An assessment tool for developing healthcare managerial skills and roles.

EXECUTIVE SUMMARY

This article is based on a study to identify, and by doing so help develop, the skills and roles of senior-level healthcare managers related to the needs of the current healthcare environment. To classify these roles and skills, a qualitative study was conducted to examine the literature on forces in the healthcare environment and their impact on managers. Ten senior managers were interviewed, revealing six roles as the most crucial to their positions along with the skills necessary to perform those roles. A pilot study was conducted with these senior managers to produce a final assessment tool. This assessment tool helps managers to identify strengths and weaknesses, develop in deficient areas, and promote competence in all areas as demanded by the market and organization. This tool can be used by organizations in the recruitment process and in the training process.

The market-driven managed care environment has intensified the need for healthcare organizations to attain higher levels of organizational performance. Senior-level managers are responsible for managing the overall performance of their organizations. As representatives of their organizations, they perform roles that enable them to identify, understand, and respond to changes taking place in the environment and within their institutions (Jansen 2000; Ross, Wenzel, and Mitlyng 2002). To perform those roles, they must have the knowledge to make informed decisions that lead to higher quality, improved outcomes, decreased competition, and increased market share.

This study develops an assessment tool to determine the most essential skills and roles of managers in the current healthcare environment. Specifically, managers should use this assessment tool to critically identify their areas of strengths and weaknesses. Knowing their areas of strengths allows managers to perform their roles with confidence; knowing their areas of weaknesses enables them to take the first step in developing these deficiencies. Thus, managers can use this tool to reinforce areas in which they are lacking and to gain competence.

This article is organized in five sections. The first provides the background, outlining forces in the healthcare environment and roles of managers. The second describes the methods used to develop the assessment tool. The third presents the results for refining and finalizing the tool. The fourth discusses the useful purposes of this tool, including helping managers to (1) identify strengths and weaknesses, (2) develop in deficient areas, and (3) promote competence in all areas as demanded by the market and organization. This tool can be used by organizations in the recruitment process, to select candidates who are most appropriate for organizational needs, and in the training process, to help retain managers who are able to improve their skill levels and role performance. The fifth section addresses limitations of the study and makes recommendations for future research.

BACKGROUND

Major forces in the healthcare environment include the rise of cost-containment mechanisms, the growth of managed care, increased use of technology, and existence of and reliance on performance and outcomes indicators. As a result of these systemic complexities, healthcare organizations must seek innovative ways to deliver healthcare more efficiently and effectively. Although management is held accountable for acquiring and combining resources to accomplish these organizational goals, its responsibilities are increasingly demanding and difficult in a rapidly changing, turbulent, and often hostile external world (Zuckerman, Dowling, and Richardson 2000). Traditional roles of managers that examined only functions are inadequate in the evolving healthcare market. Researchers find the roles of hospital administrators to be broader and involve more complex responsibilities in response to external changes (Forrester, Johnson, and Mosher 1976, 1977; Shortell and Kaluzny 1997). Thus, a closer examination of managerial roles is required to understand risk, reward, and survival in the managed care market (Ross, Wenzel, and Mitlyng 2002).

The literature shows that several studies have been conducted on managerial roles. First is Mintzberg's (1973) research on roles, which led to a typology of ten work roles of the manager. This model is still deemed as one of the most comprehensive list of managerial roles. However, Mintzberg's roles were based on the study of managers in several industries and not limited to healthcare; thus, the results, in original format, are unsuitable for use in the current healthcare environment. Second is the work of Zuckerman and Dowling (1997), who arrived at a trinity model of managerial roles that is specific to the healthcare industry. Their research outlined roles of a manager as strategist, leader, and designer. Although these roles appropriately define the focus of today's managers, they are too broad to provide concrete guidance.

A third model identified roles of CEOs in academic medical centers and is very similar to that of Zuckerman and Dowling's. Like the previous model, Guo (2002) also described the roles of a CEO as a trinity model made up of strategist, communicator, and delegator. Although these roles accurately describe the responsibilities of CEOs in academic medical centers, they lack detailed descriptions of managerial skills associated with the performance of roles. A fourth model that recognizes the importance of situational differences is based on the work of Quinn and colleagues (1996). They found that "multiple roles" must be employed because a single management role will not suffice in complex situations such as those faced by managers today. Organizations must balance among the competing values, and managers must be able to examine a situation, assess it from different perspectives, and address it through multiple roles.

Thus, this study aims to discover the multiple roles needed for today's challenging healthcare environment. Unlike the broad models found in the literature, the study is not simply a description of the wide-ranging roles of managers. It takes into account situational differences to create multiple roles that are specifically geared for the healthcare industry, and it establishes a set of skills needed by senior level managers as they perform those roles. Furthermore, this study offers guidance for managers to determine their degree of role performance and level of skills attainment through the creation of an assessment tool.

METHODS

The first step of the qualitative study was a review of the literature on the healthcare system, classification of managerial roles, and managerial roles particular to the healthcare industry. The literature revealed that existing models were insufficient to portray managerial roles for the current healthcare environment (Guo 2001). In fact, several models were combined to produce a new model depicting the most essential roles of senior-level managers under stressful, uncertain, and complex environment conditions. This new model is based on the framework of Mintzberg's (1973) three role groupings and excludes overlapping content from the work of Guo (2001), Mintzberg (1973), Quinn and colleagues (1996), and Zuckerman and Dowling (1997). Six roles of managers make up the new model.

The second step involved a number of semistructured interviews with key informants (n=10) from the healthcare industry. Ten senior-level managers in provider settings were asked to identify specific roles and skills they consider necessary for the current environment. Based on these interviews, managerial skills and roles were categorized to create a new assessment tool, which in turn was pilot tested on ten senior-level managers in provider settings. Two reasons exist for conducting a small pilot study. The first is a lack of resources, which results in a small convenient sample. The second and most important reason is the uniqueness of the tool. Unlike any other found in the literature, the tool proposes to integrate a specific listing of managerial skills with precise roles needed to conduct defined activities in particular situations. The pilot study was used to confirm that this integration is essential to managerial work. Another distinguishing feature of the tool is that it allows managers to capture and develop their weak skills and roles. To explore these areas of distinction, the small pilot study served its purpose. At this early stage of the study, testing on a larger sample requires extra resources and may only lead to unpromising results. Testing on a smaller scale led to encouraging findings that were then used to develop a full-scale model of the assessment tool. Revisions to the tool were made to create the final version.

The final assessment tool (shown in Figure 1) includes the skills required within each role grouping, definitions of each role, and sample activities in each role. The three role groupings are depicted as I, II, and III; the numbered statements (1-6) define each role; and the lettered statements (A-M) describe the skills required for each role grouping. Both the roles (1-6) and skills (A-M) are followed by a scale ranging the level of performance from 1 to 3, with 1 as none, 2 as low, and 3 as high. This scale enables managers to assess their own role performance. Ratings in the categories of 1 and 2 suggest that the manager must develop these areas of deficiencies.

RESULTS

The assessment tool combines several models to create six essential roles of senior-level healthcare managers. The key informants identified these six roles: leader, liaison, monitor, entrepreneurial strategist, disturbance handler, and resource allocator. In selecting these roles, Mintzberg's framework was used to categorize managerial activities into three role groupings. The interpersonal roles described in the tool include the work of the manager as a leader and liaison, eliminating Mintzberg's ceremonial figurehead role (Guo 2001). As a leader, a senior manager provides purpose, motivation, and direction in the organization. The second essential role is that of the liaison, which calls for the manager to serve as the link between the environment and organization.

The next role grouping is informational, consisting of the monitor role. As a monitor, a senior manager gathers information and seeks to identify" problem areas, ensures that operations run smoothly, and observes the external environment to draw positive and negative lessons. Collected information allows the manager as a monitor to seek and understand changes taking place in and out of the organization. The monitor is a vital role that has been noted by the models of both Mintzberg and Quinn and colleagues. Unlike Mintzberg's model, which consists of three roles in the informational grouping, the model from this study includes only one role because research has found the other two roles are primarily used by first-level and second-level managers rather than senior-level managers (Allan 1981).

The decisional roles consist of the manager's roles as disturbance handler, resource allocator, and entrepreneurial strategist. These roles are crucial and therefore have been expanded. Guo's strategist role, Zuckerman and Dowling's strategist and designer roles, and Quinn and colleagues' innovator and broker roles are incorporated into Mintzberg's decisional role of entrepreneur to form the entrepreneurial strategist. In this role, the manager acts as a designer of change, initiator of strategies, visionary, and risk taker who is willing to make decisions in the face of uncertainty. This role is especially vital in today's complex healthcare environment. The entrepreneurial strategist is willing to take risks by investing in new projects and markets. At the same time, the entrepreneurial strategist uses a variety of strategies including integration, diversification, and market research to achieve economies of scale, improve resources, enhance access to capital, and extend the scope of the market (Zuckerman, Dowling, and Richardson 2000).

Another crucial role is that of the disturbance handler, which combines the activities found in Quinn and colleagues' facilitator role. The disturbance handier manager is responsible for all problem solving, which encompasses resolving conflicts and restoring stability to the organization. By motivating workers, the emphasis is placed on maintaining a work environment that is conducive to goal attainment.

The final decisional role is that of the resource allocator, which is a combination of Quinn and colleagues' coordinator, director, and producer roles and of Mintzberg's resource allocator role. In this role, the manager is responsible for authorizing all major decisions through creative use of resources to maximize productivity and outcomes. This role involves planning and organizing work, defining expectations and job responsibilities, and giving instructions to achieve progress and productivity for survival and growth (Guo 2001; Quinn et al. 1996).

Skills associated with the abovementioned six roles were found through interviews with ten key informants and were categorized into three role groupings. Interpersonal roles require managers to possess human relations skills such as motivation and understanding individual and group feelings (Vance and Davidhizar 1998). The informational role requires skills in listening, communication, and sharing of information. The decisional roles are most vital because they require all three types of skills: human relations, technical, and conceptual abilities (Kowalski and Campbell 2000; Long 2001; Robbins, Bradley, and Spicer 2001; Weaver and Ringhouse 1997). The pilot test of the assessment tool revealed that senior-level managers in finance and information systems management used more technical skills, while senior-level managers in planning, presidents, and CEOs relied on more conceptual skills. Conceptual skills required for the entrepreneurial strategist role include coordination, design/redesign, strategic planning, and change management (Weaver and Ringhhouse 1997).

DISCUSSION

This study indicated that senior-level healthcare managers perform similar roles (Dunn 2002; Guo 2001, Zuckerman and Dowling 1997). Through the creation of an assessment tool, managerial skills and roles appropriate for the current healthcare environment have been identified and can then be used for further training and development. To aid in developing and mastering these skills, the literature has noted the importance of combining experience with education through the pursuit of graduate programs in health services administration (Kadushin 1997; Mecklenburg 2001; Robbins, Bradley, and Spicer 2001).

As challenges in the healthcare environment intensify, managerial role performance is increased (Longest 1997). Thus, this assessment tool serves several purposes. First, it outlines important skills and roles of senior-level managers who operate and respond to challenges in the current environment. Senior-level managers must possess a wide range of human relations, technical, and conceptual skills to perform various roles. Second, it lists a number of sample activities that managers should become involved in as they perform their roles. Third, and most critically, it can be used to develop in areas of managerial deficiencies. For instance, managers who are deficient in technical skills or cannot perform the resource allocator or the entrepreneurial strategist roles must take steps to acquire or improve the respective skills and roles. Although roles vary for different levels of managers, the focus of the assessment tool is relevant for senior managers at provider settings, including hospitals, academic health centers, and integrated delivery systems. To study managers at first-level or second-level positions, the tool would need to be altered to reflect skills and roles for those positions. However, for first-level and middle-level managers who strive for higher management positions, the tool can serve as a guide in understanding, developing, and mastering skills and roles for senior management positions.

Furthermore, not only should the individual manager be responsible for training and learning to promote management skills, but organizations must also show that they value their human resources by creating an environment that is conducive to learning. Therefore, healthcare organizations can use this tool as well to aid in selecting ideal candidates. When organizations seek managers competent in the decisional roles, they can use this assessment tool to determine the levels of skills for the candidates so that the candidates with the highest ratings are hired. Organizations can use this tool in their retention efforts as well. As skills and roles change in the rapidly changing environment, managers may lack new skills and fail to perform new roles. In this case, organizations can use the tool to help managers improve in their particular deficient areas, allowing them to gain competence. Organizations benefit when senior managers advance their knowledge and skills to perform their roles. As healthcare organizations continuously adjust to changing internal and external pressures, managers, especially at senior levels, must change their roles to be more flexible and creative in adapting to new demands (Moss Kanter 1989). Managers should expand their roles to allow for greater access to multiple channels of information. They must use human relations skills to recognize and establish important linkages between organizations and environments.

RECOMMENDATIONS AND DIRECTION FOR FUTURE RESEARCH

The discussion above pointed out several useful features of the assessment tool, but the study that initiated the tool has certain limitations. The study involved a small sample because of limited resources. In addition, it focused on the perceptions of skills and roles required by senior-level managers in provider settings. Consequently, the findings may not be generalizable beyond this population segment and study context. Accordingly, the scales and measures employed in the study lack independent evidence of reliability and validity.

Given the aforementioned limitations, recommendations and directions for future research can be made. First, similar research designs need to be replicated for larger samples and for different levels of managers. The same instrument can be sent to all managers in healthcare settings, rather than just to senior-level managers. Another possible method is to conduct the study on a random sample of healthcare managers; this will allow the researcher to examine the skills and roles of managers using the same approaches described in this study. The larger sample will enable generalizability. Furthermore, the causal relationship formed in the proposed assessment tool needs to be established better, ideally by means of correlational methods and by the use of more sophisticated causal modeling techniques.

In conclusion, this article presents a study that proposes essential skills and roles for senior-level managers as they face the demands and pressures of the complex healthcare environment. Highly skilled managers performing crucial roles produce results that are linked to the growth of their organizations.

FIGURE 1

Assessment Tool of Senior-Level Managerial Roles and Skills

For each of the role groupings (I, II, III) containing the lettered
statements (A-M) indicating skills requirements, circle the degree
of skills you (as a senior-level manager) possess. (1-none, 2-low,
3-high)

For each of the numbered statements (1-6) defining the roles of a
manager, circle the degree of role performance you (as a senior-level
manager) conduct. (1-none, 2-low, 3-high)

Sample activities are included to describe each role.

I. Interpersonal Roles--require skills in
    A. Motivation (influencing, persuasion)                   1   2   3
    B. Group and Teams Behavior (partnering,
         coaching, persuasion)                                1   2   3
    C. Listening *                                            1   2   3

    1. Leader--provides organization with direction and
       purpose                                                1   2   3
    Sample Activities: A manager in the leader role must motivate,
       inspire, and support subordinates in the development of shared
       organizational vision and achievement through group and team
       participative decision-making sessions.

    2. Liaison--builds networks of contacts with individuals who are in
       positions to provide information to enhance the nature of the
       organization                                           1   2   3
    Sample Activities: A manager in the liaison role must join external
       boards to seek and provide information, attend conferences to
       keep in touch, network with counterparts, form coalitions, and
       enhance the organization's image and reputation.

II. Informational Role--require skills in
    C. Listening *                                            1   2   3
    D. Communication **                                       1   2   3
    E. Sharing of information ***                             1   2   3

    3. Monitor--gathers information and seeks to identify problem
       areas                                                  1   2   3
    Sample Activities: A manager in the monitor role meets with
       subordinates to check on progress, tours facilities to detect
       disturbances, analyzes reports, and receives and requests
       information from the environment and within the organization.

III. Decisional Roles--require skills in

    D. Communication **                                       1   2   3
    F. Conflict resolution                                    1   2   3
    G. Operations management                                  1   2   3
    H. Information systems management                         1   2   3
    I. Industry knowledge                                     1   2   3
    J. Coordination                                           1   2   3
    K. Design/redesign                                        1   2   3
    L. Strategic Planning                                     1   2   3
    M. Change management                                      1   2   3

    4. Disturbance Handler--addresses all major problems and
       restores stability to organization                     1   2   3
    Sample Activities: A manager in the disturbance handler role
       resolves all major conflicts and maintains cohesion, commitment,
       and morale.

    5. Resource Allocator--allocates appropriate sources to various
       projects                                               1   2   3
    Sample Activities: A manager in the resource allocator role makes
       choices on how resources are spent, approves the budget, directs
       workers toward the completion of tasks, gives instructions, and
       prescribes policies and rules.

    6. Entrepreneurial Strategist--creates, innovates, and takes risks
       and opportunities to enhance the organization          1   2   3

    Sample Activities: A manager in the entrepreneurial strategist role
       designs and supervises new project developments, develops and
       markets programs and products, invests in information systems,
       integrates to form a continuum of care and economies of scale,
       formulates strategy planning sessions, and conducts market
       research.

Notes:

* The listening skill, letter C, is found in both interpersonal and
informational roles.

** The communication skill, letter D, is also found in both
informational and decisional roles.

*** The sharing of information skill, letter E, is found only in the
informational role and therefore is not repeated in the decisional
roles section.

References

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--. 2002. "Roles of Managers in Academic Health Centers: Strategies for the Managed Care Environment." Healthcare Manager 20 (3): 43-58.

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PRACTITIONER APPLICATION

Joan B. McCabe, director, Facility Planning, Design, and Development, Broward General Medical Center, Fort Lauderdale, Florida 

This article identifies useful senior-level managerial roles and skills. As a senior-level manager responsible for regional strategic planning in the North Broward Hospital District, I find that my skills in strategic planning are put to the test on a daily basis. Often, I must make important decisions under great uncertainty. Therefore, having an assessment tool such as the tool described in this article enables me to focus on my areas of weaknesses. For instance, to decrease my sense of uncertainty, I should perform more of the entrepreneurial strategist and liaison roles. These roles allow me to network, thus providing me with knowledge and opportunities to make better and more informed decisions. At the same time, to perform these roles, I need to develop and master conceptual skills related to coordination and change management. Gaining these competencies is important not just to me but to my organization as well.

To survive in our industry marked by increasing financial pressures and competition, we must work on improving our skills to be better prepared for the changing environment. We can use this assessment tool in our organization to develop our managerial roles and skills and to address our areas of deficiency. Having identified those areas, we can work as a team to improve our levels of competency to maximize our human potential in our organization.

Kristina L. Guo, Ph.D., assistant professor, Health Services Administration, Florida International University, Miami

For more information on this article, please contact Dr. Guo at [e-mail].