Grigsby, R Kevin DSW; Hefner, David S. MPA; Souba, Wiley W. MD, ScD, MBA; Kirch, Darrell G. MD
Recruiting department chairs at academic health centers (AHCs) has become an even more challenging endeavor in recent years. Long gone is the perception held by some faculty members that the position of department chair is honorific and reserved for the person who has demonstrated personal excellence across all three missions of patient care, research, and education (the so-called triple threat). Being a department chair now requires greater preparation and broader expertise than ever before. Drawing on our own experiences as leaders and managers in AHCs, in this article we describe the current dilemma facing AHCs as they recruit department chairs. We outline the desirable characteristics of department chairs in the current environment, and offer concrete recommendations for recruiting, retaining, and sustaining department chairs. In sharing our experiences we wish to encourage readers to adopt these or similar approaches at their own institutions.
The Current Dilemma Facing Academic Health Centers
Over the past decade, the turmoil ensuing from the transformation of the health care industry has been impressive. Stemming largely from a major revision of the industry's payment structure, AHCs have experienced the interplay of powerful market forces and a shift in the power base away from providers and toward payers (employers and insurers) and the pharmaceutical industry. Physicians have less clout in the marketplace and less autonomy in practice. In the past, faculty leaders at AHCs were concerned predominantly with fulfilling the missions of patient care, research, and education. Today, their time and energy are occupied by a more business-oriented set of tasks that include winning contracts, enhancing revenue, reducing costs, recruiting and managing a diverse workforce, and dealing with consumer satisfaction and marketing. Reductions in reimbursement for clinical services, cutbacks in funding for graduate medical education, a nationwide nursing shortage, and the rise of consumerism have intensified the competition in the health care industry. While department chairs are ostensibly hired to promote the tripartite mission of patient care, research, and education, they find themselves investing more and more effort in management. It is important to understand this dilemma, because the position of department chair may be the greatest point of leverage for implementing organizational change in AHCs.
The Changing External Environment
AHCs are being challenged along the spectrum of their cultural values and traditional roles and responsibilities. Medicine is becoming an industry governed by free market competition, where, at the end of the day, the bottom line is what counts. The doctor–patient relationship, once honored as a covenant based on trust, now has prominent elements of a commercial transaction governed by contract law and the marketplace. The conviction that illness is a significant human condition and the notion that the physicians’ primary obligation is to alleviate suffering seems to be fading.1
New visions and strategies must be developed to maintain the viability and professionalism of academic medicine. This requires a different mode of leadership, but a fresh start is hard to come by. The few, but powerful individuals who exert significant influence within AHCs often have little interest in any changes that might jeopardize their influence. In the process of acquiring power, the historical AHC currency has been to cut many backroom deals with the dean and hospital CEO, thereby creating a climate of mistrust. Organizations cannot change unless and until the people who work in them change first. To build AHCs that can carry out their missions and engender faculty support while delivering a sustainable bottom line, first we must convey a clear sense of what we value in academic medicine.
It is clear that department chairs are key to this process and need to be equipped to deal with the changing environment and the cultural evolution in academic medicine.2 Skill sets required in the past are no longer adequate; a different set of qualifications applies.3
The Traditional Search Process
Search committees continue to recruit and select new academic department chairs. While this process historically was an effective way to select leaders for medical schools, it is not clear that it is as effective in the new “business environment” of the AHC. Search committees tend to use the same criteria from the past when the job of department chair was less complex and centered on delivering the tripartite mission in an era of abundant resources. In the past, a candidate's national prominence was a key factor, as were a personal track record in research, demonstrated clinical excellence, and an appreciation for the educational mission. In addition, search committees focused on easily measured criteria, such as the candidate's publication record, history of securing extramural funding, and awards and honors. An understanding of the business of medicine, communication skills, the ability to confront and resolve conflicts, the skill sets required to manage a diverse portfolio of faculty talent, and the ability to tolerate ambiguity rarely were considered.
Now, there is often a misalignment between the desires of the typical search committee and the new skills required of the department chair such as business acumen and leadership skills. The current system of recruiting and hiring a department chair has been described as being in “disarray.”4 Hoffmeir5 argues that the term “search committee” may be a misnomer, as most committees are ill equipped or unwilling to undertake the labor intensive process required to truly search for a new chair. The significance of the search process becomes clearer as one investigates costs. An investment of approximately $63,000 is required to conduct a national search.6 The return on investment is difficult to measure, but should be considered in the overall examination of the search process. We ask: Is it prudent for the typical search committee to identify candidates by using many outdated criteria and focusing on individual achievement? We believe that an orientation toward the future and a focus on collective achievement may be better markers of a chair's success. Even in the best circumstances, when an abundance of information about the candidate is available, it is difficult to know how a candidate will perform as a department chair. Successfully recruiting, retaining, and sustaining “future-oriented” department chairs require a different approach.
Characteristics and Qualifications of a Future-Oriented Department Chair
To prepare for the demands of the present and the future, the future-oriented department chair should think and operate from simultaneous, yet disparate points-of-view. Linking departmental and institutional priorities requires new ways of working. To prepare for the demands of the present and future, the future-oriented chair must be able to think and operate in ways that surpass a narrow focus on the department. The insular or “silo” approach of the past, which emphasized departmental hegemony, led to departments competing with each other for limited resources. Institutions can no longer afford to waste time, energy, or resources on internal struggles between departments. The new demands require that all departments meet or exceed financial expectations, all while actively supporting their interdependence. Budgeting, staffing, and personnel and financial management skills traditionally required of chairs continue to be necessary, but are not sufficient for success. The chair must be facile with the operational and fiscal aspects of the department, as well as with connections to cross-departmental initiatives such as service lines, programs, centers, and institutes. It is imperative to remain strategic and solution focused within this complex financial matrix, even in the face of poor financial performance and constrained resources.
At the same time, the chair should be available to mentor junior faculty while meeting the operational and financial needs of the department and institution. Learning to share leadership and to shine in the reflected light of others’ performances, while aligning the faculty and staff with the institutional strategy, have become much more important in today's environment. In short, the future-oriented department chair must be able to see beyond the crisis du jour and consider the future consequences of actions or inaction. The ability to tolerate ambiguity is vital, as is the ability to shift the focus from personal success to the success of others. Preparing others for change and assisting them through turbulent times requires leadership skills that simply were not required of the department chair in the past.
The new qualifications of the department chair include, but are not limited to, promoting collaboration, building and supporting a culture of peer accountability, having an institutional orientation, and demonstrating the ability to have frank, face-to-face discussions with faculty members regarding detailed aspects of performance. Alignment with the organization's values and guiding principles provides a strong foundation for building organizational success. However, this alignment with the organizational values and guiding principles is not sufficient. The future-oriented chair must embrace a skill set that helps her or him to “deliver” in meeting new institutional expectations. Possessing basic business and administrative skills in finance and management can help department chairs equitably distribute resources, responsibilities, and rewards.
Adopting an institutional perspective helps the leader to see the “big picture” and break through the insularity of the departmental structure that too often leads to internal competition for scarce resources. Working with, rather than competing against, other components of the organization increases efficiency. Likewise, strong communication skills, including the ability to truly listen, are important in building trust and, ultimately, in building teams. The advantages of using teams are well-known in the business community.7 Building and leading teams allows the future-oriented department chair to strengthen commitment and articulate a shared vision while using the collective wisdom of the team to remove obstacles to success and to provide resources.
Resilience, the ability to rebound from setbacks or failure, is another important skill. While formal training can be helpful, resilience is a skill learned typically “on the job.” Moving out of one's comfort zone involves risk as one stretches beyond the mundane and accepts new challenges. Learning from one's own missteps and blunders requires the opportunity to make mistakes. Future-oriented department chairs must have the skill to assist others in accepting and engaging in ventures that inherently involve risk.8
At the same time, setting clear expectations and holding responsible parties accountable are characteristic of a results orientation, another skill that is fundamental to success as a department chair in the current environment.
Helping others discover their own talents and develop new skills requires a reorientation away from the self and toward the development of others. Coaching, mentoring, and encouraging others energizes them to work toward and build a better future.
Table 1 shows the principal characteristics that have been sought in “traditional” department chairs and the additional characteristics that are important for “future-oriented” department chairs.9 These key skills and abilities are fundamental to the success of the future-oriented chair and, ultimately, the department. Unless the individual possesses these skills, she or he will be unable to craft a strategic vision to which everyone in the department is committed and contributes. Strategic vision helps members of the department deal with change, and reflects good organizational health. Politics and hidden agendas no longer drive the work of the department, as clarity of mission, trust, and teamwork help the members to forge ahead and tackle challenges.
Finding the Right Person
The recruiting process begins with both the composition of and the charge to the search committee. Committee members should have diverse backgrounds, perspectives, and interests. Focusing on skills and perspectives the members bring to the table rather than on which department they represent increases the strength of the committee. The committee chair should embrace diversity and commit to ensuring that the committee members have a broad perspective.
Likewise, the dean should charge the committee by explicitly discussing expectations, including specific reference to the new demands placed on department chairs and a review of the organization's core values and principles, as well as institutional strategy. The dean also should inform the committee members that part of their charge is to inform candidates of the new demands and expectations.
Recruiting department chairs has never been an easy or simple task. In fact, recently the Association of American Medical Colleges10 developed a publication to assist AHCs in successful recruitment. To recruit a future-oriented department chair with the characteristics necessary to “get the job done,” the search process must consider the skills and core competencies necessary for success.
Few candidates possess every skill and competency needed; it may be necessary to coach or train a potential appointee in additional skills. Therefore, focusing above all on the candidate's values offers the most fruitful approach to finding “the right person.” Does the candidate espouse the organization's values? If the candidate's values fit with those of the organization, then he or she can always acquire any skills that are lacking. Acquiring new values to match those of the organization is a daunting task. Is it possible to train someone to have a different set of values? Behavioral science suggests that this is possible, but typically happens when children develop into adults and are influenced by parents, family environment, schools, and other social factors. It is unlikely that an AHC will be willing to invest years of training with an uncertain outcome.
Position Description, Call for Applications, and Nominations
Once the desired characteristics and skills for the position are decided, an explicit, written description of the position should be composed with input from the dean, division chiefs, search committee members, and others. This position description should not be confused with an advertisement for the position. A well-written position description will allow for the extraction or distillation of a Call for Applications and Nominations, as well as for advertisement. The description should state the organizational values, the desired qualifications, the expected demands, and the performance expectations for the person appointed to chair the department. A brief history of the organization and the department should be included, as well as highlights of notable achievements of the college, the department, and the members of the department.
Applicants should be asked to send a copy of a recent curriculum vita. Even more important, however, is a cover letter explicitly addressing the candidate's competence and experience regarding the new expectations. Typically, search committees have paid little attention to cover letters and have focused immediately on “weighing” the curriculum vita. While it is necessary for candidates to demonstrate personal competence in academic, research, and service missions, relying on success in these areas alone is not sufficient for identifying the best candidates.
Candidate Review and Interviews
The search committee's challenge is to recognize those persons with the greatest potential for success as a future-oriented chair. A baseline set of very broad screening requirements should be developed that include eligibility for licensure, board certification, degree from an accredited program, and some experience, as well as demonstrated competence, across the missions. However, demonstrated excellence in all missions is not necessary. Categorizing characteristics into groups labeled Essential, Important, Desirable, or Optional is a means for starting the review process. Candidates lacking essential characteristics can be screened immediately from the roster of viable candidates. Candidates with a very limited list of important characteristics are unlikely to be as desirable as those candidates who possess all of the “essentials,” as well as most of the “important” characteristics.
Application materials should be screened to determine which candidates meet the minimum requirements. Following this with a careful reading and discussion of the cover letters is helpful in developing a list of candidates to be interviewed. The most qualified candidates are then invited to interview with the search committee and key leaders.
Interviews with the search committee members and key organizational leaders should focus on leadership qualities, personality traits and “goodness of fit” within the organization, and on the candidate's unique and/or specific skill set. Use of a common framework for evaluating candidates is helpful. College and university human resources offices typically encourage the use of common tools for evaluating potential candidates. These tools may be sufficient or easily adapted for use in the search process. At some institutions, the interview process culminates in a debriefing of the candidate with the entire search committee followed by a meeting of the committee alone. At other institutions, the candidate does not participate in the search committee debriefing. Debriefing allows the search committee to have a frank discussion about the relative merits and deficits of the candidate in comparison to other candidates. Ultimately, the search committee must develop a “short list” of candidates to be presented to the dean.
The Candidate's Interview with the Dean
A forthright approach in advertising, in the review of qualifications, and during the interview process leads to the development of the “short list” of candidates to be presented to the dean. During the interview, the dean discusses the candidate's vision for the department. The vision is not a business plan, but an articulation of a proposed outcome or goal(s) and a related strategy. Candidates will need to have reviewed critical information collected during the interview with the selection committee and gleaned from the department's most recent annual report or external review report.
Following the interview with the dean, the candidate should prepare a written summary of the plan for fulfilling his or her vision for the department to include a statement of what the candidate expects of the hiring institution. The summary should cover the next three to five years and may include statements about salary expectations, resources needed to implement the vision, expectations about hiring additional faculty members, and expectations related to space and capital for investment.
In turn, institutional representatives review the plan, not only for the institution to make commitments, but also to be clear regarding a new chair's expectations. The goal is a mutual agreement on a “roughly hewn” plan, bilateral individual and institutional commitments, and the beginning of a timetable for implementation.
Letters of Agreement
Once a candidate is chosen, it is necessary to develop a letter of agreement, a task that requires patience, skill, and a commitment to the bilateral nature of the document being developed. In the past, final offer letters consisted of the title, academic rank, tenure status, a starting salary, effective date, and were usually limited to one page. All too often, they did not include the details of other verbal or written “side deals” made with the candidate. Griner and Blumenthal11 describe the use of detailed letters for regularly appointed faculty. Letters of agreement for department chairs would be expected to include even greater detail. Biebuyck and Mallon10 offer an excellent guide for creating these letters.
Constructing letters of agreement is labor intensive, as the goal is to work with the candidate to implement her or his vision for the department and to assure its alignment with the institution's vision. Development of a business plan in concert with the administrative deans representing the areas of finance, research, academic affairs, and faculty affairs takes place through an iterative process that allows for positive relationships to be developed between the candidate and the college representatives who are preparing the letter. The process results in a clearly articulated implementation plan that has been woven into the fabric of an appointment letter.
The letter of agreement is important because it serves as the starting point for all the dean's subsequent performance reviews of the new chair. Mutual expectations and commitments are clearly articulated in the body of the letter. Well-written letters of agreement also include a leadership development plan for the chair for the coming year.
Developing clearly articulated plans, with mutual expectations and the commitment of resources, helps to eliminate the “binge and purge” cycle of chair recruitment. In the past, institutions recruiting chairs (and many senior faculty) have used a mechanism akin to a “dowry.” Chairs made fantastic demands that typically were met by a commitment to a portion, albeit generous, of what was requested. Then to avoid losing the resources, the new chair quickly expended them over the early years of the appointment. In too many cases, some of the original commitments were not delivered, the resources that were given quickly disappeared, no significant progress was made, and after a period in the doldrums, a search for yet another new chair began. The development of a realistic business plan allows for more orderly growth and creates a sense of trust.
How to Sustain and Retain Future-Oriented Chairs
When the search has concluded and the new chair arrives on campus, the difficult task of sustaining the chair must begin. This is a time to invest wisely. Typically, it is better to invest in improving the performance of an existing chair than to expend resources recruiting a new chair. However, when the new chair is in place, the resources have already been invested.
Sustaining the future-oriented chair requires more than adequate compensation and a commitment to provide physical and capital resources. A culture of peer support in an environment where leaders “live out” the espoused organizational values is necessary for sustaining leaders who seek to balance the competing demands of the AHC. Continuous renewal and replenishment, as well as appropriate recognition and reward for a job well done, contribute to organizational stability as chairs continue to function efficiently and effectively.
Leadership training is a critically important component for sustaining chairs. Leadership encompasses a set of skills that can be developed and enhanced.12 Although a chair may demonstrate competence as a manager, lack of leadership skills may eventually have negative consequences for the department. Leadership is different from management. Kotter13 argues that most “U.S. corporations are overmanaged and underled.” One might argue that the same is true of today's AHC. Adding new leadership skills can result in improved organizational performance, if for no other reason than to build the leader's confidence.
A leader who is confident will in turn cultivate other leaders in the organization. Succession planning—the intentional development of “replacements”—will be successful in a climate that allows others not only to be successful, but also to excel beyond the limitations of the current leader. Experience mentoring a protégé or being a protégé oneself is often instrumental in the succession planning process. Too often, mentorship is seen as a one-to-one correspondence between a senior male colleague and a junior male protégé. As more women and underrepresented minorities assume leadership positions, an understanding, acceptance, and promotion of “multiple” mentors may be critical to their success as leaders. The mentorship needs of women and underrepresented minorities may be distinct from those of the men.14
Likewise, developing the mentoring skills of the chair will enhance the development of junior faculty. Quality mentorship experiences are especially important in succession planning. This is not to say that the chair must or should serve as a mentor for every junior faculty member in the department. Rather, developing the chair's mentoring skills allows for the successful matching of junior faculty with “multiple mentors” and creates an opportunity to target professional development needs, especially for female faculty members. Targeting professional development needs of women can help all faculty members. With appropriate guidance, many male faculty members can learn to be more effective mentors for female faculty.15 Future-oriented department chairs must recognize that recruiting women into academic medicine and retaining them will require female role models.16 However, chairs who are committed to recruiting, promoting, and retaining women in the department must have the skills to do so.
As a new chair demonstrates success and as the chair's reputation outside the institution grows, retaining successful leaders is likely to become a challenge. Other organizations will want to draw upon the skills and wisdom of future-oriented chairs and will present them with opportunities. The best retention strategy is to ensure that the chair is fulfilled in his or her position and in the organizational culture. Again, continuous renewal and replenishment, appropriate recognition and reward, a climate of peer support, and an environment that is demonstrative of the values and ideals of the leader are far more important than compensation alone. Leading others in a culture that rewards collective achievement, intentionally prepares future leaders, and truly celebrates success provides the impetus to “stay put” when attractive offers appear again and again.
The spirit of annual performance evaluation should transcend a shortsighted focus on what is necessary to sustain and retain the chair. Rather, the annual performance evaluation represents an opportunity for the dean, as well as the AHC leadership, other key individuals, and the chair to reflect upon the achievements, or lack thereof, of the previous year and to assess future needs. The chair and dean will assess future needs and put into place a plan for developing the skills of the chair. Annual performance “review” should be seen as a misnomer, as the purpose of the review is to inform the future rather than to dwell on the past. Performance evaluation of the chair should be strategic, that is, preparing the chair for the challenges of the future. Resting on laurels will cause the department, and ultimately the institution, to fall behind when maintaining progress is necessary for survival in the market-driven environment.
The environment and culture of academic medicine are in the midst of rapid, dynamic change. The challenge of leadership is daunting. The skill set once required to be a successful department chair is no longer sufficient. Qualifications that were important in the past have given way to a new set of qualifications. Likewise, methods for recruiting, retaining, and sustaining department chairs need to change in order to secure effective leaders for AHCs. A deliberative, thoughtful process of engaging chair candidates should focus on the candidates’ values. Candidates sharing organizational values may then be engaged in an iterative process of developing a shared vision, resulting in a letter of agreement that explicitly states the candidate's and the organization's expectations and commitments.
Once chairs are in place, ongoing development through leadership training, mentoring, and other investments will help to retain and sustain them. The dean's annual performance evaluation of the chair should be explicit in assisting chairs with honing and upgrading their skills in preparation for the demands of the future. Better equipping chairs will not guarantee the success of the department. On the other hand, not selecting the right candidate and equipping her or him for the future is very likely to guarantee failure.
Some might view this process as moving toward “business” and away from the “academic.” We do not, however, abandon the academic; rather we offer a strategy to preserve our raison d'être through improving organizational performance in our patient care, research, and educational missions. The result will be a stronger academic health center.