Identifying and Assessing Competencies: A Strategy to ... - CiteSeerX

Identifying and Assessing Competencies: A Strategy to Improve Healthcare Leadership COMMENTARY

G. Ross Baker, PHD Professor, Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto Chair of the Association of University Programs in Health Administration (AUPHA)


ABSTRACT There appears to be a growing consensus that better leadership is needed in healthcare, although there is much less agreement on the specific knowledge and skills required to improve performance. This commentary suggests that the articulation of healthcare leadership and management competencies provides a framework and a language for identifying the leadership knowledge and skills required for highquality healthcare in the 21st century. performance. In this commentary I want to suggest that the articulation of healthcare leadership and management competencies provides a framework and a language for identifying the leadership knowledge and skills required for highquality healthcare in the 21st century. Efforts to identify and measure competencies serve needs at three levels: individual development, organizational improvement

Leatt and Porter outline some key directions for leadership development in healthcare. They identify the need to improve leadership, and their recommendations offer sound advice. Indeed, there appears to be a growing consensus that better leadership is needed in healthcare (like many other fields), although there is much less agreement on the specific knowledge and skills required to improve 49

HealthcarePapers Vol. 4 No. 1

as well as the capital assets and operating funds necessary to realize their goals. The successive waves of new challenges that wash across the healthcare industry create new demands on healthcare leaders. In the 1990s many healthcare organizations identified cost containment, integrated health systems and managed care as critical strategies. This focus has now broadened to encompass redesign of the healthcare system at all levels. The Institute of Medicine in its recent report Crossing the Quality Chasm (Institute of Medicine 2001) noted the need to provide care that was effective, patient-centred, timely, efficient and equitable, and assessed the current healthcare system as falling short of those goals. The IOM has argued that health professions education needs to be restructured to support the redesign of healthcare delivery by individuals, microsystems and organizations (Institute of Medicine 2003). Yet there are many competing demands on educators and disagreement on how much emphasis should be given to new topics and traditional materials. Identification of core competencies provides a means to identify the learning necessary to develop the skills and knowledge for effective practice. Better understanding of this knowledge and skills will assist in raising the performance of regional and national healthcare systems. Growing recognition of the potential leverage for change that comes from competency-based assessment and learning has spread quickly across healthcare. Several healthcare professional associations have developed lists of leadership and management competencies in the last decade. The Health Financial Management Association (HFMA), the

and health-system performance. A competency is an “underlying characteristic of an individual which is causally related to effective or superior performance in a job” (Spenser et al. 1996). Competencies are often used for recruitment and individual performance reviews. Job-related competencies can also be used to assess individual needs for development. Although research on competencies has a long history, the explicit application of a competency approach to executive recruitment and development is fairly recent but expanding rapidly (Briscoe and Hall 1999). Many leading organizations, including AT&T, Hewlett Packard and PriceWaterhouse, have used the development of executive competencies as a way to ensure superior performance by executives. On an organizational level, a competency framework can help to identify leadership skills and knowledge needed to achieve an organization’s strategic agenda. As organizations identify new strategic goals, they need to assess the knowledge and skills necessary to achieve those goals (Prahalad and Hamel 1990). For example, the development of integrated delivery systems in healthcare has demanded new knowledge and skills from clinical leaders and managers. Senior managers must reconceptualize the mission of the organization as enhancing the health of the population and consider how different network components contribute to that mission. These managers must develop facilitation and relationship skills to coordinate service delivery across the continuum (Longest 1998). Identifying these skills and knowledge and creating a plan to improve them ensures that organizations are investing in the human resources 50

Identifying and Assessing Competencies: A Strategy to Improve Healthcare Leadership

career stages. The competency model provides a conceptual chassis for educators, in universities, professional associations and elsewhere, in assessing learning needs and achievement. The competencies will be useful in designing educational programs, assessing the performance of individuals and cohorts and clarifying the needs of organizations for leadership knowledge and skills. The competency model will also be a valuable component in the redevelopment of the accreditation standards for health administration education. Thus, the model will serve needs at all three levels identified above: individual development, organizational improvement and health systems redesign. Most important, the competency framework provides a language for talking more precisely about leadership knowledge and skills. It offers a way to deepen current conversations about the specific knowledge and skills necessary for leaders at different career stages and in various roles and settings. Current conversations about leadership skills in healthcare include debates about the needs of current leaders (Do they understand how to improve quality of care? How to forecast costs?), the relative value of different university programs (Are MBAs better than MHAs?) and the usefulness of midand advanced-career development programs (Which programs provide the skills necessary to prepare the senior leaders for tomorrow? How do we know?). These questions about leadership skills are difficult to answer. Few evaluations are available; fewer still are based on objective criteria or yield comparable data. Degree programs, for example, are compared mostly on reputation, and skills of graduates from different degree streams are

Health Information and Management Systems Society (HIMSS), the American College of Medical Practice Executives (ACMPE) and the American College of Healthcare Executives (ACHE), among others, have developed competency frameworks for healthcare leaders. Competency frameworks have also been created in clinical disciplines, including a model of six general competencies that applies across medical specialties developed by the Accreditation Council for Graduate Medical Education (ACGME). More recently, the National Center for Healthcare Leadership (NCHL), a nonprofit association based in Chicago, has undertaken a project to identify competencies for healthcare leaders. The NCHL healthcare leadership competency framework was developed through a synthesis of the literature on leadership and management competencies in healthcare and related domains. Existing competency models were also reviewed, and their specific lists of knowledge and skills were included in this review (Vincent and Calhoun 2003; Calhoun et al. 2002). An expert panel of practitioners and academics guided this work; two surveys of practitioners and academics have provided an initial validation of the framework. The model includes six overarching competencies. Each of these core competencies will include a number of more specific skills, knowledge, attitudes and values. See Table 1 for a listing of the competencies along with some illustrative examples. The NCHL competency model provides a framework for a range of leadership activities, including the identification of necessary knowledge and skills at career-entry, mid-career and advanced51

HealthcarePapers Vol. 4 No. 1

Table 1: NCHL Healthcare Management Leadership Competency Framework, Version 1.1 Leadership Create and communicate a shared vision, champion solutions for organizational and community challenges and energize commitment to goals. Illustrations • Create and clearly communicate shared missions, visions and values • Effectively articulate, champion and implement well-conceived directions and strategies for a better future • Energize commitment, involvement and empowerment for addressing challenges and achieving goals • Foster the development and advancement of human capital and the organization at large • Use political skill and power to resolve conflict, manage resistance and improve relations among stakeholders • Recognize and promote diversity as a business imperative Collaboration and Communication Develop cooperative relationships and effective information exchanges within the organizations and the broader communities served. Illustrations • Use effective oral and written communication techniques • Employ effective group process management techniques • Ensure appropriate communications stewardship and management of constituent concerns, adverse events and other failures • Effectively use change, conflict and resistance management tools, as appropriate • Develop approaches to enhance teamwork and collaboration among clinicians and professionals Management Practice Identify, evaluate and implement strategies and processes designed to yield effective, efficient and high-quality customer-oriented healthcare. Illustrations • Design a functional organizational structure, reporting procedures and incentive strategy to fulfill missions, visions and goals • Manage committees and deliberative processes efficiently through the use of organization, time management and planning skills • Manage resource allocation processes effectively • Partner effectively with financial experts to manage all aspects of fiscal responsibility • Manage information resources to ensure the integrity and integration of management and clinical reporting systems and databases for clinical and operational decision-support Learning and Performance Improvement Continuously assess and improve the quality, safety and value of healthcare. Illustrations • Establish systems and processes to manage and continuously improve the quality of patient care • Utilize national benchmarks to identify opportunities for improvement • Use relevant and measurable results for improving organizational efficiency and effectiveness • Contribute to improvement in healthcare to reduce medical errors • Establish effective structures to improve the clinical effectiveness of healthcare • Use evidence and knowledge of best practices to improve care and services • Apply engineering principles to the redesign of care processes

52

Identifying and Assessing Competencies: A Strategy to Improve Healthcare Leadership

Professionalism Demonstrate ethics, values and professional practices; stimulate social accountability and community stewardship; and commit to personal and institutional development. Illustrations • Promote and adhere to high standards for personal and organizational integrity, honesty and respect for people • Embrace a sense of community and commitment to address the health needs of diverse populations • Adapt to new languages, cultures and attitudes about health and healing • Develop processes for reporting and maintaining social accountability • Value lifelong learning in order to develop professional knowledge and skills through continuous learning and education • Promote the development of professional roles and values that are compatible with the improvement of population and patient health Personal and Community Health Systems Integrate the needs of individuals with those of the community, optimizing opportunities to improve the health of the populations served within the context of the healthcare environment and policy. Illustrations • Use an integrative perspective to understand the healthcare organization within the larger context, including the community, nation and global environments • Understand the relative contributions and limitations of personal healthcare, public health community health and prevention in terms of the health of the community • Assess and respond to changing demographics, economic, political and epidemiological needs and demands of clientele and the community • Lead health sector change and effectively represent healthcare organizations in the local community and in various levels of government • Advocate reliance on scientific evidence and use it effectively to evaluate and change systems of care and health sector organizations

faculty to identify and assess the impact of different learning experiences on the development of knowledge and skills. Health administration programs in universities have long benefited from criteria-based reviews carried out by peers. Accreditation (for graduate programs) and certification (for undergraduate programs) has provided an assessment of the quality of these programs and directions for improvement. (Schools of business and public health also have accreditation processes.) However, the greatest growth in educational offerings in the last decade has occurred in continuing education.

rarely compared to each other. More important, the current questions focus only on asking which programs are better without addressing the more difficult questions: Better for whom? In what ways? If we had a clearer understanding of the relative advantages of different educational programs (e.g., MHA versus MBA), and the performance of different universities offering these programs, it would be much easier for students to identify where they want to enrol and much clearer to faculty where they need to improve. Identification of core competencies will be invaluable in helping both students and 53

HealthcarePapers Vol. 4 No. 1

the definition of specific skills and knowledge in each specialty. Thus, the leadership at ACGME has also encouraged residency programs to consider the scope and focus of their competency definitions as they evaluate their achievements. Ongoing dialogue on the experiences of program directors, faculty and residents in the identification of competencies, assessment of the learning experiences and improvements in residency education will help to improve the outcomes. This dialogue is aided by a series of meetings with program directors and the posting of examples from leading programs on the ACGME website and elsewhere (Batalden, Leach et al. 2002; ACGME 2003). Similarly, the development and testing of competencies for healthcare leaders will require careful and staged development of knowledge and tools over a number of years. The benefits heralded by the development of explicit statements of knowledge and skills, the clarification of what we expect from leaders at different levels of their careers, and from the educational programs that prepare them, are considerable. We need to ensure that these benefits are not undermined by poorly developed assessments and attempts to judge performance before the science is available to support these assessments. In the meanwhile, we should not view the process of developing new assessment tools and sharpening the language of leadership competencies as a necessary but unproductive delay. Instead, this period offers an opportunity for important and useful discussion and program development. Providing a language to talk about competencies will permit us to have useful conversations about leadership, its successes and failures, and to initiate useful pilot

These programs are highly marketed and often quite expensive. But little information (aside from the testimonials of selected participants) is offered to those interested in these programs, and few direct comparisons of program offerings are available. The development of a widely used competency framework provides an opportunity to assess the focus and perhaps the comparative performance of these programs in developing leadership knowledge and skills. Realistically, it will be many years before enough information is available to assess individual programs in terms of their impact on healthcare leadership competencies. The tools necessary to assess competencies are lacking or, at best, in the early stages of development. Assessment of competencies and the impact of learning experiences on competency development require valid test instruments, comparable data and careful analysis. Moreover, competency assessment will require a range of evaluations, including 360-degree feedback and project portfolios in addition to more traditional cognitive testing methods such as multiple-choice questions. Few of these tools are available now for wide-scale use. Their development will require an iterative process of design, pilot testing among different cohorts and improvement. The ACGME, for example, which accredits graduate medical residency programs in the United States, has launched an ambitious redesign of residency program evaluation based on six core competencies. But the development and evaluation of new assessment tools is planned to take place over a number of years. The improvement of assessment tools will provide useful information for sharpening 54

Identifying and Assessing Competencies: A Strategy to Improve Healthcare Leadership

possible to “mass-customize” leadership training, responding to specific needs while providing basic knowledge and skills? Second, we need to recognize that the educational and experiential needs of healthcare leaders will vary depending on the stage of their development. Hubert and Stuart Dreyfus (Dreyfus and Dreyfus 1986; Dreyfus 2001) have described the learning of new knowledge and skills as a progression through five stages, from novice to expert. This continuum has been applied to nursing students (Benner 1984) and to medical residents (Batalden, Leach et al. 2002). The skills and knowledge needed by healthcare leaders and the effectiveness of different approaches to learning will vary depending on the stage of leaders’ development. There is a third, more fundamental reason why we will not move quickly to consensus on a list of competencies for healthcare leadership. Healthcare is a complex field that creates problems that are often not easily reducible to simple subsidiary problems and that require an understanding of unique local conditions (Glouberman and Zimmerman 2002). When we say that healthcare is complex, we mean it exemplifies what some organizational writers describe as characteristics of a “complex adaptive system” (Stacey 1992; Anderson and McDaniel 2000; Plsek 2001). Such systems demonstrate moderate to high levels of interdependency between key actors, recurring uncertainty about what actions will yield positive results and a capacity to adapt to situations over time, thus altering the extent to which past solutions will fit current problems. Complex adaptive systems are often contrasted with simple or mechanistic systems. In mechanistic

projects and assess new approaches. But we must recognize that this dialogue will not lead immediately to clear and unambiguous decisions about the specific skills and knowledge needed by managers working in particular environments. There are several reasons for why the development of healthcare leadership competencies is likely to be a slow, deliberate process. Competency models have often been developed for technical fields where there is high consensus on the necessary work tasks and the work processes needed for successful outcomes are well understood. Healthcare leadership is not this simple. First of all, healthcare leadership is a very heterogeneous field. While traditional healthcare administration programs prepared leaders for senior positions in hospitals, today graduates assume posts in many different types of healthcare delivery organizations, plus government, consulting firms, pharmaceutical and supply groups, biotechnology enterprises, insurance organizations and many other organizations. While there are certain basic competencies that apply across the range of these endeavours, there are many specialized fields and roles. The implication for leadership development of such heterogeneity suggests that no one approach will satisfy all needs. One positive result of developing competencies will be a better understanding of how best to respond to this diversity of roles and needs. How do we create an effective educational enterprise that ensures that all graduates are competent in critical common skills, but also competent in the specific knowledge and skills necessary for their current or projected next positions? To what extent do educational programs need to specialize? Is it 55

HealthcarePapers Vol. 4 No. 1

the types of skills and knowledge that are necessary in complex adaptive systems. Anderson and McDaniel (2000) suggest that leaders in complex adaptive systems need to alter their leadership behaviours, focusing, for example, more on building relationships within and between organizations rather than defining roles narrowly. Successful leaders need to develop the capacity for diverse and flexible responses to changing environmental conditions rather than attempting to simplify organizational strategy (Brown and Eisenhardt 1998). Despite the widespread circulation of the “complex adaptive systems” approach by the Institute of Medicine committee, many have not accepted its implications. It is precisely this dialogue that will foster the development of leadership competencies. A validated set of competencies for a complex field like healthcare leadership is likely to be extensive. The review of the literature undertaken for the NCHL project identified several hundred discrete competencies (Vincent and Calhoun 2003). The “Guide to the Body of Knowledge for Medical Practice Management” created by the American College of Medical Practice Executives runs to more than 100 pages (ACMPE 2002). To be useful for individual development and recruitment, the critical skills and knowledge relevant to a specific position and appropriate career stage need to be identified. For example, the skills and knowledge needed by a risk manager in a community hospital or a chief information officer for a regional health system should be specified. Where individuals fall short of position requirements, a learning plan can be developed. In the long run, however, it is the

systems, cause and effect relationships are well understood, and there is a high level of consensus on what solutions are needed to address current problems. By contrast, complex systems, like healthcare, exhibit novel and non-linear behaviours; predictions about future behaviours in complex adaptive systems are difficult to make, and control is widely dispersed. Attempting to manage complex adaptive systems using traditional management techniques (more appropriate to simple problems) can be frustrating and counterproductive. Some experts have argued that if we understand the properties of complex adaptive systems such as healthcare, we can develop leaders who have the perceptions and skills necessary to create positive results. The Institute of Medicine report Crossing the Quality Chasm (Institute of Medicine 2001) identified a clear vision and a number of “simple rules” whose adherence might create a more effective and responsive system. These are tools for managers in complex adaptive systems. At the same time, however, more mechanistic solutions, such as the need for increased regulation or tighter control of professional training, and a variety of other solutions are heralded by others. This lack of consensus on next steps is one hallmark of a complex adaptive system that is approached with traditional management tools. If healthcare is a complex adaptive system, then some might view the idea of identifying the critical competencies of healthcare leadership as antithetical. How can we specify the necessary skills and knowledge for healthcare leaders if we are uncertain what solutions will work in different contexts? The answer to this puzzle requires that we consider further 56

Identifying and Assessing Competencies: A Strategy to Improve Healthcare Leadership

learning (in degree programs and advanced leadership courses) needs to be integrated with the experiences gained on the job. Experience must be linked to reflection and learning to ensure that success in solving problems translates into growing capabilities to work more effectively. One drawback to any competency framework is the temptation to reduce these frameworks to “To Do Lists” rather than use them as tools for learning and growth. We must learn how to integrate competency tools into strategies for individual and organizational development. There are major technical and conceptual challenges in developing and measuring competencies. But current efforts to define the skills and knowledge necessary for high-performance healthcare leadership offer an important lever to improve healthcare.

broader categories of competencies and the critical knowledge and skills distinguishing successful healthcare leaders that are the most important aspects of this work. Hall argues that there are a small number of “metacompetencies” that influence the ability to learn other knowledge and skills (Hall 1986; see also Briscoe and Hall 1999). Possible metacompetencies for individuals are “continuous learning” and “adaptability.” These characteristics influence the ability of leaders to become aware of new situations where new skills and knowledge are needed, to seek such knowledge personally, and to encourage others to do so. The articulation of competencies also provides a means to build consensus about current needs and future requirements. The six core competencies developed by the ACGME for medical residency education have been adopted by other medical specialty groups and provide a means to broadly improve medical education and practicum. Leatt and Porter join a growing chorus of influential voices in Canada and the United States who are raising concerns about healthcare leadership. But considerable uncertainty and disagreement exist about what skills and knowledge are needed for successful healthcare leaders. The development and use of a competency framework will advance our understanding about the critical skills and knowledge needed and the more effective ways of gaining this learning. Leadership development is a complex activity that depends in part on individual capabilities and motivation, the presence of a supportive work environment that offers meaningful opportunities to learn, and support in undertaking that learning. External

References ACGME. 2003. Outcomes Project. 2003. Chicago, IL: Accreditation Council for Graduate Medical Education. www.acgme.org/Outcome. Accessed May 20, 2003. ACMPE. 2002. “Guide to the Body of Knowledge for Medical Practice Management.” Englewood, CO: American College of Medical Practice Executives: 139. www.mgma.com/acmpe/ bokguide.cfm. Accessed May 21, 2003. Anderson, R.A. and R.R. McDaniel. 2000. “Managing Health Care Organizations: Where Professionalism Meets Complexity Science.” Health Care Management Review 25(1): 83–92. Batalden, P., D. Leach et al. 2002. “General Competencies and Accreditation in Graduate Medical Education.” Health Affairs 21(5): 103–11. Benner, P. 1984. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley. Briscoe, J.P. and D.T. Hall. 1999. “Grooming and Picking Leaders Using Competency Frameworks: Do They Work? An Alternative Approach and New Guidelines for Practice.” Organizational Dynamics 28(2): 37–52.

57

HealthcarePapers Vol. 4 No. 1

Brown, S.L. and K.M. Eisenhardt. 1998. Competing on the Edge. Boston, MA: Harvard Business School Press.

Institute of Medicine. 2003. Health Professions Education: A Bridge to Quality. Washington, DC: National Academy Press.

Calhoun, J.G., P.L. Davidson et al. (2002). “Toward an Understanding of Competency Identification and Assessment in Healthcare Management.” Quality Management in Health Care 11(1): 14–38.

Longest, B.B. 1998. “Managerial Competence at Senior Levels of Integrated Delivery Systems.” Journal of Healthcare Management 43(2): 115–35. Plsek, P. 2001. “Redesigning Health Care with Insights from the Science of Complex Adaptive Systems.” Crossing the Quality Chasm: A New Health System for the 21st Century. pp. 309–22. Washington, DC: National Academy Press.

Dreyfus, H. L. 2001. On the Internet. London: Routledge. Dreyfus, H.L. and S.E. Dreyfus. 1986. Mind over Machine: The Power of Human Intuitive Expertise in the Era of the Computer. New York: Free Press.

Prahalad, C.K. and G. Hamel. 1990. “The Core Competence of the Corporation.” Harvard Business Review 68(3): 79–91.

Glouberman, S. and B. Zimmerman. 2002. Complicated and Complex Systems: What Would Successful Reform of Medicare Look Like? Ottawa: Commission on the Future of Health Care in Canada.

Spencer, L.M., D.C. McClelland et al. 1996. Competency Assessment Methods: History and State of the Art. Boston, MA: Hay/McBer Research Press. Stacey, R. 1992. Managing the Unknowable. San Francisco: Jossey-Bass.

Hall, D.T. 1986. “Dilemmas in Linking Succession Planning to Individual Executive Learning.” Human Resource Management 25(2): 235–65.

Vincent, E.T. and J.G. Calhoun. 2003. Plan for Competency-Based Learning and Assessment in Healthcare Management Leadership. Chicago: National Center for Healthcare Leadership.

Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press.

What has the Academy of Canadian Executive Nurses ever done for you? Produced 15 years of best practices in nursing management, practice, education and research. But you have to subscribe – paper for individuals, virtual for organizations.

[ the Canadian Journal of Nursing Leadership is published for the Academy of Canadian Executive Nurses. Dorothy Pringle, Editor-in-Chief. Nursing programs at colleges and universities can receive this free of charge. ] For paper subscriptions contact Barbara Marshall at [email protected] For e-subscriptions contact Susan Hale at [email protected]

58