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WHO SHALL LEAD? CIVILIAN LEADERSHIP SKILLS FOR THE 21ST CENTURY ARMY MEDICAL DEPARTMENT
By Kathy H. Dexter Seminar 19
Paper Submitted in Partial Fulfillment of the Requirements of the Army Management Staff College February 26, 1999
ABSTRACT
BACKGROUND In 1998, the Department of Defense federal civilian work force numbered 726,811, second only to the U.S. Postal Service in the number of civilians (Whitehead 1999). This number represents a decrease of 24.8% since 1993. The Army Medical Department has shared in this downsizing. A concomitant decrease in the number of Medical Service Corps (MSC) officers has created a crisis in the AMEDD’s ability to provide peacetime healthcare. Increasingly, civilians are moving into roles traditionally held by MSC officers as well as into administrative positions that were filled by Army Nurse Corps officers. While these civilians possess a depth and breadth of experience, the lack of a coherent recruitment, training, and retention strategy has hampered the organization’s ability to react to the challenges of today’s military healthcare environment. The most significant challenge faced by the AMEDD is the TRICARE program. While managed care demonstration projects were taking place throughout the Military Health System (MHS) during the late 1980’s and early 1990’s, the sweeping changes presented by the TRICARE program were for the most part unanticipated. TRICARE offers a Health Maintenance Organization (HMO) managed care option to MHS beneficiaries which differs significantly from the traditional military healthcare delivery system. In addition, TRICARE has been phased in across the MHS, which means that some regions of the country are more advanced in their implementation efforts than others. The transition to TRICARE has been a massive re-education process for both beneficiaries and healthcare leaders. Before 1997, little had been done to develop competencies for civilian healthcare administrators in the AMEDD. Beginning in 1993, one Department of the Army civilian was accepted into the U.S. Army Baylor University Graduate Program in Health Care Administration at the AMEDD Center and School (AMEDDC&S) at Ft. Sam Houston, Texas. This program has trained military healthcare administrators from all three services for over 50 years. The following year, two DA civilians were accepted into the program, followed by one more DA civilian in 1995. However, this initiative lacked focus, and, as a result, the civilians who graduated from the Baylor Program were provided with no clear career goals or direction. Without clear objectives, military treatment facility commanders were unable to properly utilize and mentor these civilians. No DA civilians have entered the Baylor Program since 1995. One outcome of this limited initiative was the recognition by the leadership of the AMEDD that a career program needed to be developed for AMEDD health systems specialists and administrators. In 1997, the Army Personnel Proponency Directorate (APPD) was directed to develop an ACTEDS (Army Civilian Training, Education, and Development System) for career series 670 and 671 (Career Field 53). A group of Subject Matter Experts (SME) consisting of two senior Medical Service Corps Officers and two mid-level career civilian employees was mobilized to begin the planning process. One of the civilian participants (this author) graduated from the Baylor Program in 1996. The other was an instructor at the AMEDD Center and School. In conjunction with advisors from APPD, this group spent almost one year identifying key positions, competencies, training opportunities, and career plans for the AMEDD’s civilian healthcare administrators. It is anticipated that implementation of this career program will begin in 1999. ACTEDS is only the beginning. The purpose of this paper is to take the next step: To identify those critical skills that will be needed by AMEDD civilians to carry the organization into the 21st century, as well as to make recommendations for recruiting, training, and retention of civilian leaders. Using a qualitative analysis, a comprehensive literature review will be presented that will elucidate those particular competencies and executive skills that will be of greatest utility in the AMEDD’s transition to a 21st century healthcare system. Leader competencies in the MHS are not unique for the most part. Private and public sector healthcare systems face similar challenges and must therefore require that their leaders possess similar competencies. The military-unique competencies can be readily identified. Dr. Sue Bailey, Assistant Secretary of Defense for Health Affairs (ASD(HA)), in a recent speech to the annual TRICARE Conference in Washington, D.C., pointed out that the MHS is "the only HMO that goes to war." Implications of this special mission will be addressed later in this paper. Some definitions are in order. Webster’s Dictionary provides the following:
In the federal system, we are accustomed to recognizing skills, knowledge and abilities as the basic tools required to accomplish the mission. "Competence" is a concept that, in the medical arena, pertains to that specific set of skills, knowledge, and abilities that are necessary for the delivery of quality patient care. For purposes of this paper, competency will encompass the skills, knowledge, and abilities that make up the healthcare executive’s tool box. Values and attitudes are also components of competency assessment. It is important to recognize that the operating environment governs the competencies required for mission accomplishment. As this paper will show, required competencies are generated by the challenges encountered, not vice versa. LITERATURE REVIEW The Changing Federal Work Force The shift in the demographic composition of the U.S. population to an older work force will affect the federal service in a number of ways. Crampton, Hodge and Mishra (1996, p. 247) state, "By the year 2000, nearly one third of the population will be over age 55, qualifying them to be categorized as older workers." As a result of this aging work force, there will be fewer younger workers to take the place of older workers when they retire. Recruitment of younger workers may become more difficult as the private sector and the public sector compete for the best and the brightest. Federal managers must be aware that older workers have different satisfiers on the job. They focus more on social contact and quality of life than on promotion and status (Crampton et al.). Studies have shown that the number one reason for older workers to remain in or return to the work force is financial necessity, followed by emotional fulfillment. Ting (1997) found that 3.5% of the federal workforce strongly disagreed with the statement, "In general, I am satisfied with my job." Based on a survey of 56,767 federal employees in 1992, the determinants of job satisfaction had less to do with individual characteristics and more to do with the individual worker’s commitment to the organization. When employees feel that their unique skills and abilities are recognized and used appropriately, their level of commitment to the organization is enhanced. Essential job characteristics include task clarity, skill utilization, and task significance. The individual supervisor must provide sufficient guidance, based on the organizational mission and vision, to empower and challenge each worker. Ting (1997) also found that the individual characteristics that influence job satisfaction in the federal work force are public spirit (commitment to public service), age, education (higher education levels lead to lower job satisfaction), race and gender (white males tend to be the most satisfied with their jobs.) The finding that more educated workers are less satisfied is of particular concern for recruitment in an increasingly competitive job market Given the brave new world of TRICARE, DoD’s managed healthcare plan, of particular relevance to this discussion is an article by Klingner and Lynn (1997) which examines the changing focus of public personnel management. The authors state that the current trend is for public programs to be performed by "alternative" organizations or mechanisms rather than by career public servants. Public agencies, they say, are more likely to be staffed by workers brought in on an "as needed" or contingency basis through more flexible employment mechanisms. These mechanisms can fall into a number of categories, to include purchase of service agreements with other public agencies, privatization, and gain-sharing franchise agreements. Such alternative staffing reduces the need for qualified technical and professional employees in the public service. The authors state,
Indeed, this is exactly the situation faced by many military treatment facilities (MTF) where constrained budgets have resulted in decreases in the civilian work force . In order to continue to deliver the level of care that is needed by the beneficiaries, the MTF contracts with outside sources to deliver that care within its walls rather than to send the patients to civilian facilities at greater cost. For healthcare administrators, knowledge of government contracting law is quickly becoming a core competency. Also, the management of personnel with little commitment to the organization presents unique challenges. However, the ability to dismiss alternative workers who do not perform is easier than with permanent employees under current federal service rules. Confounding this process is that many federal employees are covered by collective bargaining agreements. Daley (1997) points out that downsizing in the federal service has often hit the middle managers the hardest, leaving the first-line supervisor as a much more important member of the management team. Under this scenario, the remaining middle manager has a much greater number of supervisors to oversee, resulting in less individual attention and more reliance on the first line supervisor to communicate the organizational goals and objectives to subordinates. Daley points out that increasing numbers of governmental supervisors are now "player-coaches," that is, working supervisors, necessitating a stronger ability to juggle multiple roles and tasks. He identifies the concept of coordination and cooperation as replacing the older practice of command and control. Pickett (1998) examines the development of training in core competencies in conjunction with a performance management program. He defines competencies as "…the sum of our experiences and the knowledge, skills, values and attitudes we have acquired during our lifetimes" (Pickett, p. 103). He states that the development of core competencies within an organization must reflect the needs of the organization in order to be effective. In any organization, competent people at all levels, not just at the leadership level, are necessary to guarantee the success of the enterprise. His research has shown that one of the major causes of business failure is resistance to change in the work force. A program to continually assess the required competencies throughout the organization is the only way that organization will survive. Nowhere is this more evident than in the federal sector. Change is the one certainty for federal workers, and it is the responsibility of managers to ensure that their subordinates are prepared for the future. Picket points out that learning is an important business strategy. He states, "A key responsibility of senior management is to ensure that organizational learning equals or exceeds the rate of change, or that organization will die" (Pickett, p. 108). The Changing Military Environment The National Military Strategy (NMS) no longer focuses on global war, but instead concentrates on threats of regional instability, local conflicts, and limited operations other than war (Chairman of the Joint Chiefs of Staff, 1997). Four strategic concepts govern the use of our forces: Strategic agility, overseas presence, power projection, and decisive force. Strategic agility is a concept with special relevance to this paper. The NMS defines strategic agility as "the timely concentration, employment and sustainment of US military power anywhere, at our own initiative" (Chairman of the Joint Chiefs of Staff, p. 3). This strategic agility requires our forces to be "versatile, that is, to conduct multiple missions simultaneously, across the full range of military operations, in geographically separated regions of the world" (Chairman of the Joint Chiefs of Staff, p. 19). LTG (ret) Walter F. Ulmer (1998), writing in Parameters, criticizes today’s Army when he says that the leadership philosophy focuses "…on the immediate (non-tactical) mission along with institutional systems that cater to conspicuous short-term results" and that such a focus represents a major challenge to both current and future leadership. (Ulmer, p. 6) The title of the article sums up his theme: "Military Leadership into the 21st Century: Another "Bridge Too Far?" He believes that the basic leadership competencies have changed little in 2000 years and identifies these as integrity, high energy, courage and commitment to institutional values. He distinguishes between the leader’s need to achieve well-defined short-term goals and the need to improve the workings of the system. This distinction is a critical factor in the sustainment of the organization over the long term. He finds little emphasis on leadership challenges in the current military literature nor does he find a strategic design for changing the Army culture. Ulmer lays out a strategy for leader development based on best practices. These best practices are readily recognizable by industry, but may not be as familiar to the Army leader. His best practices include early opportunities for young officers to be placed in responsible positions of command, clearly defined leader behaviors, extensive use of developmental feedback and mentoring, actual measurement of organizational climate, leader education, revision of promotion criteria to a broader focus, and strong support for continuous learning. He stresses that the Army leads the way in providing formal educational opportunities for its personnel, but urges a shift from program content to a focus on actually "learning how to learn." He stresses that the Army needs to move from defining requisite leadership to a focus on developing and sustaining leadership. He concludes, "…Our challenge is to move into the 21st century with a good record of practice, not just a solid platform of theory" (Ulmer, p. 23). GEN (ret) Colin Powell spoke about his thoughts on leadership in a speech to the Sears Corporation in early 1999. His speech was entitled, "Great Lessons in Leadership". Among the lessons he cited was his belief that
Current Army leaders are recognizing past deficiencies in civilian leader development. In a memorandum dated May 10, 1996, the Chief of Staff of the Army, GEN Dennis J. Reimer, recognized the need to integrate civilians into the total force. He goes on to say,
He emphasizes to commanders that a well-educated, professional civilian work force is one of their most valuable assets and should receive the same level of focus as military personnel assets.. The schisms that often exist between the military leader and the civilian manager/leader will prove to be detrimental to mission accomplishment. The NMS recognizes the contribution of the civilian work force by stating, "From depot workers to senior-level leaders, they work together to perform functions ranging from policy direction to maintenance of our total force" (Chairman of the Joint Chiefs of Staff, p. 23). Once military commanders recognize that the total force concept includes civilians in the sustaining base, the competency development that civilians need will occur. The Changing Healthcare Environment Private sector healthcare trends will have great influence over the direction of the MHS. Russell C. Coile, Jr. (1996) is the preeminent healthcare futurist. In his article on management teams for the 21st century, he outlines trends that have applicability for private and public healthcare systems as well as military systems. He maintains that risk management will steer decision making in the future. The focus will shift to managing and integrating patient care across the entire continuum of care, a type of "cradle to grave" philosophy. He also foresees that clinical management will be decentralized in order to be closer to the patient care setting. Networks of collaborating providers and support companies will be linked contractually to provide a seamless healthcare system. He says that "managing a decentralized healthcare network will require a broader range of skills and expertise" (Coile, p. 12). He predicts that management structures will be flatter and broader. Of special interest is his prediction that clinical executives will play a larger role. Here the MHS leads the way. Until recently, all military treatment facility commanders were physicians. He sees these clinical executives as having advanced degrees in management or health administration in addition to advanced clinical degrees. This does not signal a diminution of the role of the traditional healthcare executive. Instead, the traditional healthcare executive will be called on to build trust between these diverse groups of key players, a skill that has been essential to the success of healthcare systems for many years. Their negotiation skills will serve them well as will their ability to build effective management teams. 21st Century Challenges for the Army Medical Department The misson of the AMEDD is to
The medical readiness mission is paramount, supporting not only the deployment of a healthy force, but also the ability to project a fit and healthy medical force into a theater of operations. This duality of mission is one that depends heavily on strong civilian leadership to support the provision of healthcare to the remaining beneficiaries during deployments. The entire Department of Defense is moving from one set of assumptions to another in light of the end of the Cold War era. In a 1997 article, COL (ret) Scott Beaty, former Director of the Army Center for Health Care Education and Studies (CHES) at Ft. Sam Houston, TX, examines the revolution in military medical affairs (Beaty, 1997). In previous scenarios, medical assets consisted of large field hospitals in the theater of operations whose mission it was to return soldiers to either to the combat environment or to CONUS for discharge to the VA system for rehabilitation. Today’s AMEDD has an increasingly mobile function, with theater operations restricted to "treat and stabilize" facilities and rapid evacuation to CONUS for more complex procedures. This change in focus was prompted by changes in the geostrategic environment, changes in medical practice, and the effects of information technology. In the medical arena, the "center of gravity" is no longer the large field-hospital-based specialized treatment center. One traditional principle of war calls for massing forces to project overwhelming superiority on the battlefield, with medical assets close by. Today’s technology, however, allows for increased dispersion of forces, which may mass for a specific purpose, then disperse upon mission accomplishment. The traditional field medical facility is incompatible with this mobile, agile force. The new mission is to establish three levels of care: Level 1 is comprised of "brilliant medics" who will do the minimum necessary to keep the soldier alive until he can be transported to the theater-level hospital (Level 2). This hospital will not follow combatant formations around the battlefield. Instead, it will remain within reach of air and ground transport. These hospitals will receive casualties, will do what is necessary to prepare the soldier for extended transport, and send the soldier back to Level 3 care in CONUS. This tiered system is designed to support a battlespace with low disease and non-battle injury rates. The unit commander, rather than the traditional medical community, will manage health promotion and wellness for his troops (Beaty, 1997). Many MTF military personnel fulfill a dual role under the Professional Filler System (PROFIS). These soldiers are the deployable force and participate in extensive training for deployment. When these field units deploy, the MTF must obtain backfill personnel, either from other MTFs, from the reserves, or from direct hire or contract with Managed Care Support Contractors (MCSC) in order to continue providing healthcare to the family members and retirees who depend on the MTF for their healthcare A core resource for this paper is an article by CDR John W. Sentell and Kenn Finstuen, which explores the executive skills and competencies that will be needed by hospital administrators in the U.S. Navy in the 21st century. Using a Delphi technique, the authors identified nine domains or major areas into which all competencies for health care administrators could be grouped. The domains of leadership, health care delivery, and cost-finance were rated by over 50% of the respondents as the most critical areas. Other domains included technology, accessibility, professional staff, marketing, quality/risk management, and ethics. This paper has broad applicability across the Military Health System (MHS), even though the respondents were all naval officers, in that the three services face almost identical challenges. Sentell and Finstuen also identified the rapidity of change across the MHS as a particular area of concern. A recent speaker likened the current OPTEMPO to "trying to change a tire while going down the road at 60 miles per hour." The authors conclude by identifying the top ten rated skills, knowledge, and abilities needed for future success. In rank order, they are:
In a related article that focused on behaviors in dental corps senior executives (Wineman, Mangelsdorf, and Finstuen, 1998), the authors also used the Delphi method to identify the attitudes and behaviors believed to be required to perform successfully in dental corps leadership positions. Honesty was the most cited behavior, but did not correlate significantly with the total score. The other behaviors that topped the list were integrity, accountability, dedication, caring and compassion, and strong interpersonal skills. The authors’ findings very closely parallel those of Sentell and Finstuen (1998). Military Treatment Facilities do not operate in isolation. The predominant theme across the MHS today is the necessity to function as an integrated healthcare system. Unity of command is a principle of war that applies equally to the peacetime provision of medical care. The recognition that the three services of Army, Navy, and Air Force share great similarities in their healthcare systems prompted the Department of Defense to unify the budgetary stream (though not the command and control functions) under a single entity, DoD Health Affairs, in 1992 (U.S. Department of Defense, 1992). The Assistant Secretary of Defense (Health Affairs) (ASD(HA)) was charged with the implementation and oversight of the TRICARE program as well as with healthcare policy development. The ASD(HA) is the principle staff assistant and adviser to the Secretary of Defense for all DoD Health policies, programs and activities. The service Surgeons General are still vested with the command and control of the medical force. However, to the extent that budget governs operations, the ASD(HA) is able to influence the day to day tactical and operational settings in which healthcare is delivered. RESULTS AND DISCUSSION The identification of competencies that will be required by tomorrow’s civilian leaders in the AMEDD is grounded in a basic set of assumptions. These assumptions are:
The latter assumption is not frivolous. These are turbulent times for the AMEDD and indeed for the entire military healthcare system. While some changes are clear, others are not. For example, funding for the MHS has been dropping steadily over the past five years. However, in FY 1999, the precipitous drop in allocated funds leveled off. It is not yet certain that this represents a trend. MHS leaders are told to continue to prepare for an austere future. Long term planning is difficult when funding is so uncertain in the out-years. Based on the literature that has been reviewed for this paper, ten core competencies can be identified as essential to the AMEDD civilian leader (in random order):
Individual characteristics also play a critical role for the successful civilian healthcare executive in the MHS:
TRICARE is our healthcare system, now and into the foreseeable future. This partnership with large civilian HMOs will continue to cause seismic changes in the medical departments of all three services. Very large amounts of money are at stake, in the billions of dollars over the life of the various contracts. Many civilian leaders in the AMEDD are ill-prepared to operate in this brave new world of high finance, although many are acquiring those skills out of necessity. Beneficiaries of the MHS are increasingly demanding a healthcare system that is personal, of high quality, and, most importantly, comparable to the private sector. The AMEDD has been slow to recognize this demand, having only recently implemented mandatory customer relations programs in MTFs. Again, civilian leaders will be required to be on the forefront of this trend, and will undoubtedly find themselves as the primary point of contact for training personnel. The inclusion of COL (ret) Beaty’s article on the changes in the concept of operations for medical forces in theater forms a foundation for the identification of core competencies for civilian leaders in the AMEDD. While civilians remain primarily in garrison, the potential exists that they could be deployed along with the medical forces. Civilians were deployed during Operation Desert Storm/Shield (ODS/S). GEN Reimer points out in his 1996 memorandum that civilian maintenance workers were essential during ODS/S (Reimer, p. 1). Civilian leaders will be the mainstay of the MHS during deployments. Maintaining continuity of leadership during the transition of personnel that occurs during deployments is a core competency. The concept of strategic agility is of particular relevance, as units may deploy with very little notice. In wartime, U.S. fixed military treatment facilities will play a key role by providing the most complex care to soldiers. Civilian leaders must have a firm grasp of theater operations in order to fulfill the AMEDD’s wartime mission. During times of deployment, brief periods of a leadership vacuum may occur as key personnel deploy. The ACTEDS process is a first step in the development of civilian leaders. However, when identifying the core competencies for civilian leaders, the methodology was to look backwards, not forwards. The focus was on the current, rather than future, knowledge, skills and abilities that are needed by executives in the AMEDD. Appendix A contains the competencies that were identified for the ACTEDS program. Fifty-seven individual competencies were included, grouped into thirteen domains. In most cases, the competencies were those that could be acquired through specialized training programs. Due to the structure of the ACTEDS, individual characteristics discussed above, such as commitment to public service, etc. were excluded from the analysis. It becomes clear, then, that, while competencies can be learned, individual values and attitudes cannot. This inevitably leads to a discussion of whether leaders are born or made. It is not the intent of this paper to resolve this dilemma, but rather to identify those variables that can be controlled, that is, the set of competencies that are pre-requisites to effective leadership. Current graduate healthcare administration programs provide a broad range of knowledge, skills and abilities. In fact, domains identified in Appendix A reflect the coursework that most programs offer. The list was intended to provide a structured framework for the advancement of personnel from entry-level positions to higher level executive positions. The groupings correspond very closely with those identified by authors Sentell and Finstuen (1998) which were previously discussed. Of special interest is that healthcare-specific competencies comprise a minority of the core competencies. Instead, the competencies that received higher value were those dealing with leadership, ethics, personnel management, decision-making, resource management and organizational behavior, competencies that are the focus of graduate programs in business administration. While it is arguably a better healthcare executive who has had healthcare-specific training, it is by no means a disqualifier for the placement of the MBA candidate in a healthcare leadership role. The ACTEDS process represented a fundamental change in thinking for those who were involved. Key positions were identified that had never been held by civilians before. Military participants often expressed their fears that the rest of the Medical Service Corps would find the concept of civilian leadership a threat to their careers. Indeed, this author faced such attitudes frequently during the course of the Baylor program. However, the reality is that survival of the AMEDD will depend on a particular synergy between military and civilian leaders. The demographics of current health systems specialists and administrators reveal an additional challenge. While the average age of full-time federal workers is 45.3, the average age of AMEDD Health Systems Specialists is 48 (52 for Health Systems Administrators). This means that the next ten years will see a number of these employees retiring, with a much smaller pool of replacements in the system. Also, the educational level of these workers can be broken down as follows: For Health Systems Specialists, the average educational level is two years of college with no degree. Health Systems Administrators, on average, have fours years of college with no degree. Until the AMEDD is able to train or recruit and retain college graduates, particularly masters-prepared administrators, the organization’s ability to survive in a managed healthcare environment will be severely limited. As a result, the AMEDD (and the other services as well) will be faced with stiff competition from the private sector for healthcare executives where salaries are much higher than federal salaries. Today’s healthcare executives have more formal education than their predecessors and demand higher salaries as a result. Other implications for the AMEDD include the absolute necessity to develop an employee-centered philosophy that enables each subordinate to achieve at his or her highest level. No longer do middle managers have the luxury of being able to "work around" the non-productive employee. Instead, the manager must work to garner loyalty and high productivity in an increasingly stressful environment. RECOMMENDATIONS FOR THE AMEDD In light of the foregoing discussion, the AMEDD is going to have to focus on recruitment of capable civilian leaders as well as upon the training and development of current employees. The federal civilian personnel system presents a number of challenges for ensuring that the right people occupy the right leadership positions. The AMEDD must develop a multi-faceted training and recruitment program. The ACTEDS is a beginning. The program identifies formal educational programs so that civilians can acquire the knowledge, skills and abilities that are necessary for advancement to leadership positions. However, it will be several years before the benefits of this educational system can be realized. Today the focus must be on recruitment, how to attract the best and brightest from the private sector. Pay incentives in the form of retention bonuses and quality step increases must become more prevalent. Then, retention initiatives must focus on developing the competencies that are required for tomorrow’s AMEDD. As civilians increase their value to the AMEDD, they will find enhanced job satisfaction as their reward, but only as long a military leaders acknowledge the essential role that civilians will play in the future. The current job standards for health systems specialists and administrators were developed in 1978, when the healthcare system was fundamentally different than it is today. These standards must be updated, since they form the basis for job analysis and grade determination. The antiquity of these standards does not allow a true assessment of grade level (and, thus, compensation) for today’s healthcare executive. It must be pointed out that these standards were developed primarily for the Veterans Administration, where civilians do have the ultimate decision-making authority. Today’s AMEDD continues to be structured so that military officers are the decision makers, although this is certain to change in the future. Until civilians are granted more decision-making authority, the civilian healthcare executive will operate under referent, rather than actual, power. Recruitment must focus on those competencies that will be the most likely to add value to today’s military healthcare system. Restrictive hiring practices must be replaced with more liberal guidelines for the skill set that healthcare administration requires, to include those with business backgrounds as well as those with healthcare backgrounds. The current practice of allowing experience to substitute for education will eventually prove to be destructive to the system. Many senior health systems specialists and administrators have no formal education in the healthcare field (nor, in some cases, in any other field, for that matter). A commitment must be made to require every civilian leader in the AMEDD to have completed a formal course of instruction that will prepare him or her for a leadership role. While adequate to meet the needs of today’s AMEDD, the competencies developed for the ACTEDS must continue to be refined to keep pace with changes in the MHS. During the initial development of the ACTEDS, little emphasis was placed on the military readiness facets of the Department of the Army civilian leader. The future may depend on the civilian leader’s ability to serve with a forward-deployed force. Personnel shortages may dictate that civilians assume leadership roles during times of transition. CONCLUSION It will be essential for AMEDD leaders from the Surgeon General on down to acknowledge that military medicine has become a partnership, a joint force consisting of military personnel, civilian federal workers, and civilian contractors. The challenge is to meld conflicting goals and attitudes into a single coherent healthcare system. Civilians, for their part, must continually reassess their role in that system and work towards acquiring the competencies that will ensure excellence in healthcare for all beneficiaries of the Military Healthcare System.
REFERENCE LIST
APPENDIX A
COMPETENCIES FOR HEALTH SYSTEM ADMINISTRATOR AND HEALTH SYSTEM SPECIALIST
DECISION MAKING 1. Ability to identify and evaluate alternatives, choose the best alternative and implement the chosen alternative. 2. Ability to synthesize new approaches using existing information and data. COMMUNICATION 3. Ability to effectively exchange ideas and transmit information in all directions. 4. Ability to communicate through oral, written, and visual methods. INFORMATION MANAGEMENT 5. Ability to collect, analyze, process, and deliver information to meet requirements. 6. Knowledge of forecasting techniques and simulation models. GENERAL MANAGEMENT 7. Knowledge of statistics, analytical aids and methodology by which information is obtained, organized, arranged, and evaluated using quantitative methods. 8. Knowledge of the long range, comprehensive and structured decision processes within an organization. 9. Knowledge of workload management systems and principles of productivity. 10. Ability to analyze productivity measures and to recommend improvements. 11. Ability to assign work, evaluate employee performance, manage staffing and scheduling, and write job descriptions. 12. Ability to select personnel, administer progressive discipline to employees when needed, and mentor employees. HEALTH LAW AND POLICY 13. Knowledge of Federal, state and local as well as Department of Defense, service, medical department and DOD Health Affairs policies that impact healthcare organizations. 14. Ability to implement and oversee compliance programs. 15. Knowledge of tort and criminal jurisprudence in order to structure risk management programs. 16. Knowledge of policies that govern the conduct and privileges of the medical staff. 17. Knowledge of the process by which medical staff bylaws are developed and amended using Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) requirements. 18. Knowledge of the evaluative process performed by accrediting organizations that ensures the delivery of high quality medical care, such as JCAHO and the College of American Pathologists, (CAP). 19. Knowledge of contract law and contracting procedures in the private sector as well as in the government. RESOURCE ALLOCATION 20. Knowledge of and ability to utilize analytical techniques to monitor and evaluate the allocation of funds, to include maintaining financial records, controlling financial activities, identifying deviations from planned performance, and forecasting future funding requirements. 21. Ability to develop budgets, and determine the optimal allocation of monetary resources needed to support programs. 22. Ability to perform make/buy and cost benefit analyses. 23. Knowledge of the process of acquiring and retaining human resources. 24. Knowledge of materials management and medical logistics functions, including the management, cataloging, requirements determination, procurement, distribution, maintenance, and disposal of supplies and equipment. 25. Knowledge of upkeep and maintenance of real property, such as a building, structure, or utility system. 26. Ability to ensure compliance with regulations such as Occupational Safety and Health Administration (OSHA), fire codes, American with Disabilities Act (ADA). 27. Knowledge of the financing of military and civilian healthcare, healthcare economics, reimbursement methodology, capitation financing, and the healthcare insurance industry. PATIENT RIGHTS 28. Knowledge of those moral principles and laws that govern patient autonomy and self-determination. 29. Knowledge of the principles of informed consent and legal implications of failure to obtain informed consent. 30. Knowledge of the ethical and legal principles governing the patient’s right to die; to include do not resuscitate (DNR) orders, advance directives, living wills, and the legal and moral implications of the removal of life support systems. 31. Knowledge of the ethical foundations that govern clinical investigation, to include the use of human subjects and informed consent. ORGANIZATIONAL BEHAVIOR 32. Knowledge of the behaviors that define interaction among members of an intact group, to include team building, empowerment, individual and group responsibility, and motivation to enhance group productivity. 33. Knowledge of individual behavior and performance, with focus on motivation, retention, personal growth and development, and how individuals contribute to the organization. 34. Knowledge of the design and analysis of organizational structures (e.g., hierarchy, matrix, and teams) and how they affect the operation of an organization. 35. Knowledge of collective bargaining and the impact of the negotiated agreements on the healthcare organization. 36. Ability to recognize and implement fair labor practice, effective interactions with union officials, and effective management of grievances. 37. Ability to employ techniques such as negotiation and active listening to resolve conflicts. 38. Ability to introduce change or technical innovation in the workplace. HEALTH CARE DELIVERY 39. Knowledge of the on-going, iterative process used to assess and monitor the organization’s ability to meet standards of care. 40. Knowledge of and ability to conduct an on-going assessment of patient care, management of risk, the assessment of provider competencies and performance, the process of utilization review, and the implementation of corrective and follow-up actions, where indicated. 41. Knowledge of how trends in the population disease states effect the delivery of health care and the utilization of health care services. 42. Knowledge of the methodology used to assess the quality of patient care through comparison of actual versus expected outcomes. 43. Ability to apply the results of outcomes research to the improvement of the operation of the healthcare system. 44. Knowledge of practice guidelines. 45. Knowledge of wellness and health promotion programs. 46. Knowledge of the principles of demand management and disease management. 47. Knowledge of medical terminology. 48. Knowledge of the principles and philosophy of managed care and alternative delivery systems. 49. Knowledge of healthcare marketing principles. LEADERSHIP 50. Ability to work with and through others to accomplish the goals of the organization, including the formulation and communication of the strategic vision. 51. Ability to encourage, guide, empower and assist others in the accomplishment of organizational goals and mission. 52. Ability to lead a diverse workforce. MILITARY MISSION 53. Knowledge of the integration of the medical mission into the larger mission of the Army and its line units. PERSONAL AND ORGANIZATIONAL ETHICS 54. Ability to articulate a personal moral code that defines how the individual will operate within the context of the larger ethical framework of the organization. PUBLIC AND MEDIA RELATIONS 55. Ability to shape public opinion and perceptions by effectively delivering the organization’s message through local media. 56. Ability to effectively communicate ideas and concepts to others with different technical or experience backgrounds. 57. Ability to speak to audiences from varied backgrounds, such as the military chain of command, health care professionals, military family members, internal staff, professional groups, community organizations and others. |