Tag Archives: leadership

Leading the Way in Health Care

As the mantra states: when you have it, well, you just have it. As true as that may be in regards to political and social attributes, the statement does not preclude the ability of anyone to learn to ‘have it’, but what is ‘it’? Every enterprise is started by a singular idea, and many ideas may come together to form the basis of any enterprise, but it takes a visionary mind to manifest these ideas. The people with these ideas are leaders who, by their very nature, are agents of change. These leaders tend to seek each other out when they have a common purpose and create solutions and fill voids that address problems in need of answers. However, once the paradigm of the enterprise is expressed, manpower is needed to ensure its operation and success. Much of this manpower is entrusted to managers who may appreciate the vision and goals of the enterprise but lack the vision themselves to affect significant change, and although this statement sounds pessimistic towards the manager’s abilities, hope is not lost. Managers can, and do, learn to be leaders. Further, one does not require a management position to be a leader; leadership is both intuitive and learned (Buckbinder, Shanks, & McConnell, 2012).

Aside from being visionaries, leaders need to be socially adept in order to promote their views and constructs; therefore, in order to gain the trust and respect of subordinates, managers should strive to hone attitude and behavior to be more fit to lead (Freshman & Rubino, 2002). Mayer and Salovey describe four specific abilities that can improve one’s emotional skill set, also known as emotional intelligence (EI): “(1) the accurate perception, appraisal, and expression of emotions; (2) generating feelings on demand when they can facilitate understanding of yourself or another person; (3) understanding emotions and the knowledge that can be derived from them; and (4) the regulation of emotion to promote emotional and intellectual growth” (as cited in Freshman & Rubino, 2002, p. 3).

The importance of EI is evident in the highly ethically charged environment of health care. Many recommendations have been made to cultivate EI within health care, both with clinicians and administrators, yet it is not evident that this has been taking place, according to Freshman and Rubino (2002). Perhaps, at least philosophically, one must know themselves before attempting to truly know others, but being comfortable with one’s self and possessing the ability to relate and empathize with others, especially in the health fields where patients are vulnerable and providers are, themselves, empaths, will offer a manager leadership capabilities that will create trust and mutual respect in the workforce. Applied to health care adminstration, EI can be divided into five components (e.g. self-awareness, self-regulation, self-motivation, social awareness, social skills) that can be programmatically improved using training and career development opportunities with the organization.

Self-awareness goes back to the previous philosophical statement about knowing one’s self. We must take inventory of ourselves constantly in order to ensure that we understand our own strengths, weaknesses, as well as our motivations. Self-regulation, an important ethical descriptor, allows us to improve our own personal ethics in order to make difficult decisions more easily and without troubling remorse. Tough choices are made daily in the health care setting, and a leader should be able to make these decisions ethically with compassion and understanding. Self-motivation involves challenging one’s self daily to preserve the desire and passion personally and professionally. Social awareness is borne of the former components that allow one to consider the effect decisions have on others. Finally, social skills are necessary for effective communication, especially when considering the need to promote ideas and negotiate with others. These skills, inherent in great leaders, are beneficial to the health care administrator and beneficial, over all, to the health care organization.

References

Buchbinder, S. B., Shanks, N. H., & McConnell, C. R. (2012). Introduction to healthcare management. Sudbury, MA: Jones and Bartlett.

Buchbinder, S. B. & Thompson, J. M. (2010). Career opportunities in health care management: Perspectives in the field. Sudbury, MA: Jones and Bartlett.

Freshman, B. & Rubino, L. (2002). Emotional intelligence: a core competency for health care administrators. Health Care Manager, 20(4), 1-9.

Pay-for-Performance

Challenges in Developing  Standards

The U.S. health care industry is contemplating the implementation of pay-for-performance reimbursement schemes in order to increase quality and safety in the delivery of health care. Pay-for-performance is a business model that combines reduced compensation for those who fail to meet standards and bonus payments for those that meet or exceed the stated expectations, but the results of such programs, thus far, is mixed (Baker, 2003; Campbell, Reeves, Kontopantelis, Sibbald, & Roland, 2009; Lee & Ferris, 2009; Young et al., 2005). The introduction of pay-for-performance models is primarily to provide relief from other, more extreme, reimbursement models, such as fee-for-service (which rewards overuse) and capitation (which rewards underuse), and with rising health care costs, a diminishing economy, and the increasing number of Americans lacking adequate health insurance, its introduction to the U.S. health care system could not be more timelier (Lee & Ferris, 2009).

The impetus of contemporary pay-for-performance schemes is derived from a report from the Institute of Medicine (2001). This report argued that current reimbursement schemes fail to reward quality in health care and may possibly create a barrier to innovation (Baker, 2003; Young et al., 2005). There are many international supporters of health care pay-for-performance, especially in England where the National Health Service employs pay-for-performance to keep costs under control while attempting to provide for quality and safety in the delivery of primary health care (Baker, 2003; Campbell et al., 2009; Young et al., 2005). However, the adoption of pay-for-performance seems to face many challenges.

One challenge to pay-for-performance implementation concerns the effectiveness in the overall continuity of care. Campbell et al. (2009) conducted an analysis of the effect of pay-for-performance in England and found that, although implementation of pay-for-performance in 2004 resulted in short-term gains in the quality of care, the improvements receded to pre-2004 levels. Beyond the pay-for-performance standards, though, the quality of care in areas not associated with incentives declined. Cameron (2011) reports on a recent study of the effectiveness of pay-for-performance on hypertension – the study shows no improvement in any measure including the incidence of stroke, heart attack, renal failure, heart failure, or combined mortality among the group (Lee & Ferris, 2009). McDonald and Roland (2009) describe these effects on other aspects of care as unintended consequences detrimental to health care quality and safety as a whole.

Another significant challenge to pay-for-performance implementation is ensuring that certain patient populations continue to be able to access appropriate care (McDonald & Roland, 2009). Under some pay-for-performance schemes, practices with a sicker patient demographic (i.e. geriatrics, oncology, neonatology, etc.) will suffer economically despite providing a higher level of care than their counterparts in family medicine or other more generalized practices. Specific concerns address a physicians ability to choose not to treat patients due to their non-compliance with medical orders (McDonald & Roland, 2009). Equity and access cannot suffer under a just reimbursement model, just as physicians with a sicker demographic should not suffer.

Identifying a reliable standard of measure in health care quality proves difficult. Earlier methods, such as those developed by Campbell, Braspenning, Hutchinson, and Marshall (2002), initially appeared sound, but ineffective methods and unintended consequences were soon identified (Cameron, 2011; Lee & Ferris, 2009; McDonald & Roland, 2009). More recent work by Steyerberg et al. (2010) shows that new approaches are on the horizon and that pay-for-performance may still remain a viable scheme, providing the measures and standards are, in fact, legitimate and accurately identify improved quality without detracting from other aspects of heath care. Steyerberg et al. identifies novel approaches to prediction models that may help to standardize measures in pay-for-performance schemes to be more realistic and reliable without causing many of the unintended consequences of earlier plans.

As we become more technologically advanced and find ways, albeit expensive, to cure and treat diseases that until now were intractable, we must address the ethics surrounding the provision of this care as a system of management. By combining the whole of health care into the ethics discussion, we opt to leave no one wanting for care, but we now have to address the problem of paying for the expensive care that we have all but demanded. Pay-for-performance, though not perfect, shows much promise in keeping health care costs manageable. However, we must strive to identify those patients and practitioners that lose out under this system of reimbursement and strive to identify just and ethical means of repairing the scheme. Though, we should first answer the question: is health care a right or a privilege?

References

Baker, G. (2003). Pay for performance incentive programs in healthcare: market dynamics and business process. Retrieved from http://www.leapfroggroup.org/media/file/Leapfrog-Pay_for_Performance_Briefing.pdf

Cameron, D. (2011, January 27). Pay-for-Performance does not improve patient health. Harvard Medical School News. Retrieved from http://hms.harvard.edu/public/news/2011/ 012611_serumaga_soumerai/index.html

Campbell, S. M., Braspenning, J., Hutchinson, A., & Marshall, M. (2002). Research methods used in developing and applying quality indicators in primary care. Quality and Safety in Health Care, 11(4), 358–364. doi:10.1136/qhc.11.4.358

Campbell, S. M., Reeves, D., Kontopantelis, E., Sibbald, B., & Roland, M. (2009). Effects of pay for performance on the quality of primary care in England. New England Journal of Medicine, 361(4), 368-378. doi:10.1056/NEJMsa0807651

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Retrieved from http://www.iom.edu/reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx

Lee, T. H. & Ferris, T. G. (2009). Pay for performance: a work in progress. Circulation, 119(23), 2965-2966. doi:10.1161/CIRCULATIONAHA.109.869958

McDonald, R. & Roland, M. (2009). Pay for performance in primary care in England and California: comparison of unintended consequences. Annals of Family Medicine, 7(2), 121–127. doi:10.1370/afm.946

Steyerberg, E. W., Vickers, A. J., Cook, N. R., Gerds, T., Gonen, M., Obuchowski, N., … Kattane, M. W. (2010). Assessing the performance of prediction models: A framework for traditional and novel measures. Epidemiology, 21(1), 128–138. doi:10.1097/EDE.0b013e3181c30fb2

Young, G. J., White, B., Burgess, J. F., Berlowitz, D., Meterko, M., Guldin, M. R., & Bokhour, B. G. (2005). Conceptual issues in the design and implementation of pay-for-quality programs. American Journal of Medical Quality, 20(3), 144-50. doi:10.1177/1062860605275222

Challenges Developing Measurement Tools

Common sense would dictate that a person should want to purchase quality when choosing any product or service, and as health care costs soar in the United States, we also want to ensure that we, as consumers of health care and taxpayers who subsidize health care, are reaping maximum quality for that cost (Buck, Godfrey, & Morgan, 1996). According to McGlynn (1997), the costs for health care in the U.S. have been rising dramatically causing disruption in the manner of which professionals provide care and patients seek it out. It is important to realize the impact that these increasing costs and other changes have on the delivery of care, and, as McGlynn points out, assessment of quality measures are the means of evaluation. Unfortunately, McGlynn and others at the time have found quality measures to be lacking the requisite data needed to make an accurate evaluation of the delivery of health care (Brook, McGlynn, & Shekelle, 2000; Grimshaw & Russell, 1993; McGlynn, 1997).

Over the past decade, many efforts have been made to develop quality measures in order to direct quality improvement; however, these efforts, though effective, have been disjointed and ad hoc at best. McGlynn and Asch (1998) cautions that careful attention to methodology is essential when developing these measures. Accurate methodologies can be reproduced and used to effectively compare efforts between institutions. This leads to a best practices continuum of health care provision.

Recently, researchers have studied teamwork behaviors and their influence on patient and staff-related outcomes, but many of the discussions were institution-centric and may not have applied in the macro environment of U.S. health care. Reader, Flin, Mearns, and Cuthbertson (2009) recently attempted to organize these studies and develop a portable and robust framework which would lead to the development of effective team performance and provide means of further testing and improvement of team dynamics. Their findings suggest that effective teamwork is crucial to providing patient care in critical settings. Reader et al. shows one of the shortcomings of recent quality measure development but also illustrates a manner in which to overcome the limitations.

Developing methods for measuring and evaluating performance in health care have been challenging, overall. Campbell, Braspenning, Hutchinson, and Marshall (2002) identify three component issues to addressing these challenges: “(1) which stakeholder perspective(s) are the indicators intended to reflect; (2) what aspects of health care are being measured; and (3) what evidence is available?” (p. 358). This addresses the qualitative concerns of capturing indicators, while efforts like those of Steyerberg et al. (2010) concern themselves with quantitative abstraction and portability, as well as predictive value. Steyerberg et al. promotes the use of reclassification, discrimination, and calibration when using statistical models to develop valid prediction models and novel performance measures.

Performance indicators that are an accurate reflection of health care provision can lead to development of best practices, lower overall health care costs, and improve the delivery of care which will decrease mortality and morbidity. When considering these performance indicators, especially during development, researchers and administrators need to ensure the validity of the measurements. Approaches to developing quality improvement measures are constantly evolving, and new and novel methods are being designed to standardize the instruments, the application, and the reporting. Quality improvement is still, however, a challenge to many health care providers.

References

Brook, R. H., McGlynn, E. A., & Shekelle, P. G. (2000). Defining and measuring quality of care: a perspective from US researchers. International Journal of Quality in Health Care, 12(4), 281–95. doi:10.1093/intqhc/12.4.281

Buck, D., Godfrey, C., & Morgan, A. (1996). Performance indicators and health promotion targets (Discussion paper No. 150). York, UK: Centre for Health Economics, University of York. Retrieved from http://www.york.ac.uk/che/pdf/DP150.pdf

Campbell, S. M., Braspenning, J., Hutchinson, A., & Marshall, M. (2002). Research methods used in developing and applying quality indicators in primary care. Quality and Safety in Health Care, 11(4), 358–364. doi:10.1136/qhc.11.4.358

Grimshaw, J. M. & Russell, I. T. (1993). Effect of clinical guidelines on medical practice: A systematic review of rigorous evaluations. Lancet, 342(8883), 1317-1322. doi:10.1016/0140-6736(93)92244-N

McGlynn, E. A. (1997). Six challenges in measuring the quality of health care.Health Affairs, 16(3), 7-21. doi:10.1377/hlthaff.16.3.7

McGlynn, E. A. & Asch, S. M. (1998). Developing a clinical performance measure. American Journal of Preventive Medicine, 14(3), Supp. 1, 14–21. doi:10.1016/S0749-3797(97)00032-9

Reader, T. W., Flin, R., Mearns, K., & Cuthbertson, B. H. (2009). Developing a team performance framework for the intensive care unit. Critical Care Medicine, 37(5), 1787-1793. doi:10.1097/CCM.0b013e31819f0451

Steyerberg, E. W., Vickers, A. J., Cook, N. R., Gerds, T., Gonen, M., Obuchowski, N., … Kattane, M. W. (2010). Assessing the performance of prediction models: A framework for traditional and novel measures. Epidemiology, 21(1), 128–138. doi:10.1097/EDE.0b013e3181c30fb2

Quality and Safety Measurement

In regards to the incident surrounding the death of Josie King (Josie King Foundation, 2002), there have been many great improvements in the delivery of care at Johns Hopkins (Niedowski, 2003; Zimmerman, 2004). Those aside, and if I was faced with having to develop performance measures of quality and safety in the context of such a tragedy, I would strive to ensure that my measures were accurate and valid to identify areas of grave concern where Johns Hopkins would do good to improve.

First, I would consider measuring the structure of the care delivered. In Josie’s case, a medical response team responded when it was identified that she was in the midst of a medical crisis. The first measurement would serve to identify the availability of such teams and the adequacy of the team’s staffing. The measure would indicate the response time of the team and the licensing and certification level of each team member.

Second, I would consider measuring processes that might have contributed to the death of Josie King. In this instance, Josie was administered a narcotic while suffering acute dehydration. The administration of this medication was contrary to the physician’s orders regarding pain medication for this patient. This measure would indicate the appropriate use of narcotic analgesia in patients faced with contraindications, such as acute dehydration or shock. This measure would be a cross tabulation of recent vital signs and laboratory results.

Third, I would consider measuring outcomes. In cases where pediatric patients are downgraded from the pediatric intensive care unit (PICU) to a general ward, any adverse condition should prompt an upgrade back to the PICU. This measure would identify the number of cases in each reporting period that any recently downgraded patient was upgraded back to the PICU. This measure should account for the time between a crisis and upgrade along with a statement indicating the cause of the crisis and resultant upgrade. This measure should be augmented by a mortality and morbidity subset involving any patients who were downgraded from PICU.

My considerations for these processes are to determine if general ward nurses should be administering any medications on standing order or if there should be a requirement to ensure that any medication administered to a general ward patient is explicitly written in the patient’s chart at the time of administration. Also, nurses should be acutely aware of the contraindications of any medications that they are administering. The process measure will, hopefully, identify misuse of narcotic analgesia and any failure to assess the patient for other possible causes of distress before assuming the distress is in response to pain. Ultimately, a more timely and efficient use of medical response teams should result, which would avail physicians and more experienced nurses to the original patient care team. This should lead to an open discussion of how to better manage the patient post crisis. Also, a greater understanding of medication administration concepts should result, benefiting all patients.

References

Josie King Foundation. (2002). About: What happened. Retrieved from http://www.josieking.org/page.cfm?pageID=10

Niedowski, E. (2003, December 15). From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl’s death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish. The Sun, pp. 1A. Retrieved from http://teacherweb.com/NY/StBarnabas/Quality/JohnsHopkinsErrors.pdf

Zimmerman, R. (2004, May 18). Doctors’ new tool to fight lawsuits: Saying ‘I’m sorry’. Wall Street Journal, pp. A1. Retrieved from http://www.theoma.org/files/wsj%20-%20medical%20error%20-%2005-18-2004.pdf

The Patient Perspective: Patient Safety

The Speak Up materials provided by The Joint Commission (2011a, 2011b) do a great service in succinctly illustrating the need to be educated about health care issues. Patients and their families have a unique perspective to understanding their (or, their family member’s) health (Vincent & Coulter, 2002). Although physicians, nurses, and allied health providers are responsible for providing quality care, it remains the domain of the patient to express uncertainty or provide additional information to guide the provider. Ultimately, the patient or surrogate decision-maker must provide consent for treatment and must do so with full understanding. There are times, however, that the scope of treatment is so drastic, emergent, or specialized that the patient may not have the facilities to gain a full understanding of care needing to be rendered (Vincent & Coulter, 2002). This is the exception.

In the case of Josie King (Josie King Foundation, 2002; Niedowski, 2003; Zimmerman, 2004), which I elaborated on last week, Sorrel King, Josie’s mother, was educated about her daughter’s condition and spoke up as The Joint Commission recommends. Unfortunately, this case turned into tragedy not because Sorrel King did wrong but because the nurse disregarded her apprehension. This was tantamount to malpractice and no patient or family member could have prevented this, save for using force to physically prevent the administration of medicine. According to MacDonald (2009), there are nurses that believe “[patients] have no say and that medications are the domain of doctors, leaving the nurse and the patient to trust that the doctors would do the right thing” (p. 29).

Perhaps things were slightly different, however. As MacDonald (2009) explains, patient’s who are knowledgeable of their illness and take an active role in their health care decisions add another layer of safety, especially when considering medication action, reaction, and interaction. Medication prescription errors are numerous within health care, and as in the case of Josie King, improved communication between the physicians, nurses, and Sorrel King might have prevented Josie from being administered the narcotic and instead receiving the fluid she so desparately needed (Vincent & Coulter, 2002).

Health care should be patient-centric as it remains the responsibility of the patient to be educated about the care they receive and to provide consent for that care and treatment to be rendered. An uneducated patient does add risk, but sometimes this is unavoidable. It is in these instances that special care should be taken until a full medical history can be attained.

References

The Joint Commission. (2011a, March 7). Speak up: Prevent errors in your care [Video podcast]. Retrieved from http://www.jointcommission.org/multimedia/speak-up-prevent-errors-in-your-care-/

The Joint Commission. (2011b, April 5). Speak up: Prevent the spread of infection [Video podcast]. Retrieved from http://www.jointcommission.org/multimedia/speak-up–prevent-the-spread-of-infection/

Josie King Foundation. (2002). About: What happened. Retrieved from http://www.josieking.org/page.cfm?pageID=10

Macdonald, M. (2009). Pilot study: The role of the hospitalized patient in medication administration safety. Patient Safety & Quality Healthcare, 6(3), 28-31. Retrieved from http://www.psqh.com/

Niedowski, E. (2003, December 15). From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl’s death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish. The Sun, pp. 1A. Retrieved from http://teacherweb.com/NY/StBarnabas/Quality/JohnsHopkinsErrors.pdf

Vincent, C. A. & Coulter, A. (2002). Patient safety: what about the patient? Quality & Safety in Health Care, 11(1), 76–80. doi:10.1136/qhc.11.1.76

Zimmerman, R. (2004, May 18). Doctors’ new tool to fight lawsuits: Saying ‘I’m sorry’. Wall Street Journal, pp. A1. Retrieved from http://www.theoma.org/files/wsj%20-%20medical%20error%20-%2005-18-2004.pdf

Medical Error: The Josie King Story

Josie King’s story (Josie King Foundation, 2002; Niedowski, 2003; Zimmerman, 2004) is heartbreaking, but the events told herein empowered Sorrel King, Josie’s mother, to take on a mission responsible for numerous patient care recommendations that have enhanced the safety of pediatric patients throughout the country. Josie King was only 18 months old when she climbed into a hot bath and suffered 1st and 2nd degree burns which led to her being admitted to Johns Hopkins pediatric intensive care unit (PICU). Within 10 days, Josie was released from the PICU and brought to the intermediate floor with all assurances that she was making a remarkable recovery and would be released home in a few days. Josie did not continue her remarkable recovery, however.

According to Sorrel King (Josie King Foundation, 2002), Josie began acting strangely, exhibiting extreme thirst and lethargy, after her central intravenous line had been removed. After much demanding by Sorrel, a medication was administered to Josie to counteract the narcotic analgesia she had been administered. Josie was also allowed to drink, which she did fervently. Josie, again, began recovering quickly. Unfortunately, the next day, a nurse administered methadone, a narcotic, to Josie as Sorrel told her that Josie was not supposed to have any narcotics… that the order had been removed. Josie became limp and the medical team had to rush to her aid. Josie was moved back up to the PICU and placed on life support, but it was fruitless. Josie died two days later and was taken off life support.

The Institute of Medicine (2001) published six dimensions of health care: safety, effectiveness, patient-centered, timeliness, efficiency, and equality. In Josie’s case, the care was not delivered efficiently, effectively, safely, or in a patient- or family-centered fashion. The overuse of narcotics in Josie’s case was certainly not effective or safe. Additionally, withholding fluids and allowing her to become dehydrated was detrimental to her recovery, which was neither safe nor effective. As Josie exhibited extreme thirst, her symptoms were dismissed, which does not follow patient-centeredness. Moreso, when the nurse administered the narcotic to Josie despite the pleadings of her mother, it demonstrated a lack of family-centered care, safety (in that, the order should have been double checked), efficacy (further demonstrating overuse of narcotic analgesia), and efficiency, as medication orders were either unclearly written or removed.

This story is clearly a demonstration that mistakes can happen at even the best of hospitals.

References

Institute of Medicine. (2001, July). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

Josie King Foundation. (2002). About: What happened. Retrieved from http://www.josieking.org/page.cfm?pageID=10

Niedowski, E. (2003, December 15). From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl’s death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish. The Sun, pp. 1A. Retrieved from http://teacherweb.com/NY/StBarnabas/Quality/JohnsHopkinsErrors.pdf

Zimmerman, R. (2004, May 18). Doctors’ New Tool To Fight Lawsuits: Saying ‘I’m Sorry’. Wall Street Journal, pp. A1. Retrieved from http://www.theoma.org/files/wsj%20-%20medical%20error%20-%2005-18-2004.pdf

Leadership & Character

Juxtaposing Two Renowned Leaders of Health

When considering leadership in health care, I think first of how that leadership has affected health care in particular. Being a leader in health care does not guarantee great impact; however, an effective leader can have great impact over a large scope. This is how I framed my search to find two leaders in health care to highlight in this paper.

The first leader of health care that I will discuss is Clara Barton. According to Chambers (2002), Barton, independent to a fault, has been described as having a persuasive power about her. A fairly timid girl, Barton had self-image problems growing up that were at times debilitating; however, it seemed that as long as her interest was in helping others Barton performed selflessly, with heroism and bravado usually reserved for men during the time. Barton, a school teacher, found herself in the middle of the Civil War caring and tending to the soldiers on the battlefield. Dubbed the angel of the battlefield, Barton would not cease in caring for the soldiers even under enemy fire.

Barton, according to Chambers (2002) was not a very effective manager, but she could convince anyone to do anything that she needed to get done, it was said. Barton presents with a leadership style that is transformational (Robbins & Judge, 2010). She sees a need and immediately works to fill the void, inspiring others to do the same. Barton was ultimately responsible for founding the American Red Cross, a neutral organization that today responds to over 67, 000 disasters per year providing medical supplies, food, and housing in order to promote health equity even during wartime. Barton was a socialized charismatic leader, and her accomplishments are truly inspirational (Robbins & Judge, 2010).

The second leader of health care, more so in death than in life, that I chose to discuss is Johns Hopkins. Most people are familiar with Johns Hopkins Hospital and Johns Hopkins University, but it might be surprising to know that these namesakes were only made possible by the posthumous gift of $7-million from Hopkins’s estate (Herringshaw, 1901; “Johns Hopkins,” 1891). Hopkins started life from an affluent family, but a choice to free the family’s slaves forced Hopkins out of his formal education to help on the family tobacco farm. Since leaving the family farm, it seemed, by all accounts, that Hopkins had an innate ability for business (“Johns Hopkins,” 1891). Hopkins became very successful in business early in his lifetime, and he always tried to return his good fortune to the community. This innate ability for business, along with his unwavering business ethics, would seem to make Hopkins a likable and well-respected leader, possibly invoking a sense that he was born with these traits (Borgatta, Bales, & Couch, 1954; Cawthon, 1996; Robbins & Judge, 2010). It was in the spirit of community leader that Hopkins fulfilled his final philanthropy by funding an orphanage, a university, colleges, and a hospital that to this day is world-renowned. Johns Hopkins was an authentic leader (Robbins & Judge, 2010).

Whether a leader is naturally born with certain traits or learns behaviors from their environment, what matters most is that they be prepared to lead when the time comes. Without the onus of personal responsibility, no true leaders can exist.

References

Borgatta, E. F., Bales, R. F., & Couch, A. S. (1954). Some findings relevent to the great man theory of leadership. American Sociological Review, 19(6), 755-759. doi:10.2307/2087923

Cawthon, D. L. (1996). Leadership: the great man theory revisited. Business Horizons, 39(3), 1-4. doi:10.1016/S0007-6813(96)90001-4

Chambers, L. (2002). Fearless under fire. Biography, 6(4), 64-67, 96-97.

Herringshaw, T. W. (Ed.). (1901). Johns Hopkins. Herringshaw’s encyclopedia of American biography of the nineteenth century. Retrieved from http://books.google.com/

Johns Hopkins. (1891). The national cyclopaedia of American biography (Vol. 5). Retrieved from http://books.google.com/

Robbins, S. P. & Judge, T. A. (2010). Leadership. Essentials of Organizational Behavior (pp. 159-180). Upper Saddle River, NJ: Pearson Prentice Hall.

Theories of Motivation

Perhaps, one of the most difficult aspects of managing human resources is understanding the motivational factors present that promote or inhibit work product. I believe it is also difficult for managers to take inventory of their own motivational factors. I will discuss some of the major motivational theories and apply them to a hypothetical scenario. The scenario portends to be a synopsis of Susan Smith’s typical day. Susan is a Human Resource Manager at a health care provider and must manage both the employees’ and her own priorities.

One of the founding theories of motivation is Maslow’s heirarchy of needs (Banerjee, 1995; Maslow, 1943; Robbins & Judge, 2010). In it, Maslow describes how people prioritize needs based on the weighted fulfillment of those needs; ergo, a starving man may kill for food, yet may not if he is also acutely dehydrated. This example demonstrates that although the starving man might not kill normally, he may in order to combat the physiologic need of hunger to survive. This hunger can be shadowed, however, by a lower-order physiologic need of thirst which will mute the desire to fulfill the food craving while in search or water. Maslow’s heirarchy includes (from lowest-order to highest-order): 1) physiologic, 2) safety, 3) social, 4) esteem, and 5) self-actualization needs.

In this scenario, Susan is confronted with the stress of fulfilling her job and meeting her deadlines. This could trigger a want of fulfilling safety needs if she feels that her livelihood is threatened. These needs are motivating Susan to stay late in order to meet deadlines; however, the lack of fulfillment is creating stress that is manifesting within her family and impacting her negatively at work. A further demonstration of Maslow’s hierarchy is Susan’s desire to increase the pay for the workers. This may help Susan to fulfill a social need of helping those in her charge, but with the lack of lower-order fulfillment, it has a lower priority. Instead, Susan acknowledges that she must offer pay that is commensurate with the work being performed by her employees. This is Susan’s attempt to fulfill the workers’ safety, esteem, and self-actualization needs. In general, according to Banerjee (1995), Maslow’s theory has merit, but it remains too generalized for practical purposes as people vary greatly in the priorities placed on the higher-order needs.

Herzberg’s hygiene-motivation theory (Banerjee, 1995; Robbins & Judge, 2010), on the other hand, attempts to validate measures to prevent dissatisfaction (hygiene) while promoting a different set of measures designed to increase satisfaction (motivation). Hygiene measures, according to Fred Luthans (as cited in Banerjee, 1995), are “a necessary floor to prevent dissatisfaction and a take-off point for motivation” (p. 80). Herzberg’s theory can be applied to this scenario, also (Laureate Education, n.d.). Susan attempts to mitigate employee dissatisfaction by using hygienic control measures increasing pay. Unfortunately, Susan feels that this might have an adverse effect on current employee morale as there is only enough money to increase the starting pay for new employees. While Susan thinks additional pay would seem to positively impact motivation by increasing job satisfaction, providing raises only to new employees seems contradictory and may only serve to negatively effect hygiene causing dissatisfaction among the ranks of employees. Susan should find other ways to mitigate hygiene factors and promote novel motivational factors. Susan shows low need for power, an elevated need for achievement, and a questionably neutral need for affiliation, in this case (Robbins & Judge, 2010).

People are motivated by a number of factors, both intrinsic and extrinsic, according to Deci’s self-determination theory of motivation (Robbins & Judge, 2010; Ryan & Deci, 2000), and later, Vroom’s expectancy theory (Banerjee, 1995; Robbins & Judge, 2010). In the scenario, there is limited information with which to draw definitive conclusions as to the sincere motivations of Susan. However, based solely on the information provided, Susan appears to be driven mostly by intrinsic factors of self-efficacy. Though it would be difficult to consider that Susan might perform her job without extrinsic reward, it seems that the self-recognition of her ability to earn money for her household is a more satisfying reward than the pay, itself. This might explain why Susan is willing to stay late often and complete her tasks in a timely manner. Also, this might explain her frustration with her administrative assistant: a perceived lack of internal motivation on Grace’s part (Heath, 1999). Further, Susan’s boss is setting a deadline that, although difficult, is obtainable, thereby also demonstrating an effective example of goal-setting theory (Robbins & Judge, 2010).

More important, though, to many people is their sense of justice and equity. Equity theory tells that work put in should equal reward output. In this sense, I worry that Susan will soon suffer fatigue, a lower-order need will avail itself for fulfillment, and Susan will no longer perceive the output as great as the effort. If this occurs, Susan will feel slighted and will lose motivation. Ironically, this is the exact fear she has about her employees who will not receive a raise.

Overall, the scenario plays out just as any day in any office might. Susan is performing the common tasks of a manager, ensuring a smooth and efficient business operation, while trying to remain fair and just to the employees. If Susan has a concrete understanding of the motivational forces within and without her workforce, she would do well to harnessing those.

References

Banerjee, M. (1995). Theories of motivation. Organization behaviour (3rd ed.; pp. 72-108). Retrieved from http://books.google.com/

Heath, C. (1999). On the social psychology of agency relationships: Lay theories of motivation overemphasize extrinsic incentives. Organizational Behavior and Human Decision Processes, 78(1), 25–62. doi:10.1006/obhd.1999.2826

Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370-396. doi:10.1037/h0054346

Robbins, S. P. & Judge, T. A. (2010). Motivation concepts. Essentials of organizational behavior (pp. 62-79). Upper Saddle River, NJ: Pearson Prentice Hall.

Ryan, R. M. & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55(1), 68-78. doi:10.1037//0003-066X.55.1.68