Health Services Management: A Case Study Approach, Twelfth Edition

By Ann Scheck McAlearney and Anthony R. Kovner

Health Services Management: A Case Study Approach provides an overview of management and organizational behavior theory by inviting readers to analyze and respond to common managerial predicaments. The book includes a mix of vignette-style anddata-driven cases, each of which enables readers to hone their management skills by navigating challenges that, just as in real life, do not have a single "right" answer.

This 12th edition contains 54 cases, 18 of which are new and address timely issues such as the following:

Managing virtual team membersConfronting racism and disparities in careLaunching diversity, equity, and inclusion initiativesAdapting to crises such as the COVID-19 pandemicSustaining a population health improvement programAddressing employee burnout and turnover

This updated edition arranges its cases into five parts: one section focusing on the fundamentals of becoming a healthcare manager and four sections highlighting values and culture, organizational focus, performance evaluation, and authority and responsibility. Each part begins with a discussion of the management theories and principles that are presented in the ensuing cases.

• Language: English
• Publisher: AUPHA/HAP Book
• Release date: Oct 30, 2023
• ISBN: 9781640553583

Book preview

INTRODUCTION TO CASES

What Do Healthcare Managers Do?

Managers work with others to achieve organizational goals. Managers of healthcare organizations (HCOs) confront reality, develop agendas and networks, and strategize. They work with and react to other managers. Because they generally lack ownership of the firm, healthcare managers are often risk averse. They worry about their own survival as well as goal attainment. They negotiate trade-offs between improving patient care or keeping it from deteriorating, breaking even financially or operating at a profit, and controlling clinician dissatisfaction or engaging clinicians in the organization’s mission.

Healthcare managers address a variety of challenges. Purchasers demand low prices, documented quality, and responsive services. Competition—either from existing or new organizations—may be increasing. HCOs primarily provide medical care, yet a growing emphasis has been placed on efforts to improve population health, whether or not such efforts contribute to the bottom line or have been scientifically validated.

Clinicians may regard managers primarily as support staff, and they may consider working with managers or meeting at a manager’s direction a waste of time relative to the important work of providing patient care. They may view the manager’s important work as relating the organization to its environment or coordinating processes of care to achieve measurable objectives. Reasonable people may differ—and they often do—over the extent to which medical care and population health are measureable.

The work of healthcare managers varies by type of organization, as well as by the manager’s level within the organization. Types of HCOs include academic medical centers, neighborhood health centers, small community hospitals, large public hospitals, visiting nurse services, accountable care organizations serving Medicaid recipients, Veterans Health Administration hospital networks, and health departments, among others. These organizations can be for-profit, not-for-profit, or governmental; large or small; rural, suburban, or urban; financially strong or struggling. The managers of these organizations face different challenges and have different capabilities in responding to these challenges and to market opportunities.

Professionalism of the Healthcare Manager

The concept of a profession denotes that an occupation possesses some sort of abstract knowledge (Abbott 1988). Healthcare managers are presumed to be the business experts on the multidisciplinary team. Clinicians provide patient care and healthcare managers focus on operations, marketing, strategy, finance, and human resource management. While these skills are commonly held by businesspeople in other industries, healthcare managers embrace special professional motivations, such as helping patients, empowering clinicians, building community ties, and serving society. Moreover, healthcare managers accept tremendous responsibilities uncommon in most other industries, such as intense regulatory oversight, around-the-clock demands for services, and life-and-death consequences of decisions.

While healthcare management does not technically require an advanced degree, such as a master of health administration or master of business administration, these credentials can be pivotal in getting or keeping management positions. In fact, the lack of such can make it difficult for managers to progress to senior levels in HCOs, although in many instances, a law or medical degree is regarded as acceptable in lieu of higher education in management. Notwithstanding these special educational qualifications and skills, the healthcare management profession lacks the exclusivity afforded to clinicians who earn practice licenses in medicine, nursing, and allied health professions. The healthcare manager might be relegated to a certain quasi-professional status, subordinate to the clinical professions in the social and political structure of the HCO (Begun, White, and Mosser 2011; Garman, Leach, and Spector 2006). In the worst light, the profession suffers from mistaken assumptions that healthcare managers just run the numbers, hold the clipboard, or hide in their offices.

What healthcare management lacks in formal professionalization, therefore, must be overcome through trustworthy, dignified, and respectful behaviors. Along with their business skills, healthcare managers should elevate the profession by conducting themselves with something called professionalism. Colloquially, professionalism has been described as the ability to keep people who are not in the profession off your turf. Scholars and educators have tried to clarify the definition of professionalism by describing competencies, skills, and behaviors representative of healthcare managers’ professionalism (Agris et al. 2018; Brehm et al. 2006; NCHL 2018; Sakowski et al. 2020), including:

Building and sustaining trusted work-related relationships

Seeking feedback to accelerate personal growth

Participating in professional association activities, such as lifelong learning, mentoring, and credentialing

Holding themselves and others accountable to standards of performance

Adapting to organizational norms on how to dress, act, and work collaboratively

Embracing a continuous improvement orientation to ensure highly reliable health services and safe patient care

Committing to diversity, inclusion, and equity

Modeling integrity and a commitment to ethical decisions, practices, and behaviors

Without these behaviors, healthcare managers diminish the authority of the profession and become vulnerable to surrendering decision-making control to those outside the profession who may lack the necessary knowledge and skills to run an HCO. Various HCO stakeholders—boards of directors, medical staff, donors—will fill the power vacuum created when health administrators behave unprofessionally. The individual consequences of weakened authority include lack of effectiveness within the organization and, potentially, loss of a job.

Managers should consider whether their behaviors can enhance the stature of healthcare management as a profession. Do they represent integrity when interacting with others, especially patients? Do they treat people fairly? Are they truthful in their verbal and written communications? Do they admit mistakes? Do they continuously seek improvement? In addition to engendering respect for the healthcare management profession, these behaviors can benefit individual careers and maximize HCO effectiveness.

Thinking Strategically About the Job

Managers should understand the flexibility of their position. Each managerial job has three characteristics: (1) the demands that the manager must actively carry out; (2) the constraints on the position, or those activities that the manager is not allowed to carry out; and (3) the available options or choices about how the manager is going to spend their time and attention (Stewart and Fondas 1992). Managers should think about what they plan to accomplish at least every quarter. They should determine whose support they need to achieve these goals, and consider how they can strengthen relationships with those people; managing oneself is essential for this purpose.

Managers should consider their resume their lifeline and keep it current. They should ask themselves, What results did I achieve last year? What results will I achieve this year that show a convincing track record of accomplishment? Managers, on average, spend six years in their positions. They should consider themselves independent contractors in charge of their own careers, and they should not accept a position without an exit strategy. They should determine, in advance, the conditions under which they would no longer be willing to work in the position, and they should know what steps to take once that decision has been made.

Goleman (1998) stresses the importance of emotional intelligence (EI) for management success. He suggests that EI can be learned and that it is more important than IQ and advanced technical skills. According to Goleman and Boyatzis (2017), the 4 domains and 12 competencies of EI are as follows:

A table listing the parameters of emotional self-awareness.

Another way to think about EI centers on the skills of interaction that enable managers to hear what people are saying, understand what they are not saying, and then adjust their own communications based on that.

Barends, Rousseau, and Briner (2014) have written extensively on managerial decision making, emphasizing the need for managers to make decisions based on the best evidence available from multiple sources. This process includes the following steps:

Translating a practical issue or problem into an answerable question

Systematically searching for and retrieving the evidence

Critically judging the trustworthiness and relevance of the evidence

Weighing and pulling together the evidence

Incorporating the evidence into the decision-making process

Evaluating the outcome of the decision made

Self-evaluation—reflection on one’s skills and experience in terms of the job—is key. McCall, Lombardo, and Morrison (1988) have suggested the following framework for management development:

Find out about shortcomings.

Accept responsibility for shortcomings, which may result from a lack of knowledge, skills, or experience; from personality or limited ability; or from a poor fit for the situation.

Decide what to do about the shortcomings accordingly. Either build new strengths, anticipate situations, compensate, or change.

Obviously, managers should also do an assessment of their strengths and consider how to take advantage of and build upon those strengths. Such an assessment can help ensure a good fit between the job a manager has or seeks and the manager’s own skills and experience.

Good health services management generally makes a difference to the patient, as well as to the organization’s ruling coalition. How much of a difference is open to discussion. But who will look after the managers’ interests if they don’t look after them themselves? This is the first rule of managerial survival. Looking after one’s own interests does not mean that the manager should close their office door, read reports, and tell subordinates what to do. Instead, there are opportunities to strategically plan one’s professional development, as considered in the cases Now What? and What Then? Similarly, as described in The First Day, managers must understand the expectations for performance beginning on their first day on the job, even though sometimes a job does not meet the expectations held by the managers themselves, as is the case in Facing Reality in a New Job. Sometimes, the right move for a manager may be looking for another job.

Conclusion

The world of large and complex HCOs has led to managers’ specializing in areas such as operations, marketing, strategy, knowledge management, internal auditing, compliance, and human resources, among others. Many of these functional specialists and managers have not been trained in healthcare prior to being employed in HCOs. Meanwhile, clinicians require licensure, which bolsters their stature within the HCOs. To improve the healthcare management profession within the social and political structure of the HCO, managers must exhibit certain behaviors that reflect the concept of professionalism. However, healthcare managers should be aware that various HCO stakeholders (e.g., patients, clinicians, board members) value the role of the healthcare manager to various degrees. With that in mind, professionalism includes understanding the ways that healthcare managers add value to the HCO and to the community. Without this knowledge, self-assessment of management performance and ways to create improvement within the HCO becomes difficult, if not impossible.

Managing one’s career, like the function of management itself, involves judgment, which in Ray Brown’s (1969, p. 9) phrase, is knowledge ripened by experience. For management students, case discussions are an excellent way of obtaining safe experience in forming judgments about their developing healthcare management careers.

Discussion Questions

How is healthcare management similar or dissimilar to management in general?

How can managers demonstrate professionalism when working with interdisciplinary teams in the HCO?

What can a manager do to successfully move from one managerial position to another?

What are the obstacles to managerial self-improvement, and how can these best be overcome?

References

Abbott, A. 1988. The System of Professions. Chicago: University of Chicago Press.

Agris, J., E. Brichto, M. Meacham, and C. Louis. 2018. Developing Professionalism in Healthcare Management Programs: An Examination of Accreditation Outcomes. Journal of Health Administration Education 35 (2): 187–203.

Barends, E., D. M. Rousseau, and R. B. Briner. 2014. Evidence-Based Management: The Basic Principles. Center for Evidence-Based Management. www.cebma.org/wp-content/uploads/Evidence-Based-Practice-The-Basic-Principles.pdf.

Begun, J. W., K. R. White, and G. Mosser. 2011. Interprofessional Care Teams: The Role of the Healthcare Administrator. Journal of Interprofessional Care 25 (2): 119–23.

Brehm, B., P. Breen, B. Brown, L. Long, R. Smith, A. Wall, and N. S. Warren. 2006. An Interdisciplinary Approach to Introducing Professionalism. American Journal of Pharmaceutical Education 70 (4): 81.

Brown, R. 1969. Judgment in Administration. New York: McGraw-Hill.

Garman, A. N., D. C. Leach, and N. Spector. 2006. Worldviews in Collision: Conflict and Collaboration Across Professional Lines. Journal of Organizational Behavior: The International Journal of Industrial, Occupational and Organizational Psychology and Behavior 27 (7): 829–49.

Goleman, D. 1998. What Makes a Leader? Harvard Business Review 76 (6): 93–102.

Goleman, D., and R. E. Boyatzis. 2017. Emotional Intelligence Has 12 Elements. Which Do You Need to Work On? Harvard Business Review 84 (2): 1–5.

McCall, M. W., M. M. Lombardo, and A. M. Morrison. 1988. The Lessons of Experience: How Successful Executives Develop on the Job. Lexington, MA: Lexington Books.

NCHL (National Center for Healthcare Leadership). 2018. Health Leadership Competency Model 3.0. Chicago, Illinois: National Center for Healthcare Leadership.

Sakowski, J. A., A. M. Hewitt, N. Johri, and S. L. Wagner. 2020. Implementing an Incremental Approach for Developing Leadership and Professionalism Skills Among Early Careerists in the Health Administration Curriculum. Journal of Health Administration Education 37 (1): 89–104.

Stewart, R., and N. Fondas. 1992. How Managers Can Think Strategically About Their Jobs. Journal of Management Development 11 (7): 10–17.

Recommended Readings

Alexander, B. 2021. The Hospital: Life, Death, and Dollars in a Small American Town. New York: St. Martin’s Press.

Arndt, M., and B. Bigelow. 2007. Hospital Administration in the Early 1900s: Visions for the Future and the Reality of Daily Practice. Journal of Healthcare Management 52 (1): 34–48.

Barends, E., B. Janssen, and W. ten Have. 2014. Effect of Change Intervention: What Kind of Science Do We Really Have? Journal of Applied Behavioral Science 50 (1): 5–27.

Barnett, B. 2015. The Strategic Career: Let Business Principles Guide You. Stanford, CA: Stanford University Press.

Berry, L. L., and K. D. Seltman. 2008. Management Lessons from Mayo Clinic. New York: McGraw-Hill.

Burnett, B., and D. Evans. 2016. Designing Your Life: How to Build a Well-Lived, Joyful Life. New York: Alfred A. Knopf.

Burns, L. R. 2021. The U.S. Healthcare Ecosystem: Payers, Providers, Producers. New York: McGraw-Hill Education.

Christensen, C. M. 2010. How Will You Measure Your Life? Harvard Business Review 88 (7–8): 46–51.

Ezekiel, E. 2017. Prescription for the Future: The Twelve Transformational Practices of Highly Effective Medical Organizations. New York: Public Affairs.

Friedman, L., and A. Kovner. 2017. 101 Careers in Healthcare Management. New York: Springer.

Gabarro, J. J., and J. R. Kotter. 2005. Managing Your Boss. Harvard Business Review 83 (1): 5–12.

Griffith, J. R. 1993. The Moral Challenges of Healthcare Management. Chicago: Health Administration Press.

Institute of Medicine. 2001. Crossing the Quality Chasm. Washington, DC: National Academies Press.

Kovner, A. R. 2000. Healthcare Management in Mind: Eight Careers. New York: Springer.

Lee, T. H., and J. J. Mongan. 2009. Chaos and Organization in Health Care. Cambridge, MA: The MIT Press.

McAlearney, A. S. 2008. Using Leadership Development Programs to Improve Quality and Efficiency in Healthcare. Journal of Healthcare Management 53 (5): 319–31.

Pfeffer, J. 2015. Take Care of Yourself. In Leadership BS: Fixing Workplaces and Careers One Truth at a Time, 171–92. New York: Harper.

Topol, E. J. 2019. Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again. New York: Basic Books.

 CASE 1

The First Day

Ann Scheck McAlearney

Susan was both thrilled and terrified. Tomorrow was her first day as a manager. Having recently completed her master’s degree in health administration at a prestigious local university, she had conducted a thorough job search and been hired as the new manager of patient accounts at University Health System. She had had numerous interviews with various directors and other managers in the health system, as well as a lunch interview/meeting with six people who would report to her, but those interviews seemed very far away.

Susan wanted to make a good impression and get off to a positive start, yet she wasn’t sure what to do first. She had learned the importance of listening in management, but she also knew she was the boss. Further, her own boss, the director of patient care services, had emphasized the importance of getting her employees to improve productivity at any cost. Susan had heard that, although her new direct reports were nice to one’s face, they had a tendency to complain and scapegoat, which had led to the sudden departure of the previous manager of patient accounts. Susan was particularly nervous about being younger than all her new employees. To quell her fears, she decided to make a list of what she wanted to accomplish in her first days and weeks on the job.

Case Questions

Assume you are a friend of Susan’s considering a similar position. What would you recommend that she put on the list?

How would you suggest that she prioritize her goals?

 CASE 2

Now What?

Ann Scheck McAlearney

Kelly Carmon had been working at West Liberty Health System for four years, and she was starting to wonder what was next for her career. She remembered her graduate school experience in health administration fondly, especially now that she had been in the same position for three full years since her first promotion. The excitement of learning new things and the terror of exams and presentations were distant memories. Instead, she felt stuck in her present job as manager of operations for the division of cardiology.

West Liberty Health System was a large multihospital system located in a competitive Midwestern market. Though West Liberty was both large and doing fine financially, Carmon’s expectation that she could grow and learn within the health system was not becoming a reality. She found that the day-to-day existence of this operations management position was about as unglamorous as she could imagine, and she was unable to envision a promotion in her near future. Carmon had tried to continue to read and learn on the job, but there just wasn’t enough time in the day. The firefighting of operations and real-time crises were always first priorities, and she was afraid that she would soon be unable to remember how to analyze the business case for a new venture or how to think strategically about just about anything.

As Carmon returned home at the end of the week, she decided things had to change. Even though West Liberty had seemed like a good and caring employer when she originally interviewed, the company now seemed much better at talking about caring about employees than actually doing something about it. When Carmon looked back on the past three years, she realized that she had yet to successfully participate in any seminar or educational class offered by the health system because she could never seem to get away from her job. She also realized that she was not alone. Her friends in other departments had similar complaints, and they often felt that the only way they were able to take a break was to take a vacation that involved leaving the country, but nobody had enough time or money to do that frequently.

At 28, Carmon was still single, but she was starting to feel that the time she was investing in her career was not paying off professionally and it was certainly not helping her social life. Feeling burned out and disappointed, Carmon knew she needed to do something different, but she didn’t know what. She wanted to take the educational programs West Liberty offered, but she needed to find some protected time. She also needed to figure out how to navigate the politics and chaos of West Liberty.

Carmon set up a meeting with her boss, Patricia Edwards, director of cardiology, to voice her concerns. Although she told Edwards that the reason for the meeting was professional development, she wasn’t sure that Edwards understood what Carmon meant; she also wasn’t confident that Edwards would be able to provide the guidance Carmon sought. She had other mentors at West Liberty who had suggested different ways to develop herself professionally, but Carmon knew she had to get Edwards’s support before she could reallocate her time to focus on her professional development.

In getting her thoughts together for her meeting with Edwards, Carmon considered what information she should send to Edwards ahead of time and what she should leave for the actual meeting. Knowing Edwards hated to be surprised or caught off guard, Carmon decided to compile all her preliminary planning ideas in a for your eyes only document that she could send a week in advance of the meeting. She knew Edwards’s time was limited, but she wanted to make sure Edwards understood how important this issue was to her future at West Liberty. Carmon was dependent on Edwards’s buy-in to help her achieve her professional development goals, and she felt that a personal professional development plan would provide a solid framework with which she could guide the discussion. Knowing her resume would be a good starting point, she decided to go ahead and update it (see exhibit 2.1), and then consider her next steps.

EXHIBIT 2.1

Resume for Kelly Carmon

An illustration showing the resume for Kelly Carmon.

Case Questions

What constraints does Carmon face within her position? What options does she have to overcome those constraints?

What can Carmon do within her present job to learn on the job?

What should Carmon do to prepare for the meeting with Edwards?

What should be part of her personal professional development plan? What documents should she bring or send in advance of the meeting?

 CASE 3

What Then?

Ann Scheck McAlearney

Planning Her Professional Development

Kelly Carmon knew that the best approach to obtaining endorsement from her boss, Patricia Edwards, for her professional development was to develop a formal plan. By doing so, Carmon would be able to outline her professional development goals and describe why achieving her goals was important. Further, by creating a formal plan, Carmon would build the evidence case for her professional development, drawing from the available research literature she knew Edwards respected.

Though this process was difficult, it helped her focus her own goals so she could be clear and compelling when she presented her case to Edwards. She focused on two- and five-year horizons to keep herself from feeling completely overwhelmed. Knowing that the best goals were those that were measurable, Carmon outlined her professional development goals and their associated metrics as a starting point for her discussion with Edwards. This preliminary outline is presented in exhibit 3.1.

EXHIBIT 3.1

Professional Development Goals

A textual illustration listing the two-year and three-to-five-year professional development goals.

Focusing Professional Development Options

Once Carmon had outlined her goals, she saw that the next step in her professional development planning process was to highlight specific areas of development necessary for achieving her goals. Several areas jumped out at her in particular: (1) conflict management, (2) building professional teams, (3) internal networking, (4) cross-system collaboration, (5) leadership development, and (6) employee development.

Carmon recognized that Edwards, like many others, was a visual thinker. One tool Carmon knew of that might help both her and Edwards envision alternative professional development options was a scenario-analysis exercise that described what success might look like if things did or did not go as planned. Carmon got herself a glass of iced tea and imagined how things might happen for good or bad, considering whether she would be able to enlist the support and make the personal and behavioral changes she believed were necessary. Exhibit 3.2 shows how she envisioned these three scenarios for the two-year