Bridging the Strategic Leadership Gap

A Model Program for Transformational Change

Gail Wolf, DNS, RN, FAAN

Juditb Bradle, BA

Gregory Nelson, BA

The University Of Pittsburgh Medical Center (UPMC) recognized the impending crisis‑a vast nurse I leader shortage, especially at the strategic level. UPMC's new development model establishes a dependable leadership pipeline. The model identifies high‑potential individuals, verifies required competencies, assesses participants' strengths, and provides a didactic and experiential Learning curriculum. Within 2 years, the program produced a 4‑50‑0 return on investment and evolved into the Health Care Leadership Academy, an open enrollment program for emerging, operational, and strategic leaders nationwide.

The looming nurse leadership crisis is well documented.' .2 Most experts agree that the main reasons behind this leadership shortage are the pervasive cost cutting that thinned the ranks of middle managers (eliminating informal, on‑the‑job development) and the subsequent cutbacks in formal training and development. As a result, very few nurse leaders at all levels are prepared to step into advanced roles and perform successfully.

This problem is exacerbated when operational level leaders are transitioning to strategic leadership levels, where authority, responsibility, and pressure are significantly elevated. Strategic leaders require significant adjustments in their frame of reference. For instance, the vice president (VP) of nursing position has expanded to become VP of clinical care, blurring the focus from one of strictly nursing t(,‑ include pharmacy, respiratory, therapy, dietary, and other clinical areas. Strategic leaders also take on more risk and more personal stress. They often are called upon to balance process optimization and short‑term financial concerns, with a longer view on driving organizational competitive advantage.

For the University of Pittsburgh Medical Center (UPMC), this impending leadership problem was compounded. It came on the heels of UPMC's major initiative that integrated 20 independently run hospitals into a single health system and the growth, control, operational, and other issues that manifested during the integration process. With 4000 beds, 35,000 employees, and annual revenue exceeding $3 billion, UPMC is one of the nation's largest integrated delivery systems.

Initial Needs Analysis

As UPMC's system integration got fully underway, the corporate chief nursing officer (CNO) began an in‑depth review of the system's clinical leadership development programs, especially at the strategic leader level. There were substantial voids‑there was no formalized program to aid the transition from operational to strategic leader; there were no "high‑potential" individuals targeted for development; and there was pervasive misperception of what a strategic leader is and does. Through surveys, one-on‑one interviews, group discussions, and hospital rounding, it was clear that many of the nurse leaders who should have been implementing strategy were instead working at the operational level.

Moreover, these nurse leaders recognized the need to change, but found it difficult to articulate exactly what needed to change or how to go about effecting change. Clearly, UPMC needed to bolster its leadership development pipeline‑especially at the strategic level‑to allow system leaders of the future to emerge.

To address these issues, in 2000, UPMC and its Beckwith Institute for Innovation in Patient Care launched the Beckwith Fellows Leadership Program, an ambitious, comprehensive program designed to identify top performers for accelerated learning. The Beckwith Institute provides creative and innovative solutions to contemporary problems in healthcare practice, with one of its focus areas being management, leadership, and organizational development in healthcare. The Beckwith program model

• defines leadership needs for the future,

• assesses current talent and identifies development gaps,

• creates a competency‑ based development curriculum that addresses talent needs,

• establishes a safe culture of support and learning, and

• introduces program metrics to measure results.

Success Profile Framework

As the first step in developing strategic leadership bench strength, UPMC adapted the success profile framework (Figure 1) created by Development Dimensions International (DDI), Pittsburgh, Pa. 3 UPMC had partnered previously with DDI, a leading in selection and leadership development, on previous executive leadership projects. This simple framework leverages the abundance of research and concepts related to successful leadership. Relevant across all leadership levels, the framework provides a holistic "wiring diagram" for profiling. leadership success. DDI research and experience demonstrate that leadership performance can be best predicted through collective consideration of 4 key descriptors:

• preparatory experiences (What I have done);

• organizational knowledge (What I know);

•   behaviorally defined competencies (What I am capable of); and

• personal attributes (Who I am), which also can become derailers.

To create sustainable leadership readiness and effectiveness, UPMC identified the competencies required for strategic leadership success. A competency‑profiling model provides clear definition of the behaviors, motivations, and knowledge needed by an individual to be successful in his or her work. Competency models can be used to drive multiple HR initiatives, including selection, promotion, training and development, performance management, succession planning, and career planning.

On the basis of secondary research and personal interviews, UPMC identified 10 core competencies essential for success at the senior manager/executive level (Table 1). These competencies, which were confirmed as effective performance criteria through DDI's in‑depth job analyses, serve as the foundation of the Beckwith Fellow's assessment, development., and succession management initiatives.

As leaders advance in their careers, they often rely on personal traits, styles, or approaches to help them achieve goals. At higher levels of leadership‑particularly in the transition from operational to strategic leader‑these favored styles can become problems, or derailers, when leaders overuse them, such as when high standards manifest themselves through overcritical, perfectionist behavior. Or, when assertiveness crosses the line into defensiveness (Table 2).

Beckwith Fellow Selection

The candidate selection process included 3 parts: nomination by current leaders, an introspective application tool, and comprehensive data evaluation by Beckwith program leaders.

First, separate group meetings were held with chief executive officers (CEOs), then with VPs, from each of UPMC's 20 hospitals. The Beckwith program concept was presented to each group. Nominations were sought for individuals with demonstrated leadership ability and who were part of their organization's succession management plan for future senior leadership roles. In program year 1, this resulted in 20 nominations.

Table 1. Essential Competencies

Competency                                                                                                                                                      Description

Communication skills                                                                                                                                                                                                                                                Expressing thoughts, feelings, and ideas effectively in individual and group situations

Customer  relations                                                                                                                                                                                                                       Deals effectively with the broad range of customers

Building trust             Developing other people's confidence in leadership through consistent action, values, and

                                                                                                                                                                                                                      communications

Building business                                                                     Using appropriate interpersonal styles and communication methods to work effectively with

     partnerships                                                                                                                                    business partners to meet mutual goals and objectives

Visionary leadership                                                                                                                                                                                                                     Creating a clear view of the future state, and influencing movement and compelling action toward

                                                                                                                                                                                                                         the future state

Coaching and developing                                                          Providing timely feedback, guidance, mentoring, and training to help individuals reach goals

     employees

Valuing diversity                                                                       Developing and maintaining an environment that enables full participation and development

                                                                                                                                                                                               of all backgrounds and cultures

Strategic thinking                                                                                Assesses a situation broadly, defines realistic goals, and conceives effective strategies

Program/project          Defines objectives, develops plans, and implements plans to achieve needed business results;

     management                                                                                           leverages internal and external resources to achieve priority goals and objectives

Change leadership                                                               Continuously seeking (or encouraging others to seek) opportunities for different and innovative

                                                                                                                                      approaches to addressing organizational problems and opportunities

Nominees were asked to complete an application process that tested their response to leadership oriented essay questions. In essence, this was the candidates' introduction to the type of personal insight required of strategic leaders. Applicants were required to address the following:

• What are your career goals, and how will participating in this program help you attain them?
• Identify what you think are competencies required of successful strategic leaders.
• Provide an example of your best recent leadership achievement, and explain the skills that led you to be successful in this endeavor.
• What competencies would you like to further develop?
• Indicate interest in one of the following identified system‑wide projects that you would like to work on over the next year (several projects are listed).

The corporate CNO, CFO hospital d vision, system VP for HR, and the Beckwith Institute director scored and evaluated the nomination documents and application responses. Ten individuals were determined to have demonstrated the right mix of leadership ability, motivation, and fit, and were accepted into the inaugural Beckwith Fellows Program. UPMC has continued to accept only 10 individuals per year into this program to provide a focused, individualized approach to learning.

Table 2, leadership derailers

Derailer                                                                                                       Description

Impulsive                                        Doesn't consider the consequences of his or her actions

Concrete                                          Focuses on things he or she can control, short‑term focused, dislikes ambiguous situations

Arrogant                                          Self‑important, self‑absorbed, or inconsiderate

Micromanager                                  Controlling and demanding, high attention to detail

Self‑promoter                                  Demands attention and sometimes takes credit for others' success

Volatile                                            Moody, touchy, short attention span

Risk averse                                      Cautious, indecisive, dislikes change

Defensive                                        Argumentative, suspicious, resists authority

Imperceptive                                    Misunderstands others, doesn't know the effect he or she has on others

Approval dependent                        Avoids confrontation, fails to stand up for ideas or other people

Eccentric                                          Creative, odd, takes unusual approaches

Accurate Assessment and Personal Insight

Assessment against success profiles offers information essential for a solid understanding of a leader's ability to demonstrate the critical behaviors and competencies required for successful leadership. For participants, it is a process that reveals unique personal insight. ,

Beckwith Fellows completed DDI's Global Leadership Inventories battery and completed a half-day assessment at DDI's assessment center. During "day‑in‑the‑life" exercises, participants review information about their role in a fictitious organization. Simulations replicate realistic leadership situations and measure core competencies across various activities; for example, in‑basket exercises, analysis and/or planning work, interaction simulations, and group discussions. Most important, the Beckwith program assessment process does not have a healthcare theme; participants are not being measured on their ability to make good clinical decisions, but on their decision‑making process. The simulations provide a comprehensive picture of leadership ability or potential in a pressure situation, and increase the accuracy of evaluations.

After the assessment, DDI scored videotapes and written exercises, and provided detailed performance analyses on each of the candidates. Participants receive a thorough analysis of their performance, highlighting strengths and development needs. For each competency identified as a development need, leaders receive a comprehensive, user friendly development guide with specific activities-exercises, tips, readings‑on how to improve performance. This information is considered confidential and is not shared with anyone other than the participant and the program directors, without the permission of the participant.

Generally, participants can be understandably wary of the assessment process. They are taken out of their "comfort zones" and know that their strengths and vulnerabilities are being scrutinized. Being deeply rooted in day‑to‑day work leaves little time for introspection and strategic planning about how to tie daily tasks to system‑wide goals. In reality, however, it is highly unlikely that participants fully possess the competencies against which they are being assessed, as they have not served in strategic roles, but operational roles, to this point. Behaviors and skills that are appropriate for the current level are not necessarily those required for the next level.

For each participant, assessment is an enlightening experience and is the beginning of his or her transformation to developing personal insight and strategic thinking. The process helps participants gain a greater awareness of self, their role, and how they can contribute to the system at a higher level.

Key Assessment Findings

The purpose of assessment, of course, is to identify the personal strengths and development opportunities of individual leaders. When assessment data are considered collectively, they reveal group performance gaps and specific learning needs. For instance, 96% of the 40 program participants evaluated to date demonstrated a learning need for 2 competencies, visionary leadership, and program and project management. Valuing diversity was next with a gap of 90%, with change leadership and building business partnerships demonstrating gaps of 80% and 66%, respectively.

That these areas were identified as the greatest gaps was not particularly surprising, given the fast‑paced, high‑pressure clinical environment that the assessed nurses had been working in for several years. Again, participants had been working at the operational level, not the strategic level. Therefore, the scores for strategic‑level visionary leadership, program/project management, change leadership, and building business partnerships were not unexpected. Valuing diversity is our term for one's ability to embrace different points of view. Especially in urgent situations, people entering this stage of development tend to gravitate toward like‑minded. individuals rather than seek people who bring multiple perspectives to a problem.

What was surprising, however, was that during the subsequent 3 years of the program, the largest development gaps remained consistent across all classes, both for UPMC participants and for those from outside the system. This is good news. It has confirmed the original findings, enabling the Beckwit Institute to truly focus and concentrate on applying curricula that addresses core development needs.

The Core Curriculum

Based on assessment center results, the program directors created a customized development program for each of the Fellows. The collective data also revealed the development needs of the entire group, providing the basis for the institute's core development curriculum. The learning structure consisted of 2 weeks of intense classroom sessions, integrating didactic learning, dynamic role plays, case studies, and other interactive exercises designed to help the Fellows learn how to apply their newfound behavioral, strategic, and practical skills to make a difference in their job performance

Faculty were selected based upon their depth of experience in management operations and executive strategy at the unit, organization, and system levels. This group consists primarily of doctorate and master's‑prepared, executive‑level nurses with extensive knowledge gained from real‑world experience.

Graduates of the Beckwith program may earn certificates, continuing education credits, and/or pre-graduate and postgraduate credit for successfully completing certain learning pathways through the University of Pittsburgh School of Nursing.

The core curriculum topics are as follows:

1 . Transformational leadership teaches Fellows about the clinical, organizational, and economic implications of change. Coursework helps leaders hone influence skills to better lead teams through change to achieve enhanced business results. Fellows learn how successful transformational leaders can lead people to where they need‑but don't necessarily want‑to go.

2. Strategic planning and decision making helps leaders identify and overcome obstacles so that they can plan and execute more effectively under pressure. Fellows learn to assess and prioritize issues, manage projects and programs for results, and link organizational strategy with system‑wide goals. The result is an improved ability to make quick, accurate decisions.

3. Developing people provides participants with perspective on leveraging the unique talents and skills of others. Course content addresses negotiation, conflict and collaboration, communicating effectively in difficult situations, managing complex "people problems," providing constructive, results‑oriented feedback, developing a high‑performance team, and DDI's Targeted Selection(g) competency‑based interviewing system.

4. Innovation and change encourages participants to recognize and seek change in opportunities in day‑to‑day activities by overcoming resistance and breaking down barriers so that change "sticks." Course content examines the dynamics of today's complex health systems, change management principles, and clinical work redesign.

5. Healthcare economics improves participants' understanding of organizational and strategic‑level financial principles. Course content emphasizes strategic finances for healthcare, improving financial performance. computer‑based productivity systems, and clinical problem solving and decision making based on economic data.

Real‑world Learning With Bottom‑line Results

Beckwith Fellows' project work plays a pivotal role in participants' development as strategic leaders. It provides the opportunity to immediately apply new learning to real‑world issues and experience meaningful results. For most, as they learn how to make a business case for change, this is their first exposure to demonstrating tangible, high‑level financial improvement as a result of their efforts.

The yearlong project work begins immediately following classroom sessions. The selected projects are linked directly to UPMC system‑wide initiatives and organizational goals. Participants work individually, or in groups of 2 or 3, and are assigned projects that may be out of their area of experience. This is done deliberately to get participants out of their comfort zones and to stretch the] r learning and development as much as possible.

Each participant or team also has a project mentor. The mentor, usually an executive‑level leader, I s selected by the program directors on the basis of subject matter expertise. Project mentors serve as advisors, confidants, and coaches, and all communication between project mentors and participants is strictly confidential. The program directors serve as hands‑on executive coaches to help guide individuals from a behavioral and developmental perspective. This aids individuals as they apply their developing strategic‑level skills to situational work problems. The teams meet together and with mentors on an as‑needed basis. Project mentors submit quarterly project status and participant status reports to the program directors.

Additionally, all project teams gather for monthly learning sessions. These meetings have become one of the most important features of the Beckwith program, proving to be a fertile environment for group situational learning. Over time, the progress and improvement in sophisticated reasoning has been quite remarkable, as participants learn from and coach one another. The process also has confirmed vulnerabilities, as individual derailers are revealed.

The 2‑hour meetings consist of 2 learning processes:

1.   Each Fellow presents a brief synopsis of the status of his or her project, leading to a rich group discussion of opportunity, situational approaches, and overcoming specific barriers.

2. "On‑the‑spot" learning sessions provide participants with new knowledge of how to apply leadership concepts or skills in their real‑world projects.

For participants who are external to UPMC, the program experience is exactly like those of our internal participants, , except that they work with projects that are applicable to the goals of their own organizations, and the sponsor and project mentor are selected from their organization as well. Participants also joined the monthly learning meetings via conference call.

Examples of Beckwith Fellows projects include:

• Redesigned patient hand‑off processing saved up to 30 minutes daily for each nurse‑cost savings that could be redirected to hire 58 new nurses across UPMC.
• Analysis of workplace injuries related to patient movement (lifting) resulted in a comprehensive training program to improve body mechanics through simulation exercises.
• A study of temporary nurse staffing problems enabled UPMC to consolidate multiple outside agency providers, standardize rates, and dramatically reduce staffing costs.
• Assessment of the forces of magnetism within the healthcare system resulted in an improved, formalized program to attain magnet accreditation.
• Analysis of emergency department procedures significantly increased patient throughput rates.
• Standardizing clinical documentation across the system eased paperwork burdens and paved the way for conversion to an electronic medical records system.

Participants, faculty, and mentors provided valuable feedback that was used to enhance program effectiveness. For instance, where project selection initially was determined mainly by participant choice, now it is a joint decision made by the individual, project mentor, CNO, and Beckwith Institute director. Other content improvements were made as well.

Beckwith Program Outcomes

Since its inception in 2000, the Beckwith program has been successful across personal, program, and system levels. Forty individuals have completed the program. Of that group, 35 remain in the system (others left UPMC for personal reasons, such as moves out of town with spouse). Participant evaluation scores over the 3 years are a cumulative 2.8 on a 3‑point scale, with Fellows consistently indicating that it is the most beneficial and rewarding professional development experience they have ever had. Fellows are embracing their newfound challenges and advancing professionally, as evidenced by superior annual performance reviews. The achievements of Beckwith Fellows have captured the attention of UPMC's executive leadership. Hospital CEOs and others in senior leadership positions have personally recruited Fellows for new permanent positions or to tackle tough strategic projects. Clearly, UPMC has been successful in attaining its major Beckwith program goals:

1. Creating a pool of high‑potential talent ready to step into strategic‑level leadership positions.

2. Promote a dynamic culture that embraces change through progressive ideas, innovation, and flexible processes.

Additionally, the cumulative project work completed by Beckwith Fellows has demonstrated substantial financial rewards:

• Actual system‑wide savings to date: more than $530,000 directly attributed to Fellows' project work.

• Potential saving opportunities of $ ' 38.5 mil­

     lion from Fellows' project work.

* A return on investment of 450% for the first 2 years of the program.

Birth of the Health Care Leadership Academy

While the Beckwith Fellows program focused solely on developing UPMC's nurse strategic leaders during its inaugural year, it became obvious that individuals in other disciplines would benefit as well. In program years 2 and 3, the Beckwith Fellows program opened its doors to a broader clinical audience, including participants from outside of the UPNIC system.

In 2004, UPMC, the Beckwith Institute, DDI, and University of Pittsburgh School of Nursing built on the strong foundation established by the Beckwith Fellows program to create the Health Care Leadership Academy. The Academy serves as a proven resource, dedicated to leadership development for nurses and other healthcare professionals, and is a viable option for hospitals and healthcare systems to send future leaders for targeted development. Enrollment is open to healthcare leaders nationwide. The Academy's key principles assessment, strong developmental curriculum, real‑world project work, and organizational support‑are formalized across 3 leadership levels:

• Emerging leaders‑nurses transitioning into their first leadership roles.

• Operational leaders‑nurses experienced in managing others and who are now counted on to drive change and impact staff performance.

• Strategic leaders‑‑VP or aspiring VP‑level leaders (Beckwith Fellows program).

In Spring 2004, inaugural sessions for Emerging Leaders and Operational Leaders were filled to capacity. Open‑ended feedback confirmed that the course content was on target, held tremendous value, and lead to practical application for academy graduates.

The UPMC Beckwith Fellows Leadership Program has exceeded initial expectations in terms of system‑wide project results, integration and acceptance into UPMCs culture, and growth and influence across the UPMC leadership spectrum. Lessons learned have allowed UPMC to cascade development down through the organization to operational and emerging‑leader levels. Ultimately, the program has succeeded in building a rich pipeline of next generation leaders ready to step forward and be productive. The participant satisfaction and feedback, as well as requests from external organizations to make all 3 levels of the leadership academy available to them, confirm for us that the need to develop our next generation of healthcare leaders is imperative.

References

the Work Environment of Nurses. Washington. DC: National Academy Press; 2004.

3. Smith A, Rodgers R. The Blueprint for Leadership Success. Pittsburgh, Pa: Development Dimensions International; 2003.