Souba, Wiley W. MD, ScD, MBA; Mauger, David PhD; Day, David V. PhD
It is widely accepted that good leadership is critical to the success of any large organization. Academic health centers (AHCs) are no exception. Effective leadership has been especially important in the past decade, a period of major change during which AHCs have struggled to successfully carry out their core missions of patient care, research, and education in the face of severe financial pressures and an increasingly turbulent health care environment. These challenges require leadership across all levels. Regardless of the strategies that are implemented, external partnerships that are forged, or other kinds of institutional approaches, without a significant number of people across all organizational levels on board and engaged in the leadership process of the AHC, it is unlikely that any seriously complex challenge can be addressed successfully.
During such challenging times, when their most fundamental beliefs are often tested, most people look to their core values for guidance when making choices or setting priorities.1 Effective leadership is anchored by an unwavering set of core values that can set an AHC apart by clarifying the beliefs and guiding principles that govern it.2 As noted by James MacGregor Burns, “The ultimate act of moral leadership is its capacity to transcend the claims of multiplicity of everyday wants and needs and expectations and to relate leadership behavior—its roles, choices, style, commitments—to a set of reasoned, relatively explicit, conscious values.”3 But core values have a downside. They sometimes limit what the organization can do and unduly constrain how individuals can behave. Abiding by core values is not always easy, because leaders are under constant surveillance. It takes intestinal fortitude for leaders to make their values count and to confront those persons in the institution who won’t honor or embrace those values.
Effective leadership also requires a leadership climate, defined as the individual organizational member’s perceptions of the work environment.4 Our experiences have shown us that the most healthy leadership climate is one where leadership is viewed as not just emanating solely from one person at the top. More than ever, leadership must permeate all levels of the organization to include those people who have, in the past, viewed their jobs as having nothing to do with leadership. Greater participation in leadership, coupled with transparent systems, open and frank communication, enhanced collaboration, greater accountability, and better mission alignment are keys to success. It is the collective energy of many people pursuing a common direction that enables an organization to make headway.
We carried out the present study to gain a deeper understanding of the guiding core values that medical school deans and surgery chairs consider most essential for effective leadership, to assess their perceptions of the leadership climate in their respective AHCs, and to examine the relationship between their agreement on leadership values, leadership climate, and organizational effectiveness. We wanted to learn more about how these leaders think about leadership. What are the positive values they espouse? How widely shared are these values among them? How do they judge the leadership climate at their institutions? Do these leadership dimensions influence effectiveness? Given the many complex challenges that confront deans and chairs, we hypothesized that agreement between them on leadership values and leadership climate could predict greater organizational effectiveness and performance.
Questionnaires were mailed to college of medicine deans and surgery chairs of the 125 AHCs in the United States. The data were collected from June 2005 through March 2006. Written informed consent was obtained. A small portion of the data for the deans was collected during a pilot study and has been previously reported.5 The study was approved by the institutional review board of the Penn State Hershey Medical Center.
Participants were presented with a list of 38 positive leadership values (Appendix 1) and asked to sort them into nine categories (as two of us have described in a previous report5). Briefly, participants were asked to rank the values (each presented on a three- by five-inch index card) into a set category configuration based on how essential the value was for effective leadership in their institution. The procedure followed a recommended forced grouping protocol in that the sorting configuration adhered to a 1-2-4-7-10-7-4-2-1 normal distribution arrangement.6 Thus, only one leadership value could be placed in the category of “most essential,” followed by two values in the “next most essential,” down to the ninth category (“least essential”), in which only one value could be placed. Resulting value scores were assigned on the basis of how each participant sorted the respective value. A value placed in the most essential category was scored as 1, those in the next most essential were scored as 2, and so forth to the very least essential value, which was scored as 9. Thus, the more essential values have lower average scores than do the less essential values.
Leadership climate scale.
A survey questionnaire was constructed to assess participants’ perceptions of the leadership climate in their respective institutions (Appendix 2). All items were rated by respondents on a five-point scale, where 1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, and 5 = strongly agree. Seven dimensions of a positive leadership climate were identified through a review of the literature on leadership and the authors’ experience with leadership across various AHCs. Positive and negative markers were included in each category. The different dimensions are discussed below, along with a brief description, justification, and marker items.
* Participation–involvement–engagement in leadership. One aspect of a positive leadership climate is inclusion of others in leadership activities. Opportunities for leadership development through involvement and participation in ongoing leadership processes are key. Leaders who tightly hold power and discourage participation in leadership contribute to shaping a climate that impedes the development of leadership skills in others. A positive marker for this climate dimension (Table 1) is “Leadership is widely shared,” whereas a negative marker is “Leadership is the responsibility of only those at the top.” This climate dimension is based on the concept of shared leadership,7 which has been shown to be related to team effectiveness.8,9
* Transparency in decision making. We believe that one of the key features of effective leadership is transparency, the open, bilateral access to information between partners that is essential to building collaboration and facilitating resource exchange, key enablers of systemic leadership. A corollary at the organizational level is the transparency of decision making by those in visible leadership positions. Sharing information widely contributes to openness, trust, and an overall positive leadership climate. A positive marker for this climate dimension is “Decision making is transparent to those at lower levels,” whereas a negative marker is “Decisions are made in secret.” Transparency is an integral component of authentic leadership,10,11 in which authenticity is defined as acting in ways that are in accord with one’s true self and expressing oneself in terms of decision making as well as other forms of communication that are consistent with inner thoughts and feelings.12,13
* Accountability. Setting clear performance expectations and holding oneself and others accountable for meeting those expectations is a central element of effective leadership. Those who have the formal responsibility of holding others accountable for their behavior must be able to see the situation from the other people’s perspectives and understand the kinds of constraints and situational obstacles that may explain why performance expectations have not been met. A positive indicator for this climate dimension is “Performance expectations are clear.” A negative marker is “People are not held accountable for their performance.” Setting clear performance standards and holding oneself to those standards is an important component of self-regulation,14 and modeling those standards and behaviors that are desired in others sends a powerful message to others in the organization. Fostering accountability is also considered a key aspect of strengthening others. As noted by Kouzes and Posner, “accountability is a critical element of every collaborative effort.”15
* Alignment. Strategic alignment is what allows leaders to link strategy to vision and goals at all levels of the organization to ensure that everyone is pulling in the same direction. Building alignment—be it structural (e.g., alignment between the medical school and teaching hospital around programmatic development), cultural (e.g., encouraging basic scientists and physicians to collaborate to improve translational research), or role focused (e.g., cooperation, teamwork among what have historically been parochial, silo-oriented departments)—is a major leadership challenge at AHCs. A positive marker for this climate dimension is “The clinical, research, and teaching missions are aligned,” whereas a negative marker is “Departments have their own agendas, which take priority over the institutional mission.” Building strategic controls that align the various units or divisions is thought to be an important component of strategic leadership.16
* Collaboration. Unhealthy competition can undermine trust, respect, and teamwork. Collaboration makes it more likely that high-quality connections will develop among members of an organization, which can serve as a catalyst to learning and development.17 Collaboration also reinforces the notion that no single leader is likely to have all the answers. Healthy collaboration is a powerful antidote to the kind of self-centered and destructive behaviors that are hallmarks of inauthentic leaders.18 A positive marker for this climate dimension is “Physicians work together in solving problems,” and a negative marker is “Competition is the norm between departments.” Collaborative problem solving is a key competence for effective teamwork19 and, as such, is particularly relevant for team leadership.
* Constructive conflict. A conflict-avoidant workplace may seem friendly and open, but it often masks serious dysfunctions. People cannot easily voice their concerns or disagreements. This creates a climate that fosters fear of conflict, in which people are incapable of fervent debate. Instead, they resort to backroom discussions and personal agendas. The opportunity to voice opinions in the workplace—especially dissenting opinions—is the sign of a healthy leadership climate. Furthermore, organizational learning and cooperation are the result of resolving conflict. Ultimately, a fear of conflict and the artificial harmony that results is thought to stem from an underlying lack of trust.20 A review of the literature has demonstrated a robust relationship between a climate of trust and numerous positive outcomes in organizations.21 A positive marker for this climate dimension is “People feel open to disagreeing with others on key issues,” whereas a negative marker is “Constructive conflict is not tolerated.”
* Open communication. Open communication is essential for recognizing problems, especially those that could be considered moral dilemmas. Making moral issues salient to a leader requires an open dialogue and a climate in which others feel safe to bring these kinds of difficult issues to light. Just as no single leader can hold the answers to the wide variety of complex challenges in an organization, any leader can inadvertently wear “moral blinders” and fail to attend to a presenting moral dilemma. Thus, it is essential to have a climate of open communication so that others feel that it is appropriate and acceptable to recognize moral dilemmas and to discuss them openly. If decision making is impeded by a lack of communication, it is difficult to imagine a healthy leadership development occurring. Thus, one of the most important things a team leader can do is set a climate for open communication, which has been shown to improve team learning.22–24 A positive marker for this climate dimension is “People provide honest feedback to others,” and a negative indicator is “Communication is driven by hidden agendas.”
To examine the relationship between agreement on leadership values, psychological climate, and organizational effectiveness, the following statistics were obtained from the Internet: the National Institutes of Health (NIH) standing of the medical school and the surgery department (2004 data were the most recently available), medical school ranking by U.S. News and World Report (2007 data), and hospital ranking by U.S. News and World Report (2005 data).
The Q-sort and climate perception data were analyzed using the SAS statistical software package (SAS Inc, Cary, NC) to compute descriptive statistics as well as significance tests. Overall differences between chairs and deans with respect to scores for individual values, as determined by Q-sort, were assessed by the two-sample t test. Bowker’s test of symmetry was used to assess differences between chairs and deans at the same institutions with respect to responses on the leadership climate questionnaire. The association between Q-sort and leadership climate responses with respect to differences between chars and deans was assessed using only those data from institutions for which both the chair and the dean participated. The disparity between Q-sort results from chairs and deans at the same institutions was calculated as the average absolute difference between value scores. Similarly, the disparity between leadership climate results from chairs and deans at the same institutions was calculated as the average absolute difference between responses to items on the climate questionnaire. The association between Q-sort disparity and leadership climate disparity was assessed using the Kendall correlation coefficient. Associations between disparity and performance measures were also assessed with the Kendall correlation coefficient. Statistical significance was determined at the 0.05 level.
Sixty deans (48%) and 68 chairs (54%) returned their mailed surveys. Fifty-six deans (45%) completed the Q-sort and 59 (47%) completed the climate survey. Sixty-eight chairs (54%) completed the climate survey and 65 (52%) completed the Q-sort. In 34 cases (57% of deans responding, 50% of chairs responding), the dean and chair were from the same institution (matched responses).
The results of the Q-sort exercise demonstrated surprising similarities on how surgery chairs and their deans ranked values that they found most and least essential to their leadership. The values and their means are shown in Table 2. Thirty-eight deans (68%) and 47 chairs (72%) ranked integrity as the single most important value. The next most essential values across participants were trust (ranked second by chairs and third by deans) and vision (ranked second by deans and third by chairs). Values that were considered to have low essentiality for leadership were also ranked similarly by chairs and deans. The three values considered to be least critical were business acumen, authority, and institutional reputation.
Significant differences in the order in which deans and chairs ranked the 38 values existed for only five values. Whereas deans ranked vision as the second most essential value and chairs ranked it third, deans as a group ranked it as a significantly more important value (P = .048). Similarly, deans ranked decisiveness more highly than did surgery chairs (P = .032). Chairs, on the other hand, ranked accountability (P = .03), fairness (P = .046), and drive (P = .01) more highly than did deans.
Leadership climate survey
A list of all of 35 scale items, organized by the seven climate dimensions, is presented in Table 2. In contrast to the results of the Q-sort, which displayed strong similarities in the way deans and chairs ranked the values they thought were most essential to leadership in their organization, there existed major disparities in their assessments of the leadership climate in their institutions. Along multiple dimensions, deans believed that a healthier leadership climate exists in their institutions than their surgery chairs did. Deans ranked the leadership climate as being more positive than did surgery chairs in six of the seven leadership climate dimensions. Only in the constructive-conflict climate dimension were no differences noted. Statistically significant perception differences were observed in 15 of the 35 scale items: leadership is widely shared; everyone is encouraged to lead; leadership is the responsibility of people at the top; information is widely shared; people are not held accountable; good performance is rewarded; leaders are held accountable; poor performers are held accountable; missions are aligned; people from different parts of the organization would give similar answers to the question “What are we trying to accomplish here?”; physicians, researchers, educators, and administrators share similar values; competition is the norm; teamwork is widely practiced; communication is driven by hidden agendas; and open communication is the norm.
Although there was generally good agreement between chairs and deans with respect to values, this concurrence was not perfect—there were still (unsurprisingly) differences in rankings between both paired (dean and chair from same AHC) and unpaired responses. Interestingly, when this discrepancy was analyzed statistically, there was a positive correlation between the degree of disparity in values and the extent to which chairs and deans disagreed about the leadership climate (P = .02).
Association with performance measures
For each of the 34 AHCs where there were paired responses for the climate survey (i.e., the dean and the surgery chair were from the same institution), the following statistics were also obtained: private versus state institution, NIH standing of the medical school and the surgery department (2004 data most recently available), and hospital and medical school ranking by U.S. News and World Report (2005 data). When correlating the climate perception gap between the dean and chair for these 34 pairs, we noted several interesting observations. Tighter alignment between chairs and deans on the leadership climate scale correlated with being at a private (versus state) institution (P = .03), higher medical school and department NIH standing (P < .05), and higher U.S. News and World Report ranking (P < .05). Likewise, better agreement between chairs and deans on the Q-sort correlated with higher medical school NIH standing (P = .07) and higher U.S. News and World Report hospital and medical school rankings (P < .05).
We carried out this study to gain a better understanding of the values that medical school deans and surgery chairs consider most essential for effective leadership, to assess their perceptions of the leadership climate in their institutions, and to test the premise that agreement on leadership values and climate predict better organizational effectiveness and performance.
Q-sort results on 38 positive leadership values indicated that integrity, trust, and vision were considered the most important values for effective leadership by both surgery chairs and deans. This surprising but heartening observation suggests that despite the substantial differences between the institutions we studied, the challenges they faced, and the personalities and leadership styles of their deans and surgery chairs, there were remarkable similarities in their rankings of leadership values. A common, shared set of core values were ranked as most important, and another set of values ranked as least important. The observation that integrity was the leadership value considered most essential across participants is consistent with the finding by other researchers that integrity was the trait most frequently cited by their sample of senior executives as being highly associated with ethical leadership.18
The finding that vision was highly ranked as a leadership value by both deans and chairs may signal the vital importance of setting a clear direction in the face of limited resources and the growing inability to be all things to all persons. Strategy is as much about what the AHC decides not to do as it is about what it chooses to do. In the face of scarce resources and an uncertain future that create angst, the organization’s strategic vision must be clear. “Clarity is the antidote to anxiety,” notes Marcus Buckingham.25 The need for strategic alignment is also critical. Weak alignment, be it structural, role, or cultural, is a major impediment to linking institutional and departmental strategy to achieve the organization’s goals.5
Behaviors are thought to be the manifestation of personality traits and values. A fundamental question, then, is: Do espoused values actually translate into “lived out” values? The present study does not definitively answer this question of cause and effect. However, the observation that deans and chairs who differ more greatly with respect to their perceptions of leadership climate also differ more greatly with respect to their values suggests that if espoused values are lived out, less healthy climates are more likely to be realized in institutions where there is a values discrepancy.
In contrast to the notable values congruence, there were significant disparities between deans and surgery chairs in their assessment of the health of the leadership climates in their organizations. This discrepancy raises the question: Why do such differences exist? It is not unheard of for a top-level leader to be somewhat out of touch with what others at lower organizational levels are experiencing. On the one hand, the deans’ higher scores may reflect their egos or their fear of acknowledging a negative, unhealthy culture. Alternatively, the deans’ higher scores may suggest that they tend to be more optimistic in portraying their institutions as having a healthy, positive climate. This makes sense if one assumes that in their top leadership position in their medical schools, deans must be optimistic and hopeful, even when the future looks gloomy. Chairs, whose assessments of the leadership were more negative than those of their deans, may be assessing a microclimate that differs from the broader environment of the dean.
We did observe an interesting, statistically significant correlation between the alignment of leadership climate perceptions and organizational performance. Using NIH funding (a surrogate marker for scientific excellence), medical school research rankings by U.S. News and World Report (an indicator of research standing), and hospital rankings by U.S. News and World Report (an indicator of clinical excellence), we noted that a tighter alignment between leadership perceptions of deans and surgery chairs was correlated with better organizational effectiveness, whereas a misalignment was associated with poorer institutional performance. We recognize that NIH standing and U.S. News and World Report rankings are not perfect measures of the quality of research and patient care that occurs in our AHCs. But they are measures that a number of stakeholders—including students, faculty, payers, and patients—pay attention to. In particular, these measures are not very good for evaluating teaching excellence.
It is also important to point out that no cause and effect between leadership assets and performance can be established. One might speculate that enhanced performance and outcomes are by-products of an organization in which multiple constituencies experience the leadership climate as being healthy. Conversely, one might speculate that positive perceptions of leadership climate are one effect of superior performance. Further studies will be necessary to tease out the role of factors such as organizational structure, governance, and fiscal solvency in creating a healthy leadership climate.
A question of great practical importance concerns how to change a negative leadership climate. It may be premature to offer definitive prescriptive advice on this, especially because a negative leadership climate is likely a manifestation of a whole host of organizational problems. However, we believe that some sound general advice is to promote and to model the types of behaviors reflected in the leadership climate scale.11,26,27 For example, a leader should:
▪ encourage participation, involvement, and engagement in leadership processes;
▪ practice transparency in decision making and invite collaboration and open communication;
▪ hold one’s self and others accountable for meeting performance expectations and setting positive behavioral standards;
▪ not shy away from conflict but, instead, use it constructively; and
▪ seek to align personal values with the organizational mission and to support all key elements of the mission.
We know that modeling is a potent force on human thinking and behavior. Effective leadership begins with embracing a set of core values and engaging in authentic decision making and behavior. A positive example of authentic leadership at the top of the organization can have a powerful cascading effect throughout the entire organization. Although one person may not be able to completely change the leadership climate of an organization single handedly, we believe that positive role models can certainly make a difference and contribute to climate change.
It is interesting and perhaps somewhat paradoxical that business acumen was listed as a less important value, especially given the financial challenges that exist at most AHCs. Both chairs and deans ranked “results” relatively highly (15th and 16th, respectively) among the 38 values. This may seem to be an inconsistency, but we believe chairs and deans view getting results as requiring much more than business savvy. Achieving meaningful results requires trust, teamwork, vision, and other values in addition to business sense. Of note, we didn’t ask the participants how essential the core values were to solving their fiscal challenges. Rather, we asked them how essential these values were to how they thought about leadership in their organization. These questions are different and may also explain why business acumen did not emerge as a highly espoused value.
Of the dozen most essential leadership values ranked by both deans and chairs, there are at least five (trust, developing people, teamwork, building relationships, and open communication) that could be considered more collective than individual in their orientation. The wide average endorsement of these values bodes well for the development of shared leadership and building leadership as a property of a living system.27,28 It also indicates a willingness to promote the importance of sharing power and influence. Values such as integrity, trust, open communication, and teamwork can be developed in leaders, and we believe this holds continuing promise for the development of positive organizational leadership in AHCs. Because of their leadership positions, medical school deans and surgery chairs play a vital role in creating the conditions and the climate that will help others make the right choices. In view of the clash that seems to exist between climate perceptions, this role is absolutely crucial. Future research is needed to determine whether other AHC leaders (i.e., other department chairs, hospital executives, center directors, practice plan leaders, nursing directors, administrators, and faculty at large) endorse similar values and, more important, whether shared values that are truly enacted to contribute to building a healthier climate and improve organizational performance. There is some evidence that shared values do improve institutional outcomes.29
Although surgery chairs and deans espouse similar values, our study indicates that there exist major disparities in their assessment of the leadership climate in their institutions. Along multiple dimensions, the responding deans said that they believe that a healthier, more positive leadership climate exists in their AHCs than their surgery chairs do. Tighter leadership alignment between deans and surgery chairs is correlated with better organizational results, whereas major disparities indicating a misalignment of perceptions and values are associated with poorer institutional effectiveness in the clinical and academic missions. On the basis of these observations, it seems that developing effective leaders and leadership in an AHC requires a proper context—that is, a healthy climate and a set of “real” (not just espoused) core values. Rather than just hoping that deans and chairs are unified on these dimensions, we believe that creating alignment between deans and chairs should be an explicit and important goal.
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