Closing the Gender Gap in Healthcare Leadership: Can Administrative Fellowships Play a Role? : Journal of Healthcare Management

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RESEARCH ARTICLES

Closing the Gender Gap in Healthcare Leadership: Can Administrative Fellowships Play a Role?

Robbins, Julie PhD; Graham, Brooke Z.; Garman, Andrew N. PsyD; Smith Hall, Randa; Simms, Jeffrey

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doi: 10.1097/JHM-D-21-00314
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Abstract

INTRODUCTION

Women represent 70% of the global health workforce; however, only 31% of health organizations are led by women, and only 20% of those organizations' board chairs are women (World Health Organization, 2019). The U.S. healthcare industry workforce, which includes hospitals, health services, and social assistance, is 77.8% women (U.S. Bureau of Labor Statistics, 2021). Although women make up the vast majority of the healthcare sector workforce, they are considerably underrepresented in executive positions (Soklaridis et al., 2017). Women do not advance to CEO positions at rates equal to men (Sexton et al., 2014), despite higher levels of educational attainment in the field; as a group, women earn more bachelor's, master's, and doctoral degrees than their male counterparts (Okahana & Zhou, 2018).

In 2018, the American College of Healthcare Executives (ACHE) surveyed its members to compare career attainment between men and women among healthcare executives. This survey was the sixth in a series that has been conducted every 5-6 years since 1990 (Athey & Kimball, 2020). Results revealed that women healthcare executives are significantly less likely than their male counterparts to perceive their employers as gender-neutral when it comes to critical employment aspects such as hiring, promotion, evaluation, and compensation (Athey & Kimball, 2020). The study's authors noted that this perception of “lack of gender equity is associated with lower overall satisfaction, engagement, and willingness to stay with the organization on the part of women executives” (p. 307). The 2018 ACHE study also indicated that 16% of male healthcare executives started their careers at the vice president level or higher, whereas only 8% of women healthcare executives started at that level (Foundation of the American College of Healthcare Executives, 2020). The results also revealed that 86% of women believed that change is needed to increase the number of women in senior healthcare management positions (Foundation of the American College of Healthcare Executives, 2019).

Having senior leadership that reflects the community is important; however, the representation of women in healthcare declines at senior leadership positions (Berlin et al., 2019), a pattern reflective of leadership roles more broadly (Eagly & Heilman, 2016). According to Women in the Workplace 2018, a joint report from LeanIn.org and McKinsey, in 2017, women in healthcare represented 63% of entry-level positions, 58% of managers, 50% of senior managers/directors, 42% of vice presidents, 31% of senior vice presidents, and 30% of C-suite positions. Gender diversity is particularly important in hospitals, health systems, and physician practices because women make up a large portion of the patient population (Berlin et al., 2019). In addition, merging healthcare providers into larger systems requires cooperation (Foundation of the American College of Healthcare Executives, 2019), and healthcare providers now more than ever are facing increasing pressure to improve quality and reduce costs (Garland et al., 2021). All these challenges faced by today's healthcare organizations require diversity in leadership.

Organizations that can more successfully attract and retain top talent women executives have an advantage over their competition (Foundation of the American College of Healthcare Executives, 2019). Considering that there is a lack of representation when it comes to women in top healthcare leadership positions, it is important to identify different paths and strategies that can help women face obstacles and overcome barriers in their journeys toward higher-level leadership positions. One approach that may be especially impactful is completing administrative fellowship programs. Postgraduate administrative fellowship programs emerged in the late 1970s as a bridge for recent graduates to help them move to leadership positions in healthcare organizations (Howard & Lomperis, 2014). Fellowships are widely believed to provide valuable opportunities for healthcare management graduates in their leadership careers (Garman et al., 2014).

Administrative fellowship programs offer a professional foundation for early careerists and provide them with practical experience. In addition to their potential role in helping early careerists build valuable skills, fellowships may help participants develop their professional networks in ways that can accelerate their careers by building competencies critical for career progression (National Council on Administrative Fellowships, n.d.). In a national survey conducted to understand how fellowship programs have adapted through the COVID-19 pandemic, the authors found that increasing gender diversity is one of the top five goals of administrative fellowship programs (Robbins et al., 2021). Although fellowships appear to enhance women senior leaders and executives in their career trajectory (Sexton et al., 2014), there are far fewer fellowship programs than there are interested and qualified candidates pursuing them, making fellowships highly selective (Howard & Lomperis, 2014). This disparity between the number of available fellowship spots and the number of qualified candidates can limit the impact that fellowship programs have on the overall healthcare leadership workforce.

Few studies have examined the impact of fellowships in career progression, leaving a gap in the literature when it comes to addressing gender disparities in healthcare leadership (Sexton et al., 2014). In this study, we sought to contribute to the literature by examining the impact of fellowship programs on career attainment generally and for women specifically. Through this study, we hope to help strengthen the evidence base for how these types of programs can affect career progression. In addition, this research can help early careerists and especially women better understand their career planning steps and developmental opportunities to reach leadership positions.

METHODS

Sample and Data Source

The protocol for this study was approved by the institutional review board of the lead investigator's organization. Data collection took place during 2018. To create our sample, we extended a request of participation to a consortium of 15 graduate program directors who have been collaborating on alumni relations and benchmarking work. Eleven of the graduate program directors agreed to participate. All programs were accredited by the Commission on Accreditation of Healthcare Management Education (CAHME), were generally similar in scope of size, and had a well-established history (20+ years) of success in helping their students develop competitive fellowship applications. All programs provided full-time residential courses of study typically involving early careerist students (<5 years postbaccalaureate) and emphasized preparations for entry-level management roles in healthcare.

Participating programs were asked to provide individual-level demographic and career attainment data for their graduating classes from 5, 10, and 20 years prior (the graduating classes of 2013, 2008, and 1998, respectively). Anonymized data were compiled at the individual graduate level, including program name, gender, race/ethnicity, graduation year, job at graduation (organization type, title), and employment status in 2018 (work status, organization type, title), including an assessment of whether the individual was still working in the healthcare field (yes/no). Graduate program directors and their staff reported using a variety of sources to complete data collection, including historical student records, alumni databases, and/or publicly accessible career sources such as LinkedIn. Data were collected centrally using a common Excel template and data dictionary to ensure reliability. To preserve anonymity, all data were de-identified prior to submission to the principal investigators.

Analysis

To measure our outcome variable of career attainment, we developed a set of standardized definitions for equating job titles with organization levels; this enabled us to consistently compare attainment over time and across different types of organizations. We completed this step through a consensus process with research team members, based on their prior organization experience, leading to a four-level classification scheme. These levels, and sample titles within each, include (1) nonleadership/staff (e.g., project manager, analyst), (2) management (supervisor, manager, director), (3) senior management (senior director, associate/assistant/vice president), and (4) executive (C-suite/president). All data were coded centrally to ensure consistency across programs, and codes were then sent to each individual program director to review for accuracy. Our predictor variables included graduation year (1998, 2008, 2013), gender (male/female), and fellowship at graduation (yes/no).

We then completed a multiple regression analysis, testing the relationship of the three independent variables—graduation year, gender, and fellowship—on career attainment. This analysis enabled us to answer the following questions:

  • Is there a difference in career attainment between male and female graduates?
  • Is there a difference in career attainment between individuals who started their career in fellowships versus other jobs?
  • Do postgraduation administrative fellowships have a differential impact on career attainment for male versus female graduates?

All analyses were completed using in IBM SPSS (Version 26).

RESULTS

Our final sample included 689 student-level records across the three graduating classes. Demographics are summarized in Table 1. Alumni identifying as women were consistently a majority of graduates, increasing from 52% in 1998 to 54% in 2013. Overall, the majority of graduates in our sample (59%) started their careers in hospital or health system jobs, either in administrative fellowships (32%) or other positions (27%). The proportion starting in fellowships increased from 32% in 1998 to 38% in 2013. Across the three graduating classes, 80% were still working in healthcare in 2018, with some variation by graduating year; most recent graduates had the highest proportion (89%) still working in healthcare, whereas those who graduated in 1998 had the lowest (68%). A comparison of these trends by gender suggested that men (86%) may be more likely to remain in the field than women (75%), with the gap growing over time; however, these differences were not statistically significant. It is worth noting that overall record completeness also declined over time, such that the employment status of 25% of 1998 graduates (n = 24) were listed as “unknown,” compared with only one “unknown” among 2013 graduates. Potential factors contributing to “unknown” status included less public and/or social media visibility and usage (e.g., LinkedIn profiles) among more senior graduates and possible name changes due to marriage.

TABLE 1 - Alumni Demographics, By Graduation Year (n = 689)
1998 2008 2013 Total
n % n % n % n %
Total graduates 203 212 274 689
Female 106 52 117 55 148 54 371 54
Male 97 48 95 45 126 46 318 46
Job at graduation
Administrative fellowship 41 20 75 35 103 38 219 32
Hospital/health system 45 22 62 29 81 30 188 27
Consulting 19 9 18 8 30 11 67 10
Other 47 23 34 16 49 18 130 19
Unknown 51 25 23 11 11 4 85 12
Total still working in healthcare (2018) 138 68 168 79 245 89 551 80
Female 62 58 85 73 131 89 278 75
Male 76 78 83 87 114 90 273 86

Next, we examined career attainment among graduates who were still working in healthcare in 2018 (n = 551). This group was evenly split between females (n = 278) and males (n = 273), with 41% (n = 226) who started their careers in administrative fellowships. In terms of career attainment, 52% of graduates across the classes held either senior management (37%) or executive-level (18%) positions; not surprisingly, the proportion of graduates in these senior management/executive roles is higher (71%) for graduates who have been out of school the longest (1998) and lower (45%) for those who graduated most recently (2013). Characteristics of graduates still working in healthcare and career attainment outcomes are summarized in Table 2.

TABLE 2 - Alumni Still Working in Healthcare (2018), Characteristics and Career Attainment by Graduation Year (n = 551)
1998 2008 2013 Total
n % n % n % n %
Still working in healthcare (2018) 138 168 245 551
Female 62 45 85 51 131 53 278 50
Male 76 55 83 49 114 47 273 50
Job at graduation
Administrative fellowship 41 30 74 44 111 45 226 41
Other 97 70 94 56 134 55 325 59
Career attainment (2018)
Nonleadership/staff 18 13 24 14 49 20 91 17
Management (supervisor, manager, director) 22 16 49 29 86 35 157 28
Senior management (senior director, vice president) 51 37 62 37 91 37 204 37
Executive (C-suite, president/CEO) 47 34 33 20 19 8 99 18

Finally, we completed a multiple regression analysis to test the effect of three predictor variables (gender, graduation year, fellowship) on career attainment as summarized in Table 3. Our first model considered the main effects of the three predictor variables and found that men have higher career attainment than women (p < .01), individuals who graduated earlier have higher career attainment than those who graduated most recently (p < .001), and individuals who started their careers in an administrative fellowship have higher career attainment than those who started in other roles (p < .001). In our second model, we added the interaction effects for gender and year and starting in an administrative fellowship. The second model shows that the main effect for gender is no longer significant after controlling for interaction terms. However, graduation year (p < .001) and fellowship (p < .001) remain statistically significant. Also, starting one's career in an administrative fellowship accelerated career attainment for both men and women, but the effect is significantly stronger for men than for women (p < .05) as represented in Figure 1.

F1
FIGURE 1:
Impact of Completing a Fellowship at Graduation on Career Attainment by Gender
TABLE 3 - Regression Results Predicting Career Attainments
Predictora Model 1 Model 2
B SE B SE
Gender –0.23** 0.079 0.04 0.155
Graduation year –0.31*** 0.049 –0.25*** 0.068
Fellowship 0.33*** 0.080 0.50*** 0.110
Gender × Year ____ ____ –0.11 0.098
Gender × Fellowship ____ ____ –0.33* 0.160
aDependent variable: career attainment.
*p < .05.
**p < .01.
***p < .001.

DISCUSSION

This study makes several important contributions to our understanding of both the role of administrative fellowships and career progression by gender in healthcare management. First, our findings clearly suggest that fellowships make a significant difference in accelerating career progression among early careerist healthcare management program graduates and thus represent a potentially powerful resource for leadership development in healthcare organizations. However, our results also suggest that gender gaps in career progression persist even within this group. Although fellowships can accelerate career progression for both men and women, the effect is significantly stronger for men, suggesting that, in aggregate, there is some risk that fellowships may be widening the leadership gender gap, rather than attenuating it.

More broadly, this study contributes to the literature regarding the persistence of gender gaps in healthcare leadership and career paths among early careerist healthcare leaders. Whereas previous studies have primarily examined gaps in leadership from the organization perspective and at a specific point in time (Lyness & Grotto, 2018), this study provides a rare longitudinal investigation into career attainment over time among individuals with similar educational preparation and similar career-starting points. The strong history of participating programs' graduates starting their careers in administrative fellowships provides a sample size that is sufficient to evaluate the impact of this role broadly across organizational settings and time. These factors contribute to the strength of our findings and their broad insights for the field.

Drawing from our findings, we have four practical suggestions that may, in combination, put fellowships in a better position to address gender gaps in healthcare leadership. First, we recommend that leaders proactively design their programs to ensure equitable and ongoing success of graduates in their fellowships and beyond. Both ACHE (“Fellowship Resources” at www.ache.org) and the National Council on Administrative Fellowships (“Student and Prospective Fellow Resources” at www.nchl.org) offer comprehensive resources on their websites to assist in creating high-quality fellowship programs.

Our second suggestion relates to access to fellowships. Because we found that women who complete a fellowship have higher career attainment than those who do not, expanding the number of opportunities for women to complete fellowships may help address the leadership gender gap. Although our findings suggest that male and female graduates have been securing fellowships at comparable rates, there are significantly more qualified applicants interested in fellowship programs than there are fellowship roles available. We therefore strongly encourage readers whose employers do not currently offer fellowship programs to consider developing them—and, if they do have fellowship programs, to consider expanding the number of fellowships available. We especially encourage organizations outside of the traditional hospital and health system sector to consider developing administrative fellowships as a pipeline for top management talent.

A third suggestion relates to recruitment and selection processes for both educators and employers. For educators, we encourage program directors to monitor patterns of fellowship application within their own programs related to gender. Similarly, we encourage the leaders of established fellowship programs to review their own data about applications, interviews, hires, and leadership development during and after the fellowship period through the lens of gender to identify any evidence of potential unconscious bias and/or opportunities to better promote inclusion. Beyond attraction into fellowships, additional research is needed regarding progression into senior leadership roles, as well as the kinds of supports that can best help leaders from underrepresented groups to succeed.

Finally, at the level of the profession, we recommend that organizations such as the National Council on Administrative Fellowships work more closely with their stakeholder groups to promote the collection of demographic data that will allow for better monitoring of progress over time, as well as calls for action when the pace of progress is lacking.

Study Limitations

There are several limitations of the study that are important for us to acknowledge. First, gender aside, it is plausible that there are motivational differences between students who decide to pursue fellowships in the first place in comparison with those who complete fellowships and those who do not. Our data did not allow us to compare graduates who may have been interested in fellowships but unable to obtain them with graduates who chose not to pursue fellowships in the first place. These differences may have explanatory power beyond the impact of the fellowship itself and may be a valuable focal point for future research. Second, although our data set identified whether a graduate completed a fellowship, we did not have any details about the content, quality, or duration of that experience, limiting our ability to draw specific conclusions regarding any specific mechanisms by which fellowships affect career attainment. Third, our data revealed differences only in leadership level and not in career satisfaction. So, although this study can shed light on gender differences and the role of fellowships in career attainment, it does not offer insight into other types of goals that may be very important at the individual level. Finally, although every effort was made to fully and accurately capture detailed personal characteristics and career outcomes within the 11 participating graduate programs, factors such as experience prior to enrollment, incomplete administrative records, and challenges finding information publicly (e.g., outdated records, name changes) may have had some impact on our findings.

CONCLUSION

Our research suggests that while fellowships play an important role in supporting leadership career progression, they may not be living up to their full potential in addressing gender and possibly other diversity gaps. Our findings also highlight the critical importance of studying leadership development over much longer time periods, in order to fully understand both the opportunities these types of programs can provide and the broader support structures needed to address leadership gaps. We hope our findings inspire additional work in these areas in the years to come.

ACKNOWLEDGMENTS

The authors acknowledge the faculty who provided program-level data for this study and thank members of the National Center for Healthcare Leadership's Graduate Education in Healthcare Management Leadership Excellence Network's Career Trajectory work group for initiating and supporting this project.

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