by Elizabeth Forrestal, PhD, RHIA, CCS, FAHIMA
Leaders have the responsibility to develop leadership in their departmental members. Leadership capacity is needed so that health information professionals will be able to successfully respond to the constant changes in the healthcare environment. This article demonstrates how leadership can be modeled and developed through the redesign of jobs in departments of health information services.
Keywords: leadership, health facility administrators, organizational innovation, job description
In the dynamic and changing healthcare sector, two current issues for health information leaders are building leadership capacity and sustaining efficient organizational design in health information services (HIS) departments. These issues are explored in the literatures of organizational behavior and organizational theory through the lens of leadership.
McConnell writes that “leadership is either intuitive or gained through experience. The best leaders strive to develop the leadership skills of their teammates so that the success of the team does not depend on a single person.”1 How do today’s directors of HIS departments develop the leadership skills of all members of their departmental team (managers, supervisors, employees, and themselves as directors)? Experts propose that leadership can occur in performing managerial activities related to health information management (HIM).2-5
This article proposes that leadership skills may be developed in the course of performing the managerial activity of job redesign. Combining the development of leadership skills with job redesign is particularly timely because experts have predicted approximately 25 new roles for health information professionals.6–23 Thus, leaders can act synergistically and efficiently by conducting job redesign for these new roles and concomitantly developing leadership capacity.
The article first provides preliminary groundwork in the form of indicators that signal that job redesign may be warranted. Then, the main content of the article demonstrates how leadership skills can be developed during job redesign. Examples of concrete applications are provided. Finally, several tables concisely present information on the factors, primary data collectors, and tools of job redesign.
Change is constant in the healthcare sector, and HIS departments are not exempt from this constant change. For example, members of HIS departments have seen implementations of electronic health records (EHRs), enactments of new regulations, revisions of multiple payment systems, and refinements of policies and procedures to protect the privacy and security of records and systems. Changes in the sector, in healthcare organizations, and in the HIS departments themselves result in changes in the work of these departments.
Need for Job Redesign
Changes in work include the nature of work, its flow and scheduling, relationships among workers, technologies, policies and procedures, volumes of tasks, and types of tasks. Changes in work can result from events or from changes in the pace of tasks or services. The end result, however, may be an alteration of work and jobs to the point of distortion, fragmentation, and overload. In the face of these misalignments, it is the responsibility of management to reorganize work and redesign jobs for maximum effectiveness and efficiency.
Events that change work may be industrywide or department specific. For example, identity theft is an industrywide event. Thus, protecting identity-specific information and preventing identity theft is necessary across the nation and in all sectors of industry. On the other hand, creating a mechanism that allows coders to work from home is a department-specific event.
Additionally, time is an element of change because the pace of changes affects the work of HIS departments. For example, some changes are incremental. A prime example is the slow and gradual increase in the volume of e-mail. Responding to the current volume of e-mail in the morning and throughout the day may not be factored into the task and time allocation of jobs. Yet, responsiveness is a key expectation of the “service orientation” of many healthcare enterprises. On the other hand, an example of a sudden change is the implementation of the Recovery Audit Contractor (RAC) program under Section 302 of the Tax Relief and Health Care Act of 2006. To HIS departments came the new tasks of receiving, reviewing, coordinating, and tracking responses and appeals to the queries and denials of the RACs.
Over time, changes caused by new events and their pace modify a department’s work and jobs. In the case of gradual and incremental change, this modification may be almost imperceptible to health information leaders—particularly as they are caught up in immediate and pressing tasks.
As previously stated, experts predict many new roles and, correspondingly, new functions for health information professionals. These roles and functions are emerging from the implementation of EHRs and their meaningful use; from adoption of other health information technologies; and from future organizational needs related to project and financial management, globalization, and clinical terminologies and classification systems. As these roles are initially established in HIS departments, they are typically added to the set of tasks—the job—of a current employee. This addition represents a familiar past practice. For example, the roles of privacy officer and RAC coordinator were added to the role of director of HIS services. While a common past practice, this multiplication of roles may result in fragmentation. These new roles alone demonstrate the need for job redesign.
Indicators Warranting Monitoring
Experienced leaders monitor indicators that signal the need for job redesign. These indicators exist at the levels of the sector, organization, and employee.
At the level of the healthcare sector, changes occur on an ongoing basis because of socioeconomic events, cultural shifts, new technologies, new or revised regulations, and new or revised accreditation or certification standards. One technological change at the sector level is the transition from a paper-based environment to an electronic environment in healthcare. This change not only alters the nature of work but also affects the economy, regulations, and accreditation standards.
Indicators of organizational changes include enterprise-wide initiatives and HIS department initiatives. At the organizational level, changes may occur in goals, in the patient or client population, or in the service mix. For example, an organization may decide to focus on improving the quality of its services, reducing its costs, or both. The population around a healthcare organization may change. The suburb may gradually age from growing families to empty nesters and the elderly. These demographic changes affect the case mix and the HIS department’s work by increasing the number of Medicare patients or by requiring specialized knowledge in coding or registries. Other changes that affect the organization include regional health information exchanges, state registries for various conditions, and relocations of military bases. These events may affect the services and products of the healthcare organization. As the changes occur, managers and directors may assign tasks to employees. Over time, jobs may be significantly altered.
Employees’ perceptions of the work environment and their jobs are another set of indicators that may signal the need for job redesign. Typical of these indicators are declines in employees’ performance or motivation. Examples related to performance include careless errors, minimal or low productivity, and diminished quality. Declines in motivation may be demonstrated by changes in employees’ work habits and personalities, such as absenteeism, tardiness, a lack of collegiality and professionalism, negativity and dissatisfaction, stress, and burnout. At the department level, increased or high turnover may be an indicator.
Leading in a Job Redesign
Gardner states that there are nine tasks of leadership.24 These tasks are envisioning goals, affirming values, representing the group externally, serving as a symbol, achieving a workable level of unity, explaining, motivating, managing, and renewing. In this section, these tasks will be linked to various activities in job redesign. Ways to develop leadership skills in all team members include modeling leadership behaviors and creating opportunities for team members to emulate and practice those behaviors.
Envisioning Goals and Affirming Values
Envisioning goals is an imperative given the constant change in the healthcare sector. As the sector changes, organizations’ goals must change to match the new environment. Concomitantly, the changes in the sector’s environment also alter the organization’s or, in our case, the department’s work. Goals and work have a symbiotic relationship. Work reflecting all of a department’s goals is the overall effort to produce the desired results.
Together, all members of the departmental team (directors, managers, supervisors, and employees) can inspect and revise the mission, vision, and strategic goals of the department. This exercise prepares members of the team to think strategically. Members of the team can conduct environmental scanning, which is a review of environmental factors that may affect the department’s work. The department’s mission, vision, and strategic goals may need to be refined as a result of the environmental scanning.
During envisioning, experienced leaders should encourage all team members to think globally and beyond their individual functions. As the American Health Information Management Association (AHIMA) Core Model shows, the work of HIS departments is more than ensuring authenticated signatures or “being custodians of health records.”25 Instead, HIS departments are responsible for the stewardship and governance of health information.26 In stewardship, health information professionals manage health data and information as an ethical trust.27 As stewards, health information professionals provide quality information and knowledge that support clinical and administrative decision making. In governance, they develop and maintain the infrastructure to support stewardship.28 The governance infrastructure undergirds stewardship with requisite accountability. Both stewardship and governance are needed components.
Once all team members have identified the overarching goals, they can frame their own jobs in terms of these goals. Each employee’s connections to the mission, vision, and goals through their jobs must be made explicit. Aligned individual functions collectively achieve the department’s work. Misalignments must be corrected through job redesign.
AHIMA lists four organizational values: quality, integrity, respect, and leadership.29 The Mayo Clinic lists eight values: respect, compassion, integrity, healing, teamwork, excellence, innovation, and stewardship.30 All team members (directors, managers, supervisors, and employees) should reflect on their departments’ values and the concordance of their departmental values with the organization’s values. Additionally, values may change over time. More importantly, whatever the values, all team members should assess whether the actions of departmental members actually represent those values. A mismatch between stated values and behaviors, or a lack of authenticity, breeds cynicism, insincerity, and venality. Finally, by acting in accordance with values, experienced leaders provide positive models that all team members can emulate. Experienced leaders affirm values by living them.
A recent AHIMA practice brief highlights the importance of envisioning and affirming values. The practice brief describes the frequency of mergers and acquisitions among healthcare organizations.31 These mergers and acquisitions occur because leaders of the respective organizations believe that they can achieve operational cost savings through streamlining and thereby improve their competitive positions.32 To achieve these operational cost savings, organizational administrators often consider merging functions and departments. For example, a potential merger could take place in which a community hospital is absorbed into an academic health center. Subsequently, the organizational administrators could consider merging the HIS departments at the two sites. The community hospital may have had mercy as one of its values; correspondingly, its HIS department had mercy as a value. The academic health center may have had innovation as one of its values; correspondingly, its HIS Department had innovation as a value. Upon absorption into the academic health center, directors and managers of the former community hospital’s HIS department should take the following actions:
- Ensure that each of them can state the values of the former community hospital and the values of the new merged entity.
- Ask each departmental member to list departmental values of both entities.
- Have supervisors correlate the two sets of values.
- Have supervisors lead unit (section) meetings in which they and their line employees document how their tasks relate to the values of the new merged entity. For example, the HIS department at the academic health center is known for its cutting-edge clinical health record and integrated decision support systems. Supervisors and line employees may decide to emphasize their innovations in service delivery.
- Conduct a leadership meeting at which the documents from the unit meetings are integrated.
Once the values are established, the directors, managers, and supervisors can begin the collaborative task of writing the mission, vision, and goals for the department. In terms of building leadership skills, the supervisors have now led one aspect of strategic planning.
Representing the Group Externally, Serving as a Symbol,
and Achieving Workable Unity
Job redesign is not the only potential outcome when misalignments between the environment and work are determined. Job redesign is one of four different levels of reorganization that align a department’s activities with organizational goals. In terms of scope, job redesign is the least extensive. Progressively more extensive are work redesign, restructuring, and re-engineering (see Table 1). Concomitantly, as more extensive realignments are indicated, increasingly higher levels of administration are involved. For example, restructuring and reengineering are typically the initiatives of upper administration. However, in these more extensive realignments, leaders of HIS departments can model appropriate interactions with upper administration. It is their role, or their job, to represent the interests and functions of the departmental members to groups and administrators outside of the department. Eventually, all members of the department should be able to serve as departmental champions, representing the interests and functions of the department to other departments and staff members, many of whom may be unaware of the contributions of the HIS department to the success of the organization.
While representing the group to other organizational departments and their staff members, leaders also serve as symbols. They symbolize all the employees in their departments, and they symbolize their profession. In this role, leaders’ grace, diplomacy, and knowledge can positively influence the organization’s members’ perceptions of both the HIS department, collectively, and its members, individually. Also, importantly, leaders symbolize professionalism and competence to everyone in their HIS department. As an internal symbol, leaders can guide and inspire their department’s members. The value of symbolism cannot be overstated.
Finally, directors, managers, and supervisors must deal with conflicts to achieve a workable unity. Conflicts occur, both externally and internally, because resources are limited. Departmental heads compete with one another in order to garner resources needed for the optimal functioning of each of their departments. Leaders of HIS departments must engage in this competition to gain resources needed to advance the work of their department. As Gardner writes, “one could argue that willingness to engage in battle when necessary is a sine qua non of leadership.”33 Intradepartmental conflicts may also occur as unit heads within the department compete for limited departmental resources. However, the goal of all competitors should be a healthy competition that builds mutual respect. Thus, it is the task of leadership to productively resolve conflicts, not to avoid them.
Conflicts and competition do occur within organizations; directors, managers, and supervisors should be prepared to secure the resources of the HIS department during these conflicts and competitions. Terms used to describe organizational conflict and competition include departmental politics, divisional rivalry, or turf wars.34 For example, a director and privacy officer of a large health center’s HIS department described competition during the implementation of an EHR system. The application team and the information technology (IT) team “competed for resources.”35 In an example related to job redesign, the job redesign may show that upgraded employee skills are needed and, correspondingly, upgraded job classifications and associated salaries are necessary. The HIS department must then compete for an increased personnel budget to support the upgraded job classifications as identified during the redesign. To build the abilities of representing the group externally, serving as a symbol, and achieving workable unity, directors may assign their managers and supervisors the task of exploring their feelings about engaging in departmental politics to increase the HIS department’s personnel budget. The process might include the following steps:
- Directors begin an open discussion about departmental politics in a web-based collaborative environment that allows file sharing. An opening scenario could be posted about a department head who avoids departmental politics because she believes that the allocation of organizational resources should be based on fairness and merit.
- Assistant managers and supervisors share three to four sentences that explain their feelings about the fictitious department head’s beliefs and about departmental politics.
- Directors and managers share experiences in which they garnered resources through co-option, competition, and collaboration. They also share the potential negative consequences that would have occurred for the HIS department had they not garnered those resources.
- In the course of the discussion, the statement should be made that leaders have the responsibility to put the needs of the HIS department before their own personal squeamishness and reticence.
- If additional work is needed, 10 to 15 minutes could be carved out of a team meeting to conduct role plays. In the role plays, the assistant managers and supervisors try “standing their ground” when confronted by vociferous opposition.
While this example described interdepartmental conflict and competition, directors can also take this approach to identify situations of intradepartmental competition between and among units within the HIS department. The focus should be on producing mutually beneficial solutions and on sustaining healthy relationships.
Leaders explain to departmental members that job redesign is an expected and necessary activity stemming from changes in work. They clarify that the job redesign is an ongoing process. They assure the departmental members that job redesign is not a negative reflection on the department or on its leadership and employees.
To reassure employees that job redesign is not a negative reflection on them personally, departmental leaders should explain the extent of change within the field of HIM. For example, the president of AHIMA wrote that “the migration to EHRs changes the design and operations of traditional” HIS departments.36 Additionally, departmental leaders may want to emphasize the great degree of change within the field of HIM. Again, for example, the president of AHIMA stated that “every HIM function performed to support the paper record today must be re-engineered.”37 One way to describe the sweeping changes in the field is to share select articles on the transformation in HIS departments, as follows:
- Directors may share with managers and supervisors articles about managerial issues in an e-HIM environment, such as virtually managing employees.
- Managers and supervisors may share articles specific to their units’ employees, such as sharing articles on computer-assisted coding with coders, sharing articles on telecommuting with release-of-information staff, and sharing articles on document imaging with filing and records staff.
In fact, it has been predicted that once EHRs become widespread, many HIS departments will become virtual.38 Thus, job redesign must be expected to keep pace with this revolutionary change.
The complex environment of healthcare and HIS departments can create situations that may decrease employees’ motivation. These situations represent inherent conflicts between aspects of the structure of jobs.
The structure of a job includes the following:
- Types of tasks that the job encompasses (unit/custom, mass/batch, process/routine)39
- Nature of the job (serial, parallel, unit assembly)
- Characteristics (control or autonomy, task identity, cognitive demand, responsibility, social interaction, variety, feedback)40, 41
- Demands of the job and role (quantitative work overload, qualitative work overload, role ambiguity, role conflict)42
Conflicts within the structure of a job undermine employee satisfaction. For example, responsibility and control are related to employee satisfaction. However, by their very nature, some jobs are sequential, and thus the timing of these jobs is out of the employees’ control and is dependent upon the timing of other employees’ achievements. Jobs on the “boundaries” that require interaction with other departments and units are prone to role ambiguity. It is unclear where one employee’s job stops and the other employee’s job begins. Yet, in the complex environment of healthcare organizations, these boundary-crossing activities are common. Directors can encourage managers and supervisors to carefully scrutinize the structure of jobs to eliminate sources of conflict and to increase characteristics associated with employee satisfaction (see Table 2). Thus, directors, managers, and supervisors can optimize employee motivation by structuring jobs to build employee satisfaction.
The environment of HIS departments will be fluid and dynamic as EHRs are implemented. Many new roles will be introduced and established. Concomitantly, the number and structure of other jobs will be altered. For example, clerical jobs will be “notably reduced,” and higher analytical and qualitative jobs will increase.43 This environment demands attention to job redesign.
As one type of job redesign, tasks that involve abstracting, assembly, and quantitative analysis may be automated.44 In a paper environment, these tasks are considered “mass/batch” (see Table 2).
- As these tasks are automated, all team members (directors, managers, supervisors, and employees) should review the structural factors of jobs and their corresponding potentially positive and negative aspects (Table 2).
- As a means to build leadership skills, directors and managers may assign supervisors and their employees to write proposals for their redesigned jobs. In the redesign of the automated job, all team members should strive for a balance among the type of task, the nature of the job, and the characteristics and demands of the job and role. For example, for an automated quantitative analysis job, team members may decide to seek a balance among specialization and efficiency, variety, control, and task identity.
- Directors and managers will review the proposals for function, logistics, and workflow. Results of this review will be shared with supervisors and employees. Collaboratively, all the proposals can be reworked until, in aggregate, they achieve the work of the department.
- As an additional leadership-building exercise for supervisors, directors and managers may share with supervisors insights on how the positive aspects of factors related to organizational theory and bureaucracies can be balanced by their equally negative aspects (see Table 3). For example, on the positive side, specialization and standardization promote efficiency. On the negative side, these factors may result in tedious, repetitive tasks. Therefore, in terms of outcomes, rather than the expected increased productivity, these factors may actually result in boredom, inattention, fatigue, stress, and decreased productivity.
The use of EHRs may also result in having only one or two employees on site in the department because the number of employees working remotely from home is increased.45 In this situation, managers and supervisors must consider how one or two employees can cover the needs of on-site customers.46 The following exercises are suggested to build leadership capacity:
- All team members (directors, managers, supervisors, and employees) should list the functions that on-site customers will need. In the redesigned job, these functions must be covered.
- All team members should review the skills and requirements needed to perform these functions. Traditional motivational actions may be one way to prepare current workers for these future expanded jobs. Commonly used motivational actions are job enlargement, job enrichment, and job rotation (see Table 4). These commonly used motivational actions also have the benefit of building departmental capacity (more employees trained for tasks and trained for supervision).
- Directors, managers, and supervisors should monitor employees’ stress (see previous section on employees’ perceptions). Both job enlargement and job enrichment add tasks, yet most employees mention that work overload is their stressor. In the fluid and dynamic environment of HIS departments in transition to the use of EHRs, this overload may be especially exacerbated. Thus, rather than increasing motivation and building capacity, these actions may actually tax employees beyond their limits. Therefore, these actions are not universal solutions. These traditional motivational actions must be balanced with the specific situation in the work site.
Specifically to develop the leadership skills of managers and supervisors, experienced leaders can demonstrate the cross-disciplinary integration of organizational theory (structure) and organizational behavior (motivation and human resources).
- Experienced leaders and novice managers and supervisors can work through a scenario in which the indicator of employees’ perceptions has revealed boredom, careless errors, tardiness, absenteeism, and low morale.
- Experienced leaders ask the novice managers and supervisors for potential solutions.
- From the structural factors of jobs (see Table 2), a novice manager or supervisor could suggest the strategy of “increase variety.”
- An experienced leader could respond that this strategy is the equivalent of decreasing specialization (see the list of hard factors of organizational theory in Table 3). Both disciplines provide caveats: increased variety could result in fragmentation and decreased productivity. Another team member could suggest “job enrichment” (Table 4).
- A peer of the novice manager or supervisor could caution that this strategy may result in qualitative work overload, quantitative work overload, and stress and burnout. Thus, the team members gain the valuable experience of balancing job structure, the hard factors of organizational theory, and motivational actions (Table 2, Table 3, and Table 4).
Typically, textbooks do not explain the delicate balance between organizational theory and organizational behavior. Experienced leaders, though, can guide novice managers and supervisors through this integration, giving them the experience they need and building their managerial capabilities.
Being an effective manager is a task of leaders. As effective managers, leaders develop the managerial capabilities of all team members. They build the members’ capabilities in the functions of planning, organizing, directing, and controlling. While this article’s discussion focuses on job redesign, an activity in the function of organizing, the other managerial functions are involved and can be developed as well. For example, in envisioning goals, experienced leaders are building the planning skills of all team members. In motivating, experienced leaders are increasing managers’ and supervisors’ directing skills. The focus on accountability in health information governance links to the function of controlling.
In job redesign, experienced leaders have the opportunity to share some of their experience to which McConnell refers.47 One valuable experience is the realization that, for most situations, multiple right answers exist and rarely does only one right answer exist. Instead, as the application in the section on motivation above shows, leaders strive for the “most” right answer, balancing the pros and cons of various solutions. While textbooks list the pros and cons of various managerial solutions, experience teaches how to balance them. Therefore, leaders need to share their strategies to achieve a balance.
Experienced leaders manage effectively by using the right tool for the right task. For job redesign, tools exist to identify and analyze problems and to generate solutions (see Table 5). These tools use data collected by employees, supervisors, managers and directors, and external consultants. In terms of using the right tools for the right task, Table 6, Table 7, and Table 8 match the tools with the indicators and the data collectors. Generally, all team members (directors, managers, supervisors, and employees) can use these tools to identify and analyze problems and to generate solutions. No simple, magic tool exists; instead, job redesign requires the collaborative, creative efforts of all team members.
The dynamic environment of healthcare requires that all team members in HIS departments engage in renewal. Ongoing changes are occurring in the delivery, financing, and technologies of healthcare. These changes are transforming the work environment of HIS departments. Concomitantly, all team members need to make significant adjustments in their processes and procedures. Renewing readies team members for innovations and changes that align departmental processes and procedures with the environment.
Too often, though, the notions that prevail are “we’ve always done it this way” or “we tried that before and it didn’t work.” These notions are deterrents to innovation and change. Organizational members continue to do things the way they’ve always done them. For example, Social Security cards are no longer considered proof of identity, their use being limited to taxes and credit applications. Yet, in 2012, at least one county in the state of North Carolina still requires applicants for marriage licenses to provide their Social Security cards. When questioned why, county workers could only respond that the number was sent to the state capital—a nonanswer. Similar vestiges of former methods and old regulations can still exist in HIS departments.
In renewing, leaders offset this stagnant thinking. One method of renewing directly related to organizing is “zero-based job redesign.” In zero-based job redesign, experienced leaders guide managers and supervisors through assessments of each job and its tasks. Similar to zero-based budgeting, all jobs are assessed in terms of their contribution to the provision of current services or products. All jobs and their tasks must be justified.
Renewal is important because organizational inertia typically prevails. Organizational inertia is the natural organizational tendency to perpetuate the status quo. While the stability and reliability associated with inertia can be positive, inertia can stymie needed innovation and change. Renewal has the potential to offset this resistance.
Finally, celebrating the success of a job redesign or other departmental accomplishments is a way to achieve renewal. Celebrating includes formal public recognition for everyone involved in the success. Leaders should congratulate themselves and all other team members on the department’s success.
One experienced practitioner explains how she addressed the status quo of the HIS department’s invisibility.48 She notes that HIS departments are often unacknowledged and are excluded from organizational decision making.49 This practitioner forged relationships with key departments in her organization and ensured that the department’s vision aligned with the organization’s strategic goals.50 Returning to the leadership task of envisioning goals, envisioning can combine synergistically with renewing.
As all team members engage in envisioning, renewal may occur, as in the following examples:
- Information gained during environmental scanning may uncover discrepancies between the activities of employees or units and the needs of users and customers in the environment. Thus, environmental scanning allows all team members to discover for themselves the need for change.
- Envisioning may reveal that the HIS department has gradually deviated from its original mission and purpose or is deviating from the healthcare organization’s current mission and purpose. As the department realigns its vision, putting it back “on track,” all departmental members may experience a sense of renewal.
Development of the leadership skill of renewing in all team members has the benefits of rekindling enthusiasm and solidarity of purpose.
Job redesign is a vehicle for building leadership capacity in HIS departments. Job redesign is especially relevant and timely as many new roles are emerging in the transition from a paper-based environment to an electronic environment. Environmental monitoring may provide evidence to support job redesign. Job redesign encompasses all nine tasks of leadership. Tools exist to identify and analyze problems and to generate solutions in job redesigns. Leading by design builds leadership capacity and prepares HIS departments to meet today’s challenges.
Elizabeth Forrestal, PhD, RHIA, CCS, FAHIMA, is a professor in the College of Allied Health Sciences at East Carolina University in Greenville, NC.
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