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Leadership development programs for health care middle managers: An exploration of the top management team member perspective

Whaley, Alan; Gillis, William E.

doi: 10.1097/HMR.0000000000000131

Background: Hospitals throughout the United States establish leadership and management programs for their middle managers. Despite their pervasiveness and an increased emphasis on physician leadership, there is limited research regarding the development programs designed for clinical and nonclinical health care middle managers.

Purpose: Using two theoretical lenses, signaling and institutional theory, this exploratory study investigates mid-sized hospital development programs from the perspective of top management team (TMT) members. Our objective is to find out what types of programs hospitals have, how they are developed, and how they are evaluated.

Methodology/Approach: We conducted semistructured interviews with 13 TMT members in six purposefully selected hospitals and matched these interviews with program curricula. Careful coding of the data allowed us not only to show our data in a meaningful visual representation but also to show the progression of the data from raw form to aggregate themes in the qualitative research process.

Findings: We identified four types of development programs used in the selected hospitals: (a) ongoing series, (b) curriculum-based, (c) management orientation, and (d) mentoring. Challenges existed in aligning the need for the program with program content. Communication occurred both through direct messaging regarding policies and procedures and through hidden signals. TMT members referenced other programs for guidance but were not always clear about what it is they wanted the programs to accomplish. Finally, there was limited program outcome measurement.

Practice Implications: Our small sample indicates that specific, structured, and comprehensive programs perform best. The better programs were always trying to improve but that most needed better accountability of tracking outcomes. In setting up a program, a collaborative approach among TMT members to establish what the needs are and how to measure outcomes worked well. Successful programs also tied in their leadership development with overall employee development.

Alan Whaley, DBA, is Chief Strategy Officer, University of South Alabama Health System, Mobile.

William E. Gillis, PhD, is Associate Professor, Department of Management, Mitchell College of Business, University of South Alabama, Mobile. E-mail:

The authors have disclosed that they have no significant relationship with or financial interest in any commercial companies pertaining to this article.

Hospital middle managers exercise great influence on the delivery of high-quality, safe patient care. (Garman, McAlearney, Harrison, Song, & McHugh, 2011; MacDavitt, Chou, & Stone, 2007; Singer et al., 2011). Their role in creating and maintaining efficient operations continues to grow (Birken et al., 2015; Birken, Lee, & Weiner, 2012). Middle managers are challenged by an increasingly complex work environment, adding pressure to jobs that are already difficult. In response to this, health care executives establish and implement leadership and management development programs to prepare managers, both clinical and nonclinical, for the demands placed upon them by the challenging changes occurring across the industry (McAlearney, 2010; Thompson & Kim, 2013). Despite the pervasiveness of development programs and an increased emphasis on physician leadership (Hopkins, O’Niel, FitzSimons, Bailin, & Stoller, 2011), there is limited theoretical and empirical research regarding programs designed for health care middle managers. Because little is known about how these programs are structured to meet hospital and middle manager needs, this article explores the complex nature of development programs from the perspective of top managers.

In 2013, over $15 billion was spent on leadership development programs (PR Newswire, 2014). The number of health care organizations incorporating leadership development programs into their organizations has increased significantly in recent years (Woltring, Constantine, & Schwarte, 2003) with almost half of 3,000 recently surveyed hospitals reporting that they have some type of leadership development program (Thompson & Kim, 2013).

Even with the growing number of leadership development programs in hospitals, there are few studies that consider leadership development in health systems and hospitals in terms of content and effectiveness (McAlearney, 2006, 2008, 2010; McAlearney, Fisher, Heiser, Robbins, & Kelleher, 2005; Thompson & Kim, 2013). Primarily, these studies have focused on leadership development for executives (top management team [TMT] members) and physicians but not for the hospital middle manager (Frich, Brewster, Cherlin & Bradley, 2015; Hopkins et al., 2011; McAlearney, 2006). We define TMT members as employees that directly or indirectly supervise middle managers. They typically have the title of vice president or above and are considered executives of the organization. Hospital middle managers are employees who are supervised by a TMT member and who also supervise other employees (Birken, Lee, Weiner, Chin, & Schaefer, 2013). We specifically include both clinical and nonclinical supervisors in this definition. We also found that mid-sized hospitals had TMT members who are more involved in overseeing the programs, but only one program had any physicians (Hopkins et al., 2011; Pappas, Flaherty, & Wooldridge, 2004). Because of the lack of theoretical and empirical research in this area, McAlearney (2010) specifically called for research in leadership development for hospital middle managers. This study begins to answer that call.

A standard method of creating any leadership or management development program is for the top executives of the organization to identify the competencies they believe are most needed to fulfill the mission and vision of the organization (Kaiser & Curphy, 2013). Hospital top executives such as the CEO or vice presidents are the individuals who establish the strategic direction and goals for the program and then develop these leadership and management programs (McAlearney, 2006, 2010). Although larger hospitals will then run these programs through Human Resources (McAlearney et al., 2011), small- and medium-sized hospitals may be more hands on in their implementation. Furthermore, no research has been conducted that investigates the role TMT members have in structuring these development programs.

Drawing on observations from top executives from similarly hospitals located in the southeastern United States, we undertook an exploratory study of leadership and management development programs designed for hospital middle managers. We focused on the role that TMT members play in establishing the programs, determining the programs’ content, and ultimately judging their success. In addition, we used signaling and institutional theory lenses to examine some hidden messaging sent from executives to middle managers and reasons behind the similarity of programs across hospitals.

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Conceptual Framework and Theory

TMT members have many responsibilities such as developing and implementing new policies, managing budgets, and other executive responsibilities in addition to running these development programs. Thus, anytime these TMT members can combine activities, they may be able to save time. In addition, they may save time developing programs by referencing other hospitals’ programs. We explain these two perspectives below.

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Signaling Theory

Organizations need to communicate policies and procedures to employees. This communication can be direct with clear meaning or include hidden meanings. Both the obvious and hidden types of messages that TMT members communicate to subordinates are referred to as signaling (Spence, 1973). For example, managers signal to employees that they are committed to patient safety by making it a major focus of their time and attention (Singer et al., 2011). Organizations also send less obvious signals to their employees. For instance, McNall (2010) found that employees in organizations with family-friendly policies interpreted these policies as a sign that the organization was concerned for them.

Signals are also viewed as tactics that organizations use to shape members’ views and actions (Bowen & Ostroff, 2004). Signals help employees better understand organizational interests, values, and strategic direction. Organizations use signaling to communicate expectations regarding specific behavior. As specific skills, routines, and systems are made known, middle managers develop a shared understanding of the performance requirements. To the extent that these signals are unambiguous, performance should improve for both middle managers and the organization (Biron, Farndale, & Paauwe, 2011). We investigate whether and how TMT members use the development programs to send both overt and hidden signals to their middle managers.

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Institutional Theory

Institutional theory explains isomorphism or why over time organizations begin to resemble one another. Regulatory, mimetic, and coercive pressures give organizations incentive to adopt similar practices regardless of their effectiveness (Meyer & Rowan, 1977). Instead, organizations seek and gain legitimacy by adopting practices or programs from other organizations. For instance, a regulatory pressure might originate when an accrediting body finds a problem during an inspection and suggests to the organization a possible solution, which is then instituted. Other hospitals copy the approach knowing that it will satisfy regulators regardless of whether a better, more effective solution is possible. Over time, this approach becomes the standard, and more institutions use it (DiMaggio & Powell, 1983).

Hospitals often mimic the practices and programs of other hospitals without basing the adoption of these practices and programs on their effectiveness. Mimetic isomorphism occurs when an organization is uncertain of what actions to take or programs to adopt so it copies a program of a nearby institution. For instance, hospitals may institute development programs simply because other nearby hospitals have begun these programs or because there has been national coverage of similar programs. We primarily investigate this mimetic explanation for the existence of similar development programs among hospitals (Mascia, Morandi, & Cicchetti, 2014; Miles, 2012).

Signaling theory has often been combined with institutional theory, as firms seek to signal their legitimacy (Connelly, Certo, Ireland, & Reutzel, 2011). The hospital industry is subject to strong institutional pressure in which there is a need to appear legitimate to constituents such as employees, colleagues, and the community (Meyer & Rowan, 1977). Institutional theory has been used to examine reasons for adoption of new practices and programs by health care organizations (Mascia et al., 2014). In combination, these two theories provide the background for our exploratory investigation of how and why hospital TMT members make and implement decisions related to middle managers development programs.

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We conducted semistructured interviews with 13 TMT members in six purposefully selected hospitals. We selected hospitals that were large enough to have programs but small enough that the CEO and other TMT members would most likely be directly involved in development and implementation of any programs. We interviewed the President/Administrator of each hospital as well as a vice president level position. For Hospital 6, we interviewed an additional TMT member, as this hospital had been acquired within the past 3 years, there was limited corporate knowledge due to turnover, and it was our only “for-profit” hospital. Vice president level interviews included two Chief Nursing Officers, two vice presidents responsible for multiple clinical service lines, a Chief Financial Officer, a Chief Operating Officer, and one vice president responsible for support services (see Table 1 for TMT and hospital demographics). The structure of the interviews allowed the voices of the TMT members to be prominently reported in the research (Gioia, Corley, & Hamilton, 2012). This process enabled us to investigate how key TMT members influence the formation, content, and direction of hospital leadership and management development programs targeted for hospital middle managers. We coupled the interviews with archived curricula, meeting minutes, and field observations to triangulate an assessment of each hospital and its development program.

We selected hospitals to represent similarly sized facilities with different ownership structures. The different ownership structures gave us the advantage of investigating commonalities and differences among nonprofit and for-profit hospitals of a similar size but had the limitation that differences might be just unique to each hospital’s ownership structure and not indicative of all hospitals of that type. Each hospital is located in a different metropolitan city in the Southeastern United States across three states. Hospital 1 is a community-owned hospital that operates as a part of a multihospital regional system. Hospital 2 is a university-affiliated facility with extensive residency training programs. Hospital 3 is a county-owned hospital. Hospital 4 is affiliated with a national faith-based health system. Hospital 5 is a member of a community-owned, multihospital system. Hospital 6 is part of a for-profit national chain. We asked each hospital interviewee (and confirmed with Human Resources) about the number of clinical and nonclinical middle managers and report these numbers in Table 1. Through follow-up questions, we were able to ascertain that these numbers varied partly due to each hospital self-classifying its own management structure. The leanest hospital, based on bed size and annual discharges per number of managers, was Hospital 6, the for-profit hospital, whereas the hospital with the most middle managers for its bed size (Hospital 1) classified some as managers even though they did not function in a management role.

On the basis of the fact that only half of all hospitals have leadership programs (Thompson & Kim, 2013), we were initially surprised to find more than one program at every hospital. Three of the hospitals have had middle manager development programs in existence for over 8 years. One hospital began a development program within the last year. Two hospitals discontinued at least one of their development programs, one for financial reasons and the other for performance outcome reasons. These discontinued programs are included in Table 1 but were not annotated to help retain hospital anonymity. Hospitals appeared committed to improving the skills of the middle managers and the multiple program approach offered flexibility to achieve this, but the multiple program approach also showed the difficulty of using just one method.

Interviews ranged from 30 minutes to 1.5 hours and contained a series of open-ended questions (see Appendix A) that asked the TMT members about various aspects of their development programs. We specifically and intentionally used the generic term “development program” to not bias interviewees toward either the use of the term leadership or management and allowed the TMT members to determine what constituted a development program. Each interview was digitally recorded and then transcribed. The transcribed interviews were then analyzed according to qualitative rigors outlined by Gioia et al. (2012). We obtained human subjects approval through the institutional review board of the authors, and all study participants were assured that their responses would remain anonymous.

We employed NVivo 11.0, a software tool for qualitative data analysis, to facilitate the data coding. First, we adhered to the terms used by the informants providing over 40 categories in the first-order analysis. Next, we analyzed these categories for similarities and differences using axial coding (Strauss & Corbin, 1998), allowing for the combination of categories into similar themes. We eliminated some first-order categories as they were not relevant to further assignment. By combining similar first-order themes, we developed second-order concepts allowing us to obtain a more clear understanding of what was occurring in the programs. We further combined these second-order concepts into second-order “aggregate dimensions” (Gioia et al., 2012), the final element of the data structure (see Figure 1). The data structure allows us not only to show our data in a meaningful visual representation but also to convey the progression of the data from raw form to themes in the qualitative research process (Gioia et al., 2012).

Figure 1

Figure 1

Table 1

Table 1

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All hospitals identified managers and directors as the primary audience for development programs. One hospital periodically allowed nonmanagers to attend its curriculum-based program if these individuals had been identified by the organization as potential managers. Vice president level positions often served as instructors or facilitators during program sessions. As noted in Table 1, we identified four types of programs: (a) ongoing series, (b) curriculum based using an academic classroom format, (c) management orientation, and (d) mentoring. These are expounded upon below.

Five hospitals used ongoing series programs, regularly conducted (monthly or quarterly) meetings with no formal curriculum for all middle and some top managers. Monthly programs lasted about an hour, whereas quarterly programs typically were half-day sessions. Program content varied with minimal consistency between sessions.

Three hospitals used curriculum-based programs, scheduled meetings lasting from 1 to 4 hours in a classroom with start and end dates and a limited number of invited participants. Only one hospital allowed any staff employees to participate. Programs ranged from 5 to 12 months in duration with classes scheduled either bimonthly or monthly. These programs covered a broad spectrum of mostly management topics including but not limited to statistics, finance, health care law, human resources, communication, and budgeting. These more structured curriculums generally remained the same or changed only slightly from cohort to cohort.

Newly promoted or new to the organization middle managers participated in the manager orientation programs. Three hospitals conducted these programs two to four times a year as part of both an orientation and development process designed for middle management. Each program generally consisted of two or three structured sessions that introduced policies, procedures, and resources of the organization. They emphasized technical responsibilities to ensure managers had a basic understanding of their new role.

Four hospitals implemented some mentoring. No set time frames existed for the mentoring programs, and they were used for both development and orientation. Administrators mentioned that selected middle managers were occasionally assigned a peer or executive mentor to serve as an informational resource or help them get acquainted with their new organization or role. However, because Human Resources had limited knowledge of their existence and no actual documentation existed, we considered them unstructured but still relevant and important to the organization and our inquiry.

In the next sections, we explore how these four program categories align with the findings of four “aggregate dimensions” developed from the interviews (see Figure 1). First, we discuss the TMT members’ description of the needs and reasons for their hospital’s programs. Second, we analyze the similarity of the programs that arose from administrators not being sure of what they wanted from the programs. Third, we examine the communication aspects in terms of their transparent and hidden messaging. Finally, we address the difficulty of defining and measuring outcomes.

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A recurring theme among TMT members was their recognition of the degree of variability in skill sets of the middle managers and their desire to address these shortcomings. All programs were attempts to shore up these deficiencies. Two factors contributed to this skill set variability. First, hospital middle managers are often selected for their position as a result of strong clinical, technical, and interpersonal skills without regard to background or education with some middle managers only completing high school whereas others held master’s level degrees (Kovner, Channing, Furlong, Kania, & Pollitz, 1996; Roemer, 1996). Second, there is often great discrepancy in the tenure and experience of middle managers with some occupying their positions for over 20 years whereas others were new to the position.

In summary, TMT members attempted to design and implement programs that would improve middle managers’ abilities to resolve conflict, communicate with their staff and physicians, prepare budgets, analyze financial results, flex staff, understand and implement human resource policies and procedures, address employee turnover and retention, work in teams, communicate concisely with superiors, drive process improvement in their departments, and accurately evaluate staff performance. However, the programs still had difficulty in meeting the needs of these managers.

Hospital 4, TMT member A: One manager may be really good at flexing the staff; the next manager is really good at motivating people. Those don’t necessarily, two skill sets, align at the same time

Hospital 5, TMT member A: My assessment was the sheer variation of skill set and knowledge that our leaders have. It’s just all over the map. If you say, “What’s baseline? Define baseline.” You can probably define it a number of different ways, but what’s baseline?

Other administrators echoed these reasons identifying that a major intent for the programs was to expand the middle managers’ abilities and improve various managerial subareas by providing them educational opportunities. Although there was broad consensus regarding this general intent across all hospitals, there was less agreement between hospital TMT members of the same hospital regarding the specifics of their own program content. For instance, one TMT member thought that the program content design focused more on improving leadership and management skills of the middle managers whereas the counterpart thought that the program primarily existed as a method to communicate policies and procedures and provide updates regarding hospital initiatives.

This may have been a result of not all team members participating equally in creating or modifying program content. Thus, TMT members who were not as involved in determining program content had a different understanding than those who were more directly involved. In addition, some programs, such as the mentoring programs were so unstructured that they had no real content.

The ongoing series programs held on a monthly or quarterly basis offered a more difficult environment in which to maintain program format consistency. Because this program format was often changed for each session, it led to no ingraining of cultural expectations. Thus, both the passage of time and changes in the composition of the TMT led to significant evolutions in program content and to changes in the understanding of its intent. For example, Hospital 5’s ongoing series program, in existence for over 10 years, evolved from a program to simply improve managerial skills into one emphasizing policies and procedures as well as updating managers on new hospital initiatives.

Because they were more structured and formalized, hospitals with curriculum-based programs had more agreement between TMT members as to their collective understanding of the programs. These curriculum-based programs provided consistency of program content from cohort to cohort. This facilitated the institutionalization of the program and its purpose into the culture of the organization and provided a clearer understanding among the TMT members regarding program needs.

Similarly, we found little disagreement between TMT members concerning the intent and content of the manager orientation programs. These programs provided the new managers with specific training regarding policies and procedures. Topics included hiring procedures, employee evaluation policies, and budgeting.

Overall, the various interpretations of program needs resulted in both a general consensus that middle managers needed improvement in some areas but disagreement on some specifics. Over time some TMT members saw the programs as a means of communicating information, and this divergence in understanding resulted from a lack of consistency in program structure and lack of involvement by some TMT members in determining program content. The passage of time and changes in the TMT composition also played a key role in explaining these differing views.

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TMT members from four of the six hospitals specifically stated that they reviewed programs from other hospitals before beginning at least one of their programs. The two hospitals that did not view other programs also add support to the mimicry nature of these programs. The for-profit national system, owners of Hospital 6, purchased a development program from a nationally known consulting firm and implemented it in each of its hospitals. This nationally known program was also mentioned as a reference by another TMT member, suggesting that referencing what major consultants are offering is a common practice. The other hospital had its program in existence over 10 years, so no information was known about whether it had modeled the program on another at the time. However, it had become the standard in its area and was frequently visited by other hospitals seeking to begin programs. Thus, each hospital experienced some mimetic element as it related to its development programs.

This mimetic nature of hospital development programs was also related to the ambiguity, noted above, in what the administrators believed was the purpose of the programs. Some executives specifically wanted management training, whereas others exclusively used the term leadership training. Still others switched back and forth between the terms. This might have stemmed from an ambiguity in program purpose noted above. When you don’t know exactly what you want, you look to other programs to see what they have and copy it (Mascia et al., 2014; Oliver, 1991).

Although the literature views the terms differently, interviewees used the terms leadership and management interchangeably when discussing all program types (Bass, 2008; Burke, 2010; Day, 2000; Keys & Wolfe, 1988). However, the printed program curricula outlined sessions primarily designed to improve the managerial skills of participants. This does not mean that the sessions themselves did not cover or address leadership needs. In fact, one TMT member noted that the management training was for its designated future leaders. Ultimately, however, the interchangeable use of these terms by TMT members provided another explanation for the ambiguity of program intent.

The programs that were most easily copied were the mentoring programs. This makes sense as informal mentoring programs are quite common and easily implemented. Another executive mentioned that she had investigated other curriculum-based programs to find out the concept and format, but not to copy the specific training covered. Finally, one hospital specifically noted that it tried to integrate the structure and training topics of multiple established programs into its ongoing series program.

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We found two recurring communication themes emerging from the interviews. First, programs provided opportunities to communicate directly with middle managers regarding policies, procedures, and organizational initiatives. Second, by simply establishing the development programs, hospitals signaled they cared about the middle managers and acknowledged their important role.

This communication most often occurred in the ongoing series programs. Although these programs varied in their structure and content, executives mentioned several times that they used them to communicate new policies or initiatives. Curriculum-based programs did not appear to have this communication element. On the other hand, management orientation programs seemed designed to communicate this information. There was no information regarding any specific communication policies regarding the mentoring programs.

Beyond the obvious messaging regarding strategic initiatives and policies and procedures, three other hidden types of communication existed. First, development programs signaled the important role that middle managers play in the hospital and that the organization cares about the middle managers.

Hospital 4, TMT member B: Of course that’s a discussion we’ve recently had in terms of retention and trying to do everything that we can to keep them here.

Hospital 2, TMT member A: There’s parts that don’t need to be evaluated; that is, these folks work very, very hard and I like to give them a day away from the office sometimes. I think that does us some good to recharge. We try to avoid getting calls all day when we’re gone. I think the idea of going away has benefit.

Second, there was cross signaling or mixed messages that occurred when TMT members from the same hospital had different understandings regarding program content. When this occurred, middle managers could receive conflicting messages from top executives, possibly leading to confusion and misunderstanding. Because ongoing series programs had more of a changing structure and content, TMT members were more likely to have differing views about these programs.

Third, we found that most hospitals in this study structured their development programs based on information they had obtained from other hospitals that had already initiated what they considered successful development programs. This mimicry in establishing development programs possibly signaled legitimacy to stakeholders outside the organization such as other middle managers and could aid in recruitment.

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Performance and program outcome measurement in hospitals is an important issue (Walker & Dunn, 2006). For instance, quality and patient satisfaction metrics are mandated at the federal and state levels, and these metrics are part of the accrediting process. Most hospitals also have internal metrics addressing financial performance, clinical performance, utilization, patient safety and satisfaction, as well as metrics for monitoring cost and productivity. Measuring the performance or benefit of a task or process is a common practice. However, only Hospital 6 with its for-profit ongoing series program had any formal method of measuring the overall benefit of its development program either at an individual manager level or at the organizational level. Hospital 6’s national chain used the Studer training system and tied this program to quantitative measures in order to compare top and bottom performers across all hospital in the system.

A recent review of physician–leader programs by Frich et al. (2015) used a four-level hierarchical method of evaluating outcomes of these programs. The lowest level is Reaction, simply evaluating how well the employees liked the training. Level 2 is Learning, defined as whether the attendees understood what was taught. Level 3, Behavior, evaluates whether what is learned in a program is actually used in the job. Finally, Level 4, Results, evaluates whether the overall program outcomes are achieved.

In the 14 programs from our study, none of the mentoring programs used any evaluation technique. The other 10 programs used at least Level 1, a standard end-of-training evaluation, both paper and online, to improve programs and provide feedback. Two programs, both curriculum-based, used Learning by having end-of-course evaluations to measure whether some objective knowledge was learned through an oral exam in one case and a case study application in the other. Behavior was seen in only one curriculum-based program in which graduates were expected to complete and document annual additional management training. Finally, one hospital achieved Level 4, Results, by evaluating its program performance based on system-wide patient satisfaction scores as a means of determining the success of the training program. Thus, it is not surprising that, when asked what advice to give to other hospitals considering starting a development program, a common theme was to first identify what you want to accomplish:

Hospital 1, TMT member A: You got to really define what you’re trying to do when talking about leadership development…. Really sit down before you go out so you can do it and figure out what it means.

Hospital 2, TMT member B: What I would advise is to clearly identify what your goals are….

This advice begins to underscore the difficulty of measuring program outcomes, as it is often a complicated undertaking (Day, Fleenor, Atwater, Sturm, & McKee, 2014). Unless a hospital clearly knows what goals it is attempting to accomplish, it is difficult to know whether any program is successful, a common dilemma for all the programs in this study. Even when a hospital knows what it wants, there may be issues if the training is not tied to these metrics. For instance, Hospital 6’s training, which was implemented across the system, was directed only at middle and upper managers, yet the entire hospital (as well as each hospital in the national chain) was ranked based on metrics supposedly tied to this training.

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Our exploratory study examines how top executives at mid-sized hospitals develop and implement programs for middle managers who play a vital role in their ongoing operations. Our TMT interviews and other data offer some support for both signaling and institutional theory as well as the view that, because top administrators have multiple needs, multiple programs are used to address them. However, hospitals had some problems with the evaluation of program outcomes.

Hospital top executives sent both obvious and hidden messages to middle managers. They used development programs as both a communication forum for new initiatives and an employee development program to improve specific skill sets. However, mixed messages about the programs were also sent. Because executives were not always on the same page about some programs, middle managers may have been confused as to the true purpose of the program. Future research can match middle managers’ understanding of these programs with this top manager perspective.

Institutional isomorphism partly explains why organizations conform to their environment through the mimicry of practices. Programs are validated through external norms and obtain status in the industry rather than being analyzed for the value that they bring to the organization (Oliver, 1991). By copying other programs or using purchased programs, hospitals limit their ability to clearly define reasons for program existence within their organizations or fail to develop programs to meet the unique needs of their middle managers. This isomorphism thus results in some ambiguity in terms of the purpose and value of the programs. TMT members were not able to say exactly why they were doing a specific program or what value they were getting from it.

Hospitals face tremendous financial pressure with decreasing reimbursements, increasing expenses, and a changing care delivery model. Although the value of development programs for middle managers is difficult to quantify at the individual and organizational level, there is a real cost associated with operating and maintaining the programs. These costs include missed time on the job, associated salaries, and speaker or consultant fees associated with each program (with the exception of the mentor programs that had little to no support). Financial pressures resulted in termination of a program, but because there was no formal evaluation, it is unclear whether this was a wise decision. Certainly, there is no industry standard for measuring the value of hospital programs so there are only anecdotal stories of improvement or participants’ feelings regarding program satisfaction and value.

Evaluating program outcomes is always difficult but can be done at two levels (Day et al., 2014). First, individual participants can be evaluated on what they learned. Second, programs can be evaluated for organizational effectiveness over time. There are challenges with each option. Option 1 is more time- and resource-consuming. Option 2 assumes that the program has a direct and measurable effect in the aggregate. We found very little use of any in-depth evaluation of the programs. Although executives knew they wanted the manager skill sets to improve, programs were rarely being evaluated this way. In fact, one administrator cancelled a program for subjective performance reasons, that is, he just did not feel that the program was worth the time and money.

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Practice Implications

Although our sample size was relatively small, we did find several implications and the start of some best practices relevant to researchers and practitioners. First, we found that the more specific, structured, and comprehensive a program, the better it performs. For instance, at Hospital 3, the TMT members noted their curriculum-based program as a significant tool for retaining strong middle managers and providing them opportunities for professional growth through assuming additional responsibilities. Thus, we advise that the best initial program a mid-sized hospital should have is a curriculum-based leadership development program. With it, executives can design it to teach exactly what they need, limit it to selected individuals, and evaluate participants for both learning and results. If hospitals need and can afford a second program, we advise developing an ongoing series program for all middle managers. The next best program for cost-conscious hospitals would be a mentoring program, as they will be less expensive than any of the other programs.

Second, we found that the better programs were always looking to improve. In fact, during the interview with an administrator from a hospital that had a highly regarded program, the administrator flipped the script and started asking us, the interviewers, about other programs and their best practices. He was genuinely interested in improving his already excellent program. Third, there needs to be some accountability and tracking of program outcomes. All programs tracked attendance; however, one hospital with a 10-lesson, curriculum-based program added a requirement that an attendee could only miss one lesson and still graduate. If a second lesson was missed, the manager would need to reapply. In addition, the annual evaluations of program graduates included an expectation that graduates would continue training and learning by taking other management courses.

To help with both assessing needs to begin a program and outcomes to be evaluated, a collaborative approach among top managers appeared to work best. One program had three meetings with consultants to establish what was to be taught. Other programs gathered the top executives for multiple brainstorming sessions. Thus, we recommend that hospital executives meet to determine how a new program should be structured and what outcomes are desired. Annual review of programs would help improve both structure and would help determine whether outcomes are being met. Much of this may be lost, however, if hospitals merge or become part of a larger chain, such as the case with Hospital 6. In that particular case, mentoring became the only local program that TMT members had available as a tool to improve managerial skills apart from the top-down directed program.

A final implication for practice is that successful programs linked leadership development with employee development. In fact, one hospital even created a “People Development Department” that coordinated the different training programs for all employees including middle managers. Overall, we found a wide range of development programs at our small sample of mid-sized hospitals. More successful programs appeared to be more structured, continually improving, and self-reflective. Although the findings are limited to a small number of hospitals, they do reveal the complicated nature of middle manager development programs while providing insight into how they may be improved.

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Appendix A

Appendix A


leadership development; management development; middle managers; signaling

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