This month, an article in JAMA gives us some ideas of why American medical costs are so high. The authors analyzed data from the OECD (Organisation for Economic Co-operation and...
Leadership change in a healthcare organization is inevitable but every time it happens, it can be a bit unsettling to the physicians. If there are a lot of changes that occur simultaneously with sweeping changes in multiple leadership positions, then it can shift from being a bit unsettling to being a lot unsettling. And much of that arises from uncertainty of values.
In medical centers, leaders such as Deans, Department Chairmen, CEOs, and Division Directors can be roughly divided into two groups: those that are recruited from within and those who are recruited from outside. Those that are recruited from within are physicians and leaders who have worked at the institution and are “known entities” to the rank-and-file physicians and other employees. Those that are recruited from outside are largely unknown to most of the physicians. There is an often-overlooked difference between these two groups of leaders: The former are known whether they have shared values with the rest of the physicians and the latter are not.
Those shared values can mean many different things in different institutions. They can be dedication to clinical excellence, dedication, to educating the next generation of physicians, dedication to organizational financial health, dedication to creating new knowledge through research, dedication to improving diversity, dedication to care of the underserved, dedication to improving public health, etc. With leaders who are recruited from within, you know what you are getting because those leaders have shown what their values are as they have risen from one of the rank-and-file physicians to leader. And therefore, you know from personal experience and history whether that leader shares your own values.
It is harder to know what values are held as most important to leaders who are recruited from outside. You can get an idea from their curriculum vitae and from what they say in presentations and meetings. But you never really know until you experience that leader’s actions first hand.
Sometimes, new leaders are recruited specifically because they hold different values than what the existing institutional culture holds. Maybe a board of trustees wants to “change the culture” of the medical center – this really equates to changing what is valued by the medical center. This can be particularly difficult if the medical center is constantly trying to be something different than what it actually is. For example, a medical center that historically prides itself on care to underserved patients that tries to reinvent itself as a research powerhouse is going to face a lot of challenges. Nevertheless, such value disruption is often necessary to correct perceived institutional deficiencies.
The half-life of medical institution leaders is relatively short, particularly for deans and department chairmen in academic medical centers. An organization that primarily recruits its leaders from the outside can find itself in a state of perpetual value uncertainty, leading the physicians wondering whether or not the values that they hold and that brought them to that medical center originally are the values that will be used to define institutional success in the future. Such efforts to “change the culture” too frequently can result in a sense of on-going value disruption can result in non-alignment and disengagement by the physicians.
On the other hand, recruiting leaders exclusively from within the medical center can result in maintaining a sense of shared values but can also result in stagnation of values. For example, if a hospital in poor financial shape brings in a medical leader who values improving clinical productivity over everything else, then over time, the institutional shared value will become one that fosters high productivity; recruiting successors to that medical leader from within the organization will perpetuate that emphasis on high productivity rather than other values, such as education, enhancement of diversity, research, etc.
A healthcare organization can afford value disruption only so often. Too frequent of leadership changes with leaders recruited exclusively from outside the organization leads to uncertainty of institutional values that then results in high physician turnover. A goal of a healthy healthcare organization should be to create a pool of potential future leaders that have a track record of shared values with the rest of the physicians. These shared values can result in the physicians having a sense of security that what they personally value will be aligned with the values held by the next healthcare organization leader.
Hospital leaders recruited from outside are often aspiring leaders that want to be a leader somewhere and your hospital had an opening coincident with when that person was looking for a leadership job; these leaders are often effective when you need institutional value disruption. Hospital leaders recruited from within are usually aspiring leaders that want to be a leader at your hospital specifically; these leaders are often effective when you need institutional shared values. Therefore, it is on each hospital and health system to create leadership training programs to ensure a steady pipeline of future physician leaders from within who are known by the rest of the physicians to have shared values. This gives leadership search committees the luxury of being able to decide whether at that moment, what is needed is value disruption or shared values. A health system that relies too heavily and too frequently on recruiting leaders from outside of the organization will have a difficult time developing and maintaining a culture of shared values.
The true value of shared values is in improved physician alignment/engagement and in institutional stabilization.
April 5, 2018