Author: Stowe, Michael
Date published: July 1, 2010
The ever-increasing uncertainty that confronts the U.S. health services industry is placing an enormous demand on providers of care and those who lead and manage delivery systems (Hudak, Brooke, Finstuen, & Riley, 1993). Jobs in the healthcare industry are in a constant state of change, requiring a workforce that is not only prepared to adjust quickly to the changing environment but to simultaneously maintain or improve overall organizational performance. An essential determinant of healthcare organizational performance is management competence. Studies have examined the knowledge, skills, and abilities of top-level executives, primarily in hospital settings. However, there is a need for expanding that perspective of the requisite knowledge, skills and abilities beyond the hospital setting. We seek to explore those determinants beyond that previous studied and expand the perspective of managerial competence.
REVIEW OF THE LITERATURE
Review of the literature found that healthcare education studies focused on managerial skills related to business management. "The general human resources literature typically refers to competencies through the acronyms SKA or KSA, sometimes defined as skills, knowledge, and ability or knowledge, skills and abilities. Competencies have also been referred to as skills, knowledge, and attitudes (or aptitudes), with ability being subsumed under skill" (Shewchuk, O'Connor, & Fine, 2005, p. 33).
Many fulfilling those managerial roles do not appear to possess proper management qualifications or managerial experience in healthcare. If the healthcare industry is to effectively manage the growth of this customer base, managers need to possess the requisite skills and abilities to meet the changing business needs (Mathews, Tozer, & Walker, 2004). Although the labor shortages have been particularly problematic in the nursing fields and other allied health professions, there has also been some speculation surrounding a potential executive leadership shortage. Furthermore, there have been concerns that those in the youthful workforce cohorts will be poorly prepared for their new roles (S. Collins, Matthews, McKinnies, K. Collins, & Jensen, 2009).
The literature on the subject of managerial skills in healthcare is extensive focused on the hospital environment. There is overwhelming consensus that business-related analytical skills and functional abilities remain critically important ingrethents for success in managing health care organizations. However, there is strong evidence of concern among practitioners that an exclusive focus on quantitative analysis, functional specialization, and the calculative rationality of the "bottom line" may not adequately prepare new managers to be adaptive, collaborative and team-builders. These managers will be needed to lead health care organizations of the future.
The hospital industry will have to seek, hire, and retain highly qualified individuals that have a breadth of knowledge of both business and healthcare in order to remain competitive. Organizations must recruit, hire, and train individuals that possess a multitude of managerial skills (Hurley & Brewer, 1991). "In the last 100 years, technology has blossomed, healthcare has spread to near universality, and delivery organizations have exploded in size, complexity and sophistication" (Griffith, 2007, p. 11). However, novice managers often find their new roles frustrating, and consistently encounter situations that stress and strain their managerial abilities. Their inexperience and lack of knowledge contribute to a resounding lack of leadership among health care professionals. Lack of managerial development and skills often leads to employee frustration, disenfranchisement from the health care organization, and, in some cases, resignation from the health care system (Weston et al., 2008). Without formal preparation for management roles and responsibilities, novice managers learn by trial and error and thus frequently mishandle employee issues, which cause both the manager and the employee to become discouraged in the workplace. This has severely affected the management of relationships, the clarity of communication, the ability to create effective working environments, and excellence in practice.
CURRENT STUDY: RESEARCH OBJECTIVES
This study focuses on expanding previous research to another segment of the healthcare delivery systems that of managers, supervisors and directors within a broader scope of healthcare organizations. The study asked healthcare managers, supervisors and directors to rate the importance of 50 knowledge, skills, and ability (KSA) concepts perceived as being necessary for successfully managing their current type of healthcare organization. The significant changes in healthcare delivery and financing have placed tremendous stress on the system and the workers and executives in it. It is now an opportune time for further research on executive management in the healthcare industry, especially organizations that focus on a variety of organizational types. Regardless of delivery setting, in order to remain competitive and profitable, organizations must have executive managers prepared with the right knowledge, skills, and abilities and that correlate for success in their position (Hurley & Brewer, 1991).
This study addresses the gap in research by identifying the necessary knowledge, skills, and abilities for executives in a broader segment of the healthcare delivery system. Additionally, we examined the KSAs of healthcare management groups to more clearly define the domains of their positions that contribute to their success. It also examines the role of gender, age, education, years in health care and years of experience in healthcare management as factors that could influence the necessary skills needed for effective management. Since researchers have conducted many studies examining the knowledge, skills, and abilities of top-level executives, primarily in hospital settings, however, the research on executives is lacking in its focus on the knowledge, skills, and abilities of managers, supervisors and directors in a broader range of healthcare settings. This study filled that gap in research by identifying the necessary knowledge, skills, and abilities for managers, supervisors and directors in broader segments of the healthcare delivery system. We examined the knowledge, skills, and abilities of healthcare management group not extensively studied thus providing a baseline of data to examine and understand how these skills and abilities prepare these executives to be successful in their roles.
The targeted population for this study was current managers, supervisors, and executives in a healthcare setting. The participants were selected from current and former students and faculty within a graduate program in health administration. In addition to these participants, this study utilized a snowball technique and requested that the primary participants forward the email to at least three colleagues that meet the criteria for the study.
In addition, this study utilized a panel of experts to review the instrument for comprehensiveness and completeness. The expert panel included, healthcare executive directors and others currently involved in a managerial function within a in a variety of sizes of healthcare organizations. Twenty-five healthcare experts reviewed the survey for completeness, readability, and verbiage. Additionally, the expert panel provided feedback on the data elements to determine both applicability and relevance to the healthcare necessary skills and knowledge set. The final set of KSAs is presented in Table 1.
Table 2 describes the demographics of the sample. The majority were females at 78.9.2% while Caucasians represented 88.1% of the sample. The majority was 41 years or older (77.1%) while 90.8%) had a bachelor's degree or better. The average experience in health care was 24.7 years and average years in their current position was 8.5. Almost 70% of the sample was classified as middle management based on respondent position titles.
Table 3 shows the means for the 50 KSAs. Effective leadership (6.81), creating a positive work environment (6.74), effective management of conflict (6.71) and multi-tasking (6.71) had the highest importance ratings. Following closely behind was motivating others (6.63), empathy for patient/client concerns (6.56), sensitivity to staff problems (6.56), and work is consistent with personal ethics (6.51). The lowest rated items were: bond covenants (2.32), managing media relations (3.93), facility/plant management (4.14), components of marketing techniques (4.49), and utilization of a global business perspective (4.56).
When considering the statistical error of .54, the first 14 KSAs are statistically equivalent, effective leadership through use of computer technology. Bond covenants were the lowest rated item. Conduct market research, management of account receivables, managing media relations, and facility/plant management were the next lowest cluster of items.
Table 4 reviews the importance of the skills domains. Respondents rated the importance of organizations skills (6.63), business administration skills (6.36), and interpersonal skills (6.21) as the three most important domains given the statistical error of .55. The next most important was communication skills (6.08) followed by board relation skills (5.08) and fund raising skills (4.48).
A series one-way ANOVAs were run with the 50 KSAs serving as dependent variables and the demographics of years in current position, age, years of experience in healthcare, education, and gender serving as the fixed factors. Years in current position, was recoded into three categories: 1-4 years, 5-10 years, and over 10 years. Age was recoded into three categories: 25-40 years, 41-52 years, and over 52 years. Years of experience in healthcare was recoded into three groups: 3-20 years, 21-30 years, and 31-45 years. Finally, education was grouped as follows: high school/associates degree, bachelor's degree, and masters/doctorate. Tables 5-9 report these results.
Table 5 indicates that those who were in their position 1-4 years rated healthcare regulations, audits for clinical compliance with Medicaid/Medicare regulations, visibility to patients/clients of your organization, and diversity as less important than those 5-10 years. Those in their position over 10 years rated contracts/agreement, facility/plant management, communicating organizational vision to stakeholders, project management techniques, and public speaking as less important than those who were in their current position 5-10 years.
Table 6 shows that those 25-40 years old rated financial statements and critical ratios, effective implementation of clinical programs, state and federal healthcare regulations, accreditation standards, external networking, and managing media relations as less important that those 41-52 years and in some instances those over 52 years. Respondents 25-40 and 41-52 years rated bond covenants as less important than those respondents over 52 years.
Table 7 indicates that those with 3-20 years of experience in healthcare rated facility/plant management, risk management, project management techniques, ethical business practice, and ability to conduct healthcare risk assessments as less important than those with 3145 years experience and in some instances those with 21-30 years experience. For bond covenants, those respondents with 21-30 years of experience in healthcare rated them as less important than those 3 1-45 years of experience.
Table 8 shows that those respondents with a high school or associates degree rated audits for financial compliance with Medicaid/Medicare regulations, components of marketing techniques, and public speaking as less important than with a bachelor's or masters/doctorate.
Table 9 reviews the results for gender. Women rated effective implementation of clinical programs, accreditation standards, sensitivity to staff problems, creative problem solving, empathy for patient/client concerns, visibility to the patient/clients of your organizations, effectively managing conflict, risk management, project management techniques, work is consistent with personal ethics, motivating others, leading organizational change, delegate work, run effective meetings, consider ethical implications in clinical decisions, ability to be decisive, management diversity in the workplace, and utilization of research skills as more important than men.
Nine of the items that women rated as more important than men involved management/leadership skills: effective implementation of clinical programs, accreditations standards, creative problem solving, risk management, project management techniques, leading organizational change, ability to be decisive, managing diversity in the workplace, and utilization of research skills. Seven of the items that women rated as more important were interpersonal in nature: sensitivity to staff problems, empathy for patient/client concerns, visibility to the patients/clients of your organization, effectively managing conflict, motivating others, delegate work, and run effective meetings. Two were concerned with ethics: work is consistent with personal ethics and consider ethical implications in clinical decisions.
Table 10 shows that there were some demographic differences based on a series of oneway ANOVAs conducted on the 6 domains. For the business administration domain, those 25-40 years rated business administration skills as less important than those 41-52 and over 52 years old. Those who had between 3-20 years experience in healthcare rated business administration skills as less important than those in the business for 21-30 and 31-45 years. For gender, men rated organizational, communication, and interpersonal skills as less important for women.
An initial Principle Component factor analysis with a Varimax rotation was run on the 50 KSA variables. It was found that 7 items did not load on any factor. They were work with governing body, strategic planning techniques, facility/plant management, multi-tasking, ethical business practices, use of computer technology, and ability to be decisive. These items were removed for the second factor analysis. Seven interpretable factors evolved which explained 61 .5% of the variance. Only factor loadings of .40 or better are reported in Table 1 1 .
The first factor labeled External Stakeholder Domain explained the most variance at 28.0%. The second factor called Personal Ethos Domain accounted for 9.8% of the variance while the third factor, Communicating Change Domain, accounted for 6.4% of the variance. Factor 4, Clinical Compliance Domain accounted for 5.9% of the variance while factor 5, Managerial Tasks Domain, accounted for 4.6% of the variance. The last two factors, Dollars and Cents Domain and Ethics and Quality Domain each accounted for roughly 3% of the variance.
The rationale for choosing the above mentioned factor names were:
External Stakeholder Domain: These factors focus on areas related to how the organization is viewed by outside entities. These skills not only help establish the organization's image within the community but also establish necessary relationships that allow the organization to exist or continue to operate within external guidelines/requirements.
Personal Ethos Domain: These factors demonstrate the personal internal skills necessary to help manage from within the organization. These skills help develop internal relationships to help the organization focus on organization efficiencies.
Communicating Change Domain: These focus on how communication is shared both within and external to the organization. With a myriad of external stakeholder requirements, there is a need to not only effectively plan and implement these requirements but manage and communicate so that the organization can be as effective as possible.
Clinical Compliance Domain: Internal processes to maintain practices that meet external stakeholder requirements, like documentation, clinical and financial standards. Additionally there can be opportunities to develop and implement new programs that increase the efficiencies/revenue to meet internal customer needs.
Managerial Tasks Domain: These are primary managerial tasks to organize and manage personnel that create a positive environment within the organization.
Dollars and Cents Domain: The domain demonstrates the requisite knowledge of finance and how to interpret and manage the cash necessary to meet financial obligations but also make a profit.
Ethics and Quality Domain: These factors focus on creating an environment where the actions of the employees are conducted in an ethical manner. Additionally focused on tasks that are not only completed within requirements but also strive to meet a quality measure in the delivery of care and program outcomes within the organization.
CONCLUSIONS AND RECOMMENDATIONS
Even though there have been a substantial amount of studies conducted on the knowledge, skills and abilities of hospital managers, this study further clarified and expanded the KSAs across a wider spectrum of supervisors, managers and executives. Additionally, the identification of seven interpretable factors has evolved which explained 61.5% of the variance in this study. These factors further define those KSA clusters that supervisors, managers, and executives identify as being most important for their success.
Those respondents that were employed earlier in their career focused on regulatory compliance and patient interaction than those later in their career. Those later in their career focused more on those factors that continued to contribute the organizational continuation. This could demonstrate the increased commitment to the organization and its continued success but further research would be required to confirm this perspective.
The gender findings are perplexing. Women rated organizational KSAs more important than men and the skills were focused on traditional managerial tasks. Women could possible no longer shy away from tasks/behaviors that have traditionally have been associated with male dominate virtues of strength and power in executive roles within healthcare organizations.
Therefore, a key factor to success with these respondents was longevity in the business and age of the respondents. The more successful hospital managers, not surprisingly are the seasoned veterans. This conclusion indicates that education may well be a key variable that can help lead younger managers to success more quickly. An appreciation of the fundamentals of basic strategic thinking and leadership development is crucial. This industry cannot wait for the years to pass for a manager to accrue the necessary skills to become successful given the pressures of the healthcare delivery for the U.S. population.
Healthcare education programs can use these results of this study to evaluate curriculum and address the key KSAs to prepare future executives to be effective and successful in managing in a healthcare environment. In addition, current board of directors of the healthcare organizations should use the results of this study in two ways. First, the KSAs identified as contributing to the success of the supervisors, managers, and executives should be used to evaluate potential candidates moving into this management role within the healthcare organization. Second, the board of directors should use these results to evaluate the level of competence of the current supervisors, managers, and executives to identify potential areas of strengths or gaps in the KSAs identified in this study.
Further opportunities for research, based on the results of this study, include the changes in healthcare delivery as a resulted of current changes in the laws from the federal government. There should be a focus to solicit perspectives from supervisors, managers, and executives under-represented by this study, to increase minority and multi-cultural representation. Additional study on the changes in the knowledge, skills, and abilities of future supervisors, managers, and executives appears to be warranted to address the needs of these changing healthcare demographics. In this current study, nearly 98% of the respondents were Caucasian, which suggests further research should evaluate any changes in the responses to the identified KSAs as the ethnic representation shifts over the next 5 to 20 years.
Validation of the newly identified domains, External Stakeholder Domain, Personal Ethos Domain, Communicating Change Domain, Clinical Compliance Domain, Managerial Tasks Domain, Dollars and Cents Domain and Ethics and Quality Domain should be conducted especially as it applies to other types of organizations. These domains may vary in importance based on the levels within the organizations or the types of organizations being studied.
Further expansion of the list of the key knowledge, skills, and abilities for supervisors, managers, and executives needs to be explored. One of the limitations identified was the finite list of KSAs and the potential for KSAs that are required to be successful yet not addressed in the current survey instrument. The survey instrument used in this study provided a comprehensive list of KSAs but the list was not exhaustive and further research to add to those already identified appears warranted.
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Michael Stowe, University of St. Francis
James Haefner, University of St. Francis
Robert J. Behling, University of St. Francis