Gender and leadership in healthcare administration: 21st century progress and challenges.
Subject: Leadership styles (Analysis)
Health services administration (Management)
Health services administration (Social aspects)
Gender equality (Analysis)
Gender equality (Social aspects)
Author: Lantz, Paula M.
Pub Date: 09/01/2008
Publication: Name: Journal of Healthcare Management Publisher: American College of Healthcare Executives Audience: Trade Format: Magazine/Journal Subject: Business; Health care industry Copyright: COPYRIGHT 2008 American College of Healthcare Executives ISSN: 1096-9012
Issue: Date: Sept-Oct, 2008 Source Volume: 53 Source Issue: 5
Topic: Event Code: 200 Management dynamics; 290 Public affairs Computer Subject: Company business management
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 186268972
Full Text: EXECUTIVE SUMMARY

The need for strong leadership and increased diversity is a prominent issue in today's health services workforce. This article reviews the latest literature, including research and proposed agendas, regarding women in executive healthcare leadership. Data suggest that the number of women in leadership roles is increasing, but women remain underrepresented in the top echelons of healthcare leadership, and gender differences exist in the types of leadership roles women do attain. Salary disparity prevails, even when controlling for gender differences in educational attainment, age, and experience.

Despite widespread awareness of these problems in the field, current action and policy recommendations are severely lacking. Along with the challenges of cost, quality, and an aging population, the time has come for a more thoughtful, policy-focused approach to amend the discrepancy between gender and leadership in healthcare administration.

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The healthcare and public health systems in the United States face a number of opportunities and serious challenges related to access, quality, cost containment, and infrastructure (Baker and Koplan 2002). Demand for significant change and strong leadership to guide the necessary transformations is forceful and pervasive (Health Research and Educational Trust 2006), and agreement is widespread that the clinical staff and management of healthcare organizations should reflect the gender, racial, ethnic, and cultural diversity of the communities they serve (Dreachslin 2007). The latest trade and academic publications feature numerous articles on the business case for diversity, especially diversity within executive healthcare leadership (Anderson, McLaughlin, and Smith 2007; Swedish 2007; Lofton 2007).

Women compose 78 percent of the healthcare industry's workforce and are the largest consumers of healthcare (Kirchheimer 2007). They remain underrepresented in top management and executive leadership positions, however, and serious structural barriers appear to be impeding progress toward greater gender diversity (Weil and Mattis 2001).

The focus of this article is the published literature regarding gender and leadership in the healthcare industry. This review includes an examination of relevant research/data that exist in the public domain and proposed action agendas/policy prescriptions that have been put forth by professional associations, organizations, and individuals.

GENDER AND EXECUTIVE HEALTHCARE LEADERSHIP

American College of Healthcare Executives Surveys, 1990-2006

The American College of Healthcare Executives (ACHE) conducts periodic surveys of random samples of its affiliates to describe and compare key aspects of male and female executives' career attainment. It conducted surveys in 1990, 1995, 2000, and 2006 and achieved response rates of 68, 60, 57, and 52 percent, respectively (ACHE 2006). Survey results suggested that women executives are much more likely than males to be a department head or to fill some other staff position, whereas men are much more likely to be chief executive officer (CEO), chief operating officer (COO), president, or vice president. Among ACHE's executive members, the proportion of female CEOs changed insignificantly between surveys: 11 percent in 1990; 8 percent in 1995; 11 percent in 2000; and 12 percent in 2006.

Self-reported information on salary suggests that women healthcare executives earn significantly lower salaries than men executives (see Table 1). The male-female salary gap, adjusting for education and experience/time in the workforce, has been stable over time: men earned 18 percent more than women in 1990, 17 percent more in 1995, 19 percent more in 2000, and 18 percent more in 2006. In 2006, nearly one-third (29 percent) of women said they did not receive fair compensation because of gender, compared to only 1 percent of men.

Male and female healthcare executives differ in some key family characteristics, as shown in Table 2. Across the ACHE surveys, male executives were significantly more likely to be married than female executives (p < 0.05). About one-third of male executives who were married had a spouse who worked full time, compared to the majority of married female executives (p < 0.01). Females were significantly more likely to believe that they held a disproportionate burden of family/home responsibilities. In addition, 0 to 3 percent of males reported a voluntary withdrawal from the workforce for a family-related reason (e.g., spouse career move, children), compared to 9 to 27 percent of females across the survey years.

In 2006, ACHE asked respondents a series of attitudinal questions regarding gender equity and treatment in their organizations. As shown in Table 3, males and females differed significantly in their responses to these questions. Despite these differences, the results revealed that the majority of executive respondents--male and female--believed that gender equity was present within their organization and that they personally had experienced equal treatment.

Racial/Ethnic and Gender Comparisons of Career Attainment in Healthcare Management

In 2002, ACHE and the National Association of Health Services Executives (NAHSE, whose membership is primarily African American) conducted a study to compare career attainment across race and gender in the two associations. They distributed surveys to a random sample of men and women from ACHE and NAHSE membership lists and achieved a response rate of 41 percent. Among male members who held top executive positions, 62 percent of white males, 44 percent of African-American males, and 47 percent of Hispanic males were CEOs. Among female top executives, 40 percent of white females, 26 percent of African-American females, and 25 percent of Hispanic females were CEOs. These data do not reveal the percentages of male and female CEOs in various racial/ethnic groups.

Gender and Leadership in Solucient 100 Top Hospitals

Little information exists about the number of women in leadership positions in hospitals. To add to the literature on the subject, the University of Michigan conducted a study to identify the gender of chief hospital administrators in the United States. This study investigated hospitals considered to be high-quality, leading institutions (Solucient 100 Top Hospitals in 2005), selected under the assumption that these cutting-edge, progressive hospitals were most likely to have significant gender diversity in their leadership. The results revealed that of the 474 chief administrators of the top hospitals, 114 (24 percent) were women (Dunham and Yhouse 2007). The results also revealed that nearly one-third (30 percent) of the Solucient 100 Top Hospitals employed no female chief administrators, and another third (34 percent) employed one female chief administrator. Female chief administrators were far more likely to be CIO [chief information officer] or CHR [chief human resources officer] (43 percent of the positions) rather than CEO, COO, CFO [chief financial officer], or CMO [chief medical officer] (16 percent of the positions). Out of 100 top-performing acute care hospitals in the United States, only 15 employed a female CEO. In conclusion, the study asserted, "that so little progress has been made to close the gender gap in healthcare leadership is surprising against the backdrop of anticipated demand in hospital leadership in the near to mid-term outlook. The nation's top hospitals should be leaders in the effort to remove gender bias in the selection of chief administrators" (Dunham and Yhouse 2007).

Witt/Kieffer Report on Preparation of Future Leaders in Healthcare, 2002

Witt/Kieffer, a large executive search firm that specializes in education and healthcare, conducted a survey on leadership cultivation in the healthcare industry in 2001, targeting the CEOs of U.S. hospitals and health systems. Of the 1,600 CEOs surveyed, only 11 percent responded. Although the survey methods and response rate raise concerns about the generalizability of the results, the report concluded that many CEOs believed the healthcare industry drives away future leaders. This conclusion was based primarily on descriptive data that revealed the majority of respondents strongly agreed or agreed with the following statements about executive leadership in the healthcare industry (Witt/Kieffer 2002):

* They work unreasonably long hours (54 percent).

* Potential leaders are unwilling to spend hours working at the expense of their personal priorities (53 percent).

* A lack of financial resources does not allow for effective mentoring of future leaders (73 percent).

* Boards fail to commit to leadership development and succession planning (56 percent).

* Leaders fail to identify and develop successors (50 percent).

Sixty-seven percent of the CEOs who responded to the survey reported that they were not investing in leadership career paths for potential future leaders but tended to create short-term management roles instead. The majority of the CEOs also reported that they did not engage in future leader screening or evaluation (57 percent) and missed or ignored mentoring opportunities (75 percent). Approximately three out of four CEOs (73 percent) indicated that they prioritized strategic, financial, and operation issues over mentoring.

The CEOs believed they did a better job of mentoring future women executives than minorities into leadership roles because they perceived the talent pool of women to be larger. Forty-eight percent stated that the healthcare industry failed to develop women leaders effectively, and 68 percent stated the same about the industry's investment in developing minority leaders. Fifty-five percent believed that healthcare effectively develops women leaders through exposure to boards and board committee work, and 41 percent believed the same to be true for minorities in the field. As with many other surveys/reports on executive leadership in healthcare, the 2002 Witt/Keiffer report did not consider gender and race/ethnicity simultaneously.

CROSS-CUTTING ISSUES

Gender and Leadership Style

An important question is whether men and women lead organizations differently, and if they do, whether these differences may be influencing promotion to executive positions. Several studies have focused on differences in leadership style based on gender. Transformational or charismatic leadership is the ability to motivate, inspire, and stimulate workers to contribute toward organizational goals and organizational change (Van Engen and Willemsen 2004). Transactional leadership focuses on monitoring employee performance, intervening and correcting when necessary, and rewarding solid performance and achievement of objectives. Many studies have found that women tend to adopt a more transformational style of leadership (Bass, Avolio, and Atwater 1996; Eagly and Johannesen-Schmidt 2001). A recent meta-analysis of research on gender and leadership concluded that, although some gender differences in leadership style may in fact be present, "there is no justification for claims that female leaders are underrepresented in a leadership role because they lack appropriate leadership styles" (Van Engen and Willemsen 2004, 13).

Nonetheless, research suggests that leadership ideals and perceptions are gendered (Neubert and Palmer 2004; Gilmartin and D'Aunno 2008). Several experimental studies have revealed that men and women prefer male leaders, even when the credentials of candidates are the same (Carnes and Bland 2007). Stereotypical female attributes and behaviors--such as cooperation, modesty, and emotiveness--tend to be perceived as incongruent with strong leadership, whereas stereotypical male attributes and behaviors--such as assertiveness, stability, achievement orientation, and independence--tend to be viewed as fundamental to leadership (Eagly and Wood 2001). In addition, if women exhibit some of the traits or characteristics associated with strong leadership, they may be perceived negatively because they have stepped outside of their socially defined roles (Neubert and Palmer 2004).

A related issue is the representation of gender in healthcare leadership models and training (Garman and Johnson 2006; Calhoun and colleagues 2004). What aspects of gender, if any, should be incorporated into leadership conceptual models and theories? Neubert and Palmer (2004) warn against the strategy of proclaiming the virtues or competitive advantage of "feminine management" because it could unintentionally reinforce gender stereotypes and increase divisiveness. Additional research needs to be conducted to address the appropriate role of gender in the development and promotion of leadership competency models and executive leadership training in healthcare administration.

Key Barriers

If women are just as capable of leading complex organizations as men, what else might be contributing to their underrepresentation in top leadership and the salary differentials that exist once they achieve those positions? The data and research evidence accumulated to-date suggest that gender differences in mentoring and leadership succession planning are key barriers that need to be addressed. Healthcare executives report that this field is not investing enough in mentoring and leadership development, and that this lack of attention is even more pronounced for women and minorities (Witt/Kieffer 2002; ACHE 2006). In addition, exposure and appointment to boards and other governing bodies are critically important to women's leadership development (Catalyst 2006).

We also know that subtle yet challenging aspects of social, gender, and family roles exist that influence women's career progression. Women healthcare executives who are married are significantly more likely to have spouses who work full time than their male counterparts. In addition, among two-career families, women spend more time attending to primary care responsibilities than men and are more likely to take a leave of absence or have a respite from their jobs because of family responsibilities. As Eagly and Cadi (2007) argue, women are spending more rather than less time with their children as a result of an increased tendency toward "intensive parenting." This commitment, combined with the time pressures of most executive positions, means that women have far less time than their male colleagues to engage in socializing, network building, and accumulating social capital essential to successful career progression. We also know that career advancement often involves relocation, which provides a significant challenge to two-career families. The limited data available suggest that female healthcare executives are much more likely to leave their jobs and communities for the career advancement of their spouse than vice versa. In summary, when inevitable sacrifices need to be made in an effort to balance career and family demands, women are much more likely to make those sacrifices than men.

The Intersection of Race/Ethnicity and Gender

The data currently available regarding executive leadership in healthcare administration tend to focus more on gender than racial/ethnic diversity, ignoring the intersection of these two elements. This fact is a problem because it ignores the complexity of diversity and focuses on people only one characteristic at a time. For example, male executives of color face many of the same barriers and challenges as their female counterparts. Furthermore, women of color in executive positions are unaccounted for in most available data, overlooking the experiences and challenges that stem from being both female and from a racial/ethnic minority group in a field where leadership is dominated by white males (Hewlett, Luce, and West 2005).

State of Existing Recommendations

Many of the reports and articles on the need to increase gender and/or ethnic diversity in healthcare leadership include a set of recommendations. For example, a Witt/Keiffer report (2002) included the following set of recommendations for enhancing diversity in the talent pool of future leaders:

1. Determine your healthcare organization's talent gap.

2. Conduct a talent review at least annually to ensure the healthcare organization has management depth for future leadership success.

3. Make mentoring a priority.

4. Give future leaders a voice.

5. Create avenues of interaction with future leaders.

6. Focus on the positives about the industry.

7. Strengthen graduate education, student fellowships, and residencies.

8. Appoint a retiring senior leader to serve as a mentor.

9. Enter the debate on ways to mentor future leaders.

In a report on increasing diversity in the talent pool for healthcare leadership, none of the listed recommendations explicitly mentions gender, race/ethnicity, or the groups these recommended actions are intended to reach. Rather, the recommendations are vague, general, and global. Other public recommendations for increasing diversity also exhibit this lack of attention to gender and race/ethnicity.

Not all recommendations are vague or tread lightly around gender issues. For example, Weil and Mattis (2001) provide a detailed and well-developed set of recommendations to improve career opportunities and outcomes for women. They address both organizations and individuals in the areas of education/experience, work and family balance, organizational factors, career aspirations, and ideology. The set of recommendations for women put forth by Weil and Mattis (2001) includes the following prescriptions:

* Seek to work for organizations that are flexible.

* Avoid career interruptions of six months or more.

* Be willing to work long hours. * Be willing to relocate.

* Aim for positions that are high in the organization's hierarchy.

* Stay focused on long-term goals.

Some of these recommendations implicitly reinforce the notion that women must make great and unequal sacrifices to attain top leadership positions. A recent Catalyst (2006) survey of women in executive positions found that many women, to prove they are committed to their employers and career advancement, have made such sacrifices as not having children, returning to work immediately after childbirth, and limiting family or personal time. Additional strategies recommended consistently across reports/documents on the subject include the following (Eiser and Morahan 2006; Weil and Mattis 2001):

* Improve the mentoring of high-potential women.

* Sensitize employees to the consequences of gender stereotyping.

* Include women in and change the gender dynamics of informal social networks that facilitate advancement.

* Change organizational policies to better support work-life balance.

These recommendations and suggestions are valid enough, but many of them sound more like platitudes or goals than concrete strategies that organizations and individuals can embrace and implement.

CONCLUSION

Over the past several decades, women have achieved entry into virtually every field, including the majority of those traditionally dominated by men. Nonetheless, even with the limited data available at this time, we know that women continue to be underrepresented in top leadership positions in Fortune 500 companies, academia, and government (Carnes and Bland 2007), including private and public organizations dedicated to the delivery of health technologies and services. Progress is being made, and the number of women in leadership roles has increased, but data continue to suggest that salary differentials exist even when controlling for gender differences in educational attainment, age, and experience. The types of leadership roles people fill also continue to vary by gender.

This article has reviewed available data/information and published literature on gender and executive leadership in healthcare. Key issues that remain serious challenges and need additional research and policy attention include the following:

* The need for more effective mentoring of women and minorities

* The need for increased attention to leadership succession

* The role of exposure to boards and board committees in leadership development

* The gender-based trade-offs and sacrifices made within two-career families

* Stereotypes about gender differences in social roles, personality traits, and leadership capabilities

Although attention to the problem is growing and consensus is emerging on defining the issues regarding the advancement of women and people of color in healthcare leadership, the majority of existing recommendations' vagueness and lack of specificity/depth suggest that trepidation and uncertainty remain about how to constructively address the problem. Many of the recommendations put forth to-date are unrealistic or simplistic (e.g., women should avoid career disruptions; women should find a good mentor).

Along with the challenges of cost, quality, infrastructure, and an aging population, the time has come for a more focused and thoughtful approach to the issue of gender and leadership in healthcare administration. Action agendas and concrete policy strategies need to be developed and embraced at the individual and organizational levels (Weil and Mattis 2001). Development of a substantive and meaningful set of recommendations is beyond the scope of this article. Rather, healthcare administrators must prioritize this development and tackle it as a community committed to increasing diversity in its leadership.

Almost ten years ago, Catherine Robinson-Walker (1999, 18) concluded in her Gender and Leadership in Healthcare Study that, "although the future for women leaders is hopeful, progress in attaining top leadership positions is slow. There is little doubt that the future for women in care giving roles is secure, and the groundwork for attaining positions of significant leadership responsibility is laid. Yet, there are still real concerns about when women will arrive in these positions." As we move further into the 21st century, we can recognize and respect the tremendous progress we have made in terms of diversity in healthcare leadership, but we need fresh, creative, substantive approaches to overcome the challenges and barriers that remain.

Acknowledgments

Several colleagues provided useful insights and feedback on this manuscript, including Lois Joy, PhD, Linda Grosh, Patricia Warner; and Jennifer McIntosh. Excellent research assistance was provided by several graduate students in the Department of Health Management and Policy at the University of Michigan School of Public Health: Niquole Dunham, Nonie Hamilton, Margaret Parker, and Helen Reid.

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PRACTITIONER APPLICATION

Patricia A. Maryland, DrPH, president and chief executive officer, St. John Health Warren, Michigan, and ministry market leader, Ascension Health, Michigan

This article is comprehensive and thought provoking. I agree with its findings: Women are still underrepresented in the top echelons of healthcare leadership, and executives of hospitals and health systems have to do more to encourage greater gender (and racial) equity in leadership. My career has tracked differently from those of most women and other minorities within healthcare. Here are some of my experiences and suggestions as they relate to the key findings in this article.

MENTORING

Mentoring has been integral to my success. Throughout my career, I have had strong male mentors who have provided guidance and encouragement. I have not had many female mentors because many women leaders are on their own sort of treadmill, balancing the busy demands of work and family within time constraints. That is changing, however, as more women assume leadership roles and realize the values of mentoring. As a minority female healthcare executive, I understand the importance of a mentoring relationship, especially for women and other minority professionals.

One of my mentors is Dr. Fred Loop, whom I met early in my career at The Cleveland Clinic. Our mentoring relationship has changed throughout the years. Initially, he provided much needed career guidance and counseling, and today, he offers strategic advice and help in brainstorming ideas. Leaders must recognize the continual need for professionals, no matter their position level, to be mentored. Mentors should be aware of a person's capabilities and match that person with the appropriate opportunities. Mentors should also provide continual feedback, encouragement, and any tools that support that person's career goals and ultimate success.

LEADERSHIP STYLE

I agree with Paula Lantz's finding that women's leadership style tends to be transformational whereas men's style is transactional. However, the most effective leader is the person who incorporates both leadership styles. People are generally less threatened by a leader who is emotive and personable. A transformational style can inspire others and create a shared vision among team members. My approach is transformational, but it is underpinned by a transactional philosophy, with a strong focus on accountability and measurable performance.

SOCIAL NORMS AND WORK--LIFE BALANCE

This article thoroughly notes the social differences and family focus between male and female healthcare executives. In my experience, there have been trade-offs, requiring long work hours, relocation, and a high level of personal organization to achieve a work-life balance. Women should not expect an organization to be accommodating to their needs. Rather, they should take the responsibility to effectively manage their needs and goals. I am fortunate for having a flexible and supportive spouse, which has made all the difference in my ability to pursue and focus on my career.

HOSPITAL LEADERSHIP AND AN "ONBOARD" BOARD

The article indicates that Solucient's 100 Top Hospitals included few institutions led by female healthcare executives. To rectify this matter and introduce more gender equity, hospitals must reassess their recruitment practices to better identify the best and most diverse candidates. A good recruitment model is Ascension Health's Talent Management Program, which identifies (1) existing diverse leaders who are highly promotable and are ready for growth opportunities at the top level and (2) current diverse managers who possess excellent skills and proficiencies but require further development to become effective leaders. Once a diverse leader is hired, hospitals must ensure that the individual is positioned for success, providing the necessary tools and "background" support (e.g., mentoring, feedback).

Hospital and health system leadership and governance should reflect the diverse patient population of their communities. This is not just a culturally sensitive practice, it is also smart business. A diverse board is also critical. Such a board heightens the organization's sense of awareness to and support of gender and racial equity in leadership. In addition, a diverse board is more apt to hold the organization accountable and insist on recruitment of diverse leaders.

For more information on the concepts in this article, please contact Dr. Lantz at plantz@umich.edu. This article was prepared for presentation at the Women in Health Care and Bioscience Leadership: State of the Knowledge Symposium, held at the University of Michigan, Ann Arbor, on March 7, 2008. Symposium collaborating partners included Catalyst, the Women's Health Program at the University of Michigan Health System, and the Griffith Leadership Center at the University of Michigan School of Public Health.

Paula M. Lantz, PhD, professor and chair, Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
TABLE 1
Median Salary for Top Healthcare Executive Positions, ACHE Surveys

                            1990       1995       2000       2006
CEOs
  Male                     $88,000   $104,600   $125,700   $170,400
  Female--all              $73,500    $98,500   $104,700   $133,400
  Female--no interruption  $70,000    $98,200   $118,100   $130,900
COOS and Senior VPs
  Male                     $76,300    $92,700   $120,600   $150,200
  Female--all              $70,100    $86,000    $99,300   $125,700
  Female--no interruption  $73,900    $89,500    $94,100   $135,000

TABLE 2
Family Characteristics by Gender, ACHE Surveys

Characteristic                                1990   1995   2000   2006

Currently married *
  Male                                         87%    86%    90%    90%
  Female                                       63%    75%    75%    76%
Spouse works full time *
  Male                                         34%    36%    34%    35%
  Female                                       93%    87%    86%    80%
Mean share of family income contributed *
  Male spouse                                  84%    82%    83%    85%
  Female spouse                                55%    55%    61%    64%
Voluntarily withdrew from workforce
3+ months for spouses career, childbearing,
or childcare*
  Male                                          2%     3%     0%     0%
  Female                                       18%    27%    11%     9%
Responsible for most family/home
obligations *
  Male                                          9%    G%      8%    16%
  Female                                       38%    37%    39%    41%

* p < 0.05 for male/female comparison for all four years

TABLE 3
Attitudes Regarding Gender Equity, 2006 ACHE Survey
                                                      2006     2006
Attitudes Regarding Gender Equity in Organization     Males   Females

Executives here have a track record of hiring          84%     74% *
  employees objectively, regardless of their gender
Executives here have a track record of promoting       86%     71% *
  employees, regardless of their gender
Executives here give feedback and evaluate             85%     74% *
  performance fairly, regardless of the employees
  gender
Executives here assign projects according to the       80%     73% *
  skills and abilities of employees
All in all, I think there is gender equity in my       86%     69% *
  organization
I feel I have been treated differently because          9%     21% *
  of my gender

* p < 0.05 for male/female comparison
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