases that have plagued humankind throughout its history. However, these changes often complicate our lives in unforeseen ways. Leaders know that the current change simply brings us closer to the next one.

Living during times of great ambiguity and uncertainty requires tremendous energy, both personal and organizational. Because influencing others positively when we are exhausted is difficult, leaders must take good care of themselves during changing times and manage their energy wisely (Loehr and Schwartz, 2003; Cox, Manion, and Miller, 2005). Not all changes are for the better, and a leader is challenged to remain optimistic and enthusiastic yet truthful. This can be arduous in the face of personal discouragement. Transformational leaders have a high degree of resilience in their ability to demonstrate courage, strength, and flexibility in the face of change and frightening disorder.