Study: Approaches to Leadership Training at Top Nonprofit Hospitals

The authors assess the kinds of development programs used, why similar organizations take different approaches and how physicians participate.

ABSTRACT: This study gathers information about the types of leadership development approaches and programs being used by the top 50 nonprofit hospitals in the United States. Authors assess the kinds of programs used, why similar organizations take different approaches and how physicians participate. Surveys provide preliminary information about the type, objectives and costs of each organization’s programs, and interviews provide insight about whether established programs meet CEO intent.

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Leadership development programs are found in almost all types of organizations. But depending on the industry, programs are diverse in approach, have a range of associated costs and show varied outcomes in contributing to leader attributes, leader competencies, professional culture, team performance and organizational objectives.1,2,3 Not all industries face the same challenges, though, and the transference of approaches from one type of industry to another does not always address relevant professional issues or organizational team-building requirements.4 For that reason, it’s appropriate to gather information and analyze the types of leadership development programs executed in the health care industry.

In this paper, we assess current leadership development programs in the nation’s top 50 nonprofit hospitals. We collected data from those who administer leadership development programs in those health care organizations with the goal of attaining information about the objectives and methods of execution used. The data measures program participants, resources expended, stated learning and program objectives, and metrics used to determine success. We also got input from CEOs of select organizations about what they want their programs to achieve.

Background

Health care has much in common with other industries. There is a need for professional growth and team leadership in such areas as market orientation, strategic development, financial strategies, human relations and other administrative functions. Because of that, health care industry executives often attempt to mirror leadership development programs used by other industries. That’s understandable, given most HCO programs are designed with the objective of developing those who drive the business of health care.5,6,7 But health care is much more than a business — it is also a profession.

Health care industry executives often attempt to mirror leadership development programs used by other industries. That’s understandable, given most HCO programs are designed with the objective of developing those who drive the business of health care. But health care is much more than a business — it is also a profession.

Myriad studies describe deep rifts between the way executives and medical professionals view and lead the health care industry.8 Executives are drawn toward the core business elements of improving effectiveness, efficiency, systems and processes. Medical professionals are primarily focused on treating disease, operating across the care spectrum and interacting with patients. While there is undoubtedly the need for executive leadership to run the business, there is also a requirement for the growth of clinical professionals to contribute to high-performing medical teams and organizational processes and systems.

This research offers insight into how the top 50 largest (as determined by number of beds) nonprofit health care organizations address the issue of leadership development for their interprofessional teams. We limited our study to hospitals, or groups of hospitals under the same name within a distinct geographical location, rather than health care systems that provide care over large areas or in multiple cities and states. We sent surveys to these organizations to help us learn about the types of leadership programs they conduct, their stated objectives, whether physicians are included, what types of programs are offered, how they are being measured, the costs of the programs and how the hospitals measure return on investment. We then conducted postsurvey interviews with CEOs to determine how programs are synchronized with desired goals.

Methods

For this research, we used the positivist case study approach. Obtaining access to the American Health Association Fiscal Year 2014 Annual Survey database9 allowed us to determine the top 50 U.S. nonprofit hospitals. The number of beds for these top 50 ranged from 831 beds to 2,478.

Using the point of contacts from the AHA database and publicly available information, we sent emails to the CEO of each hospital asking if they had a leadership development program and if they’d be willing to participate in the study. We also asked the CEO to provide a contact person to provide information about their programs. We promised anonymity and used the singular incentive of an intent to share results.

The initial response was low, with only seven of 50 (14 percent) responding. Three follow-up requests gained additional responses, and eventually 16 organizations (32 percent) committed to participating. Eleven others said they did not have a formal program. One acknowledged having a program but was unwilling to share information. Twenty-two organizations did not respond. The 16 participating hospitals were stratified within our hospital list, with four hospitals in the top third and six hospitals each in the middle and bottom thirds. While we know that 11 of 50 of the HCOs said they didn’t offer leadership development, we do not know whether the 22 nonresponding organizations do.

Those responsible for the programs mostly work in the human resources arena and have a variety of titles, such as senior vice president for leader development, executive director for HR and organizational development, vice president of talent management, and director of learning. In three organizations, the programs are administered by executives who are not part of HR and report to the CEO. In two organizations, the chief medical officer oversees the programs, but only for the physicians.

Five CEOs were willing to give interviews, meeting our desired objectives. Those CEOs were from each segment of the list, with one CEO in the top third, and two CEOs each in the middle and bottom thirds. Telephone interviews of CEOs were conducted with an interview guide and these were recorded and professionally transcribed. Coded data allowed us to classify topics into larger themes.10

Survey and Interview Results

Each HCO provided unique methods of program design, objectives and approach used toward leadership program goals. The HCOs also vary in the approach to developing physician leaders. (Survey questions, see Table 1.)

TABLE 1: KEY SURVEY QUESTIONS

  • Number of hospital employees/number of privileged physicians?
  • Does your hospital have a formal leadership development program?
  • Does your hospital have objectives for your leadership development program?
  • Is there a formal program for physicians/are they incorporated into other programs?
  • How is the physician leadership development conducted?
  • What are the objectives for the physician leadership program?
  • How long has your hospital conducted a program for physicians?
    • How many physicians have matriculated from your program?
    • How many hours of instruction make up the physician program?
    • What is the length of the physician program?
    • What is the approximate/estimated cost of the physician program?
    • How are physicians selected to attend the program?
  • What methods does your hospital use in measuring the effectiveness of your program?
  • Is attendance of courses required before physicians assume a leadership role?

The hospitals provided information on how long their formal leadership development programs have existed, length and types of classes, number of physicians included, hours of instruction required of participating physician, length of any physician program and estimated costs. Several trends emerge from this data. The HCOs have conducted leadership development programs for an average of 3.1 years, with one hospital having held a formal, internally designed and managed executive program (geared toward development of C-suite leaders) for 12 years. The majority — nine of the 16 HCOs — reported executing a formal leadership development program for two to four years. Six hospitals designed their programs to address specific leadership development issues, a cultural requirement or to improve perceived organizational deficiencies. Three organizations describe courses for mid- and upper-level directors and managers; most of those courses center on executive and administrative functions, job skill and advancement requirements rather than on leadership topics.

Fourteen organizations have their own leadership directorates and resources (e.g., leadership development managers, organizational design experts, full-time employees) allowing them to plan, execute and conduct training and education to address leadership and management subjects for administrative leaders. Two of the HCOs depend exclusively on subject-matter expert consultants, coaches or firms. Five hospitals conduct programs for executives but send physicians to leadership seminars at universities, think tanks or other corporate programs. One of the five designates these courses as “physician fly-away programs” and states they are used because of their lack of expertise to teach leadership to physicians.

To determine each HCO’s approach toward outcome-based training and education,11 two questions requested information on program objectives. Four of the 16 programs responded that they had spent considerable time establishing objectives for their hospital’s leader development approach. Two of those had both mission and vision statements for their leadership programs, incorporating the idea of culture and values as being critically important to a leader’s success. Both tied the objectives of their executive program to a leadership professional growth model. One of these had their 15 objectives linked to a five-year strategic plan, with goals for the organization as part of a sophisticated planning matrix. The other organization had both a leader model and an influence model with requirements at different stages of a leader’s development, from entry level to CEO. This same organization had begun the work of doing the same for physicians, showing developmental requirements from resident to newly employed physician to director to CMO. The other 12 HCOs had less-clear objectives. Some comments about leadership development objectives included:

 “Our program strengthens leadership skills and ensures for succession planning.” 

“Our leader development team provide classes on effective communication, conflict management, team building, interview techniques.”

“Our objectives are to grow leader competencies and strengthen strategic capabilities, test new concepts and launch innovative initiatives.”

In several comments, there was a lack of defined leader development goals:

“Though labeled ‘leader development,’ this program is more of a forum for our strategic leaders, with key doctors, to communicate strategy and other initiatives … it is not focused on enhancing leadership skills, talents or abilities.”

“We call our leadership development program the ‘management academy,’ and we focus more on courses connected to things like safety, human resource issues, diversity and inclusion.”

Other comments included: “our physicians participate in CME events, and those programs determine the learning or course objectives” and “our physicians are sent to leader development programs/seminars away from our hospital, usually as part of their physician groups, but we do not know/do not track the training objectives of those courses. 

The average number of nonphysician employees in the 16 hospitals is 14,200, with the largest hospital having 27,000 and the smallest having 3,800. The number of physicians (combined employed and privileged) across the 50 hospitals had a mean of 1,627, with the largest having 2,550 and the smallest having 537. Eleven hospitals reported programs for physician leadership development, but four state their programs consist of consultants, universities or professional bodies to teach courses “two or three times a year.” Those organizations also state most physician programs are required as continuing medical education credit.

Four HCOs send selected physicians to programs outside their hospital (two via association with a medical university leadership program; two others with a consultancy program). One hospital takes a multifaceted approach, with some physicians attending a formal executive leadership program with senior administrators, some participating in programs exclusively designed for physicians, and others being sent to programs outside the hospital. Three of the 16 hospitals report new initiatives started within the last four years that include physicians in formal, hospital-run leadership development programs.

Two of those three HCOs exhibit great pride in their programs, with one saying their organization is “leading the way” in physician leadership by conducting interprofessional education courses (i.e., physicians in classes and seminars with a mix of executives and nurses). That hospital reported a formal program, with rigorous course objectives, unique selection criteria for attendees, a plan for collecting data on individual improvement, and an approach for placing graduates into key leadership roles after matriculation. Four hospitals report their physicians are supported and encouraged to take either Master of Business Administration or Master of Health Administration courses at universities or colleges, with one hospital offering tuition assistance for these programs for a limited number of physicians. 

Selection for physician attendance in the programs varies. Five organizations say doctors are selected by either the CEO, chief medical officer, chief operating officer or a dean, or a combination of two or more such individuals. Two HCOs report selection comes from nominations by the medical staff or medical executive committee, and one hospital solicits recommendations from the chair or director of physician groups. Another HCO has an elaborate process of physicians volunteering for the program with an established selection board of both executive and physician members. 

FIGURE 1: HISTOGRAM OF COURSE LENGTH

hurtling fig 1

In answering “how many physicians participate in a formal leadership education at your organization and graduated from that program last year?” the answers range from 10 to 75 physicians, with a mean of 23. Two HCOs said physicians do not participate in any formal leadership programs sponsored by the hospitals, but physicians do participate in programs with their specialty group that the respective hospitals do not track. 

Asked about course length and the associated hours of instruction, the answers vary. One HCO has a one-hour session every Friday for 12 weeks; another reports a 40-hour course lasting more than three months; a third program totals 18 hours — two hours a month for nine months. The median course length was 32 hours in duration (see Figure 1). The training events last somewhere between three and 18 months, with the mean being 9.4 months and the median being nine months in duration. 

TABLE 2: KEY CEO INTERVIEW QUESTIONS

Objective Information

  • Time in position and personal familiarity with organization’s leadership development program?
  • Objectives of your program?
  • Are physicians incorporated into interprofessional programs, or conduct their program separately?
    • How are physicians selected to attend?
    • What are specific objectives for physician leadership development?
    • Are there positional requirements for attendance, or post-attendance placement, for physicians?
    • What resources (costs) are specifically allocated to the physician program?

Subjective Opinion

  • After graduating, how do you see attendees contributing to quality improvement in health care?
  • How is your leadership program contributing to the culture of the organization?

Sensory (Anecdotal) Experience

  • Anecdotes of physicians who have improved, or not improved, as a result of program?
  • Stories of physicians who have taken on new roles as a result of program?

The eight hospitals that provided financial figures state the physician cost per course ranges from $1,000 to $20,000. The average price was $5,937 per physician per course, with more expensive courses associated with the “fly-away” programs at institutions outside the hospitals. No cost was provided for MBA/MHA tuition assistance.

To evaluate program effectiveness, most organizations cite post-training surveys, tracking of overall employee engagement, or monitoring results from government-mandated Hospital Consumer Assessment of Healthcare Providers and System scores. Only one hospital appeared to have a plan to collect specific metrics on each attendee:

“We assess team projects executed in class, do a pre- and post-class 360 assessment, with members of the attendees’ leadership team providing input before and after attendance at the seminars. We send questionnaires to the attendees regarding the effects the course had on their performance one year after the graduation from the capstone classes, and we have twice conducted research projects that measured pre- and post-class leadership traits. We anticipate doing more directed research in the future.”

Most HCOs do not have a rigorous means of collecting data to assess return on investment or return on value. Directors explained their programs are subjectively evaluated by key individuals in the organization (such as the CEO, CMO, HR director, administrators and team leaders) rather than objectively evaluated through specific metrics.

After obtaining the surveys from participating hospitals, we scheduled a one-hour interview with a select number of CEOs (see Table 2). Response to our questions fell into three themes with a variety of descriptive topics of “areas of importance,” and these topics emerged during coding of the interviews. The themes: building a strong team, building a strong organization and building the future of health care.

Building a strong team indicates the desire for creating a collaborative work environment on small teams. Building a strong organization includes creating a vibrant hospital culture, sharing the mission of the hospital and being involved in the community. Building the future of health care is the desire to build a talented pool of leaders, including physicians for hierarchical leadership roles for future strategic advances. Table 3 lists the various coded topics gleaned from CEO interviews about areas of importance.

In the theme of developing strong health care teams, CEOs shared how they wanted their leaders to cultivate empathy, trust, loyalty, collaboration and overall well-being among and between employees, with the two biggest topics being collaboration within the team and an employee sense of well-being that results from being well-led. In this category, CEOs repeated 19 coded mentions in the interviews. Some of the CEO comments: 

 “… having [leaders within the organization] for the types of activities that make large organizations smaller …”

 “… to have engaged and involved physicians as leaders to help develop teams.”

 “… leaders learning what makes individuals tick, [learning] their priorities and motivations, what makes them choose to be in an industry that has great reward but is sometimes thankless in many ways.”

“… the basic human behavioral need for people to feel a part of something bigger than themselves, and leaders must contribute to that.”

TABLE 3: CEO “AREAS OF IMPORTANCE”

In the theme of building strong health care organizations, CEOs describe how they want leaders to evolve from the daily challenges associated with leading small teams to the broader leadership demands associated with solving complex, organization-level challenges. Coded comments were geared toward fostering the culture, the mission and the social connection of the hospital with the local communities (a critical dynamic of nonprofit HCOs). A few quotes demonstrate these desires: 

“If we put 10 people on any of our challenges and didn’t have the right leader with the gravity to move toward a solution, we wouldn’t be as effective.” 

“Strong cultural dynamics impact the ability to lead, but leaders contribute to ensuring that strong cultural dynamic exists.” 

“The heart of the organization [requires] that [leaders] actually want and accept feedback, leaders provide guidance, and [leaders] know that is part of their core requirement, and [they know they have to do] more than just what’s popular.”

“We want individuals who are committed to the organization and who understand to do that requires collaborative intervention between hospital executives and physicians.”

In the theme of building for the future of health care, the CEO comments are coded toward the external changes occurring in health care, the need to develop long-term or strategic talent, and retaining talent. There was a total of 34 comments and 17 observations, focusing on developing talent for the industry: 

“I think there has to be a basic belief that [physicians] are essential to success in driving health care operation, so helping them learn how to lead and helping those that want to develop their leadership skills is important … if (the) system does this kind of training, it really benefits the organization and the strategic environment.”

“Programs [must] confirm to the physicians their connection with the organization, confirm that we thought that they’re willing to grow, and confirm for them that they’re at where they need to be.”

“The future of health care requires effective physician leaders standing beside capable administrators.”

While we coded to the strongest theme emerging with each statement, many of the statements overlap with other themes, highlighting the interconnectedness the CEOs see in building interprofessional teams that maximize effectiveness through collaboration, that understand the organization’s culture, and that develop strategic physician talent ready for the ever-changing industry.

While CEOs and directors of the programs appear to agree on the selection criteria for participation and the overarching content and schedule of the classes, CEOs seem unaware of metrics being applied to evaluate success of the participants in any of the three desired levels. Essentially, the CEOs confirm the directors’ comments that the programs are subjectively rather than objectively evaluated, and one CEO perhaps best summarized the subjective feeling of all others this way:

“I don’t have any subjective metrics available, but I just feel that things have improved since we began our physician program.”

Conclusions and Recommendations

Our study sought to determine the prevalence of leadership development programs, the rigor of the stated objectives in these programs to drive outcomes, whether physicians are included as part of the health care team or trained separately, the costs of the programs, how organizations collected data on objective metrics that could indicate ROI, and if there is a synchronized effort between those who run the programs and the CEOs who provide the resources. This information is important — to foster advancement of leadership development for those who serve in health care, to build the interprofessional teams required today, and to contribute to the kind of change that addresses the tactical and strategic challenges within the U.S. health system. Our research uncovered some emerging dynamics, and we noticed interesting trends in four distinct areas: 

Rigor and Connectivity in Objectives and Design: It appears most HCOs do not design or coordinate stated objectives for organizational leadership development programs. Outcome-based training, which generates and drives specific learning objectives, is the most-effective method to achieving productive results. Yet most of the organizations we surveyed do not appear to link their strategic objectives to desired hospital-specific and CEO-approved program outcomes. Two of 16 organizations have identifiable goals for physicians who are attending their offered courses, and those organizations appear to have stated and coordinated desired outcomes.

The prevailing objectives provided by the program administrators for most of the HCOs do not appear to describe the objectives that will produce the desired outcomes. Rather, the objectives describing the courses and training are almost singularly focused on required learning of administrative tasks (effective communication, diversity and inclusion, equal opportunity, patient improvement initiatives, financial accountability, etc.) and the learning of specified processes or technical skills associated with the business management aspects of health care. The coding of responses indicates CEO aspirations for leadership development programs are threefold: building strong health care teams, building stronger health care organizations within their firms, and building for the future of health care networks. But with one exception, CEO intentions are not reflected in stated or published organizational objectives for leadership development provided by program administrators. 

We recommend health care organizations conduct a comprehensive review of their current training and education objectives and the overarching leadership strategies to determine if their approach matches the desires or guidance provided by the CEOs.

We recommend health care organizations conduct a comprehensive review of their current training and education objectives and the overarching leadership strategies to determine if their approach matches the desires or guidance provided by the CEOs. 

Physician Inclusion: Most responding organizations want to include physicians in their leadership development programs. However, while 11 of 16 institutions have established programs for developing physician leaders, only three conduct interprofessional collaborative practice training or have designed their programs to incorporate interprofessional education techniques. All CEOs see the importance of programs that improve the professional and personal leadership development of their physician and nonphysician employees, and they see the importance of collaborative health care teams, but separate training of physicians seems to be the norm in all but three of the surveyed institutions.

To improve team and organization collaboration and shared trust, we recommend HCOs design hierarchical leadership development programs while incorporating the concepts of IPE and outcome-based training and education. That would require including physician attendance in more of these executive programs. 

Cost of Programs: Most leadership development directors either could not or did not provide precise descriptions of where and how they were allocating financial and personnel resources to various leadership development programs. None of the five CEOs could estimate the details of resource costs associated with the training programs, yet all CEOs interviewed say they support the expenditure. There are challenges associated with delineation of resource allocation spent on leadership development, to be sure; it is difficult to calculate “we spend X amount of money and allocate Y instructors to Z program.”

We recommend HCOs review their expenditures and their leadership development programs, determine which programs could be placed into an IPE framework, and which programs might not be contributing to either the CEO’s desire or an objective ROI for the organization. 

Development of Metrics and Determination of ROI/ROV: In describing how success of programs is judged and evaluated, 15 of 16 organizations provided statements indicating they had not applied rigor in assessing value through objective measurements. Most organizations state that the effectiveness of their leadership development programs is measured through HCAHPS scores or employee engagement scores; they also say those scores do not assess individual leadership growth of graduates but, rather, evaluate the teams where new graduates work or practice. Four of the five CEOs say evaluation of the success of their programs is based more on gut feel than any objective evaluation. Only one of the 16 HCOs surveyed provided an attempt to measure effectiveness of individual improvement through pre- and post-course surveys, pre- and post-course 360 assessments, participant self-assessment, and applied research in such areas as leader communication, leader-led relationship and leader trait perspective.

Future study?

We hope this research provides relevant information for nonprofit health care organizations attempting to establish successful physician or interprofessional leadership development programs. Future researchers using this methodology to measure the effectiveness of ongoing programs might consider testing our themes with a larger pool of nonprofit HCOs, directing similar research with for-profit hospitals, or even conducting analysis between nonprofits and for-profits to compare results. Research might also include interviews with physicians to determine additional observation of personal leadership growth. Finally, researchers might also expand the scope of interviews to include more CEOs.

Mark Hertling, MS, MMAS, is a retired Army lieutenant general and a senior vice president for Florida Hospital in Orlando. He is the author of Growing Physician Leaders (Florida Hospital Publishing, 2016) and studies, speaks and teaches health care leadership.

Melissa Dennis, MBA, is a customer engagement marketing professional with vast experience in hospitality sales and marketing.

Rhonda Bartlett, RN, MBA, works for Cerner Corp. as client leader for New York-Presbyterian Brooklyn Methodist Hospital. She previously was a vice president at Siemens Healthcare and held numerous positions at Florida Hospital in Orlando. 

REFERENCES 

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