Perhaps the most widely overlooked element of all in healthcare management development is that of the jobs themselves. Very often organizations will invest in programs to train more dynamic, transformational and entrepreneurial managers only to place them back into roles that are narrow, restrictive and hierarchical. Disruptive change is welcomed in theory, but quashed once it arrives in person.

Organizations with weak management cultures often have a symbiotically low view of their contribution – one feeds the other. Administrative and operational skills are devalued and managers are seen as overpaid and out of touch with clinical realities. The reaction to this is a greater reliance on force to make staff comply, and a fear based culture is created.

Changing this negative cultural pattern is as much about giving managers real autonomy and authority in their jobs as it is teaching new skills. This means any leadership and management development strategy should carefully consider the universal lessons that contribute to creating successful organizational design, for example:

• Structure: Can hierarchies be flattened to devolve greater power to managers and leaders at middle and lower grades?
• Incentives: Do the systems of reward, remuneration and promotion encourage the behaviors you want to spread, or focus on the same old narrow targets and transactional goals?
• Reputation: Healthcare management jobs are rich in pace and complexity, but often enjoy a ‘second tier’ status in the eyes of staff and patients. They need to be visibly valued.
• Talent management: Is there an ongoing rigorous process for identifying and supporting potential leadership and managerial talent across all disciplines?

The presence of physicians in positions of senior management is both an important catalyst and litmus test for the quality of managers’ roles. While doctors by no means make better managers necessarily, organizations that struggle to recruit clinicians into administrative roles often find themselves in a damaging spiral of tribal divisions with frontline staff and lower value attached the contribution of management professionals.

Having doctors view management as a legitimate second career (in the same way they do research, education or private practice) is an important statement about the status of these roles. In weak or toxic management cultures there is often a divisive atmosphere among clinicians that ‘our job is to look after patients and the manager’s job is to look after the money’.

As Kaiser Permanente’s story below shows, rebranding the role of management and leadership is possible but is no overnight task, taking years or even decades to produce results. It requires more than warm words, but an unwavering strategy of praise, role redesign, and revised incentives.

Symptoms of failure:

• Few or no doctors in senior non-clinical management roles.
• Attrition of those in whom the organization has invested in in the past.
• Low job satisfaction among managers and a low opinion of them among other staff.

Key action for boards:

Survey management staff and ask them if they feel they have the authority to make real improvements in care.

List the ways in which your organization systematically and publicly is making managers feel valued on a regular basis (e.g. awards, recognition, named praise). Ask yourself if you could be doing more.

“25 years ago physicians would look with disdain upon colleagues who took up leadership roles,” says Dr Sharon Levine, a senior executive with The Permanente Medical Group, an independent multi-specialty group practice of more than 9,000 physicians serving almost four million Kaiser Health Plan members in Northern California. “Now we have multiple applicants for every leadership vacancy”.

Kaiser Permanente’s seven regions/business units are each multi-billion dollar enterprises, with active leadership of medical professional at every level. Personal and professional authority has been key to this success, as has along-term strategy of skills development.

“Strategy is running the culture; tactics are running the institution” explains Levine, and focusing on this represents a significant ‘new specialty’ for most physicians. Indeed, it marks a transition of identity, and takes some internal readjustment, “finding the ability to step back and trust that you don’t have to do everything, that your job is to provide the tools, the resources and encouragement”. Once you have gone through the rigors of training to be a physician, you never lose that identity.

Kaiser Permanente has learned that as much as leadership is additive, rather than are placement, for the clinical identity, there is always some loss. “You are chosen because of your excellence in your medical specialty, a preeminence which you will no longer be able to maintain easily as you take on this new role”. No wonder many feel ambivalent about these roles, which is why for over 20 years Kaiser has made a definite case that leadership is valued, with awards, financial stipends, and top-level recognition – making it clear that this is not an ‘off ramp’ from your career. The CEO never misses an opportunity to express gratitude to those who serve in this way.

Importantly it must be easy for physicians to step out of these roles, as well as into them. For example, once a Department Chair has completed their five year term they have the opportunity to return to the clinical workforce – and fulfil an important role model function. “Good leaders make good followers”.