Kathleen D. Sanford

At a Glance

To fill strategic positions in their organizations with top talent, nursing and finance leaders can:

  • Start by determining which jobs are truly "mission critical"  
  • Align the individuals in these positions on strategic teams  
  • Strengthen partnerships between key clinical leaders, such as the CMO and CNO  

Healthcare leaders are no strangers to strategic planning. They have developed visions. They have analyzed strengths, weaknesses, opportunities, and threats (SWOT). And they have allocated resources to best pursue their goals. However, strategic planning is about to become more challenging. Anticipating major payment changes in the near future, hospital leaders are struggling to maintain positive margins at the same time they must boost their strategic capabilities.

One of these capabilities is the efficient deployment of human resources. That's why most hospitals have a plan for their workforce development, although they may call it by different names. Some hospitals may refer to it as a "people strategy," while others may use another trendy title.

Traditionally, we hospital leaders have been eloquent about the need to hire and retain only "outstanding" people who are "team players." The current environment, however, calls on us to question whether this is a fiscally sound, or even attainable, goal. Can we realistically expect that we will be able to hire the "best and the brightest" for every job? Not likely. However, what we can, and must, do is identify, hire, and nurture top-of-the-line talent for the most critical jobs-those who could mean the difference between our organizational success and failure.

The idea that hospitals should strive to place only exceptional performers in every job is problematic for a number of reasons. It assumes, for instance, that:

  • Everyone agrees on the definition of outstanding as it applies to each position
  • There will always be enough skilled people available for hire in every job market to allow an organization to select only the top performers
  • A hospital will be unable to meet its goals if it does not have the "cream of the crop"-the equivalent of a straight-A student-in every job

Key Questions Around Competence

In an environment of constrained resources, strategic planning should include an examination of these assumptions. Can we hire or develop only outstanding performers in every job, particularly with projected clinician shortages? Is every position equally important to attain our goals? If not, how do we determine which positions and which teams should be a priority for development? Given our limited budgets, should we prioritize our development dollars by position?

Appropriate education and training, as well as clear expectations and standards, can help all people improve their competence. However, with the rapid change in our industry, just maintaining competence requires continual education for most of the workforce. Some of that education is required by regulatory or accrediting bodies, which may not be as focused on strategic goals as is the hospital itself.

Hospitals should invest in their workforce simply to ensure they have competent individuals, not valedictorians, in each job. Outstanding individuals exist in every type of job, but that does not mean that each job requires every individual to perform at a higher level than his or her competent peers. Some expectations for job competence are reasonable for all employees, and others are not. For example, it is reasonable to expect all employees in the organization to show competence in customer service by following hospital scripts when answering the phone. And it is also reasonable to expect all nurses to be competent in placing an intravenous (IV) line according to an evidence-based procedure. But only a few nurses may be able to insert "difficult" IVs in veins that the majority of their peers can't "hit," and the fact that these nurses possess this exceptional IV ability does not mean their colleagues are incompetent.

That's not to say that there are no specific jobs that demand only excellence. The challenge is in knowing which jobs truly require only the most talented people if the hospital is to excel. Part of the organization's strategy should be to identify those positions.

Identifying Strategic Positions

In their book The Differentiated Workforce: Transforming Talent into Strategic Impact (Harvard Business School Publishing, Boston, 2009), authors Brian Becker, Mark Huselid, and Richard Beatty explain that a limited number of an organization's positions "have significant impact on one or more of the firm's strategic capabilities." These jobs are "characterized by a significant amount of variability in the performance of employees holding them." In other words, a large gap exists between high and low performers.

Although scarcity is not a determinant of strategic value, top talent for strategic positions is difficult to attract and retain. According to the authors, significant consequences to an organization can occur if a person who is not "top talent" is hired for and retained in a job that requires an "A" performer.

The idea of filling strategic positions with top talent is not new. One organization that has long practiced workforce differentiation is the U.S. Army. As officers move up in rank, they gain more control over assets essential to the success of military strategy. Promotion is strongly influenced by the officer's efficiency report, or annual evaluation, which is designed to evaluate strategic abilities needed by the Army. Not every officer will be promoted to the next level (there aren't very many generals, and there are many more lieutenants than colonels). Part of the evaluation is to compare each officer with his or her peers so the most capable will move into more strategic positions. Some years ago, this became a truly forced ranking, meaning each superior officer could place only a limited number of subordinates in "top box" ratings.

Strategies in the civilian world are different from those in military organizations. Becker, Huselid, and Beatty note that strategic positions are not necessarily the "top" positions in a hierarchy but exist at all levels of an organization. The authors caution that these jobs should not be confused with important positions. In health care, every job is important to the success of the organization or it would not exist.
Hospital leaders expect competence from every employee and provide education to help ensure this expectation is met.



However, some jobs have an inordinate influence on the success of a hospital or health system. These jobs also may differ from organization to organization, depending on the organization's strategic plan, but certain positions are likely to be more critical strategically than others. These positions include world-class clinicians in the organization's top service line, the financial leader responsible for investing the hospital's funds, (especially if much of the organization's income comes from investments rather than operations), and others responsible for the successful implementation of a strategic objective.

To be successful, each hospital or health system must determine which jobs are strategic positions in its own organization. As strategies change, the strategic job list may change as well.

When Talent Drives Strategy

At Denver-based Catholic Health Initiatives (CHI), we have instituted a process for identifying these "mission-critical" jobs. Hospital leaders have designed a systemwide talent management program to ensure that top talent is hired and retained for specific strategic positions. We deem a position to be strategic based on its significance for improving finances (by substantially enhancing revenue or reducing costs) and its impact on CHI's patients and communities.

To help determine the most critical positions at CHI, we've identified six capabilities essential to the organization's strategic plan. These capabilities are clinical excellence, operational excellence, strategic growth, transference of the ministry into the future, improvement of community health, and physician engagement.

At CHI, hospital leaders use these six capabilities as a basis to determine which job titles are most critical to advance a particular goal. This also assists the organization in assessing which individuals should be a priority for strategic team building. The rationale is simple: When those who are most important to the success of a particular strategy are working in sync, an organization is more likely to meet its goals.

Some positions, such as the CEO, CFO, CMO, CNO, and practice management leader, have a substantially higher impact on multiple strategies than other positions do. Many of our strategies depend on strong clinical leadership. At CHI, one of our first team building priorities is to strengthen CMO and CNO partnerships. Both leaders are members of clinical professions with strong experience and knowledge of patient care, quality, and safety. However, these leaders come into management with different knowledge and skills. For example, an individual CMO may have exceptional talent in understanding the medical profession and medical care, as well as the realities of working in an outpatient arena. On the other hand, a CNO may have more experience in operations, having progressed from staff nurse to middle manager to nurse executive. The CNO may understand nursing, as well as how to get things done in a complex organization. For an organization to meet the clinical goals that support its strategies, it needs the coordinated talents of both leaders.

An additional strategic position is the CFO. Besides having outstanding financial skills, top talent CFOs have exceptional interpersonal abilities. They are able to explain the organization's strategies to diverse stakeholders as well as communicate with, and sometimes teach, nonfinancial leaders about the connection between finances and continuation of the mission. These leaders partner with their clinical and operational peers to produce the value that results from high-quality care and high-quality financial management.

A Team Approach to Talent

Clinical leaders are ideal for team building because of their strong impact on a system's strategic capabilities, says Lou Forbringer, CHI vice president for strategic talent management. "Successful facilities have CNOs and CMOs who work well as partners," he says. "If the CNO and CMO do not effectively collaborate, the probability of achieving the desired clinical and financial outcomes in our facilities is greatly diminished."

At CHI, the chief clinical officers' development program involves individual leadership skills assessments, followed by individualized management and leadership education, with special attention to cultivating the CNO-CMO dyad. This end is accomplished through shared formal educational experiences, joint responsibilities for projects, and open conversation about the two professions, which may be facilitated by a coach. Building strategic teams of any size requires that team members understand each person's role and responsibilities, and how his or her work enhances the rest of the team. Hospital leaders should not assume that everyone has the same picture of what a collaborative partnership looks like. Part of team building is to develop a shared understanding of actions, behaviors, and effective communications that are essential to true teamwork.

Although CHI is currently focused on nurturing CMO and CNO partnerships, system leaders will continue to focus on developing other positions, with an emphasis on building collaborative skills. One important triad to develop will be among the two clinical leaders and the organization's CFO. It will take the three of these strategic positions to ensure that the organization maximizes value through care quality and financial excellence.

Kathleen D. Sanford, RN, DBA, MA, FACHE, is senior vice president and CNO, Catholic Health Initiatives, Denver (kathleensanford@catholichealth.net).


A Final Word on Top Talent  

Good leadership requires collaboration throughout the organization, just as good management demands that all employees are competent, and that each has an opportunity to excel in his or her job. Outstanding individuals exist at every level in an organization. However, not enough resources-human or financial-exist for every hospital or health system to hire and retain only top talent in every job. For hospital leaders, identifying and developing the individuals and teams with the highest degree of influence on the successful implementation of strategic plans is not just good strategy. It is good stewardship.

Publication Date: Wednesday, June 01, 2011

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