4.1 Leadership Models, Processes, and Practices

Abstract

There are many aspects to effective leaders. Several have been identified by Lowder

• 1. Personal effectiveness dimension. Successful leaders certain personal characteristics that trustworthiness, a strong moral compass, intellectual fortitude and optimism. They tend to be self-motivated, goal-oriented and work towards self-improvement. They manage time effectively and set priorities for important issues.

• 2. Interpersonal relationship effectiveness dimension. To make peace among other workers, leaders must embody trust, compassion, empathy, fairness and objectivity. They encourage, guide and motivate. People with these attributes are often perceived as charismatic and influential. In any charismatic leader, there is always a potential to pursue self-interest at the cost of the organization.

• 3. Managerial effectiveness dimension. The leader exudes team spirit, improves the productivity of other people, delegates authority, empowers others, communicates with candor, seeks organizational improvement, and emulates high organizational values.

• 4. Operational effectiveness dimension. The leader is an expert in relationship building, understands customer needs, propagates the organizational vision and mission, promotes organizational stability, and maintains customer satisfaction. Using these tools, he improves numerical measures like net profit, return on investment, earnings per share, etc.

• 5. Societal effectiveness dimension. The leader (or the organization) positively impacts the environment, communities, governments, suppliers, or consumers through community involvement, public relations and environmental stewardship.

4.1.1 Dimensions of Effective Leadership

There are many aspects to effective leaders. Several have been identified by Lowder¹

• 1. Personal effectiveness dimension. Successful leaders have certain personal characteristics such as trustworthiness, a strong moral compass, intellectual fortitude and optimism. They tend to be self-motivated, goal-oriented and work towards self-improvement. They manage time effectively and set priorities for important issues.

• 2. Interpersonal relationship effectiveness dimension. To make peace among other workers, leaders must embody trust, compassion, empathy, fairness and objectivity. They encourage, guide and motivate. People with these attributes are often perceived as charismatic and influential. In any charismatic leader, there is always a potential to pursue self-interest at the cost of the organization.

• 3. Managerial effectiveness dimension. The leader exudes team spirit, improves the productivity of other people, delegates authority, empowers others, communicates with candor, seeks organizational improvement, and emulates high organizational values.

• 4. Operational effectiveness dimension. The leader is an expert in relationship building, understands customer needs, propagates the organizational vision and mission, promotes organizational stability, and maintains customer satisfaction. Using these tools, he improves numerical measures like net profit, return on investment, earnings per share, etc.

• 5. Societal effectiveness dimension. The leader (or the organization) positively impacts the environment, communities, governments, suppliers, or consumers through community involvement, public relations and environmental stewardship.

Barsch et al. list five dimensions of “centered leadership”:²

• 1. Meaning: finding strengths and putting them to work in the service of a purpose that inspires.

• 2. Positive framing (or optimism): adopting a more constructive way to view your world and convert even difficult situations into opportunities.

• 3. Connecting: building a stronger sense of community.

• 4. Engaging: pursuing opportunities disguised by risk

• 5. Energizing: practicing ways to sustain your energy on a long leadership journey.

Much distinction is made between the manager and the leader. In general, managers are appointed in an organization and have people who work for them on a transactional basis. For example, if the subordinate works for 40 h, the manager will pay him a salary. Leaders, on the other hand, don’t have subordinates, and may occupy no official office in their organization. Rather, they inspire followers with promises of transformation (i.e. follow me to a brighter future). Managers tend to seek a stable environment and are focused on getting work done. Leaders are often risk-takers and focus on people.

The following table shows some of the differences between managers and leaders.³

Subject	Leader	Manager
Essence	Change	Stability
Focus	Leading people	Managing work
Have	Followers	Subordinates
Horizon	Long-term	Short-term
Seeks	Vision	Objectives
Approach	Sets direction	Plans detail
Decision	Facilitates	Makes
Power	Personal charisma	Formal authority
Appeal to	Heart	Head
Energy	Passion	Control
Culture	Shapes	Enacts
Dynamic	Proactive	Reactive
Persuasion	Sell	Tell
Style	Transformational	Transactional
Exchange	Excitement for work	Money for work
Likes	Striving	Action
Wants	Achievement	Results
Risk	Takes	Minimizes
Rules	Breaks	Makes
Conflict	Uses	Avoids
Direction	New roads	Existing roads
Truth	Seeks	Establishes
Concern	What is right	Being right
Credit	Gives	Takes
Blame	Takes	Blames

Leadership Models

There are many leadership models with varying degrees of academic basis. The Great Man Theory , proposed in the 1840s for example, believed that great leaders were born, not made.⁴ The Trait Theory listed certain traits (e.g. assertiveness, dependability, persistence, adaptability, etc.) which were correlated with great leaders. Most of these traits were considered innate, though some skills (such as being knowledgeable, tactful, or organized) could be learned.

Blake and Moulton proposed the leadership/managerial grid to describe four types of leaders based on their concern for results and people.

• 1. The authoritarian (or autocratic) leader is concerned with results, but not with people. He issues edicts and expects them to be followed. He does not tolerate negotiation or collaboration.

• 2. The country club manager is concerned with people but not with results. He is affable and political and people like working with him. He is not the most effective leader.

• 3. The impoverished (or laissez-faire) manager has no interest in either people or results. He allows his teams to work without guidance or punishment.

• 4. According to the authors, the best kind of manager is the team leader, who has concern for both people and results. He inspires confidence and people want to work harder because they are inspired by his motivation.

Situational Leadership

The Situational Leadership^® Model , developed by Paul Hersey and Ken Blanchard states that different tasks and different people require different kinds of leadership. They list four degrees of Performance Readiness (or Maturity):

• 1. M1—(lowest maturity) lack skills to perform the job at hand

• 2. M2—willing to work at the task, novice and enthusiastic

• 3. M3—experienced, but lack confidence to take responsibility

• 4. M4—mature, willing to do the task and take responsibility for it.

These maturity levels roughly correlate with four levels of supervision

• 1. S1—Directing; the manager tells the subordinate exactly how to do the task

• 2. S2—Coaching; the manager is providing direction but is working with the subordinate on the task

• 3. S3—Supporting; the manager and subordinate employ shared decision making

• 4. S4—Delegating; the manager is still involved in monitoring the process, but the subordinate makes most of the decisions.

4.1.2 Governance (e.g., Processes; Responsibility Versus Authority)

Governance is the way the rules, norms and actions in an organization are structured, sustained, regulated and enforced. This is distinct from process governance, which is the use of rules to manage programs and initiatives in order to optimize business process and to make workflow more efficient. For more information on governance of health information systems, see Sect. 3.5.1)

Authority is the power to give orders and have them obeyed; the power to make decisions. Responsibility is being accountable for an obligation, trust or debt, such as the obligation to complete an assignment.

Authority and responsibility operate hand in hand. Having responsibility without authority leaves a person incapable of finishing the work because he lacks the ability to make others work with him or to utilize resources. Having authority without responsibility is equally problematic, as it leads a person to make decisions that affect others without taking into account the impact on the project.

Governance requires structure. In most American corporations, the board of directors are elected by shareholders and hold fiduciary responsibility for the organization.⁵ They select the Chief Executive Officer (CEO) and often other members of the management team. The organization will also have divisions based on regions or function, each with their own hierarchy answering to different members of the management team. In addition, there may be various committees which are drawn from across the organization and empowered to manage certain aspects of the business.

Governance should include fixed policies and procedures which are fair and predictable, the governing body for should include important stakeholders as well as members of the executive team. Including representatives from many different disciplines enables the body to understand problems from different angles. Some of the values of good governance include:

• 1. Standardizing the process of decision making helps establish expectations for all stakeholders. This can be especially important in large organizations with many different departments.

• 2. Decisions that are made according to a fair process have greater legitimacy than those that are made arbitrarily or capriciously. Employees are much more likely to respect a process that has internal and external consistency.

• 3. Governance has the ability to align decisions with the organization’s mission and vision.

• 4. When all large purchases are passed through a single body, there is a much smaller likelihood of duplication. For example, two departments simultaneously recognize the need for a specific technology. Instead of allowing both departments to purchase it independently, they create a system where they can share it.

• 5. Workers are much more likely to invest their time and energy into an organization when they perceive it as predictable and fair.

4.1.3 Negotiation

Negotiation is a dialogue between two or more parties intended to reach a mutually beneficial outcome or to resolve a conflict. Negotiation is a skill, and seasoned negotiators tend to fare better than new ones. It has been said that the object of negotiation is to show the other party a way to solve its problem by doing things your way.

Negotiation is not always successful, and when the parties are unwilling to agree, there are several further options: mediation, arbitration and finally, litigation.

Mediation is when an independent third party is brought in to help find a resolution. Often, the mediator will suggest a resolution. Ultimately, however, both sides must agree to the proposed solution. Arbitration involves hiring a third party to effectively act as a judge and dictate a solution to the problem. In binding arbitration, both sides agree, a priori, to follow the decision of the arbitrator. Litigation involves using the traditional court system to resolve the matter. Arbitration and mediation are desirable because they tend to be significantly less expensive than litigation. Collectively, any solution that avoids expensive litigation is called alternative dispute resolution.

Distributive Bargaining and Integrative Bargaining

There are two common forms of negotiation: distributive bargaining and integrative bargaining. Distributive bargaining (also called zero-sum ) is encountered when there are a fixed number of resources that are to be divided among participants. There is no expectation of a further relationship. For example, when purchasing a car, the buyer wants to keep as much money as he can, while the seller wants to collect as much money as he can. In integrative bargaining (also called win-win ), the parties are building a lasting relationship and have to make sure that both sides will thrive under the new agreement. An example of integrative bargaining, is hiring a new employee and deciding on compensation, benefits, work expectations, etc. One way to think about the difference between distributive and integrative negotiations is that distributive negotiation is about how to fairly cut up a pie for all to share, while integrative negotiation seeks to enlarge the pie so that everyone comes out with more.

Techniques for effective bargaining

There are many techniques which can enhance a negotiator’s position:

• 1. Research the opposition. It is very important to know what resources the opposition brings to the table. Asking for things that they can not provide will not bring about a successful negotiation. Perhaps more importantly, knowing the opposition’s wants and needs enables the negotiator to develop more effective strategies. Asking open-ended questions during the negotiation can help. When doctors negotiate with patients, this is a very effective means of figuring out not only the medical issue, but also the social ramifications and the patient’s emotional context.

• 2. Research the alternatives. Before initiating a negotiation, know the fallback options. This is often called BATNA (Best Alternative To a Negotiated Agreement). In salary negotiations, the BATNA may be an offer from another employer. For a patient selecting treatment options, the BATNA may be watchful waiting.

• 3. Nearly everything is negotiable separately. When one party offers a package deal, it need not be accepted as a whole. Unbundling various parts can make for a more equitable agreement. For example, in a salary negotiation, the salary itself may be fixed by an institutional rule, but the employer may be willing to pay for other benefits, such as medical staff dues, moving expenses, computers and continuing medical education.

• 4. Know the range. Identify each of the issues which are important and set minimum, optimum and target goals for each. The optimum is the best deal one could reasonably expect. The minimum is the lowest acceptable level before selecting the BATNA. Target is somewhere in the middle and represents the expected endpoint for the negotiation.

• 5. Identify the leverage points. Knowing the opposition’s needs and desires is important as it can help the negotiator prioritize his offers. Similarly, it is important to know what items are of lesser value to the negotiator himself, as these can be easily given up in trade for items that are more valuable.

• 6. Only negotiate with the decisionmaker. A classic dodge in negotiation is for one party to make an appeal to a higher authority. (e.g., “this offer sounds good, but I have to ask my wife”) This tactic effectively stalls the negotiation. Before starting the dialog, ensure that the person capable of making the decision is at the table.

• 7. Start with common ground. The experienced negotiator begins the discussion with items that are already mutually agreed upon. By doing this, the negotiator has built trust and the opposition has gotten comfortable saying yes. This makes it much easier to find agreement when more contentious items are raised.

• 8. Don’t ignore the hard points. The goal of negotiation is to find a complete solution. Some aspects may be painful to mention, but if they are not addressed up front, they will be much harder to rectify later.

• 9. Bring data to the table. Nothing argues a point as well as independently verified evidence. This may take the form of scientific literature, comparable real-estate sale prices, national salary surveys, etc.

• 10. Separate problems from solutions. Discussion of potential problems needs to be complete before searching for suitable solutions. Failure to fully understand the problems at hand may lead to a premature agreement which must be later revised.

• 11. Do not compare external offers at the negotiating table. Regardless of how many competing offers are available, the current deal is the only one that can be negotiated right now. It must be accepted or rejected on its own. If it is rejected, both parties must resort to their BATNA.

• 12. Delayed gratification. In most cases, it is preferable to defer a reward until a later date rather than give it up entirely. For example, while negotiating with an insurer, a physician is offered $6.45 per RVU, even though his target was $7.00 per RVU. Instead of ceding the point, he agrees to $6.45 for the current year with an automatic raise to $7.15 for the second year. In this way, he shows confidence that the relationship will be successful.

• 13. Create a win-win. Another possible solution the previous scenario is that the physician agrees to $6.45 with a bonus of up to $1.00 if certain productivity thresholds are met. In that way, when the physician benefits, the insurer benefits as well. This is called a win-win situation, and is the most effective type of negotiation.

4.1.4 Conflict Management

Conflict is inevitable in any organization, but not all conflict is bad. Sometimes, conflict can be used to discover shortcomings, inspire teamwork and generate novel approaches to problems. Conflict resolution aims to end conflicts completely, while conflict management attempts to preserve the positive aspects of conflict while minimizing the negative ones.

Positive conflict encourages employee interaction. Managers who identify positive conflict should encourage it.

• 1. Competition can often be a positive force in the workplace. Consider a pharmaceutical company where two sales representatives vie with each other to be the lead seller. Managers should beware that too much competition may have undesirable results, such as cheating, cutting quality or frustrating a section of the workforce who are not as successful.

• 2. Conflict can spur creativity as employees seek new answers to problems. As these solutions become established, overall productivity for the group increases (Fig. 11-1).

FIGURE 11-1

Productivity declines with conflict and returns after resolution

Negative conflict is, unfortunately, more familiar to most of us than positive conflict.

• 1. Personal conflict results from issues entirely unrelated to the workplace and may have roots in personal dissatisfaction, emotional problems or substance abuse. Managers must attempt to intervene as soon as possible to ensure productivity of other workers. Human Resources may be involved in remediation. When personal conflict becomes severe, it may result in mobbing, bullying or harassment, which are punishable under state and federal law.

• 2. Discrimination exists when selected populations of workers experience unjust treatment based on biological or social differences unrelated to their work capacity. For example, a group of nurses from a particular country believe that they are given work schedules that are less desirable than those of their colleagues. To resolve this issue, a manager could objectively review all the work schedules to ensure fairness. If he finds significant anomalies, he would have to change the method by which schedules are assigned.

• 3. Performance Review can generate conflicts when workers receive ratings below their expectations. If not addressed, this can lead to resentment and (paradoxically) worsening productivity. One way to remedy this is for the manager to provide the worker with specific instructions on how to improve performance.

• 4. Conflicts with customers and patients. Medical providers often have disagreements with patients when their expectations are not met. This may be due to inattention on the part of the provider or lack of understanding on the part of the patient or family, or some combination of both. The Joint Commission demands that a rigorous and impartial system be used for patient complaints. By assuring both sides that their treatment is fair and unbiased, most conflicts can be resolved.

• 5. Leadership disputes. Conflict often exists between managers and subordinates, particularly in terms of tactical decisions. A common healthcare example arises when a physician places an order but a nurse feels that it is unsafe or not in line with institutional policy. Sometimes, this can be resolved by having both parties sit down and learn what each other’s motivations are. More likely than not, once each understands the other’s concerns, a favorable solution can be found (Fig. 11-2).

FIGURE 11-2

Graphic of Pruitt’s model of conflict management where degree of assertiveness and cooperativeness determine the style of management (Yielding, Problem Solving, Inaction and Contending). Rahim and Thomas use similar ideas with different nomenclature, as noted with (R) and (T), respectively

Approaches to Conflict Management

Pruitt⁶ classified approaches to conflict management based on two dimensions: Assertiveness (pursuit of a solution benefiting me) and Cooperativeness (pursuit of a solution benefiting all). See Fig. 11-1. By creating a 2 × 2 table, he is able to classify different styles of conflict management.

• 1. Inaction is a result of people who have low assertiveness and low cooperativeness. They are unconcerned with how the outcome affects either themselves or the other party.

• 2. When one party is highly assertive but not cooperative, they pursue their own victory and are called contending.

• 3. The opposite end of the spectrum is the Yielding type who wants to find a solution—any solution—and is willing to give up his own needs.

• 4. When parties have both characteristics, they are called Problem Solvers and are most likely to find a mutually beneficial solution.

A similar model, by DeChurch and Marks⁷ used activeness (how direct the participants are) and agreeableness (how nice people are) to classify conflicting parties. When studied, they found that activeness had minimal effect on ultimate resolution of the conflict, while agreeableness had a positive impact⁸.

Rahim⁹ suggested five different management approaches, which are very similar to Pruitt’s: integrating, obliging, dominating, avoiding and compromising.

• 1. Integrating: studying differences, exchanging viewpoints and seeking alternatives in order to find a mutually beneficial solution (i.e. Problem Solving)

• 2. Obliging: minimizing differences in order to appease the other party (i.e. Yielding)

• 3. Dominating: pursuing a solution that benefits one side at the cost of the other (i.e. Contending)

• 4. Avoiding: trying to find an answer that ignores the needs of both parties, especially by pretending the problem doesn’t exist. (i.e. Inaction)

• 5. Compromising: similar to problem solving, where each party gives up something to achieve peace.

Thomas and Kilmann¹⁰ have also proposed five styles of conflict resolution which are also quite similar to those of Rahim and Pruitt. Their nomenclature is: Competing, Compromising, Collaborating, Avoiding and Accommodating. These names are summarized in Table 11-1.

Table 11-1 Approaches to conflict management with terms used by Pruitt, Rahim and Thomas

4.1.5 Collaboration

Collaboration is the process of two or more parties working in a coordinated fashion in order to achieve some purpose. A similar term is cooperation , however collaboration connotes some form of leadership and coordination of efforts and is more disciplined. For example, two authors collaborate to produce a scientific study, while their kids cooperate to clean up the back yard.

Collaboration is an attempt to create a whole that is greater than the sum of its parts. By bringing together the competencies, experience and judgment of a variety of professionals with different skill sets, multidisciplinary teams are able to outperform their more homogenous rivals.

Determinants of successful collaboration have been classified as systemic factors (conditions outside the organization), organizational factors (conditions within the organization) and interactional factors (interpersonal relationships between team members).¹¹

Systemic determinants include differences in power among members of the group, such as the differing roles between physicians and nurses. For physicians, professional development is characterized by the acquisition of authority, responsibility and autonomy, rather than collegiality and trust. Collaboration, however, relies on the mutual recognition by professionals of their interdependence as well as the acceptance of areas where their competencies overlap. When physicians act territorially, the result is fragmented care.

Organizational factors are determined by the organizational structure. One of the most important conditions for meaningful collaboration is establishing time and space for interaction. For example, in many community hospitals, physicians act dyssynchronously with the rest of the care team. Doctors come to the hospital at their convenience, round on their patients, enter orders, request consultations and return to their busy practices, often without directly interacting with other professionals. In academic hospitals, the organizational structure demands greater collaboration. Rounds are usually at a fixed time and there is an expectation that all resident and attending physicians will be present. In yet more collaborative environments, rounds are made with physicians, nurses, social workers, case managers and a host of other ancillary services. This degree of planning fosters better collaboration

Interactional determinants include the individual’s desire to collaborate, trust, communicate with and respect other team members. Of these, trust seems to be the most important factor, as the other aspects will usually fall into place once trust is established. Physicians often devalue the time they spend communicating with other professionals. As a result, the respect is eroded and trust is never formed. When physicians realize that better outcomes are had through effective collaboration, they make time to communicate, which in turn generates trust and respect.

4.1.6 Motivation

• Olivia Dudley 

Motivation is defined as a combination of external and internal factors that stimulate incentive and desire in people to work hard on refining their role either individually or as part of a team. Motivation is also key in inspiring an individual toward achieving a goal. Teamwork has the potential to take individual based motivation and apply it to a collaborative group. If all individuals of a team are motivated, then their collective work will be greater than a single individual’s work alone.

Motivation is typically derived either intrinsically or extrinsically. Intrinsic motivation refers to actions driven by internal reward, such as personal satisfaction or a sense of accomplishment. Extrinsic motivation is driven by external reward, such as a promotion or employee of the month nomination.

Motivational Theories

Maslow’s hierarchy of needs states that humans have certain needs which motivate them to achieve. Individual behavior is motivated first by basic needs including physical survival, safety and security. Once that is fulfilled, individuals are then motivated by psychological needs and then finally, by self-fulfillment.

The Herzberg Motivation-Hygiene theory describes two classes of motivators: hygiene factors and motivation factors. Hygiene factors are required to prevent dissatisfaction, but are not positive motivators themselves. They are factors that cannot be avoided nor prevented such as job security, working conditions, and salary. Motivation factors like recognition, advancement, and growth are most important to inspire a team. They are most closely related to job satisfaction.

McClelland’s acquired needs theory states that an individual’s specific needs are acquired over time and shaped by personal life experiences. These needs influence a person’s motivation and can be categorized into three classes:

• 1. Need for achievement—a strong need to excel by setting and accomplishing challenging goals.

• 2. Need for affiliation—an individual’s need to belong to a group, be liked by the group, and be accepted by others.

• 3. Need for power—the need to be strongly influential, lead, and make a lasting impact on others.

Motivation is a result of both unconscious and conscious factors including personal achievement, individual needs and desires, individual expectations, personal growth, and incentive or reward. Motivators are drivers of human behavior and are essential to inspire individuals to accomplish a goal. By understanding what motivates not only one’s self, but a team of people, it will make for a more successful, enriched, and productive workplace.

4.1.7 Decision Making

The job of a manager is, above all, to make decisions . There are several common classifications of decision makers. The first distinction is based on how much information is required to feel comfortable making a decision. Maximizers are people who research exhaustively before coming to a conclusion. The alternative is called satisficing, in which research is conducted only until an acceptability threshold is met. Presumably, this level is lower than that of the maximizer.

Another axis to classify decision makers is the number of options that they pursue. Single focus decision makers routinely pick the single best option. Multifocussed deciders may pursue several options at a time to see which one shakes out. Single focus deciders put their energy and resources into making things turn out how they see fit, while multifocus people are more adaptive to changing circumstances.¹²

With these two axes in mind, we construct yet another 2 × 2 table (See Fig. 11-3).

FIGURE 11-3

Types of decisionmakers are classified based on the amount of information they require and how many options they pursue

Decisive. People using the decisive style want few options and minimal information. They value action, speed, efficiency, and, most of all, brevity. Once a plan is in place, they stick to it. Emergency physicians tend to be decisive.¹³

Flexible. Flexible decision makers keep the information burden at a minimum, also keep their options open. They focus on speed and adaptability. If they choose an option and it becomes undesirable, they quickly change course. Surgeons tend to be flexible.

Hierarchic. Hierarchic people collect much more data than decisives or flexibles. They involve others in their thought process and expect to arrive at decisions that will last. Radiologists and pathologists fall into this category.

Integrative. The integrative person seeks copious information before taking a first step, but even then, he is not committed to the decision. He tends to continuously evaluate many different choices and may pursue multiple different valid opportunities at the same time. Decision making for the integrative is not an event, but a process. Think Internal Medicine.

Gleason has also proposed an alliterative classification of decision makers:¹⁴

• 1. Command. Command decisions are made quickly with minimal information and minimal consultation. This is most similar to the Decisive style.

• 2. Collaborative. The leader seeks counsel from all stakeholders before making the decision.

• 3. Consensus. All team members are invited to contribute ideas and majority rules. This is different from the collaborative approach where the leader makes the decision.

• 4. Convenience. Sometimes, the best decision is to allow someone else to decide. This is also called “complete delegation”.

After the decision is made, it is valuable to review the decision to make sure it was correct. Sometimes, this is very easy (i.e. did the patient survive? Did the project earn money?) Other decisions require more in depth analysis. By studying the lessons learned from a decision, a manager will be more ready the next time a similar situation arises.