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.
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.
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.
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.
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.
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.
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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Keywords:Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved
leadership development; management development; middle managers; signaling