Competencies for a Reformed Health Care Environment

Last month I raised a few questions about team competencies in a reforming health care system. I heard from several readers asking for a more general set of leadership competencies that this same environment would likely demand. Here are five general leadership skills that will need to be particularly refined, if health care institutions, practices, and professions are going to adequately meet the demands of a rapidly changing health care world. 

Firstly, leaders will need to create a vision of the whole. We have been successful in leading institutions that are isolated in silos by location and professional focus or orientation - such as in-patient, acute care, behavioral health, primary care, specialty care, insured and non-insured. As we head into reform, these distinctions will mean less and less. Real value to society and to individual consumers will come more from those institutions that can imagine a vision that expands to a broader horizon and over a longer period of time than just a single acute care encounter. Some institutions and arrangements for health service have pursued or are positioned to generate such a vision. The Veterans Administration Health Care, Kaiser Permanente, and community clinics all have many parts of the whole and have been engaged for a decade or more in thinking through what a framework for inclusive care and health would look like. I have addressed this need here in considering how Health Commons on the local level might be assembled. As we go forward, these visions should not be hijacked by the government, professions, or the market, but build on an improved understanding of what health consumers as customers need, want, and are willing and able to pay. The vision will need to be one that serves short-term purposes such as the assembly of practices and institutions into new arrangements and associations and longer term perspectives that change the way society promotes health through traditional and non-traditional means. In this final regard, there will need to be visions that can go beyond a first round of assembling provider organizations and linking them to payers in new ways. This next round of vision will need to encompass the entire array of health and health care resources and institutions in a state or sub-state region and it will need to align these resources with the needs and desires of the entire population of these regions. Such a denominator driven vision will become a powerful perspective for both the political and market driven interests. 

Such lofty work will capture the imagination and focus a few leaders, but many more will be challenged by how to design transition strategies to that vision. One of the keys in this endeavor will be how to realign professionals to play leadership roles in the transition. The overall process of change should be thought of as a series of smaller changes in the ways in which care practices are organized, regulated, staffed, evaluated and financed to meet the changing needs and performance expectations of the emerging system. It will not be obvious to most or even many professionals that much of current practice will need to change, as these professionals have carried out their work for decades in which they were independent and isolated from each other as well as broader system considerations such as cost or quality, and even consumer preferences. Moreover, these professionals have been compensated and rewarded handsomely for such splendid isolation; and they will be challenged to reframe the context for their work. Policy levers are now in place to bundle payments and pay for performance toward new outcomes. But these exist in only the most general way. Leaders will need to drive them down into operational policy and transition strategies that can use the leverage of professional commitment, but redirect it toward new goals. 

Few of the professional and institutional resources that will be needed to create new systems are currently joined or even aligned. Leaders will need to develop and manage partnerships, alliances and acquisitions across these institutional and sector lines. This will be difficult for a variety of reasons. Firstly, the cultures, processes, vocabulary, aims and purposes of these organizations vary greatly. Secondly, there is little historical experience to draw upon to make such integration work. In many instances, the type of deep collaboration that will be needed has often times been called collusion and was illegal. Finally, relationships that have existed have more often than not been acrimonious and have been built on a tradition of disadvantaging the other through the contracting process. To remake leadership in this domain will need clear vision coupled with the particulars of the necessary transition strategies. The effective leader will have to see the value of the common ground and of working together. The commitment to advocating for such a future direction will need to be both strenuous and continuous for and extended period of time. This work will require working across cultures to integrate them into new patterns of work. Incentives for such collaborative will need to be real and substantive, not just token acknowledgments. Throughout every effort at integration, a steady focus on lowering the transaction costs will produce many of the gains in cost savings and quality improvements that will fuel additional integration. 

The work to construct new partnerships should build upon the decade long progress inimproving performance in health care. These gains in clarifying goals, measuring progress, testing and improving innovations through small changes will need to be applied to the larger and more complicated undertaking of aligning organizations. In such a context, the steps to performance improvement will need to accommodate significant changes in professional and institutional practices. For instance, discovering that managing a population with a chronic disease using new information technology, paraprofessionals, and different education resources for the patient is likely to disrupt the established role of specialists and in-patient facilities. Effective leadership will need to position performance improvement in this context in order to ensure its success. 

Finally, all of these special competencies to move toward a reformed system will require an improvement in the general leadership skills across institutions and professions. The four general domains of leadership development advanced by the Center for the Health Professions at UCSF serve as a good reminder of the range of skills that will be needed: purpose, process, people, and personal. Or a little more expansively: is there a coherent direction for the organization in turbulent times, are there efficient practices for operation and improvement, do the leaders work effectively through others both within and outside of the organization, and finally does the leader have a good sense of their leadership profile and how to best use it and improve it? Developing such human capital will be a mark of successful systems as they move toward delivering the potential of a reformed system.