Workforce Feature
CSIRO PUBLISHING
www.publish.csiro.au/journals/ahr
Australian Health Review, 2010, 34, 52–58
Competencies required by senior health executives in New South Wales, 1990–1999 Zhanming Liang1,2 MBBS, MSc, PhD, Senior Lecturer Peter F. Howard1 MBBS, MSc, Adjunct Associate Proffessor 1 2
School of Public Health, La Trobe University, HSC 1–126, Bundoora, VIC 3086, Australia. Corresponding author. Email:
[email protected]
Abstract. It is accepted that health care reforms and restructuring lead to the change of the tasks and competencies required by senior health care managers. This paper examined the major tasks that senior health executives performed and the most essential competencies required in the NSW public health sector in the 1990s following the introduction of major structural reforms. Diverse changes, restructuring and reforms introduced and implemented in different health care sectors led to changes in the tasks performed by health care managers, and consequently changes in the competencies required. What is known about the topic? The literature confirms that health reform affects senior health care managers’ acquisition and demonstration of new skills and knowledge to meet new job demands. What does this paper add? This paper provides a detailed description of the competencies required for senior health care managers in New South Wales in the 1990s after the introduction of the area health management model, the senior executive service and performance agreements. It confirms that restructuring and reform in the health care sector will lead to changes of the tasks performed by health care managers and, consequently, changes in the competencies required. What are the implications for practitioners? The competencies required by health care managers are affected by distinct management levels, diverse health care sectors and different contexts in which health care systems operate. The competencies identified for senior health executives in this study could guide educational programs for senior health managers in the future.
Health care reforms and restructuring have been a global phenomenon since the early 1980s to produce better, more responsive and efficient systems.1–3 Reforms have been seen as not only inevitable, but also necessary. Due to the different contexts in which the health care systems operate, the content and the process of the reforms may vary in different countries or different parts of a country.4 However, Altenstetter and Bjorkman5 recognised that there has been some borrowing from one system by another. After an extensive study of the literature, Liang et al.4 summed up health care reforms around the world in the following three main areas: changes of conceptual and legislation frameworks, changes of health care financing and changes of health care provision and management frameworks (p. 285). In New South Wales, Australia, significant structural reform was introduced and implemented in the mid 1980s. Liang et al. provided a useful summary of the major changes witnessed in NSW since 1986, which included the introduction of the Area Health Management Model, the Senior Executive Service and performance agreements.6 Three major forces were behind the changes: the pattern of population redistribution, the inefficiency of a regionalised structure and public sector reforms. After critical analysis of the literature, Liang et al.4,6 suggested that health reforms have affected senior health care managers in a number of ways including high levels of burn-out and turnover, changes in Ó AHHA 2010
managers’ career paths and the introduction of new tasks, roles and competencies. They concluded that reforms have heralded a new era in management responsibility and accountability, which resulted in the change of competencies required for senior health care managers. No studies have been published examining the competencies required for senior health care managers in the NSW health public sector since the significant reforms implemented in the mid 1980s and 1990s. Studies examining the competencies required by senior health care managers since the mid 1980s used two competency assessment methods. The first was to provide an extensive list of competencies (knowledge/skills/attitudes) from which senior health care managers selected their choices.7–15 The other was to ask senior health care managers to express their perceived competencies freely.16,17 A number of studies18–22 were conducted with the intention of examining and establishing a list of reliable competencies or a competency assessment approach. Although sharing some similarities, the lists of competencies in these studies are diverse, not only in the number of competencies developed or identified, but also in the content of each competency. In addition, the lists of competencies developed by recent studies have not been replicated by other studies. Individual studies have tended to develop and use a competency list of their own. This may be due in part to the lack of well tested and recognised lists of competencies 10.1071/AH09571
0156-5788/10/010052
Managerial competencies required for health executives
or competency assessment models and, in part, due to the different levels of management and context being addressed by the various studies. At this point, a brief review of competency is needed. Manley and Garbett23 provide a definition from the nursing management literature: ‘Competency is a person’s underlying characteristics and qualities that lead to an effective and/or superior performance in a job’ (p. 349). Harris and Bleakley10 pointed out that ‘competency’ was used to describe managers’ expertise in the late 1980s and 1990s, replacing the previously accepted term ‘skill’ used to demonstrate the ability and capability of managers throughout the 1970s and early 1980s. Building on the definition of the National Training Board: ‘Competency comprises the specification of the knowledge and skills and the application of that knowledge and skills within an occupation or industry level to the standard of performance required in employment’24 (p. 364–5) and ‘the specification of the application of management knowledge and skills within an industry to the standard of performance required in employment given favourable environment and psychological circumstances’24 (p. 365). Similarly, Wright25 viewed competency as the minimum standard necessary to perform a job; knowledge, skills and abilities. In contrast, Goldstein26 defined competency as those skills, abilities and knowledge that contribute to over average or minimum performance. According to McLagan and Suhadolnick,27 competency is ‘an area of knowledge or skill that is critical for producing key outputs’ (p. 392). In addition, Hudak et al.28 believed that skills, knowledge and abilities were what were required to support the achievement of competencies. Shewchuk et al. stated that the definition of competency from previous studies was unclear.22 After summarising the definition from three papers,29–31 Shewchuk et al. accepted ‘competency’ as a cluster of related knowledge, skills and attitudes, which may optimise job performance, can be measured well against standards and can be improved by training and development.22 Although the interpretations of competency are diverse, competency was consistently seen as the skills, knowledge and attitudes required to perform a task or job. A list of competencies for senior health care managers was developed.7,10,11,16,19–22 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
Decision making Providing leadership Planning and evaluation Marketing and promoting Information management Responding to clients’ needs Human resource management Negotiation and conflict resolution Personal and interpersonal qualities Background knowledge and capability Coaching, mentoring and team building Evidence-based health care management Managing change and future development Financial management and resource allocation Public and industrial relations, liaising and networking
The purpose of this paper is to examine the competencies required by senior health executives (SHE) in the NSW public health care system between 1990 and 1999 specifically in the
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context of NSW Health within the public sector. This paper aims to contribute to the knowledge of the most important competencies required of SHE in the NSW public health care system between 1990 and 1999 and the application of research findings to management practice. Methods The first step of this competency assessment approach was to identify the major tasks on which SHE spent the majority of their working hours. Then the most important competencies (knowledge, skills and attitudes) required to perform each task at a satisfactory level were determined. The methods for the study were triangulated. Firstly, analyses of relevant government documents to develop a list of tasks for SHE were performed. These documents included industrial awards, position descriptions, position agreements, senior executive service agreements and annual reports for SHE positions in the NSW Health public system. Secondly, a survey by postal questionnaire was sent to SHE in the NSW Department of Health and Area Health Services between 1990 and 1999. Thirdly, in-depth telephone interviews were conducted. The study targeted the following four levels of SHE within NSW Health: * * * *
Director General; Deputy Directors General; Department of Health Division Directors; and Chief Executive Officers of an Area Health Service (rural and metropolitan).
Between 1990 and 1999, 79 senior health executives occupied positions in these categories. Of these, contact details were available for 60 (85%). Questionnaires were mailed to all managers to gather information on their demographic characteristics and employment status, and to seek their agreement to participate in a telephone interview. In addition, the four major tasks on which SHE spent majority of their working hours were identified. Questionnaires were returned by 29 SHE (48% response rate). In total, 22 of the 60 (37%) agreed to participate in an interview, and from these, 13 were randomly selected for interview. In-depth telephone interviews were then conducted in mid 2005 using open-ended questions. During the interview, participants were asked to identify and describe the key competencies needed for them to perform each of four major tasks. All interviews were tape-recorded and transcribed. Transcriptions were examined for accuracy, subjected to content analysis and sorted for their relevance to the research questions. All data were scrutinised for emerging patterns. The Griffith University Ethics Committee approved the research project. Results Major tasks for senior health executives From the 13 tasks (details in Box 1) provided to survey participants for consideration, the following four tasks were selected by a majority of the respondents: ‘leading staff and stakeholders’ was chosen by 90% of respondents; ‘organisational
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planning’ was chosen by 72% of respondents; ‘external relations’ was chosen by 72% and ‘monitoring and evaluation’ was chosen by 48% of respondents. Key competencies During the interviews, participants identified the most important competencies required to complete each of the four major tasks. As a result, a large number of skills, knowledge and attitudes were identified and classified into competencies. Four competencies were not mentioned by the interviewees: ‘managing change and future development’, ‘marketing and promoting’, ‘responding to clients’ needs’ and ‘evidence-based management’. However, two
new competencies were created to group those skills, knowledge and attitudes, which could not be incorporated into the 15 competencies. The two new competencies were ‘political skills and awareness’ and ‘survival skills’. Thus, the number of important competencies identified by SHE in NSW totalled 13, including the seven competencies viewed as extremely important (Box 2). In total, eight sub-groups of skills, knowledge and attitude were created under some of the competencies to reflect their importance (Box 2). The knowledge and skill areas under each competency are discussed below. Competency 1. Political skills and awareness
Box 1. Major tasks undertaken by senior health executives, New South Wales, 1990–1999, identified from questionnaire Tasks
*
*
*
*
*
*
*
*
*
*
*
*
Provide leadership to staff and stakeholders with clear vision and direction, including ensuring clear alignment between various levels of corporate goals, and lead the implementation of management strategies (In short: leading staff and stakeholders.) Determine organsation objectives, policies and programs and set standards and targets (In short: organisational planning) Maintain community and business relations, including consultative processes with the community, other health providers, area health professionals and stakeholders (In short: external relations.) Appraise the activities of the department, division or area according to strategies and objectives, and monitor and evaluate performance (In short: monitoring and evaluation) Deliver specific programs and projects within agreed financial and staffing resource levels Ensure that actions and policies of the agency accord with government direction and facilitate policy coordination and cohesion between government agencies Represent the department, division or area in negotiations, at conventions, seminars and official occasions, and liaise between areas of responsibility and with other organisations Provide the minister with frank advice that is relevant, accurate and timely Prepare or arrange the preparation of reports, budgets and forecasts and present them to the directly accountable officer Authorise funds to implement policies, programs and projects within agreed financial and staffing resource levels Ensure satisfactory introduction and operation of internal controls and reporting systems including internal audit Ensure that good employment and management principles and practices consisting of EEO (equal employment opportunity) and OH&S (occupational health and safety) principles operate within the department, division or area
Percentage of all participants 90
72
Overall, this competency was seen as important for performing the major tasks by all of the interviewees and was particularly important to task three (external relations). This competency theme includes knowledge, skills and attitudes (KSAs) relevant to the politics within the organisation, among the key stakeholders, and more significantly the ability to work with political parties and politicians. One interviewee highlighted that sometimes it meant being involved in balancing the public and political roles, such as hiding facts from the public for the benefit of the organisation, and avoiding further conflict. You need to know how to manage the local politician, the media is a highly political environment and people that are good at health care, the technical stuff is an added bonus, but it is not an essential criteria, you have to be a political animal to survive.
72
48
38
According to the interviewees, SHE work in a highly politicised environment where many people from various departments and institutions are involved. The ability of keeping the balance between different parties at the same time representing the interest of the Health Department is vital.
31 Box 2. Competencies viewed as extremely important by senior health executives, New South Wales, 1990–1999 Numbers 1–7 indicate those competencies viewed as very important
31
Competency 28
1 2
21 3 21
14
4 5 6
14 7
Political skills and awareness Personal and interpersonal quality Communication skills Ability in managing process Planning and evaluation Organisation and service planning, and development Policy development Monitoring, quality control and evaluation Leadership Background knowledge and capability Survival skills To be practical Flexibility and adaptability Public and industrial relations and networking Inclusive of other stakeholders
No. of participants 13 13 11 9 12 12 12 10 11 10 9 9 6 9 9
Managerial competencies required for health executives
Competency 2. Personal and interpersonal qualities All of the interviewees believed that this competency was important in performing the major tasks. More than half of the interviewees viewed these competencies as important to the performance of task one (leadership to staff and stakeholders), task two (organisational planning) and task three (public relations). This competency theme covers a wide range of KSAs: communication, presentation, demonstrating trust and respect to others, intellectual ability, problem solving, a sense of direction, ability in learning on the job and time management. The importance of communication skills, ability in managing processes, and self-awareness were recognised by more than half of the interviewees. A number of interviewees also recognised the importance of analytical skills. In addition, interviewees highlighted the importance of the ability to manage processes, including a monitoring system to obtain and interpret feedback. They interpreted self-awareness as being realistic about strengths and what could be done, having the confidence in what you were doing and having the ability in recognising your own limitations. Self-awareness also meant only making promises you could keep, ability in acknowledging failure and accepting changes to be made. Competency 3. Planning and evaluation This competency was mentioned as important by nearly all of the interviewees but not linked to a specific task. The KSAs under this theme can be grouped into the following three sub-themes ‘monitoring, quality control and evaluation’, ‘organisation and service planning’ and ‘policy development and planning’. They are related to organisation, system and policy areas, ranging from setting strategic directions and vision for organisations; organisation and policy planning; setting priorities, realistic goals and measurable objectives and achievable outcomes; identifying and meeting community needs; getting feedback; developing a control and monitoring system, and setting evaluation criteria and conducting systematic evaluation. The sub-competency of ‘monitoring, quality control and evaluation’ can relate to system, organisation and service levels. It is about getting feedback from others, having the ability to set operational targets and using appropriate measurement tools and efficient systems to monitor performance. The sub-competency of planning and development is related to both short and long-term development of the organisation and system. In terms of short-term planning, competencies required included priority and direction setting, and establishing realistic goals. The ability to define targets and timelines, set up measurable objectives and interpret and report outcomes were also important. In terms of long-term planning, skills included developing strategic vision and determining directions, planning skills, and the ability to design long-term objectives, priorities and indicators of achievement. The most important skill I required was to keep focussed strategically, to ensure what we did or how we managed and how I reported to the board was on the strategic outcomes. That was a mindset I had to keep and train the board. I also
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needed to get onboard a very good strategic planner and thinker who could articulate at a strategic level the types of things we wanted and we had to also craft them in what State Health required and then how we interpret that locally and then any local initiatives that we could put into our strategic planning direction. The sub-competency of policy development included the ability to match supply and demand, meet the needs of the community, and set priorities in addressing identified needs. SHE were also required to demonstrate the skills, knowledge and abilities in setting clear direction and realistic strategic goals for the organisation, monitoring progress, and to evaluate performance and provide feedback to the policy development process. Competency 4. Leadership Competencies related to the leadership role were also seen as important to the performance of the major tasks by nearly all of the interviewees, especially to leading staff and stakeholders. The KSAs included in this theme were ‘showing confidence to others such as staff and representatives from stakeholders’, ‘ability in leading’, ‘ability in motivating others and forming productive relationships’, ‘sharing visions with and giving directions to others’, ‘ability in influencing and engaging others’, ‘ability to build personal credibility’, ‘having a strong mind and being able to listen and empathise with people’ and ‘having the ability in keeping everybody working together in the same direction’. People competent in leadership are visible, well spoken and know how to maintain progress. Being able to gain trust from others was also mentioned by a number of interviewees: It’s very similar to the leadership thing, you had to be upfront and be able to articulate well and be convincing, be transparent about it, and I guess the thing is it had to be implemented quickly because the world went on around you, you couldn’t just stop and take your time. Competencies in leadership have been frequently linked to the ability to engage others and encourage teamwork. The ability of a good administrator is to weld the skills of the people underneath him or her to reach the objectives that you want. To do that, you have to be a key player. You have to be a person who is respected by the people underneath you. You have to give them authority to do the job, give them a pat on the back when they’ve done a good job and if they are having difficulties, they should be able to talk to you about that and how to proceed forward. Competent leaders are not only able to perform their job at a satisfactory level, but also have the ability to identify the right people for the work, to delegate the right job to the right people, and to motivate and encourage others to perform their job to a satisfactory level to achieve the same organisational or service goals. Competency 5. Background knowledge and capability This competency was also seen as important for the major tasks by the majority of the interviewees, especially leadership to staff and
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stakeholders and organisation planning. The background knowledge and competence refer to the knowledge in health care and its history; the context in which health care is being provided; knowledge of the community and its diversity; knowledge in organisational history and development, and knowledge of various models of running the system. Senior health executives should also have working knowledge and ability in drawing on historical analogies, and running the system. Having an understanding on the socioeconomic issues was also seen as important by some interviewees. To perform tasks on a satisfactory level, SHE are required to have comprehensive understanding of the historical development of the health care system. A few interviewees also pointed out that they were required to possess the knowledge when they were offered the position, and were responsible for helping their staff understand the health care system. Competency 6. Survival skills Knowledge, skills and attitudes grouped into this new competency were viewed as important by more than half of the interviewees, especially for organisation planning. The KSAs under the sub-competency of ‘to be practical’ mainly referred to the ‘ability of bringing and transferring knowledge, experiences and expertise into practice and the job’, ‘the ability in translating visions, plans and board statements into practice’, ‘the ability to work with limited resources and at the same time achieving organisational goals and objectives’ and ‘the ability to translate knowledge and expertise into what the community wanted or needed’. The KSAs under the sub-competency of flexibility and adaptability are mainly related to ‘the ability to modify plans and processes to meet the changing needs of the system’, ‘ability in recognising limitations and accepting inability in achieving the outcomes as planned’, ‘ability in responding and adapting to change’, ‘the ability to adapt to changing roles’, ‘having the ability to survive in a demanding and complex environment and working with uncertainty and ambiguity’ and ‘the ability to enjoy the work and face the challenges’. To be flexible and adaptable also means ‘having the ability to accept different views’, ‘recognise the limitations of others’, ‘have tolerance for what people can achieve and accepting being unable to achieve the best outcomes’, ‘being able to adapt to the political role thus keeping the balance between representing the government of the day and working towards meeting community needs’. In addition, interviewees mentioned the importance of having the ability to work with challenging community groups and stakeholders and dealing with criticism. You must be of really strong mind to deal with conflicting issues. That’s a key criteria, is your ability to survive and if you live in the community and have family, they will ostracise you in a split second. The kids get worked over at school, your wife can’t get a job, the GP won’t see you if you are sick. A number of interviewees also pointed out the importance of being able to have fun on the job. An important skill is you have to learn how to enjoy it. I say this very seriously, in my view, an absolute critical things
Z. Liang and P. F. Howard
about leadership . . . is to try and make the job fun for people around you by actually creating a social environment in the place that’s conducive to people enjoying being there and supporting each other . . . otherwise it won’t be enjoyable and instead of being a constructive group, they will become destructive. When you stop having fun, it’s time to leave an organisation. SHE were required to manage and lead the changes within the health care system. Therefore, they were required to possess and demonstrate knowledge and skills in leading these processes, and to achieve success in the continuously changing and challenging environment. Among all the knowledge and skills required, being practical, flexible and adaptable was viewed as extremely important. Competency 7. Public and industrial relations and networking This competency was also mentioned by more than half of the interviewees as necessary for performing the major tasks, especially for task three (external relations). The KSAs grouped in this competency ranged from ‘visibility and contactability by staff and stakeholders’, ‘the ability to form trusting and productive relationships with stakeholders’, ‘the ability to work with different groups and different government departments on issues’, ‘the ability to form a supportive external network’, ‘to work with the media’, and ‘to develop appropriate approaches of dealing with criticism externally’ and ‘having an appreciation of human dynamics’. The KSAs in involving and including other people in their work were highly regarded by the interviewees. Therefore, the sub-group of ‘inclusive of others’ has been created to reinforce its importance including the following skills and abilities: ‘ability in sharing information with others and giving feedback’, ‘ability in seeking inputs and support from others’, and the ‘ability in conducting consultations with the community and stakeholders’. Interviewees pointed out that it was important to be able to engage people and share a vision with them. . . .really being able to engage people verbally and being able to manage the media effectively so that you would be able to market your goods effectively, to be able to speak competently to a whole range of stakeholders, translate the vision to them so they might come on board in terms of fundraising, etc. . . . whatever process you put into place, you have to ensure that process will deliver on what you actually said you were going to do. The SHE were required to work with a large number of people from various backgrounds to achieve the best possible outcome. Most of the time, they had to rely on others to complete tasks and progress. Therefore, the cooperation and involvement of others was vital for achieving success. Discussion Tasks versus competencies This study has identified the tasks and competencies required for SHE in the NSW public health care system between 1990 and 1999. Both the questionnaire survey and telephone interviews
Managerial competencies required for health executives
confirmed the four major tasks that senior health executives of the NSW health public sector had to perform between 1990 and 1999. By examining the important competencies required for performing each of the major tasks (Box 3), seven essential competencies were identified. The interviews also allowed the collection of detailed descriptions of the knowledge, skills and attitudes that constituted each of the competencies. Another six competencies were viewed by interviewees as important for their major tasks: ‘coaching, mentoring and team building’, ‘decision making’, ‘financial management and resource allocation’, ‘human resource management’, ‘information management’ and ‘negotiation and conflict resolution’. Among these six competencies, decision making was selected by nearly half of the interviewees. Interestingly, all of these six competencies were seen as important competencies required by senior health care managers in studies carried out in the 1990s and early 2000s.10,11,19,21,22,32–34 Although these six competencies were selected by less than half of the interviewees in this study, they should not be overlooked. They may not be vital to the performance of SHE major tasks, but may be important in performing other necessary tasks, especially by SHE from different health care contexts and at different management levels. Decision making is a case in point. Whilst it is beyond the scope of this paper for a detailed discussion, the current developing trend of using ‘evidence’ as a basis for making decisions in health service management was not common practice during the decade of this study. The application of the findings from the current study to educational design Findings from the current study can be used to guide the development of both degree and non-degree educational programs for future senior health care managers, taking into consideration three key factors. Firstly, the sample for this study may be different from those for whom the educational programs are designed. Competencies for health care managers are associated with the seniority of the management level.21,35,36 Secondly, the health care sector and the contexts from which the target populations were selected were diverse. Competencies
Box 3. Major tasks and competencies for senior health care managers in NSW, 1990–1999 Major tasks to perform
Key competencies required
Leading staff and stakeholders
Personal and interpersonal qualities Leadership Background knowledge and competence Political skills and awareness Personal and interpersonal qualities Planning and evaluation Background knowledge and competence Survival skills Personal and interpersonal qualities Political skills and awareness Public/industrial relations, liaising and networking Planning and evaluation
Organisational planning
External relations
Monitoring and evaluation
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for health care managers are also relevant to the particular sectors and health care context.21,27 Thirdly, health systems worldwide have been experiencing constant and rapid change.1–3 Although, there are borrowing of changes among different health care systems and sectors, restructuring and reform in a particular sector or system are often unique.5 The variety of reforms across different health care systems will lead to diversity in the roles and responsibilities of senior health care managers.3,34–42 Therefore, the competencies required by senior health care managers will vary accordingly. Conclusion We have presented and discussed the four major tasks and the seven most important competencies required by SHE in the NSW public health sector between 1990 and 1999. Among the most important competencies identified, differences and similarities have been found with previous studies. It concludes that competencies required by health care managers vary because of the numerous management levels, different health care sectors and diverse contexts in which health care systems operate. The varied restructuring and reforms introduced and implemented in different health care sectors will also lead to changes of the tasks performed by health care managers and consequently, changes in the competencies required. The most important competencies identified for SHE in this study could be used to guide the modification or redesign of educational programs for senior health managers in the future. However, it is essential to take into consideration the context in which the health care systems or organisations operate and the types of reform/restructuring/change being implemented. In addition, the list of competencies established and the competency assessment model developed can be used by future studies to assess the most important competencies required by health care managers from different management levels and from different health care contexts. Competing interests The authors declare that they have no competing interests. Acknowledgements We thank all the people who participated in both the questionnaire survey and telephone interviews, and the invaluable support from Australian College of Health Service Executives (ACHSE), in particular, Mr. Bill Lawrence, former National Director of the ACHSE. We acknowledge the contributions from Prof Stephanie Short and Dr Claire Brown of the School of Public Health, Griffith University during the study design and the data collection and analysis phases.
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Manuscript received 19 August 2007, accepted 2 March 2009
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