quality assurance healthcare systemsrey writer

Assignment 2: Discussion Question

Based upon the assigned reading for Module 5, how do legal, regulatory, and economic issues affect quality? Provide examples with your response


CHAPTER 18 Conclusion: Leading the Way


After reading this chapter, readers will:

  • Appreciate the need for managers to have leadership competencies.
  • Know about the philosophy and associated practices of servant leadership, collaborative leadership, and complexity leadership.
  • Understand the need for versatility in leadership style throughout one’s career.
  • Understand differences among members of demographic groups in the workplace.
  • Know about appropriate behaviors for career advancement.

Chapter Summary

This chapter reviews important aspects of leadership. These include theories most relevant to health-related organizations and their implementation. Examples are provided. The personality patterns and values of different demographic groups are reviewed. When persons seeking employment understand these differences, the frustrations associated with looking for a job and staying in a present position are lessened. Thoughts concerning careers are also offered.


Case Study

Roger, President of the Board of Health, and Tracy, the Board Human Resources Committee Chair, were talking.

“We have an opportunity to make some needed changes,” noted Roger, “with the retirement of the Health Officer and the need to replace the agency’s epidemiologist occurring together. By hiring the two right people, we can take a big step into the 21st century. Just think, we can advertise for both positions at the same time. Why, the combination of an experienced health officer and a newly graduated epidemiologist from the MPH program over at the university could …”

“Wait a minute,” Tracy interrupted, “You are making a number of assumptions. Some are good, and others are not. Let me offer some thoughts.”

“Okay,” Roger said. “This is your domain. I’m ready to listen.”

If Tracy could take a time out and ask for your help, what advice would you offer?


This book is about management. Many people distinguish management from leadership. Kotter (1990), for example, argues that managers plan and budget, while leaders set direction. Managers organize and staff, while leaders align people. Managers control and solve problems, while leaders motivate and inspire. Others have summarized the distinction between leaders and managers with the adage that leaders do the right thing, while managers do things right. Often, the distinction between managers and leaders in organizations is based on hierarchy (position). Those at higher levels (leaders) are given more control over resources and decisions related to vision, mission, and strategy.

The authors believe that the distinction between leaders and managers has limited value in the new workplace. Managers need leadership skills (such as strategic planning), and leaders require management skills (such as the ability to implement and execute organizational plans). An organization benefits when managers, and indeed all employees, think of themselves as leaders and are treated as leaders. All employees in a workforce that is fully engaged in quality improvement and committed to delivering value are expected to lead. Employees are expected to exhibit the traits of credibility and inspiration that are associated with leadership. Employees are expected to lead themselves and their teammates. Employees are expected to do the right thing as well as to do things right. In these ways, everyone in an organization is expected to develop both leadership and management skills.

Managers of organizations that are dedicated to health can benefit from knowledge of leadership models and should integrate the elements of models into their work. Three related models of leadership are particularly useful when working with individuals and entire organizations that are engaged in providing health-related programs, services, and products. Servant leadership is a philosophy that many health workers embrace. It provides a useful philosophy for communicating and drawing on the energy and service commitment that many employees of health organizations feel. Collaborative leadership is a philosophy that is quite useful in health organization management as well, because organizational work inevitably involves multiple stakeholders that must negotiate, compromise, collaborate, and work together. Finally, complexity leadership builds on the interactive, relationship-based, and complex nature of much of health-related work.

Servant Leadership

Robert Greenleaf (2002) first articulated the philosophy of servant leadership in the 1970s. He argued that leadership should flow from a motivation to serve, rather than from a desire to get out front or be in command. Leaders are servants to their organizations and their employees and to their communities. In contrast, leaders who are motivated by pursuit of their own agendas or by power for its own sake can take an organization or community in directions not supported by either employees or stakeholders.

Servant leadership is a philosophy rather than a set of prescribed and evidence-driven practices. However, many authors have attempted to transform the philosophy into workplace behaviors. Although there is a wide range in such applications, the following guidelines are useful for employees and managers who consider service to be their primary motivator.

Dye (2010) has articulated seven broad behavioral attributes of servant leadership. Servant leaders share information, rather than hoarding it for personal gain. They delegate authority in order to develop others and disperse power. They take their organizational or community missions to heart, spreading the missions throughout their own organizations through policies and practices. Servant leaders support the development of their employees through coaching and continuing education. They celebrate and praise accomplishments, building commitment and energy in employees. They shift the focus of performance reviews from attack to development. Finally, they connect with employees rather than standing aloof from them. Servant leaders put their employees first, ahead of themselves.

Servant leaders are most effective when employees share their commitment to their organization and its vision and values. This is the case in many successful health organizations and agencies.

Collaborative Leadership

Collaborative leadership involves working together with shared power and inclusive decision making. Some would argue that collaborative leadership is the only path to effective leadership, but such a conclusion ignores the reality that hierarchical leadership (use of authority based on position) is effective under certain conditions such as when emergency decision making is required, when the leader holds the expertise, when employees are not committed to organizational goals, and when consensus cannot be reached. Hierarchical leadership is of limited use in many situations faced by managers of organizations delivering services and programs that are related to health, however. Collaborative leadership should be a competency that is embraced by any manager in a health-related organization. For many such managers, collaborative leadership may be their preferred and typical style of managing and leading.

In a study of community health partnerships, researchers observed five themes in the collaborative leadership of those partnerships (Alexander et al. 2001). The first theme is systems thinking, which has been covered extensively in this book. Systems thinking encourages a population view of health, helps the group to identify high-leverage strategies for promoting health, ensures inclusiveness of all components of the health promotion system in the group, and keeps the group’s focus on the broadly shared vision. Second, because there are few other options for motivating participation in collaborative activities, vision is a key motivator or driving force for group members. The vision is designed through a systematic and inclusive process. A third theme in collaborative groups involving multiple organizations is collateral leadership. Collateral leadership is the use of small, rotating, diverse subgroups to execute elements of a larger group’s vision and mission. Collateral leadership reduces the burden on any single organization or individual to keep the group moving. A fourth theme in collaborative leadership groups is power sharing, which builds broad support among individuals and organizations. Often, organizational leaders have to resist the urge to assert power when they are working in multipartner collaboratives. A final characteristic of collaborative leaders is the ability to remain accessible and listen attentively so that partners feel included and valued.

Koh and McCormack (2006, 108) argue that “In public health, the traditional leadership trait of fierce independence must give way to the higher value of fierce interdependence.” The interdependence of almost all workers in public health organizations with citizens and with other community organizations makes “fierce independence” a negative leadership trait. The same statement can be applied to providers of clinical services. The “fierce independence” of many clinicians is related to their training and the fact that they typically interact with only one person at a time. Yet collaborative care is a growing fact of life for most clinical situations, particularly for individuals with chronic conditions and for problems treated in hospitals. Collaboration helps individuals and organizations address complex challenges because it is powered by the skills, knowledge, experience, and insights of many people, not just one (Frisina 2011).

Complexity Leadership

In many activities that involve collaborations, the direction of a group, team, project, task force, committee, organization, or collaborative is less than clear. The strategies or even the mission of the entity may be ambiguous or uncertain. Direction and action can be imposed by command-and-control leadership, but such activity is unlikely to engender commitment and support. Alternatively, direction and action can emerge from participative decision making and from learning. Under these conditions, complexity leadership is a useful model.

From the perspective of complexity leadership, all complex human systems need direction, commitment of participants, and the ability to adapt in the face of challenges (Drath 2004). In successful complex systems, leadership arises from a variety of sources to accomplish those three important tasks. Direction, commitment, and adaptive actions emerge from dialogue and learning among diverse individuals, organizational units, and, in most cases, multiple organizations and their stakeholders. The task of individual leaders in such settings is to provide time and resources for shared learning, to encourage participation, and to do the attentive listening that is preferred by the collaborative leadership model. Because solutions to complex challenges are rarely clear or easily discovered, complexity leadership benefits from maximal input of employees and stakeholders, including customers and clients. Complexity leadership also requires tolerance for uncertainty, taking some risks, trying new solutions, and occasionally failing, but learning from those failures. In many health settings, this model of leadership is far more effective than the traditional command-and-control model of leadership.

Versatility in Leadership Approach

Successful managers are able to adapt their approach to the situations they face. This is particularly true in the long run, because managers are more apt to face different situations as they change jobs, organizations, or locations. If leadership is the ability to get people to work together, command-and-control can be the best choice when employees share the same goals and agree on the substance of the command, or when time is short and a decision must be made. Under most conditions faced by managers in health organizations, however, goals are often diverse and conflicting, and agreement on the substance of management actions is more difficult to achieve. The importance of this statement increases as individuals rise in their organizational hierarchies and their authority increases. The tenets of collaborative leadership, complexity leadership, and servant leadership are powerful tools for improving the quality and performance of health organizations under those conditions.


The need for versatility and flexibility in management and leadership is illustrated by striking patterns in worker characteristics based on the time periods in which they were born. Those patterns reflect significant continuities among individuals who share similar experiences with major social, political, technological, and cultural events. Managers need to motivate and lead individuals from several different generations. Managers who understand differences among generations are likely to be more successful than managers who ignore the differences.

Demographic Profiles of Employees

Demographers have divided people into four categories: Traditionalists, Baby Boomers, Generation X, and Generation Y. Brief profiles of each group follow. Although the profiles are generalizations that do not apply to all people in the categories, the profiles give managers a starting point for better understanding the workplace behavior and attitudes of diverse employees.


Traditionalists are also called the Silent Generation. They were born between 1927 and 1945. This is currently the smallest generation of workers in the United States. Members of this group may be near retirement, but they often have both power and responsibilities due to their senior positions in organizational hierarchies. Traditionalists have strong work ethics and have worked long hours to advance their careers. They tend to be loyal and express this loyalty to their employers through years of continuous service.

Traditionalists respect authority and work well in groups. They tend to avoid being the center of attention. Many have been slow in adapting to technological innovations in the work environment. Their moral, social, and personal values are traditional. Their working attire is appropriate, although younger colleagues may judge them to be overdressed.

Baby Boomers

Baby Boomers were born between 1946 and 1964. Although they have started to retire, an estimated 80 million are still working. Members of this group often hold positions of power and influence. They are hardworking and often define themselves by their professional accomplishments. Advancement, prestige, and perquisites provide motivation on their jobs. They are willing to make sacrifices to succeed. Because this generation came of age during a time of social upheaval, Baby Boomers are not afraid of confrontation when it is backed up by hard work. They are highly competitive and goal oriented. Their careers provide focus in their lives. Most believe that work should be done in an office. They seek out challenging projects that allow them to showcase their knowledge and skills.

Generation X

Generation X includes people born between 1965 and 1980. Between 45 and 50 million members of Generation X are working in the United States. The number of workers from Generation X is growing at a rapid pace. Just under two-thirds (60%) of these workers have college educations. As a group, they currently hold mid-level managerial positions.

Members of Generation X are resourceful, independent, and self-sufficient. As a consequence of these traits, they dislike structured working environments and often openly ignore authority. They prefer to work at home and set their own working hours. Generation X employees value responsibility but prefer it to be accompanied by personal freedom. They are technologically competent.

As a group, Generation X does not emulate the organizational loyalty of earlier generations. Members of Generation X are committed to their own well-being and freely change employers. Leisure time is an important aspect of their lives. Careers are important but tend to be subordinate to their personal interests.

Generation Y

Generation Y comprises the remainder of the American workforce. These people are also called the Millennial generation and were born between 1981 and the present. As of 2010, experts estimate the number of Generation Y workers in the American workforce to be approximately 70 million. Most contemporary college graduates are members of Generation Y.

These individuals rely heavily on technology. They use e-mail far more extensively than traditional mail. Text messaging is preferable to personal contact. In school, they have a strong preference for online learning and find traditional lectures to be boring. Members of Generation Y readily accept lower salaries when they are accompanied by flexible hours and working conditions. They want their jobs to be meaningful and are not afraid to convey that message to their managers. They have few qualms about questioning authority. Generation Y individuals value teamwork and constantly seek praise and approval from supervisors and coworkers.

Intergenerational Friction

With members of four different generations in the workplace together, friction between them is inevitable. Older workers criticize Generation Y for lacking commitment and behaving in a selfish manner. Generations X and Y criticize Traditionalists and Baby Boomers as being too rigid and being too focused on goals. Older employees think that younger ones are insubordinate, while younger individuals think that the values of older employees are flawed. No group is immune to criticism concerning their attitudes toward technology.

Cross-understanding among the generations provides a key to creating collaborative and open work environments that include members of all four generations. Managers can help by educating their employees about such generational differences.


We conclude by offering a few thoughts about careers. We do not intend to preach or lecture readers. Rather than envisioning a classroom or lecture hall, transform the venue to a table surrounded by a few individuals sharing age-appropriate beverages.

No Learning Is Ever Lost or Education Wasted

In 1854, Louis Pasteur said that “Chance favors the prepared mind” (Kubinyi 1999). Education is the key to being prepared. Within wide limits, individuals cannot have too much education. Education can be acquired formally or informally through reading. Because the future is impossible to predict with total accuracy, having a broad fund of knowledge is one of the best ways to be prepared for unknowns.

Be Prepared to Work Hard to Succeed

Advancement is rarely automatic. Most organizations promote people who achieve results. Over time, having a focused approach to work in general and to one’s job in particular maximizes the chances for success and advancement.

Establish a Goal, and Then Take Steps to Achieve It

Goals provide focus for activities. They also provide a basis for evaluating progress. Periodically, goals should be reset. Immediately after completing an evaluation is a good time to review and reset goals.

Appreciate the Importance of Networking

Networking provides links with other people and organizations. These links are especially useful when seeking employment or information. Prior interaction adds a personal dimension that is missing from contact information obtained from a directory or the Internet.

Good Manners Are Essential

Parents teach manners to their children. All too often, such lessons are forgotten when parents are not present. However, clients and customers appreciate politeness. More to the point, rude employees can cause potential consumers to postpone or change their decisions about health care or health prevention. Good manners contribute to good customer service.

Give Good Client and Customer Service

Customer service is a core concept of quality management. Poor service can lead to upset consumers or lost sales. In most cases, the recipients of poor service seek other sources for the services or programs in which they are interested. They also tend to discuss their experiences and frustrations with friends. This often leads to further loss of clients and revenues.

Apply the Lessons of Quality Management

Quality improvement, quality management, and customer service are mainstays in many manufacturing and service industries. They are being successfully integrated into health care organizations. Public health agencies are just beginning to embrace them. Individuals who ignore this reality are unlikely to achieve sustained success in a health organization.

Never Burn Bridges

Because the future cannot be predicted, individuals never know when they might need something (information, a referral, a letter of recommendation, or a favor) from a former supervisor or employer. Irrevocably severing ties with a person or organization closes all channels of communication. Telling someone off may provide a momentary release for anger. However, such an action usually burns a bridge and can lead to unwanted future consequences.

Don’t Say Bad Things about Other People

Offering negative opinions about other people is a form of gossip and should be avoided. If cruelty is not a sufficient reason to avoid criticism, burning bridges should be. The object of gossip may be a friend of the person receiving or hearing about an unkind comment. When criticism is needed to correct an inappropriate behavior, it should be provided directly and in private. Praise can and should be given in public.

Understand Politics

Politics are common in organizations. Prudent individuals take the time to understand and constructively use power relationships in organizations. The same people do not allow destructive politics to consume them.

Most people begin their careers by obtaining a job for which they have adequate technical skills and expertise. Over time, many start to rely on political rather than technical skills for job security. As this process continues, politics based on personal interest rather than organizational interest can become predominant. As this replacement occurs, it is usually accompanied by an increase in fear. A common outcome is job loss. The antidote has two parts: maintain technical competence through continuing education while avoiding the allure of self-interested politics.

When You Slow Down, Prepare to Be Passed Up

The workplace is a competitive environment. A continuous supply of new graduates wants to begin their careers. They have fresh educations, lots of personal energy, and a desire to succeed. Existing members of the health (or any other field) workforce must invest some time and energy to advance their competencies. Ignoring the need for this investment may give new job seekers an advantage that leads to employment. A gradual loss of energy is a typical aspect of normal aging. Knowing this fact may be helpful when contemplating retirement.

The authors of this book are members of the Baby Boom generation. To a degree, this career advice reflects their personal values. However, they are senior members of their respective professions. In this respect, their values are similar to the values held by the people most likely to be setting policies in organizations for the next decade. Although organizational mores are likely to change, they are not likely to do so overnight.


Effective managers use the competencies that traditionally have been associated with leadership, and vice versa. In the management of organizations that provide services and programs related to health, useful leadership competencies include delegating tasks, developing others, encouraging participation, sharing power, celebrating organizational accomplishments, and inspiring others. Such competencies are particularly important when people are being considered for promotion. Managing one’s career is essential for timely advancement and promotion. An understanding of differences in workplace attitudes among members of the Traditionalist, Baby Boomer, Generation X, and Generation Y groups is useful when managing and working with others. Advancing one’s career requires hard work, continuous learning, an appreciation for client and customer service, and participation in organizational politics without abusing it in the pursuit of self-interest.

Systems Thinking about Leading the Way

The butterfly effect is a metaphor based on the idea that the flapping of a butterfly’s wings in, for example, Brazil can cause a tornado in a distant location, for example, the state of Texas in the United States. There is at least a kernel of literal truth in that assertion. The butterfly effect gained popularity based on work done by meteorologist and mathematician Edward Lorenz in 1961 (Gleick 1987). Building a 12-equation computer simulation model of the weather, Lorenz entered the number 0.506 for one of the initial values of a weather parameter, truncating the intended value of 0.506127. He assumed that the difference was too small to matter. Instead, the small difference in the initial value of the parameter created wildly different weather conditions when he ran the simulation.

To return to the butterfly metaphor, the insect’s actions do not literally cause a weather disturbance by providing energy to fuel the tornado. But the butterfly’s actions do create new initial conditions that can lead to a chain of events resulting in a tornado. In the same way, a small alteration in a complex and dynamic system can cause a chain of events leading to large-scale changes. Most of us work in complex and dynamic organizations, and all communities and societies are both complex and dynamic.

The bottom line is that the butterfly effect reminds us that each person has the potential to initiate or lead a transformation. Even when working at the lowest microsystem level, alone in a cubicle or interacting with a group or team, our actions matter. They always matter to us and our group, even our organization, and they have the potential for moving hundreds, thousands, millions, and possibly billions of human lives toward better health.

Case Study Resolution

Returning to Tracy and Roger’s meeting, Tracy considered the situation and offered the following advice.

“Hiring a new Health Officer is the Board’s responsibility. All the other employees, including an epidemiologist, are ultimately managed by the Health Officer. We should decide on the style of leadership and personal values we prefer in a Health Officer and then find such a person. To meet the needs of the community, we need a Health Officer who works hard, is collaborative, and is focused on serving our customers and clients at the highest level of quality.”

Tracy continued, “But we should allow the Health Officer to make the final decision about a new epidemiologist. The board should not micromanage the agency. Besides, consider the hiring decision as a test of the new Health Officer’s ability to select employees and a ratification of the Board’s ability to hire a Health Officer who is aligned with its expectations.”

Tracy and Roger shook hands and departed. Both were smiling.


Alexander, J. A., M. E. Comfort, B. J. Weiner, and R. Bogue. 2001. Leadership in collaborative community health partnerships. Nonprofit Management and Leadership 12 (2): 159–75.

Drath, W. H. 2004. Leading together: Complex challenges require a new approach. In The CCL guide to leadership in action, eds. Wilcox, M., and S. Rush. San Francisco: Jossey-Bass.

Dye, C. F. 2010. Leadership in healthcare. 2nd ed. Chicago: Health Administration Press.

Frisina, J. E. 2011. Influential leadership. Chicago: AHA Press.

Gleick, J. 1987. Chaos: Making a new science. New York: Penguin Books.

Greenleaf, R. K. 2002 (original copyright 1977). Servant leadership. Mahwah, NJ: Paulist Press.

Koh, H. K., and M. McCormack. 2006. Public health leadership in the 21st century. In Working papers of the Center for Public Leadership, 101–16, ed. Kellerman, B. Ca

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