CHAPTER 1

Introduction to Health Care Management

Chapter Overview

This chapter introduces the unique challenges of new health care managers, explains their importance, and provides practical guidance to help you succeed in these new situations. Insights and themes from interviews and conversations with 64 health care managers and administrators are summarized. We identify some special features of managing in health care and the particular challenges in refocusing your clinical training to succeed as a health care manager as we apply some of the lessons gleaned from interviews. Initial activities are proposed to help you get started in comprehending the scope and skills that health care managers need to learn and master.

Topics in this chapter:

• Motivation for developing management skills
• What’s so special about health care management?
• Interviews for a variety of perspectives
• Interview questions
• Themes from interviews
• Who can help? Get a mentor!
• Chapter summary and key points
• Introductory activities to get you started

Motivation for Developing Management Skills

Interviews with many health care leaders provided real-world examples and recommendations that confirmed the importance of the topics in this book. These address skills that may be particularly challenging to new managers in health care because they were not part of their professional education and may be considered at odds with traditional values associated with caring for patients. In this chapter, we introduce some of the themes and lessons gleaned from interviews, identify some particular challenges in refocusing your clinical training to succeed as a health care manager, and offer some activities to help you focus as you get started.

For example, holding staff accountable for performance metrics may feel uncomfortable and in conflict with clinical training that taught us to be nonjudgmental and emphasized support, comfort, and understanding toward patients when they were going through difficult times. Getting teams focused and moving forward on higher-level organizational goals requires teamwork and collaboration that might have been absent from highly competitive and demanding clinical programs that required mastery of complex scientific material.

On the other hand, our clinical training and experience provide valuable assets for us to build on in our journey toward being successful in management. What we learned and practiced in goal-setting with patients can teach us about setting realistic and relevant goals, which is helpful in managing teams and projects.

What’s So Special about Health Care Management?

Health care is a complex business. It is not just the patients and clients, being the direct recipients of our care and treatment services, who are considered our customers. In addition, the organizations we work for are accountable to the payers of those services, typically insurance plans, grant funding administrators, and other government entities, who also require data and reports to monitor organizational performance. Perspectives from a variety of clinicians, managers, and administrators help us understand and manage successfully in the challenging and rewarding arena of health care.

Deep Caring about the People and the Work

People who work in health care really care about the people they help and the work they do. Everyone I interviewed cares deeply about the people and communities they serve and the teams of people they lead. Paul Bretz, LCSW, DDiv, Executive Director of Centus Counseling, has a wide collection of educational degrees, has earned professional certifications in clinical practice, quality, and compliance, and has in-depth experience in clinical, spiritual, administrative, and leadership roles. He expressed this commitment vividly when he said, “In a meeting, every person who talked about a client teared up. It doesn’t get much better than that!”¹

When I asked Preston Simmons, MHA, DSc, FACHE, “What is special about working in health care?” from his perspective as the administrator of one of the largest health care organizations in the United States, he explained that people working in health care want to make a difference; clinicians have a passion for patient care and pay attention to good outcomes. High integrity is particularly important.²

Rapid Change for Efficiency

Ken Bellian, MD, MBA, has a range of valuable experiences as a physician, chief medical officer, university instructor on health care innovation, entrepreneur, and advisor for organizations developing technological solutions to difficult health care problems. He describes the world of health care as changing rapidly with continuing need for efficiency to drive down costs as expectations rise for patients’ needs to be met quickly with good outcomes. This requires focus, persistence, and insistence, enveloped in the driving context of meeting patient needs. He believes an effective health care leader must communicate to the staff the process and strategy for meeting these needs.

He described change as unsettling to most people; as a leader, your ability to make your staff feel valued, heard, understood, and respected is essential to manage the change successfully. Managers can help people move forward by identifying the early adopters who figure out how to improve their patient flow to see more patients while completing their administrative requirements promptly, and supporting others in adopting effective practices, utilizing helpful technology, to improve their working lives and the experience of their patients.³

Complicated Drivers of Delivery

Indeed, the complicated operational levers that drive health care delivery can be very difficult to understand. Vonderembse and Dobrzykowski (2016) explain managerial challenges that are specific to health care. For example, supply and demand for health care services can be difficult to balance because of insurance payment systems that insulate patients from true costs of care and may lead to overutilization of services. Rapidly shifting reimbursement models can be difficult to comprehend and implement, especially when technological infrastructure for information sharing is still evolving. And, the total cost of health care is driven not only by the number of units of care delivered, but also by the price of each claim or unit of care, thereby causing increasing pressure to enhance efficiency, reduce waste, and improve collaboration and resource management.⁴

Ensuring Standards Are Met

In health care settings, you may find that as you rise to higher levels of management, you spend more time dealing with people and organizations outside of your own. Patients, clients, and their family members may seek a manager, someone in charge—you! —when they are dissatisfied with the care and treatment they received from a clinician. You are also likely to deal with external administrative functions involved in the payment for health care services, assurance of compliance with health and safety rules and regulations, and patient privacy laws. You will be responsible for ensuring that the work of your team or department conforms to standards of clinical care, documentation, and billing, along with internal performance targets that are needed to keep the organization running well.

Interviews for a Variety of Perspectives

More than 60 accomplished health care professionals across a wide range of health care professions and settings graciously participated in interviews and conversations with me to share their insights and recommendations about becoming an effective health care manager. All of them are listed in Appendix A along with some selected highlights of interview themes. You will meet some of these people in this chapter, and you will see others later in chapters where their advice and examples are particularly relevant. They bring valuable experience from many roles and levels, including clinicians, early-career initial supervisors and managers, through directors, vice presidents, executive directors, chief executive officers, and governing boards of directors.

You will see experiences and insights from physicians, nurses, psychologists, social workers, psychotherapists, and other providers and administrators. Their experience comes from a variety of settings from outpatient, hospital, academic medical centers, and universities, with health care focus in physical and behavioral health, home health care, physical and voice therapy, dental practice, pharmacy operations and other specialty areas. They represent different sectors such as not-for-profit, for-profit, and governmental.

I selected effective managers and leaders to interview to explore specific aspects of their experience as new and developing managers. As I have worked with many of them, I have admired their effectiveness and know the value they have contributed to their organizations and professions. I wanted to find out and share with you more about their backgrounds, perspectives, and the history and application of tools and approaches they contributed to our work practices and cultures.

Other participants were recommended by people I had selected to interview, who envisioned particular value that could be added by some of their trusted colleagues. And I sought out additional participants through my network of contacts and their contacts to broaden the field of multiple clinical perspectives and deepen the perspective constructed from multiple contributors. I chose them specifically to broaden the base of experience and perspectives from a wider variety of health care professions and settings.

And in the course of my ongoing activities, I encountered others whom I already knew or was just meeting; when I told them about this book and its purpose, they strongly agreed with the need and offered insights and examples from their experiences that can help address important issues that new health care managers face.

Many shared experiences and recommendations are collected and summarized throughout this book. To bring to life key points and illustrate how you can apply them in practical situations, some composite scenarios are drawn from interviews, conversations, and my prior experience and observations. Some details are combined and altered to highlight important principles while preserving confidentiality and privacy of interview participants and others who were involved in sensitive situations.

Interview Questions

I started with a structured form to elicit specific information from those I interviewed about their backgrounds and experience as new and evolving health care managers, along with their recommendations and advice for others starting out as new health care managers. I asked:

1. When and where (in what organization) did you have your first experience as a manager?
2. What were you doing before this transition to manager?
3. Why did you want to be a manager?
4. Why do you think you were selected to become a manager?
5. How much were your initial expectations met about your new role?
6. What pleasant surprises and unexpected challenges did you find?
7. What do you think contributes to the success of a new manager?
8. What worked well for you in getting started in your new role?
9. What would you have done differently?
10. What helped you get started in your new position as a manager?
11. Was there particular training, support, mentoring, materials, or other resources that you found helpful?
12. What else would have been helpful to you in getting started as a new manager?
13. How did you fill the gaps or get these other things?
14. What advice do you have for other clinicians moving into manager roles?
15. What other things would you like to share about your experience?

Ad-hoc questions were used as needed to clarify and explore interesting things that came up.

The interviews were designed to start by eliciting some specific information about how people got started as new managers, what did and did not work for them, for the purpose of guiding other new managers. Later questions broadened to allow participants to expand on relevant parts of their experience and to contribute interesting insights and recommendations. Several of the later conversations and interviews were less structured to allow deeper exploration of some specific perspectives and insights that were particularly relevant to those participants’ experiences or disciplines.

Themes from Interviews

A number of experiences and suggestions emerged as commonly mentioned themes throughout the interviews. This chapter includes a small sample of the comments from some of the interviewees. For more examples, please see Appendix A. You’ll meet more of the interviewees and hear from them as you progress through later chapters.

Expectations

A number of meaningful themes emerged in discussions with these managers and leaders across roles and settings. Many emphasized the importance of understanding performance expectations; managers should know clearly what is expected of them from the manager and leaders above themselves and must be clear in communicating expectations to the people they supervise.

Stepping Up to Earn Credentials and Responsibility

Most of the clinically trained people mentioned the value and importance of earning credentials, experience, and in many cases licensure that established their credibility and responsibility. This willingness and ability to step forward helped prepare these clinicians for greater responsibility and facilitated their selection for promotion and expanded roles that became available within their current workplaces or to transition to higher levels of responsibility and leadership in new settings.

Several nurses talked about the value and importance of being credentialed as registered nurses and how it helped establish their leadership with hospital teams. As charge nurses, they began to assume responsibility for coordinating activities on their shifts and making sure the patients in their charge received high-quality care. Part of this responsibility included advocating for their patients and other staff, which required being in tune with the needs of others and being willing to negotiate with higher-level administrators to meet those needs.⁵,⁶,⁷

Managers working in behavioral health care, in outpatient clinics, or in residential treatment settings, began as therapists, case managers, or counselors, and earned their licensure as licensed clinical social workers, licensed professional counselors, or licensed addictions counselors while working directly with patients (whom they also refer to as clients and consumers). Yet, not every licensed or certified clinician makes the move into a manager position, and so what differentiated these people? What emerged was not only a willingness to accept responsibility when it was offered but the initiative to seek greater challenges, to risk trying new things, and to embrace uncertainty and change.⁸,⁹,¹⁰

Seek and Be Sought for Leadership

The MDs who spoke with me exemplify impressive careers of increasing responsibility and leadership.¹¹,¹² As Kenneth T. Bellian, MD, MBA, observed, medical education is devoid of management training and does not prepare you for the increasing responsibilities of management. Some of the common ways to gain more management responsibilities are to either actively seek out leadership positions or to be identified as a potential leader. Commonly, providers are recognized as great clinicians, excellent teachers, or successful researchers. They are subsequently promoted as future leaders into management. Without formal management training in the medical educational system, it is incumbent upon the individual and the organization to actively support the provider’s leadership development.¹³ For most of the MDs, in their initial transition to managerial responsibilities, they stepped up to fill the need for leadership.

Kristi Mock, LCSW, Chief Operating Officer of the Mental Health Center of Denver, started 34 years ago as a therapist. Her continual progression to higher levels and broader scopes of responsibility began with volunteering to cover interim management responsibilities when there was a gap. “Be that person leadership can count on,” she advises, and “volunteer to do lots of different things to expand viewpoints and perspectives, while continuing to be a high performer in your primary responsibilities.”¹⁴

Constructive Engagement

Several said that although they did not see the transition to administration coming, they embraced it. Donald Penning, MD, of Denver Health, sought education and training in management, and continues to proactively handle culture change. It means getting truly involved with the work and people, continuing to build clinical competence, and not focusing on job titles. When Dr. Penning was at Denver Health as director of anesthesia, he broadened his reach by assuming responsibility for all operating room functions, while conducting research and applying operations research methodology to increase efficiency. He later moved to Henry Ford Health System as vice chair of research, head of neuroanesthesia, and professor of anesthesiology and neurosurgery.

When Dr. Penning invited me to visit and observe him and his Denver Health team in action, I found it inspiring to see him actively leading his staff in a daily check-in. His team members were busily engaged in working collaboratively on their team when they were recognized by their leaders and their peers for the successful events of the previous day, followed by constructive conversation with the team on what could be improved. Dr. Penning attributes his success to a collaborative attitude and willingness to “not just have the job but do the job,” which he learned in a management course he completed.¹⁵

Helping People Get the Work Done

A leader who has led in many different settings is licensed clinical psychologist Jesús Sanchez, PhD, who has worked in medical rehabilitation, community mental health, a state psychiatric hospital, private practice, student health center, group consulting practice, and as a member of governing boards of directors. He has mastered a range of skills as a manager and administrator. Like others I spoke with, his strong performance as a clinician and his abilities to organize and take responsibility for strategically important preparation for managed care implementation were noticed by top management, and soon he was promoted into a program manager role. “I didn’t know anything about management, but I knew my job was to help my team do their job. Managers need to facilitate the team doing its work more efficiently,” he explained, and added that facilitating is not just telling people to do things; it involves building relationships with other teams and organizations that foster productive collaboration that helps people get the work done.¹⁶

Applying Varying Experiences and Perspectives

Many people demonstrated talents such as seeing opportunities to make things work better,¹⁷ understanding potential challenges and strategizing how to navigate successfully in their work settings, along with focusing on the important details that are needed to implement projects while growing and empowering their staff members to develop their abilities as clinicians and leaders. Many interviewees applied transferable skills they developed in earlier settings, including general business settings¹⁸ and military service¹⁹ to help their new organizations operate more effectively. “Military service was one of the most valuable experiences of my life,” said Bill Milnor, MA, VP of Business Processes at the Mental Health Center of Denver. There he learned discipline and to work as a team toward the mission.²⁰

Apply Your Strength and the Strengths of Others

Many people had assessed their strengths and those of their teams. Many used formal assessment tools, and others learned to recognize what they and their team members naturally gravitated toward doing. Mary Ellen Benson, VP of Healthcare Transformation and Development at Aspen Pointe, started as a physical therapist and advanced to leadership roles and high levels of executive management through her abilities to work well with people and get things done effectively. She shared good advice she received from a CEO she reported to, “Be who you are and lead from within.”²¹

Relationships Foster Learning and Growth

These leaders all demonstrate deep self-awareness with openness to learn and explore new approaches and share them with others. Clinical and medical training taught them to focus on patients and listen to others. They recognize the importance of building relationships within and outside their organizations to foster their growth and help get things done.

Most of our interviewees started in their new manager roles with no prior training in how to be a manager, and many have been fortunate in gaining such development opportunities from training offered later by their organizations or through actively reading articles and books, enrolling in courses, and through continued self-directed learning.²² We heard from many of the leaders that they knew they did not know everything and found it helpful to admit what they did not know, and so they asked questions and consulted with others with more experience.

Mentoring

Almost everyone mentioned mentoring and its value in helping people grow. Many mentioned their appreciation for mentors whom they encountered and developed helpful relationships with along the way. Some joined external mentoring groups with peers in other organizations, or even other industries, to give them nonbiased feedback and guidance.²³ Others sought mentors in their own organizations to offer advice and guidance that fostered their development. Several actively and intentionally mentored others.

For example, Darcy Jaffe, MN, FACHE, Chief Nursing Officer at Harborview Medical Center, invites new hires out for coffee to connect with them and offers to have them shadow her to see what an administrator does. This gives these new nurses access to an experienced senior leader and helps shape their vision for possible paths for their own growth.²⁴

Learning to Run the Business of Health Care

Be honest about what you do and do not know, and be open to learning from other sources and people to get better at what you do. Do not be afraid to ask questions and admit what you do not know. Build relationships with people in other departments to support you in handling new business areas where you do not have training or experience.

For most of us, our clinical education did not include topics on running the business side of a clinical practice with the need to understand different insurance reimbursement rates, office overhead expenses, and comply with billing and regulatory requirements. Some figure it out later when they are running their own practices such as dentistry,²⁵ speech therapy,²⁶ or psychotherapy.²⁷ When some went on to work in larger community health systems, they were faced with increasing complexity of multiple public funding streams²⁸ and new organizational dynamics to understand.²⁹ These leaders continue to learn, grow, and contribute, working closely with the teams they manage to continually earn the credibility and respect of followers, peers, and the administrators to whom they report.

Accountability for Productivity

As Dixie Casford, LPC, MBA, Vice President of Acute Care at Mental Health Partners explains, there can be challenges to hold people accountable for doing such required parts of the job while running the business of providing help. She recommends separating therapy from supervision—or, as others have expressed, supervision is not therapy and you are not your employee’s therapist! As a supervisor, acknowledge the difficulty of meeting performance expectations (e.g., meeting a specified number or percentage of work hours providing direct service to clients) and ask, “How can we put the right things in place?” to encourage engagement in accomplishing what is needed to provide help to clients in a productive way.³⁰

Collaboration Enhanced with Nonclinical Disciplines

As their career successes illustrate, becoming a manager in health care is not a one-time event but a continual unfolding of growth, responsiveness, and anticipation of change driven by health care needs and requirements in a rapidly changing, tightly regulated environment with uncertain financial resources and extremely thin profit margins. The management perspectives in this book are enriched by several nonclinical people who shared their observations and experience working closely with clinically trained people.³¹,³²,³³,³⁴ Such people contribute valuable partnership to the success of health care organizations, especially in hospital systems where it is common for top leadership responsibility to be shared in dyads or triads such as a physician in the chief executive officer role working closely with a nurse leader, such as a chief nursing officer with advanced nursing credentials, along with an administrative leader with advanced experience and education such as a master’s degree in health administration or master’s in business administration.

Shifting Your Perspective to Systems and Teams

In health care, there is particular emphasis on patient safety, access to appropriate treatment, and continuity of care. This may require you as the manager to get involved in designing schedules and protocols that deliver needed, high-quality care to patients while providing the systems, tools, and supports needed by your team members who report to you.

As Kenneth T. Bellian, MD, MBA, explained, as a provider you are focused on the needs and expectations of each individual patient. Now, in a leadership position, it requires you to think at a system level and to bridge across many silos or departments to achieve success. This can be especially hard for some people in medicine and health care, particularly if their training was delivered in hierarchical or authoritative cultures.³⁵

Preston Simmons agrees that people need to think differently. Key skills include the ability to bring people together to make success happen. It is a matrixed environment where people need to work with and through others. New models emphasize team leadership, and people need to think differently. Health care delivery operates in teams, which is not taught to physicians in medical school. Older physicians were taught more of a command-and-control approach. The work is extremely challenging due to very complex regulations and razor-thin profit margins.³⁶

Who Can Help? Get a Mentor!

There is so much complexity and subtle nuances that you now must master although they were not included in your clinical training. So, it is not surprising that the vast majority of interviewees mentioned the need for others with wisdom to help guide them. When asked what advice they would give other new managers, many replied without hesitation, “Get a mentor!” Mentors are typically wise people with more experience than you who are willing to help guide you in your development. Sohnen-Moe (2016) explains that they often serve as trusted confidantes to help you assess yourself honestly and figure out what you need to work on to achieve your goals.³⁷

Look for Others

Ideally, the person you report to (your boss) provides some of this mentoring support and guidance to help you grow and develop in your role and career. However, there are benefits of finding other mentors and people who can help. One is for candid conversations in which you might want to be more open to admit your shortcomings and weaknesses to someone other than your boss, who is in a position to evaluate you to strongly influence your advancement and rewards. And, as Jeff Zayach, MS, pointed out, it is helpful when you are new to have other people available to help you so you do not have to take every question to your boss.³⁸

Peer-Level Help on Typical Activities

Your peers in the organization are a valuable resource to help you learn how things are done in your new role. This can cover your questions about routine forms and typical activities. For example, you might need to ask someone how to handle specific activities such as, “How do I approve time sheets for the people who report to me?” “How do I enroll in seminars offered by other departments?” as well as questions about organizational norms and how things get done, such as, “If you have a technical emergency and can’t reach anyone on the help desk, who do you work with to get it fixed fast?” or, “Is it okay to approach the controller to ask for approval of an unexpected large expenditure if I can’t find the chief financial officer? In your experience, does our director want to be involved in things like that?”

Craig Iverson, MA, offered a practical suggestion for working with mentors or other guides, which might include a peer-level “buddy,” another manager with whom you can talk things over and get feedback. He recommends as a first step for new managers to sit down with someone more experienced and to develop a list of typical things to anticipate happening so you can be prepared when they do. Having someone to help you work through unfamiliar situations can help you develop your managerial skills as you learn about your options and available solutions to challenges. From his experience as a clinical program manager he offered an example of having several team members asking for the same holidays off when coverage was needed for the clinic. His suggestion was to be prepared with a way of responding, such as prioritizing requests for time off according to seniority.³⁹

Help with Your Professional Development

Mentors can enhance your overall professional development by helping you explore options and develop your overall capabilities. You may find mentors in your own organization, or outside in other organizations. Peer-level “buddies” can help you answer specific questions in your work environment, help you anticipate and prepare for expected issues, and guide you to respond confidently and effectively to unfamiliar situations.

In your new role, unfamiliar issues will come up for you about your new level of power and influence that will affect your working relationships with your team members and others in your organization. Remember, your clinical skills helped you recognize and respond to others’ needs. These are still important approaches for you to use and build on, and you will need to expand your perspective and learn to adapt in new ways. Take heart, mentors can help so you don’t need to do this alone!

Chapter Summary and Key Points

In this chapter, we considered some of the special aspects of working in health care that require you to develop new management skills that probably were not part of your clinical training. You have seen a summary of important themes that emerged from interviews with many different people working in a variety of health care roles and organizations, with their suggestions and recommendations, which we will explore further in later chapters.

Key Points:

1. Managing in health care is complicated by funding and accountability from multiple sources aside from patients themselves.
2. Health care managers are under increasing pressure to increase efficiency, reduce waste, and improve collaboration and resource management.
3. Shift your perspective from individual patients to developing effective systems of care.
4. Step up and seek new challenges.
5. Get needed training and experience to earn credentials.
6. Be the person others can count on to get things done.
7. Get a mentor to help guide you.
8. Help your people do their jobs better.
9. Apply your skills and prior experience to help things work better.
10. Build relationships, internally and externally.
11. Know what is expected of you, and let others know what is expected of them.
12. Collaboration between clinical and nonclinical staff is enhanced with learning among people who have different training and disciplines.

With this introduction, we welcome you to this exciting and fulfilling journey as you too become the most effective health care manager you can be!

Introductory Activities to Get You Started

You may use these as group discussion questions or write down your individual responses. These questions can help you identify where you may need to concentrate on skills and chapters in this book. We recommend you develop a file or notebook to keep track of your progress. Do not worry if you do not have all the answers now. You may use this as a baseline assessment of your preparation for management and revisit questions to help you measure your progress as you continue in your management role and your progress through the book.

1. Review the Contents and Organization of the book, above.
   • Which chapter with its topics feels most familiar to you and why? What are your top three existing areas of knowledge or competency in this area? How do you know how strong you are in these areas—what feedback have you received or other evidence do you have? What other sources of feedback will you get as you advance as a manager in your current organization?
   • Which chapter do you have the least knowledge and experience in? How does this topic relate to your current managerial job and how do you anticipate that might change?
2. Consider examples of experience or recommendations from the interviews described in this chapter.
   • What ideas would you consider adopting for your own management development?
   • What resources could you use for more information (e.g., targeted chapters of this book, people in your workplace or other mentors, books, articles)?
3. What skills or experiences that you developed before your health care management role will be valuable to you now? What opportunities do you see to apply them that will benefit your team and organization?
4. From your experience working in other kinds of organizations and your perspective as a customer of different kinds of businesses, what have you found that is different in your health care organization and the way it runs?
   • Consider things such as the reason the organization exists, how it earns money to pay for its expenses, the skills and training of people who work there, special risks and benefits of working there.
   • What do these different characteristics suggest that you need to learn in order to succeed as a manager in your health care organization?
5. What relationships would you like to develop to support your team and you in your role? How will you cultivate your contact and collaboration with these people and their teams or organizations?
6. Many of our interviewees mentioned the importance of having a supportive and experienced mentor to give you advice and guidance in your early journey into management.
   • What mentors or advisors have you had before? Consider work, school, family, and other activities. How did their guidance help you develop?
   • What people do you know who might be helpful mentors for you? Think about people with valuable experience who seem willing to help you. What advice would you like from them and how will you approach them?
   • What new traits or knowledge in a mentor would be most helpful for you as you transition or develop now into a management role?
   • Identify at least two candidates you are already acquainted with who could be a helpful mentor for you as a new or evolving manager. How will you approach them and establish a relationship and dialogue that is mutually beneficial?
   • Where could you find mentors or peers outside your organization? Do you belong to or have access to existing groups that could be helpful, such as a professional society for your clinical discipline, former classmates, other groups; or how could you start your own group? What are the benefits of external resources, possibly from other industries (not health care)?