Leadership For Health Care In The 21st Century A P

Leadership For Health Care In The 21st Century A Personal Perspective
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Leadership for health care in the 21st Century:
A personal perspective
Harold C Slavkin
University of Southern California,
Los Angeles, CA, USA
Correspondence: Harold Slavkin
Center for Craniofacial Molecular
Biology, School of Dentistry, University
of Southern California, 2250 Alcazar
Street CSA-103, Los Angeles,
CA 90033, USA
Tel 1 323 442 2216
Fax 1 323 442 2981
Email [email protected]
Abstract: From my perspective, there is no infallible step-by-step formula for becoming an
effective or transformational leader. My assertion is that leadership can be taught and learned.
Specifically, a person can observe and internalize select models of leadership from unique environments,
and then use these “lessons learned” to foster a potential for leadership by learning
about what- worked for others. By selecting “best practices” one can readily and selectively
apply those lessons learned to one- own situation. Leadership opportunities abound in a broad
array of environments including health professional education (eg, medicine, dentistry, pharmacy,
nursing, physical therapy, occupational therapy, dental hygiene), academic health sciences centers,
specific clinical disciplines in acadême, or in private as well as nonprofit clinical practices
(eg, primary care, various specialties), domestic as well as international health policy, large
and small hospitals and clinics, and a myriad of health care industries such as insurance, major
pharmaceuticals, information technology, supplies, and the industries that embrace equipment
manufacturers and distributors. I hope this “personal perspective” prompts and encourages the
reader to think about leading and leadership, and qualities that often describe leaders such as
integrity, being trustworthy, “learning organizations”, and leading genius within the health care
enterprise at this time in the 21st Century.
Keywords: leadership, learning, best practice, health care, education
Introduction
A precise definition of leadership can often be elusive. Distinctions or clarifications
are attempted with limited success between “leadership” as opposed to “management”.
Whether reflecting on your own experiences, browsing through bookstores, or
searching
on the Internet, you will readily find thousands of incarnations of “leadership”.
For my purposes in this “personal perspective”, leadership signifies the act of
“making
a difference”. Leadership generally entails sustaining, improving, or changing
strategic
directions within small or large, simple or complex, organizations. During
the last 50 years in the United States, leadership—whether of the nation, state or city,
a university,
a foundation, or a company—has been characterized as building, creative,
innovative, and generous. Today- era raises issues for leadership that focus on reducing
social and health benefits, and downsizing workforces and related services. Leading
requires making choices with finite resources based upon plausible alternatives, and
it depends on motivating and bringing others along, on mobilizing and coordinating
human and financial resources to achieve a common goal. Leadership at its best is
when vision becomes strategic, the leader- voice becomes persuasive, and the results
become tangible.
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I have benefited enormously from many years within the
leadership crucible at the University of Southern California
(USC). University Professor Warren Bennis is a good friend
and exemplar of the Marshall School of Business through his
emphasis upon leadership and management education, and
training relevant to all sectors of society. He is the founding
chairman of the Leadership Institute at USC, and also
serves as Chairman of the Center for Public Leadership at
Harvard- Kennedy School of Government.1-3 Warren Bennis’
definition of leadership is focused on the individual leader-
qualities: “Leadership is a function of knowing yourself, having
a vision that is well communicated, building trust among
colleagues, and taking effective action to realize your own
leadership potential”.2,3
During the past few years, Professor Bennis has teamed
with USC President Steven Sample to co-teach a selective
course for university undergraduates as well as graduate
and professional students, designed to explore the content
and skills associated with leadership. President Sample-
“The contrarian- guide to leadership” provides a leadership
“manual” that highlights knowledge, eloquence, previous
experiences or “case studies”, and suggested skills for leading
in the 21st Century.4 Within this academic crucible, I
have had numerous opportunities to develop my personal
leadership as a tenured faculty member, academic department
chair, director of a biomedical research center, dean of
a health professional school, and as a member of President
Steve Sample- leadership team (2000-2008). These experiences
have also been enhanced through my leadership roles
as President, American Association for Dental Research,
and while working at the National Institute of Health on
Director Harold Varmus’ leadership team, serving as Director
of the National Institute for Dental and Craniofacial
Research (1995-2000). Additional leadership opportunities
were afforded me through my associations with the
Institute
of Medicine (IOM), National Academy of Sciences
(1996-present), The Santa Fe Group (1996-present),5 and as a
Director, Board of Directors, of Patterson Company (PDCO)
(2001-present).
Leadership opportunities
for the 21st Century
Opportunities abound in the 21st Century for activities related
to health care leadership in the United States. Perhaps as never
before, leadership is urgently needed to envision the future, to
reallocate resources, to monitor progress using information
technology, and to engender both evidence-based as well as
outcome-based health care for all Americans. Clearly these
executive opportunities reside throughout the academic
sector, public and private, through local, state and federal
governments, from public health to private sector health
care delivery, throughout all levels of biomedical research
(eg, basic, translational, clinical, and outcomes research),
health-related private industries (eg, manufacturing, distribution,
insurance, etc) and, of course, throughout both public
as well as private health care policy formulations.
According to a simple assertion made by Peter Drucker,
“The only def inition of a leader is someone who has
followers”.6 In a formal sense, “leaders” can be appointed
for specific terms of tenure, voted into political positions, or
informally assume a position of leadership within an informal
setting. We know that to gain followers requires influence such
as a formal appointment of a CEO by a Board of Directors
of a corporation (public or private), a formal appointment by
the President with Senate approval for an individual to lead
a federal agency (eg, Secretary of Department of Treasury,
Director of the National Institutes of Health), a formal appointment
of a university president by a board of trustees of a private
institution, or by election for public office (eg, federal, state,
county, and/or city levels of government), or by election by
a group to lead a local or community organization (eg, local
PTA, sorority or fraternity). And we further know, that each
of us are often presented with “leadership moments” when
we least expect them.
In the formal sense, the evaluation or assessment of
a leader- performance is often based upon qualitative
(eg, integrity, character, trustworthiness, communication
of mission and vision, the capability to influence) as
well as quantitative measures (eg, financial gains, market
share, acquisitions, leverage of assets, rankings as found
for academic
institutions in annual US News and World
Report, federally-sponsored research gained by faculties
through peer-review processes, peer-reviewed scientific
or technical papers, success in gaining patent approval to
protect intellectual property, percent students accepted into
an academic institution, etc). For example, a major metric
for the private sector might be stated simply as “the bottom
line”. Have the CEO and team increased net profits over
some period of time, and what was the rate of increase? Has
CEO leadership resulted in a greater market share? Under
turbulent economic conditions, have the CEO and team
sustained the enterprise through storms? What innovations
were introduced by the CEO and which of these succeeded?
Highly successful leaders, in all types of organizations, project
the abilities to think and act strategically. They influence,
motivate and inspire, thereby enabling others to realize their
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Leadership for health care
potential. They usually lead by example, and possess talents
of a superb communicator,
reflect selflessness, and are often
perceived as making a significant difference to the organization
or institution.1-4,6
One valuable assessment tool for evaluating a leader is
found in the “360-degree feedback” also known as “multisource
assessment”. This strategy is designed to gain perspective
from individuals selected from various positions around
the leader such as trustees, provost, deans, faculty, students
and staff, and other collegial presidents, for example, selected
from around a private university president. These disparate
points of view offer a leader or executive a remarkable set
of assessments from which to engage in self-assessment as
well as self-improvement: “How am I doing and how can I
be better?”.7
Health professional education
Technological, demographic, social, and economic forces
will continue to have a significant impact on access and
affordability to comprehensive, quality health care from
prenatal through hospice care stages of life. Meeting the
public- comprehensive health needs, and quality of life in
the coming decade, will require transformational leadership
and profound revisions in the entire health care enterprise.
Many futurists assert that gaining synergy within and between
health professional schools, departments and programs
(eg, medicine, dentistry, pharmacy, nursing, physical and
occupational therapy, speech therapy, and dental hygiene,
etc), will be the key to best optimize the health care workforce
to meet the changing health needs of society. The Institute
of Medicine (IOM) of the National Academy of Sciences
has engaged thousands of experts to delve into what is, and
what should and could be, for health professional education,
clinical practice, biomedical research including clinical and
outcomes research, and continuing professional education for
the early 21st Century.8 In most of these reports the emphasis
has been placed upon measurable outcomes, evidencebased
health care, and robust informatics needed to manage
the health care enterprise - patients, families, communities,
health care providers, health care policies, costs and affordability,
and quality and comprehensive health care.
Significantly, dozens of IOM reports focus on analyses
of issues coupled with recommendations that will require
leadership to achieve major revisions in the health care
enterprise (eg, pre-doctoral and doctoral education models
based upon inquiry-based learning, specialty training,
evidence-based clinical practice coupled to bioinformatics,
multidisciplinary professional continuing education, ongoing
portfolio performance
assessments and rewards, etc).9-11
One exemplar for the need of transformational leadership and
recommendations can be found in the IOM report “Academic
health centers: leading change in the 21st Century”.11
The meaning of “transformational” leadership through
my prism is a form and style of leadership that literally
provides “positive” changes in followers, enhancements or
radical changes of infrastructure processes, and significantly
increases performance and measurable outcomes. In this
leadership model, the leader enhances motivation, morale,
and performance. For example, a new leader recruited to a
top-down, command and control, organization introduces a
series of candid group discussions that audit the culture of
the organization. Through strategic planning processes the
leader slowly builds trust, flattens the hierarchy, rewards open
criticism and suggestions, cultivates strategic versus tactical
approaches, and routinely celebrates accomplishments both
“big and small”. The transformational leader stimulates
organizational learning practices, nurtures, and grows a
sense of “enlightened self-interest among all stakeholders”.
I have personally been involved in several such “transformational”
experiences such as (1) changing the name and
mission of a federal agency, (2) serving as the lead agency
for the first-time ever Surgeon General- report “Oral health
in America”, (3) introducing institution-wide information
technology to replace “paper-based processes”, (4) introducing
digital technology such as computer-aided design
and computer-aided manufacturing (CAD-CAM) to design
and fabricate prostheses, (5) introducing “learner-centered
education” into a traditional passive learning organization,
and (6) investing in life-long learning for all staff and faculty
within a health professional school to change expectations
and aspirations of the workforce. The cultural consequences
resulting from such transformational leadership was to produce
pride, trust, admiration, and loyalty and respect between
faculty, staff, students, patients, and alumni. Candidly, such
desired outcomes can be achieved within 70% of the entire
organization but never in 100%. The leader- expectations
are very important.
A few examples are highlighted to illustrate opportunities
for major revisions in health professional education
in response to societal needs and IOM recommendations.
One example is the introduction of problem-based learning
into health professional education, specially medical and
dental education.12-16 Another is the innovation to introduce an
expanded “oral health curriculum” into the medical education
for physicians at the University of Washington.17 Yet another
is the innovation a few years ago to realign the College
of
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Nursing with the College of Dentistry at New York University.
A fourth example is the new realignment of the Program in
Biokinesiology and Physical Therapy, and the Program of
Occupational Science and Occupational Therapy, with the
School of Dentistry at the University of Southern California.
Each of these examples provided enhanced opportunities
for transdisciplinary professional education, research, and
patient and community health care.
Achieving health and well being for all Americans will
require leadership at many levels of the enterprise, the strategic
management systems necessary to create environments
conducive for innovations, and coordinated and cohesive
system-wide views across disparate disciplines and values.
Leadership is imperative to build and sustain information
systems, rewards and mechanisms for accountability that
can measure and reward accomplishments. Leadership
training, development, and support are critical for the
present and future of health care diverse organizations and
institutions.1-6,18,19 The scope of the suggested content for
such leadership development courses within a “learning
organization” includes defining leadership models in their
social context, analysis of strategic versus tactical approaches
to problem solving, learning to listen and analyze before
making decisions, oral and written communication styles,
resource management, creating coalitions and collaborations,
leveraging resources, conflict resolution, fiscal and specific
budget management, and creating environments of trust (after
Peter Senge).18,19 It also means leading for measurable results,
managing change, and personal and team life-long learning
and development.18,19
Biomedical research
The biological and digital revolutions have yielded remarkable
advances that have and continue to profoundly influence
a paradigm shift in health care. Genomics, postgenomics and
the dividends from the transcriptome, proteome, metabolome,
and the microbiome, with accompanying bioinformatics,
information technology, and imaging, are shaping health care
in the 21st Century.9-11,20 In tandem, remarkable health disparities
based upon socioeconomic determinants have also been
illuminated. These “drivers” add additional complexity for
leadership in biomedical science and technology. Success in
these endeavors is often dependent upon cooperation and collaboration
between “different ways of knowing” or so-called
multidisciplinary or transdisciplinary team approaches. Leadership
in these fields of inquiry requires organizing highly
creative people into effective collaborative groups or teams,
motivated by common goals and incentives.
Three examples,
requiring very different but highly effective transformational
leadership skill sets, include J Robert Oppenheimer and The
Manhattan Project of World War II, Francis Collins and The
Human Genome Project (1988-2004),20 and the International
SARS Consortium (“team-driven”), and The SARS
Project created to rapidly define and understand the nature
of SARS virus in February and March 2003.21 Not only are
the results noteworthy from these three different examples,
the processes used to achieve these remarkable outcomes
must to be studied.20,21
Biomedical research leadership positions abound
throughout public and private academic organizations, state
and federal research organizations, nonprofit foundations,
as well as the medical device, biotechnology, and pharmaceutical
industries. Importantly, old stereotypes have been
challenged and new paradigms have emerged.
The distinct organization of the health and biomedical
research professions into specialties and subspecialties,
into disciplines and subdisciplines according to body organs
and systems, was often more pragmatic and historical than
scientific. As scientific progress has advanced, for example,
“genetics” as a discipline has become a “way of knowing”
as well as a “tool” for all health care professionals.20 Similar
transformations are observed for cellular, molecular and
developmental biology, physiology, biochemistry, immunology,
inflammatory diseases and disorders, autoimmune
diseases and disorders, acute and chronic pain management,
biostatistics, the Health Insurance Portability and
Accountability Act (HIPAA) compliance, and so much more.
These and many other important aspects of being a health
professional are clearly “transdisciplinary” and argue for
increased integration and collaboration between all health
professionals. Bioinformatics is another such example: how
to access information, be equipped to “mine” databases and
extract relevant information for solving a specific question
or problem.
We now know, for example, that the immune system
and inflammation are closely related to many chronic
diseases and disorders22 including hypertension, diabetes
mellitus, arthritis, psoriasis, atherosclerotic cardiovascular
disease, and periodontitis. The research-derived evidence
(see recent consensus report)23 supports the assertion that
physicians, dentists, nurses, pharmacists, and allied health
professionals should be required to have a common knowledge
base to enable seamless comprehensive care for patients
and their families. Health promotion, risk assessment, disease
prevention, diagnosis, treatment and therapeutics, and
prognosis and outcomes, must be coordinated between all
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Leadership for health care
health professionals.24-26 This is particularly evident when
considering the association between periodontal disease
and cardiovascular disease.22,23 Similar calls for integration,
cooperation, and collaboration between health professionals
has been heralded for cohorts of patients and their families
such as: congenital birth defects, for example syndromic and
nonsyndromic cleft lip and palate (eg, pediatrics, surgery,
anesthesiology, neurology, speech therapy, nursing, physical
therapy, social services, embryology, pediatric dentistry and
prosthodontics, etc); or head and neck cancers (eg, family
medicine, internal medicine, oncology, radiology, dermatology,
plastic surgery, oral and maxillofacial surgery, otolaryngology,
etc).22
Lessons learned
Throughout my leadership experiences over four decades
(1968-2010), I have observed and learned that humans
possess a passion to understand and predict the future, and
that a transformational leader takes on the responsibility
for molding and shaping the possibilities within a tangible
dream of the future. I have also learned that success
is never 100%. From my perspective, highly successful
leaders possess unconditional integrity, charisma, and a
powerful drive for authenticity. Based on my experiences
within academics, federal agencies, and private industry,
I enthusiastically endorse the key principles of leadership
for the 21st Century, here adopted from Bennis and Thomas’
“Geeks and geezers: how era, values, and defining moments
shape leaders” (2002).3
Greatness starts with superb people; recruitment of talent
is essential.
Great groups and great leaders create each other.
Every great group has a strong and effective leader.
The leaders of great groups love talent and know where
to find it.
Great groups are full of talented people who can work
together.
Great groups think they are “on a mission from God”.
Every great group is an island - but an island with a bridge
to the mainland.
Great groups see themselves as “winning underdogs”.
Great groups always have an external threat or
“enemy”.
People in great groups are enormously focused and “have
blinders on”.
Great groups are optimistic, not realistic, and sense that
“anything is possible”.
In truly great groups the right person has the right job.
The leaders of great groups give them what they need,
remove obstacles, and always promote creativity.
Great groups produce dreams with deadlines (they are
action groups).
Great work is its own reward (incentives help).
I invite the reader to reflect on outstanding leadership
coupled with great groups or teams that they have personally
experienced, and then compare your experiences and assessments
with those characteristics highlighted by Professor
Warren Bennis. Sharing the lessons learned from highly
innovative leadership moments can illustrate principles and
select techniques of leadership.27,28 Nine leadership moments
led to nine leadership principles as learned and then described
by Michael Useem, as follows:27
Roy Vagelos
at Merck
Know yourself: understanding your
values and where you want to go
will assure that you know which
paths to take.
Wagner Dodge
in Mann Gulch
Explain yourself: only then can
your associates understand where
you want to go and whether they
want to accompany you.
Eugene Kranz
and Apollo13
Expect much: demanding the best
is a prerequisite for obtaining it.
Arlene Blum
on Annapurna
Gain commitment: obtaining
consensus before decision will
mobilize those you are counting
upon after the decision.
Joshua Lawrence
Chamberlain
Build now: acquiring support today
is indispensable if you plan to draw
upon it tomorrow.
Clifton Wharton
at TIAA-CREF
Prepare yourself: seeking varied
and challenging assignments now
develops the confidence and skills
required for later.
John Gutfreund
at Salomon
Move fast: inaction can often prove
as disastrous as inept action.
Nancy Barry at
Women- Banking
Find yourself: liberating your
leadership potential requires
matching your goals and talents to
the right organization.
Alfredo Cristiani
in El Salvador
Remain steadfast: faith in your
vision will ensure that you and your
followers remain unswerving in
pursuit of it.
As an exercise, the reader is encouraged to reflect on
the triumphs and the disasters as part of their leadership
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experiences. Use these as “case studies” that can become
“lessons learned” and extremely useful for leadership training
and development. Further, revisit this exercise at different
stages of your life and within diverse social, economic and
political contexts. The nine examples shown above, in my
opinion, are very beneficial towards leadership training and
development.27 In particular, leaders with a command of
history coupled with great storytelling have often become
transformational leaders as documented in Howard Gardner-
“Leading minds”.28 Gardner discovered that informal as
well as formal speeches by great leaders, such as George
C Marshall,
Winston Churchill, Franklin D Roosevelt,
Margaret Mead, and Mahatma Gandhi, were almost always
highly persuasive, mobilizing, and rich in metaphor and
historical truths.28
I have been inspired by President Steve Sample and Professor
Warren Bennis that broad reading habits (ie, “the great
books”, biography and history, great fiction) actually translate
into “seeds” that motivate leaders to better understand the
human condition throughout the ages. I find that leaders,
especially transformational leaders, love to read, learn, and
revise their understanding and views of the world.
Summary and prospectus
I assert that the future of leadership in the health care workforce,
whether within public or private organizations, will
continue to require creative, interdisciplinary, and most often
culturally diverse collaborations. The structure and mission
of existing traditional agencies and organizations are, and
will continue to be, rapidly changing. Command and control,
anchored to ownership or formal authority, is being replaced
by an intermixture of tentative and changing teams of people
organized to solve problems within predefined timelines and
budgets. Solving problems that are significant to the larger
society will increasingly dominate the public and private
sectors - health and well-being, health care, energy, deficits,
credit and savings, science and technology literacy, retirement
versus work, terrorism, etc.
Academic medicine, dentistry, pharmacy, nursing, and
allied health professions will be required to meet the rapidly
changing needs of the larger culturally diverse society
through major revisions of their academic programs, as well
as the design and implementation of integrated education,
research, and clinical research and clinical services. The
amount of change in organizations has grown tremendously
over the past few decades, and the rate of change will rapidly
accelerate into the future. Leading change will increasingly
be required. National debates over entitlements versus
commodity
when discussing health care will continue.
Predicted as well as unanticipated changes must be part
of business plans as well as national policies, as we have
learned during the last decade. Numerous social, economic,
and political factors will continue to shape many directions
for change. Communities that present excessive burdens of
disease based upon socioeconomic determinants will increasing
require a culturally competent health care workforce that
will emphasize health literacy, health promotion, disease
prevention, and risk assessment that can effectively reduce
health disparities in America. Our future will present a culturally
diverse health care workforce (eg, clinicians, scientists,
engineers, sociologists, law and public policy, business, and
journalism) that must be educated and trained to meet our
nation- needs for wellness in the 21st Century.
“It is not just how many followers one has; it is also how
many leaders one has created among them. The more leadership
in the ranks, the more effective is one- own”.27
Michael Useem
Director of the Wharton School-
Center for Leadership and Change
Acknowledgments
The author- prism has been influenced over these many
years being a tenured faculty within a research-intensive
private university, a previous director of one of the National
Institutes of Health (NIH) institutes (ie, the National Institute
of Dentistry and Craniofacial Research (NIDCR)), a previous
chairman of academic departments (eg, biochemistry and
nutrition, craniofacial biology), a previous dean of a school
of dentistry, a member of the IOM, and a director within a
board of directors for a major corporation listed on the stock
exchange. I also wish to acknowledge my inspirations including
John Ingle, Lucien Bavetta, Richard Greulich, George
Martin, Dushanka Kleinman, Warren Bennis, Steve Sample,
Harold Varmus, Lloyd Armstrong, and Max Nikias, from
whom so much has been learned about the commitment to
responsible change and service to a better future.
Disclosure
The author reports no conflicts of interest in the material
presented.
References
1. Bennis WG. Managing the Dream: Reflections on leadership and change.
Cambridge, MA: Perseus; 2000.
2. Bennis W, Spreintzer GM, Cummings TC, editors. The Future of Leadership.
San Francisco, CA: Jossey-Bass; 2001.
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3. Bennis WG, Thomas RJ. Geeks and Geezers: How era, values, and
defining moments shape leaders. Boston, MA: Har

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