Academic health centers (AHCs) are facing unprecedented challenges. Decreasing state and federal funding, changing health care delivery systems and payment structures, and educational expansion due to labor shortages are among the pressures currently straining AHCs across the United States.1,2 Today, academic department chairs are expected to be competent in multiple aspects of the enterprise including “winning contracts, enhancing revenue, reducing costs, recruiting and managing a diverse workforce, and dealing with consumer satisfaction and marketing.”1 Recruiting and developing top talent into the critical leadership role of department chair is one of the most important ways to shape the future of academic medicine.
Despite the crucial need to recruit competent leaders into these roles, studies show that multiple challenges are inherent to the process.3,4 One study of deans and teaching hospital chief executive officers (CEOs) showed that problems in recruitment include the following: haphazard administrative practices, difficulty identifying leadership competencies to assess in candidates, challenges in assessing candidates’ institutional fit, lack of diversity in the pool, and misalignment between the goals of the dean and of the hospital CEO.5 Other authors cite challenges such as variable training and effectiveness of search committees, loss of information and best practices from search to search, a regulatory rather than proactive approach to recruiting diverse candidates, and a lack of strategic approaches for recruiting dual-career couples.5–7 At the same time, the search process for department chairs can be protracted; some searches last a full year or more.8 This long process often creates additional stressors (e.g., faculty uncertainty about the future, difficulty recruiting resident/fellows) within the unit.9
These shortcomings have persisted for multiple reasons. Although the academic medicine enterprise has increased in complexity and grown tremendously over the past 20 years, many of the institutional practices that are still in place and were effective in the past have not kept stride. Medical schools have traditionally been structured around highly independent departments and rigidly defined ranks and hierarchies.10 Regrettably, this traditional structure leads to silos, barriers against centralization, and limited sharing of effective processes both internally and externally. Further, chair candidates are often still judged primarily on the strength of their academic credentials on the basis of the assumption that the skills that lead to being a well-funded, tenured, high-ranking faculty member will translate into being an effective department chair. The literature indicates that these challenges can lead to a precarious outcome: department chairs who are selected because of their reputation within their discipline, rather than their leadership skills.6 Further, after starting their new role, chairs often receive little formalized training or feedback, and many struggle to transition smoothly into their new leadership role.1,6,11,12 Gmelch11 contends that academic leaders such as department chairs
typically come to their positions without any leadership training, without prior executive experience, without a clear understanding of the ambiguity and complexity of their roles, without recognition of the metamorphic changes that occur as one transforms from an academic to an academic leader, and without an awareness of the cost to their academic and personal lives.
Although experts have recommended more comprehensive strategies for chair development and evaluation for a number of years,13–15 few resources exist16 to help institutions develop such strategies. A few organizations offer discipline-based development programs for new chairs. Specifically, the Council of University Chairs in Obstetrics and Gynecology has a “School for New Chairs,” and the Association of Medical School Pediatric Department Chairs hosts a “New Chairs” meeting. Additionally, “toolkits”17 have become more widely available, yet institutional support is still greatly needed. The need is particularly apparent given the diminishing tenures and higher turnover rates of academic medicine department chairs over the past 25 years.6,17,18 Not surprisingly, these troubling turnover rates coincide with multiple reports of significant burnout in chairs, especially for those who have served for fewer than 5 years.19–22 Thus, attending to the professional development needs of chairs may be critical to enhancing not only their effectiveness as leaders but also their longevity as chairs.
It is ironic that department chairs are often ill prepared to lead because few roles in AHCs have such tremendous influence on the culture of an institution.23 Given this potential to effect institutional change, the academic medicine community must first select the right individuals to lead departments and then help them hone their leadership skills. To that end, we sought to ensure the success of chairs at our institution, the Indiana University School of Medicine (IUSM), and in turn to improve the institution as a whole, by developing a comprehensive talent management model for recruiting, developing, and giving feedback to department chairs. The purpose of this Perspective is to share our approach as a potential model for other institutions.
Using Competencies to Drive Change
Prior to launching the initiative to improve our chair recruitment, development, and feedback processes, IUSM faced a number of challenges in the recruitment process including (similar to some of those described above) large and highly variable search committees that lacked clarity regarding expectations for members, selection criteria, and even the search process itself. Further, once on the job, chairs rarely interacted with one another and did not receive structured professional development or feedback to help them assess and increase their effectiveness. Without standardization in the recruitment, development, and feedback processes, each department often reinvented the wheel for each new search.
The ultimate goal of the initiative was to enhance the institution through recruiting and developing the future-oriented, emotionally intelligent, talented leaders necessary for success in the changing and complex environment of the current and future AHC. In an effort to improve IUSM’s recruitment of and support for department chairs, we first reviewed literature in academic medicine as well as in higher education that examined the attributes of successful department chairs and other academic leaders.6,24–26 We searched PubMed as well as online education databases such as EBSCO. Given the scant amount of literature on academic chairs, we reviewed articles from the last 15 years. We reviewed research studies as well as general perspectives and firsthand commentaries about the roles and responsibilities of these leaders. We also reviewed literature on emotional intelligence27—that is, the ability to effectively manage oneself and one’s relationships with others. To arrive at our competencies, our faculty development group, which consists of six individuals, discussed the cross-cutting themes from the literature. These conversations, resulting in initial drafts of the competencies, took place during our weekly meetings over a three-month period. Once we established our initial set of themes, we evaluated the extent to which these attributes matched those of our most effective department chairs. Thus, our six competencies—leadership and team development; performance and talent management; vision and strategic planning; emotional intelligence; communication skills; and dedication to the tripartite mission—were ultimately informed by both a review of relevant literature and our experiences as faculty developers.
Because the initial review of chair candidates includes a rigorous evaluation of their academic credentials (e.g., research, funding), we did not include the academic and/or clinical background of the candidate in our competency model. Although some of the competencies we identified such as communication and self-awareness overlap with the Accreditation Council Graduate Medical Education (ACGME) and CanMEDS Physician Competency Frameworks, the emphasis of our model is on leadership skills versus clinical skills and medical knowledge. Table 1 lists the competencies we identified as well as a subset of skills associated with each competency, and some of the literature that inspired us to include the competency in our model. It should be noted that rather than focus on a very specific skill (e.g., managing a budget), we developed broader categories and then worked to define the subset of skills associated with each competency. We found the 2007 meta-analysis completed by Bryman28 and the Five Practices of Exemplary Leadership developed by Kouzes and Posner29 to be especially helpful.
Our draft competencies were widely discussed among IUSM’s leaders (including the dean, executive associate deans, research center directors, and chairs) and further vetted by search committee members. We further refined the competencies after their initial use, incorporating feedback we received from a committee that actually applied the competencies to a search. This initiative took place over the course of two years (2009–2011), and we continue to modify and enhance our department chair processes using the competencies. These competencies now form the basis for our department chair recruitment, development, and feedback process.
Use of the competencies.
Starting at the recruitment stage, we refer to the leadership competencies. In our advertisements, we cue applicants to address some or all aspects of these in their initial letters of interest (e.g., Please include discussion of your leadership experiences and approach). Search committees screen every chair applicant’s letter of interest and CV according to the competencies; that is, committee members rank items [high–medium–low] in the letters and CVs via electronic surveys. In addition, we have developed sample behavioral interview questions, mapped to the six competencies, which we share with everyone scheduled to interview the candidates (e.g., Emotional Intelligence: What is the toughest decision you have ever had to make?; Communication Skills: Can you tell us about a time you had to communicate an unpopular decision to an individual or group? Please describe your approach and the outcome). Search committee members and those who meet with candidates are asked to assess candidates on each competency, again, through an electronic survey that has a structured response scale (high–medium–low) and through open-ended questions. Additionally, the questions we use to query candidates’ references also focus on the six competency areas.
New recruitment processes.
In our efforts to improve the recruitment process, we have also addressed a number of organizational and logistical issues that caused delay and introduced unwanted bias. Although these are not directly related to the leadership competencies, we implemented several changes, including the following:
- Developing a transparent process map to outline the structural, regulatory, and process issues involved in searches.
- Clarifying staff and faculty roles of search committee members and adding an assistant or associate dean from the Office of Faculty Affairs and Professional Development (OFAPD) as a co-chair on each search committee to ensure the integrity of the process.
- Creating greater consistency in search committee size and composition. (Specifically, committees now have nine or fewer members, including the chair and co-chair and one to three members from the department–all of whom are selected by the dean as much for their capability to identify leaders as for which stakeholder group they represent. The dean seeks input from the OFAPD as well as from the other executive associate deans.)
- Standardizing certain practices through communication templates, a committee member code of conduct, and the dean’s charge guidelines.
- Minimizing the potential impact of unconscious bias through the interviewing processes described above and having committee members view the Association of American Medical Colleges–developed module on unconscious bias30 and/or read the Analysis in Brief31on the same topic.
Outcomes so far.
Thus far (November 2014), we have successfully recruited six department chairs using our new standardized, competency-based approach. A review of institutional documents and records for the three searches conducted just prior to our intervention indicate that the average number of months per search was 18.33 (range: 16–22 months). A review of three searches conducted post intervention (through July 2014) shows that the average number of months has decreased by about 5 months to 13.33 (range: 10–15 months). Thus, we believe that by standardizing the process and providing centralized support, our searches are now far more efficient. On the basis of anecdotal evidence and from extrapolating calendar data from our administrative and professional staff, we previously spent about 260 hours of staff time per search, including scheduling meetings, developing itineraries, escorting candidates, and compiling evaluation data. Currently, each search takes about 150 hours of staff time. This reduction in expended staff time has decreased both the direct expenses associated with each search and the indirect costs of faculty and staff time and effort.
In addition to attending to the recruitment process, we also launched a professional development series to create opportunities for our chairs to develop knowledge and skills around the leadership competencies. We began by conducting a workshop for department chairs that served as both a needs assessment and a kick-off event for the series. This workshop included a facilitated discussion of challenges and areas for development in an open and safe format. Not surprisingly, many of the topics the chairs wanted to discuss were areas that directly related to our identified leadership competencies (e.g., team development, communicating a vision, conflict and change management, fundraising, and fiscal management).
Using both local and national resources, we now host quarterly, voluntary workshops over breakfast or dinner for chairs. The format allows for chairs to share concerns as peers and to learn promising practices from each other, which cultivates among them a greater sense of community. Since beginning the series in fall 2011, we have held a total of 10 sessions (see List 1 for session titles). The feedback we have received from deans has been positive; they have described elements of the sessions they hope to apply and have identified key takeaways (see Table 2).
List 1 Examples of Topics (Titles) of Quarterly Meetings for Department Chairs at Indiana University School of Medicinea Cited Here
- What Keeps You Up at Night
- Leading Change
- Faculty Vitality
- Valuing Education in a Difficult Funding Climate
- Leading Teams Effectively
- Improving Faculty Search and Screen
- Managing the Talent Pipeline
- Creating a Positive Work Life Culture
- Avoiding and Managing Legal Issues
aThe meetings, held during breakfast or dinner, are voluntary and allow department chairs to build community by sharing concerns and best practices.
Providing chairs with feedback
Each year, IUSM conducts a survey of faculty as a way of providing feedback to chairs. Two types of surveys are conducted in alternating years. First, faculty are able to provide an assessment of their chair’s leadership via the Department Chair 360° Leadership Survey.32 The 360° instrument includes two open-ended questions and 20 questions with Likert-type responses that are mapped to the competencies. Faculty provide an assessment of their chair through questions such as “My leader is able to articulate a vision that inspires a sense of purpose in others,” “My leader is able to change to meet the needs of a changing environment,” and “My leader is able to effectively lead a team.” Chairs also complete a self-assessment answering the same questions during the 360° process.
In alternating years, faculty participate in the Faculty Vitality Survey, an instrument IUSM designed to measure faculty satisfaction, productivity, and engagement; faculty members’ perceptions of the climate and leadership in their units; and faculty members’ views on their own careers and work–life integration.33 This instrument offers more insight into the experiences of the faculty members themselves, thereby providing a snapshot of the overall health of the department. Both the Department Chair 360° Leadership Survey32 and the Faculty Vitality Survey33 are approved by Indiana University’s institutional review board and are administered off-site to allow for confidential responses.
Annually, chairs receive feedback from one of the two aforementioned instruments, both of which are aligned with the competencies and reviewed during a department annual review (DAR) meeting. Conducted by the dean and the five executive associate deans for clinical affairs, educational affairs, research affairs, faculty affairs and professional development, and finance and administration, DARs include a discussion of key metrics from each mission area. The two instruments mentioned above are included in the section of the DAR devoted to faculty affairs and professional development.
Further, as a result of these surveys, department chairs receive information in the aggregate about other departments and other chairs’ performance on the leadership competencies, so they know where they stand in relation to their peers. Clinical chairs are benchmarked against the mean for all other clinical chairs, and likewise, basic science department chairs are benchmarked against the mean for other chairs of basic science departments. The dean uses the benchmarking data to encourage the sharing of promising practices and approaches across academic departments, and IUSM uses the data to think more strategically about its efforts to continually improve department chair processes across the life cycle of that role.
We have learned a number of lessons through the process of developing and applying leadership competencies to our department chair recruitment, development, and feedback processes that may be useful for other AHCs interested in improving their own chair activities. To begin, support from the dean and other executive leaders is critical. Support is particularly helpful when the AHC moves from using traditional metrics (e.g., number of funded grants, number of peer-reviewed articles) to a focus on leadership competencies. To ensure the buy-in of all faculty, current chairs as well as executive leaders should be involved in the identification of specific leadership competencies and in the process of determining how they will be used, communicated, and measured.
Centralizing and standardizing the search and screen process requires dedicated staff and faculty effort. Although this effort may require the creation of one or more new position(s), the more efficient, streamlined searches may create cost savings. Further, the cost associated with an internal search specialist is considerably less than regularly consulting search firms.
The review of chairs must align with the identified leadership competencies and should include feedback from faculty. Aligning the review with the competencies means that, from the point of interview onward, the chair has a clear set of expectations for the areas in which he or she must be competent. Further, annual department reviews, which address the leadership competencies as well as all three mission areas, may inform not only the professional development goals of individual chairs but also professional development programming for chairs and other leaders in the AHC.
Given the initial success of the competency-based approach to recruiting, developing, and giving feedback to department deans, it would be useful to cascade efforts to parallel processes at the department level. At IUSM, we have already begun to apply the leadership competencies through training department administrators and chairs. Further, we are challenging chairs to use a competency approach to recruiting their department faculty, and we intend to generate a competency framework for schoolwide (IUSM) use. A competency framework could also inform faculty annual reviews and individual faculty development plans—just as it does for department chairs. Finally, the use of leadership competencies for faculty recruitment, development, and reviews is an important area for further research.
Indeed, as with any intervention, we must continue to assess the effectiveness of our efforts over time. Through future research, we plan to evaluate the degree to which our recruitment practices yield greater recruitment and retention of women and underrepresented minority faculty, in both department leadership roles and at the faculty level. In addition, we plan to study whether this leadership-competency-based talent management approach leads to greater retention (or longer service) of department chairs, increased personal career satisfaction among chairs, and more favorable faculty perceptions of chair leadership.
The role of an academic department chair is not becoming any easier; leadership is especially daunting in the ever-changing academic medicine environment. Department chairs must respond to issues such as clinical market share, patient safety, and quality of care amidst health care reform and changing payer systems—while at the same time, both striving to advance the research mission in a highly competitive funding environment and continuing to provide a high-quality education for diverse learners. Thus, we believe that using a literature-based, standardized talent management approach that focuses intentionally on core leadership competencies to recruit, develop, and give feedback to department chairs is critical to the success of AHCs.
Attending to the manner in which institutional leaders are selected, developed, and given feedback yields tremendous benefits to the institution and represents a critical lever for shaping the culture and diversity of an AHC. Our program seeks to recruit and equip the future leaders of our institution with the necessary tools for success. Department chairs need a conceptual understanding of their roles, opportunity for skill development, and time for reflective practice and growth.12 The use of leadership-competency-based department chair processes promotes a culture in which department chairs feel supported and are primed to excel. The full success of this approach will be realized only after chairs have been on the job for a few years, but evaluation tools such as the Department Chair 360° Leadership Survey32 and Faculty Vitality Survey33 allow timely evaluations of chairs and departments—as well as a comparison of chairs’ skills and department culture before and after the implementation of leadership-competency-based processes. Although better-prepared chairs do not guarantee success, explicitly hiring for and developing leadership skills can only encourage department effectiveness and stability.
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