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The Uniqueness of U.S. Healthcare : A Linguistic Analysis 197

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The Uniqueness of U.S. Healthcare Management: A Linguistic Analysis of Competency Models and Application to Administration

John W. Huppertz, PhD, Martin Strosberg, PhD, Stacey Burns, MBA, & Imran Chaudhri, MBA

Abstract Faculty in healthcare administration education programs frequently discuss whether their curricula contain the right balance between general manage- rial and healthcare-specific content. Some take the position that a good, basic management education prepares for any setting, healthcare included. Others consider healthcare so unique that students significant context and exposure to the . Although most educators believe that some mix of general managerial and healthcare-specific skills are needed, no con- sensus has emerged regarding how much of each is optimal. In this study, we content-analyzed five well known competency models, to assess the general managerial and healthcare-specific qualities articulated by the industry’s lead- ers. Competencies were classified as either specific to healthcare or common to most any industry. Results showed that less than 25% of the competencies contained any mention of healthcare, suggesting that educational of health administration students can be satisfied by mostly general managerial content. However, some unique characteristics of healthcare require managers to obtain deeper theoretical of the context in which these operate. Students must understand why healthcare organiza- tions behave as they do, and the search must continue for the right proportion of general versus specific content in healthcare-management programs.

Please address correspondence to: John W. Huppertz, PhD, Union Graduate , 80 Nott Terrace, Schenectady, NY, 12308, [email protected] 198 The Journal of Health Administration Education Summer 2014

Introduction The optimal proportion of healthcare-specific content that healthcare man- agement education programs should include in their curricula has prompted debate among faculty, program directors, and administrators. Inside their programs, faculty members often discuss whether students need more or less educational content that is specific to healthcare versus generalized manage- ment education that can apply to a variety of industries and settings. From time to time, evidence of these discussions appears in public (AUPHA Open Forum, 2013), demonstrating that no consensus has yet emerged. However, there has been no systematic attempt to measure the ratio of general versus specific content in healthcare management education, much less to define what that ratio should be. Thus the debate turns on individual opinion and respective department or . The U.S. has often been characterized as unique. Its size, complexity, regulatory requirements, and structure have led observers to declare that it stands apart from other industries as well as from healthcare systems of other countries (Shi & Singh, 2010). The assertion of uniqueness has influenced the education, supervision, and development of healthcare managers and leaders for many years. Specialized programs in of business, health , , and have focused their cur- ricula on the challenges of managing complex healthcare systems to deliver a quality product to a vast and diverse market in a fast-changing environment. Yet others remain convinced that healthcare operates for the most part like any other business, albeit with certain industry-specific aspects that require managers to develop particular knowledge. Under this view, the basic tools employed by most businesses can be used for managing healthcare organiza- tions. For example, Swayne, Duncan, and Ginter (2008, p. 9) suggest that with some customization the same kind of strategic management used in business applications “does seem to provide the necessary processes for health care organizations to cope with the vast changes that have been occurring.” As a result, some have questioned how much of the healthcare manager’s involves unique responsibilities found only in the healthcare industry, and how much is transferable from any business or organizational setting (Bois- soneau & Kirkman-Liff, 1991). Healthcare executives engage in managerial activities that are specific to healthcare, yet many of their job duties are present in nearly all industries. For example, all managers need good communication, leadership, teamwork, and interpersonal skills no matter what industry they serve (Blair & Hunt, 1986; Clement, et al., 2010). Furthermore, as corporate institutions, healthcare organizations must comply with the same regulations The Uniqueness of U.S. Healthcare Management: A Linguistic Analysis 199 that govern all businesses and incorporated nonprofit entities. All healthcare organizations must follow Generally Accepted Accounting Principles (GAAP), they must comply with the reporting requirements of the Sarbanes-Oxley , and they must establish human resource and workplace safety practices that conform to federal and rules governing employers. On the other hand, meeting the needs of patients and ensuring a commu- nity’s health require a managerial focus found only in the healthcare industry. The healthcare management and health administration education programs have created and adopted competency models that articulate the industry’s needs and its expectations of the managers and leaders it employs. Because these models have been developed by healthcare industry insiders, it makes sense to assume that the competencies they contain are specific to healthcare. However, to our knowledge, no one has critically examined these sets of competencies to determine which are exclusive to healthcare managers and leaders, but not necessarily essential for executives in other industries. Of the competencies a healthcare manager should be expected to master, how many should focus specifically on healthcare? This question has important implications for healthcare management educators. If most of the competencies required of executives are unique to healthcare, then programs need to ensure that their curricula are appropriately designed to deliver this content, and a greater proportion of faculty with specific healthcare expertise is needed. However, if healthcare executives mostly need to exhibit managerial skills that are commonly found across many industries, then programs can either outsource portions of their curricula to general man- agement education programs, or employ faculty who have expertise in the discipline they teach regardless of their healthcare . As Weil (2013) observes, most healthcare management educators do not have MHA degrees and/or professional experience as healthcare administrators, and individuals with diverse backgrounds do the job of educating future healthcare leaders (Ginter, Menachemi, & Morrisey, 2009). Is this cause for concern? In this paper, we first examine the general versus specific nature of man- agement in healthcare, briefly reviewing the literature on the topic. We then analyze five well known competency models to measure their healthcare-specific content. We conclude by highlighting aspects of the industry that distinguish it from other kinds of businesses, to suggest some areas of industry-specific instruction necessary to develop good healthcare managers and leaders.

Healthcare Management Competencies Though some prominent and medical statesmen have argued that healthcare should not be considered a business (Arrow, 1963; Relman, 2005), 200 The Journal of Health Administration Education Summer 2014 all agree that its institutions must be run efficiently. For years, healthcare administrators have applied lessons learned from successful businesses in other industries. The application of management principles and to healthcare delivery dates back to the 1920s, and the field grew rapidly in the 1950s and 60’s (Hilsenrath, 2011; Weil, 2013). Healthcare delivery organizations, especially , have borrowed a great deal from manage- ment and practices developed for firms in many different industries. Adoption of these practices has been encouraged by management researchers inside and outside healthcare, resulting in improved quality and efficiency for those who embrace them (Gawande, 2010; Griffith, 2007, 2009). In addition, management have recommended that healthcare administrators ex- amine the business models of companies in other industries (e.g., Christensen, Grossman, & Hwang, 2009). This is not a new trend. Some years ago, hos- pitals began adopting Lean, Six-Sigma, and Process Improvement programs, all of which were originally developed for applications. The business press has periodically published reports of executives visit- ing Toyota factories in Japan where they have learned methods such as Root Cause Analysis, Kaizen, and Stream Mapping (Wysocki, 2004), ideas which have become commonplace in healthcare today. A number of scholars have noted that healthcare management requires both general and specific competencies, a distinction between context-specific knowledge, skills, and abilities that apply to healthcare - tings, and context-free disciplines that apply across many different kinds of organizations (Blair & Hunt, 1986; Clement, et al., 2010; Shewchuk, O’Connor, & Fine, 2005). Competency models were developed through -based methods that involved healthcare educators and practitioners who provided input regarding the knowledge, skills, and abilities (KSAs) needed to man- age healthcare organizations. These efforts employed qualitative interviews (Bradley, 2003; Campbell, Lomperis, Gillespie, & Arrington, 2006), quantita- tive surveys (Clement, et al., 2010), and both (Calhoun, et al., 2008; Shewchuk, O’Connor, & Fine, 2005, 2006). The resulting models were deemed specific to healthcare because they were based on research that queried stakeholders in the healthcare industry, not necessarily because the KSAs that emerged were unique to healthcare. The very nature of competency models relies on a more general system of articulating duties that certain require, and thus they are adaptable to a variety of settings (Garman & Johnson, 2006). The need to separate context-specific from context-free managerial activities is rooted in the management research field, where it is useful to distinguish between variables that apply to one type of from those that apply to multiple organizations (Blair & Hunt, 1986). Less specificity implies a certain The Uniqueness of U.S. Healthcare Management: A Linguistic Analysis 201 level of general skill that someone entering the healthcare management field will need in order to succeed. For example, in the Yale model (Bradley, et al., 2008, p. 41), a competency related to is written generically as “financial analysis, including financial statements.” Thus, an individual who achieves this competency by completing designed to produce it should be able to succeed in just about any industry that needs people to perform financial analysis and read financial statements. On the other hand, higher specificity implies a certain body of knowledge required to dothe job; another competency in the same domain of the Yale model focuses on a particular problem in healthcare management: “Analyzing social and behav- ioral determinants of health.” Though some general courses can contribute to a ’s ability to perform this task, discipline-specific coursework is required to achieve this particular competency. The Healthcare Leadership Alliance (HLA) assembled the competency models of six major professional membership associations and observed a significant amount of overlap among the items (Stefl, 2008). A task force examined these items and combined them into five common clusters, mean- ing they existed among the models of all six associations even though their members had compiled them independently. The five clusters, or domains, were 1) Communication and Relationship Management; 2) Leadership; 3) Professionalism; 4) Knowledge of the Healthcare Environment; and 5) Busi- ness Skills and Knowledge. The fact that these domains cut across the six professional associations representing healthcare executives, medical group managers, nurses, and executives suggests the existence of a more general model of management education that applies to multiple healthcare and settings. The main competency models developed for healthcare administration education (both programs and professional leadership develop- ment) contain both general managerial and healthcare-specific KSAs, but to our knowledge, no research has been conducted to estimate the proportion of each. We report an exploratory study of five well known competency models in order to assess the proportion of general versus healthcare-specific KSAs that the industry has articulated. The incidence of healthcare terms in com- petency models serves as a measure of the healthcare-specific content within the various models and thus an indication of the need for healthcare-specific KSAs among managers. Because this study is exploratory, we have made no a priori hypotheses about the expected proportion of generalized managerial competencies versus healthcare-specific competencies in the models. 202 The Journal of Health Administration Education Summer 2014

Methods and Data We examined five competency models that have been developed in recent years. The five models were: 1. ACHE (2012), 229 competencies. ACHE offers a tool for its members to assess their KSAs in healthcare management. ACHE describes its competencies as a subset of those articulated in the Healthcare Leader- ship Alliance (HLA) Model, which covers a larger number of healthcare settings and disciplines. 2. Four-University Model (Clement, et al., 2010), 30 competencies. A group of four university health administration programs reviewed several existing competency models, including ACHE. The group settled on a set of 30 competencies, which they validated with a survey of their respective constituencies. 3. The Healthcare Leadership Alliance (2010), 801 competencies. The Health- care Leadership Alliance (HLA) is collaboration among six healthcare management professional associations: ACHE, ACPE, AONE, HFMA, HIMSS, and MGMA. The collaboration resulted in an extensive inven- tory of competencies, which can be filtered to produce subsets tailored to the setting and/or responsibilities of an individual manager (Stefl, 2008). Though there is duplication with the ACHE model and considerable overlap of competencies among the other five organizations as described above, we analyzed all 801 competencies in this study. 4. NCHL (2006), 26 competencies. Based on job analysis, the NCHL effort resulted in fewer – but more detailed and articulated – competency state- ments under three domains (Transformation, Execution, and People), each of which also contained more complete explanations than most competency models’ domains (Calhoun, et al., 2008). In addition, for each competency the NCHL overlaid “levels” of performance intended for use in personal assessment practices, an added dimension that resulted in 149 data points (26 competencies with 3 to 6 performance levels each).1 5. Yale Model (Bradley, et al., 2008) 20 competencies. A simpler model designed to focus on core elements of healthcare management identified in prior research, the 20 competencies in three domains map readily

1The fact that each performance level was articulated to include behaviors relevant to the competency prompted us to consider whether to analyze this model as 26 competencies, or as 149 competencies with levels. We chose to analyze only the 26 competencies because although the performance levels contained verbiage relevant to their competencies, they represented scaled measures of performance, rather than competencies themselves. The Uniqueness of U.S. Healthcare Management: A Linguistic Analysis 203

onto the program’s . Linguistic content analysis was performed on the five competency mod- els. Following commonly used content analysis procedures, the comments were coded by two independent researchers. The researchers followed the customary protocol used in textual analysis studies where the content is given a specific code representing categories of interest (Krippendorff, 1980). In this study, we employed a categorical scheme in which the two researchers coded each competency as either “healthcare-specific” or “general-managerial.” A competency was defined as “healthcare-specific” if it contained any verbal reference to health, healthcare, health systems, medical facilities, the commu- nity or population served, patients, doctors, nurses, other providers, insurers, regulators, or any other health-related term. We were deliberately liberal in defining “health-related” terms, expanding the definition to include words like “,” “public,” or “population,” since these concepts have specific meaning for healthcare managers and those working in health , as well as educators in public health programs. Although some could argue that the latter set of terms simply describes any business’s customers or markets, in the context of healthcare management, we interpreted them as representing a stakeholder segment specific to the industry. The researchers worked independently of each other and did not consult during the coding process. After the five competency models were evaluated by each researcher, the results were compared, and the percentage agreement between the two researchers was 97.1%. Discrepancies were flagged and subsequently discussed in order to come up with a “consensus” code, which was then used in the analysis.

Results The analysis of healthcare-specific and general managerial competencies is presented in Table 1. The mean percentage of healthcare-specific content across the five competency models was 22.1%, ranging from a low of 16.7% for the Four-university model to a high of 25.3% for the HLA model. Thus, over three-fourths (77.9%) of the competencies in the five models were not healthcare-specific, but rather were general managerial. The percentages were quite consistent across models, and we found no significant differences between the models (χ2 = 2.55, df = 4, p = .635). In addition, the three industry-created competency models did not differ from the two university-created models in terms of their numbers of healthcare specific competencies. 204 The Journal of Health Administration Education Summer 2014

Table 1 Healthcare-Specific and General-Managerial Competencies in Five Compe- tency Models.

Compentency Model Four- ACHE University HLA NCHL Yale Number of competencies 229 30 801 26 20 Number of healthcare-specific 50 5 203 5 5 competencies Percent healthcare-specific 21.8 16.7 25.3 21.7 25.0 compentencies Percent general managerial 78.2 83.3 74.7 78.3 75.0 competencies

Discussion The majority of items in five well known competency models have to do with general managerial (as opposed to healthcare-specific) KSAs. Furthermore, the proportion of healthcare-specific competencies did not differ significantly from one competency model to another. This latter finding is not surprising given the overlap, borrowing, and duplication among all the models, as well as their common roots in the research defining the field. These findings have several implications. First, many items in the com- petency models we analyzed are tools that any good manager should have in order to perform well on the job in healthcare or elsewhere. Every employer needs managers who can write well, make cogent and persuasive presenta- tions, think strategically, act professionally, and get along with people. While generic, these skills are so important that they must appear in organizations’ competency models and university programs’ curricula. Other competencies are specific to healthcare, but not necessarily unique to healthcare. An individual who enters an industry having successfully mastered a general business discipline (e.g., finance, accounting, management, market- ing) must learn industry-specific methods, practices, language, and norms in order to become an effective contributor. For example, someone working in healthcare finance must know about coding, billing, revenue cycle, third-party payers, and regulatory compliance, among other things. If he/she did not learn these specifics in school, they must be learned on the job, along with all the associated terminology. The same principle applies in other industries that employ people to perform duties in finance. In the apparel manufacturing and industry, for instance, finance executives with third-party The Uniqueness of U.S. Healthcare Management: A Linguistic Analysis 205 payers known as Factors, that play a crucial role in guaranteeing payment and managing receivables. Billing and handling inventory for the garment business is complicated and much of the industry relies on export-import trade, which is regulated by U.S. and foreign governments, necessitating industry-specific compliance expertise. Some basic, general financial-management KSAs are required in both healthcare and apparel industries, but the context-specific applications differ. In healthcare, as in many other industries, a particular set of KSAs is necessary but not sufficient to achieve success, both individually and organi- zationally. This distinction is illustrated by an example from the HLA (2010) Model, which contains a competency that states, “Promote decisions that are patient-centered.” Changing the word “patient” to “customer” turns this competency into a general managerial item that applies to just about any business: “Promote decisions that are customer-centered.” In both of these cases, the phrasing of the competency has considerable face validity. Organizations require that managers consider the needs of their constituencies when they make decisions, and this competency implies that organizational changes be made in such a way that the constituents’ needs receive greater priority than the staff’s . The words “patient” and “customer” imply specific kinds of business organizations set up to serve them, but neither suggests that its industry is unique. The competency is industry- specific but transferable across industries. Our analysis of the five competency models provides useful insight into the healthcare-specific versus generic aspects of the managerial responsibilities within the industry. However, as the preceding paragraph illustrates, simple changes can transform most healthcare-specific competencies such that they can be adapted and applied across different industry settings, leaving one to wonder whether healthcare is simply a different vertical in an array of industries.

What Makes Healthcare Unique? It is important to draw a distinction between the industry-specific aspects of healthcare management and the ways in which healthcare is truly unique – how it stands apart from other industries and why it requires KSAs that managers in other industries do not share. Here we put forth a set of propositions that we believe help to illustrate some ways in which healthcare is like no other industry. These apply primarily to institutions engaged in health services delivery rather than to organizations like pharmaceutical companies, medical device manufacturers, health plans, specialists, makers 206 The Journal of Health Administration Education Summer 2014 of medical supplies, and others that provide or services to healthcare delivery organizations. This list is not meant to be exhaustive, but rather il- lustrative of some unique characteristics of the industry.

The unique responsibility to deliver care to the community Institutional providers bear the burden of a public health imperative that other industries do not share, and it manifests in several ways. Since the pas- sage of the Emergency Medical Treatment and Active Labor Act (EMTALA) in 1986, hospitals may not turn away patients because of a lack of ability to pay. Though hospitals have shifted the costs of treating non-paying patients to other payers and have built these practices into their business models, one is hard-pressed to find another industry in which customers may, under certain circumstances, demand goods or services without payment. Hospi- tals must demonstrate not only EMTALA compliance, but also that they are meeting the community’s needs and providing charity care by off uncollectable debts of patients unable to pay (Schlesinger & Gray, 2006). In addition, many hospitals maintain unprofitable service lines because patients need the services and cannot access them elsewhere (Halley, 2007). Finally, healthcare organizations must maintain ongoing readiness to accept a surge of patients in the event of a natural disaster or epidemic. In order to perform this function effectively, institutions must put aside competitive differences, coordinate activities, and cooperate with one another for the good of the public. Collaborating closely with rival hospitals to respond to a community health crisis is something that healthcare executives plan for and actually practice; in no other industry must intra-market competitive organizations collaborate to ready themselves for such crises that the public.2

The unique role of The medical problem-solving process takes place in what Mintzberg (1983) terms the “professional bureaucracy,” where professionals work with a great deal of autonomy in serving their individual clients. Through long periods of education and socialization, physicians have been trained to be autono- mous decision makers working independently of each other and free from administrative supervision. Tension occurs between officials whose primary authority and loyalty are rooted in their supervisory positions and profes-

2One could argue that public utilities are also required to cooperate and coordinate with other utilities in the event of an emergency that knocks out power, sometimes to millions of residents. However, unlike hospitals, utilities are granted rights to operate in geographic service areas, so they do not coordinate their disaster recovery efforts with direct competitors in the same market. The Uniqueness of U.S. Healthcare Management: A Linguistic Analysis 207 sionals whose authority is derived from a fealty directed toward a discipline and its concomitant norms and obligations (Schultz & Pal, 2004). Etzioni (1964) crystallized the basis of the tension: “The ultimate justification for the professional’s act is that it is, to the best of the professional’s knowledge, the right act. The ultimate justification of an administrative act, however, is that it is in line with the organization’s rules and regulations, and that it has been approved, directly or by application, by a superior rank” (p. 77). Mintzberg (1983) cites three managerial challenges unique to professional organizations. First, there are problems of coordination. With a high degree of autonomy and fragmentation driven by specialization, managers lack the means to coordinate care processes in the name of efficiency and effectiveness. Second are problems of discretion. While professional judgment depends on discretion, the downside is that some professionals may find the room to ignore needs of clients and overall needs of organization. Finally, there are problems of . Professional bureaucracies, similar to machine bureaucracies, are designed for stable environments. Their tendency is to make processes as predictable and routine as possible. The ability to innovate in this type of environment is severely constrained. In healthcare, these problems are extremely difficult to manage by indi- viduals who are not members of the profession, and they are amplified by increased financial pressures and demands for of hospitals, especially regarding metrics for quality processes, outcomes, and patient experience. Hospital administrators, tasked with improving these metrics, have no control over physicians’ clinical decisions, which can affect hospitals’ quality outcomes and patient experience. The ethical obligations of physicians to serve the needs of their patients come at the expense of the corporation’s needs, regardless of whether they are employed in independent private practices or by institutions (American Medical Association, 2012; Liebler & McConnell, 2011). A key characteristic of the professional bureaucracy such as the medical care organization is that the work of professionals in diagnosing, prescribing, and treating is too complex to be easily standardized and the outcomes are difficult to measure. Therefore, professionals must be free to exercise their judgment. Their judgment is based on a fund of knowledge and skill set that comes from long periods of , , and socialization. Lack- ing this knowledge base, others (e.g., managers) cannot claim to understand what is transpiring in the medical problem-solving process.

The unique level of scrutiny and regulation that institutional providers must undergo3 This aspect is not entirely unique to healthcare, since other heavily regu- lated industries are subject to inspection and oversight by state and federal 208 The Journal of Health Administration Education Summer 2014 regulatory agencies (e.g., , , utilities). However, institutional healthcare providers (especially hospitals) experience more intensive regula- tory examination than any other regulated industry. Banks, for example, are inspected for their financial soundness, lending practices, and transparent transaction processes, but regulators do not worry about customers’ safety. regulators examine carriers’ maintenance procedures, training, and safety practices, but they do not review the financial transactions between companies and customers. Utilities must demonstrate consistent quality service, as well as service restoration after disasters and unexpected outages, but regulators rarely need to assess how well the utilities guarantee customer safety or examine the financial transactions between companies and custom- ers. Institutional healthcare providers, on the other hand, must offer for inspection all records for all actions every day. This requires an intense level of recordkeeping and compliance which must be managed closely and will become increasingly important as Medicare and Medicaid reimbursement is tied to performance outcomes.

The role of third-party payers Healthcare is almost always paid for by third parties, insulating consumers from the true cost of the services they use, and most people have no idea what healthcare costs. Nor is it easy to find out. The RAND Health Experiment showed that, when consumers are not engaged in paying for the cost of their care, over-utilization often results (Keeler, Buchanan, Rolph, Hanley, & Rebous- sin, 1988). This problem, known as moral hazard (Pauly, 1968), is common to all forms of , but the scale of coverage makes it a unique aspect of healthcare utilization. These findings were reinforced in a recent study showing that when insured patients need medical care, they want providers to make decisions without considering the costs of tests and treatments (Sommers, Gould, McGlynn, Pearson, & Danis, 2013). If they have paid for health insurance, consumers want no expense spared when they need to use it. Thus, the normal market forces that constrain demand in most in- dustries (i.e., prices paid by customers) are less prominent in healthcare, and demand grows in ways that other industries do not experience. In addition, third-party payers are playing a more active role in healthcare delivery, from CMS’s Value-Based Purchasing initiatives, to shared-risk programs such as Accountable Care Organizations and Patient Centered Medical .

3We single out institutional healthcare providers like hospitals because private practitioners operate with far less formal regulation. Individual physicians’ practices are not regulated by state departments of health, for the most part, even though many tests and procedures that were once performed only in hospitals are now performed in physicians’ offices or in facili- ties owned and operated by physicians. The Uniqueness of U.S. Healthcare Management: A Linguistic Analysis 209

Ethical issues Healthcare organizations place additional burdens for ethical judgment on administrators who often deal with and establish policies that affect patients and family members facing end-of-life decisions, chronic illnesses, or rare diseases. Furthermore, administrators must deal with the unique role of the physician in the medical problem-solving process and the special relationship between doctor and patient, even as greater numbers of physicians become employees. It is clear from professional codes of ethics that whether the physi- cian is an independent practitioner or an employee, the primary loyalty should be to the patient. Only the physician can articulate the best interests of the patient. In earlier decades, management’s major ethical responsibility was to properly maintain the “doctor’s workshop.” Physicians could then be relied on to protect the integrity of the clinical decision-making process, buttressed by their codes of ethics and their self-regulating, autonomous medical staff organization, which in turn was defended by politically powerful professional associations. To be sure, a lot has changed over the years, including the erosion of the medical staff organization. Healthcare managers now have ethical obligations not only to support the doctor-patient relationship, but to steward scarce re- sources for their organizations and , and to consider the ethical ramifications of resource-allocation decision making. For example, the deci- sion to discontinue an unprofitable program that the community needs so that the hospital’s resources can be devoted to a more profitable, fully reimbursed service line has serious ethical implications for both medical professionals and administrators. To say the least, the tensions between the best interests of the patient as determined by the professional and the obligations of management can never be fully resolved, but most certainly the list of ethical issues facing healthcare managers has expanded dramatically.

Conclusion Extrapolating from the results of this study, one might conclude that since less than 25% of the competencies are healthcare-specific, programs need only devote 25% of their curricula to healthcare courses. But it is not so simple. First, our analysis measured a simple division between general and specific competencies, but we do not know how educators and administrators would regard the ratios we found. To our knowledge, programs’ curricula have not been evaluated through the lens of general managerial versus healthcare-specific content, and we do not know whether 25% is high, low, or about right, in the minds of faculty and practitioners. Further research should investigate the perspectives of healthcare leaders, program directors, and faculty with regard to the need for each form of content. 210 The Journal of Health Administration Education Summer 2014

Second, the ways in which healthcare delivery represents a unique indus- try (five of which we outlined above) are almost always covered in programs’ curricula within courses on the healthcare system, health policy, healthcare management, and ethics. However, they are somewhat difficult to discern in competency models. By , competencies are behavioral, while the factors we listed to illustrate the industry’s uniqueness are conceptual. In light of the constraints that these challenges impose on healthcare managers, programs must emphasize them in the curriculum so that students gain a theoretical understanding of why professionalized organizations behave as they do. Students must understand these contextual factors to perform effectively as healthcare managers and leaders, but the behavioral competencies they need to demonstrate may be general managerial, healthcare-specific, or both. It is not clear that revising competency models to highlight this theoretical context more explicitly would be worth the effort, but it is clear that competencies are not context, and this represents a limitation of competency-based education. Finally, the industry requires an appropriate mix of general managerial and healthcare-specific competencies. Paying too much to general managerial competencies significantly lengthens the curve for students who enter healthcare because they must learn the specifics on the job. On the other hand, focusing too much on healthcare industry-specific practices may result in a narrow that deprives both individuals and organizations of valuable lessons from the outside. We have much to learn from others. Years ago, forward-thinking administrators ventured to Japan to learn about Toyota’s Lean processes, and then successfully applied them to hospital operations. More recently, Gawande (2012) ventured to The Cheesecake Factory to learn the insights, tools, and processes needed for consistent service production by a chain, musing whether scalable practices from large chain organizations can be applied to achieve more effective delivery of healthcare services. Chassin and Loeb (2013) benchmarked practices from industries with excellent records for safety, in hopes of learning lessons that could be applied to healthcare to reduce the number of errors. And discussing the need for more innovation in healthcare, Coye (2013) encouraged administrators to borrow “shamelessly” from other industries to gain insights that can improve patient experience and operational effectiveness. Resistance to improving the organizational efficiency of the healthcare delivery system may partly be due to the that healthcare is so unique that lessons from outside the industry do not apply. Although a combination of general and healthcare-specific KSAs is needed by students who will someday lead the healthcare industry, no consensus exists regarding how much of each would be . This is important to healthcare The Uniqueness of U.S. Healthcare Management: A Linguistic Analysis 211

management educators because time limits the amount of industry-specific content and theoretical context programs can offer (Mick, 2004). This problem is aggravated by the increasing number and diversity of settings that employ healthcare managers, as well as the varied backgrounds of faculty (Weil, 2013). It is our hope that this study will initiate a more rigorous analysis and a broader discussion of what constitutes the right proportions.

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