Health Care Leadership Ain’t What It Used To Be: Emotional Intelligence Competencies Of Hospitalist Leaders

Introduction

The national debate regarding the state of the healthcare system in the United States is decades old. Several administrations, and most recently President Obama, have targeted healthcare reform as a top initiative. Consequently, the United States healthcare system is viewed by many as broken (Kirchhemer, 2008; Wachter, 2004a). Concerns about the healthcare environment include: the rising costs for individuals, businesses and hospitals, lack of access, the advent of managed care, the increased importance and visibility of hospital performance metrics, the influence exerted by insurance companies on care decisions, union relations, and greater media coverage and scrutiny related to the quality of care and ethics have kept the debate in the forefront.

As the healthcare environment continues to gain complexity, the past practices of physician leaders may no longer be effective (Beckham, 1995). Physician leaders are being challenged to change, adapt and improve their approach to effectively lead their organizations (McAlearney, Fisher, Heiser, Robbins, & Kelleher, 2005). As a result, many physician leaders are not prepared for the current leadership demands of their roles (Kaplan & Feldman, 2008).

This researcher has participated in numerous physician leader coaching engagements since 2002. One particular group, hospitalist medical directors, are seeking coaching with increasing frequency. Hospitalists are physicians who specialize in inpatient medicine and manage the care of hospitalized patients (Wachter & Goldman, 1996). A hospitalist medical director leads a hospitalist program within an organization. Through an analysis of the strengths and areas of improvement as articulated by physician leaders and those who they lead, this researcher believes that one method for improving some facets of the healthcare system in the United States is by enhancing the leadership acumen of hospitalist medical directors.

Statement of the Problem

The challenges facing the healthcare system in the United States have raised expectations for physician leaders to direct their organizations more effectively and efficiently (Beckham, 1995). Physician leadership is essential because these leaders serve at the intersection of clinical care and business realities (Gerbarg, 2002). Deficient leadership negatively impacts the organization, which can lead to lower performance of the hospital and can impact the performance of the healthcare industry (Greeno, 2003). The purpose of this study was to determine hospitalist medical directors’ performance on emotional intelligence (EI) competencies and their perceptions of the importance of these competencies to their leadership role.

Research Questions

  1. What are the EI competencies identified as important for leadership by hospitalist medical directors?
  2. How do hospitalist medical directors rate their EI performance?
  3. How do self-reported EI competencies correlate to hospitalist medical directors perceptions of their leadership role?

The Changing Landscape of Healthcare in the United States

Over the past century, reforms such as the institution of health insurance, the creation of Medicare and Medicaid, the increased use of technology, and improved medications have aimed at improving the efficiency and effectiveness of healthcare in the United States. However, many of these initiatives have not led to substantive change. As a result, the United States healthcare system is viewed by many as broken (Kirchhemer, 2008; McGlynn, et al., 2003; Starfield, 2000). Several of the reforms and influences are show in the following graphic.

 

Reforms

  • Health insurance
  • Medicare and Medicaid
  • Increased use of technology
  • Improved medications
  • Obama Care
Influencers

·       Consumerism & Patient autonomy

·       Pricing pressure

·       Regulatory oversight

·       Marketplace competitiveness

·       Cost containment

 

These are challenging all healthcare leaders and specifically, physician leaders.

The Changing Roles and Responsibilities of Physician Leaders

As the United States healthcare system gained complexity, the practices of physician leaders in this system may no longer be effective (Beckham, 1995; Lloyd & Lyons, 1995; Smith, 1990; Van Harrison, 2004). Physician leaders are being challenged to change, adapt and improve their approach to effectively lead their organizations (Lazarus, 1997; McAlearney, et al., 2005). Gerbarg (2002) suggested that, “Hospitals…were in short supply of experienced physician leaders and managers who could help to combine the business needs and models with the realities of clinical practice” (p. 3). As a consequence, many physician leaders are not prepared for the current leadership demands of their roles (Kaplan & Feldman, 2008). An approach to assist with this challenge has been the creation of the hospitalist specialty.

Hospitalists: Responding to the Changing Landscape of Healthcare

Healthcare organizations, such as hospitals, have looked for care models to manage complexity and improve system performance metrics such as length of stay, quality of care, and patient satisfaction. One model was the establishment of the hospitalist specialty. Wachter and Goldman (1996) first coined the term “hospitalist” as a physician who treats patients in a hospital setting rather than an outpatient setting. Hospitalists generally do not have their own private practices rather, they care for patients who are hospitalized and referred to them by primary care providers (PCP). Upon completing the needed medical procedures and discharge from the hospital, the patients will return to their PCP for follow-up care and health maintenance. This specialty has proven to be an effective method for improving business performance.

¨ Influencers

¤ Consumerism & Patient autonomy

¤ Pricing pressure

¤ Regulatory oversight

¤ Marketplace competitiveness

¤ Cost containment

A 2007 study determined that;

67 percent of CEOs said hospitalists affective the cost of care positively. CEOs cite the following as being enhanced by their hospitalist program (in order of positive impact): quality of care (88 percent), quality of physician/hospital relations (74 percent), referrals from primary care physicians (72 percent), cost of care (67 percent), patient satisfaction (66 percent), independent physicians’ on-call coverage (60 percent) and attracting primary care physicians to the hospital’s staff (59 percent). (“On educating”, 2007, p. 74)

The results listed above appear to confirm that the hospitalist specialty is an effective method for navigating complex hospital settings and improving hospital performance metrics (Craig, et al., 1999; Wellikson, 2008).

However, researchers have cautioned that healthcare organizations critically evaluate the need and risks of adopting hospitalist programs (Alpers, 2001; Auerbach, et al., 2000; Brown, 1998; Lindenauer, et al., 2007; McDonald, 2001; McMahon, 2007; Plauth, Pantilat, Wachter, & Fenton, 2001; Sox, 1999; Srivastave, et al., 2005; Terry, 2008a; Vasilevskis, et al., 2007; Wachter & Goldman, 1999; Wachter & Pantilat, 2001; Wachter, Whitcomb, & Nelson, 1999). The potential disadvantages of hospitalists included discontinuity of care caused by the “hand off” of patients from PCPs to hospitalists which may lead to lower patient satisfaction (Calzada, 2002; Lo, 2001; Wachter, et al., 1999; Weissler, 1999), and hospitalist burnout because of the intense clinical pace (Goldman, 1999; Hoff, Whitcomb, & Nelson, 2002; Schroeder & Shapiro, 1999). In addition, researchers expressed concern over the ability of academic medical training to properly prepare hospitalists for the wide variety of competencies that are needed to function effectively in this role (Schroeder & Shapiro).

The Value of EI in Healthcare Leadership Practice

The term and concept of EI was popularized by Salovey and Mayer (1990) as well as by a series of books and articles by Goleman (1995, 1998a, 1998b, 2000, 2001a, 2001b, 2002, 2006). EI is the ability to recognize one’s own emotions, sense emotional input from others, and react appropriately to that input (Noland, 2008). The concept of EI is tightly linked to IQ (Goleman, 1995) hence EI has also been called Emotional Quotient or EQ (Bar-on, 1988). For this research, EI was used.

The EI survey instrument adapted for this study was based on the EI theory proposed by Freedman (2007a). Freedman (2007b) defined EI as, “the ability to integrate thinking and feeling to make optimal decisions” (p. 81). Freedman’s (2007b) model of EI included three pursuits; emotional literacy, emotional management, and empathy. At the core of the model was the belief that “there is wisdom in feelings” (p. 34). The complete model is show in the table below:

EI Model: Freedman

Pursuit Competency Definition
Know Yourself:

 

Increasing self-awareness, recognizing patterns, and identifying feelings lets you understand what “makes you tick” and is a first step in growth.

 

Notice what you do

Enhance Emotional Literacy

(EEL)

Accurately identifying and interpreting both simple and compound feelings.
Recognize Patterns

(RP)

Acknowledging frequently recurring reactions and behaviors.
Choose Yourself:

 

Intentionality. Building self-management and self-direction allows you to consciously redirect your thoughts, feelings, and actions (vs. reacting unconsciously).

 

Do what you mean

Apply consequential thinking (ACT) Evaluating the costs and benefits of your choices.
Navigate emotions (NE) Assessing, harnessing, and transforming emotions as a strategic resource.
Engage intrinsic motivation (EIM) Gaining energy from personal values and commitments versus being driven by others
Exercise optimism (EO) Taking a proactive perspective of hope and possibility.
Give Yourself:

 

Purpose. Aligning your daily choices with your values, combined with compassion, allows you to increase your wisdom and achieve your vision.

 

Do it for a reason

Increase empathy

(IE)

Recognizing and appropriately responding to others emotions
Pursue noble goals

(PNG)

Connecting your daily choices with your overarching sense of purpose

(Six Seconds, 2010)

 

EI and Healthcare

The investigation of EI in relation to healthcare was primarily conducted in the areas of patient care and medical education (Birks & Watt, 2007; Clarke, 2006; Humpel, et al., 2001; Kooker, Shoultz, & Codier 2007; Pau & Croucher, 2003; Wagner, Ginger, Grant, Gore, & Owens, 2002). EI has been shown to lead to higher patient satisfaction and improved clinical performance (Austin, Evans, Magnus, & O’Hanlon, 2007; Deshpande & Joseph, 2009; Fariselli, Freedman, Ghini, & Valentini, 2008; Freshwater & Stickley, 2004; Smith, et al., 2008; Wagner, et al., 2002). Through using EI, physicians and caregivers are able to recognize and use emotions to facilitate communication, decision-making, and information gathering. Akerjordet and Severinsson (2004) concluded, “EI integrates important personal and interpersonal skills, which can lead to flexibility in handling change and better quality of care in the future, creating a more humanistic, compassionate and healing environment within health care” (p. 170). Unfortunately, studies have stated that critical EI competencies of, “self-awareness, initiative, empathy, conflict management, integrity, team management and other professional behaviors are typically missing from the clinical evaluation checklist” (Smith, et al., 2008, p. 298). While high value was placed on EI competencies in a healthcare environment, it appeared that practicing and applying EI competencies in this environment was a challenge.

Although EI has been shown to be important in the delivery of excellent patient care and improved administration, much less research has been conducted on the links between EI and physician leaders (Epstein & Hundert, 2002; Kerfoot, 1996). There have been no studies, to this author’s knowledge, that links hospitalist medical directors and the use of EI to their leadership approach.

Research Design

This research employed a number of statistical techniques. For research questions numbers one and two descriptive statistics such as mean, standard deviation, and range were used. For research question number three two techniques were used. The first was the Analysis of Variance (ANOVA) which, “determine the effect of independent variables on dependent variables” (Gay, Mills, & Airasian, 2006). The second was correlation which, “involve[d] collecting data to determine whether, and to what degree, a relationship exists between two or more quantifiable variables” (Gay, Mills, & Airasian, 2006, p. 191).

Limitations

Assessing EI

A limitation for this study related to the multidimensionality of the EI construct (Bechara, et al., 2000; Davies, et al., 1998; Lam, & Kirby, 2002; Mayer, Caruso, & Salovey, 2000; McCallum & Piper, 2000; Rozell, et al., 2002). Due to this multidimensionality accurately assessing an individual’s or a group’s EI presents a challenge. Cherniss (2001) admitted, “There is still much that is unclear about the nature of emotional intelligence, the way in which it should be measured, and its impact on individual performance and organizational effectiveness” (p. 9). Becker (2003) supported this conclusion and proposed that EI, “has proven resistant to adequate measurement” (p. 193). Some authors have proposed that a standard definition be established and, based on this definition, standardized measures be developed (Davies, et al., 1998; Law, Wong, & Song, 2004). While these suggestions require caution, given the continued development of the EI construct, “one should anticipate the body of reliability and validity evidence to be growing with each new study” (Gowing, 2001, p. 131). To limit the challenge of multidimensionality, the researcher chose a survey instrument that was founded on an approach and theory that was developed in 1997 (Freedman, 2007b). In addition, this theory has been widely adapted to multiple industries (Freedman, 2007a). However, another challenge was faced because the participants were self-reporting.

Self-Reporting

This study sought to determine how hospitalist medical directors assess their performance on EI competencies and their perceptions of the importance of these competencies to their leadership role. This approach was a potential limitation because self-report survey designs could be subject to respondent bias. Respondents, “may intentionally misrepresent the facts in order to present a more favorable impression” (Leedy & Ormrod, 2005, p. 184). Essentially, the respondents may provide answers that the researcher wants to hear (Joseph, Berry, & Deshpande, 2009; Robson, 2002). This bias can impact the validity of EI assessments.

Sample

In total, 178 hospitalist medical directors, managing three or more hospitalist physicians, working in multistate, outsourced physician services organizations were invited to participate in this survey. This sample size represented 39.5% of the total population of hospitalist medical directors working in multistate, outsources physician services organizations. As with any quantitative survey, “the larger the sample, the better” (Leedy & Ormrod, 2005, p. 207). However, since this was a correlation study the sample size was representative because, “at least 30 participants are needed to establish the existence or nonexistence of a relationship” (Gay, et al., 2006, p. 110).

An additional limitation of this sample was the use of hospitalist medical directors from outsourced physician services organizations. With any research that focuses on a specific population, the ability to generalize the research findings to other populations may be challenging (Gay, et al., 2006). In essence, this specific population may not be representative of all hospitalist medical directors and certainly may not be representative of all physician leaders.

Survey Limitations

In addition to sample size concerns, the reliability of the survey instrument was questionable. The Cronbach’s alphas, measure of reliability for the original SEI 360 Feedback International Edition were determined yet the reliability statistics for the revised survey used in this research had not been calculated at the time of this study. To address the reliability of the instrument, the researcher calculated the Cronbach’s alpha for the collected data. This calculation was shown in the following table.

Cronbach’s Alpha Calculation

Pursuit Competency Cronbach’s Alpha
Know Yourself EEL .761
RP .712
Choose Yourself ACT .687
NE .766
EIM .614
EO .635
Give Yourself IE .628
PNG .418

 

Since several of these Cronbach’s alphas are below the .70 level, the researcher explored different combinations of questions to determine if higher Cronbach’s alphas could be reached which would indicate higher reliability (Garson, 2010; UCLA, 2010). For example, in this research, by removing one item from the ACT competency the Cronbach’s alpha increased from .687 to .721. For the competency EIM by removing two items the statistic increased from .614 to .653. Therefore, the revised ACT and EIM competencies were used for further calculations in this study.

For the competency PNG the highest Cronbach’s alpha statistic determined through various combinations of items was .507. For this competency the researcher then calculated correlations and found that no items correlated above a moderate level, .450 (p<.01 or p<.05). This result could be related to the multidimensionality of the EI construct. Therefore, the researcher decided not to include PNG in further research because the measure did not represent the variable, thus the resulting calculations would not accurately represent the degree of the relationship (Gay, et al., 2006) and compromise the findings.

Findings

Descriptive Statistics

In summary, the majority of the respondents worked in 100-200 bed suburban hospitals. A majority of respondents indicated that they had been physicians for over 11 years and had been with their current organization for less than five years. In addition, a majority of respondents indicated that they had been in an appointed hospitalist leadership role for less than five years which also corresponds to their length of tenure as a hospitalist. Finally, respondents indicated that most supervised between six and 10 hospitalist physicians. In addition to these demographic questions a number of questions were asked to determine whether, as leaders, respondents had influenced programmatic success since becoming medical directors. The responses to these questions are shown in the following table.

Descriptive Statistics for Hospitalist Success Factors Ordered by Question Number

Since I have become a medical director… N Range Mean Std. Error Std.

Deviation

I make decisions that lead to positive results 57 2 4.75 .063 .474
Length of stay at the hospital has been reduced 57 4 4.19 .129 .972
Quality of care indicators have improved 56 2 4.63 .083 .620
Cost of hospitalization has been reduced 56 4 4.02 .141 1.053
Patient satisfaction scores have improved 55 4 4.27 .133 .990
My time spent on direct patient care is appropriate 54 3 4.30 .144 1.057
My time spent on administration (i.e., budgets, strategic planning, employee evaluations, policies and procedures, and committees) is appropriate 55 4 3.55 .179 1.331

 

EI Importance

The first research question in this study was, “What are the EI competencies identified as important for leadership by hospitalist medical directors?” This question sought to elicit how important the leader felt an EI competency was to their leadership role. A Likert-type scale was used in the questionnaire to measure the importance of the 32 EI items. Numbers were assigned to the responses for coding and analysis. The choice of “not important” received a 1, “unimportant” received a 2, “neutral” received a 3, “important” received a 4, and “very important” received a 5. The results for the top five and bottom five ranked items are show in the following tables.

Top Five Items Ranked by Means

N Range Mean Std. Error Std. Deviation
I have integrity 58 1 4.90 .040 .307
I genuinely care about people 59 1 4.83 .049 .378
I take responsibility for solving problems instead of blaming 59 1 4.73 .058 .448
I make decisions based on important values 58 1 4.72 .059 .451
I think of solutions even in challenging situations 59 2 4.69 .065 .500

 

Bottom Five Items Ranked by Means

N Range Mean Std. Error Std. Deviation
I discuss the emotional impact of decisions 59 3 4.07 .093 .716
I accurately explain why someone feels a particular way 59 3 4.03 .108 .830
I appropriately communicate about emotions with others 58 3 4.00 .107 .816
I use a wide variety of feeling words 59 2 3.95 .089 .680
I am able to talk about what makes me anxious 59 4 3.88 .135 1.035

 

Based on these findings, the surveyed physician leaders ranked the importance of ethical problem solving higher than the importance of discussing emotions.

EI Performance

The second research question in this study was, “How do hospitalist medical directors rate their EI performance?” This question sought to elicit the participants’ perception of their EI performance. A Likert-type scale was used in the questionnaire to measure the importance for the 32 EI items. Numbers were assigned to the responses for coding and analysis. The choice of “not important” received a 1, “unimportant” received a 2, “neutral” received a 3, “important” received a 4, and “very important” received a 5. Again, descriptive statistics were employed to assess the participants’ perception of their EI performance. The results were shown for the top five and bottom five are shown in the following tables.

Top Five Items Ranked by Means

N Range Mean Std. Error Std. Deviation
I have integrity 59 2 4.78 .064 .494
I genuinely care about people 59 2 4.66 .075 .576
I make decisions based on important values 58 2 4.64 .068 .520
I take responsibility for solving problems instead of blaming 59 2 4.54 .074 .567
I think of solutions even in challenging situations 59 3 4.49 .095 .728

 

Bottom Five Items Ranked by Means

N Range Mean Std. Error Std. Deviation
I am able to explain my feelings 59 4 4.00 .118 .910
I discuss the emotional impact of decisions 59 3 3.95 .109 .839
I accurately explain why someone feels a particular way 59 3 3.76 .112 .858
I appropriately communicate about emotions with others 59 3 3.75 .110 .843
I am able to talk about what makes me anxious 59 4 3.69 .139 1.071

 

Based on these findings the participants ranked their problem-solving performance higher than their performance in emotional dialogue.

EI and Leadership Role

The third research question sought to identify the relationship between self-reported EI competencies and the respondents’ perceptions of their leadership role. As indicated earlier, two statistical techniques were used including correlation and ANOVA. Correlation was used to analyze the relationship between EI competencies and hospitalist success factors. The EI pursuit Choose Yourself which is comprised of the EI competencies ACT, NE, EIM, and EO was hypothesized to be positively correlated to number of years as a hospitalist, number of years at the hospital, and number of years as a hospitalist medical director based on the medical directors’ choice of the organization and role. This conclusion was not supported. However, there was significance at the p < .05 level regarding ACT and “number of individuals that report direct to you” [F (2, 51) = 3.319, p = .044]. A post hoc comparison was conducted using Bonferroni. This test indicated that there was a significant difference in ACT and 11+ individuals reporting to the leader. This result may indicate that when hospitalist medical directors lead larger staffs they are taking greater care in evaluating the consequences of various choices.

EI and Hospitalist Program Success

There was a weak correlation between the “length of stay at the hospital has been reduced” and Exercise Optimism (EO) (r = .284, n =57, p = .05). In addition, there was a weak to moderate correlation between “quality of care indicators have improved” and Engage Intrinsic Motivation (EIM) (r = .329, n =56, p = .05). Finally, there was a weak to moderate correlation between “my time spent on administration (i.e. budgets, strategic planning, employee evaluations, policies and procedures, and committees) is appropriate” and Navigate Emotions (NE) (r = .354, n =54, p = .01).

Implications and Recommendations

A finding of this research is that the hospitalist medical directors believed EI to be important for leadership. It would be important for future researchers to employ a multi-rater approach when exploring EI and leadership. Bailey and Austin (2006) proposed that “utilizing such systems [multirater feedback] for employee development, organizations are tacitly endorsing an assumption of many learning theories — that providing feedback on performance will result in improvements in individuals’ subsequent performance” (p. 51). Surveying those that are being led and those that interact with a leader regarding their perceptions of the leader’s EI performance would provide valuable insight for both the leader’s and the organization’s development.

It would also be important for future researchers to utilize data collected by hospitals and other groups regarding the performance of the medical directors. In this survey the “hospitalist success factors” were self-reported. In future research the “hospitalist success factors” could be determined, for example, by Press-Ganey scores, hospital data, and data collected by the outsourced physician services organizations. By using this data the comparison would be based on objective performance measures rather than perceptions of success.

Another exploration for further research would be to use additional statistical techniques. One such technique would be the analysis of covariance (ANCOVA). ANCOVA is a, “technique for controlling extraneous variables” (Gay, et al., 2006). The technique adjusts scores and essentially “levels the playing field”. For example, perhaps the comparison of EEL and number of years at your current organization is being influenced by the variable, number of years in your current leadership role. ANCOVA would adjust the comparison by moderating the effect of number of years in your current leadership role.

As with any research that focuses on one population, the ability to generalize the research findings to other populations may be difficult (Gay, et al., 2006). Future researchers may be interested in expanding the scope of physician leaders beyond hospitalist medical directors, managing three or more hospitalist physicians, working in multistate, outsourced physician services organizations.

Conclusion

The challenges facing the healthcare system in the United States continue to evolve and raise expectations for physician leaders. These leaders play a vital role in the effective and efficient functioning of their organizations (Beckham, 1995). They serve at the intersection of clinical care and business realities thus have a unique place and ability to influence organizations to both improve quality of healthcare and business performance (Gerbarg, 2002). As highlighted previously, deficient leadership negatively impacts organizations which, in turn, can impact the performance of the healthcare industry (Greeno, 2003). Physician leaders would be well served to focus on developing their leadership acumen and EI training could be an effective leadership tool and topic for research.

 

 

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One thought on “Health Care Leadership Ain’t What It Used To Be: Emotional Intelligence Competencies Of Hospitalist Leaders

  1. August 5, 2018 at 3:32 am

    I really appreciate your post and you explain each and every point very well.Thanks for sharing this information. And I’ll love to read your next post too.

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