Management and leadership concepts and practice

Medical Management

The primary goal of both private- and public-sector medical organizations is, of course, to provide the highest standard of medical care to their patients. This requires, of course, professionals who are trained in the latest scientific and medical techniques and both private and public health-care institutions in Great Britain in general accomplish this element of their task. However, providing quality health care is not simply a medical issue: It is also a question of management principles and in this area it is all-too-often the case that health-care organisations fail. It is perhaps inevitable that publicly run health-care institutions are even farther a field in their management style from the best run corporations than are privately run health-care institutions (which are legally constituted along the lines of other for-profit firms) and this fact has a number of important drawbacks for institutions that are a part of the NHS. However, it must be acknowledged that there are some advantages that institutions that are a part of the NHS have some advantages that privately run institutions do not.

It is certainly true, however, that while on the whole publicly administered health-care organizations have farther to go in terms of approaching a state of the most highly skilled management, both publicly and privately administered health-care institutions can improve their management strategies. While this is not a trivial task in any sense, neither is it an insurmountable one in no small measure because health-care organizations have the advantage of being able to borrow and borrow liberally from the advances that other firms have already made. Health-care organizations may be particularly aided in borrowing from the management strategies of high-tech firms because the two types of organizations share key management challenges.

Both high-tech firms and health-care organizations share the need to be able to meet the needs of an increasingly mobile workforce even as they are able to obtain from these same often-transient employees their best work. In our uncertain economic times, employees feel increasingly less loyalty to their employers and are more and more likely to consider themselves to be independent contractors whose fealty is to themselves alone. This means that every aspect of staffing at health-care organizations - from recruitment to retention - is increasingly difficult. This in turn means that senior managers must take on increasing responsibilities, especially in the arena of communicating with workers at every level and in every department of the organization.

The Centrality of Communication

This communication must be aimed at reconciling the different needs and stakes of various employees as well as of the patients themselves. Effective managers are those who create a work environment in which each employee is used to his or her best advantage but also feels that he or she is begin fulfilled. Balancing the needs of both employers and employees - while taking in to account people's skills - is a difficult task and requires well-developed communication skills. An effective manager must recognize the various individual needs and desires people and be able to facilitate communication about these issues. This is true regardless of the field, but is an issue that has generally received more attention within the sphere of private firms rather than publicly administered services. The managers at the NHS hospital in this study all too often failed to listen to attentively to their employees (or the patients), perhaps because they believed that the possible responses that they might make were so rule-governed that it did not matter whether they were attentive or not.

Good managers must understand how human needs cause people to act as they do and how their motivations and actions can be changed. In their book, Getting To Yes, William Ury and Roger Fisher emphasize the need to recognize these basic needs before moving on to other aspects of communication.

What is true for individuals remains equally true for groups and nations. Negotiations are not likely to make much progress as long as one side believes that the fulfillment of their basic human needs is being threatened by the other (49).

Communication is the act of sharing information through connections that we make with other people - whether in speech, writing, or through body language. Most of our daily communication is personal communication, a sharing of information with one person or perhaps a few people. Good communication skills include both the ability to convey one's own ideas clearly as well as to listen carefully to other people's ideas. And yet despite the centrality of good communication skills to good management - as well as to personal relationships - developing good listening habits is something that too few people do.

The proof of good listening is an appropriate response" Brownell (177) argues, and to a large extent it is true that employees will judge the effectiveness of a manager's interpersonal skills by what the leader says or does in response to what employees say. But what exactly do these good listening skills that a leader should have consist of?

First, a good manager demonstrates a sincere interest in what her or his workers have to suggest. Since "communication is a dynamic, reciprocal process" (Brownell 230), a good manager will be an attentive listener - striving to gain a more accurate understanding of what an employee is saying. The employee in turn will sense this attentiveness because the manager is providing appropriate feedback to what the worker is saying - something that is only possible through careful listening.

Managers must demonstrate a sincere interest in what others are saying; in other words, if someone expresses a concern about an issue that is important to the speaker, a yawn and a nod are not appropriate responses. These are typical human responses (especially toward the end of a busy day), and the manager must be particularly aware of this tendency to downplay the importance of what others have to say.

A good leaders develops "active" or "empathetic" listening skills. Much of the time spent by managers involves communication in one form or another - from internal memoranda and e-mails to telephone calls and meetings to personal interviews. Each one of these demands active listening. Stewart & Thomas (379) define active listening as "effective sensing, interpreting, and evaluating the other person's meanings" - a definition reflected in the anonymous maxim, "I know you believe you understand what you think I said, but I'm not sure you realize that what you heard is not what I meant" (Howell 9). The findings of this research have been that those in executive and supervisorial positions at NHS organizations are less likely to engage in these kinds of highly effective communication behaviors than are those at privately administered health-care organizations. This may be because of the inherent structure of each type of organization, its "corporate culture" or because of the differing backgrounds of the managerial staff at the two types of hospitals, with those at NHS facilities more likely to have spent their lives in government service and in highly bureaucratic organisations while those working for privately administered health-care organisations may not crafted their management philosophies in the private sector where competition (both in terms of competing against other health-car organisations for patients and in terms of competing against other organisations in terms of hiring and retaining the most highly qualified staff) is a more central concern.

Reengineering the Hospital

It often seems that many of today's businesses simply do not have the leadership that they need - or at least to both John Kotter, in his What Leaders Really Do and Michael Hammer and James Champy, in their revised book Reengineering the Corporation: A Manifesto for Business Revolution - argue this point. This is true not just within the arena of health-care but in general in our high-tech world. This should perhaps make those managers within the field of health-care who are struggling feel reassured that they are not alone; however, they should not be satisfied with struggling to meet their goals simply because others are given that there are clearly more efficient ways to manage both people and other resources than we see in today's publicly and privately run health-care organisations.

The problems that we see both within and outside of health-care result not of incompetence on the part of the entire managerial class but rather of a failure of many companies and their managers to make the changes necessary to keep pace with the rapid technological and human resources changes that are occurring in the business world. Hammer and Champy in particular argue that the primary problem with the management of both large and small companies today is the fact that companies are still using a mid-twentieth-century - and even in some ways a nineteenth-century view - of the process of work and of the relationship between employer and employee. Kotter argues that managers all too often manage without leading, failing to understand the complex ways in which staff relationships are created and maintained. (This is not necessarily different from Hammer and Champy's argument, for the traditional relationship between employer and employee was not characterized by a high degree of subtlety and nuance. This paper examines the opinions of all three of these authors on the issue of leadership and its relationship to management.

One of the most important thing that managers must consider as we proceed into our still-new century is the importance of recognizing and nurturing change: One of the most important characteristics that sets leaders apart from managers is the ability to welcome change. One of the most difficult aspects of management is the fact that even when people want to make and succeed in making changes, they have difficulties in making those changes last. Even most desired significant changes fail to be last even when people want them to because there is an ingrained bias against change in the very ways that people think. A good leader - and all managers should aspire to be good leaders - must be able to overcome such biases against change (when change is appropriate) even as she or he works to prevent change when it is not appropriate or needed.

As will be discussed further below, humans are genetically programmed to accept and even encourage some change while at the same time we are also genetically programmed to reject rapid, radical change. Evolution has conditioned us, as it has conditioned other biological entities, to change gradually (actually, biologists disagree over the extent that this is true). Anyone who wishes to make lasting changes must address both the mechanics and dynamics of change as well as the dynamics of stasis. That ability to balance change and continuity lies at the heart of good management, as shall be discussed below as each of the six areas for management strategy is considered. These strategies apply to a range of organisations, not simply health-care ones. However, they are in many ways most sorely needed in health-care organisations (especially those that are allied with the NHS) because of the rigidly bureaucratic nature of these organisations, because of the poor communication in these organisations (both between staff and clientele as well as between and among different divisions of the staff), and because of the tendency of NHS hospitals (as well as privately administered ones) to be dismissive of the contributions of "lower-level" workers, especially nurses.

Shared Competitive Agenda

Far too often the vision that the executives are managers of an organization have is not shared by those who are below them in the hierarchy. This is in many ways understandable: A secretary is less likely to value the competitive agenda of the company equally with a CEO because he is far less likely to share in the benefits of that agenda in terms of either monetary rewards such as raises or stock sharing or in terms of prestige. He is also less likely to share in the competitive agenda than is the CEO because the secretary - or the assembly line worker or even the design engineer - is less likely to have been included in any way in the planning of that agenda.

While to some extent this differential is inevitable, this does not mean that organisations should not work to minimize it. For example, a company can also ensure that the opinions of employees at all levels are solicited and considered - and rewarded when they prove to be useful. It is, after all, often employees in what may seem insignificant positions who come up with the best ideas because it is they who are most familiar with the daily operations of the company in each department, and it is often precisely at this level that substantial improvements can be made in terms of efficiency and productivity. Lab technicians and nurses often have a great deal to say that can be highly useful to the managers of a health-care organization (especially nurses, given the percentage of patient care for which they are responsible) but too often their opinions are dismissed, if they are even considered at all.

Clear Charter of Values

One of the most important things that any manager can do is to ensure that the standards that apply to one person apply equally to all. There is probably no better way to ensure poor morale in an organization than to ensure that there is one standard of behavior for those at the top of the hierarchy and those at the bottom. For example, if executives are known to sexually harass their staffs but lower-level workers are instantly dismissed over even the rumor of such a charge, then workers will become dispirited and leave on their own as soon as they can.

If executives boast about their clever tax dodges and the ways in which their off-shore banks help them shelter their bonuses from stockholders, they can hardly be surprised if their employees filch sugar packets from the company lunchroom or fiddle their timecards. A loose ethical standard quickly permeates a company, and the only thing worse than this is for executives to get away with unethical behavior while their employees are punished for what are in all likelihood (given their relative power and authority) far less serious ethical lapses.

Competing for Talent

One of the most important challenges for organizational leaders in the 21st century is their ability to compete for the relatively limited supply of workers that may be available for the work that the company does. This is most likely to be true for high-tech jobs in which a large number of firms are competing for the same group of individuals who have a range of computer skills. However, it is also true for other professions as well, such as those that need a workforce that speaks a wide range of languages.

One of the lessons that high-level managers should have learned from the rise and near fall of the dotcom industry is that it is not enough simply to recruit bright young professionals with the latest skills (thus securing their talents for one's own company even as one prevents other organisations from benefiting from their skills). It is also important to have people with a range of talents. At least some of the dotcoms that went under with the same dazzling rapidity that they rose would have been able to save themselves had they not relied so heavily on tech-savvy younger workers with little experience with or appreciation for basic business skills such as balancing long-term goal-setting with short-term goal-setting and understanding how much debt a company can wisely take on during its set-up phase. All organisations need different skills from their workers, and creating the proper balance is at least as important as the depth of skill of any one worker or any one department in the company.

This problem is easy to understand within the high-tech world, but it has clear implications for the world of medicine as well and health-care organisations must be more attentive to the needs of their workers if they wish to avoid the high cost of constant recruitment and retraining.

Speed of Reaction

It is certainly imperative that the manager of the 21st century be able to help design a workplace that allows a company to react to political, economic and other changes in the marketplace with sufficient speed (and flexibility). Again, this model may seem appropriate for the business workplace but not for the health-care organization but this is only because we have become so accustomed to thinking of the health-care organization as fundamentally different (and perhaps fundamentally better) than a widget-making factory because in the case of the former there are lives on the line.

However, while of course human lives and human health are far more valuable than are widgets, this does not in and of itself mean that the same principles that a manager applies in making more and better widgets faster and more efficiently and for a lower cost cannot be applied in creating healthcare that is more efficient, more effective, more humane and cheaper.

One of the most important changes that has occurred in many companies during the last few decades of the 20th century was a shift toward a less hierarchical organisational structure in many firms. More firms now allow employees at all levels a greater degree of autonomy, encouraging them to help design or redesign the work that their own department is responsible for (on the grounds that these employees are of course the ones that know the most about those work processes).

While it is probably impossible to run a company without any sort of traditional hierarchy at all (and this is more and more true the larger the company is), it is imperative that companies are not wedded to a rigid top-down structure in which a single person or a small handful of people make all of the decisions from long-range planning to day-to-day scheduling. Those companies that are the most efficient are those in which the appropriate level of authority exists at each level - which means that executives do not cede to much authority (there still needs to be someone in charge, of course) but do not gather too much authority to themselves either.

This is also true of health-care organisations: There is a need for some degree of hierarchy. But the degree of top-down structure that exists in many health-care organisations, and especially in those that are publicly administered, is harmful to the "product" of healthcare. It is incumbent on health-care organisations to rely upon hierarchies only when they are actually useful and not simply when they are traditional; this is especially true vis-a-vis the roles and relationships of physicians and nurses. Despite the fact that nurses now have greater training and education and responsibilities than then did 50 years ago, they are still quite often treated as a sort of decorative help-meet rather than as the medical professionals and partners that they actually are.

A more equal working relationship would promote better patient care while allowing the nurses to feel as valued as they should be and would no doubt increase the retention rate of those nurses.

Leveraging Resources

To some extent it is true that organisational resources must be combined and recombined as an organisation shifts to meet the needs of a changing marketplace. (And health-care is affected by market-place structures, although it is more insulated from them than is a product like computer chips, for example.) However, top-level managers must be careful to ensure that there is not a constant shifting of such resources because while change is certainly good, chaos is not. An organisation must be willing to make shifts in resources when necessary, but the necessity of such a rearrangement of resources must be well established each time otherwise the company will find itself rushing back and forth putting out spot fires without ever having sufficient resources to move forward.

To return to the authors whose critiques we began with, it is imperative that managers remembers that change for its own sake has little appeal. Profound change is difficult to accomplish but it is possible if it is well planned and - most importantly - change in a positive direction. Change that makes people's lives worse is even harder to accomplish, and yet often management plans either do precisely this or fail to stress how change will in fact make an organization and the lives of the people in it better. Change just to change, Kotter especially argues, is a sign of a manager rather than a leader, someone who is just trying to do something to create momentum without stopping to ask in what direction that momentum is carrying the company. A leader, on the other hand, decides where he or she wants to move and then finds a way to get there.

The (Stumbling) Dance of Change

Humans are genetically programmed to accept and even encourage some change while at the same time we are also genetically programmed to reject rapid, radical change (Rampersad and Leonard, 2003; Drucker, 1999, Hammer and Champy, 2001). Evolution has conditioned us, as it has conditioned other biological entities, to change gradually (actually, biologists disagree over the extent that this is true). Anyone who wishes to make lasting changes must address both the mechanics and dynamics of change as well as the dynamics of stasis.

As Senge etal (1999) suggest, one of the reasons that organisations fail to make needed changes is that they fail to attempt to make changes on the proper scale: They either make changes that are so small that they do not matter or they attempt to make changes that are so sweeping that they overwhelm the organisation and its staff. Health-care organisations, and especially those that are publicly administered, tend to err in the former direction. However, it is important that in trying to compensate for this tendency they do not go overboard in the opposite direction.

Senge etal argue that change for its own sake has little appeal. Profound change is difficult to accomplish but it is possible if it is well planned and - most importantly - change in a positive direction. Change that makes people's lives worse is even harder to accomplish, and yet often management plans either do precisely this or fail to stress how change will in fact make an organization and the lives of the people in it better.

The authors argue that all too often organizations do not set aside sufficient time for those charged with bringing about change in an organisation (such as the members of a pilot group) to accomplish the hard work that is needed to create and institute change. This is an example of a very common workplace problem: Management gets so caught up in short-term problem solving that it does not set aside time for solving - or even avoiding - long-term problems. This is something that health-care organisations must in particular consider given that such changes have the clear potential to affect the quality of patient care as well as staff efficiency and morale.