Hla competency directory

Common Competencies for All Healthcare Managers: The Healthcare Leadership Alliance Model MaryE. Stefl, PhD, professor and chair. Department of Health Care Administration, Trinity University, San Antonio, Texas - - • .

E X E C U T I V E S U M M A R Y Today's healthcare executives and leaders must have management talent sophisti- cated enough to match the increased complexity of the healthcare environment. Executives are expected to demonstrate measurable outcomes and effectiveness and to practice evidence-hased management. At the same time, academic and profession- al programs are emphasizing the attainment of competencies related to workplace effeaiveness. The shift to evidence-based management has led to numerous efforts to define the competencies most appropriate for healthcare.

The Healthcare Leadership Alliance (HLA), a consortium of six major profession- al membership organizations, used the research from and experience with their indi- vidual credentialing processes to posit five competency domains common among all practicing healthcare managers: (1) communication and relationship management, (2) professionalism, (3) leadership, (4) knowledge of the healthcare system, and (5) business skills and knowledge. The HLA engaged in a formal process to delin- eate the knowledge, skills, and abilities within each domain and to determine which of these competencies were core or common among the membership of all HLA associations and which were specialty or specific to the members of one or more HLA organizations. This process produced 300 competency statements, which were then organized into the Competency Directory, a unique and interactive database that can be used for assessing individual and organizational competencies. Overall this work helps to unify the field of healthcare management and provides a lexicon and a basis for collaboration among different types of healthcare executives.

This article discusses the steps that the HLA followed. It also presents the HLA Competency Directory; its application and relevance to the practitioner and academ- ic communities; and its strengths, limitations, and potential.

For more information on the concepts in this article, please contact Dr. Stefi at msten@trinity.edu.

360

COMMON COMPETENCIES FOR ALL HEALTHCARE MANAGERS

P eter Drucker (2002) has said thatlarge healthcare institutions may be the most complex in human history and that even small healthcare organiza- tions are barely manageable. Some time has passed since Drucker's observation, but the complexity of healthcare orga- nizations, along with the demands on managers and leaders, has not dimin- ished in any way. Today, executives in all healthcare settings must navigate a landscape influenced by complex social and political forces, including shrinking reimbursements, persistent shortages of health professionals, endless require- ments to use performance and safety indicators, and prevailing calls for trans- parency. Further, managers and leaders are expeaed to do more with less.

Since 1999, the Society of Health- care Strategy and Market Development and the American College of Healthcare Executives have been producing Future- scan, a compendium of healthcare trends and projections for the next five years. In Futurescan 2008, the publication's execu- tive editor, Don Seymour, reflected on the past ten years in healthcare:

society appears to be sending a clear, overarching message to the nation's hospitals: Take care of more people who have growing expectations and more complex medical needs v̂ -hile providing increasingly sophisticated care with relatively fewer resources.

In an environment of escalated public demand, it is only lógica! to question the competence of healthcare lead- ers and managers. As noted in Griffith (2007), the increased difficulty of run- ning a healthcare organization has led to the need for managers with more sophisticated capabilities.

The questions now become. Have mid- and senior-level managers been keeping pace with changing demands? Are healthcare academic programs at- tracting sufficient numbers of students ' and adequately preparing them to oper- ate effectively in this dynamic environ- ' ment? These concerns were the focus of the 2001 National Summit on the Fu- ture of Fducation and Practice in Health ' Management and Policy. Principally fiinded by the Robert Wood Johnson Foundation, this conference brought together practitioners, policymakers, and educators to examine the effective- ness of healthcare administration and the role of academic preparation and continuing professional development in tackling the current and future chal- lenges of healthcare delivery.

The Summit's deliberations focused on evidence-based approaches (see Kovner 2001 ) to developing manage- ment talent, including how to measure the outcomes of health management education (Griffith 2001) and how to determine whether administration students and practicing managers had acquired the competencies necessary to perform effectively in their roles.

THE COMPETENCY MOVEMENT The emphasis on measurable outcomes and competencies did not happen ovemight. The widespread acceptance of evidence-based medicine was a natural precursor to an evidence-based approach to healthcare management (Kovner and Rundall 2006). Also, the development and promotion of compe- tencies for graduate medical education (Batalden et al. 2002) set the stage for healthcare administration.

361

OF HEALTHCARE MANAGEMENT 53:6 NOVEMBER/DECEMBER 2008

More broadly, higher education has struggled with the issue of compe- tency-based education for some time (Calhoun et al. 2002; Westera 2001). The main idea behind this initiative is to design curricula based on the roles that graduates will assume after complet- ing their degree and to incorporate the specific knowledge, skills, and abilities (KSAs) that future employees will need. Efforts to promote competencies have been undertaken in numerous fields, including public health (Council on Linkages Between Academic and Public Health Practice 2001) and the health professions (IOM 2003). The controver- sial Spellings report (issued in 2006 by the Secretary of Education's Commis- sion on the Future of Higher Education convened by U.S. Secretary of Education Margaret Spellings) pushes universi- ties nationwide to measure student outcomes and then make these results available to the public.

To meet the needs of healthcare administration, a number of univer- sity programs have developed a set of competencies (e.g., Cherlin et al. 2006; Shewchuk, O'Connor, and Fine 2005; 2006; White, Clement, and Nayar 2006) or competency models (e.g., Campbell et al. 2006) for their students. A review of these efforts is beyond the scope of this article, but note that these various programs typically use a similar pro- cess for developing their competencies: (1) existing competency literature is reviewed, (2) subjea matter experts (either faculty or practitioners) are ap- proached to provide depth and content validity, and (3) a survey of practi- tioners is condurted. In other words, academic programs take steps to ensure

that their competency models are tied witb the realities and needs of health- care management practice. However, little evidence shows a link between actual performance and competency attainment (Bradley 2003), an area of inquiry tbat clearly needs more atten- tion as competency models continue to develop.

Aside from this work in academia, the National Center for Healthcare Lead- ership has expended considerable effort in creating a competency model that can be applied to professional development and to academic programs (Calhoun et al. 2004; NCHL 2005). In addition, many healthcare associations have used expert opinion and job analysis surveys to delineate the KSAs that form the basis for their credentialing exams. However, these KSAs were not usually shared with tbe broader healthcare management community.

THE H E A L T H C A R E L E A D E R S H I P A L L I A N C E The Healthcare Leadership Alliance (HLA) is a consortium of major profes- sional associations in the healthcare field:

• American College of Healthcare Executives (ACHE);

• American College of Physician Executives (ACPE);

• American Organization of Nurse Executives (AONE);

• Healthcare Financial Management Association (HFMA);

• Healthcare Information and Manage- ment Systems Society (HIMSS); and

• Medical Group Management

362

COMMON COMPETENCIES FOR ALL HEALTHCARE MANAGERS

Association (MGMA) and its educa- tional affiliate, the American College of Medical Practice Executives (ACMPE).

Together, these associations represent more than 100,000 management profes- sionals. II '

In response to concerns about the adequate preparation of healthcare managers and administrators, the HLA convened the Competency Task Force to examine the credentialing and certifica- tion processes of its member organiza- tions. First meeting in late 2002, the Tasii Force was composed of a repre- sentative from each organization' and a facilitator (this author). The Task Force was charged with a straightforward responsibility: Determine if there were management competencies shared by all members of the HLA organizations. If so, the Task Force would determine how these competencies could be used to advance the field.

Reviewing the Credentialing and Certification Processes I ask Force work began with an exchange of information regarding each associ- ation's credentialing and certification processes. Five of the six organizations had well-established processes, while AONE was considering launching its own certification program.^ Certifica- tion programs are designed to ensure that individuals in a professional posi- tion meet the basic educational, skill, and/or experiential requirements of their respective profession (Raymond 2001 ). Thus, credentialing or certifica- tion exams should be job-related and should be designed to test whether the professional possesses the KSAs essential

for his or her job. For large organiza- tions, certification exams are typically objective, with questions constructed following the job analysis studies.

Four associations (ACHE, HFMA, HIMSS, and ACMPE) used well- established psychometric processes (job analysis surveys or role delineation studies, review by subject matter experts, and content analysis) to determine the KSAs for their certification exams (NCCA 2007). All engaged reputable psychometric firms to ensure the reli- ability and validity of their processes. The ACPE's certification process was slightly different from that employed by the rest of the group. Following an on-site tutorial session, ACPE candidates were tested by faculty experts using an in-basket exercise and requiring a verbal presentation. All associations' certifica- tion exams were discriminatory; first- time pass rates ranged from 60 percent to 85 percent (Stefl 2003a).

In general, the certification processes of the HLA organizations were intended to provide early careerists an opportuni- ty to demonstrate their competence. At the time of the Competency Task Force's review of KSAs, most HLA associations (except AONE) offered a fellowship status for those with more senior-Ieve! accomplishments and contributions. Most associations (except HIMSS) awarded the Fellow status only after that member had attained certification and the requisite competencies. Thus, the Task Force's review excluded the fellow- ship processes.

Identifying Common Competencies The extensive review of the credentialing and certification processes of the HLA

363

JOURNAL OF HEALTHCARE MANAGEMENT 53:6 NOVEMBER/DECEMBER 2008

members revealed a number of overlap- ping and complementary competencies. The Task Force determined that these KSAs clustered into five competency domains that were common among the membership of all six associations (Stefl 2003a):

1. Communication and Relationship Management: The ability to com- municate clearly and concisely with internal and external customers, to establish and maintain relation- ships, and to facilitate constructive interactions with individuals and groups

2. Leadership: The ability to inspire individual and organizational excel- lence, to create and attain a shared vision, and to successfully manage change to attain the organization's strategic ends and successful perfor- mance

3. Professionalism: The ability to align personal and organizational con- duct with ethical and professional standards that include a responsibil- ity to the patient and community, a service orientation, and a com- mitment to lifelong learning and improvement

4. Knowledge of the Healthcare Environ- ment: The demonstrated understand- ing of the healthcare system and the environment in which healthcare managers and providers function

5. Business Skills and Knoivledge: The ability to apply business principles, including systems thinking, to the healthcare environment; basic busi- ness principles include (a) financial management, (b) human resource

management, (c) organizational dy- namics and governance, (d) strategic planning and marketing, (e) infor- mation management, (f ) risk man- agement, and (g) quality improve- ment

In keeping with the current focus on outcomes and evidence-based manage- ment, these five domains were viewed as common competencies or compe- tency domains. While "competency" can be defined in a variety of ways, the Task Force adopted a definition from Ross, Wenzel, and Mitlyng (2002): Competencies are clusters that "tran- scend unique organizational settings and are applicable across the environ- ment. "That is, the domains identi- fied by the Task Force are generic and demonstrable.

The Task Force viewed these com- petency domains as interdependent (see Figure 1). Because leadership competencies are central to a healthcare executive's performance, the Leadership domain anchors the HLA model. All other domains draw from the Leader- ship area, but the other competencies also feed and inform leadership. In Figure 1, the two-way arrows outside the circles indicate that the other four do- mains draw from each other and share overlapping KSAs.

The identification of these five domains sends a powerful message to the healthcare field: Healthcare managers in a wide range of positions and settings share a common body of knowledge and a common lexicon. Such a message can break down bar- riers between various health manage- ment professionals, provide a stronger

364

COMMON COMPETENCIES FOR ALL HEALTHCARE MANAGERS

F I G U R E 1 The Healthcare Leadership Alliance Competency Model

Competency Domains

Communtcation and Relationship

Management Professionahsm

Business Knowledge and

Skills

Knowledge of the Healthcare Environment

Source: ^ 2005. M\ Rights ReservedbyMembtrrs of the HLA Competency Task Force: American College of Healthcare txeaiiives.

American College of Physician Executives, American Organizalion of Nurse Executives, Heallhrare Pinancial Management

Association, Healthcare Information and Management Systems Society, and the certiñcation body of the Medical Group

Management Association—American College of Medical Practice Executives.

basis for collaboration, and engender mutual respect and teamwork. Most importantly, the work itself suggests that a common background, expertise, and language are shared by members of the C-suite, the practice management com- munity, and healthcare managers in a range of positions and settings (Rossiler and Stefl 2005).

Using the Dreyfus Model Much of the discussion regarding competencies attempts to distinguish the performance expectations for

entry-level, mid-career, and senior-level managers. In its deliberations, the Task Force was guided by the skill acquisition model developed by Stuart Dreyfus and Hubert Dreyfus (1986). The Dreyfus model has been applied to the nursing field (Benner 1984), and it guided the development of ACMPE's competency and certification model. More recently, the Accreditation Council for Graduate Medical Education applied the model to develop core competencies for medical residents (Batalden et al. 2002), and the model has been discussed in relation to

365

JOURNAL OF HEALTHCARE MANAGEMENT 53:6 NOVEMBER/DECEMBER 2008

health administration education (Stefl 2003b).

The original Dreyfus model outlined five stages for skill development: novice, advanced beginner, competent, profi- cient, and expert. As skills develop, the individual's reliance on rules decreases and the ability to make independent judgments increases. By the time a person reaches the proficient and expert levels, he or she can recognize patterns in the environment and operate (at least partially) on intuition.

For example, an entry-level manager will consult a policy manual to deal with a distraught and angry patient or family member. A mid-level manager, however, is already thoroughly familiar with the protocols governing the situ- ation and will employ strategies and responses that have effeaively diffused similar situations in the past. A se- nior-level executive will respond more intuitively, recognizing patterns in the situation and knowing implicitly when to apply rules and when to be more creative. This intuitive and discrimina- tory knowledge can only come from experience and practice in applying management skills. Each manager in this scenario is using KSAs in the Com- munication and Relationship Manage- ment domain.

When the situation is viewed in terms of the Dreyfus model, the new manager is acting as a novice, the more experienced manager is functioning at the competent level, and the senior ex- ecutive is responding at the proficient or expert level. Progressing from one skill level to another, especially from novice to competent, typically requires experi- ence coupled with guided reflection.

This progression underscores the need for mentoring throughout career stages as well as the importance of continued professional development and lifelong learning.

The HLA Task Force recognized that the Dreyfus model could serve as a framework for individual development in all competency areas (Stefl 2003a). An individual who was competent in one domain (e.g.. Knowledge of the Healthcare Environment) could be a novice in another (e.g.. Professional- ism). Members who achieved certifica- tion by each HLA organization were considered to be at the competent level. Members who sought Fellow status within their respective associations could operate at the proficient level. The Task Force believed that the expert level was beyond the realm of testing or cre- dentialing. Experts are acknowledged by their peers and typically receive honors or distinctions from their professional associations.

Organizing and Generating Competency Statements According to Shewchuk, O'Connor, and Fine (2005), broad competency domains have limited usefulness. Their lack of specificity prevents any real application in the work setting or for curricular design. Although core compe- tencies common among all healthcare executives engender understanding and collaboration, they mask the different expectations for each type of healthcare manager. For example, chief financial officers are expected to have a wider range of financial analysis competen- cies (a subset of the Business Skills and Knowledge domain) than are needed by

366

COMMON COMPETENCIES FOR ALL HEALTHCARE MANAGERS

the general membership of ACHE. Simi- larly, information systems managers are expected to have broader abilities in technology design and implementation than required of chief nursing officers.

Specialty competencies for the membership of each HLA association would likely complement the core competency domains. More specific KSAs within each domain would also be useful. In fact, many of the competen- cies outlined by the individual associa- tions in their job analyses were more detailed and unique to their own group. What was needed was a mechanism that combined and compared the various KSAs and tbat determined wbich of the detailed competency statements could apply across the entire healthcare man- agement field. A competency directory was conceived as a way to accomplish those tasks.