Feb 18, 2011
The Military Health System (MHS) faces several challenges: exploding health care costs, an increased emphasis on performance management, combat operations that have placed unparalleled pressure on the health care system both at home and abroad, and a need to integrate the medical force into joint operations. Leadership will play a central role in responding to these challenges. In this context, the MHS Office of Transformation asked RAND Health and the RAND National Defense Research Institute to examine how leaders in the health care field are prepared and supported in the civilian and military sectors and to recommend improvements to the ways in which the MHS identifies and develops potential leaders. In response, RAND researchers undertook three major tasks. First, they reviewed health care leadership competency models—including the military health care leadership competencies identified by the Joint Medical Executive Skills Program (JMESP) as necessary for successful command of a medical treatment facility or for other executive MHS positions—as well as relevant documents on the development of health care officers in the military services. Second, they interviewed almost 60 military health professions officers and community managers and 30 civilian health care leaders from 25 organizations. The study team also conducted a case study of how one government agency—the Veterans Health Administration (VHA)—approaches executive leader development. The case study included interviews with 16 top-level leaders and network and facility directors. The interviews were conducted over a period of two years—2007 through 2009. The results of this research appear in Developing Military Health Care Leaders: Insights from the Military, Civilian, and Government Sectors.
The findings fall into three broad areas:
Both the literature review and interviews showed that desirable characteristics of leaders include a combination of knowledge and experience in three categories: management, leadership, and enterprise knowledge.
Health care leaders must be able to manage human, financial, and information resources. Thus, effective leadership requires a combination of both "hard" and "soft" skills. Hard skills include the ability to manage information and technology, financial resources, and human resources, i.e., recruit, train, and evaluate people. Financial resource management requires skills such as budgeting, asset management, and monitoring financial resources. The soft skills, or interpersonal and communication skills, were considered as important as the hard skills.
Leadership skills were perceived to be as important as management abilities. These skills enable leaders to provide an organization with the necessary strategic and visionary guidance. Competencies in this category include visionary leadership (i.e., envisioning a future state and influencing movement toward it), change leadership (i.e., continuously seeking innovative approaches and welcoming changes as opportunities for improvement), flexibility and adaptability, and creative and strategic thinking and planning.
Finally, enterprise knowledge includes competencies that demonstrate a sound understanding of the larger context in which the organization exists, such as organizational stewardship and systems-level thinking.
The context in which military health leaders operate is quite complex, especially when they are faced with the additional demands of war. They must manage not only military personnel but also civilian employees and contractors. Added to these demands is a growing emphasis on the bottom line. While medical leaders have more leadership opportunities, many of them also face pressure to perform in clinical specialties that reduce the time available to prepare for leadership positions.
The services differ in their approaches to preparing medical leaders, and the perceptions of the officers interviewed varied as well. Those in the Air Force generally agreed that the system provided reasonable preparation. While still positive, views were mixed in other services, with some officers perceiving a less structured system that was more susceptible to happenstance.
Selection processes also drew mixed reviews. All the services employ formal and informal methods of selecting those with high leadership potential. All use written evaluations in the selection process, but there was concern about the inflated nature of evaluations. Further, some concerns were voiced about the objectivity of the promotion boards that review these evaluations. Many officers noted the role that informal systems played in identifying potential leaders and believed that such systems could be more important than formal assessments. Some mentioned the need to accord diversity more consideration in the selection process.
When it comes to developing officers, on-the-job experience was widely regarded as the most valuable and effective means. At the same time, many officers noted the difficulty of serving in both clinical and leadership assignments. Physicians often lacked business and management skills because their leadership opportunities came somewhat later in their careers. Some interviewees were also concerned that services had a "career template" that limited an individual's flexibility to gain varied experience. While education was recognized as a valuable development tool, professional military education—either joint or service-specific—could be problematic for officers in the health professions. Concerns included the time required for such education, especially at the services' war colleges, and the relatively few spaces allotted to officers in the health professions. Education outside the military, such as graduate school, was perceived as valuable. Some also noted that longer job assignments would be beneficial in providing greater experience and might help increase retention.
Interviews with senior leaders in civilian health care organizations and the VHA provide additional insights into the development of MHS leaders. These organizations strongly support leader development, seeing it as one of their most important tasks. Many also endorse a "living" competency model that is linked to organizational goals and strategic plans and that drives the organization's approach to leader development. As an example, the VHA's High Performance Development Model does not focus on developing only senior leaders but rather provides training and development for a larger segment of the workforce so that the organization can grow as a whole. Leader selection is a high priority, and organizations employ different techniques to ensure that they recruit or advance exactly the type of leader they want. Some use behavioral interviews designed to ascertain whether individuals exhibit desired behaviors. The VHA uses performance-based interviews, in which the interviewer carefully defines the skills needed for the job and manages the interview process to elicit examples of past performance.
Leader development is emphasized in these organizations and includes a range of approaches. Respondents reported that, in addition to job assignments, their organizations offered coaching and mentoring, cross-functional and team development, and 360-degree feedback (that is, feedback from subordinates as well as superiors) as forms of leader development. Incentives to spur good performance include monetary rewards and are typically tied to measurable goals that connect to both organizational and individual goals. In some organizations, these financial incentives are linked not only to results but also to how results are obtained. Some organizations use nonmonetary incentives to develop and reward leadership, such as special projects or job titles.
The majority of the military personnel interviewed for the study believed, with some caveats, that the services do a reasonable job of preparing their military health care officers for executive positions. The findings reveal several ways to improve leader development of health professions officers. For example, from the standpoint of expectations for leaders, the U.S. Department of Defense could reexamine the JMESP competency model to ensure that it meets the MHS's strategic goals, infuses the competencies throughout the leader development process, and emphasizes the importance of both soft and hard skills in selection and evaluation. Other recommendations pertain to how to select, develop, and provide incentives to health leaders.