Health Information Management Leaders and the Practice of Leadership through the Lens of Bowen Theory

by Patty Thierry Sheridan, MBA, RHIA, FAHIMA; Valerie Watzlaf, PhD, RHIA, FAHIMA; and Leslie Ann Fox, MA, RHIA, FAHIMA


Even though leadership is one of the most examined topics in the organizational literature, its application in the field of health information management (HIM) has not been studied extensively. This descriptive, mixed-methodology study examined HIM leadership through the lens of Bowen theory. The researchers conducted surveys of HIM directors and managers, administrators and colleagues of HIM leaders, and HIM staff using focus groups, observations of meetings, and face-to-face interviews. Results showed that HIM leaders are valued for HIM expertise in electronic health records, privacy, security, and coding; for being the center or heart of the organization; and for commonly valued leadership behaviors and skills including dependability, strategic planning, project management, listening ability, and fairness. Leadership was seen as a reciprocal process, and a team approach was preferred. Good communication, education, and training on HIM topics were also valued. However, HIM leaders believed that they spend more time on management activities than on leadership activities, although they would prefer the reverse. Future research is needed to examine how HIM leadership can be practiced more consistently in the workplace across different HIM functions.

Keywords: leader, leadership, Bowen theory, health information management, management, reciprocity, relationship systems


Leadership is one of the most examined human behavioral phenomena. Leadership appears easy to identify, and the expression “you know it when you see it” may come to mind. However, no widely accepted definition of leadership exists. In fact, there may be as many definitions of leadership as there are leaders and leadership theories. Leadership is difficult to define precisely.

The study of leadership in health information management (HIM), including how leaders within HIM develop, how they conduct their workday, how they manage and lead, and how they see themselves as leaders, is needed. This research project is a descriptive study that examines leadership in HIM. The need for HIM leadership is growing in number and in criticality within healthcare delivery organizations.1–4 Healthcare systems across the country are redefining the way health information is collected, processed, used, stored, and retrieved. This change is the result of healthcare providers’ transitioning from paper-based medical records to electronic medical records, as well as moving to the use of automated technologies such as voice recognition and computer-assisted coding.


HIM as a profession has historically been oriented toward producing HIM professionals with technical and managerial skills and behaviors rather than leadership skills and behaviors. HIM leaders in authority positions have largely attained their leadership skills by learning on the job.5 The challenge of navigating a rapidly changing healthcare delivery system that includes data collected, processed, and used outside of the traditional HIM boundaries has created a significant need for HIM professionals to add leadership skills to an otherwise management-focused skill set. At the same time, the increase in new disciplines within the areas of data analytics and health informatics challenges HIM professionals to demonstrate subject-matter expertise and the ability to exercise leadership.


Viewing leadership as a reciprocal process is a critical framework for today’s leader. In leadership research conducted by the Center for Creative Leadership, organizations were reported to be moving away from individual leadership approaches and toward more collective approaches. Respondents viewed “leadership as a process that happens throughout the organization through independent decision making.”6 A growing body of knowledge within complexity science recognizes that “leadership is an emergent event, an outcome of relational interactions [relationships] among agents [individuals]. In this view, leadership is more than a skill, an exchange or symbol—leadership emerges through dynamic interactions [relationships].”7

Another perspective from which to view relationships in the workplace is provided by Bowen theory.8 Bowen theory is a theory of human behavior that has steadily moved toward a science of human behavior since the 1950s. Bowen theory is not a leadership or management theory per se. However, with deep roots in biology, the natural sciences, and evolution, and more recently in the neurosciences, Bowen theory can be used as a framework for developing operating principles of leadership or management in any social group, organization, business, family, or wider community or society. It is a foundational body of knowledge that should underlie any sound theory of leadership or management. The authors use it as a lens through which leadership behaviors can be viewed and analyzed across a continuum of lower-function to higher-function behaviors in the workplace. Individuals can use it to reflect on their own approach to leadership and their own behaviors in the workplace and in other social groups.

“Bowen’s great insight was the reciprocal nature of human behavior. 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 Everyone can exercise leadership whether or not in an authoritative role. Authority, by virtue of one’s hierarchical position, exerts power and influence as critical tools, but authority does not necessarily define leadership. Authority, power, and influence can be used for many tasks that have nothing to do with leadership. Your organization will call you a leader because you have done something very well and it meets or exceeds the expectations of the authorizers; however, doing a great job has very little to do with exercising leadership. “Leadership is not about meeting or exceeding your authorizers’ expectations; it is about challenging some of those expectations, finding a way to disappoint people without completely pushing them over the edge. And it requires managing the resistance you will inevitably trigger.”10 Many people in authoritative positions exert leadership; however, many people who are not in authoritative positions also exercise leadership. HIM professionals fall into both groups. The HIM professionals in this study included directors and managers, administrators and colleagues of HIM directors and managers, and staff who participated in surveys, interviews, and focus groups to discuss the value of HIM leadership and the role it plays in the organization.


It is important to distinguish between leaders and leadership. For the purpose of this research study, the authors define a leader as a person in an authoritative, hierarchical role who is in charge of a function or responsible for direct reports. Leadership has sometimes been defined as a process or an activity that happens in a reciprocal relationship between people:

“A good leader inspires people to have confidence in the leader; a great leader inspires people to have confidence in themselves.”—Eleanor Roosevelt

“Leadership is 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.”—Leslie Fox and Katharine Gratwick Baker

“Leadership is the key to 99 percent of all successful efforts.”—Erskine Bowles

“Adaptive leadership is the practice of mobilizing people to tackle tough challenges and thrive.”—Heifetz, Grashow, and Linsky

HIM professionals are emerging across the country as leaders in the transformation of HIM practice, but little is known about what makes these leaders successful. In response to the significant need for HIM leaders and to learn more about the role of HIM leaders within healthcare delivery systems, the American Health Information Management Association (AHIMA) developed a program called the Action Community for e-HIM Excellence (ACE), which was subsequently transitioned to a new program called Engage. Announcing the ACE program, AHIMA stated: “Times of enormous change require change agents: people with the vision, expertise, and leadership skills necessary to lead transformation.”11 The program aspired to promote leadership skills and engage leaders in sharing their HIM leadership experiences. While not a formal research agenda, developing members’ capacity to exercise leadership is first and foremost on the mind of AHIMA volunteers and staff. This focus is demonstrated in the association’s strategic framework, which includes initiatives related to leadership engagement, leadership development, and industry leadership. The 2014–2017 AHIMA strategic plan includes leadership as one of five major goals, with the plan to develop leaders across all healthcare sectors.12

Research to date on HIM leadership is primarily anecdotal or tends to focus on leaders within the academic work setting. Leadership skills of HIM program directors are critically important in achieving transformative education reform.13 Similar leadership research is needed with a practitioner focus. The impact of performing applied research in the area of practitioner HIM leadership is twofold:

  1. Research on HIM leaders who are in authoritative positions, such as leading committees, heading departments, and so forth, creates a more formal framework for modeling HIM leadership.
  2. AHIMA must demonstrate that HIM leadership is urgently needed to transform medical records and the data acquired from them into data analytics. AHIMA must also demonstrate, through applied HIM leadership research, the strategic plan, and professional development offerings, that all HIM professionals need to engage in leadership activities for the success of the organizations they serve.

Leadership researchers such as Antonakis et al. believe that knowledge of leadership must be derived from the results of scientific leadership research.14 The experience and insights found in their leadership research, along with that of David Silverman,15 the authors’ own experience as leadership consultants, and the faculty of the Research Training Institute sponsored by the AHIMA Foundation, have been used as resources in the research design of this descriptive study. In addition, Bowen theory will provide the framework through which the data will be analyzed.

Specific Aims

Given the significant changes in how organizations think about the value derived from health information and the significant need for HIM leadership, this is a critical time to conduct formal leadership research aimed at understanding the following questions: How do HIM practitioners spend their day? What are their roles and responsibilities as leaders? What are the characteristics and behaviors of HIM practitioners who are leaders? And what does HIM leadership activity look like within the context of the broader organization? Little is known about the HIM leaders in positions of authority and their leadership activities. To that end, the following specific aims were defined for this study:

  1. To identify the role of HIM leaders in positions of authority who are valued within their respective healthcare organizations.
  2. To identify characteristics and behaviors of HIM leaders who hold authority positions.
  3. To define what leadership activities look like in a HIM department and in the broader organization.
  4. To develop a quantitative leadership assessment instrument that can be disseminated across geographic regions, HIM roles, and work settings and to the general HIM population to further study HIM leadership.

Research Questions

Four research questions were evaluated against the data collected. They are as follows:

  1. Is HIM valued in organizations in which HIM practitioners are recognized for their subject matter expertise and leadership?
  2. Are leadership and management different?
  3. Are HIM leaders more likely to spend their day paying attention to relationships than they are to the management of HIM functions?
  4. Is leadership considered a relationship process rather than a position or person?


Study Design

The design of this descriptive, mixed-methodology study used both quantitative and qualitative research methods that included surveys, interviews, focus groups, and real-time observation. Research methods and associated tools are described below. This design was chosen because the study includes a number of independent variables and human characteristics that are not subject to randomization, experimental manipulation, or identification of causation. In addition, the researchers’ experience in consulting and performing leadership assessments, and a review of the leadership research literature, suggest that it is more realistic to explore this phenomenon in its natural environment—studying what naturally occurs or has already occurred. This study is designed as a descriptive study intended to provide valuable insights on HIM leadership and serve as the foundation for the further development of the quantitative instruments, refinement of qualitative methods, and design of additional HIM leadership research. In fact, further research using the instruments is being performed to examine information governance among HIM leaders.

Sample Size and Selection

Ten healthcare delivery systems located throughout the United States were selected for inclusion in this study. Healthcare delivery sites and associated HIM practitioners were selected using the following three-step process:

  1. Search criteria: Search the following American Health Information Management (AHIMA) databases:

Action Community for e-HIM Excellence (a community of recognized HIM leaders)

AHIMA Fellows

Attendees at AHIMA professional development seminars on leadership

Search filters:

a. State (target regions and states within travel distance of researchers):

East Region



Upstate New York

Midwest Region




West Region




b. Title: Director of Health Information Management or Corporate Director of Health Information Management

c. Work setting: Hospital, Integrated Delivery Network (health system)

2. Recruitment letter sent to HIM directors who met the search criteria, requesting their participation in the HIM leadership research study. A brief application was included with the invitation to help in further qualifying participants.

3. Select ten sites from the applications returned that best meet the following attributes:

  • Electronic health record (EHR) implementation stage: AHIMA’s EHR stages model was used to select organizations that are at later stages in the implementation of the EHR. It is preferable to study leadership in organizations adopting EHRs because these organizations reflect the environment in which most provider-based HIM practitioners practice.
  • Rural or urban: Zip code was collected and used to ensure a geographic distribution of urban and rural hospitals. The census urban and rural classification system was used to determine if an organization is classified as rural or urban.
  • Leadership training: Individuals who have attended a hospital-sponsored leadership program or have attended leadership training in the past three years. These individuals tend to have started down a path of leadership development that may create more rich and meaningful experience for the organization and contribute to the research outcomes.


The participants specifically included the HIM director, the HIM director’s immediate supervisor, HIM managers and supervisors, and HIM front-line staff. In addition, leaders from departments that work closely with HIM directors were selected for telephone or face-to-face interviews. Participants also included individuals in attendance at a meeting observed by the researcher (VW, GH, and PS).

Participants’ identities and information gathered were protected and kept confidential at all times before, during, and after the study. Only de-identified data were used in reporting results. Names of participants were assigned a unique identifier and were kept in a locked cabinet available only to the principal investigator (PS.). IRB approval was obtained at the exempt level through the College of St. Scholastica, the co-sponsoring organization of the AHIMA Foundation Research Training Institute. The Bowen theory framework and Bowen theory were used as the theoretical perspectives to define data interpretation and establish boundaries on data collection and analysis.


Leadership researchers have tended toward the use of experimental and quantitative methods; however, quantitative methods alone are proving to be insufficient in examining the phenomenon of leadership. More recently, leadership scholars have looked to understand leadership and its relational phenomena through the use of qualitative methods.16

Including collaboration with faculty of the AHIMA Foundation Research Training Institute/Bootcamp and examination of the current research on conducting qualitative leadership, the research method developed for this mixed-method, descriptive study is a holistic or naturalistic approach consisting of semistructured interviewing, use of both open-ended and close-ended questions, and Appreciative Inquiry (AI) methods. Interviews were audiotaped to ensure accuracy and completeness in data collection. The research approach is grounded in real-life experience and provides the flexibility to follow unexpected ideas and explore meanings with participants. More specifically, the research method consisted of the following components:

  1. Interviews: At each study site, the HIM director and the individual to whom he or she reports was interviewed separately for one hour each.
  2. Focus groups: Two one-hour focus groups were held.
    • Management focus group: This focus group consisted of HIM managers, supervisors, and the HIM director. During the feasibility study, the HIM director participated in the management focus group. Participation of the HIM director proved to be a significant addition to the data collection because the director was able to draw out examples from the managers that the researcher could not have known because of lack of knowledge of the institutional history.
    • Staff focus group: This focus group consisted only of front-line staff.
  3. Social lunch with the director on site: Lunch was an opportunity to clarify meanings of data collected and observe informal interactions between the director and those who interacted with the director during lunch.
  4. Real-time observation: The researcher observed one organization-wide meeting in which the HIM director was included.
  5. Telephone interviews: After the site visit, one-hour telephone interviews were conducted with two key collaborators (e.g., chief information officer, chief medical officer) identified by the HIM director.
  6. Self-assessment surveys: The self-assessment surveys were distributed after the focus groups or after the one-on-one meetings, and individuals returned them while the researchers were on site or faxed them later.
  7. Inquiry method: The primary method of inquiry used was the AI method developed by David Cooperrider. Cooperrider et al. noted that this method “is a form of transformational inquiry that selectively seeks to locate, highlight and illuminate the life-giving forces of an organization’s existence. It’s a positive questioning approach that seeks out the exceptional best in people and systems.”17 This method of inquiry is contrary to traditional approaches, which are problem-based and tend to focus on negative inquiry and on deficits. AI is both a method and a philosophy. It is a means to seek understanding using an inquiry approach based on thought-provoking positive questions. This method is used successfully in the authors’ consulting practice and has proven to be an excellent method for collecting substantive data in a short of amount of time.

The data collection process described above occurred over an eight-hour work day plus two additional hours for telephone interviews after the on-site visit.


Interview questions were created and tested for each research method noted above. The majority of the questions designed for this study have been used for more than five years as part of leadership assessments and consulting engagements performed by the principal investigator (PS.) on behalf of the principal investigator’s employer, CIOX Health (formerly, Care Communications, Inc.) (CARE). Several instruments were created by Katharine Gratwick Baker, PhD, a Bowen theory expert and organizational leadership consultant, for use in CIOX Health leadership assessment services, HIM operations consulting services, and AHIMA’s Renaissance leadership program. The instruments developed by Dr. Baker have been tested and used over the past five years. The questions and instruments performed as expected in the feasibility study and provided valuable results on HIM leader roles and responsibilities and leadership activity. (The instruments and questions are included in Appendix A.)

Data Collection

A three-step process, including the use of audiotaping, note taking, and journaling, was used to collect interview data. The steps in the process were as follows:

  1. Audiotaping of interviews and focus groups and concurrent note taking to record observations and key ideas expressed by interviewees;
  2. Reflective journaling immediately after each interview or focus group; and
  3. Listening to the recorded interviews and focus group sessions and amending notes.

The combination of audiotaping and taking field notes ensured that the flow of the interview would not be disrupted because of extensive note taking. Researchers were able to focus their note taking on impressions during the interview, noting key observations and concepts expressed by participants. Audiotaping allowed the researchers to capture the participants’ response in greater detail. Reflective journaling immediately after each interview, while the interaction was fresh, provided an opportunity to expand on initial impressions of the interaction and to focus on key concepts, ideas, and issues raised during the interview.

After researchers completed their note taking and reflective journaling, the audiotape was used to ensure that the data collected accurately and completely captured the interview interactions. It also assisted in accurately capturing quotes to be used within the resulting case studies.

All researchers had many years of experience in HIM and research and were trained on the specific AI methods of interviewing, conducting focus groups, and reflective journaling.

Data Analysis

Analysis of AI data is best accomplished using Glaser and Strauss’s Constant Comparison Method (CCM).18 Interviews, focus groups, and observations were analyzed first by case analysis to create individual case studies. A cross-case analysis of interviews, focus groups, and observations was also performed across the seven study sites to identify general patterns and categories of information by type of interview, such as HIM director interview, staff focus group, or key collaborator interview. CCM provides an organized approach to grouping data from a variety of sources in a manageable, iterative manner. This method captures broad themes and patterns that emerge from the research, which can then be tied back to the study aims, research questions, and hypotheses. The main focus of the qualitative data analysis activity is not to quantify facts but to “identify the meanings and values attributed by individuals in real-life situations, with idiosyncratic and personal views forming an important part of the overall picture.”19


Data were analyzed using the CCM developed by Glaser and Strauss.20 No identifying individual participant or organization information was included in the results. Data collected from a feasibility study conducted at a healthcare delivery system in Illinois indicated that the research methods and tools designed for the descriptive study would support its objectives, test the study’s four hypotheses, and address the aims of the study. Quantitative data analysis was also performed on the self-reflection data using averages to quantify answers on each of the self-reflection questions. Even though ten healthcare sites were selected for inclusion in the study, only seven of the healthcare sites agreed to participate in the study.


This leadership study had 102 participants across seven healthcare facilities that participated in face-to-face interviews, focus groups, and self-reflection surveys. All seven HIM directors and their bosses participated in face-to-face interviews, for a total of 14 participants. Colleagues of the HIM director participated in face-to-face interviews, for a total of 13 participants. Focus groups with HIM managers and supervisors ranged from 3 to 8 participants, for a total of 35 participants. HIM staff focus groups ranged from 4 to 10 participants, for a total of 40 participants. HIM bosses and colleagues were not asked to participate in the self-reflection survey; therefore, 43 of 82 (102 – 20 = 82) participants submitted the self-reflection survey for a response rate of 52.4 percent. Table 1 demonstrates the breakdown of the participants in the HIM leadership study.

Examples of position titles ranged from CIO, CFO, vice president, and chief quality officer for the administrators and colleagues to scanning/document management and coder for the staff. HIM managers and supervisors held positions as supervisor/manager of HIM technicians, transcription, and coding as well as application systems analyst. In each of the organizations studied, hierarchy and tenure played an important role in the functioning of the organization and relationships with HIM professionals. For example, HIM leaders were held accountable by their colleagues and bosses and were expected to perform within their functional role. Hierarchy may tend to inhibit collaboration, yet savvy HIM professionals had an awareness of their roles and respected the role that hierarchy and relationships play in relation to effective HIM leadership.

Value of HIM Leadership

When participants were asked if HIM was valued, all said that it was absolutely or very valued. When asked which roles were valued, administrators/colleagues and HIM directors and supervisors said knowledge of Health Insurance Portability and Accountability Act (HIPAA) privacy, EHR/electronic medical record (EMR) implementation, and systemwide HIM leadership were valued and that HIM was the “heart of the agency.” Staff said that roles that are valued include keeping HIM as an everyday word as well as helping with resources and expanding coding into revenue dollars (see Table 2). Administrators valued HIM subject-matter expertise and HIM knowledge in general. HIM staff valued being recognized as resources and tended to adopt behaviors related to being helpful and flexible. Some quotes of administrative participants include the following:

“HIM is the central knowledge repository for a lot of issues—it’s amazing how many committees the HIM director needs to be on. Their role is kind of like the glue that holds things together, well maybe not the glue, perhaps a spider web with their strings in everything.” 

“HIM is not valued by people who don’t realize what they do. But HIM is greatly valued by people who realize what they do.” 

“You can hire people who have the skills, but if you don’t hire people with the right heart, forget it.” 

“We need people to own the problem. Then we need people to take action about the problem. And then finally we need people to be accountable for the results.”


Characteristics of HIM Leaders

When participants were asked to identify characteristics of HIM leaders, all agreed that consistency, fairness, and communication were key to leadership success. Administrators and HIM supervisors and directors agreed that listening and strategic planning skills were important. When asked if leadership was considered a relationship process rather than a position or person, all agreed that leadership has to be a relationship or reciprocal process in order to be successful. All participants said that a “give and take” or reciprocal process, as well as caring, good communication, and teamwork, is necessary for successful HIM leadership (see Table 3).

Bowen theory suggests that individuals who are more highly “differentiated” or have higher levels of functioning have higher levels of emotional maturity and independent thought. The notion of differentiation comes from biology and refers to an organism’s ability to be independent yet connected to surrounding organisms. Bowen described behavior as occurring on a continuum or a scale of differentiation.21 Bowen’s scale of differentiation is a hypothetical scale and not an exact measurement of differentiation. Researchers are developing instruments to better measure levels of differentiation, and authors such as Fox and Gratwick Baker have published interpretations of the scale of differentiation (see Appendix B). Observed behaviors of HIM leaders in this study tended to be higher on the scale of differentiation and included HIM leaders maintaining positive relationships with decision makers and with colleagues, making decisions based on facts rather than feelings, managing their anxiety and reactivity, taking thoughtful and confident positions, and making values-driven decisions for the good of the work system. “An individual’s level of differentiation reflects his or her capacity for independent thought and action while he or she stays connected to significant others.”22

A common behavior in organizations is for people to be distant in their relationships with others, but it is important for leaders to stay in regular contact with superiors, colleagues, and staff, listening to all sides of debates and communicating their own positions thoughtfully and honestly, neither distancing nor attacking. These are examples of high-functioning behaviors for HIM leaders, as are being present, accountable, calm, and able to manage anxiety well. Successful leaders also show passion and positive energy. At this highly differentiated level of functioning, they have the capacity to collaborate effectively and are usually perceived by others as being steady, consistent, and resilient.

HIM Leadership Activities

Participants (other than staff) were asked to define leadership activities in the HIM department and organization. HIM directors and supervisors were asked to discuss whether leadership and management are different and whether HIM leaders spend more time engaging in management or leadership activities. Both administrators and HIM supervisors and directors said that leadership activities include financial management skills; EHR design and implementation; privacy and release-of-information activities; and the ability to make sure that data get to the right place in a timely manner and that the right system is designed to do that. The majority of HIM directors and supervisors said that they spend about 80 percent of their time on management activities and only 20 percent on leadership. They also wished this finding was reversed and believed that it needs to be reversed in order for them to continue their success as leaders (see Table 4). This finding is different than what the authors originally hypothesized because leaders are spending much more of their time on management than on leadership activities such as building and maintaining relationships. As Kotter observed, more time should be spent on leadership building activities and skills and less on management so that the imbalance is at least a “70–90 percent vs. 10–30 percent” difference.23 How to achieve this goal is something that HIM leaders will need to discover for themselves, by possibly reorganizing their day-to-day activities so that leadership plays a vital role each day. The authors believe that leadership should be a vital part of each daily activity. Kotter also discusses the difference between management and leadership in the Harvard Business Review article “What Leaders Really Do,”24 in which he states that organizations that embrace both management and leadership will be the ones that thrive in turbulent times. Management includes dealing with day-to-day operational issues and promoting stability in the organization, while leadership presses for change and inspires and motivates. Recognizing this, the Council for Excellence in Education of the AHIMA Foundation has developed new HIM competencies that contain a leadership domain, which also includes management. The leadership domain includes leadership models and theories, as well as critical thinking; change management; workflow analysis, design, tools, and techniques; human resource management; training and development theory and process; strategic planning; financial management; ethics; and project management.25 The competencies are being used by universities to meet accreditation requirements and by HIM professionals to perform a self-assessment. As professors teach and as HIM professionals self-assess their performance in the leadership domain, more emphasis should be placed on leadership so that HIM professionals will work confidently in accordance with leadership operating principles. Because HIM professionals have already embraced management, emphasis on leadership roles and activities is needed in the HIM profession. Teaching both leadership and management is critical and could include role playing and critical thinking debates that involve discussion of the difference between management and leadership and how HIM professionals can incorporate both into their work.

Some quotes of HIM directors and supervisors on HIM leadership include the following:

“Everyone is a leader in their own way” (said by a director referring to her staff). 

“To get to the table, we needed to create relationships where there were none.”

“Don’t label yourself. Managing HIM is not simply managing a task—go anywhere you want—don’t have boundaries.”

“Invest in people—talk with staff—help them feel valued (Stephen Covey listening).”

“Don’t try to be what I am not.”

Observation of Meetings

One or two different meetings were observed across six of the seven facilities. The meetings were either organization-wide or within the HIM department and included a mix of HIM managers, supervisors, directors, and other administrators that the HIM director reported to. The emotional tone of the meetings was friendly and relaxed. The researchers observed the meetings for triangling, which is a concept in Bowen theory. Triangling can be seen as an anxiety-driven behavior and is expressed in a three-person relationship as two insiders and an outsider, with the outside position usually being most uncomfortable. It is obvious when two or more people regularly talk about another person in a blaming, critical, or overly worried way. Triangling is also easy to see within an organization as evidenced by an overwhelming amount of times that individuals are unnecessarily cc’d on e-mails. No triangling was noted during any of the meetings.

The researchers observed that appropriate decisions were made in the meetings if needed, and the researchers’ subjective assessment of the meetings ranged from 3 to 5 (with 3 indicating that decisions are made in spite of some signs of anxiety, 4 indicating a smoothly running meeting with much accomplished and minor anxiety observable, and 5 indicating a highly effective and efficient meeting without anxiety). Some signs of anxiety or tension were noted as the result of an EHR system that was not up and running effectively or when rumors of possible layoffs and fewer salary increases were discussed.

An example of one of the meetings was a leadership meeting for all supervisory personnel. It was directed by the chief operating officer, and during the meeting the HIM director was asked to present information together with the director of case management on the Centers for Medicare and Medicaid Services (CMS) Recovery Audit Contractor program. The HIM director developed the slides for the presentation and then was asked questions by the chief operating officer about the presentation. The presentation was extremely well-received, and one could tell that the HIM director was very knowledgeable, relaxed, and very well-respected.

Self-Reflection Surveys

All respondents except the bosses and colleagues of HIM directors (43 of 82 participants, for a 52.4 percent response rate) were also asked to complete a self-reflection survey on how often they perform certain functions related to leadership. Areas in which they stated that they performed these functions always or almost always included taking responsibility, being present at meetings, taking actions based on values and principles, being aware of how they affect co-workers, being a team player, making decisions based on facts and principles, focusing on staff strengths, not attacking staff through disagreements, encouraging independence in staff, seeking positives and enduring change, and seeing many options for solving problems (see Table 5). Respondents were also asked open-ended questions such as “Are there areas you identified where you would like to improve your functioning? If yes, what are they and why?” Some answers to those questions are quoted below:

 “In regards to distancing myself from others when I am anxious, I would like to work on being able to cool and collectively utilize skills enabling me to react in a different manner when I’m feeling this way.”

“I would like to be less defensive and more open to viewing a system approach to Health Info. Departments. I would value working more closely as a team with [health information] management. I believe we all have areas to contribute and I would like to improve my abilities to work better with others who I feel are too controlling or seem to know everything! I want to be open and have facts and a good understanding of the reasons for certain decisions and approaches.”

Other open-ended questions included “Did any of your answers surprise you? If yes, which ones and why?” Responses included the following:

“Yes, didn’t realize the level of leadership I actually have involvement in personally.”

 “Yes, setting realistic expectations for myself. I believe I ‘over-set’ expectations causing unnecessary stressors, as well as requiring additional work hours to complete tasks on time.”

Areas in which respondents stated that they performed functions often or almost always included the following: recognizing the difference between feelings and intellectual principles, recognizing their contribution in the workplace, setting realistic expectations, challenging others to solve problems by asking questions to stimulate thinking, tolerating stress in the workplace, being aware of triangles, stating a position on “hot” topics clearly, not being defensive when criticized by supervisors, and not withdrawing when anxious (see Table 6).

Overall themes of self-reflection were summarized to capture the major values and principles of respondents in relation to HIM leadership. The top three themes included high-functioning behaviors such as being responsible for one’s own actions and managing reactivity, taking actions related to values and principles, and being aware of how one affects co-workers. The bottom three themes included highly differentiated behaviors such as not withdrawing or distancing from others when anxious, accepting criticism, and clearly stating a position (see Table 7). Higher-functioning individuals can stay the course in the midst of reactive situations by resisting being overly reactive to an individual or groups of individuals. Despite conflict and rejection, for example, they can stay calm and keep thinking, guided by their values and principles to make the best possible decisions for the system in which they work and for themselves. Acting in the best interest of the group, the differentiated HIM leader does not get pressured by relationships and remains objective, calm, and able to clearly express his or her own thinking without becoming emotionally reactive and disconnecting from others or an issue.

Summary of Overall Themes

A summary of overall themes for HIM leadership include being greatly valued for knowledge surrounding the EHR, privacy and security (HIPAA), and coding and for being the center of the organization. Common leadership behaviors in HIM included being consistent, being strategic, planning, listening, and being fair. Leadership was definitely seen as a reciprocal process that needs understanding, a team approach, good communication (give and take), and education and training. Major activities were similar to the areas that were greatly valued, such as privacy/security/HIPAA, EHR functions, and financial planning and budgeting. Management encompassed more of the day-to-day activities of the HIM leader than leadership did, even though respondents believed this situation should be reversed and needed to be reversed in order for the HIM leader to be successful. Even though leadership self-reflection elicited different terms compared to leadership behaviors, the overall similarities included the need to be strategic, planned, and consistent, qualities that are certainly necessary in order to be a decision maker, collaborator, and change agent (see Table 8). HIM directors also discussed their thoughts on formal and informal leadership training. Training methods included enrolling in executive MBA programs, volunteering with AHIMA, learning leadership from books, workshops, experience, and using available leadership tools.


The sample of respondents was a convenience sample and was not representative of all HIM staff, HIM directors or supervisors, or their administrators and colleagues. Therefore, the ability to generalize findings on leadership issues from the results of these case studies to all HIM professionals will be limited. However, the resulting case studies will provide examples and stories of leadership that practitioners will find practical and useful for reflecting on their own situation. Also, some of the responses were self-reported and therefore included opinions, not facts, on the subject matter.

Areas for Future Research

Future research on HIM leadership could focus on how to move forward with less focus on management and more on leadership responsibilities and functions. Creative and critical thinking skills, information governance, data analytics, visionary strategic planning, financial analysis, and communication through problem-solving teams are some of the areas that HIM leadership researchers could address. Further research could compare HIM leaders who focus their attention on these leadership functions to those who are primarily management focused, and then examine their relationship to productivity and quality outcomes. Other research could focus on quasi-experimental studies with testing before and after leadership training to measure changes in HIM productivity and quality outcomes. Demonstrating ways to prove that effective leadership education and training can make a difference in HIM outcomes may be a way to move administrators toward incentives for increasing leadership functions.


Even though leadership has been studied extensively in many areas, HIM leadership has not been examined in the workplace. This descriptive study examined HIM leadership in the workplace by collecting real-life data from administrators and colleagues of HIM professionals, HIM directors and supervisors, and HIM staff. It also collected survey data on self-reported behaviors related to leadership considerations and functions. Basic descriptive statistics and thematic measures were used to summarize the voluminous amounts of data collected. Results showed that HIM professionals are very valued and are considered the center of the organization. EHR functions, privacy and security, and coding were the major areas of expertise for which HIM professionals are valued.

HIM leadership is seen as a reciprocal process and is different than management. Management consists primarily of day-to-day activities, while leadership is visionary and needs to be expanded in the workday for the HIM leader to be successful. Future research in HIM leadership is needed to determine if leadership functions and qualities provide a positive impact on HIM productivity and quality outcomes.

Some final thoughts on exercising leadership in the day-to-day HIM world include the following:

  1. Life is a leadership laboratory
  2. Don’t go it alone!
  3. Manage your reactivity.
  4. Understand when you are working on technical vs. adaptive change.
  5. Meet people where they are.
  6. Adopt a leadership framework and make it your own.

The authors believe that, as stated by Leslie Ann Fox and Katharine Gratwick Baker, “Successful leadership is 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.”26



This research study was supported in part by the AHIMA Foundation, the CAREinnoLab of CIOX Health and the School of Health and Rehabilitation Sciences, Department of Health Information Management, at the University of Pittsburgh (I# 0038385).

The authors appreciate the participation of the seven study sites who so graciously granted access to their organization to study HIM leadership.

The authors wish to also acknowledge the following individuals and organizations:

Thank you to Gwen Hughes, RHIA, CHPS, for her participation as a researcher in this project. We are grateful for Gwen’s excellent observations and contributions related to the study sites she visited.

The authors appreciate the encouragement and support of the faculty at the Center for Family Consultation in Evanston, Illinois, and Katharine Gratwick Baker and thank them for their review and feedback of research aims, questions, and methods.

Patty Thierry Sheridan would like to gratefully acknowledge the faculty of the AHIMA Foundation’s Research Training Institute with special thanks to Susan Fenton, PhD, RHIA; Bill Rudman, PhD, RHIA, FAHIMA; and Valerie Watzlaf, PhD, RHIA, FAHIMA, for their constant encouragement as well as their review and feedback on research aims, questions, and methodology.


Patty Thierry Sheridan, MBA, RHIA, FAHIMA, is senior vice president of HIM Services CIOX Health, Alpharetta, GA.

Valerie Watzlaf, PhD, RHIA, FAHIMA, is an associate professor at the University of Pittsburgh School of Health and Rehabilitation Sciences, Department of Health Information Management in Pittsburgh, PA

Leslie Ann Fox, MA, RHIA, FAHIMA, is the former chief executive officer and cofounder of Care Communications in Chicago, IL.



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Patty Thierry Sheridan, MBA, RHIA, FAHIMA; Valerie Watzlaf, PhD, RHIA, FAHIMA; and Leslie Ann Fox, MA, RHIA, FAHIMA. “Health Information Management Leaders and the Practice of Leadership through the Lens of Bowen Theory.” Perspectives in Health Information Management (Spring 2016): 1-36.

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