Development of Administrators of Care

Medical Leadership in the Military

The military healthcare system faces several challenges: exploding healthcare costs, the increasing importance of performance management, combat operations that have placed unprecedented pressure on the healthcare system both at home and abroad, and the need to integrate medical forces into joint operations.

Leadership has a key role to play in meeting these challenges. In this context, the Department of Health's Office of Change asked RAND Health and the RAND National Defense Research Institute to examine how health leaders in the civilian and military sectors are prepared and supported, and to recommend improvements in how the Department of Health identifies and develops potential leaders.

RAND researchers responded to three key tasks. First, they reviewed models of healthcare leadership competencies-including military healthcare leadership competencies defined by the Joint Medical Executive Skills Program (JMESP) as essential to successful leadership in a medical treatment facility or other leadership roles in the MHS-and relevant literature on developing healthcare officers at military installations.

They then interviewed nearly 60 military health officers and community leaders and 30 civilian health leaders from 25 organizations. The research team also conducted a case study on how one government agency-the Veterans Health Administration (VHA)-addresses leadership development.

The case study involved interviews with 16 senior managers and network and facility managers. The interviews were conducted over a two-year period, from 2007 to 2009. The results of the study are published in Developing Military Health Care Leaders: Insights from the Military, Civilian, and Government Sectors.

The results are divided into three main areas:

• Desired characteristics of a healthcare leader.
• Military leaders' perceptions of how the current system prepares healthcare professionals to lead and succeed in a collaborative, results-oriented environment.
• The experiences of civilian and VHA healthcare organizations in leadership development.

Key findings

• The military health system faces many challenges and leadership development is essential to address them.
• Military health system leaders must have leadership skills, management experience, and business knowledge, among other things.
• Military healthcare professionals believe that the current approach to leadership development is reasonably effective, but have suggested improvements.
• Civilian healthcare organizations and the Veterans Health Administration have a systematic approach to leadership development and use a number of best practices that benefit the military healthcare system.

What qualities do military healthcare experts need?

The literature review and interviews revealed that the desired attributes of leaders include a combination of knowledge and experience in three categories: leadership, management, and business skills.

Healthcare managers must be able to manage human, financial, and knowledge resources. Therefore, effective leadership requires a combination of “hard” and “soft” skills. Hard skills include the ability to manage information and technology, financial resources and human resources, i.e., hiring, training and evaluating people. Managing financial resources requires skills such as budgeting, asset management and control of financial resources. Soft skills, i.e. communication and interpersonal skills, are considered as important as technical skills.

Management skills are considered as important as leadership skills. These skills enable managers to provide the organization with the necessary strategic and visionary direction. Competencies in this category include visionary leadership (i.e., seeing and influencing the future), change leadership (i.e., constantly seeking innovative approaches and embracing change as an opportunity for development), flexibility and adaptability, and creative and strategic thinking and planning.

Entrepreneurial competencies also include skills that demonstrate an understanding of the broader context in which an organization operates, such as organizational leadership and systems thinking.

How well does the system prepare leaders at the moment?

The context in which military healthcare leaders operate is quite complex, especially when you add in the demands of war. They have to manage not only military personnel, but also civilian personnel and contractors. In addition to these requirements, there is an increasing emphasis on performance. Although medical leaders have more leadership opportunities, many of them are also under pressure from clinical specialties, which reduces the time available to prepare for leadership roles.

Departments approach medical director preparation in different ways, and the perceptions of the staff members interviewed also varied. Overall, Air Force personnel feel that the system provides reasonable preparation. Opinions remain positive, but vary in other services, with some staff finding the system less structured and more vulnerable to unforeseen events.

There were also a number of critical comments about the selection process. All services use both formal and informal methods to select individuals with good management potential. All of them use written evaluations in the selection process, but doubts were raised about their overly formal nature.

Doubts were also raised about the impartiality of the promotion boards that review these evaluations. Many officials noted the importance of informal systems for identifying potential managers and felt that these systems may be more important than formal evaluations. Some mentioned that more attention should be paid to diversity in the selection process.

In general, workplace experience is seen as the most valuable and effective tool for staff development. At the same time, many staff members noted that it is difficult to perform both clinical and managerial tasks. Physicians often lack business and management skills because leadership opportunities only come later in their careers. Some interviewees also expressed concern about the “career model” in the service, which limits an individual's flexibility to gain varied experience.

While recognizing that education is a valuable developmental tool, military professional training, whether joint or service-based, can be problematic for health officers. Among the concerns were the time required for training, particularly in military schools, and the relatively small number of places available for health officers. Non-military training, such as postgraduate training, was also seen as valuable. Some also noted that longer deployments would allow more experience to be gained and could contribute to staff retention.

What can be learned from other health organizations?

Interviews with senior officials from civilian health organizations and the VHA provide further insights into the development of senior health technicians. These organizations strongly support leadership development as one of their key missions. Many also support a “living” competency model linked to the organization's strategic goals and plans, which guides the organization's approach to leadership development.

For example, VHA's high-performance development model does not focus solely on the development of senior leaders, but provides training and development to a broader range of staff to enable the development of the entire organization. Leadership selection plays an important role and organizations use a variety of methods to ensure they hire or develop the type of leader they want.

Some use behavioral interviews to test whether people exhibit the desired behavior. VHA uses performance-based interviewing, where the interviewer carefully defines the qualifications required for the position and guides the interview process to elicit examples of past performance.

Leadership development is emphasized in these organizations, with a variety of approaches. Interviewees reported that their organizations offered coaching and mentoring, cross-functional and team development, and 360-degree feedback (i.e., feedback from subordinates and managers) as forms of leadership development, in addition to on-the-job training. Incentives for good performance include financial rewards and are often linked to measurable objectives that meet organizational and individual goals. In some organizations, these financial incentives are linked not only to results, but also to the manner in which they are achieved. Some organizations use non-financial incentives, such as special projects or job titles, to develop leadership and reward.

What should the military do to improve the development of healthcare officer leadership skills?

The majority of military personnel interviewed in the study believe, with some reservations, that the services do a reasonable job of preparing their military health officers for leadership positions. The results suggest several ways to improve the development of health professionals' leadership skills.

For example, with regard to leadership expectations, the U.S. Department of Defense could revise the EBSM competency model to ensure that it is consistent with the strategic goals of the MHS, that it integrates competencies into the overall leadership development process, and that it emphasizes the importance of soft and technical skills in selection and assessment. Other recommendations focus on how healthcare leaders are selected, developed and nurtured.

Select

• Consider the use of performance-based interviewing in the recruitment and evaluation of managers for senior positions.
• Improve diversity among those selected for leadership development opportunities.
• Adopt a “best of show” rather than “best of breed” policy. At the same time, review the structure of the health services to ensure that all agencies have equal access to leadership.

Develop

• Reexamine the overall approach to leadership development to determine whether potential staff members can be offered shorter-term projects or enhanced assignments.
• Provide opportunities for physicians to develop their leadership, entrepreneurial, and management skills early in their careers.
• Encourage 360-degree feedback and make it an integral part of leadership development.
• Explore ways to offer and validate short-term joint training opportunities more appropriate for healthcare professionals.
• Recognize the importance of mentoring in assessments and consider formal mentoring and coaching training.
• Evaluate the timeliness and appropriateness of leadership development programs.

Provide incentives

• Consider developing a separate evaluation process or evaluation form for health officers that includes competencies considered important by the military. At the same time, consider ways to reduce subjectivity and inflation in evaluations.
• Explore options for filling three-year positions for health officers.