TQM and Transformational Leadership Traits in Healthcare

According to Total Quality Management (TQM) scholarship, and specifically the article "Implanting Total Quality Management in Healthcare: The Critical Leadership Traits" by Nwabueze (2011), TQM is an increasingly critical part of ensuring cost-effective management of healthcare in the modern economic environment. However, there are often substantial institutional and personal obstacles to realizing its benefits. "TQM leadership is therefore about presence, and a process carried out within an organizational role that assumes responsibility for the needs and rights of employees who choose to follow the leader in achieving results" (Nwabueze, 2011, p. 331). In the article, leadership in general is conceptualized as motivating people to do what you want them to do of their own free will, without constant supervision and coercion, and TQM in particular is described as a values-based system (Nwabueze, 2011, p. 332). The concept of zero defects and continuous improvement must be instilled within all employees on a consistent basis throughout the organization, and this requires a transformation of past ways of thinking.

Such a transformation is, of course, more easily said than done. By surveying 50 chief executive officers in the British National Health Service, Nwabueze (2011) attempted to better understand what leadership traits facilitate the use of TQM within healthcare organizations. Although the National Health Service is a single-payer, government-run and government-funded organization, cost containment remains of paramount importance. Five traits are viewed as key in all theories of leadership: intelligence, knowledge, dominance, self-confidence, and creativity (Nwabueze, 2011, p. 332). Nwabueze (2011) would also add courage: even though this is often thought of as a trait primarily confined to physically active leadership such as in the military, implementing a TQM program is often so far-reaching that considerable boldness is necessary to challenge the organizational paradigm. A leader must also be highly skilled both technically and interpersonally — the leader must know what he or she needs to do and how to do it.

In his specific application of trait-based theory to the NHS, Nwabueze notes that an authoritarian style is likely to be particularly unhelpful in implementing TQM directives. First and foremost, the NHS is a heavily bureaucratic organization, and issuing categorical directives is not effective in such a context. However, a purely situationally based style of leadership that self-adjusts according to the organization's immediate needs is not necessarily beneficial either. TQM is still a fairly standardized process, and being cognizant of this fact is essential for the organization to thrive. It "continues both in wartime ... and peacetime" — in other words, the emphasis is on staying the course rather than adjusting strategy to suit the needs of a down versus an up market (Nwabueze, 2011, p. 334).

The preferred modes of leadership, based upon Nwabueze's literature review, are transformational and/or visionary leadership styles that entirely reconfigure how members of the organization see themselves. "TQM is transformational in outlook in the author's opinion, requiring first and foremost, a transformation in managerial style, employee behavior and attitudes, systems, structures, processes, and skill sets" (Nwabueze, 2011, p. 335). Visionary leaders inspire organizational members to rise above political conflicts and make a substantive commitment to the organization's goals (Nwabueze, 2011, p. 335). In short, they appeal to employees' higher selves.

Although Nwabueze's article does not discuss the specific application of these principles to healthcare in great depth, it is easy to see why transformational and visionary philosophies might be particularly appealing for a healthcare entity. Whether for-profit or not-for-profit, healthcare organizations must be driven to serve the needs of the consumer, given that consumers are entrusting the precious commodity of their health to the organization. A failure to ensure quality can have serious and lasting repercussions for consumers. In one pertinent example used in the article, the need for the TQM leader to embody the ideals of the organization is underlined: it is not simply enough to articulate goals such as timeliness — the leader must personally uphold them in practice, or employees will not believe in the leader's vision. In the specific survey of the 50 NHS executives, the leadership qualities that emerged as critical among effective leaders included being a "good communicator, a good commander, 'hands on,' a 'planner,' 'enthusiastic,' 'strong-minded' and a 'good listener'" among others (Nwabueze, 2011, p. 339). Overall, these qualities suggest that TQM requires assertive leadership that remains sensitive to employee needs.

However, the article "Trait and Behavioral Theories of Leadership: An Integration and Meta-Analytic Test of Their Relative Validity" by Derue, Nahrgang, Wellman, and Humphrey (2011) questions whether viewing leadership as a trait-based dimension at all is helpful. Although it acknowledges the appeal of trait-based theories — which suggest that character is a stable construct — leader behaviors, rather than leadership character, are increasingly coming to the forefront of managerial literature. In Nwabueze (2011), no real distinction between traits and behaviors is made, although the emphasis is clearly upon traits. It is assumed, for example, that visionary leaders will embody values such as being good listeners and communicators as a matter of course. While Nwabueze discusses certain theories that might be conceptualized as behaviorally based, he does not distinguish them from character-based approaches.

In contrast, Derue et al. (2011) attempt to synthesize what the authors consider opposing paradigms that have more in common than the current literature might suggest. For example, in the contrast between transactional and transformational leaders, the authors note that transactional leaders may be more authoritarian and less relational in their trait-based orientations than transformational leaders. Character leads to certain types of behavior, and behavior in turn reveals character. A leader might advocate a visionary approach in words but fail to embody it in action. In addition to breaking down leadership literature into character-based versus behavior-based distinctions, Derue et al. (2011) also note that certain studies have focused more on leadership effectiveness in group versus individual situations, and this perspective can influence which traits are deemed more significant.

Such a lack of integration between behavioral and trait-based theories is problematic given the complexity of leadership. Focusing on one component of leadership to the exclusion of others can result in an unbalanced perspective. "Considering that leader traits such as gender and personality are often discussed in terms of the behaviors associated with those traits, the idea that leader behaviors mediate the relationship between leader traits and effectiveness seems especially plausible" (Derue et al., 2011, p. 12). Integration of studies is especially essential given that various traits and behaviors may be interrelated. For instance, "meta-analyses on the relationship between intelligence and personality suggest that Extraversion and Openness to Experience are related to intelligence," even though the Big Five model of personality traits conceptualizes them as separate entities (Derue et al., 2011, p. 12).

Of the specific hypotheses advanced by Derue et al. (2011), hypothesis one is that "task competence" has a "stronger, positive relationship with task performance dimensions of leadership effectiveness than leaders' demographics or interpersonal attributes," while hypothesis two holds that among character-based traits, "interpersonal attributes" — that is, the leader's actions with subordinates — are far more important than more abstract, character-based dimensions (p. 15). It is further hypothesized that competency at tasks and interpersonal skills will have a higher positive association with leadership effectiveness than demographic aspects such as gender (Derue et al., 2011, p. 15).

The formulation of hypotheses in the Derue et al. (2011) article is thus very different from Nwabueze (2011), given that it takes the form of scientific hypotheses rather than a general literature review. Subsidiary hypotheses also emphasize the importance of relationally oriented and change-oriented leadership traits, which are hypothesized as more effective than passive, hands-off leadership methods — an idea commensurate with Nwabueze's emphasis on the need for firm leadership that is not purely situationally based (Derue et al., 2011, p. 18). Overall, eleven hypotheses were advanced by Derue et al. (2011); this proliferation is specifically intended to demonstrate the interrelated nature of a multitude of leadership theories and to show that the failure to integrate them represents a weakness in the literature. A meta-analysis of existing studies was deployed, and the authors "created a comprehensive list of codes for the variables reported across all studies. The studies were divided among the authors who then coded the meta-analytic estimates for the variables of interest from each study" (Derue et al., 2011, p. 26).

Overall, a meta-analysis is considered to offer higher-quality evidence than a single study of the type offered by Nwabueze (2011). Yet the findings were not dissimilar. It was determined that "conscientiousness was the most consistent trait predictor of leadership effectiveness. Within the behavioral paradigm, transformational leadership was the most consistent predictor across the criteria. Other behaviors contributed to effectiveness, but their relative validity was contingent on the particular outcome of interest" (Derue et al., 2011, p. 37). In other words, a transformational, visionary approach emerged as a great asset to leadership, and conscientiousness and consistency — rather than a situational, case-by-case approach — emerged as a superior strategy. Unlike Nwabueze (2011), whose aspirations were relatively focused on suggesting how to better integrate TQM into organizations using effective leadership approaches, the hope of Derue et al. (2011) was no less than a complete paradigm shift in leadership studies as a whole: "Our hope is that this study begins to reverse the trend of construct proliferation in the leadership literature, and thus provides some clarity" (Derue et al., 2011, p. 43).