Leadership is one of the most examined human behavioral phenomena. While leadership appears easy to see, it remains difficult to define. Despite the abundance of leadership theories and widely known experts, there are no generally accepted definitions of leadership. The challenge of redefining health information management (HIM) leadership is compounded by the ongoing changes in HIM and the critical state of healthcare in the United States.
HIM leaders have a unique opportunity and a professional responsibility to create a new vision of HIM leadership and to develop their own leadership framework. To do this they should draw on leadership theories that most resonate for the profession. Leadership theories are the frameworks that provide a guide and a lens through which leadership can be better understood and integrated into a professional’s daily life.
The need for HIM leaders is growing and becoming more critical as healthcare organizations redefine the way health information is collected, processed, used, stored, and retrieved.1 This evolutionary trend and other market forces bring a new urgency for the HIM workforce to demonstrate HIM thought and practice leadership. Given that there are likely as many leadership definitions as there are theories and experts, to which expert or theory does the HIM professional look to in developing a leadership framework? In moving toward a new HIM leadership framework, it is helpful to understand some significant insights gained from the contemporary study of leadership.
It has been stated that the study of leadership has never been the same since 1977, when Abraham Zaleznik, a Harvard Business School professor, challenged the notion that management and leadership are not the same. Much has been published on this topic since then, most notably by John Kotter, a retired Harvard Business School professor and accomplished author who introduced a new way of thinking about management and leadership in the early 1990s that permeates the leadership literature today. Kotter suggests that while managing and leading are different, they are complementary and both are needed. He purports that most organizations, however, are “overmanaged and underled.”2 While leadership is acknowledged as critical to success, organizations unintentionally undermine the effort to build leadership capacity because of their focus on management. Understanding that “management is about coping with complexity and leadership, by contrast, is about coping with change” is essential to developing a resilient organization and one that embodies a culture of leadership accountability throughout the organization.3
Why is it important for HIM professionals to understand the differences between management and leadership and to consider this difference when identifying an HIM leadership framework? HIM as a profession has historically been oriented toward producing managers and transactional leaders with HIM subject matter expertise. In part, the historical focus on and need for mastering management, transactions, and subject matter expertise are contributing factors in what HIM professionals anecdotally report as difficulties in “getting to the table.” The challenge of navigating a rapidly changing healthcare delivery system that includes data collected, processed, and used outside of traditional HIM boundaries has created a significant need for HIM to add leadership acumen to a well-developed set of management skills. At the same time, there is an increase in new disciplines within health informatics that challenges HIM professionals to demonstrate not only subject matter expertise but also leadership skills.4 HIM professionals have largely developed their leadership skills by learning on the job. However, on-the-job leadership experience with a management framework does not necessarily guarantee success or a seat at the table.
Leadership as a Relationship Process
There is a significant trend, supported by leadership research, toward viewing leadership as a relationship process. Leadership research conducted by the Center for Creative Leadership on the changing nature of leadership revealed the observation that organizations are moving away from individual leadership approaches and toward more cooperative approaches. Survey respondents viewed “leadership as a process that happens throughout the organization through independent decision making.”5 Complex systems leadership theory, a theory derived from complexity science, has made a similar observation about the leadership process. Complexity theory also moves away from the idea that leadership resides in an individual and is evolving toward a definition that describes leadership as an activity that transcends the individual and emerges within the workplace system. Leadership, through the complexity science lens, is also seen as a “whole system” with less focus on individual variables and component parts.6
Another leadership framework that moves away from focusing solely on the individual as a leader and toward describing the reciprocity of behavior within a relationship system is provided by Dr. Murray Bowen, who developed a universal theory of human behavior known as Bowen theory. Bowen theory describes relationship patterns and how humans function in their families, their primary relationship system.7 One of the most important concepts in Bowen theory is the notion that the basic unit of human functioning is not the individual; it is the family system. Bowen observed that families can be characterized as mutually interdependent relationships. Bowen’s concepts are transferable to relationship systems beyond the family such as the workplace, schools, and other social and professional organizations. Like families, organizations are also characterized by mutually interdependent relationships.8 The interdependency observed by Bowen is described by Leslie A. Fox, using the mobile as a metaphor: “Just as when one pulls a piece of a mobile and all pieces move in response, a change in behavior of one member of a relationship system automatically results in changes in the behavior of others in the system.”9
Bowen’s work has inspired business consultants Fox and Katharine Gratwick Baker to develop Systems-based Leadership, which is the application of Bowen theory to the workplace. Fox and Baker define successful leadership as “a relationship process among members of an organization that inspires them to take full advantage of opportunities, recognize and minimize threats to success and avoid catastrophic failures.”10 For example, in healthcare organizations seeking to achieve higher levels of performance through the implementation of electronic health records (EHRs), HIM leadership is needed not only to assure that the health information function emerges better than ever, but to help the organization withstand the turbulent nature of such large-scale change as efficiently as possible. Relationship issues are sure to emerge during the anxious times that accompany the change to an electronic work environment; HIM professionals who are savvy about the relationship system can help ensure a smoother transition and better outcomes.
This way of thinking about leadership challenges more traditional leadership theories, which are framed in an individual way of thinking about leaders. A new definition based on Bowen theory introduces an interpersonal, interactive, relationship-focused way of thinking about leaders and leadership.11
Work in organizations is accomplished exclusively through human relationships. Viewing leadership through the lens of Bowen theory provides insights as to why implementing change is so difficult. Thinking about leadership as a relationship process is also useful to gain new insights into one’s functioning as a leader and how that functioning affects the workplace system and its relationships. Viewing leadership from this perspective requires a departure from traditional thinking about leadership that focuses on the behavior of individuals to more contemporary thinking on how interactions between people impact the effectiveness of a work system.
Most traditional leadership theories discuss some aspect of relationships, but it is typically in the context of leader-follower relationships. This research, while useful, tends to focus more on the two-person relationship. As we know from working in complex healthcare organizations, we rarely find ourselves working in dyadic relationships and are most often navigating complex three-person relationships, known as triangles in Bowen theory, as well as interlocking triangles. Awareness of the concept of relationship systems in the workplace is useful for HIM professionals because of the need to collaborate regularly with multiple departments to accomplish the profession’s vision of quality healthcare through quality information. Understanding relationships and relationship patterns in the workplace system helps leaders to become more self-aware in that system and manage their own interpersonal behaviors. Regardless of the leadership techniques one has learned or one’s HIM subject matter proficiency, if one does not understand relationships and relationship patterns, workplace leadership and management efforts are inevitably compromised.12
Traditional leadership experts often ignore the idea that workplaces are complex emotional systems. Leaders who understand the emotional process in their workplace are better at understanding and navigating the “people issues” that make leading and organization-wide leadership so difficult. The idea of an organization as an emotional system is also derived from Bowen theory. Organizations, like families, have patterns of behavior throughout the relationship system, which an emotionally aware leader can perceive and use to gain a broader perspective on workplace issues.13
John Kotter introduces similar ideas about the role emotions play in the workplace, particularly as they relate to change. Kotter observed the organizational patterns that emerge during transformative change. Observing these patterns led him to the development of an eight-step change leadership framework and the observation that change is not so much about strategy but about people’s feelings. He believes that the “true heart of change is in the emotions” and recognizes the power of emotions to sabotage a change effort, even after a change has been implemented and assumed to be successful.14, 15
Daniel Goleman, the author of Emotional Intelligence and Working with Emotional Intelligence, takes an individual perspective rather than a systems view, but his research is important in that he has made the discussion of emotion in the workplace and its impact on performance mainstream. In his article “What Makes a Leader?” he indicates that intellectual and technical skills are important but emotional intelligence is the sine qua non of leadership. Further more, he states that “people who have mastered their emotions are able to roll with the changes. They don’t panic.”16
Leadership as a Relationship Process: Case in Point
What makes an effective HIM leader? The following case study illustrates leadership as a relationship process.
The director of HIM has been invited to a meeting with the hospital’s chief executive officer (CEO), chief medical informatics officer, chief nursing informatics officer, and chief information officer (CIO) regarding the selection of a document management solution. There has been a lot of conflict over what system to purchase and the meeting has been scheduled to determine which solution is best for the organization. The CIO favors a single-source solution to minimize costs and interface issues and therefore wants to utilize the document management technology module that is a part of the current clinical system, while the HIM director favors a best-of-breed route to achieve maximum functionality not possible with the single-source solution.
On her way to the CEO’s office, the HIM director reflects on the conflictual relationship she had with the CIO and the CIO’s information technology staff in the past. HIM was often excluded from important technology decisions, and the topic of a document management system was mostly ignored. Fast forward to now, three years later, and the effort the director has put into developing a relationship with the CIO and the IT staff has resulted in HIM being part of critical decision making and implementations related to health information technology and health informatics and information management. The director is sought out for her opinion and involvement, as are the HIM managers, supervisors, coders, and data analysts. When the director decided to work on managing her own anxiety and reactivity while developing better relationships with the CIO and the IT department staff, she asked the HIM staff to do the same.
The HIM staff has developed relationships with their IT counterparts, resulting in greater customer satisfaction and more timely advancements in health information technology, informatics, and information management. Having a collaborative relationship has not occurred by happenstance. It required daily attention and a commitment to work through different viewpoints in a respectful and patient manner. It also required that all staff do their homework and present their perspectives objectively while managing their anxiety about how they believed things “ought to be,” especially in the initial stages of discovery. The HIM director created a vision for her staff that their role was to collaborate with IT and to listen before raising objections. She also asked her staff to return to their offices or cubicles following a meeting that was particularly challenging and think the issue through, talk with others about ideas they had, and then come back to the table with IT. This applied to working with IT on more routine projects such as encoder updates, remote coding workflow issues, interface problems, speech recognition implementation, advocating for document imaging, or preparing systems for the recovery audit contractor (RAC) workflow or ICD-10. She encouraged her staff not to be “NoNos” and to work toward being open to new ways of thinking and delivering heath information technology, informatics, and information management services. This has resulted in the HIM staff being sought out for their opinions and participation at the table.17
As the director enters the CEO’s office, she knows she has done her homework, and she believes she can present a compelling case that even the CIO will sign on to. It’s out of the box and economical. Whatever the outcome, she knows the decisions made in the CEO’s office will be made collaboratively and in the best interest of the hospital’s patients and the broader community.
The Importance of an HIM Leadership Framework
Why is an HIM leadership framework needed? A framework provides structure and a set of processes that support success at work and can also extend positively into one’s personal life. Given the complex nature of working in the healthcare industry, especially during a time where healthcare reform is needed, leadership has become every HIM professional’s responsibility. An HIM leadership framework is just as necessary for individuals in the trenches as it is for those in the boardroom.
A framework for leading should include theories from the behavioral sciences, such as Bowen theory, and management literature, such as John Kotter’s eight steps for successful large-scale change. An example of an HIM leadership framework is Systems-based Leadership and Change Management. This framework was introduced to HIM professionals during AHIMA’s leadership program, “Renaissance for the 21st Century: Leading the Way to the EHR.”18 The framework was developed by Leslie A. Fox and Patricia T. Sheridan and includes four familiar bodies of knowledge: Systems-based Leadership, change management concepts derived from management expert John Kotter, transition management concepts derived from William Bridges, and project management derived from the Project Management Institute.19, 20
The framework’s four bodies of knowledge and associated concepts, which are noted in Table 1, when woven together yield a comprehensive set of leadership processes and tools to support HIM professionals in the delivery of the HIM services for which they are responsible.
The foundation of this framework, derived from Systems-based Leadership, is what makes it uniquely different from other traditional leadership frameworks. Viewing the workplace as a relationship system enables individuals to better address the emotional side of workplace issues. The other three bodies of knowledge integrate with Systems-based Leadership to ensure an all-encompassing approach to leadership.
This commentary suggests new ways of thinking about leadership and advocates that HIM professionals adopt a leadership framework that understands the emotional and mutual interdependence of workplace systems, the importance of effective relationships, and the effect of anxiety on individual and organizational performance. Frameworks that consider the relationship process provide a wider lens through which to view leadership. The Systems-based Leadership and Change Management framework introduced in this commentary was selected because of its unique perspective on leadership, and for its departure from a technique-driven framework to a deeper understanding of human behavior and change management as a way to approach leadership.
In the words of AHIMA’s president Vera Rulon, “Leadership does not apply to only those who are in leadership positions in their organizations. Being a leader, of which we all have the potential, means taking charge of you.”21 Today’s healthcare system needs leadership from all HIM professionals, regardless of their position on the organizational chart. Employers expect HIM professionals to use their leadership skills for collaborative problem solving and in delivering a range of quality HIM services.
The current healthcare crisis is a call to action for all HIM professionals to improve their leadership competencies and play a significant role in U.S. healthcare reform. It is also a call to action to ensure the continuity of the HIM profession, not as we know it today but as it is shaped by the needs of tomorrow. To further develop leadership competency, one must first examine the value system that drives one’s own leadership behavior and then reflect on the way one manages anxiety in the workplace. Once this is complete, applying a framework for leadership becomes essential for navigating constant change and complex workplace relationship systems. Achieving quality healthcare through quality information requires all HIM professionals to redefine HIM leadership using the frameworks discussed herein and fully engage in the healthcare information management conversation and transformation.
Patricia Thierry Sheridan, MBA, RHIA, is the president of Care Communications, Inc., in Chicago, IL.
LaShunda Blanding Smith, MSM, RHIA, is an instructor in and the interim chair of the Department of Health Information Management at Alabama State University in Montgomery, AL.
The frameworks discussed in this article are currently being used in “HIM Leadership through the Lenses of Bowen Theory and Complex Systems Leadership Theory,” a research study in progress by Patricia T. Sheridan that aims at defining HIM leadership and identifying HIM leadership roles, behaviors, and activities. The study is funded in part by the AHIMA Foundation and Care Communications, Inc.
1. Hagland, Mark. “Leading from the Middle.” Journal of AHIMA 76, no. 5 (2005): 34–37.
2. Kotter, John, P. “What Leaders Really Do.” Harvard Business Review, December 2001. (First published in 1990.)
4. AHIMA. A Blueprint for Quality Education in Health Information Management. September 24, 2007. Available at http://www.ahima.org/emerging_issues/Vision2016BlueprintforEduc.pdf.
5. Martin, André. “The Changing Nature of Leadership.” Center for Creative Leadership, 2007. Available at http://www.ccl.org/leadership/pdf/research/NatureLeadership.pdf.
6. Hazy, James K., Jeffrey A. Goldstein, and Benyamin B. Lichtenstein. Complex Systems Leadership Theory: New Perspectives from Complexity Science on Social and Organizational Effectiveness. Mansfield, MA: ISCE, 2007.
7. Bowen, Murray. Family Therapy in Clinical Practice. New York: Jason Aronson, 1978.
8. Fox, Leslie Ann, Jean Clark, Rita Bowen, and Susan Postal. “Using Systems-based Leadership to Advance the Future State of HIM.” AHIMA’s National Convention and Exhibit Proceedings, October 2007.
9. Fox, Leslie Ann. “Fitting In, Standing Out: Leading Effectively within Your Organization.” Journal of AHIMA 76, no. 1 (2005): 24–28.
10. Fox, Leslie Ann, and Katharine Gratwrick Baker. Leading a Business in Anxious Times. Chicago: Care Communications, 2009.
11. Fox, Leslie Ann, Jean Clark, Rita Bowen, and Susan Postal. “Using Systems-based Leadership to Advance the Future State of HIM.”
12. Fox, Leslie Ann. “Emotional Process in the Workplace.” AHIMA’s National Convention and Exhibit Proceedings, October 2000.
13. Fox, Leslie Ann, Jean Clark, Rita Bowen, and Susan Postal. “Using Systems-based Leadership to Advance the Future State of HIM.”
14. Kotter, John P., and Dan S. Cohen. The Heart of Change: Real-Life Stories of How People Change Their Organization. Boston: Harvard Business School Press, 2002.
15. Fox, Leslie Ann, Jean Clark, Rita Bowen, and Susan Postal. “Using Systems-based Leadership to Advance the Future State of HIM.”
16. Goleman, Daniel. “What Makes a Leader?” Harvard Business Review, November–December 1998.
17. Kotter, John P. “Deal with NoNos: Increasing True Urgency and Managing People Who Resist Change.” In A Sense of Urgency. Boston: Harvard Business Press, 2008.
18. AHIMA, “Renaissance for the 21st Century: Leading the Way to the EHR.” AHIMA seminar, 2004–2008.
19. Bridges, William. Managing Transitions: Making the Most of Change. Cambridge, MA: Da Capo Press, 2003.
20. Project Management Institute. A Guide to the Project Management Body of Knowledge (PMBOK® Guide). 3rd ed. Newtown Square, PA: Project Management Institute, 2004.
21. Rulon, Vera, and Carolyn Valo. “Pushing Beyond Your Comfort Zone: Take Charge and Lead.” AHIMA’s 78th National Convention and Exhibit Proceedings, October 2006.
Article citation: Perspectives in Health Information Management 6, Summer 2009