What do you have to do to become a medical director?

Medical management is a large and growing profession. The need for physicians in management roles grows unabated in hospitals, managed care organizations, group practices, and myriad other environments. But entry is not merely a matter of wishful thinking. Painstakingly assembled credentials and skills are the order of the day. The advice in this column is distilled from Medical Directors: What, Why, How, a new College monograph.     

The electronic medical record system: health care marvel or morass?

The author considers the potential advantages and disadvantages, as well as possible unintended consequences, of introducing electronic medical record systems in health care organizations. Special consideration is given to the issues such information systems raise concerning privacy, confidentiality, and quality of care from both patient and provider perspectives. The potential gains from computerizing medical records include the benefit of instantaneous availability of patients' medical history, treatment regimes, and current health status in routine and emergency clinical situations. Ease of access to this information should reduce adverse outcomes. The added value of a complete and up-to-date medical record immediately available to medical caregivers seems undeniable. The potential disadvantages include issues around patient confidentiality and unauthorized access to records, the enormous capital investment for computer hardware, and system maintenance.     

Following the Herd or Not?: Patterns of Renewal in the Netherlands and the UK

How do large firms conduct their strategic renewal journeys in an increasingly turbulent environment? Are there generic industry patterns, or are these renewal journeys country- or firm-specific? To answer these questions, we examine the relative incidence of external versus internal and explorative versus exploitative renewal actions, and their speed, in leading Dutch and UK financial service companies using longitudinal data. The context, content and process dimensions of strategic renewal are distinguished, and research questions about these attributes are formulated and investigated using new metrics. Findings show that while exploration/exploitation ratios are fairly similar for firms across the entire industry, systematic differences are evident between the external/internal renewal ratios of Dutch and UK firms, and that speed of renewal is largely determined at the firm level. Thus we find that industry-, country- and firm-specific factors all influence journeys of strategic renewal in distinctive and complementary ways.     

Concise or comprehensive? Predictors of impact assessment choices for electric transmission line projects

Environmental impact assessment (EIA) procedures required in the United States and many other countries are often highlighted as a major hindrance to timely and efficient deployment of critical infrastructure projects. Under the U.S. National Environmental Policy Act, a more extensive environmental impact statement (EIS) review can take several more years and cost much more than a succinct environmental assessment (EA). This not only affects the project in question, but also likely informs how—or whether—additional projects are pursued. Thus, understanding key predictors of the EA versus EIS choice sheds light on supply-side considerations affecting infrastructure deficits. Using the case of NEPA reviews conducted for 244 transmission line projects between 2005 and 2018 by two U.S. federal agencies in the western United States, the Bureau of Land Management (BLM) and Department of Energy (DOE), this addresses the following question: What project features most predict whether EA or an EIS is used to assess a transmission line project? Drawing upon NEPA assessment guidance and agency NEPA records, we use a regression classification tree to analyze how protocols and project attributes relate to assessment choice. The result is essentially a null finding: transmission line length is by far the most important predictor of whether a project receives an extensive EIS or a shorter EA, with little predictive value provided by other attributes. While absolute project size undoubtedly influences impacts, the lack of further differentiation in what predicts use of EISs versus EAs suggests assessment does not simply respond to project details but also shapes proposal and design choices beforehand.     

Trust in Risk Regulation: Cause or Consequence of the Acceptability of GM Food?

Although there is ample empirical evidence that trust in risk regulation is strongly related to the perception and acceptability of risk, it is less clear what the direction of this relationship is. This article explores the nature of the relationship, using three separate data sets on perceptions of genetically modified (GM) food among the British public. The article has two discrete but closely interrelated objectives. First, it compares two models of trust. More specifically, it investigates whether trust is the cause (causal chain account) or the consequence (associationist view) of the acceptability of GM food. Second, this study explores whether the affect heuristic can be applied to a wider number of risk-relevant concepts than just perceived risk and benefit. The results suggest that, rather than a determinant, trust is an expression or indicator of the acceptability of GM food. In addition, and as predicted, "affect" accounts for a large portion of the variance between perceived risk, perceived benefit, trust in risk regulation, and acceptability. Overall, the results support the associationist view that specific risk judgments are driven by more general evaluative judgments The implications of these results for risk communication and policy are discussed.     

A systematic review of executive coaching outcomes: Is it the journey or the destination that matters the most?

In this article, we focus on a specific type of personal and professional development practice -executive coaching- and present the most extensive systematic review of executive coaching outcome studies published in peer-reviewed scholarly journals to date. We focus only on coaching provided by external coaches to organizational members. Our purpose is twofold: First, to present and evaluate how executive coaching outcome studies are designed and researched (particularly regarding methodological rigor and context-sensitivity). Secondly, to provide a comprehensive review of what we know about executive coaching outcomes, what are the contextual drivers that affect coaching interventions and what the current gaps in our understanding of coaching practice. On that basis, we discuss and provide a research agenda that might significantly shift the field. We argue that methodological rigor is as important as context-sensitivity in the design of executive coaching outcome studies. We conclude with a discussion of implications for practice.     

Which way to the frontier? Physician executives talk about the future

The author interviewed trustees, senior managers, and physicians at Moses Cone Health System in Greensboro, North Carolina, Legacy Health System in Portland, Oregon, and Henry Ford Health System in Detroit, Michigan. These three successful health care systems bracket the national market in size, geography, and managed care penetration. The comments of physicians are presented here, drawn from the book, Designing 21st Century Health Care: Leadership in Hospitals and Healthcare Systems. What emerges most clearly from their comments is the enormity of the task ahead. There is wide-spread agreement that substantial improvements in the quality and cost of care are possible, an encouraging stream of anecdotes and ideas about how to proceed, but a lack of consensus on critical components of how to organize practices and promote effective care.     

Safety culture: Philosopher's stone or man of straw?

This introductory paper to the special issue on Safety Culture considers some of the key issues relating to the nature, measurement and utility of this concept. It argues that there are many important questions still unanswered: what is safety culture and what is its theoretical basis (the question of definition), is it synonymous with safety climate, what are the essential characteristics of a 'good' safety culture and how might they be best measured, what are the reliability, validity and utility of existing measures of safety culture, and how does the concept contribute-if at all-to good safety systems and performance? Can an organization's safety culture be related to additional parameters (such as accident and incident performance) which are judged both within and outside the organization by the full range of stake-holders? Finally, the authors consider future issues and the future direction of work in this area.     

The ascendancy of primary care: permanent or temporary?

The conventional wisdom strongly suggests a health care provider food chain for the future: Primary care physicians (PCPs), principally family practitioners, on the top playing the lead role, distantly followed by specialists, with hospitals and other ancillary services even further down the line. Is this a reasonable expectation? Will PCPs dominate the new systems? Or will they be but one of many equally necessary components of these developing integrated health care delivery organizations? Looking at the various models now developing, it would seem that future integrated delivery systems will utilize both PCPs and specialists, but with strong augmentation from a diverse assortment of other health care professionals, including nonphysician providers, educators, and administrators. To separate the illusion of primary care dominance of the coming health care system from the likely reality, we should first determine what is driving the apparent present demand for primary care physicians. Next, we will examine the possible and probable reactions to that demand from an economic standpoint and from the points of view of both health care professionals and the public. Finally, we must try to picture how health care provider organizations of the future are likely to look and how they will integrate their health care professionals.     

Strategic vision or strategic con?: Rhetoric or reality?

Major companies devote considerable effort to communicating corporate visions and missions. Yet three recent surveys suggest that much of this effort has been counter-productive. A gap has emerged between rhetoric and reality. Arenas of confrontation have arisen between directors and managers, head offices and business units, holding companies and their subsidiaries, and between specialists and generalists. A widespread desire for corporate transformation is not matched by understanding of how to bring it about. The lack of top management commitment and of communication skills are major barriers to change. More competent directors and more effective boards are needed. The article suggests key roles for the chairman and the chief executive. It examines how best to share a compelling vision, and identifies a requirement for new attitudes and approaches to communication.     

Public or Private? Public Corporations,Companies and the Decline of the Middle Ground

In the era of New Public Management in the Anglo-Saxon countries, governments have become infatuated with things private and disparaging of things public. This dramatic attitudinal shift has been reflected in the importation of private sector business method into so much of what government does, and in the championing of privatization in its various forms as a way of reducing the size and importance of public sectors. The change represents a retreat from the more traditional acceptance that a valuable social purpose was served by middle ground structures and activities located in the outer parts of these public sectors, i.e., between the highly politicised cores of government systems and the highly commercialised institutions of private enterprise. In particular, this article argues that the form of the public (or government, statutory or crown) corporation epitomised such social value, and that the state-owned company which is now so often replacing it represents an abandoning of social value.     

Becoming the best: by beating or ignoring the best? Toward an expanded view of the role of managerial selection in complex and turbulent environments

This paper explores how the rules that guide search affect organizational adaptation in complex and turbulent environments. Our consideration of such rules extends beyond search scope—i.e., exploitation of current technologies vs. exploration of new technologies—to include focus on competition. We consider two types of competitive focus—i.e., external, where the choice of focal technology to be improved is influenced by information about other organizations and internal, where it is not influenced by others. We refer to this expanded set of rules as managerial selection and vary it to explore how it affects organizational adaptation. Employing an agent based simulation model, built on the framework of NKC fitness landscapes, we consider multiple types of interdependencies within and between technologies and across competitors. We show that in the presence of these multiple interdependencies, the ability of organizations to adapt is conditioned as much or more by the focus of search than by its scope. In particular, we observe that in simple and stable environments, organizational adaptation is enhanced by an external focus but in complex and turbulent environments, such external focus is counterproductive.     

The Role of Entrepreneurship in the Context of Career Trajectories: Moving Back into Wage Employment or into Unemployment?

This study investigates patterns of movement from self‐employment to wage employment or to unemployment in Belgium. Non‐parametric techniques and complimentary log–log analyses are used to determine the significance of stable individual traits (e.g. gender) and of time‐dependent characteristics (e.g. family and organizational context, labour market mobility) in moving back to wage employment or to unemployment. Evidence is provided on the possibility of entrepreneurship acting as a ‘steppingstone’ between long‐term unemployment and paid work. Yet, significant relationships also emerge between ex‐ante time spent in unemployment and the possibility of continued unemployment upon self‐employment exit.     

Elected medical staff leaders: who needs 'em?

Authority, influence, and power are not synonyms. In working with elected medical staff leaders, a physician executive who chooses to exert authority may soon find him- or herself relatively powerless. But one who chooses to downplay authority, to influence through persuasion, and to coach leaders to lead effectively soon generates support for his or her ideas. The need to coax, cajole, explain, persuade, and "seek input" frustrates many leaders in all kinds of organizations. It would be much easier just to order people about. It's so tempting to think: "Who needs 'em? I'm the 'chief physician.' I know what needs to be done. Let's weigh anchor, take her out, and do what it takes to sail those rough, uncharted seas." If you really enjoy sailing a large ship in rough seas without a crew, go right ahead. Or if you think it makes sense to run an organization with only an executive staff and no knowledgeable middle managers, by all means let clinician leaders know that, now that you're aboard, they're just window-dressing. If you can make this approach work, well and good. Your life will be much less complicated, each day will have far fewer frustrations, and progress toward established goals will be much faster. However, given the reality of traditionally thinking physicians, it would be best to keep an up-dated resume in the locked lower left-hand drawer of your desk.     

Motivational or dispositional? The type of inference shapes the effectiveness of leader anger expressions

Existing leadership research has presented conflicting views on the effects of leader anger expressions. The present research aims to reconcile these findings by proposing that the type of inferences followers make (i.e., motivation-focused inference or trait-focused inference) is a key factor determining the outcomes of leader anger expressions. Through one survey study (Study 1) and two experimental studies (Studies 2 and 3), the present research indicates that the effectiveness of leader anger expressions is associated with the type of inferences followers draw from the anger. In general, we found support for the negative relationship between trait-focused inferences and leader effectiveness, but were unable to properly test the positive relationship between motivation-focused inferences and leader effectiveness due to the lack of appropriate instrumental variables. We also investigated whether followers' implicit theories of personality (i.e., entity versus incremental theory) would moderate the effect of leader anger expressions on the type of inferences made by followers, which in turn shapes leader effectiveness. The results of Study 3 provide evidence of the moderating role of implicit theories of personality. Theoretical contributions and practical implications of the present research are discussed.