why hospital improvement efforts fail: a view from the...

Why Hospital ImprovementEfforts Fail: A View From theFront LineClinton O. Longenecker, PhD, Stranahan professor of leadership and organizationalexcellence. Department of Management, College of Business and Innovation, Universityof Toledo, Ohio, and Paul D. Longenecker, RN, PhD, senior instructor. Departmentof Health and Sport Sciences, School of Professional Studies, Otterbein University,Westerville, Ohio

E X E C U T I V E S U M i V I A R YIn the 21st century, healthcare executives are facing changes of unprecedented magni-tude in virtually every area, affecting their ability to compete. That hindrance bringswith it a greater need for rapid and effective organizational change and improve-ment. Yet changes in the U.S. healthcare delivery system have historically been criti-cized as slow and less than effective in responding to the changes necessary for rapidperformance improvement. To that end, the purpose of this applied research studywas to help healthcare executives better understand the barriers to effective organi-zational change and improvement from the perspective of frontline leaders. Focusgroups were conducted with 167 frontline leaders from four community hospitalsto explore why hospital change efforts fail. Participants representing 11 differentfunctional areas, including all facets of hospital operations, were asked to identifythe primary causes of failure of a recent change initiative at their hospital. A contentanalysis of the focus group data identified 10 primary barriers to successful hospitalchange, some of which are ineffective implementation planning and overly aggressivetimelines, failure to create project buy-in and ownership, ineffective leadership andlack of trust in upper management, unrealistic improvement plans, and communica-tion breakdowns. Leadership lessons and recommendations based on the researchfindings are provided.

For more information about the concepts in this article, contact Dr. Clinton Lon-genecker at [email protected].

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I N T R O D U C T I O NTo say that hospitals and healthcaresystems are in the midst of revolutionarychange is an understatement. In the 21stcentury, healthcare executives are facingchanges of unprecedented magnitudein virtually every area, affecting theirability to compete (ACHE, 2011). Thesechanges range ftom new governmentpolicy and regulation to technologi-cal breakthroughs to the demand forcost containment to the search for newsources of revenue to dealing with talentshortages, as well as a wide variety ofhuman resource issues (Dye, 2010;McAIeamey, 2010). And all the while,most organizations in the United Statesare dealing with an abnormal increase involume that brings with it a greater needfor rapid, ongoing, and effective organi-zational change and improvement.

Traditionally, medicine, technology,and reimbursement have been the pri-mary drivers of change in the healthcaredelivery system (Bazzoli, Dynan, Bums,& Yap, 2004). Now, new laws, rules, andregulations associated with the Afford-able Care Act (ACA) have become thedrivers of the healthcare revolution.Open up any current healthcare or busi-ness publication, and you are imme-diately bombarded with eye-poppingheadlines, dire predictions, and datasuggesting that the time for healthcarechange, improvement, and transforma-tion is now. Yet changes in the health-care delivery system are criticized asslow and less than effective in respond-ing to the changes necessary for rapidperformance improvement (Bazzoli etal, 2004).

For the past 30 years, we havebeen involved in both the practice of

healthcare delivery and research onlarge-scale organizational change andimprovement. We have found that akey set of components needs to be inplace for an organization to implementsuccessful change and improvement onan ongoing basis (Longenecker, Papp, &Stansfield, 2007, 2009). Healthcare lead-ers must foster an organizational culturethat embraces and enacts these critical,fundamental practices with passion andacumen. When organizational leadersdo not create such a culture, change andimprovement efforts are problematic.

But why specifically do currentorganizational change and improvementefforts in healthcare often fail to deliverdesired outcomes? Rather than approachthis question ftom the perspective ofsenior leaders who create healthcare strat-egy, policy, and structure, we sought theperspective of ftontline leaders responsi-ble for actually implementing the myriadchanges that are becoming part of theincreasingly large healthcare fabric.

Thus, the purpose of this appliedresearch study is to help healthcareexecutives better understand the fac-tors that allow real, rapid change andimprovement to take place by betterunderstanding the needs of frontlinehealthcare leaders. A quote from onefrontline nursing supervisor who partici-pated in our study helps underscore theimportance of this research effort:

It is hard to get around the fact thatour hospital has to improve muchfaster than it has in the past if we areto make it in the future.. .. One of thebig problems we face in trying to dealwith all this is that we don't always dothe things necessary to make changereally happen; we are always rushing.

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plans can be half baked, and there isusually a gap between what our topadministrators want to have happenand what we are up against on thefloor. . . . We spend a lot of time goingbackwards to try and make changes andfix things when we could have done itbetter the first time.

METHOOSTo explore the barriers to effective orga-nizational change and improvement inthe healthcare industry, we conductedfocus groups with 167 frontline leadersftom four Midwest community hospitalsas part of a formal leadership develop-ment experience that we led. The fourparticipating organizations were non-profit entities; ranged in size from 197to 294 beds, with an average of 238beds; and were secondary care hospitals.For purposes of this study, a frontlineleader is defined as a member of theorganization's management team withdirect supervisory responsibility overemployees who deliver the organiza-tion's services (Longenecker & Simonetti,2001). The frontline leader participantsin this study were 61% female and 39%male, with an average age of 37.9 years.They represented 11 functional areas oftheir hospitals: 68.3% were from clinicaloperations (nursing, respiratory therapy,physical therapy, pharmacy, labs, andtransportation), and 31.7% were frombusiness operations (front office services,information systems, facilities, security,and food services).

In Part 1 of the study, participantswere asked the following questionindividually:

Based on your experience, pleaseidentify a recent organizational change/improvement effort that was ineffective

in that it did not produce the results/outcomes that were desired by yourorganization. Please describe in specificdetail why this effort was ineffective.

Upon completion of this task, par-ticipants were assigned to four-personfocus groups to discuss and comparetheir individual observations andexperiences as a team. All membersof a particular focus group were fromthe same hospital, and every effortwas made to ensure that each grouprepresented a cross-section of front-line leaders from different parts of theorganization to offer a variety of per-spectives on each failed organizationalchange effort discussed. Once assigned,each team was given written guidelinesinstructing each person to share his orher individual findings with the group,encourage equal participation, andencourage each group to work towardconsensus around the top 10 factorsthat caused the target improvementefforts to fail.

Following these discussions, eachteam was asked to provide the facilita-tor with the group's top 10 list. The 42focus groups generated, on average,9.85 factors, which were then content-analyzed using a three-judge reviewpanel to review and assign each focusgroup's factors to an appropriate cause-of-failure category. The three judgeswere seasoned organizational develop-ment professionals with previous expe-rience in this type of qualitative researchanalysis. It is important to note thatthese categories were not predeterminedbut rather emerged as the contentanalysis proceeded. For a factor to beassigned to a specific category, two outof three judges had to independently

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agree that a factor belonged in a particu-lar failure category.

In all, focus groups identified morethan 20 different factors that partici-pants believed cause hospital organiza-tional change and improvement effortsto fail. Eigure 1 contains the 10 mostfrequently mentioned factors, with cor-responding percentages and ranked inorder of frequency. The findings in thefigure are the basis for the forthcomingdiscussion and recommendations.

F I N D I N G SIn this section, we outline the top 10key factors that cause hospital improve-ment and change efforts to fail basedon the input of the study participants.We include verbatim quotes whena statement or comment was takendirectly from the information providedby the focus groups. In addition, a keyleadership lesson from each factor isidentified.

Key Factor 1: Poor ImplementationPlanning and Overly AggressiveTimelinesAccording to the participants in thestudy, change initiatives in healthcareorganizations fail to achieve desired out-comes because their implementation ispoorly planned and the proposed timeframes for implementation are overlyaggressive. These two issues were consis-tently linked by participants and wereidentified as the single greatest causefor failure. This finding is not surprisinggiven the economic and legislative pres-sures being brought to bear on hospitalscoupled with the depth and breadth ofchanges sweeping the healthcare indus-try. Nonetheless, participants made clearthat there is no substitute for taking thetime to develop an effective plan for theimplementation of any organizationalchange.

One major reason for poorimplementation planning was that

F I G U R E 1Top 10 Barriers to Successful Hospital Cbange as Identified by Frontline Hospital Leaders*

1. Poor implementation planning and overly aggressive timelines 73%1. Failing to create buy-in/ownership of the initiative 67%

3. Ineffective leadership and lack of trust in upper management 62%4. Failing to create a realistic plan or improvement process 55%

5. Ineffective and top-down communications 52%

6. A weak case for change, unclear focus, and unclear desired outcomes 50%7. Little or no teamwork or cooperation 43%

8. Failing to provide ongoing measurement, feedback, and accountability 38%9. Unclear roles, goals, and performance expectations 36%

10. Lack of time, resources, and upper-management support 33%

•The findings presented in this figure are from a sample of 167 frontline leaders from four Midwest community hospitals whoparticipated in 42 focus groups designed to identify the primary causes of why hospital change initiatives fail to achieve desiredoutcomes. The percentages represent the numher of focus groups, out of 42, that identified a specific factor.

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organizations frequently set unrealisticdeadlines. Ambitious schedules can beestablished, but they must be temperedwith the reality that implementationplanned for an unduly short time framecan short-circuit the change process andcause leaders to "jump from having anidea or plan for improvement directly toimplementation, " with negative out-comes. One team captured the essenceof this discussion as "bad planning plusunrealistic deadlines = failure."

Leadership lesson: There is nosubstitute for taking the time to prop-erly plan for the implementation of anydesired change or improvement initia-tive. Without proper implementation,critical resources can be wasted withoutproducing a tangible positive outcome.

Key Factor 2: Failing to Create Buy-infor/Ownership of the initiativeParticipants provided myriad examplesin their focus groups describing howchange and improvement efforts failedbecause of a clear lack of, in their words,frontline "buy-in," "empowerment,""engagement," "participation," and"ownership." A strong sense emergedfrom the discussions that hospitalfrontline personnel were frequently notincluded in important discussions anddecisions surrounding how change ini-tiatives might be rolled out to the organi-zation. It was made clear that this lack ofeffort to "create buy-in" and "ownershipfrom frontline personnel" demotivated,disenfranchised, and disenchanted thevery people who were most necessary foreffective implementation of any changeor improvement initiative.

Regardless of the nature of change,participants stated that without such

buy-in and ownership, frontline person-nel are less likely to be committed tothe change and take the steps necessaryto ensure that the change will be imple-mented properly to achieve desired out-comes. Participants added that this lackof buy-in is frequently driven by the factthat senior leaders have failed to makea strong case or provide a solid explana-tion for the necessity of the upcomingchange. This "case for change" is critical,as frontline personnel need to knowexactly why changes are being requiredand what the desired expectations andoutcomes are.

Leadership lesson: Without input,buy-in, and ownership from the peopleresponsible for making the change work,the likelihood of maximum perfor-mance diminishes significantly.

Key Factor 3: ineffective Leadershipand lack of Trust in UpperiVIanagementIt is a well-worn axiom of organizationallife that without effective leadershipat all levels of the organization, realchange or improvement is difficult atbest to achieve. Participants frequentlysupported this position as they made itclear that, more than 60% of the time,ineffective leadership was a primarycause of an inadequate effort involvingchange in performance improvement.When people do not trust their leaders,whether the issue is character or com-petency, people are unlikely to providemaximum effort. When ineffective lead-ers attempt to implement change, theirlack of credibility and trustworthinessprovides their employees with a ready-made reason to not fully engage in theseefforts.

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Study participants noted that inhospital/healthcare environments, lead-ers can ill afford to be viewed as, in theirwords, "bureaucrats," "leading frombehind," "sycophants," "politicos," or"butt-kissers. " According to these par-ticipants, ineffective leadership becomeseven more counterproductive in periodsof rapid change that demand increasedperformance.

Leadership lesson: To achievemaximum performance improvementfrom any change initiative, leaders mustdemonstrate competence and character,and they must lead by example.

Key Factor 4: Failing to Create aRealistic Plan or Improvement ProcessIt is interesting to note that two of thefirst four factors that drive failure clearlyfall into the category of leaders beingineffective in laying out a plan of actionthat will lead to a desired outcome.It is commonly stated that "failing toplan is planning to fail," and the studyparticipants clearly agree. With hospi-tals under increasing pressure to makerapid changes and improvements totheir operations, their senior leadersare quick to move forward with plansthat were described by participants asfrequently "unrealistic," "incomplete,""overly optimistic," "half-baked,""unworkable," "impractical," and even"naïve." When leaders do not take thetime to create effective action plansor processes for desired changes, theyoften lose on several counts, accordingto study participants. First, they wasteprecious time and resources in pursuingchange using plans that have not beenthoroughly and realistically thought out.Second, the outcomes associated with

the activity are almost always negativeor, at a minimum, are less than optimal.Third, the credibility, common sense,and trustworthiness of senior leaders arequickly called into question at a timewhen they need all the support thatthey can get to move their organizationsforward.

It has been said that any changeworth making is worth making right.Our study's participants indicatedthat to make change right requires aneffective, realistic plan and an improve-ment process that has been thor-oughly considered and vetted prior toimplementation.

Leadership lesson: When lead-ers ask members of their organizationto implement a change initiative, it isimperative that sufficient effort, time,input, and resources have gone into theplanning process.

Key Factor 5: Ineffective and Top-Down CommunicationCommunication is frequently a chal-lenge in any large organization, but thisis particularly true in periods of rapidchange, as affirmed by study partici-pants. Participants stated that a lack ofeffective two-way communication sur-rounding any change or improvementinitiative causes significant problems fornumerous reasons. When a change isbeing introduced, extensive and intensetwo-way communication is necessaryamong all parties involved. One of theprimary reasons that employees fre-quently fail to buy into or take owner-ship of a change initiative is that they"do not fully understand either the rea-son for the change or the process" thatwill be used to improve performance.

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One-way and top-down communi-cation has the advantage of being quickand easy. But this approach bringswith it the great disadvantage of fail-ing to create a full understanding ofwhat changes are coming, why they areimportant, the role that each individualplays in achieving a desirable out-come, and whether or not the messagebeing sent is the message that is beingreceived and understood. Study partici-pants provided a variety of examplesin which solid change initiatives couldhave provided positive outcomes ifleaders had taken the time to effectivelycommunicate the message and the pro-cess. In the words of one focus group,"It seems like we are in such a hurry allthe time that it is easy to not commu-nicate as well as we should . . . and weonly create problems for ourselves indoing so."

Leadership lesson: Any change ini-tiative that is expected to produce supe-rior outcomes needs superior, ongoing,two-way communication between thoseresponsible for leading the change andthose responsible for making the changehappen.

Key Factor 6: A Weak Case for Change,a Lack of Focus, and Unclear DesiredOutcomesWhen any change initiative gets underway, leaders must make a clear-cut casefor why the change is both necessaryand important, clarify the focus of thechange effort, and specify what desiredoutcome is needed for the change to bedeclared a success. Study participantsagain provided a wide range of examplesof "change-for-change's-sake proj-ects," "improvement projects without

measurable or tangible metrics," "petprojects that were pushed forwardwithout explanation or reason," "politi-cal change initiatives," and "feel-goodprojects" that may have had a goodintention behind them but did little ornothing to improve performance.

A laboratory supervisor providedan excellent lesson to illustrate theimportance of this finding: "If peopleare going to be asked to make changes,they need to know why they are beingasked to change, who must do what dif-ferently, how [the changes] are going tobe measured, and what success will looklike." This leader did an excellent job ofclarifying the importance of this discus-sion and defined a key finding. The why,who, how, and what must be clearlythought out by leaders and overcommu-nicated with those who must make thechange happen for desirable outcomesto take place.

Leadership lesson: If leaders areserious about change, they must make astrong case for change, create clear focuson what needs to happen, and clearlyarticulate desired outcomes so partici-pants know exactly what success willlook like.

Key Factor 7: Little or No Teamwork orCooperationIt was stated by one participant groupthat "healthcare is rapidly becoming theultimate team sport, " and this posi-tion was shared by a significant numberof people in the study. Teamwork andcooperation are important in any orga-nization, but in a hospital experiencinglarge-scale change, it becomes criticallyimportant, as shown by our findings.Participants made it dear that teamwork

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and cooperation are not natural by-products of hospital work life; they needthe foundation of effective leadershipand specific efforts aimed at "break-ing down walls, " "eliminating silos, ""reducing self-interest," and "buildingcross-functionality." For improvementinitiatives to be successful and to takehold rapidly, diverse groups must cometogether with a shared sense of purposeand vision to develop a plan or processthat encourages and even motivatespeople to work together.

It is becoming increasingly difficultto solve a problem or improve a processin one part of a hospital without thenew process affecting another part ofthe system—a phenomenon known asthe law of unintended consequences.Leaders must take into account thatactivity in one area, viewed as improve-ment, might hinder the performance ofanother unit. Thus, it is important thatthey approach improvement with theteam-based, problem-solving mind-setand introduce systems thinking intotheir efforts.

Leadership lesson: Teamwork andcooperation are critically importantto an organization's ability to increasethe likelihood of successful change andaccelerate the change improvementprocess.

Key Factor 8: Failing to ProvideOngoing Measurement, Feedback, andAccountabilityAny successful change effort is character-ized by ongoing measurement feedbackand accountability for action. Because ofthe magnitude and volume of changestaking place in hospitals, it is notuncommon to see leaders responsible

for handling multiple change initiativesat any one time. A natural by-productof this flurry of activity is a lack oftime available to establish and provideappropriate levels of ongoing measure-ment, feedback, accountability, andfollow-up.

The focus groups discussed andmade light of the fact that they were reg-ularly engaged in change activities thatfrequently "disappeared," "fell throughthe cracks," "just went away," "died aslow death," or "were simply forgotten."All of these descriptions made it clearthat those in charge of the change initia-tives were not serious about delivering areal and tangible performance improve-ment or outcome. These practices werequick to elicit and breed "cynicism,""distrust," "skepticism," and "suspicion"on the part of the organization's mem-bers, who had been conditioned to nottake these improvement efforts seri-ously. One team's description was apt:"Change efforts fail when leaders don'ttrack progress or coach people daily."Ongoing measurement allows peopleto know that performance is observed,and that observation serves as a motiva-tor. Ongoing feedback lets people knowhow well they are performing and whatthey need to do differently to improve.Finally, without enforcing accountabilityand providing follow-up, leaders sendthe message to their employees that thechanges they have been asked to makeare not important.

Leadership lesson: For a changeeffort to achieve a desired outcome,individuals and teams must receiveongoing measurement and feedback ontheir performance and be made account-able for progress.

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Key Factor 9: Unclear Roles, Goals,and Performance ExpectationsWhenever a change initiative is imple-mented, one of the first questionsemployees ask is, "How is this going toaffect me?" According to study partici-pants, change efforts become real when"people are told what they have to dodifferently," "employees are handed anew list of duties that make up theirjob," and "new goals and roles are rolledout." All of these points make clearthat organizational change efforts mustbecome "personal and/or individual"at some point if the change effort is tohave its desired outcome.

If individual employees are notbeing asked, encouraged, trained, andmotivated to behave differently, therecan be no real organizational improve-ment. While this statement may seemsimplistic, participants in the focusgroups emphasized that failure to clarifyindividual roles and performance expec-tations can be a major barrier to realorganizational improvement.

Leadership lesson: Successfulchange efforts should always translatedesired organizational performance out-comes into clearly defined roles, goals,and performance expectations for every-one involved in the change initiative.

Key Factor 10: Lack of Time,Resources, and Upper-ManagementSupportThe final factor in the top-10 list fallsinto a category that described change asfrequently taking place "on top of theirday jobs." This is an important pointbecause focus groups' descriptions ofthe change process frequently pointed tothe fact that change was not necessarily

viewed as "part of their job but rathersomething that they were being asked todo on top of their regular jobs." Whenfrontline personnel are asked to makechanges and the activity takes placeon top of their regular workload, theyendure additional stress, work, and,in some cases, hardship. Thus, studyparticipants made it clear that changeefforts will struggle when frontlinepersonnel do not have sufficient time,resources (e.g., equipment, budget,training, access, staff), and support oftop management in both word anddeed. Without identifying, discussing,and addressing these support factors,frustration and failure can easily occur.

Leadership lesson: Real, successfulchange requires leaders to provide addi-tional time, resources, and support.

D I S C U S S I O N , A N D A C A L LTO A C T I O NIn his 1995 Harvard Business Review articleentitled "Leading Change: Why Transfor-mation Efforts Fail," John Kotter chron-icled the factors that are necessary foran organization to experience successfulchange and transformation. His researchreached the conclusion that real changeand transformation take place when lead-ers manage the human dimensions ofthe change process with great care. Kotteremphasized that effective change requiresa compelling vision with a sense ofurgency, a meaningful and realistic planthat people understand, teamwork andempowerment, effective two-way commu-nications, building on success to createmomentum, and strong and effectiveleadership at every step of the process.

The key findings of our studystrongly support Kotter's research

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and provide additional details on thedangers of unrealistic planning andtimelines, failure to create buy-in andempowerment, one-way communica-tion, lack of a compelling vision, littleor no teamwork, lack of accountability,unclear performance expectations, andlack of top management support inhospital change efforts. The majority ofthe factors that cause hospital change tofail fall into the category of ineffectiveleadership and an absence of well-established and fundamental principlesof change management. And while someof these problems have been previouslynoted by other researchers (Bazzoli etal., 2004; Cunningham et al, 2002;Capoccia & Abeles, 2006), they now take

on greater urgency in light of the hyper-dynamic healthcare landscape.

The volume of real, successfulchange initiatives needed is only accel-erating in healthcare settings. With theintroduction and rollout of the numer-ous components of the ACA, healthcareleaders will need the buy-in and vestedinterest of their teams. Issues of access,quality, and cost are here to stay and aredifficult to address without strong andeffective change leadership. With theworld of healthcare becoming more of alevel playing field through the consoli-dation of providers, the ability to iden-tify, understand, plan, and implementchange initiatives will become a key areafor competitive advantage.

F I G U R E 2A Heaitiicare Leader's Ciiange Ciieckiist

When approaching a change and improvement effort, do our leaders . . .

1. Take the time to develop an effective and realistic implementation plan with realistictimelines?

2. Make it a high priority to create buy-in and ownership with the people who are respon-sible for implementing the plan?

3. Lead by example and demonstrate both competency and character?

4. Create realistic and effective action plans and processes when performance improvementis needed?

5. Practice effective two-way communication to ensure that people understand the messageand that their concerns, needs, and expectations are understood?

6. Make a compelling case for change, create a clear focus, and specifically identify desiredperformance outcomes?

7. Make it a priority to develop the teamwork and cooperation necessary to support a desiredchange or improvement initiative?

8. Provide ongoing measurement, feedback, and accountability for every change initiativethey are responsible for leading?

9. Clarify the roles, goals, and performance expectations for each individual involved in thechange improvement effort?

10. Provide people with the additional time, resources, and support necessary to create realchange in performance improvement?

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W H Y HOSPITAL IMPROVEMENT EFFORTS FAIL: A VIEW FROM THE FRONT LINE

Similarly, being unaware of, beingindifferent to, or ignoring these barriersto change may result in competitive dis-advantage and ultimate failure. On thebasis of our study findings, we encour-age hospital and healthcare executivesand their leadership teams to addresseach question listed in Figure 2 the nexttime they approach a change initia-tive in their healthcare enterprise. Theresponses may play a significant role indetermining the outcome of upcom-ing changes. And, as stated earlier, anychange worth making is worth makingright; to do otherwise is to create changein the wrong direction.

L I M I T A T I O N SA primary limitation to this researchstudy that might affect its generaliz-ability is the small sample size of 167frontline leader participants comingfrom only four Midwest communities.Small research samples may inherentlyinclude some degree of sample biascaused by the unique characteristics ofeach hospital, the unique characteristicsof the study participants or geography,or other regional influences. However,the current healthcare climate is drivingorganizations across the United States toreact to the same set of regulations andother challenges, which might help miti-gate this issue. In the end, every effortwas taken to accurately capture theinput of this sample of frontline partici-pants to provide the reader with a richdescription of the factors that cause ahospital change or improvement initia-tive to fail or succeed.

REFERENCESAmerican College of Healthcare Executives

(ACHE). (2011). Top issues confrontinghospitals: 2010. Healthcare Executive,26(2), 100.

Bazzoli, G., Dynan, L., Bums, L. R., & Yap, C.(2004). Two decades of organizationalchange in health care: What have welearned? Medical Care Research and Review,61(3), 247-331.

Capoccia, V. A., & Abeles, J. C. (2006). Aquestion of leadership: In what ways hasthe challenges of improving health andhealth care informed your understandingand practice of leadership? Leadership inAction, 26(1), 12-13.

Cunningham, C. E., Woodward, C. A., Shan-non, H. S., Macintosh, J., Lendrum, B.,Rosenbloom, D., & Brown, I. (2002).Readiness for organizational change: Alongitudinal study of workplace, psycho-logical and behavioural correlates. Journalof Occupational and Organizational Psychol-ogy, 75, 377-392.

Dye, C. (2010). Leadership in healthcare: Essentialvalues and skills. Chicago, IL: HealthAdministration Press.

Kotter, J. (1995). Leading change: Whytransformation efforts fail. HarvardBusiness Review, 93(2), 59-67.

Longenecker, C. O., Papp, G. R., & Stansfield, T.C. (2007). The two-minute drill: Lessons forrapid organizational improvement fromAmerica's greatest game. San Francisco, CA:Jossey-Bass.

Longenecker, C. O., Papp, G. R., & Stansfield, T.C. (2009). Quarterbacking real and rapidorganizational improvement. Leader-to-Leader, 5Î (Winter), 17-23.

Longenecker, C. O., & Simonetti, ]. A. (2001).Cetting results: Five absolutes for highperformance. San Francisco, CA:Jossey-Bass.

McAleamey, A. S. (2010). Executive leadershipdevelopment in U.S. health systems.Journal of Healthcare Management, 55(3),206-222.

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