Last week you designed and proposed a leadership development program based upon insights from your textbook, as well as additional research. This week, using the additional insights about the promise and challenges of Physician CEOs and leaders, it is time to broaden the discussion and look to the future of healthcare leadership and learning organizations. Consider the area of healthcare you are currently in or see yourself impacting in the future. What does the future of leadership look like for your segment of the industry? What are the specific challenges and potentials leaders must be prepared for? How can they prepare the organizations they lead to be more agile?
Use this to research and discuss leadership in a specific segment of the healthcare industry. Your analysis should discuss some of the major topics from this course such as organizational culture building, leading people in healthcare delivery, and aspects of leadership development for individuals and the organization. Be sure to use insights from your text, as well as peer-reviewed resources and industry-specific websites. At the end of the paper, you should have a well-formed conclusion about the future of leadership in the specific segment of the healthcare industry you chose supported by the research you discuss throughout the paper.
In your paper, be sure to utilize the textbook and integrate at least three peer-reviewed sources along with their citations and references. Your paper must be APA formatted and include at least 1500 words. Please use the APA 7th edition format
Question 2
Who can and should be a leader in healthcare is an ongoing debate (p. 217). Often the debates center around a binary: physician CEOs versus non-physician CEOs, but an alternative to the binary that has promising potential is the development of hybrid professionals. Read more about this in “Involving hybrid professionals in top management decision making” (available in your Instructional Resources section), then discuss the unique potentials and limitations of hybrid professional training to meet the needs of future healthcare challenges.
Primary research
Involving hybrid professionals in
top management decision-making:
How managerial training can
make the difference
Health Services Management Research
2019, Vol. 32(4) 168–179
! The Author(s) 2019
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/0951484819844778
journals.sagepub.com/home/hsm
Giorgio Giacomelli , Francesca Ferré, Manuela Furlan and
Sabina Nuti
Abstract
Hybrid professionals have a two-fold – professional and managerial – role, which requires appropriate management skills.
Investing on managerial training programs aims to empower professionals with managerial skills and competencies. Does this
pay back? Assessing the impact of such training programs is still a limited practice. This paper explores whether participation
in managerial training programs in healthcare can enhance the involvement of hybrid professionals (namely, clinical directors)
in top management decision-making. The mediational effects of knowledge of performance information and its use
are explored.
Survey data were collected from more than 3000 clinical directors of 69 public health authorities from five regional
healthcare systems in Italy. Relationships between participation in managerial training programs, performance management
practices (i.e., knowledge and use of performance information) and the level of clinicians’ involvement by the top management were studied using a three-path mediation analysis with structural equation modelling. Propensity score matching was
also performed to mitigate selection bias.
Knowledge and use of performance information positively mediate, both independently and sequentially, the relationship
between clinical directors’ participation in managerial training programs and the level of their involvement in decision-making.
The results of the study suggest that managerial training can support hybrid professionals in engaging with managerialism and
playing upward influence on top management decision-making.
Keywords
clinicians-managers, hybrid professionals, managerial training, performance information, three-path mediation
Aim of the study
The role of managerial training (MT) for professionals is
a widely studied topic in literature. Training is associated
with the creation of new roles, concepts, the development
of skills and attitudes, the synthesis of tacit knowledge,1
and it is believed to be a change-promoter mechanism.
In the public sector, MT primarily relates to strengthening employees’ engagement and promoting change, by
increasing their capacity to meet existing and emerging
demands.2 In healthcare, the purpose of training is
deeply related to the role of doctors–managers who are
often referred to as hybrid professionals.3,4 Since important leadership responsibilities are given to professionals
whose role is both clinical and managerial, clinicians are
often asked to bridge the worlds of medicine and management5 to ensure quality of care, clinical outcomes and
financial sustainability, which are tightly interconnected
rather than conflicting goals.6
Management and Health Laboratory (MeS), Institute of Management and
Department EMbeDS, Scuola Superiore Sant’Anna, Pisa (Italy)
Corresponding author:
Giorgio Giacomelli, Management and Health Laboratory (MeS), Institute of
Management and Department EMbeDS, Scuola Superiore Sant’Anna, Piazza
Martiri della Libertà, 33, Pisa 56127, Italy.
Email: g.giacomelli@santannapisa.it
Giacomelli et al
Besides, management practices related to the use of
information and performance management tools by professionals have been found to predict organizational performance7–9 thus giving further support to the claim for
having “clinicians on the board”.10,11 This refers to clinicians being actively involved in the planning, delivery
and transformation of healthcare services and, more
broadly, of the health systems they are fundamental
parts of.10 Involving doctors in management can help
improve organizational performance by nurturing
management practices in healthcare settings,12,13 and
numerous strategies have been aimed at fostering collaboration between doctors and the top management.14 The
most institutionalized one is indeed through formal MT.
However, the relationship between MT and the improvement of managerial practices is still lacking evidencebased investigations, especially when excluding
so-called smile sheets-based analysis.15
This study investigates the relationship between
the participation of clinicians with management roles
(i.e. clinical directors) in MT programs and their performance management practices, considering 69 public
health authorities from five regional health systems
(RHSs) in Italy.a We show how the participation in
MT programs predicts a higher interaction of hybrid
professionals with the top management. We explore
the mediational effects of knowledge of performance
information and use of performance information
(UPI). Our comparative analysis also raises questions
about the heterogeneity of these relationships across different RHSs.
The paper is structured as follows. The next section
gives some preliminary considerations inferred from the
literature on management practices and training within
professional organizations. The subsequent section
presents the research hypotheses and methodological
issues. The results of the analysis are then discussed,
highlighting the insights and limitations. Lastly, the conclusions and suggestions for further research are reported.
Background
HRM and MT in healthcare
Healthcare organizations are increasingly challenged by
pressures on new ways of governance, improved efficiency and patient orientation.14 Among the various changepromoting strategies available, those based on human
resources management (HRM) are the most common
in the public sector because of the people-centered
nature of service-oriented organizations. Both scholars
and practitioners have thus devoted great attention to
these initiatives particularly after the new public management (NPM) reforms, based on the existing evidence
linking HRM to performance outcomes in healthcare.16
169
Traditional professional bureaucracies have evolved
accordingly, leading to a managerial-like characterization
of professionals and their competency models, namely
throughout
performance-oriented
techniques.8,17
Performance management, indeed, is proved to be a supporting mechanism for organizational change in the
public sector by means of goal clarity and purpose, strategic alignment, motivation and adaptability.18
Training objectives depend on the training needs of
the specific organization and the tasks involved.19 In the
Italian National Healthcare System (NHS), the laws
(legislative decree 502/92 and presidential decree
484/97) require heads of department to accomplish an
MT program of a minimum of 100 certified hours, in
order to take charge of their role. The objectives of
MT, as defined by Italian law, include: training in interpersonal skills, leadership, effective communication,
conflict management, team building; training in cognitive skills and problem solving; tools and techniques
concerning the managerial role (general management
logic). The latter may include, for instance, the following: performance management, budgeting, goal setting
and strategic planning, innovative organizational and
operational schemes. MT programs are offered on a
regional basis and involve multiple methods, including
lectures in conjunction with discussions, simulations,
business case studies, role-playing and team project work.
Hybrid professionalism: Implications for competency
models and training
In healthcare, the role of management is to ensure strategy implementation through efficient and effective public
service delivery.7 In order to attain these goals, management requires a broad set of competencies, ranging from
unit-specific technical skills to engagement-building
capacity.20 Indeed, managerial apex in healthcare organizations often corresponds to clinical leadership,5 thus
requiring the hybridization (not juxtaposition) of their
clinical culture with a managerial one.3,21 The former is
based on the strong patient–doctor relationship, collegial
authority and personal responsibility for decisionmaking. In contrast, managers believe that their primary
allegiance is to the organization, authority is hierarchical
and responsibility for decision-making is shared. This
implies a peculiar “inverted” power structure, where traditional hierarchy is unlikely to be effective.22 Because of
their “hybrid” function,4 then, these roles need to encompass managerial values and cross-competencies: in the
case of clinical directors, for instance, they need to
handle not only high-level clinical competencies, but
also organizational and relational skills in order to take
charge of the overall clinical provision, organization and
leadership of their departments and report to top
170
management. This trend is also confirmed by the broad
international
attempts
to
redefine
medical
professionalism.23,24
The concept of competency is generally defined as the
“capability of applying or using knowledge, skills, abilities, behaviors, and personal characteristics to successfully perform critical work tasks, specific functions, or
operate in a given role or position” (Ennis,25 p. 4). In the
public sector, managerial competencies are multidimensional, contingent and dynamic, as a result of reforms
and the particular context in which public organizations
operate. Training is thus paramount to maintaining and
developing employees’ competencies. It is defined as the
set of organizational activities aimed at fostering the
acquisition of knowledge, rules, concepts, or attitudes
needed to build specific skills and professional competencies1 which should result in the improved performance of the trainee.26
To this end, there is an increasing demand for training
programs in healthcare management, especially for medical professionals in leadership positions who need to
acquire managerial and leadership skills.27
Does MT matter? Research question and hypotheses
Assessing training requires the systematic collection and
analysis of information on training programs, which can
be used to plan and drive decision-making as well as to
evaluate the effectiveness of the training components.
Measuring the effects of training on an organization or
individual behaviour is necessary to evaluate the return
on investment and the value-for-money of the interventions provided28 and to increase their accountability.
However, organizations spend little time on evaluating the return on investment of MT programs, due to a
lack of confidence in whether training has an impact on
organizational performance, as well as a lack of resources, expertise and organizational support. Healthcare is
no exception. Despite several significant examples, the
impact of management training on healthcare professionals still needs to be explored.
In general, there are two important issues related to
evaluating training. First, the assessment of training programs traditionally relies on the immediate feedback
provided by trainees, e.g. “smile sheets” or satisfaction
surveys. Second, measuring the effects of training on
individual behaviors creates difficulties in empirically
establishing the causal chain: the more time elapses
between the provision and the assessment, the more
likely latent intervening variables cannot be considered.
Even when some kind of relationship emerges, it is difficult to explain its nature and to suggest improvement
paths for training models.2
In the face of the limited empirical evidence, our
study aims to provide a deeper understanding of the
Health Services Management Research 32(4)
relationship between participation in MT programs in
the Italian NHS and some management practices by
clinical directors. Based on Kirkpatrick’s model,29
which assesses the effectiveness of training based on
the nature of its effects (reactions, learning, behaviours,
results), we adopt a threefold perspective dealing with
learning, behaviour and results-related effects.
Within the “learning” dimension, we measure the outcomes of the training, focusing on the acquisition of
performance information related to organizational
goals and results: indeed, the spread of a “culture of
measurement” in the Italian NHS30 followed an increasing need for timely and accurate information on care
service provision, that has been also recognized by the
law.b It is reasonable to expect management training to
provide trainees with specific performance information,
such as targets and feedback information on outputs and
outcome, efficiency and effectiveness, needed to monitor
and (re) orient their professional and managerial activities. However, a study recently carried out in the UK4
suggests that the mere acquisition of competences over
management technicalities does not make a difference in
terms of the enactment of hybrid roles.
Within the “behavioral” dimension, we then measure
the capacity effects of training. Training, indeed, is
expected to give trainees an increased individual
decision-making capacity in order to meet new demands
set by incumbent changes and reforms.2 However, in
order to provide “a basis from which leaders make
capacity decisions” (Moynihan and Ingraham,31
p. 430), performance information should be “usable”:
to this end, information should be provided through
performance measures that monitor multiple dimensions, in quantitative and aggregate format and are publicly disclosed, thus favoring benchmarking.32,33
With respect to “results-related” effects, which is the
most distal and macro criteria, we focus on the level of
involvement in decision-making of the clinical directors
by the top management. Indeed, greater clinician participation in shared decision-making is a well-recognized
key competence for clinical leadership34 and has been
found to have broad potential benefits for health organizations,35 such as the mitigation of professional conflicts, cost control, and quality improvement. Whereas
management scholarship generally confirms a positive
relationship between the involvement of doctors in clinical governance and several dimensions of performance,
it seems quite blurry what this ‘involvement’ is about.
A recent cross-country study36 shows that the role of
doctors in top management decision-making is often
consultative, more than decisional, and that this is the
case of Italy. Nonetheless, the same study shows a significant relationship of the involvement – whatever its
intensity – with quality of management systems. Since
clinicians’ involvement can be considered an antecedent
Giacomelli et al
171
of both high-quality management systems and highperforming healthcare organizations, our study aims to
investigate its association with participation in management training programs.
H1: Managerial training has an indirect, positive effect on
the level of involvement of clinical directors in top management decision-making, through its positive influence on
the knowledge of performance information.
H2: Managerial training has an indirect, positive effect on
the level of involvement of clinical directors in top management decision-making, through its positive influence on
the use of performance information.
H3: Managerial training improves the level of involvement
of clinical directors in top management decision-making.
H4: Performance information knowledge and the use of performance information sequentially mediate the relationship
between managerial training and the level of involvement of
clinical directors in top management decision-making, with
knowledge of performance information leading to the
increased use of performance information, which, in turn,
leads to an increased involvement in decision-making.
Sample and methodology
regarding attendance at an MT program and contains
items related to on-the-job management and performance management behaviors and skills. The survey
can thus be used to assess the learning and behavioural
effects of MT. The organizational survey is administered
via computer-assisted web interviewing (CAWI) on a
census basis,37 and its data contribute to the InterRegional Performance Evaluation System (IRPES).
IRPES is an evaluation tool currently adopted and
funded by a network of 13 Italian regional administrations on a voluntary basis, aimed at collecting the performance data of health authorities for benchmarking.38
Surveys were administered between 2014 and 2017
involving 219,084 employees, of which 9095 were professionals with a managerial role; 4174 professionals with a
managerial role took part in the surveys. To answer our
research question, only medical personnel’s responses
were considered in the analysis, though the authors
acknowledge an extensive stream of research dealing
with other health professionals’ managerial role, such
as nurses’ managers39; also administrative and technical
managerial personnel were excluded; after this exclusion
step, 3084 observations were considered (corresponding
to 43% of the overall medical population). After controlling for listwise-deletion, all these observations were
included as no incomplete responses were detected. The
final sample was composed by 72% male and more than
90% over 50 years’ old respondents, with noticeable differences across Regions (see Table 1).
Sample
In order to test the four hypotheses, we used data collected from a routine organizational climate survey sent
approximately every two years to the healthcare personnel and staff of 69 public health authorities from five
Italian RHSs. The five Italian RHSs are a balanced representation of northern, central and southern Italy. The
sample includes 14 teaching hospitals and 55 local health
authorities. The organizational climate survey is an
individual-based questionnaire with a specific item
Measures
This section provides an overview of all the measures
included in the study (see Table 2). The independent
variable is MT, a binary variable that measures participation, whenever in time, in an MT course by clinical
directors (as defined by legislative decree 502/92 and
presidential decree 484/97). The mediator variables are
performance information knowledge (PIK) and use of
performance information (UPI). The dependent variable
Table 1. Response rate and composition of the sample.
RHSs
Response rate (%)
Sex
69
Row tot.
Region 1
56.8
51.9
6
13
1
Region 3
30.5
Region 4
39.6
Region 5
25.6
42.6
96
207
82
247
27
113
121
162
30
49
1134
110
369
66
350
63
230
129
297
32
60
1706
243
641
170
637
94
353
270
479
78
119
Col. tot.
29
37
21
38
4
6
17
17
7
6
182
2
15
Region 2
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
–
3
9
4
36
2
4
3
26
172
Health Services Management Research 32(4)
Table 2. Composition of the variables.
Variable
Item(s)
Management training (MT)
I have attained/I am taking part in a training course
aimed at attaining the managerial certificate as
defined by Legislative Decree 502/92 and
Presidential Decree 484/97
I have an adequate knowledge of the annual goals of
my organization
I have an adequate knowledge of the annual performance of my organization
Data from the management control unit support me
in decision-making
The planning, programming and control system help
me in managing my organizational unit
Top management consults me when taking decisions
affecting my organizational unit
Performance information knowledge (PIK)
Use of performance information (UPI)
Clinical directors’ involvement (CDI)
is clinical directors’ involvement (CDI) in decisionmaking by the top management.
PIK is measured as a combined indicator of two items
included in the organizational climate survey, addressing
respectively the knowledge of annual organizational
goals and performance results. UPI is measured as a
combined indicator of two items reported by the organizational climate survey, addressing, respectively, the
use of information on organizational performance provided by the management control system in supporting
individual decision-making and budgeting in the daily
management of the organizational unit under the
respondent’s responsibility.
CDI is based on the response values of a single item in
the survey, addressing the level of involvement of the
respondents by the top management in decisionmaking. Cronbach’s alpha was used to estimate the
internal consistency of questions that comprised several
items (Table 3). Age and sex of the respondents were
included in the model as control variables. For all the
accounted variables, with the exception of MT, age and
sex, respondents were asked to respond to items on a
five-point scale: from 1 (strong disagreement) to 5
(strong agreement). The individual responses were then
transformed into a 100-point scale. All statistical analyses were performed with SPSS 22.
Modelling
To model the different effects of training, we used a
three-path mediation model, depicted as a path diagram
in Figure 1. According to our research model, H1, H2
and H4 represent mediation hypotheses, which posit by
what means an independent variable affects a dependent
variable through mediators. The specific mediational
effects, total mediational effects and direct effects
were calculated.
Figure 1(a) describes the total effect of MT on the
involvement of clinical directors in decision-making,
c being the path coefficient of MT on CDI. This total
effect can be arrived at via a variety of direct and indirect
forces.40 Specifically, in Figure 1(b), the total effect of
training on the involvement of clinical directors in decision-making can be expressed as the sum of the direct
and indirect effects, the latter being estimated by the
product of the path coefficients for each of the paths
in the mediational chain. The advantage of path analysis
is that it isolates the indirect effect of both mediating
variables, that is, the PIK (H1: a1b1) and the UPI
(H2: a2b2). In addition, this approach analyses the indirect effects passing through both of these mediators in a
series (H4: a1a3b2).
To test our mediation hypotheses, we used an analytical approach40 aimed at testing the indirect effect
between the independent and the dependent variables
through the mediator via a bootstrapping procedure.
This technique40 estimates the mediation effect and overcomes the limitations of other procedures (such as the
choice to free or constrain residual covariance). We then
performed the above-mentioned analyses separately for
the five RHSs, in order to highlight possible differences
in the magnitude or significance of the effects across
RHSs. We expect a positive relation between exposure
to MT and interaction of clinical directors in decisionmaking with the top management, since training should
improve awareness of performance information and
capacity to use such evidence to support clinical directors’ leadership role.
Results
Table 3 provides descriptive statistics and correlation
levels. Participation in MT programs ranges from 20%
in Region 5 to over 50% in Region 4, with a mean
Giacomelli et al
173
Table 3. Descriptive statistics and correlation levels (overall).
MT
PIK
UPI
CDI
Age
Sex
a
Mean
SD
Min
Max
N
1
2
3
4
5
6
–
0.91
0.76
–
–
–
0.38
66.70
56.23
48.91
59.04
0.72
0.48
28.63
28.36
35.29
6.01
0.45
0
0
0
0
32
0
1
100
100
100
72
1
3084
3084
3084
3084
3084
3084
1
0.22***
0.21***
0.21***
0.12***
0.09***
1
0.65***
0.56***
0.10***
0.04*
1
0.59***
0.09***
0.01***
1
0.11***
0.08***
1
0.16***
1
*p
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