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Health system mergers: the significance of leaders
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Health system mergers: the significance of leaders
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Content
Health System Mergers: The Significance of Leaders
by
Gordana Vukotich
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education
May 2023
© Copyright by Gordana Vukotich 2023
All Rights Reserved
The Committee for Gordana Vukotich certifies the approval of this Dissertation
Don Murphy
Jennifer L. Phillips
Patricia Tobey, Committee Chair
Rossier School of Education
University of Southern California
2023
iv
Abstract
While health system mergers have become a trend, debate over their success and high failure rate
continues. This study was aimed at identifying why some leaders are more effective than others
when leading transformation and healthcare industry mergers. The researcher collected
quantitative and qualitative data to examine the attributes of successful health system leaders at
the helm of mergers. A transformational leadership theory lens was applied when examining the
problem. Purposeful sampling was conducted for an intra-method interview study utilizing
closed-ended survey-type questions, followed by a series of open-ended interview questions to
identify leaders’ underlying attributes. Ten senior executives completed the survey, and nine
participated in the interviews. The results of the ten executives were compared with the group’s
self-ratings and a normative sample of 3,375 executives. The analysis compared self-reported
quantitative survey results with qualitative data revealing transformational and transactional
leadership attributes. Comparative analysis suggested that the leaders who participated in this
study successfully led health system mergers and possessed transformational leadership
attributes. Emerging themes among all participants were trust, communication, vision, cultural
intelligence, and human capital.
Keywords: Health system leaders, mergers, transformational leadership in healthcare
v
Dedication
To my son Denis Vukotich, who selflessly shared his space with me when I began this program.
I am thankful you understood the time and commitment required to complete the journey and for
your consistent “Mama, you can do this attitude.” I hope my completion of this doctoral journey
will serve as an example and reminder to you, that there truly is no limit to what we can achieve
or how much we can learn. I Love you.
To the memory of my mother and father, Darlene and Nickola Todorovich, and my extended
family, my grandparents, Miladija and Matija Jaksic. I am grateful for the foundation and values
you taught me: to understand the value of education, perseverance, and work ethics. Especially,
my late mother and grandfather who always said that I would be their doctor. Thank you for
putting it out there; you were right: I could, and it is not too late.
vi
Acknowledgments
The doctoral journey is a commitment requiring self-determination, discipline, and
sacrifice. It is also a journey that includes an incredible amount of support. I would like to begin
by thanking:
Each mentor, boss, and individual who supported my professional and educational
development before this program. I would not have gotten here without my foundation.
The extraordinary team of faculty and professors who encouraged a thorough
examination of our problem through multiple lenses as they introduced us to new theoretical
concepts, provoking a deeper level of thinking and discussion throughout curriculum courses.
My Cohort 14 and 15 colleagues and friends, especially Genevieve Carta and Philip
Katich, for their peer review; they helped me continue to see the bright light at the end of this
journey.
The doctoral support committee, Christopher Mattson, EdD, Sierra Senzaki, PhD, and
editor Guadalupe Montano, EdD, for their feedback and support.
The dissertation committee, Jennifer Phillips, DLS and Don Murphy, EdD, for their
candor and patience as I discerned my path and for their faith, support, and wisdom as I forged
ahead.
And most of all my dissertation chair, Patricia Tobey, PhD, for her guidance, patience,
support, and wisdom as I vetted my problems of practice and learned to trust the process. Thank
you for believing in me and knowing that I would complete the dissertation journey.
vii
Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ........................................................................................................................................v
Acknowledgments.......................................................................................................................... vi
List of Tables ................................................................................................................................. ix
List of Figures ..................................................................................................................................x
List of Abbreviations ..................................................................................................................... xi
Context and Background of the Problem .............................................................................1
Purpose of the Project and Research Questions ...................................................................2
Importance of the Study .......................................................................................................3
Stakeholder Group of Focus ................................................................................................3
Overview of Theoretical Framework and Methodology......................................................3
Review of the Literature ......................................................................................................4
Background ..............................................................................................................5
Current Trends .........................................................................................................8
Transformational Leadership ...................................................................................9
Merger Best Practices ............................................................................................17
Conclusion .............................................................................................................19
Conceptual Framework ..........................................................................................20
Conclusion .............................................................................................................24
Methodology ......................................................................................................................25
Research Setting.....................................................................................................28
The Researcher.......................................................................................................28
Data Sources ......................................................................................................................29
Method 1: Surveys .................................................................................................29
viii
Method 2: Interview ...............................................................................................29
Data Collection Procedures....................................................................................33
Data Analysis .........................................................................................................34
Validity and Reliability ......................................................................................................37
Results and Findings ..........................................................................................................38
Participants .............................................................................................................39
Quantitative Study..................................................................................................41
Qualitative Findings ...............................................................................................47
Summary ................................................................................................................73
Recommendations ..............................................................................................................75
Recommendations for Practice ..............................................................................75
Limitations and Delimitations............................................................................................82
Recommendations for Future Research .............................................................................83
Conclusion .........................................................................................................................84
References ......................................................................................................................................87
Appendix A: Interview Protocol ....................................................................................................96
Interview Questions ...........................................................................................................97
Appendix B: Survey Protocol ........................................................................................................99
Appendix C: The Researcher .......................................................................................................101
Appendix D: The Burke-Litwin Change Model ..........................................................................102
Appendix E: Transformational and Transactional Leadership Result Scores (Without the
Outlier) .........................................................................................................................................106
Appendix F: Definitions...............................................................................................................112
Appendix G: Theoretical Alignment Table .................................................................................114
Appendix H: Ethics ......................................................................................................................115
Appendix I: Quality Scores ..........................................................................................................116
ix
List of Tables
Table 1: The Magnitude of Health System Mergers 7
Table 2: Data Sources 27
Table 3: Key Themes With Aligning A Priori Codes With Corresponding Codes 37
Table 4: Participants 40
Table 5: Individualized Consideration and Human Capital 67
Table 6: Best Practices and Final Thoughts From HealthCare Leaders 73
x
List of Figures
Figure 1: Transformational Leadership Theory 23
Figure 2: Transformational Leadership Theory Conceptually 24
Figure 3: Transformational Leadership Participants 42
Figure 4: Transactional Leadership and Passive Avoidant Behaviors Participants 43
Figure 5: Transformational Leadership Participants Compared to Norm 44
Figure 6: Transactional Leadership Study Participants Compared to Normative Study 45
Figure 7: Overall Outcomes of Leadership Compared to Normative Study 46
Figure D1: The Burke-Litwin Change Model 103
xi
List of Abbreviations
ACA The Affordable Care Act
ACHE American College of Health Care Executives
AI Artificial intelligence
AHA American Hospital Association
AMA American Medical Association
AHIP America’s Health Insurance Plans
APG American Physician Groups
CAHP California Association of Health Plans
CMS Center for Medicare and Medicaid Services
DEI Diversity, equity, inclusion
FTC Federal Trade Commission
DOJ Department of Justice
HHS Department of Health and Human Services
1
Health System Mergers: The Significance of Leaders
If you would win a man to your cause, first convince him that you are his sincere friend.
—Abraham Lincoln, Temperance Address of 1842
Healthcare industry consolidation increased by 15% during the decade before the onset of
the COVID-19 pandemic in 2020. Despite the disruption and risk of consolidation failure, the
trend continues. According to recent Deloitte models (2022), after consolidation in the next 10
years, only 50% of healthcare systems (see Appendix F for definition) will remain as they are
today. Driven by regulatory changes, market demands, technology, and finances, the number of
healthcare organizations merging continues to rise (HealthCare Finance, 2018), thereby creating
a need for adept leaders who are prepared to respond to the environment and lead transformation.
For this review, mergers, consolidation, and acquisitions will be referred to as mergers.
Additionally, leadership is conceptualized, according to the definitions outlined by Bass (2006)
and Northouse (2019). Leadership is a process whereby an individual can influence others to
work toward a common goal.
Context and Background of the Problem
The evolution of the U.S. healthcare system has aggrandized complex business models,
requiring strong leaders who comprehend the significance of relationships with the government,
society, technology, and the economy (Brigham, 2017). Recent statistics demonstrate that
healthcare is approximately 18% of the U.S. national GDP, employs 11% of American workers,
and accounts for 24% of government spending (Brigham, 2017; U.S. Department of Health and
Human Services [HHS], 2020). Furthermore, the industry has witnessed an escalation of newly
formed relationships, mergers, and acquisitions. The trend of mergers is propelling change and
influencing the healthcare industry landscape (Brigham, 2017; Kaufmann Hall, 2018) by
2
standardizing definitions and expectations regarding clinical best practices, impacting supply
chains, drug, and labor costs, driving innovation and technology, and more (Scott, 2020; Zismer
et al., 2013).
A report by Health Care Finance in 2018 revealed the rapid increase of mergers and
acquisitions as a trend and a merger activity increase of 14.4 % from the previous year. The
activity continues into 2019 and beyond. Despite the trend, mergers are risky. In the United
States, some segments of the industry reported a drop in value of up to 34% following a merger
(La Gasse, 2018), more than 70% failed, and approximately 50% lost stock value (Robbins,
2018). There is a need for strong, competent health system leaders who are capable of leading
transformation (Herd et al., 2016; Zismer, 2013) while maintaining quality and increasing value.
Purpose of the Project and Research Questions
The study aimed to identify the attributes of healthcare industry leaders who have
successfully led mergers. The study identified skills and attributes that differentiate them from
other leaders. The research examined the problem through leadership theory by analyzing the
relationship between leadership and transformation. This study addressed the following
questions:
1. What leadership traits do leaders perceive as effective when leading mergers in the
healthcare industry?
2. How do leaders respond to the existing cultures of the organization/s when leading
mergers in the healthcare industry?
3. What are the common characteristics of leaders of successful healthcare industry
mergers?
3
Importance of the Study
Despite corporate executives leading an escalating number of healthcare organizational
mergers, there is a need for more effective and skilled leadership throughout the process.
Research demonstrates that executives struggle when combining formerly independent
organizations with larger corporations (Filer, 2018). Consequently, corporations experience a
drop in stock value, and the quality of care is threatened (La Pointe, 2017). The potential loss of
value and quality demonstrates a problem. This problem is important to address so that
healthcare industry leaders will effectively steer the integration of their partner organizations
(Britnell, 2016; Kanau & Oancea, 2020), thereby increasing value.
Stakeholder Group of Focus
The key stakeholders for the study are C-suite leaders who are either the chief executive
officer (CEO) or equivalent of their organizations, such as presidents or administrators, and led
mergers and consolidations in the healthcare industry. These are individuals who are accountable
for the results. Reporting to boards before, during, and after consolidation, the CEOs and their
designated senior leadership teams are accountable for the continued performance of the
organizations. Research has demonstrated that execution requires strong leaders (Huston, 2018;
Kamau & Oancea, 2020). Applying transformational leadership theory, this study examined the
attributes and critical behaviors of chief executives who have successfully led throughout the
process.
Overview of Theoretical Framework and Methodology
The theoretical framework for the study is transformational leadership theory. For
organizations to merge successfully, they need to transform into new entities. Therefore, leaders
who are skilled in driving change are needed. Northouse (2021) explained that transformational
4
leadership is a process that transforms people. The four factors of transformational leadership are
idealized influence, as leaders are roles models for followers; inspirational motivation, or the
motivation to attain the vision of the organization; intellectual stimulation to encourage
innovation and creativity; and individual consideration or acting as a coach and advisor
(Antonakis & Day, 2018; Northouse, 2019). Transformational leadership applies the four
components. Studies demonstrate that effective transformational leaders yield results and will
successfully merge organizations. Transformational leadership applies a motivational
management approach. Strengths include intuitive appeal and effectiveness, which have worked
for people and organizations such as Apple’s former CEO, Steve Jobs (Steinwart et al., 2012),
and Kaiser (Adams et al., 2015).
The methodology for the study was an inter-method design, which included qualitative
and quantitative data obtained through a survey and interviews. The data were obtained by
applying the multifactor leadership questionnaire (MLQ) survey tool and 12 open-ended
interview questions that examined the attributes of successful leaders and how leadership
behavior sets the stage for organizational performance (Bass, 1985; Northouse, 2021).
Review of the Literature
This review covers literature in topic areas emerging from a tiered review process. This
discussion includes additional background, current trends, and transformational leadership
broken down into four topic areas: idealized influence, inspirational motivation, intellectual
stimulation, and individualized consideration. Although the literature presented here has been
applied to various problems, this review delves deeper into positive attributes that can lead to
healthcare organizations’ successful mergers and transformation. The literature review will
assess the problem through the context of transformational leadership by responding to this
5
question: What is the significance of adept transformational leaders when merging health
systems?
Background
The Patient Protection and Affordable Care Act (ACA) “accelerates the pernicious
growth of market consolidation in American Health Care” (Pope, 2014, p. 1). On March 23,
2010, the ACA (2020), also known as Obamacare, was passed, representing the implementation
of a new health care law, expanding coverage to the uninsured and the Medicaid program (HHS,
2021, p. 13). According to the data, it may be the U.S. health care system’s most significant
regulatory overhaul, since the enactment of Medicare and Medicaid, in 1965. Nationally, the
ACA resulted in 20 to 24 million uninsured obtaining insurance coverage by 2014. Thirty-seven
states expanded Medicaid, which included increased support for those living at 138% of the
federal poverty level. The ACA also extended dependent coverage, allowing for ensuring
dependents up to 26 years of age. Additionally, care focuses on quality measures, and the Hi-
Tech Act is an economic stimulus package focused on information technology and mandates the
use of electronic health records as well as protecting patient information.
During the implementation of the ACA and increased coverage, enactment demanded
tiered implementation of technology and the evolution of private practice independent provider
practices. Subsequently, many independent entities consolidated, resulting in regional health
system mergers, which began dominating local markets (La Pointe, 2017; Pope, 2014).
Larger entities have increased purchasing power and the ability to finance the execution of
strategic plans, including conversion and adaptation of electronic health records and response to
the Hi-Tech Act. Moreover, the changes foster population health management, decrease the cost
of care, and promote innovation.
6
While the prevalence of mergers and acquisitions is not a new concept across many
industries and organizational landscapes, under the ACA and, more recently, the COVID
pandemic (HHS, 2021), an increase in mergers across the health system paradigm has been
coined a trend (Health Care Finance, 2018). Health system business leaders strategically
respond to environmental conditions with mergers as a solution to control market
interdependencies and costs, leverage debt, and increase negotiating power (Chesley, 2020;
HealthCare Finance, 2018; Malhotra, 2017, Vaidy,2021). Hospitals and health systems are
increasingly merging to implement value-based care. According to a Health Care Financial
Management Association (2016) report, to transition from volume to value while shifting to
population health management, even the most sophisticated and independent systems require
significant capital investments and experienced, adept leadership (HCFNA 2016; Hersh, 2018;
Kamau & Oancea, 2020).
Despite the trends, the failure rate remains high, demanding adept leaders capable of
effectively merging organizational cultures while responding to external barriers, including
regulations from the Federal Trade Commission (FTC). The FTC, and state regulatory
agencies, monitors merger deals to ensure they will not create a monopoly in a region. For
example, in 2016, the FTC attempted to block a merger between two larger Chicago entities.
The merger involved combining two health systems which would include 16 hospitals. The
FTC’s reasons for opposing the merger included a threat to improved quality, increased costs to
consumers, and monopolizing the region. According to the American Hospital Association
(2016), a federal judge overruled, and the merger was allowed. The merger resulted in one of
the largest integrated not-for-profit systems in the nation; to date there is insufficient data on
quality and overall success, however there are reports of successful integration of workforce.
7
Since the merger strategic leadership has resulted in cultural integration focusing on patient
safety and collective buy in for a multi -channel communication plan (AHA, 2022) to
implement a standardized safety plan; this impacts long term quality scores and improves
efficiency.
Table 1 presents examples of the magnitude of health system mergers pending approval
before 2017.
Table 1
The Magnitude of Health System Mergers
Combined
Organizations State Net rev (billions) Status
Dignity/CHI
National $28.4 Regulatory approval phase
Carolina HS/UNC
HealthCare
NC/SC $13.4 Announced August 2017
Advocate Health
Care/Aurora Health Care
IL/WI $11.0 Announced December
2017
Beth Israel
Deaconess/Lahey
Health/New
England/Mount Auburn
MA $5.0 Regulatory approval phase
Greenville Health
System/Palmetto Health
SC $3.9 Regulatory approval phase
Note. Adapted from 2018 M&A in review: A new healthcare landscape takes shape by
KaufmanHall, 2019. Copyright 2019 by KaufmanHall.
8
In summary, the merger trend continues as healthcare organizations seek economies of
scale (Brigham, 2017; Kauffman, 2017; Vaidy,2021), inclusive of ancillary services, information
technology, purchasing, and a value-based delivery system with the ability to care for large
patient populations. Consolidation is intended to mitigate financial risk. Most recently, with the
onset of the COVID pandemic in January 2020, gaps in the health system infrastructure were
highlighted as the need for population health management increased. Concurrently, so did the
merger trend.
Current Trends
While mergers are a trend (Beaulieu et al, 2020; Brigham, 2017), corporate restructuring
of hospitals becoming subsidiaries of non-health system organizations dates to the 1980’s.
Followed by with horizontal consolidation of hospitals in the 1990’s and vertical mergers and
mega-mergers representing various levels of the supply chain (Burns, 2002; Burns, 2022). As
Kanau and Oancea (2020) discussed, vertical mergers are mergers within the same industry, with
merging entities representing different products or lines of business, such as a provider
organization merging with a hospital. Horizontal mergers are two or more companies producing
the same service or product, such as two hospitals merging. Current reports by Harvard Business
Review (2021) indicate that in California, vertical mergers such as the acquisition of physician
practices by hospitals are linked to increasing insurance premiums, specialty services, and
primary care costs. As a result, the FTC has requested claims from six of the largest health plans
to review inpatient and outpatient services from 15 states between 2015 and 2020.
Recent large vertical merger trends approved by the U.S. Department of Justice’s (DOJ)
antitrust division include Cigna Corporation’s (Health plan) $67 billion acquisition of Express
Scripts, a mail-order pharmacy organization, and CVS Health Corp, Pharmacy’s $69 billion
9
mergers with Aetna, a health plan (DOJ, 2021). These two mergers overcame antitrust barriers.
One of the factors considered a barrier was horizontal overlap. Before approval, the DOJ placed
a condition on the deal, which was to divest Aetna’s Part D prescription drug plan across the
nation. In addition to leading a mega-merger, Aetna’s leaders were tasked with leading urgent
organizational change and obtaining support to proceed to next steps (Manatt, 2018).
In Southern California, a recent merger involved the DaVita Medical Group by Optum
Health. Several years earlier DaVita had merged with HealthCare Partners. Robert Margolis
(2015), the former CEO of Health Care Partners, wrote and published a case study discussing a
series of mergers and acquisitions of like-physician groups supporting the organization’s
evolution into one of the largest provider groups in the nation. When Margolis founded the
organization in 1992, he joined three smaller multi-specialty physician groups. There were fewer
than a couple of hundred employees. During the next two decades, the group expanded to
Nevada with a network of a few thousand physicians and multiple staff model sites in Los
Angeles and Orange Counties. By 2012, Health Care Partners merged with DaVita and grew to
an entity of 13,000 employed and affiliated physicians in six states. More recently, the parent
company of HealthCare Partners, Optum Health, purchased a healthcare technology company,
offering $13.5 billion dollars in January of 2021. The deal was closed beginning of the fourth
quarter 2022. The deal itself is transformational, adding data analytics, research, and revenue
cycle management to the existing portfolio of the organization, calling for astute leadership.
Transformational Leadership
Transformational leadership describes a leadership style where mission and vision-driven
leaders guide change by inspiring their teams or followers by effectively communicating the
need for change and creating a shared vision to lead or guide the change (Antonakis,2018, Bass,
10
1985, Yue, 2021). Transformational leaders inspire others to go above and beyond their
capabilities and deliver extraordinary results, and these leaders go beyond self-actualization.
They are charismatic and dominant (setting strong role models), desire to influence, and are self-
confident with strong moral values (Northouse, 2021).
In today’s health systems, transformational leadership involves the ability to assess the
organization and stakeholder needs, visualize the desired outcome, and recognize the opportunity
for improved outcomes. During a merger, the leader will play a pivotal role; according to
Northouse (2021), for successful transformation to occur, there needs to be a sturdy bond
between the leader and follower or employee. Additionally, a panel of 417 employees across the
nation was surveyed recently to ascertain how they perceived changes arising from the COVID-
19 pandemic (Yue, 2021). The study implied that during times of change, executive leaders must
communicate vision, values, and identities with employees; the studies also demonstrate that
when employers have low identification with their employees, the chief executive’s charismatic
rhetoric helps to facilitate rapid change (Antonakis & Day, 2012; Siangchokyoo et al., 2019;
Yue, 2021). Therefore, to navigate within the complex health system while steering mergers,
health system leaders should assume an interdisciplinary approach to address desired outcomes.
To be effective, the leader will apply all four leadership elements or factors, as discussed by Bass
(1994): idealized influence, inspirational motivation, individualized consideration, and
intellectual stimulation, to inspire, empower and stimulate teams and followers.
Idealized Influence (Charisma)
Bass (1985) referred to charismatic leadership as idealized influence. Because of the
leaders’ positive attributes, leaders become role models whom followers want to emulate. These
leaders have high standards, morals, and ethics. They are consistent, and they will take risks.
11
Idealized influence (behavior) emphasizes a collective sense of mission and values, as well as
acting upon these values; they are revered by followers who show loyalty and commitment to the
leaders’ cause (Antonakis & Day, 2012, Bass,1994). With the absence of trust, organizational
foundations are weakened (Lamptey, 2021); a transformational leader who obtains trust can
transform the individual and the organization (Antonakis & Day, 2018; Bass, 1994).
Trust. Leaders who are trusted are more readily able to influence. Furthermore, with
trust, sustaining transformation and executing strategy are easier. A good example of trust is a
CEO of an acquiring company or one of the merging entities being designated to lead all the
employees. To do so, the CEO needs to earn employee trust and respect and then will be able to
influence the employees (Evenson et al., 2020; Lamptey, 2021; Simonek, 2014). Additionally, a
charismatic leader who gains the trust of his or her employees is likely to attain and exceed
organizational goals (Northouse, 2019).
Vision. According to Burns’ (1978) theory of leadership, an effective leader has a vision
and will inspire others to make this vision a reality. A comprehensive analysis of leadership
needs in the healthcare industry highlights the complexities of healthcare organizations,
demanding skilled and effective leaders with a combination of technical skills, industry
knowledge, emotional intelligence (metacognition), communication skills, critical
thinking/problem solving (Sonnino,2016) and the ability to influence change. Due to the
complex nature of the healthcare delivery system, an already challenging industry issue
(Sonnino, 2016) becomes even more complicated when combining organizations. Sacks and
Margolis (2015) revealed an example of charismatic physician leadership in their case study of
Advocate Health Care, one of the largest healthcare organizations in the country and the largest
in Illinois. Under the implementation of the ACA, Advocate was one of the first health systems
12
nationally to transform its business model. In addition to operational overhaul, the organization
responded by developing a leadership institute to educate physician leaders throughout the
merging organizations on communicating the vision to transform the business model. Within 4
years, the organization had increased its value-based revenue by 53%. Executive physician
leaders recognized the importance of communicating their vision and applying charisma, which
motivated teams throughout the entities.
Inspirational Motivation
An important factor of transformational leadership is enunciating the organizational
mission and vision. A positive, vision-driven leader serves as a model which motivates
followers. Motivation is critical when leading change and merging two organizations, and it is an
element of employee performance (Deschamps, 2016; Kamau & Oancea, 2019; Maslow,1943;
Northouse, 2019). Maslow defined motivations as an active choice, persistence, and mental
effort. In other words, leaders taking the initiative, persevering, and making and working smarter
to develop solutions yielding increased performance and the attainment of goals. The factors
contributing to motivation are confidence, beliefs about the organization and environmental
barriers, the emotional climate in the workplace, and values related to their performance goals.
The leader will provide meaning, challenge, and cultivate a team spirit.
Knowledge Transfer. In their study of motivational factors influencing knowledge
transfer for hospitals, Al-Hay et al. (2019) noted that health systems are knowledge-intensive
organizations. Motivation among individuals is critical for knowledge transfer to occur.
Furthermore, the research team suggests that motivation depends on extrinsic and intrinsic
motivation, which tends to focus on knowledge transfer. To assess motivation for knowledge
transfer, researchers conducted a pilot study with 53 doctors and nurses from three hospitals. The
13
questionnaire was based on a five-point Likert scale ranging from 1 (strongly disagree) to 5
(strongly agree). The study was useful in determining the key drivers of motivation among the
hospital physicians, nurses, and staff.
Furthermore, in their research, Gagliardi and Dobrow (2016) discussed integrated
knowledge transfer in healthcare organizations, along with research methodology. They
identified conditions needed for integrating and transferring information, including aligning
business managers with clinical programs collecting internal data and other professional and
individual components. The findings were that the capacity framework is relevant for an
organization without any existing activity.
The following data were collected based on qualitative interviews with researchers
focusing on two healthcare delivery organizations: (a) a healthcare delivery organization that
employed 12,000 staff leveraging research institute support and (b) a healthcare monitoring
organization that employed 1,000 staff members and relied on an internal director for research
coordination. The combined study resulted in 43 interviews, including 13 researchers, eight
clinicians, and 22 managers, and demonstrated that no integrated knowledge transfer was
present. Respondent responses revealed similar challenges and concerns within the organization
and highlighted the need for numerous changes. The research identified core values and
conditions needed for an organization to prepare for integrated knowledge transfer.
Competencies include motivation, which is needed for successful knowledge transfer (Al-Hay et
al., 2019) in any organization.
Employees. Oancea and Kanau (2020) examined leadership and employee perspectives
during mergers. They explore why leaders and employees perceive mergers as negative and
threatening. The researchers apply skills and trait theories as they compare novice and expert
14
leaders. They suggest evidence-based leadership tools such as the Employee Emotion
Assessment Toolkit (EEAT), a management tool designed to measure and score employee
emotions after a merger. In their discussion, Kamau and Oancea (2020) provided evidence-based
reviews of negative implications resulting from a lack of motivation. Results help leaders assess
why some employees may be withdrawn, want to quit, possess low self-esteem, or lack loyalty.
Lastly, the tool is effective in determining low levels of leader motivation resulting from cultural
differences, which may be defined as organizational barriers (Schein, 2017). The tool is effective
in assessing emotions and can be used before a merger to support leaders in effectively
stimulating the employees as they lead through the merger process (Kamau & Oancea, 2020).
Intellectual Stimulation
This element reflects the leader’s ability to engage with employees on an intellectual
level. It includes challenging the assumptions of followers’ beliefs, their analysis of problems
they face, and the solutions they generate. The CEO will ask questions of the employees of
merging entities and consider their feedback and entice brainstorming activities that facilitate
intellectual stimulation. The CEO will find out individual concerns and consider their needs
individually and as a group (Kamau & Oancea, 2020; Northouse, 2019; Santoni & Siweke,
2016).
Innovation and Creativity. In addition to leading vertical mergers in the health system
space, a good example of transformational leaders applying intellectual stimulation is the
horizontal merger of two general aviation companies: Cessna Aircraft company, which had
approximately $2.8 billion of revenue in 2013, and Beechcraft corporation with $1.8 billion in
total revenues. They merged in 2014, creating Textron Aviation. Within 3 years, they began
performing as a single entity (Evenson et al., 2020). They combined two aviation companies to
15
form the largest general aviation company in the world. To accomplish this, the merging entities
required strong adept leaders who could obtain buy in, develop trust, and overcome challenges.
While the transformational leaders at the helm applied all the elements outlined in Bass’s (1985)
transformational leadership theory, the dimensions they discussed in the case study highlighted
intellectual stimulation and employee communication.
The case study (Evenson et al., 2020) discussed a study of 11 leaders employed by the
two aviation companies. The results revealed that communication was key to success. Due to the
organization’s size, leaders applied creative solutions to facilitate communication and engaged
their teams in intellectual stimulation. They also highlighted the importance of listening,
diversity and considering the individual.
Positive Reinforcement. The Cessna and Health Care Partners case studies stress the
importance of positive reinforcement and one-on-one discussions with teams and avoiding public
criticism of employees when addressing organizational issues. Instead, the focus is on listening
to hear so that employees will perceive that their contributions are valuable for effective
collaboration (Burke, 2017; Evenson et al., 2020).
Individualized Consideration
This factor of transformational leadership is defined by considering the individual needs
of followers and developing their strengths. It includes the leader recognizing differences
between individuals and their needs, acting as a mentor and coach, and following up to ensure
work is complete while ensuring employees do not feel micromanaged. Leaders will apply the
motto “manage by walking around” (Burke, 2017), which also enhances workplace culture.
Followers Needs. An example of considering individuals’ needs was published in
HealthCare Management Review (Caldwell et al., 2008) and reviewed in a case study discussion
16
of change in a large managed healthcare organization. The organization had recently made
changes to respond to environmental changes and the adversely impacted quality of patient care.
The organization adjusted its strategy by focusing on patient service as an initiative. To improve
patient care, they needed to consider the physicians who delivered the care. Caldwell et al.
(2008) found that when primarily concentrating on physician behavior, change was indeed
possible. The study was comprised of two phases. Phase 1 began with interviews of 38 physician
chiefs, followed by the second phase a year later, which was surveys following up on
information collected during the interviews. The surveys were responses from 313 physicians
across multiple specialties. The variable for the outcome was patient satisfaction.
The researchers’ primary interests were in three areas (the independent variables): (a) degree of
support from the physicians for the strategic change, (b) norms that indicated the degree of
readiness for the change, and (c) perception of medical departments’ leadership—that is, did the
department heads provide leadership for the change (Caldwell et al., 2008, p. 128)?
The overall results of the study were positive. They indicated that leadership was
successful when clinicians were considered. In their section on practice recommendations,
Caldwell et al. (2008) suggested change is possible when there is buy-in. Therefore, to drive
strategic change, leaders should focus on building support. With good communication and
consideration of individual needs, this is possible. In addition, leaders should seek to involve
staff in identifying ways to implement the strategy. Significant, transformational change is
difficult to attain in a managed care organization without the support of key stakeholders,
physicians in this case.
Culture. Culture as described by Robbins (2018), is a system of “beliefs, values and
assumptions” shared by individuals in an organization which enable collective adjustment to the
17
environment. Another example of leaders exploring individual differences was Robbins’s (2018)
disclosure that under the umbrella of the National Defense Health Agency, the Army, Air Force,
and Navy successfully consolidated operations, thereby creating the seventh-largest healthcare
delivery system in the country, providing services for approximately 9.4 million beneficiaries.
The NDAA developed an acculturation model which supported their success, resulting in one of
the largest and most diverse successful mergers in the United States. The acculturation model
adds cultural due diligence as the precursor to categories of “organizational structure, process
alignment and strategic outcomes measurement” (Robbins, 2018, p. 147). Organizations yielding
successful results following a merger are 40% more likely to perform cultural due diligence
(Robbins, 2018) or offer cultural diversity training. By introducing the application of an
acculturation model framework to their leadership teams, corporate executives can support
successful outcomes and integration.
Merger Best Practices
Due to the increased prevalence of health care mergers and their failure rate, astute health
system leaders are taking a proactive approach by joining professional organizations such as the
American College of Health Care Executives (ACHE), American College of Physician
Associates, American Health Insurance, American Medical Association (AMA), Hospital
Association Southern California, and other advocacy groups. In addition to representing
healthcare industry sectors at state and national levels, the advocacy groups facilitate education
for executives and their teams, sharing best practices and encouraging a commitment to
development and learning.
Research including leaders affiliated with ACHE demonstrates that merger activity
creates fear and distrust among employees (Chesley, 2020; Kamau & Oancea, 2020). In addition
18
to developing an awareness of preexisting trust levels to mitigate the risk of failure, assessing the
cultures of merging organizations is recommended. The Competing Values Framework measures
the current, or pre-merger, culture, and the preferred culture (Chesley, 2020). This tool was
effective in merging two competing hospital systems in Virginia and Tennessee, which included
21 hospitals over 29 counties.
Empirical data on horizontal health plan mergers demonstrates that leaders face external
threats, and that market power will raise premiums (Chelsey, 2020). This depends on whether
any market overlap exists; if so, partial, or entire market overlap may make a difference.
Furthermore, leaders of merging plans face the threat of beneficiaries leaving for rival
companies; depending on who the merging entity is, this may reduce the threat. Additionally, if
merging entities offer the same health plan product lines or options (Chorniy et al., 2020),
bargaining power increases with suppliers, such as pharmaceutical companies. Therefore,
sufficient due diligence, including market analysis, is critical when entering a merger, as
discussed by Chorniy et al., to assess cost efficiency, bargaining power with upstream providers
and market power. The data imply that leaders and organizations who perform market
intelligence and rely on data prior to merger negotiations are more likely to succeed.
In addition to merger activity, due to the recent outbreak of COVID 19, healthcare
leaders and professionals faced additional ethical dilemmas. They deferred to professional
guidelines from the AMA when making decisions during the pandemic. Empirical data suggests
that exemplar leadership is needed to respond to transformation and unprecedented events
domestically and abroad. In addition to organizational preparedness and hiring knowledgeable
leaders who understand policy, these leadership best practices were highlighted in the Science
Direct article: agility, transparent communication consideration for all stakeholders, leading by
19
example, investing in emergency preparedness, and having a backup plan. As Nicola et al. (2020,
pp. 126–127) stated, “The energy focus and resilience of a leader becomes a precious
commodity” (p. 127); leaders who are mindful of ethical dilemmas and model the way earn trust
and they are more likely to succeed.
Finally, as previously discussed, HealthCare Partners completed horizontal mergers
spanning over two decades, according to Margolis (2015). Albeit successful, the organization
was in an almost constant state of transformation. Margolis led the continued success. He
identified the importance of team buy-in, leadership, and succession planning. He and his team
also recognized that to sustain success, they had to respond to regulatory demands set forth by
the ACA and needed more efficient data-driven processes throughout the organization. As a
result, they developed a leadership institute based on leadership and management competencies
important to the organization. As the organization expanded, the institute expanded. By 2015,
they had graduated 50 leaders. Through each of their transformations, the leadership institute
helped participants gain an enhanced sense of ownership (Margolis & Sacks, 2015). Since then,
the leadership institute has evolved with a focus on research and health policy education.
Conclusion
By applying research methods to analyze the qualities of leaders responsible for
organizational transformation, it is possible to identify key qualities that differentiate these
leaders from others. More importantly, with the support of evidence-based research methods, it is
possible to identify the types of leaders who should be at the helm of organizations and facilitate
continued leadership and team training to support effective outcomes. In summary, research
demonstrates that leadership skills can be learned, and evidence-based data in some healthcare
industry sectors demonstrate that leadership skills and motivation increase after participation in
20
leadership programs (Sonnino, 2016). It is important to increase the skills of healthcare industry
leaders to facilitate effective leadership during mergers.
Conceptual Framework
Transformational leadership theory (Figure 1) was applied in this study. While
knowledge is significant, it is evident that senior executive leaders, like the president or leaders
of a nation, are not subject matter experts in every aspect of their business. Great leaders were
not always the A students; they relied on the B students to help them run their organizations.
Moreover, many key executives in health systems are not clinicians. According to Bass (1994),
transformational leaders possess charisma (idealized influence): (a) they are respected, their
followers emulate them; (b) they motivate and cultivate spirit (inspirational motivation); (c) they
urge followers to be innovative and creative, to challenge status quo (Intellectual stimulation);
and (d) the leader will be a mentor and a coach who knows and understands the team, engage by
walking around, delegate and follow up without micromanaging. An effective transformational
leader will see the big picture, and the followers may be subject matter experts with more
detailed knowledge. Nevertheless, the transformational leader will charismatically obtain buy-in
from the team to attain organizational goals.
Additional strengths of transformational leadership include disruption, which may be
needed to attain desired results and impact the healthcare industry. However, the strengths of
transformational leaders are also potential threats. While charismatic leaders are needed,
charisma may also be detrimental. A self-absorbed leader may be highly inspirational and use
charisma to attain self-serving goals (Bass, 1985; Northouse, 2019); often resulting in followers
who compromise ethics. This is referred to as pseudo-transformational leadership; an example of
pseudo-transformational leadership is Adolf Hitler or a cult leader. In the healthcare industry, it
21
may be a leader who compromises healthcare quality outcomes or does not adhere to federal and
state compliance guidelines to increase the health system’s bottom line. To mitigate this risk,
advocacy groups such as the American College of Health Care Executives (2020) provide ethical
guidelines for leaders.
A weakness of transformational leadership is leaders who do not effectively augment
transactional leadership (Bass et al., 2006, p. 11). Transactional leadership focuses on
supervision, performance, and organization and is defined by short-term planning and is based
on contingent rewards. While transformational leaders focus on motivation and positive
development of followers, the use of transactional leadership is sometimes necessary. For
example, an effective transformational leader at risk of losing an exceptional chief medical
officer may want to consider increasing the officer’s compensation package (Burke, 2017). A
weakness may be transformational leaders who do not possess transactional qualities or employ
effective transactional managers. Transactional leaders work with set established goals and
boundaries. While a transformational leader who does not take risks may inhibit success, one
who does not consider processes and steps needed to attain long-term goals will also not succeed.
Middle managers are typically transactional leaders; however, in addition to hiring skilled
managers effective transformational leaders will also be able to demonstrate transactional
qualities.
Weaknesses also include pressure on followers, possible inhibition of individual
creativity given the focus on the team and decreased focus on tasks, the potential for burnout,
unnecessary disruption, and not enough evidence to support the efficiency of the MLQ
transformational leadership assessment tool (Avolio & Bass 2010; Northouse, 2019).
Nevertheless, prior research has shown transformational leadership to be effective. The
22
facilitation and narrower scope of research that explores leaders transforming healthcare
organizations may provide additional insight.
The conceptual framework (Figure 2) displays the elements of transformational
leadership theory (Figure 1) in a circle because, as discussed in the Organizational Psychology of
Mergers and Acquisitions (Kamau & Oancea,2020), previous research by Rowold (2005)
demonstrated that the subtypes of transformational leadership are all correlated. The study’s
intent was to explore the attributes and correlation further. Theoretically, executives with
transformational leadership attributes should be capable of inspiring employees and teams to
support the merger, even if they were initially hesitant or opposed. Additionally, Bass (1985), in
his concept of transformational leadership, suggested that while transactional leadership traits are
different from transformational leadership traits, effective transformational leaders also have
transactional leadership skills and traits and know when to apply them.
23
Figure 1
Transformational Leadership Theory
Note. Adapted from Leadership by J. M. Burns, 1978. Harper & Row. Copyright 1978 by Harper
& Row.
24
Figure 2
Transformational Leadership Theory Conceptually
Note. The researcher, Gordana Vukotich, conceptualized transformational theory framework.
Conclusion
The literature review infers that leadership matters and that the influence of leaders
impacts organizational results. The evidence highlights that knowledge can be transferred,
leadership can be taught (Journal of Healthcare Leadership, 2017; Kamau & Oancea, 2020;
Sonnino,2016), and adept leaders with strong skills more effectively handle the complexities of
mergers (Huston, 2019). To probe deeper into the attributes of leaders at the helm of merging
Transformati
onal
Leadership
(Transactional
leadership traits)
Idealized
Influence
(Charisma)
• Vision
• Trust
Inspirational
Motivation
• Knowledge
Transfer
• Employees
Intellectual
Stimulation
• Innovation
• Positive
reinforceme
nt
Individualized
Consideration
• Individual
Need
• Culture
25
organizations, we will conduct quantitative and qualitative interviews to identify the secret sauce
of successful transformation.
Methodology
This section will discuss methods used to collect and analyze data for this study. This
includes an overview of the design, data collection and analysis, participants, and
instrumentation.
To examine the problem of practice, the study integrated quantitative data with
qualitative analysis, which involved the collection of both quantitative (survey), secondary data
on organizational performance, and qualitative (interview) data and rigorous methods. To
examine the problem, I developed an informal theory of change, which may appear like
“research intended to legitimize what we may know” (Tuck & Yang, 2013, p. 236), it is not. The
design is intended to gain a more thorough understanding of leaders at the helm of merging
complex health systems. They lead business that directly impacts our nation’s health and
approximately 18% of the GDP. The theory is that for successful mergers to occur, adept leaders
must begin by developing trust, defining ontological accountability, completing thorough due
diligence, negotiating mutually beneficial agreements outlining a transitional strategy and
communication plan, implementing, and sustaining. The theory applies to transformational
corporate leaders and their multi-pronged health system relationships, whereby all entities are
impacted by the environment, along with leaders at the helm who are adept at responding to the
environment. The leaders are what Northouse (2019) described as transformational leaders.
The axiology, or the “role of value and ethics,” as discussed by Creswell and Creswell
(2018, p. 88), is important for researchers as they develop trust with their participants and protect
them. Trust between leaders and followers is critical in Bass’s (1985) explanation of the four Is
26
and the components of transformational leadership (see Figure 1). However, while one’s values
drive ethical behavior, leaders also follow a professional code of (Creswell & Creswell, 2018, p.
91). Therefore, I applied the pragmatic worldview paradigm.
This worldview supported approaching the problem with mixed methodology research,
enabling a thorough examination of the elements driving leaders to integrate organizations
successfully. Tetlock (1992) noted that leaders should consider the incentives created when
accountability systems are developed to bring the two entities together. “Pragmatists do not see
the world as an absolute unity;” in a similar way, mixed methods, a pragmatic approach, is to
consider that beliefs are connected to actions (Creswell & Creswell, 2018, p. 10). This also
aligns with the element’s transformational leadership. Upon exploring effective leadership, the
researcher discovered a prevalence of individual responsibility and institutional accountability to
internal and external stakeholders. Therefore, the pragmatic worldview is appropriate to establish
a connection between organizational results and leadership by integrating quantitative and
qualitative information (Morgan, 2014).
The population for the study was the purposeful selection (Creswell & Creswell, 2018) of
10 executive leaders who have successfully led during health system mergers. A successful
merger is a merger that did (a) not result in a rapid resell due to failure, (b) maintained or
exceeded quality scores, and (c) increased value. Ten leaders took the MLQ survey, comprised
of 45 closed-ended questions, preceded by a five-question demographic survey. The results were
tallied to assess their transformational leadership qualities. Subsequently, 9 of the 10 executives
were interviewed. Each interview respondent answered the same 12 open-ended interview
questions, and their answers were later transcribed, coded, analyzed, and compared. The
27
interview questions were designed to unveil behaviors that may not have been identified during
the self-assessment survey.
Table 2
Data Sources
Research questions Survey Qualitative interviews
Why are some leaders more effective than
others when leading transformation?
X X
How do leaders respond to the existing
culture/s of the organization?
X
What are the common characteristics of
leaders’ successful mergers?
X X
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Research Setting
The research was conducted from two home office locations, constituting a natural
setting (Creswell & Creswell, 2018) conducive for Zoom video interviews. The purposeful
sample of participants consisted of senior executives, CEOs, presidents, and an administrator. All
have led through healthcare mergers. The reason for selecting these individuals was to identify
unique skills or attributes that may influence leadership outcomes.
The Researcher
My educational and professional background includes a Master of Science in Healthcare
Administration and more than 20 years of experience in the healthcare and health plan space
(reference Appendix C). While completing my doctoral studies and research, I have
independently consulted for health systems and worked in an intermittent role supporting
emergency unemployment benefits and response to the pandemic for the state of California. I am
currently on the advisory board at the CSULB Department of Health Administration, and I am
active in recognized industry groups. In recent permanent and consulting roles, I have been
directly involved with health systems undergoing mergers. I have worked on strategic planning,
execution of corporate initiatives, and leading growth. This is what motivated me to explore the
problem.
Given my understanding of the healthcare business, existing relationships in the industry,
and preexisting knowledge of competing organizations and their performance, there was
potential for bias and risk of confidentiality breaches. There is an ethics overview in Appendix
H, however, I further mitigated these risks by adhering to the American College of Healthcare
Executives (ACHE) code of ethics and standards and the institutional review board (IRB).
29
Data Sources
Ten C-suite executive leaders agreed to participate in an inter-method mixed-methods
study to identify traits of leaders who are effective throughout mergers in health systems. All 10
leaders completed a 15-minute 45-question multifactor leadership survey. Once the surveys were
completed, 1-hour in-person individual interviews were conducted with nine respondents who
could participate. See theoretical alignment table in Appendix G for additional information.
Method 1: Surveys
The participants completed a criteria questionnaire which established that they (a) were
CEO’s or equivalent thereof leading through health system merger or previously led (b) mergers
were successful, based on financials and quality scores. The participants then took a survey that
began with five demographic questions to establish their level of education and experience. The
MLQ is a survey instrument with 45 questions assessing respondents on their transformational
leadership skill styles (reference Appendix B). It measures transformational leadership on four
factors: idealized influence, inspirational motivation, individualized consideration, and
intellectual stimulation. While the theory is based on four factors, the authors of the survey break
the first factor, idealized influence, into two components, which are behavior and attributes, so
that the survey authors refer to the four Is of transformational leadership as five Is, presenting
idealized influence in two categories: idealized attributes and idealized behaviors (Avolio, 1991).
Method 2: Interview
I interviewed nine of the 10 survey participants and asked them 12 interview questions
(reference Appendix A). All the questions were open-ended and the same. This was intended to
obtain additional insight into attributes highlighted in the surveys.
30
Interview Participants
The sampling method for the study was purposeful selection (Creswell & Creswell, 2018)
of 10 individuals. I approached my C-suite network. The process involved stratifying the
population before selecting the sample (Creswell & Creswell, 2018). In this case, the
commonality was senior executive leaders who successfully led transformation throughout the
merger process. Success is defined as an organization that has maintained or improved its star
rating, based on a five-point scale, with a minimum of 3.5 at the time of the merger, retained
membership (not including loss resulting from intentional, strategic restructure and reduction) or
patients, and did not decrease its value (stocks).
A merger is defined as the consolidation of two or more healthcare organizations, either
vertical or horizontal; it is appropriate because the problem addresses leadership during this
process. Given the trend and increased prevalence of merging health systems in the United States
(HHS, 2020), the selection of participants is relevant. This study’s findings may substantiate an
emerging theory that implies that the selection of transformational leaders, their attributes, and
how they respond to the environment are significant for organizational success through the
merger process. The nine of the ten individuals who took the MLQ were then interviewed.
Concurrently, secondary data were analyzed to determine whether the organizations were stable
and/or increasing in quality and revenue scores after the merger. The interviews elaborated on
the leadership surveys by highlighting the participants’ strengths and self-awareness, fostering
discussions on how each leader overcame perceived weaknesses or areas for improvement. The
interviews further revealed an outlier which appeared during the surveys, and provided a richer
explanation of additional attributes the participants possessed.
31
Instrumentation
The inter-method study was comprised of a survey, interviews, and review of secondary
data. The survey, which was preceded by a five-question demographic survey, was the MLQ, an
established instrument designed to measure Bass’s (1985) transformational leadership model.
The independent variable was transformational leadership and outcomes, and the dependent
variable was leadership effectiveness. The survey consists of 36 questions about leadership style
and nine addressing leadership outcomes. Nine scales measure three styles: transformational
leadership (five scales), transactional leadership (two scales), and passive/avoidant behavior (two
scales), with three scales that measure outcomes. The instrument (Appendix B) has been used
across multiple industries, including health systems, to differentiate effective and ineffective
leaders; according to Stone et al. (2017), it was applied as a benchmark measure to study levels
of transformational leadership among health professionals driving practice beliefs. To date, many
studies of the psychometric properties of the survey have confirmed its effectiveness and validity
(Batista-Foguet et al., 2021).
While the surveys are recognized as successful, many researchers have criticized the
instrument, challenging the full-range theory. In their research of the MLQ and results, Batista-
Foguet et al. (2021) discussed the value of using the instrument; however, they suggest that
transformational/charismatic leadership should be treated as a multi-dimensional emerging
profile. The survey is popular and is even discussed in books on organizational leadership by
authors such as Burke (2017), Northouse (2019) and Kamau and Oancea (2020). Despite the
popularity of the multifactor leadership survey and confirmed validity in several metal analyses,
it continues to be challenged. Therefore, in addition to the survey, this study will include
interviews as an additional data collection tool.
32
The interview protocol was the data collection instrument. The interview questions
support the research questions, concept of the theoretical framework, and elements associated
with transformational leaders. While the study elaborates on deductive reason following the
MLQ survey, the interviews were inductive as they allowed me to gather additional data and
possibly identify a new theory (Merriam & Tisdell, 2016). I conducted the interviews via Zoom
and recorded them during a virtual session. I transcribed the interviews with the support of
NVivo, Otter and Zoom to support data analysis by coding and organizing. The interviews all
consisted of the same open-ended questions and included probing questions intended to gain
additional insight.
Prior to the study, I performed two mock interviews. I recorded and transcribed the
interviews and completed the analysis by manual coding. During the mock interviews, I took
additional notes and immediately reviewed responses from each participant to highlight key
findings. The mock interview analysis was useful in identifying opportunities to refine the
questions for future interviews. The first interview confirmed that a sophisticated application of
the probing questions combined with better use of summarizing transitions would allow the
respondent to be more thorough and make clarifications. The second interview resulted in fewer
revisions following the interviews’ completion because I applied presuppositions and avoided
dichotomous questions. The mock interviews also demonstrated the connection between themes
and the value of coding hierarchy (Saldana, 2021), the purpose of axial codes, and the need for
meticulous attention to language. For me, coding is organizing and helps to understand the data.
It does not, however, complete the analysis. It is only the beginning.
33
Data Collection Procedures
Once participants were qualified, I collected the data by administering the survey
consisting of 5 demographic questions and the 15-minute MLQ survey. Within approximately 2
to 4 weeks after a participant completed their survey, each of the nine individuals who
participated in the survey was interviewed. The data collection process took approximately 4
months.
As the researcher, I began by sending an introductory email to my large executive
network, which consisted of more than 200 chief executives, on social media to request
participants from the health system space who have led through mergers. Additionally, I sent
personal emails to my contacts. The communication explained the purpose of the study and
provided a proposed date to begin. While the notification of surveys and completion was
intended to take approximately 4 to 6 weeks, it took nearly 4 months to schedule and complete
data collection. This included follow-up with respondents via email or phone call to confirm
their participation.
While there was verbal interest, approximately 19 individuals responded formally, some
requested additional information or had scheduling conflicts, and some did not qualify. After
completing a qualifying survey, I assessed interested research candidates by determining they
were the first to respond and confirm their role, experience, merging organizations, status, and a
merger involving a West Coast health system. This eliminated bias. 10 individuals qualified, all
10 took the survey, and nine of the ten interview responses were used. I collected the data
electronically, as respondents submitted their answers, and generated statistics to analyze the
data. I compiled the data to determine the correlation with the interview data.
34
I asked respondents for their preferred time for a 1-hour interview and if they would
schedule a follow-up if needed and/or allow an additional 10–15 minutes if the interview ran
longer. I scheduled all the interviews in advance, using Zoom as a platform, working to
accommodate the executive’s schedule, and offering evenings and weekends as an option.
Twenty-four hours before the interview, all respondents received a script that included approval
to record/or videotape the interview; additionally, the respondents approved of interviews being
recorded, transcribed, and reported utilizing pseudonyms. All the respondents were advised that I
might take additional notes and that their identities would remain confidential.
Finally, I conducted the qualitative or depth interviews (Patton, 2002) by adhering to the
outlined questions followed by probing questions while remaining cognizant of time. For this
purpose, the tactic was to begin with the standardized questions, then end with a conversation.
The data were saved as electronic files organized by respondent name. I assigned the respondents
pseudonyms. The survey instrument was sent out by Mind Garden and organized by subscales.
The data were coded according to the MLQ protocol, and scales were then analyzed.
Data Analysis
Once respondents completed the online surveys emailed from Mind Garden, I saved and
entered the data into a data bank for analysis. The MLQ survey sections provided information on
scalable variables (Appendix B). Variance analysis, based on self-analysis, was used to
determine differences among executives. The link included an informed consent clause
disclosing the guidelines of the study along with instructions and an explanation of the survey.
The data analysis included entering introductory demographic questions responses into the data
bank to determine if there is any correlation between education, gender, experience, and
35
transformational leadership. The overall analysis measured transformational leadership qualities
to seek commonalities or differences among the leaders of the organizations.
The strategy for analyzing the qualitative data (interviews) was based on grounded theory
(Flick, 2018), with the application of axial codes. Upon completing the interviews, I conducted
data analysis by manual coding using an Excel spreadsheet, Microsoft Word, and additional
support from NVivo and Otter coding software to transcribe and identify themes and additional
findings. The software supports organizing responses by applying Axial codes and core themes
while conducting a comparative analysis (Flick, 2018).
A convergent mixed-methods design was applied. The strategy means that the data were
analyzed separately and then merged (Creswell & Creswell, 2018). The approach for analyzing
the two databases was a side-by-side comparison reporting the quantitative statistical results and
then analyzing the qualitative findings from the interviews. The results highlighted the survey
results and exposed areas that needed further probing. Creswell and Creswell (2018) referred to
this as a side-by-side comparison. This means that qualitative data analysis steps are critical. I
compiled a detailed review and comparison of quantitative and qualitative results. For the
qualitative interviews, NVivo Software was used to support data analysis and transcription. The
MLQ survey is organized utilizing five scales and categories. Each person’s score was stored
under the individual’s name, with results under each scale: charisma, intellectual stimulation,
individual consideration, inspirational motivation, and individual attribution. The scales also
represent the Axial codes intended to break down themes from the qualitative interviews.
I analyzed the data separately and combined them manually to retain a less robotic
approach and provide an in-depth analysis. The results were compared and presented separately,
highlighting similarities to outline pertinent findings in the transformation and the human
36
element of leadership without compromising validity. Additional quantitative data included
secondary information on the mergers, such as quality scores (Appendix I), financials, and types
of mergers. A high-level overview of the data analysis demonstrates the transformational
leadership.
Secondary Data Analysis
I used the HHS Centers for Medicare Services (CMS) website, confidential review of
data and statements from the participants, which supported their financial success and
demonstrated STARS quality ratings and scores during the time the CEOs of the health plans
were leading the organization for the health plan organizations, between 2018 and 2022.
Additional research was performed on each organization to determine whether it is a small,
medium, or large business entity and whether it retained and increased revenue following the
merger. The organizational size is depicted next to the participant overview, and revenue is not
included to protect the participants’ anonymity.
Qualitative Data Analysis
For the qualitative data analysis, NVivo, Otter and Zoom were used to transcribe the
audio/ video, then manually coded the transcripts in an excel spreadsheet. After reviewing each
interview, the transcripts were uploaded to NVivo for additional word sweeps. Word and Excel
were initially used to analyze the transcripts, then NVivo and Atlas were applied for additional
AI coding and word frequency. While there were five a priori codes that coincide with the codes
analysis and codes used for the survey, there were a total of 402 codes, 100 Code Groups, and
eight key themes, which are depicted in Table 3.
37
Table 3
Key Themes With Aligning A Priori Codes With Corresponding Codes
Key themes Themes Codes
Idealized influence
(charisma)
Trust/integrity, vision,
communication
Values, self-awareness, trust,
risk taking
Inspirational motivation Communication, human
capital
Kindness, perseverance,
courage;
Individualized consideration Cultural IQ, human capital Empathy, kindness
Intellectual stimulation Mentorship, learning
organization
Role models, strategic
decisions, shadow of a
leader, education
Transactional leadership Human capital, strategic
decision making
Operations, work ethic
Validity and Reliability
According to Avolio and Bass (2010), the MLQ demonstrates validity and reliability and
that construct validity is explained by factor analysis, resulting in the model of MLQ. As
explained by Creswell and Creswell (2018), construct validity is intended to demonstrate
whether the items measure hypothetical constructs or concepts. The design of the questions
applying scales supports effective construct validity. The reliability scores ranged from moderate
to good for the 45 survey questions. However, there have been additional studies that challenge
the results. Avolio and Bass disclosed a study by Muenjohn and Armstrong (2008), who applied
a confirmatory factor analysis to test and compare the reliability of the MLQ. The findings
disclosed that the data were a reasonable fit. Their study disclosed that under criticism of the
MLQ instruments, revisions resulted in the MLQ Form 5x version (Bass & Avolio, 1994).
According to Muenjohn and Armstrong, the results support research when measuring leadership
factors. The inter-method design of this study provides additional support for validity and
reliability.
38
Strategies for ensuring the credibility and trustworthiness of the findings from the
interviews included those outlined by Lincoln and Guba (1985), Merriam and Tisdell (2016), and
Creswell and Creswell (2018). For the qualitative paradigm, to ensure credibility, internal
validity encompassed triangulation, prolonged engagement, comparison, and member checks,
also known as respondent validation, which means the researcher obtained feedback from
respondents to validate interpretation during the actual interviews. Additionally, external validity
for the qualitative study was allowed enabling prolonged discussions to foster a rich description.
For the quantitative paradigm, the survey results were compared to the interview results.
Furthermore, for the qualitative paradigm, credibility was ensured by the consistency and logic
of the research, inter-rater checks on coding, and aligning the research with the design. For
external reliability, I ensured that the interviews could be traced back to the sources with
accessible audit trails. Finally, there was an ongoing peer review, and I attached a discussion of
positionality and potential bias (Appendix C) so that readers will understand how my values and
expectations may have influenced results (Merriam & Tisdell,2016).
Results and Findings
The purpose of this intra-method study was to better understand the attributes of
leadership during health system mergers. A review of the existing literature and results from the
research study suggest that leadership makes a difference. Upon review of the quantitative data
and survey results, nine participants’ scores demonstrated elements of transformational
leadership. Upon analyzing results from the qualitative study, nine participants demonstrated
transformational leadership qualities, including the outlier who scored below the benchmark on
the quantitative survey. The results from this study imply that health system leaders who
effectively lead throughout mergers are transformational leaders.
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While findings supported transformational leadership theory and the conceptual
framework previously discussed, there were differences. Outliers surfaced in the quantitative and
qualitative findings, suggesting an overlap of leadership theories such as authentic, servant, and
adaptive leadership and implying that the environment impacts leadership style. The most
common themes among the participants were trust and integrity, vision, communication,
transactional leadership qualities, emotional intelligence and cultural intelligence, human capital,
strategic decision making, and fostering learning. The findings elaborate on recurring
suggestions and key recommendations of practice discussed in the research. They suggest that all
participants are effective leaders who exhibit transformational leadership and imply that they
model the way for future leaders.
Participants
Study participants were nine CEOs or equivalents thereof who led before, during, and
after a successful health system merger/s. All the executives are educated, with a minimum
master’s degree education, except for Morgan, who holds a bachelor’s degree and an executive
certificate. Two of the executives hold clinical degrees, one is a physician, another has a
professional doctorate, and five have the equivalent of one or more master’s degrees, including
three Masters of Business Administration, one Master of Health Administration, one combined
Master of Health and Master of Business Administration. Three have been or continue to be
adjunct faculty, and all hold executive certificates in addition to their degrees. The executives
confirmed that they are committed to learning and fostering learning within their organizations.
Furthermore, the executives all have more than 10 years of leadership experience and are
well-educated. Seven have more than 20 years of leadership experience, and two have between
11 and 19 years. Five worked for one of the merging entities for 20 or more years, one for 7–10
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years, and three were with the entity for 4–6 years, demonstrating familiarity with at least one of
the organizations involved in the consolidation. All but one of the executives scored above the
3.0 benchmark for qualities associated with transformational leaders, according to their self-
assessment and the MLQ. Table 4 presents the participants’ information relevant to the study.
Table 4
Participants
Pseudonym Education
Leadership
Exp
Years with
merging
entity/ies Size of org
Ali MBA 20 + 20+ yr Med–LG
Bobbie MBA 20 + 4 to 6 yr Med–LG
Dana MHA 20 + 20+ Large
Jackie MBA, MPH 20 + 4–6 years Med–LG
Justice RN, JD 20 + 4–6 years Med–LG
Kennedy MBA 11 to 19 yrs 7–10 years Med–LG
Max MD 20 + 20+ Med–LG
Morgan BA 11 to 19 yrs 20+ Large
Pat MHA 20 + 20+ Small–med
Note. Small org ≤ 99 employees; medium org 100–499 employees; large org 500 + employees
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Quantitative Study
After completing profile questions, the executives completed an MLQ measuring a full
range of leadership with the application of transformational leadership theory, as well as
assessing leadership outcomes. The full range of leadership survey covers three broad categories
of transformational and transactional leadership and passive-avoidant behaviors. It also measures
the outcomes of leadership. Since the focus of this study was to identify attributes through a
transformational leadership lens, the scales and elements of the transformational and
transactional leadership elements were later used to support coding of the qualitative study.
The results of the ten executives were compared with the group’s self-ratings and a
normative sample of 3,375 executives. Findings show that while all the executives demonstrate
transformational leadership skills, compared to the universal norm, they score higher on
transactional leadership qualities. This study implies that healthcare leaders score higher than the
suggested 3.0 benchmark for transformational leadership qualities (Figure 3) and higher than the
transactional leadership mark range of 2.0–3.0 for contingent reward (Figure 4). The
combination of transformational leadership qualities and transactional qualities may suggest that
the health system space and/or merger activity requires the application of all these skills. Figures
3 to 7 depict overall self-assessment scores for transformational and transactional leadership
qualities and compare this group to a larger sample of executives who took the same survey.
There was one outlier whose individual score was 1.9, compared to the others’ 3.0 and above,
which was higher than the norm. The outlier scored skewed overall results by .1 and some
categories higher (reference Appendix E) for scores excluding the outlier; the scores with the
outlier are represented below.
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Figure 3
Transformational Leadership Participants
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Figure 4
Transactional Leadership and Passive Avoidant Behaviors Participants
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Figure 5
Transformational Leadership Participants Compared to Norm
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Figure 6
Transactional Leadership Study Participants Compared to Normative Study
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Figure 7
Overall Outcomes of Leadership Compared to Normative Study
The participants self-scored within the range for strong leaders on passive and avoidant
behaviors, the second element of transactional leadership. The group average with the outlier
was .7 and the ideal frequency should be less than 1.0, suggesting that the participants perceive
themselves as leaders who do not primarily focus on failures to meet standards. While they may
track mistakes, they constructively lead corrections. Likewise, they scored low on passive and
avoidant behavior, which suggests that they perceive themselves as action oriented. The overall
outcome of leadership score for the strongest leaders is 3.5. This group scored higher than the
normative sample (Figure 7) with a score of approximately 3.3. A slightly lower self-score may
indicate humility, as a higher score suggests efficiency and the ability for leaders to generate
extra effort and satisfaction among their followers and teams.
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In summary, the self-reported data, surpasses the benchmark for transformational
leadership traits. The scores suggest these leaders develop trust, act with integrity, motivate
others and involve themselves in mentoring. While their transactional leadership element scores
were not en par with the norm, they were within the suggested benchmark (Figures 4 and 6)
which implies they are leaders who more frequently apply rewards achievement, rather than
focusing or monitoring mistakes. This group scored higher than the norm on effectiveness.
However, neither the group participants nor the norm reached or exceeded this benchmark,
suggesting a further probe, such as the subsequent qualitative findings, which later revealed that
the CEOs in this study are humble, and their self-reported MLQ scores may not fully depict the
level of behavior.
The qualitative study elaborated the overall results of the MLQ survey. Seven executives
held senior operations or finance roles prior to becoming chief executives or presidents. The two
who did not hire strong chief operations or finance officers, delegated responsibilities, and
considered these individuals to be instrumental to their organization’s success. Additionally, the
overall scores changed with and without the results of the outlier, who, in the interviews, self-
reported consistently low scores on prior psychological tests and was repeatedly invited and
supported by boards to assume senior executive roles.
Qualitative Findings
The findings are explained in the context of the transformational leadership model and
were helpful in analyzing how these successful leaders handled issues such as lack of buy-in and
motivation and fear of the unknown, which often leads to disloyal employees who may sabotage
merger activities.
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Pursuant to evaluating the interview responses, there is evidence of all four factors (4 Is)
of the transformational leadership model, inclusive of transactional leadership traits, which
contributed to successful leadership and organizational transformation. Furthermore, discussions
exposed the complexity of the behavior of executives who are adaptable when leading merger
transformation while responding to unforeseen environmental impacts. The findings also imply
that the executives exhibited stronger transformational leadership qualities than they self-
reported on the survey, which suggests humility because they downplayed their attributes.
Each of the interviews tells a story providing evidence that these healthcare industry
leaders meet the definition of transformational leaders: they are self-actualized visionaries, who
communicate, motivate, and act as role models, as Justice and Kennedy implied, if you ask their
employees, they are “shadows of their leader.” All the participants displayed the four
transformational factors, idealized influence, inspirational motivation, intellectual stimulation,
individualized consideration, and transactional leadership. However, the two prevailing key
elements which appear to be critical for successful transformation during mergers are trust and
communication in that order. Additional key themes were cultural intelligence, human capital,
and knowledge.
Results Research Question 1: What Leadership Traits Do Leaders Perceive As Effective When
Leading Mergers in the Healthcare Industry?
Participants’ responses to six interview questions, and additional information, suggest
that transformational leadership theory elements define effective leaders. The interviews
provided deeper insight, highlighting attributes that may overlap with the elements and possibly
stand alone as independent themes when conducting a thorough analysis of why some leaders are
more effective than others when leading mergers.
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Trust and Vision (Idealized Influence). Idealized influence is a leadership attribute that
means leaders are capable of building trust. They instill pride while inspiring their followers to
support the vision of the organization. They exceed expectations by building trust. Throughout
each interview, the key emerging theme was trust. Each participant responded that effective
leaders command respect by modeling ethical conduct, developing trust, and genuinely valuing
their employees. Building a foundation of trust and strong relationships supports buy-in, fosters
an ability to propel the vision, and supports agile leaders while they respond to unprecedented
events. All participants spoke about integrity, including transparency, honest dialogue, values
and inculcating such values into the organization’s culture and mission. Participants’ responses
showed that all nine executive leaders developed respect and trust by modeling ethical conduct.
Dana summarized the findings from all the interviews, saying, “It is important for people
to work for a leader they respect and trust.” Dana further explained that in addition to executing
strategy, trust enables a leader to respond to unprecedented events and external influencers, such
as governmental regulations or the recent pandemic. At times like this, you “don’t ignore the
storm.” You deal with it and are honest with the teams. Previously established trust and integrity
are key ingredients for continued success.
Kennedy was leading during merger activity while also leading through union
negotiations when staff elected to decertify a union. His statement reinforced the relevance of
trust when he said there was a ‘testament to the trust,” which was built over a long period during
an organized effort to go from two unions to one. Kennedy said, “And a few months later, there
was a vote, and they were decertified. … Their comment throughout that journey is ‘we trust our
leadership.’”
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Jackie provided insight into the short- and long-term impact of trust on efficiency. For the
short-term, daily organizational goals, Jackie explained that when high levels of trust exist at all
levels of the organization, “you can get in a room and roll up your sleeves” and work toward any
goal. However, when there is low trust, it takes additional time in a meeting or before beginning
a project to work on possibly developing trust. Jackie feels “you can solve things quicker and
move forward with strategies swifter when a high level of trust exists in an organization.”
Justice also spoke to trust while stressing the importance of relationships, which led to
loyalty and employee buy-in. Justice said, “Meaningful relationships are authentic and
transparent with the people that work for you and with you that will take you and them quite a
long way. They will be willing to go through the fire.” Ali, Bobbie, Morgan, and Max all implied
that trust begets trust, so in addition to modeling the way, they empowered others and delegated
to foster trust shared that by empowering others. Max said with regard to trust, “I did, and we did
by walking the talk.” Bobbie confirmed when he said, “You’re an ethical individual and that
you’re an ethical organization. … That goes a long way. … I think it led to quite a bit of trust.”
Finally, regarding trust as key to effective leadership, Dana shared that engaging with
employees and teams helped to build trust during merger activity. Not knowing whether cuts
might be needed, Dan would say, “Look, I know that’s what you’re worried about. … I promise
you that as soon as I think it’s going to happen. … I will let you know long before.”
Furthermore, Dana walked the talk by keeping teams abreast of the situation with
communication lines open and being honest and truthful with people so “they trust you.”
Maintaining trust requires communication, which leads to the next theme.
Communication (Inspirational Motivation). Inspirational motivation is the ability to
effectively communicate, motivate, and encourage others to support the vision and mission.
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When merging organizations, knowledge transfer and integration are necessary and require
communication. Cogent communication within organizations motivates employees to support the
mission and vision, resulting in buy-in and establishing trust leading to success.
All the leaders stipulated the importance of formal and informal communication forums.
Upon entering merger negotiations and throughout the process with consistent communication
and a communication plan, the level of teamwork and spirit escalates and is felt across and
outside of the organization. In addition to formal communication plans which address external
and internal stakeholders, collectively, the CEOs spoke to daily and weekly communication
techniques as s simple as Ali’s 5-minute morning huddle via cell phone, Max’s staff meetings,
Pat’s email and telephonic communications, Bobbie’s, Jackie’s, Justice’s, and Kennedy’s
employee and stakeholder town halls, and platforms, including blogs and email newsletters. The
frequency and type of communication may include one or all, dependent on the audience,
culture, size of the organization, and stakeholders.
Max stated that physician buy-in is propelled by effective communication, which also
encourages teamwork. Max also said they held many meetings to agree upon the vision, strategy,
and goals. To attain success, there needed to be clear, consistent dialogue.
Upon completing a merger, Bobbie shared that senior executive teams, such as chief
financial and operations officers, chief medical officer, chief marketing officer, and key vice
presidents, were part of scheduled enterprise-level updates. The leaders then disseminated
information to their teams. Bobbie also implied that the organization had a comprehensive
communication plan and said, “Marketing and communications and our folks were clearly
getting scripted points from us. They could understand, they could, you know, cascade to the
organization, although we cascaded a lot of that information.”
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Additionally, Bobbie Jackie and Justice stressed the importance of in-person
communication, such as engagement and “town hall meetings, to make sure people felt good
about the new culture they would be a part of.” On the other hand, Dana highlighted the
importance of open communication even when there was bad news. Using the pandemic as an
example and the storm metaphor, “there are two aspects of the goal and vision, but you can’t
ignore the storm. You have to acknowledge it and then maintain honest dialogue.”
Despite proactive communication, as a leader Ali was aware that, potential blind spots
exist. Ali believes that silence may be misconstrued when someone is not engaging or asking
questions in a meeting or not responding to a phone call or email. Ali’s tactic was to arouse
conversation. Ali says, “Silence is a friend you cannot trust, so I would provoke.” While Ali’s
tactics appear to be more direct than some of the other executives, all nine leaders demonstrated
the facilitation of consistent dialogue.
Four CEOs, Bobbie, Jackie, Justice, and Morgan also posited that data are an effective
communication tool. Bobbie said being transparent by sharing data was effective when
communicating strengths to motivate a team. By displaying the results and telling the person or a
team, Bobbie would say, “You’ve got some excellence that many people have noticed, including
us, and in fact, there is a ton of excellence here.” Additionally, Bobbie articulated the importance
of reciprocal dialogue, which represents similar relationships among the other eight CEOs, hence
the lengthy excerpt:
I wanted to make sure that the chief medical officers had an avenue to be able to share his
or her thoughts with me. I also wanted to make sure that the CFO who I would go toe to
toe with on occasion that he felt that there was a good exchange of ideas between us. I
would do things where we did lunches kind of just one-on-one very low-key.
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While motivating others via a variety of communication methods, the participants also
perceived the ability to challenge and entice creativity was necessary to lead transformation.
Often aroused by communication is intellectual stimulation.
Intellectual Stimulation. All the executives perceive intellectual stimulation as an
important leadership factor. Despite mergers requiring strategic plans with stringent deliverables,
effective leaders are capable of stimulating others to think, question assumptions and assess
issues from different angles. When two or more organizational cultures come together, it is
necessary to consider all when executing. All the executives spoke to various tactics under the
umbrella of intellectual stimulation. These include brainstorming sessions, a leadership institute,
provocation of communication, and debates resulting in new ideas. Additionally, embracing non-
industry professionals for non-clinical roles while fostering the transferability of skills and
facilitating clinicians to lead business units.
Justice’s approach to stimulation and increased levels of creativity is to be open to
change, introduce new ideas, lead by example, and openly encourage innovation, which requires
agility. Justice said, “I always come up with the crazy ideas of things to do.” Justice invites
creativity and said that leaders should “give them the opportunity to develop and to grow and to
shine.”
By encouraging innovation, both teams and individuals rise to the occasion. Teams are
made up of individuals with strengths and weaknesses. When the lights shine, individuals stand
out, and their contributions are considered. Adept leaders can assess the strengths of the merging
entities and further develop individual strengths, which contribute to the success of the new
entity.
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The executives also have in common an ability to empower others while providing them
with opportunities, which stimulates their intellect. For example, Justice led with an attitude of “I
don’t believe in I can’t do something.” Instead, the attitude was to apply ingenuity and “figure
out how to do it.” Likewise, Pat empowered employees. Pat suggested finding the right people
who were “passionate about the job” and then “letting them run with it,” thereby stimulating.
On the other hand, Ali consciously included the biggest objector to the merger, the chief
medical officer, in the room when finalizing contracts so that holes would not be punched in it
later. Ali provided this example of why the deal was effective: “I needed the [chief medical
officer] … who was also an effective leader. Jackie’s approach was similar, saying that you get
in a room and “have a good debate. At the same time, Morgan applied a diplomatic approach,
resulting in vetting two philosophical approaches which yielded the “marriage of product and
underwriting teams” and often invited teams to “get back into the room” to “rethink” the
approach. Ali’s approach, which is also individualized consideration, enticed intellectual
stimulation by fostering debate. Ali said,
Yes, it’s trust, but it is an openness to contrary opinions. … I was saying in my manager
meetings anybody who agreed with me twice during a meeting needed to leave the room
because there’s no sense in having such agreeable people.
While stimulating others and encouraging innovative thinking, findings demonstrate that the
chief executives also consider individuals. This may serve to coach others while recognizing
their individual differences and desires yet stimulate deeper thinking, improving overall results.
Individualized Consideration. Individualized consideration is the ability to coach and
develop people while considering their differing aspirations. This includes cultural awareness,
which is discussed in the second research question. It is also a human element that displays one’s
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empathy along with an ability to mentor and coach. All nine of the CEOs spoke to the
importance of considering their teams. Jackie felt that the best decisions were made when more
“brains were in the room” and said, “I very rarely thought would I ever go against my executive
team.” Max, who led an organization based on cultural affinity, felt that despite being alike as
physicians, a big driver of physicians working together was concurrently to “maintain their
clinical autonomy and clinical mission to do it in a financially successful way with access to
technology.”
While they all spoke to consideration for their executive teams, six stressed the
importance of the staff and all employees. Justice spoke from the heart advising as if to advise
future leaders, saying, “As a leader, please don’t discount the value of your employees.” Bobbie
reminds leaders to “put yourself in the other person’s shoes and think about how they’re going to
react to the things you’re asking them to do?” Ali said that it was no good when everyone always
agreed with everything that was presented. Bobbie said, “Give the guy that maybe doesn’t fit
your model a chance and see what he can do sometimes.”
In summary, despite each leader speaking to individual consideration with varying
degrees of focus, which the organizational model may influence, they encouraged individual
consideration at all levels. Additionally, while considering their leadership teams and employees,
all the executives displayed emotional intelligence, with eight standing out as specifically
possessing cultural intelligence or the ability to cross boundaries and thrive with and in different
cultures.
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Results Research Question 2: How Do Leaders Respond to the Existing Cultures of the
Organization/s When Leading Mergers in the Healthcare Industry?
While merging vertical and horizontal organizations, leaders face, as Dana said,
combining or integrating organizations and their respective cultures. Emotional intelligence and
cultural intelligence emerged as themes in the data. They are associated with one of the four
factors (4 Is) of transformational leadership: individualized consideration. Since culture is a
factor considering the individual needs of employees, merging cultures overlaps with diversity
and inclusion, which may require training to ensure effectiveness.
While each leader considers the needs of their followers, whether overseeing vertical or
horizontal transformation, culture prevailed as a theme. The implication is that while there are
preexisting organizational cultures and micro-cultures, leaders with a vision are strategic and
genuinely mission-driven organizations whose leaders propel a culture which, especially Jackie
and Max stressed, is intentional.
Developing an intentional culture may also work to obtain buy-in from leaders of
organizations preceding a merger and throughout the process. While it can occur during vertical
and horizontal mergers, the evolution of the organizational culture tends to be more evident
during horizontal mergers. Max referred to cultural affinity when explaining the success of the
horizontal mergers, which two of the other CEOs also alluded to, while the others approached
culture through a different lens. While some of the CEOs built organizations from the ground up,
which bred culture, and others inherited existing cultures, all nine had a keen understanding of
culture and fused cultures of organizations.
Cultural Intelligence (Individualized Consideration). All the respondents
demonstrated the ability to relate to others and interact effectively across cultures. They
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illustrated an awareness of existing macro- and micro-cultures and the significance of
understanding opposing culture. To varying degrees, each participant highlighted how they
approached the cultures of the organizations to integrate and execute.
Eight of the CEOs indicated that communication and engagement were the first steps to
understanding organizational culture and underlying culture. Once dialogue is started, additional
tools such as surveys are used for in-depth assessment. Kennedy shared that upon assuming the
CEO role, a phrase shared by an influential leader about culture eating strategy for breakfast
immediately came to mind. Kennedy said it was important when leading in the hospital health
system space. Kennedy and three other CEOs shared that being present, or managing by walking
around, was effective when transforming culture. Kennedy shared,
I could overhear one nurse ask the other nurse, “That’s our new CEO. What’s the CEO
doing on the floor? What did we do wrong?” And 3 years into being their CEO, rounding
on the floors and trying to always be a present leader, those same nurses would say, “Hey
Kennedy, we haven’t seen you in a couple of weeks on our floor. Where you been?” So,
you can tell the difference there from being a present leader that it could have on a
culture.
Four CEOs, Ali, Jacki, Max, and Pat, believe organizational culture is intentional. The
leadership team is responsible for emulating a mission-driven culture, and when entities were
brought on, they were educated on the culture, or there was culture by osmosis. Jackie elaborated
with a discussion and a philosophy of fostering a mission-driven culture where the patient is at
the center. Justice, Morgan, and Dana talked about patient-centric focus as their mission, which
was to become part of the organizational culture.
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Four executives spoke directly to diversity, inferring to the diversity of teams, as it relates
to culture. One indicated that the health system had a diversity officer. Jackie’s perspective was
that while there was a diversity equity committee, Jackie did not perceive existent issues in the
organization because the culture was also to “focus on the job at hand and appreciate
differences.” On the other hand, Dana stated that understanding the existing cultures and
combining the organizations was critical. However, Dana also alluded to a level of cultural
affinity and said that you cannot force change. The employees must buy in: “You can’t impose a
culture on somebody.” Dana said that “if you have a deliberate culture, it’s helpful,” which three
of the other leaders also implied. Dana expressed “testing compatibility of cultures “prior to the
mergers is useful, suggesting that when “cultures are compatible,” then you can align around
what you want.
Morgan and Ali used marriage and family metaphors when discussing how they
combined organizational cultures along with common sense and back-to-basics tactics to support
strategy. When Morgan was explaining health plans pulling together and obtaining buy-in, he
implied that it was like marrying two teams, which evolved into a culture that included a
consumer mindset and then he said, “We did kind of win the culture war, but it took a while.”
Cultural intelligence resulted in identifying that cultural affinity was the ingredient that would
support success in an integrated physician organization.
Max led horizontal mergers, as did Dana and Morgan. However, Max led a physician
group and merged with physician-led organizations. The intentional culture brought them
together. As Max said, “physicians, like birds of a feather, flock together.” They may provide
additional insight than a chief financial officer, for example. According to Max, the joining
physicians and groups shared a like vision. Max said,
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Never were any of the mergers and acquisitions based on a financial outcome. They were
always based on a cultural affinity that we felt would be consistent with a vision of
excellent patient care and the ability of physicians to connect with their team members,
the whole clinical team, to make good patient decisions without a lot of outside influence.
Ali provided a good example of understanding the need to have a chief medical officer at the
table. It is an example of cultural intelligence resulting in diverse teams, including intellectual
diversity. To Dana’s point, Kennedy revealed that the organizational merger was at risk of failing
until leadership intervened to bring opposing cultures together. Kennedy said,
The cultures between the two organizations did not fit with each other. And there were a
lot of disagreements and perceptions that were leading to a merger that was basically
falling apart. Quality scores were at their all-time lowest, the annual losses per year at its
all-time worst and the lack of trust was extremely high.
In addition to speaking to culture, Kennedy was sincere. While talking, Kennedy’s tone
and body language expressed the significance of challenges one might face to build trust and
shift culture. Kennedy shared that it was a daunting task to build trust among a multi-faceted
entity with many stakeholders and differing opinions: “An effective leader was needed to build
trust and establish a culture within the organization that could stand the test of time.”
Finally, when leading, Pat embraced diversity and culture, explaining that diversity was
“one of the main things about anthropology. When you learn about different cultures and beliefs,
the way people do things because it’s all part of the whole thing. None of it was wrong.”
In summary, the findings suggest that to succeed, merging healthcare organizations
should develop an awareness of existing cultures and be able to respond to various cultures.
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Leaders should maintain a mission- and vision-driven organization, supporting diversity and
inclusion to ensure they foster a patient-centric organizational setting.
Results Research Question 3: What Are the Common Characteristics of Leaders of Successful
Healthcare Industry Mergers?
According to the analysis of the rich discussions with CEOs, their common
characteristics align with their perceptions discussed in the first research question. The individual
responses suggest the presence of all four Is of transformational leadership theory and the
application of transformational leadership traits. In varying degrees, the leaders demonstrated
idealized influence (charisma), inspirational motivation, intellectual stimulation, and
individualized consideration. Additionally, as depicted by their self-assessment survey, the
quantitative analysis through the MLQ provided evidence of transactional leadership qualities.
One of the commonalities that align with the four Is is vision. Dan stated, “You have to
have a vision and a long-term commitment.” A second is integrity. As Morgan explained, if there
is a shadow cast, “I hope this is it, putting the member first and keeping your promise.” A third is
communication, as summarized by Justice: you must “listen well” and then “communicate, so
they don’t make it up in their heads; be as truthful as you can.” A fourth is human capital, and a
fifth is thinking and knowledge. The leaders all demonstrated a commitment to stimulating new
ideas, sharing knowledge, and fostering learning organizations. While all foster learning
organizations, Max’s organization transcended generations, raising the bar when they began a
leadership training institute in collaboration with universities.
Finally, Ali provided a good example of the importance of transactional leadership, not
only transformational leadership, during a merger. Ali demonstrated transactional leadership
during a negotiation, where terms of the transaction are a deal breaker. In other words, if certain
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terms were met, such as a guarantee of the senior C-suite leaders continuing in their respective
roles pursuant to the merger, and Ali’s position guaranteed for 5 years, then the deal was
possible. Ali frequently used a marriage metaphor when explaining tactics, referring to the
contract as a prenuptial agreement: revealing that success was sustained because “I requested
they sign a prenup.” The data imply leaders who successfully lead throughout a health system
merger possess all four of the factors for transformational leadership as well as transactional
leadership factors. The most common emerging themes are charisma, integrity, communication,
understanding of human capital, and appreciation for learning and knowledge. Additionally, they
balance transactional leadership factors, including contingent rewards and management by
exception, to support outcomes.
Idealized Influence. Idealized influence, the first component of transformational
leadership was also referred to as charisma. This is because leaders with strong beliefs, who
skillfully build trust and build a commonly shared vision and mission, were perceived to have
charisma, a quality and ability to pull people in with effective communication or personality.
While the leaders discussed vision, they did not talk about themselves as being
charismatic. However, upon reflection on the one-on-one interaction with each executive and an
in-depth review of transcripts and audio, they all exemplified charisma. They trusted me, the
researcher, with confidential information, sharing details that clearly demonstrated an ability to
communicate and transform. All participants were transparent while responding to the interview
questions, exuding passion and demonstrating how they obtained buy-in. They verbally and
visibly displayed charisma.
For example, Max said the success of the mergers was the result of a vision supported by
a strategy and goals. This leader gained support for the vision by recognizing that healthcare in
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every part of the nation was different. All the CEOs were able to obtain support internally and
externally because, like Max, they encouraged healthcare delivery decisions to be “retained
locally” and noted that healthcare delivery begins as a “relationship business” among caregivers
and providers within a community.
Dana expressed that it is “critical to have a vision about what you’re doing” and then
said, “I’m just going to use the word combination” when speaking about mergers as opposed to
integration. A further display of charisma was Ali’s consistent application of the family and
marriage metaphor: “The single critical piece about getting management to ride on the same
train, as I did.” Justice summarized the how of execution: “There’s no magic bullet to it” or
telling the employees, “Let me do the worrying. … I think that is part of what being a servant
leader is.” Kennedy responded to a probing question: “I may have a charismatic personality or
servant leadership style or whatever you might want to call it.” Morgan, when addressing what
works, said, “what was my angle was the diplomacy.” Jackie revealed beliefs such as “managed
care is public health” and, when reminding health system professionals to go back to basics and
be genuine, said, “the value that you bring to the industry, that is paramount to me.” Bobbie,
when selling the vision, said, “I would beg to differ that there’s a different way to approach this,
and we can deliver better care.” Pat, while explaining the complexities of effectively leading and
considering all levels of employees, said, “It’s a whole thing. It’s almost its own religion.”
Albeit short excerpts from rich discussions, the demeanor of the participants, along with
their language and tone, provided evidence of charisma when leading and communicating.
Finally, at least five CEOs directly stated that charisma helped, including Justice, who admittedly
evolved from an introvert to an extrovert pursuant to leadership coaching, saying, “It was for my
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own personal development so that I could be more charismatic … to be more comfortable being
out front.”
Communication (Idealized Influence and Inspirational Motivation). As with the
perceived qualities, a key element, or common denominator for successful leadership, is
effective communication. Each of the executives spoke to the need for consistent engagement,
which also increased trust (another common denominator), awareness and the ability to
effectively integrate and transfer knowledge across complex organizational structures.
Effective communication is more than just talking or disseminating information. It
includes a combination of listening. As Bobbie said, “I tried being proactive listener.” Max
added, “You hear what people’s issues are, and you have the ability to respond and
communicate.” Effective communication entails the application of technology and platforms
while communicating. Pat explained that investment in technology was critical to stay on top of
the evolving industry. Justice also relied on technology to provide data, which was used to
communicate out: “I relied upon a couple things. One was data.” More than half of the CEOs
alluded to the importance of listening prior to responding, and they all suggested that effective
communication considers the audience and purpose of the message. Therefore, in addition to
sophisticated communication methods, more casual in-person check-ins, daily phone calls and
email are useful. Furthermore, while listening, those who have empathy encourage two-way
communication yielding mutually beneficial results.
Justice spoke to the importance of communication channels and how “4 years of being
consistent and transparent” when communicating with employees and governing bodies
supported organizational success. Additionally, Max shared that to improve communication,
tactics included training on government policy to support the relevance of the relationship and
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set a stage for effective implying that confidence assisted effective dialogue. Ali further
explained that listening to teams and approaching them as a family by understanding that when
mergers transpire, “you now have cousins, aunts, and uncles to consider. “Morgan and Jackie
discussed the importance of interdepartmental communication, requiring diplomacy to meet in
the middle to drive the same mission, and Bobbie spoke to leading a sophisticated marketing and
communication plan beginning at the enterprise level.
Albeit lengthy, the excerpt below is intentional as Justice addressed the complexity of
relationships and relevance of external stakeholder communication, which impacts all the
organizations represented in this study:
Reached out via our government affairs person. …We reached out to our liaison through
CMS … just brought the best of my team members together. … We made it very
apparent to CMS and DHS that we were subject matter experts. That helped is to
influence very much how the policies were going to be written, how things were going to
be operationalized, the timing on things. That’s what we did.
Finally, while communicating with confidence, Pat said it is important to address
employees respectfully and not talk down to them but talk to them like “adults.” Then,
communication will serve to stimulate dialogue and motivate teams.
Intellectual Stimulation. Encouraging innovative thinking may be risky during a merger
since mergers involve the integration of two or more individual entities, and a strategy is
outlined. Whether the merger is vertical or horizontal, there is a learning curve for both sides.
Furthermore, as seven participants suggested, due to legislative changes as well as the
unprecedented chain of events resulting from the COVID-19 pandemic, leaders of mergers must
balance a response to merger activity with a response to the environment. This includes Ali,
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Bobbie, Dana, Jackie, Max, and Morgan leading mergers while responding to ACA requirements
and Kennedy’s response to union decertification during merger transformation.
Despite existing strategies, healthcare leaders are called to be agile by driving their vision
and leading as the organization adheres to regulatory guidelines or responds to extenuating
circumstances, such as staff voting out one of two unions or the pandemic. As leaders react, they
endorse inter-disciplinary knowledge transfer, and this enables agile responses to patients’ health
needs under all circumstances. Dana explained how intellectual stimulation, or innovative
thinking, stemmed from the organization’s culture and increased trust. Dana said, “Culture
should support people to think creatively and have enough trust and relationship capital to
express themselves.”
During their leadership tenure, more specifically the years which impact this study, all
the CEOs were equally affected by the demands of the ACA and other government regulations.
By seeking different perspectives from external stakeholders, and internal subject matter experts,
all the CEOs either expanded upon existing strategies or a merger strategy evolved in response to
environmental demands. Max explained that larger organizations have deeper pockets when they
integrate with smaller organizations. The smaller entities gain access to capital, creating
economies of scale with more efficiency and improved quality.
Additionally, Max gave credit to the employees, the individuals working for the
organization, for making most of the decisions. Max said, “I don’t make very many of the
decisions. We had 5,000 people that worked in the organization. You work your way through
those people. … There’s got to be good ideas.” By encouraging innovative thinking, leaders are
emphasizing the value of their teams. Dana also described employee interaction: “I think I’m
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either a supporter or promoter,” which speaks to seeking different perspectives or intellectual
stimulation, as well as consideration for the individual and development.
Individualized Consideration (People, Human Capital). Participants’ responses
demonstrated that they value employees; they regard human capital as an asset. Four stressed the
importance of mentorship programs to support continued employee development and
organizational growth. They talked about the value of a strong human resource department. Two
said they had human resource experience, and all relied on other individuals in the organization
to execute the vision. Five CEOs discussed the importance of coaching managers to become
leaders, which, in turn, supports succession planning.
Collective analysis of the participants’ responses yielded individualized consideration
and human capital as themes. Table 5 presents examples from each interviewee the CEOs
displayed the traits of individualized consideration and value for human capital.
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Table 5
Individualized Consideration and Human Capital
Interviewee Response
Bobbie: knowledge transfer Training and knowledge transfer with peer-to-peer
coaching, “when we merge, we mix clinical and non-
clinical teams.”
Dana: grit and perseverance “Those who have grit can persevere and can be coached
and mentored. … We’ve had success and then
sponsoring and promoting people who are stepping up”
in areas where organizational improvement is needed.”
Jackie: mentorship and training Cross-functional training and mentorship: “Upon a chance
to talk to students, I encourage people to kind of move
around a little bit, you know, in the different types of
organization.”
Justice: coaching and mentorship “Just give people the opportunity where they feel that they
are a part of the process because then they have
something to hold on to. … They are involved. … They
don’t leave for the competition” or performance does not
suffer.”
Kennedy: human resources Having an anchor in human resource as Kennedy’s
organization does and fostering a learning organization.
Kennedy said, “As leaders, we always need to be
continuous learners in everything every day and never
think that you’ve arrived at knowing everything about
everything.”
Max: foster learning “Finding and developing team members with diverse
perspectives from all areas.”
Max: invest in employees “Investing time in the employees. … We tried to be good
stewards of our valued employees.”
Morgan: consider all
perspectives, cross-functional
training
“Began in banking. Then, started ground up, moved from
marketing, to commercial, to Medicare. … Accepting
new opportunities. … Included in the succession plan led
to CEO and modeling the same.”
Pat: promoting diversity “You look for diverse talent, but they have to be smart, and
you provide opportunities and coach and train them”
Additionally, all the organizations leveraged physicians’ clinical knowledge and
developed their leadership skills while transitioning some to administrative roles. While two
participants had clinical training, including the physician CEO who created the leadership
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excellence institute, all promoted the importance of developing physician leaders or
“champions.” The intent was for physicians to champion the vision while obtaining buy-in from
clinical teams.
Finally, all participants acknowledged that without their investment in human capital, it
would be difficult to succeed. Justice summarized, “Their willingness to go the extra mile is
what helped us to get the kind of outcomes we did.” The human element and Justice’s
summation are a good segway into the subsequent findings, which address the importance of
transactional leadership factors.
Transactional Leadership. The theme of balancing transactional leadership qualities,
with transformational leadership emerged from all nine interviews, largely because of recent
health system paradigm shifts resulting from environmental impact and the healthcare industry’s
reimbursement models. While leading through unprecedented change in an already complex
industry, agile leaders sometimes resort to contingent rewards to reach goals. Moreover, when
the intent of a merger is to expedite growth or meet sales forecasts, then management by
exception, the second factor of transactional leadership, is applied to assess teams’ and
departments’ performance. The participants are capable of skillfully combining transactional
leadership attributes with their transformational attributes; alternatively, they delegate to their
chief financial or operations officers to lead these initiatives.
Ali’s pre-merger approach tactic alluded to a marriage and “prenuptial” agreement
metaphor. To protect quality for patients and employees, Ali’s negotiation included telling the
other organization that there would be “no deal” without including three key senior executives
for a minimum of 5 years after signing the contract. For Ali, this was not about them “writing a
check.” It was about them signing a prenuptial agreement. Ali told other potential partners, “You
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have fiduciary responsibility to the group as well position.” According to Ali, remaining
accountable required being able to “transact” and negotiate with the current executive team to
stay on board the merging ship and embrace the new business partner. While all executives in the
study led prior to the merger, Ali spent the most time discussing the negotiation and the pre-
merger process, sharing this tactic with others.
The interviews enabled a more thorough examination of transactional leadership and its
application when leading transformation and sustaining success. Doing so throughout a merger
calls for considering individuals’ diverse needs. The leaders effectively applied transactional and
transformational leadership components to integrate cultures while considering these needs.
While the CEOs all exhibited transactional leadership traits, they also emphasized the
need for the right balance. An astute leader understands when intrinsic motivation is sufficient
and when or if contingent rewards and financial incentives should be used to meet goals. Bobbie
summarized, “Financial incentives are definitely a component if they are not overused because
then it is not sustainable.” Pat implied that sometimes additional incentives were needed with
clients and employees responding to governmental deadlines and upgrading software, for
example, but also recognized the value of intrinsic motivation: “Not just because they needed a
paycheck, but because we were all working together as this team that, got things done the right
way.”
Another example of applying transactional leadership is from Morgan, Justice, and Dana,
who were at the helm of organizations whose business development or sales and senior
marketing executives utilized contingent rewards to push for quotas while driving organic
growth. These actions, in turn, motivated their executive teams with year-end financial bonuses
tied into operational benchmarks and sales growth, as sales teams’ motivation requires some
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effort. According to Dana, “The organization that acts more organically can accomplish more.”
Dana highlighted that when they strive to sustain results, they recognize employees and
“promote.” While this works during and after mergers, the balance was important to ensure that
the goals were attained for the right reasons and that the financial incentives did become the
focus. Justice and Bobbie’s organizations were like Dana’s. While they all applied transactional
leadership factors during negotiations with partners like Ali, or to motivate growth, Justice spoke
to balance using personal experience prior to the first executive promotion and shared a practice
from a former boss when rewarding employees. That boss said to Justice, “We’d like to invest in
you and with some leadership development.”
In addition to the perceived and exhibited transformational leadership elements and
themes which emerged to be effective, all the leaders described the transactional leadership
behaviors they intentionally applied throughout the organizational transformation.
Additional Findings and Outliers
While the participants are transformational leaders, additional findings from the
quantitative surveys revealed some qualities or behaviors that suggested a combination of
leadership styles, which may make these transformational leaders more effective. During the
interviews, the participants shared perspectives from their point of view, stemming from
experience.
A Different Perspective. Three leaders stated that not all skills could be taught implying
that motivation was individual. Pat said the following on leadership when commenting on
whether it is a quality or a skill and how leadership impacts the organization:
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I think it’s both. If you don’t have a quality, I don’t think you can get the skill. There
needs to be this innate ability to understand what people are feeling and thinking and to
care about it. If you don’t care about that, then you can’t really be a leader.
Furthermore, Pat spoke to values and beliefs: “As long as you treat people right and you care
about them and take care of yourself and the world.” What Pat meant is that a quality or value
that is non-existent might obscure acquiring a skill. Can this core value be taught if core values,
and beliefs come from deep within. If it can be taught, then the belief may not be genuine,
resulting in a transformation that may not be sustainable. While Morgan did not elaborate to the
same degree as Pat, Morgan talked about one’s personality and the inability to learn charisma, a
contrary stance to the growth mindset displayed by Justice, who explained that applying
charisma and becoming an extrovert was “learned.”
Additional Traits. Other findings aligning with transformational leadership theory are
that successful leaders have grit. Each demonstrated that they are agile and adaptable, with the
ability to respond to environmental changes. The evidence showed they are courageous and
decisive risk takers. When discussing the possible threats of mergers or accepting accountability,
Justice said, “I think my personality is such that I am a risk taker.” Ali, who was more animated
when talking about risk taking, exemplified experiences similar to those of Bobbie, Jackie, Max,
and Pat:
I thought there’s no point in me trying to run a 50-doctor group, which was huge back in
the day, fee for service because those seats are taken, but this new managed care stuff is
the Starbucks of the time. So, I got into it and made every mistake possible, but came out
of the other end.
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Three leaders spoke to a diplomatic approach when leading through mergers, and the
outlier, Morgan, consistently referred to his style as diplomatic or diplomacy when dealing with
conflict. Additionally, intelligence and knowledge are powerful. Results from this study imply
that outliers who may not immediately demonstrate all four Is can also be successful.
The Outlier. Morgan led a successful organization, and responses to the interview
questions substantiated the same transformational leadership qualities and key elements in
common with the others. Morgan frequently applied diplomacy as a tactic. Morgan’s core
strengths are self-awareness, like acknowledging “that’s not my forte” and that power is attained
by an incredible work ethic, experience, and a keen understanding of the healthcare industry
paradigm. This became clear as Morgan explained the journey to CEO: “I was the low man on
the team, but one of the high performers, and there were loose balls and work needed to be done,
and no one was willing to do that.”
Furthermore, Morgan exuded a genuine passion for improving healthcare delivery, which
became clear throughout the interview. Morgan’s strengths compensated for the weaknesses, and
because of self-actualization and intellect, Morgan identified solutions. Therefore, despite the
MLQ self-assessment, one might challenge the results because Morgan appears to be a
charismatic leader who models the way: “Fight the good fight, do the right thing, and win. If it
seems like we’re losing, you got to keep fighting.”
While examining the data through the context of transformational leadership, the
additional findings and outliers provide descriptive examples of leaders in action and may prove
relevant to other leaders involved in mergers or organizational transformation. With the high
failure rate discussed in the presentation of the problem, it may be beneficial to examine the
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outlier along with the other healthcare industry leaders who succeed during mergers to gain a
deeper understanding of the problem and identify solutions.
Summary
The survey and interview results support the theory and discussion in the literature
review: leadership matters. Adept leaders foster trust and communicate effectively, thereby
positively impacting results. Furthermore, leadership can be taught, knowledge is transferable
internally and externally, and skilled leaders are better equipped to handle the complexities of
mergers. Table 6 depicts each participant’s final thoughts.
Table 6
Best Practices and Final Thoughts From HealthCare Leaders
CEO Best practice
Ali “Succession planning; that’s my bias on managing for tomorrow. …
Said to the medical group, ‘Don’t tell me what you want. Tell me
what is sacred to you. Top three things.’ Defining what is sacred early
on”
Bobbie “The chief medical officer has to be at the center of the table. And then
second, what I’m indicating is if you’re doing cross-training of all the
functional areas, whether it’s on the clinical side or it’s a non-clinical
side, whoever ends up having the responsibility for leading the
organization is much better off again, if you’re only hearing finance
opinions, if you’re only hearing operations opinions. You know,
you’ve got challenges, so that’s why I was big in terms of making
sure this training.”
Dana “Some of the best decisions are things that you don’t do. … You need
grit and charisma, and then you can be a good leader.”
Jackie “The goal is to keep people healthy out of hospital, and if they need the
hospital send them to the hospital. … Stay grounded, maybe as part of
the message” and “it takes a village as they say.”
Justice “Please don’t discount the value of your employees. … I can’t stress the
importance of communicating with people and letting them know
what’s happening even if you don’t know the answer yet. … Humility
is important; your team has to see that you don’t think of it as all
about you.”
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CEO Best practice
Kennedy “Always being open-minded as a leader that there might be a better way
to approach something.” “When two different companies come
together in a merger with different cultures and different ways, they
approach different things”
Max “To figure out how to educate the next generation of both the clinical
and non-clinical people and health policy so that we can develop a
cadre of leaders that find it interesting. … Education and health
policy. Health policy is almost 20% of the U.S. health economy, and
nobody sort of knows how to fix it. Figure out how to educate the
next generation of both clinical and non-clinical people, so we can
develop a cadre of leaders who find it interesting. … One of the
things that we’re proud of is the training that we did. … Now, our
senior leaders are leading other health care systems. That’s the kind of
legacy I wanted to leave.”
Morgan “Things are probably more complicated than you think they are and you
need those different perspectives. … You have got to have some grit.
… I think that you got to take care of your patients, and it’s not just
providing value, which is important, it’s making a difference in their
lives. As long as you keep that perspective, then you’ll make good
decisions in this business.”
Pat “Listen, before you make your final decision, you need to listen. … You
have to be able to deal with the mistakes and the bumps in the road.”
The results demonstrate that the successful group of health system leaders who
participated in the study, all exhibit the four elements of transformational leadership along with
transactional leadership traits as depicted in Figure 1. According to Bass, transformational
leaders “employ at least one of the four elements of Transformational Leadership to obtain
superior results” (Bass, 2006). The findings provide evidence that the leaders who participated in
this study demonstrated a combination of all four elements of transformational leadership as well
as transactional leadership, aligning with the conceptual framework in Table 2. They skillfully
communicated the vision, leading with integrity and breeding organizational trust while
effectively using contingent rewards to attain results and promote innovation They are humble
and confident leaders who are also agile while responding to environmental impact.
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Due to the complexity of the health systems and combination of skills and traits of those
who lead them hiring adept leaders who communicate well, foster trust, and adopt tools to
support learning organizations to sustain success is an obvious recommendation. The subsequent
section will provide more elaborate recommendations and suggestions for future research
stemming from the study results and findings.
Recommendations
This study explored the leadership style of 10 chief executives who have successfully
steered health system mergers. Each of the participants possessed more than 11 years of
experience and 90% had the minimum of a master’s degree education. Nine of the leaders shared
a personal perspective, their ‘story’ resembling case studies of how they led through mergers
concurrently unveiling their attributes. The findings also revealed that while these leaders
succeeded, success is not guaranteed. All the executives eluded that in addition to characteristics
and traits, strategy and tactics were needed to sustain success. They confirmed the literature that
skilled and more adept leaders effectively handle mergers (Hersch et al, 2018; Huston, 2019;
Kamau & Oancea, 2020; Sonnino,2016). The subsequent recommendations evolved pursuant to
a comparison of the results and findings; they are intended to mitigate risk of failure and support
continued organizational success.
Recommendations for Practice
To develop a solution which could increase the success rate of merging health care
organizations, I considered both previous research and this study’s findings. Section four
explained all findings relevant to this study. Trust and communication topped the emerging
theme list. Findings that influenced the following recommendations also include the leaders’
emphasis on balancing internal needs with external influencers when leading through
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transformation. For leaders to effectively lead integration while attempting to realize economies
of scale (Burns, 2022), they must astutely discern strategy and perform due diligence to combine
entities. Therefore, the recommendation resulting from this study is for leaders at the helm of
health system mergers to apply the Burke-Litwin causal change model as their road map to serve
as a reminder of the relevance of environmental impact in the health care industry, as well as the
relationship between transformational and transactional leadership factors. This key
recommendation begins with Burkes (2018, p. 348) implementation process. It encompasses self-
assessments, leadership coaching and a comprehensive communication plan. It addresses the
most frequent emerging themes while allowing for the inclusion of supplemental secondary
recommendations.
The Burke-Litwin model (Appendix D) is relevant due to the complexity of the health
and the role of the environments. Bass’s (1985) transformational leadership theory (Figures 1
and 2) aligns and fits into the Burke-Litwin model. The application of the model by existing and
future leaders is a sage choice because merger trends continue, and failure remains a threat with
or without the recent COVID-19 pandemic (Flier, 2018, HealthCare Finance, 2021, Robbins,
2018). While findings highlight leader strengths, the nine leaders confirmed that leading
transformation and merges is difficult; at least seven addressed challenges imposed by regulatory
entities, conflicting cultures, and unprecedented events. There is a continued need for adept
leaders who understand the complex health system and policy and know where and when to seek
additional resources.
Furthermore, all nine participants discussed the need to respond to environmental
challenges, while six addressed how health policy changes, such as the ACA, impact strategic
planning and drive merger activity. Three CEOs also mentioned the implications of the more
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recent COVID-19 pandemic, and one elaborated on the impact of union negotiations along with
the unanticipated external influences. Any unplanned environmental changes, whether from
regulatory agencies, union negotiations, or unprecedented events, are potential threats to leaders
and organizations and affect stakeholders.
Consequently, for leaders to successfully transform merging health system organizations,
they must hire capable leaders, comprehend the skills and attributes that differentiate adept
leaders from those who struggle, and consider underlying factors. As a result, I recommend
leaders apply the Burke-Litwin change model as a roadmap for executives at the helm of health
system mergers and develop a leadership institute and training during the phases of the change
model. Transformational leadership theory and the Burke-Litwin model are overarching theories.
For mergers to succeed, organizations need skilled and confident leaders at who will consider the
Burke-Litwin change theory while focusing on transformational factors to create a foundation for
success as they lead mergers.
The Burke-Litwin model includes two transformational levers and one transactional lever
with factors attached to each. It argues that all the factors are integrated to varying degrees. The
transformational drivers of the theory involve (a) mission and strategy development, (b)
leadership development, and (c) corporate culture. The transactional drivers encompass the daily
activities, including structure, systems, management practices, work climate, task and individual
skills, individual needs, values, and motivation. The theory suggests that a change in one will
eventually influence the other factors. In the Burke-Litwin model, environmental factors are the
most important drivers for change. The following sections present four phases of the Burke-
Litwin change model and the leaders’ role. The phases may overlap with more than one
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occurring at the same time (Burke, 2018, p. 322). They are presented as recommendations with
an outline of states which align with the research and findings.
Prelaunch Phase (Develop Trust): Leader Self Examination, External Environment, Need for
Change, Vision
To obtain trust, leaders need to be self-aware so they can model the way; hence, the pre-
launch phase is critical. It considers the leader by acknowledging that leadership is personal and
recognizing the importance of self-awareness (Burke, 2018) which research and findings
demonstrate. Additionally, the prelaunch phase includes CEOs and their leadership teams
performing due diligence (market intelligence, cost benefit analyses, ROI) and collecting as
much information as possible on the organization’s external environment.
The nine CEOs demonstrated self-awareness and the ability to respond to the
environment by leading health plan mergers through regulatory changes or union negotiations or
merging provider groups and forging alliances with health systems. To succeed, the chief
executives relied on subject matter experts, recognizing their strengths and weaknesses as well as
those of the people in their organizations. Self-awareness and self-efficacy (Bandura, 1977;
Burke, 2016, Kamau & Oancea, 2019) are important for success.
The prelaunch phase consists of four stages. The first stage is a leader self-examination.
Once the CEO or executive change agents perform a self-examination, they will recognize their
strengths and weaknesses and determine if an external consultant’s support is needed while
preparing for the future phases. Additionally, 360 assessments will be given after the self-
assessments; this process will continue and overlap into phases that occur after the merger. The
CEO change agent appointed by the board will work with human resources on a tiered plan,
beginning with self-assessments. The second stage is to gather information from the external
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environment and market studies on the competitive landscape, which includes the new
organization, design a survey to assess the level of trust in the organization, and obtain
awareness of the existing cultures/underlying culture (Kamau & Oancea, 2020). The third stage
is establishing the need for change, which will entail the leader obtaining buy-in and presenting a
vision. The fourth stage will provide clarity of the vision and direction by articulating a vision
statement. Attributes such as charisma and established trust will support obtaining internal
support to disseminate the message.
Launch Phase: Communication Plan
To succeed, a CEO or change agent needs to obtain buy–in. This happens during the
second phase, referred to as the launch phase consisting of three stages. The first stage is to
communicate the need for change. To do so, the CEO will apply Lewis’s (2019) stakeholder
theory. The second stage is initial key activities, which refer to an attention-getting event, such as
a program devoted to customer service or an event focused on promoting a culture shift to ensure
patient-centric organizational cultures, as revealed by the CEOs during the interviews. This stage
could also include cultural due diligence (Robbins, 2018) and application of tools to assess levels
of cultural awareness, as leaders whose espoused values are not in sync with the organization’s
culture will have difficulty leading (Schein, 2004).
The third stage is handling addressing resistance, which will be addressed with the
application of Lewis’s (2019) stakeholder theory and communication. Each of the nine
participants postulated the importance of effective communication and Denning (2011) in his
book called The Leaders Guide to Storytelling, prefaces his message with “strategic change
management” as “storytelling” (p. IX). Denning (2011, p. 224), provides leaders with steps on
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how to overcome “rebellion (p. 223) and “use positive stories to win set battles” (p 224) The
approach addresses both research and findings.
Furthermore, communication emerged as a key theme among the CEOs and research has
found that transformational leaders effectively communicate and are capable of inspiring (Bass,
1985, Northouse, 2019). Research also demonstrates that organizational effectiveness improves
when leaders clearly communicate with stakeholders (Burke, 2015; Oancea & Kamau, 2020;
Northouse, 2019), as we also heard from our participants. A potential threat is that many
physician leaders lack either leadership experience or communication skills (Margolis & Sacks,
2015). Therefore, during the launch phase it is recommended that the CEO hire or appoint a
communications leader or communication officer to support the strategic development of a
multi-dimensional communication plan. The CEO will communicate the need for change, and
the plan will be implemented. Surveys will be used to track effectiveness and report back
utilizing dashboards as the organization moves to the next phase.
Post-Launch Phase: Further Implementation
The third phase, called the post-launch phase, will begin with reinforcing the mission and
the vision and responding one’s feelings about the changes as well as the behavior of the
employees or followers (Burke, 2018, p. 338). This phase consists of five key stages, as Burke
(2018) discussed. The first stage, multiple leverage, includes designing corporate values and the
integrated mission, key factors in transformational leadership theory and elements that emerged
in the study. As Schein (2017) stated, reassessing organizational mission supports long-term
success. The second stage is taking the heat, wherein change agents become targets (Burke,
2018), as the findings also demonstrated. Ali, Dana, Justice, Max and Morgan provided
examples of how effective communication and tactics such as straight talk forums, newsletters,
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huddles and cross-matrix brainstorming sessions helped respond to employee concerns or doubts.
The CEO will continue to implement the communication plan and team as support.
The third stage is consistency. The nine participants also stressed the importance of
consistency. When a change leader is consistent with communication and tells the truth, trust
evolves, continuing to support change efforts. The fourth stage is perseverance; all nine CEOs
mentioned perseverance and three used the term “grit” as necessary for successful leadership
during mergers. The fifth stage is repeating the message or telling a story. As Ali, Kennedy, and
Pat demonstrated in their leadership approach, they tell a story. Teams and followers relate to
leaders who can tell a story. Again, Stage 2 of this phase will support the third stage because the
communication plan will also be designed to help the leader tell the story.
Sustaining the Change: Succession Plan
The fourth phase of the recommendation is to sustain the change. The four stages of this
phase are unanticipated consequences, momentum, choosing successors, and identifying new
initiatives which will support organizational goals. In the first stage, leaders should be prepared
for unexpected consequences, whether unprecedented events like the recent pandemic or
unexpected reactions from teams. In the second stage, as we heard from the CEOs, maintaining
organizational activity while keeping abreast of policy changes and external impact is important.
To sustain momentum, this stage will include the implementation of a leadership institute for
sustainability (Margolis & Sacks, 2015) which will prepare leaders to use the Burke Litwin
model considering mergers and leadership and DEI.
The third stage includes selection of successors, which involves identifying individuals in
the organization and preparing them to step into key leadership roles as the need arises. The
literature revealed succession planning in the qualitative study, Morgan disclosed that becoming
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a CEO resulted from a combination of work ethic, skills, along with being “fortunate to have
been selected as a successor to be part of the organizational succession plan”. This demonstrates
succession planning and a smooth transition. The phase of sustaining change includes
momentum, as maintaining it is important, and a smooth transition like Morgan’s enables an
organization to do so. Leadership training and coaching, along with 360s, will support succession
planning. This stage includes succession planning and all levels of management.
Lastly, identifying new initiatives to support organizational goals may include merging
with similar physician-held organizations over two decades, as Max discussed; creating new
benefits packages as Dana, Justice, and Morgan did; creating new programs or service lines for a
health system such as Kennedy’s; or establishing strategic alliances, as Ali, Bobbie and Pat
shared.
In summary, findings from the literature and the research study support a need for strong
adept leadership, the significance of mission, vision, and culture, and the importance of
developing trust and communication. Leaders who foster trust and who effectively use narrative
to transform organizations (Denning, 2018) are successful.
Limitations and Delimitations
Delimitations to the study include the purposeful selection of nine C-suite level
executives for the interviews. The study aimed to understand why some leaders are more
effective than others when leading organizational mergers and the significance of leadership and
its attributes. Therefore, respondents were limited to senior executive C-suite leaders and a larger
population may have included managers or other leadership roles. An observation over an
extended period could provide greater insight into transformational leadership theory. The
selection of transformational leadership theory and selected methodology are also delimitations.
83
The respondents may not have been entirely transparent, eliminated bias, or disclosed all
pertinent data. This limitation was out of my control. The correlation between the significance of
leaders and mergers may have been skewed when converting human behavior into a value to
comprehend the survey results and analyze the interview data. The limitation is the actual value
and translating leadership attributes to obtain a ratio that can support a solution. In other words,
the limitations of a qualitative study are related to reliability and validity (Simon and Goes,
2013).
Finally, the MLQ survey questions have limitations. The respondents may have been
limited when answering the questions. Because the surveys were sent out to be completed
manually, the respondents may not have taken the appropriate time to respond to each question
carefully. A larger sample of executives might yield more generalizable results. Also, 360
evaluations would provide the perceptions of the executives’ subordinates and peers to compare
with their self-assessments. While the group appears successful, additional information would
validate the study and theory. A 360 survey would provide additional insight and a deeper probe
into the leaders’ strengths and weaknesses.
Recommendations for Future Research
A recommendation for further research is to explore the influence of the environment on
the leader. The theory of change implies that leadership matters and leaders are critical in driving
successful organizational change (Burke, 2017). While the theory is that leadership matters and
leadership can be taught, there is no formula for separating the challenges imposed by the
mergers alone or with the environment or the level of impact on the chief executive or on the
chief executive with specific team members. Additionally, we do not have sufficient information
on failing organizations. While we understand that organizations fail when there is no
84
communication or cultural awareness, this research did not examine the failures. For further
research, I recommend a tiered approach. The first tier would involve a study like this one,
including 360s of the CEOs with a comparison of results from chief executives of failed mergers.
The second tier would consist of observing and surveying patients to obtain their perspectives
before and after the merger. The third tier would involve discussions with employees while
concurrently sending out a survey to patients for their perception.
Consequently, recommendations for further research include additional studies of
leadership behavior and consideration for more variables, such as the impact of the environment
and consideration of a Competing Values Framework (Chesley, 2020, p. 140) to assess internal
cultures. For leaders to transform merging health system organizations, it is necessary to
consider overarching theories that began to surface, such as ethical, authentic, and adaptable
theories, to comprehend the skills and attributes that differentiate adept leaders from those who
struggle. Finally, key findings suggest that future research should investigate the development of
credibility in leadership while identifying ways to include diverse perspectives when
consolidating organizations’ missions and vision.
Conclusion
Despite corporate executives leading an increasing number of healthcare organizational
mergers, there is a need for more effective and skilled leadership throughout the process.
Research demonstrates that executives struggle when combining formerly independent
organizations with larger corporations (Filer, 2018). Consequently, corporations experience a
drop in stock value, and quality of care is threatened (La Pointe, 2017). The potential loss of
value and quality demonstrates a problem. This problem of leadership correlation and high
prevalence of merger failure is important to address so that healthcare industry leaders will
85
effectively steer the integration of their partner organizations (Britnell, 2016; Kanau & Oancea,
2020), thereby maintaining and increasing quality and value.
The study aimed to examine the attributes of successful healthcare industry leaders to
obtain insight and find a possible road map for leaders in the health sector contemplating or
steering a merger. Key findings revealed that without a foundation of trust and communication,
success is threatened. The leaders in the study suggested that balancing transactional leadership
factors with transformational leadership along with using a combination of all transformational
leadership elements (Figure 2) enabled them to lead successful mergers. Moreover, findings
demonstrate that adept leaders are self-aware; they accept that they are not experts in all areas
encourage knowledge transfer, continued learning and mentorship. They develop trust by
delegating, and they are kind and humble leaders who share the credit for success with their
teams.
The literature further substantiated that adept leaders who develop trust and communicate
will lead mergers successfully; their organizations thrive as they foster diverse learning
organizations and support leadership training (Sacks & Margolis, 2015). In doing so, they can
maintain quality and sustain their business through the merger and beyond. The study indicated
that transformational leaders are visionaries who project charisma, and that leadership makes a
difference.
In conclusion, while the number of CEOs who participated in the qualitative study is not
large, the participants are powerful. They represent organizations that provide healthcare
coverage to millions of patients while generating billions of dollars of revenue. They lead
organizations which directly impact the overall national GDP and health of our nation; despite
the statistics, the represented organizational mergers succeeded. Furthermore, experts predict
86
health care will increase from 18% of our national GDP (HHS, 2022) to over 20 % in the next
few years. As discussed by Burns (2021), albeit innovative solutions, mergers can be disruptive
innovators impacting all stakeholders. The stakes are too high for the problem to be ignored.
Therefore, merging healthcare organizations need adept leaders to champion the vision (Kotter,
1996). When mergers fail, individual health and lives are compromised.
87
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Appendix A: Interview Protocol
For those who don’t know me: My name is Gordana Vukotich. While I have 20+ years of
progressive leadership experience in the healthcare industry space, today, I am reaching out as a
researcher and doctoral student focusing on Organizational Change and Leadership. As discussed
in my email communication, I am conducting interviews to support my research and dissertation
on why some leaders are more effective than others when leading a merger or transformation.
The interviews are intended to help me research the answer. Despite the existing theories
on leadership, I would like to probe deeper to understand and analyze the traits of leaders who
successfully handle issues such as lack of buy-in and motivation, fear of the unknown which may
even lead to employees who undermine strategic initiatives, and employees who are not loyal. In
1996 John Kotter conducted a study and suggested that change requires a strong leader who
would champion the vision and motivate employees to embrace change. This is what we refer to
as transformational leadership.
The interview questions are important to answer because statistics demonstrate that 70%
of mergers fail, and leaders’ change efforts often result in a 360. In other words, “The more
things change the more they stay the same.” Given your experience as an executive leading your
health plan/healthcare organization through a merger, in addition to the surveys you’ve
previously completed, you will provide additional information to support survey findings, which
will be used to analyze leadership traits and how they may influence the outcome of the mergers.
To facilitate our notetaking, I would like to audiotape our conversations today. Please sign
and return the consent form in your email. For your information, only researchers on the project
will be privy to the tapes which will be eventually destroyed after they are transcribed. In addition,
you must sign a form devised to meet our human subject requirements. Essentially, this document
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states that (a) all information will be held confidential, (b) your participation is voluntary, and you
may stop at any time if you feel uncomfortable, and (c) we do not intend to inflict any harm. Thank
you for your agreeing to participate.
The interview should last no more than 1 hour. During this time, we have several questions
that we would like to cover. While I don’t want to cut you off, to stay on task, I will assume the
role of timekeeper and alert you if we begin to run out of time. Do you have any questions before
we begin?
Interview Questions
1. Tell me about your transition as a leader before the health system to health system
merger and the transition. What additional skills were needed?
2. Who were the key stake holders and how much influence did they have during the
merger process? In other words, how if at all did they influence your decision
making?
3. My research indicates that individual consideration and cultural due diligence are
significant for a successful merger. How did you approach and then streamline the
cultures of the merging organizations?
4. Describe the level of consideration, engagement, and communication you had with
the employees of the organization when executing your vision?
5. Bass (1985) refers to charismatic leadership as idealized influence; in other words,
leaders with positive attributes become role models. They obtain trust,
communicate their mission, and vision and obtain buy-in. Describe how you obtain
trust and buy in from both clinical and non-clinical teams throughout a health
system merger?
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6. How did you encourage motivation and collaboration throughout the process?
7. Describe your leadership style and which attributes are most important when
leading through a merger.
8. Think of a time, if at all, when your senior executive/C Suite leadership team
questioned your approach, and how it might impact the effectiveness of the merger.
Describe the situation and how you responded.
9. While mergers are intended to mitigate financial risk, recent events such as the
onset of the pandemic challenged leaders of health systems to respond to the needs
of the population. How did you handle both internal and external obstacles to your
strategy and overcome the challenge in order to succeed?
10. To what extent do you believe your leadership cultivates spirit and influences
transformation and results?
11. Describe the plan or skills you apply believe apply to sustain results after the
integration
12. Statistics demonstrate up to a 70% merger failure rate, yet health system mergers
continue to be a trend. In closing, what are the best practices needed for success in
a health system?
Thank you for your candor and participation. Do you have any questions for me? Your
time and thoughtful responses are very much appreciated. The information you’ve provided
provides insight into my study. May I contact you with any follow-up questions? Also, if there
are any websites, videos, or other information you’d like to share with me which supports the
further examination of leadership and your organization, or your perspective please let me know.
Once again, Thank you.
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Appendix B: Survey Protocol
A brief introduction email, to introduce the survey. Part 1 will be 5 demographic
questions. Part II will be the MLQ Survey. Sample below, restricted and cannot share the
questions in the body of the dissertation.
1. What is your gender? M or F
2. What is your level of education?
3. How many years have you held a senior executive role?
4. Please confirm that you were a leader in the organization at the time of merger?
5. How many years prior to the merger did you work for the organization?
(Example: placeholder Demneeds to be purchased and license obtained a total of 45 questions)
My Name: ______________________________________________________ Date:
____________ Organization ID #: ________________________Leader ID #:
______________________________ This questionnaire is to describe your leadership style as
you perceive it. Please answer all items on this answer sheet. If an item is irrelevant, or if you are
unsure or do not know the answer, leave the answer blank. Forty-five descriptive statements are
listed on the following pages. Judge how frequently each statement fits you. The word “others”
may mean your peers, clients, direct reports, supervisors, and/or all of these individuals. Use the
following rating scale:
A five-point scale for rating the frequency of observed leader behaviors is used and bears
a magnitude estimation-based ratio of 4:3:2:1:0, according to a tested list of anchors provided by
Bass et al. (1974). The anchors used to evaluate the MLQ factors are presented as follows: 0
100
means not at all, 1 means once in a while 2, means sometimes, 3 means fairly often, and 4 means
frequently, if not always
Multi Factor Leadership Questionnaire (MLQ) Sample Items:
Sample items:
As a leader,
I talk optimistically about the future.
I spend time teaching and coaching.
Avoid making decisions.
The person I am rating
Talks optimistically about the future.
Spends time teaching and coaching.
Avoids making decisions
Copyright © 1995 by Bernard Bass & Bruce J. Avolio. All rights reserved in all media.
Published by Mind Garden, Inc. www.mindgarden.com
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Appendix C: The Researcher
I possess more than 20 years of experience in the healthcare industry. My experience
includes progressive leadership roles, and I have either previously (a) worked for some of the
organizations represented by the respondents (b) worked with the respondent as a business
partner, or (c) may have led strategic planning to compete with the represented organizations.
Additionally, I am affiliated with healthcare industry advocacy groups, consequently, my
professional network is vast. Possible bias may exist due to the relationships and my
positionality.
Despite their willingness to participate in the study, some of the respondents may feel
apprehensive, and they may limit or alter their responses. To mitigate these issues, in addition to
consent forms, I will communicate that they will be approached by me in the role of researcher
and doctoral student who is bound by IRB ethics (Creswell & Creswell, 2018), healthcare
industry ethics (ACHE, 2021) and University policy. In addition to protecting the confidentiality
of the respondents, I will also protect the integrity of the university and the research by adhering
to IRB guidelines. Finally, I am cognizant of the importance of respecting power imbalances:
The qualitative research process involves moral inquiry, participants may find some of the
questions stressful, and while it is typically not the case when interviewing executives who
powerful leaders are, power imbalances may exist between the interviewer and participants. The
interviews will be conducted respectfully, with a do no harm attitude (Creswell & Creswell,
2018) to avoid exploitation.
102
Appendix D: The Burke-Litwin Change Model
Transformational Factors are key in the Burke-Litwin model. According to Burke-Litwin
(2018) organizational transformation is influenced by the environment. In other words, climate
(input) impacts motivation; motivation, in turn, affects (output), referred to as organizational
performance and development. The model stems from practice; it was defined in the 1980s by
organizational change and cultural transformation at British Airways. As such, it will serve as a
tool to thoroughly examine leadership effectiveness, then adjust by assessing the
transformational factors and transactional factors of the model and how they are related to the
outcome of health are organizational mergers.
103
Figure D1
The Burke-Litwin Change Model
Note. From “A Causal Model of Organizational Performance and Change” by W. W. Burke & G.
H. Litwin, 1992, Journal of Management, 18(3), p. 529.
(https://doi.org/10.1177/014920639201800306)
According to Burke and Litwin (2018), to achieve successful transformation, changes
will occur by cause and effect between external and internal forces, thereby demanding
behavioral changes among organizational leaders and employees. Therefore, applying the Burke-
Litwin model for change is a cogent direction to take because the model has proven validity
among diverse organizations, including health care organizations (Burke, 2018). In his book
Organizational Change, Burke (2018) disclosed the application of the theory by Margaret
104
Thatcher, who was instrumental in driving economic change in England. This included the
transformation of British Airways from the public sector and government-held organization to a
private enterprise. Chapter 11 of the book has a section that reveals how the application of the
Burke-Litwin model was instrumental in leading successful transformational change, which
focused on culture change (Burke, 2018) in a leading airline. This is relevant because leaders of
merging organizations seek out visible and underlying cultures before they proceed to drive
change (Schein, 2017).
The Burke-Litwin model of organization supports researchers in dissecting the
complexity within the organization and understanding the links between the 12 dimensions in the
model (Figure 1). A key reason to apply this model is the transformational drivers. First, the
external environment includes politics, government, and consumers influencing the industry.
While 56 % of health care is paid by employer-based insurance, nearly 40% is government-
funded reimbursement (CMS and HHS, 2020). Second are mission and strategy; the central
purpose of the organization are what employees believe. Third is leadership, as Executive
behavior and strong leadership influencing others are critical in transformational change
(Northouse, 2019). Fourth is culture; leaders who understand the culture and effectively integrate
culture can successfully drive strategy (Filer, 2018).
Another reason for using this model is the seven levers discussed by Burke and Litwin
(2018), which outline a thought process and action steps for leading change (Burke & Litwin,
2018). The levers, according to Burke and Litwin, are
• reason: a change agent uses the application of logic
• research: evidence-based data to support decisions
• resonance: does the argument for change make sense?
105
• redescription: a change agent can be more effective when relying on a variety of
forms and data
• resources and rewards: enticement is effective in influencing change within the
organization by using incentives
• real-world events: on occasion the external environment positive or negative, i.e., a
pandemic, new technology, etc., influence those within the organization
• resistance: realistically there will be resistance
The Burke-Litwin model and survey results will serve to organization to leadership.
Along with the points mentioned above the remaining elements, research design, quantitative and
qualitative data collection are all important in diagnosing performance and compiling needs. By
utilizing the Burke-Litwin model researchers will be able to display gaps that will provide
leaders of merging health systems, adequate tools to become effective leaders who drive positive
transformation.
106
Appendix E: Transformational and Transactional Leadership Result Scores (Without the
Outlier)
107
108
109
110
111
112
Appendix F: Definitions
Culture: As defined by Schein (2017), a pattern of shared basic assumptions learned by a
group as it solved its problems of external adaptation and internal integration. A product of joint
learning. Culture is a combination of artifacts (visible), espoused beliefs and values, and
underlying assumptions (those beliefs which may not be noticeable).
Healthcare delivery: In the context of contemporary healthcare and for this paper,
healthcare delivery refers to a relationship between the patient and their provider or their
caregiver at many levels. This includes hospitals, provider groups, health plans, and health
systems. It may combine two or more entities under one umbrella to deliver an integrated
healthcare delivery system (Brigham, 2017).
Healthcare system: As defined by Robert Burns, (2021), in U.S. HealthCare Ecosystem,
it is a combination of the terms, health, care and system. Health, referring to the well-being of an
individual; care is any effort to “maintain or restore physical, mental or emotional well-being,
especially when by a licensed professional “ (Burns, 2021, p. 31). This includes primary,
secondary, or tertiary care. And, finally a system is a whole with multiple parts that are
interdependent, such as hospitals, clinics, academic institutes, insurance companies, government
agencies, etc.
Horizontal mergers: When two organizations produce similar products reaching the same
consumer market and they have equivalent market shares, they engage in a type of merger called
a horizontal merger.
Leader: According to Northouse (2019) a leader is an individual who can influence
others to attain a common goal.
113
Leadership: Webster’s dictionary definition is a “person who leads.” Northouse (2019)
defined leadership as a process whereby an individual influences a group of individuals to
achieve a common goal (p6).
Mega-mergers: A trend within a trend. The big are getting bigger. In 2018 seven
transactions involved sellers with net revenue of $1 billion or greater (HCFCA, 2019).
Mergers and acquisitions: Albeit two different concepts, for this paper, the terms
Mergers and Acquisitions will be used interchangeably. By definition, the two are different.
Mergers are two independent companies joining to create a new entity. There are five types of
mergers, they are, product extension, vertical, market extension, horizontal, and conglomerate
(Kamau & Oancea, 2020).
An acquisition is when one company purchases another, assuming the management of the
acquired entity (Robbins, 2017). Mergers and acquisitions for this paper will be used
interchangeably. A merger and acquisition are prime examples of organizational change (Kamau
& Oancea, 2017).
Team: Team refers to a group of people, employees, leaders, and followers, counterparts
within the organization who are all brought together to work to achieve a common goal.
Transformational leadership: The process whereby a person engages with others and
creates a connection that raises the level of motivation and morality in both the leader and others
(Northouse, 2019).
Transactional leadership: Transactional leadership focuses on the exchanges between
leaders and followers (i.e., politicians who gain votes by promising no new taxes, is an example)
(Northouse, 2019).
114
Appendix G: Theoretical Alignment Table
Research question Theoretical framework Data instrument questions
What leadership traits do
leaders perceive as
effective when leading
mergers?
Idealized influence
Inspirational motivation
Intellectual stimulation
Individualized consideration
Transactional leadership
Survey: transformational
leadership 5 scales,
Transactional 2 scales;
Idealized attributes, idealized
behaviors, inspirational
motivation, intellectual
stimulation items 10, 18, 21,
25, 6, 14, 23, 34, 9, 13, 26, 2,
8, 30, 32, 15, 19, 29, 31
Interview questions: 1, 6, 7, 8, 9,
10,11,12
How do leaders respond to
the existing culture of the
organization/s when
leading mergers?
Individualized consideration
Survey: 5 scales
transformational leadership
15, 19, 29, 31
Interview Questions 3, 4, 5, 6, 8,
11, 12
What are the common
characteristics of leaders
of successful mergers?
Idealized influence
Inspirational motivation
Intellectual stimulation
Individualized consideration
Transformational leadership 5
scales, 10, 18, 21, 25, 6, 14,
23, 34, 9, 13, 26, 26, 2, 8, 30,
32, 15, 19, 29, 31
Interview Questions 1–12
Demographic questions General Intro survey Questions: 1–5
115
Appendix H: Ethics
In the body of the interview protocol, is a sample informed consent. The ethical
considerations which were taken into consideration for all methods of inquiry were anonymity,
confidentiality, and informed consent (Creswell & Creswell, 2018). Additionally, I am a
healthcare professional and a member of the Southern California chapter of HealthCare
executives and bound by the code of professional ethics (ACHE, 2021).
From Creswell and Creswell (2018), for the qualitative piece of the study, ethical
considerations included presenting the research objectives clearly along with how the research
was performed and data collected, obtaining informed consent, and filing a research exemption
with IRB. I informed participants of all data collection devices and activities and made
transcribed and written interpretations available to the respondents. I consistently considered the
respondents’ rights, interests, and wishes. The final decision regarding anonymity rests with the
interviewee.
Finally, for quantitative data accuracy, it was important not to disclose information that
may be harmful and avoid suppressing information or inventing findings (Creswell & Creswell,
2018). Bias was addressed by full disclosure, including my positionality and worldview. I
avoided reporting either only positive or negative results and reported objectively. Given the
design of this study, privacy was not an issue; I always respected the privacy of respondents,
complied with guidelines by agencies providing existing data, and maintained all data and
reports for a reasonable time. I adhered to IRB guidelines and completed the IRB protocol.
116
Appendix I: Quality Scores
2018
overall star
rating
2019
overall star
rating
2020
overall star
rating
2021
overall star
rating
2022
overall star
rating
5.0 5.0 5.0 5.0 5.0
4.5 4.5 4.5 4.5 4.5
3.5 4.0 4.0 4.5 5.0
4.5 4.0 4.0 4.0 4.0
4.5 4.0 4.0 4.0 4.0
4.5 4.5 4.5 3.5 3.5
4.0 4.0 4.0 4.0 4.0
3.5 4.0 4.0 4.0 4.0
3.5 3.5 3.5 3.5 4.0
3.0 3.5 3.5 3.5 3.5
3.5 3.0 3.0 3.5 3.5
4.0 4.0 4.5 5.0
Note. Adopted from Centers from Medicare and Medicaid Services (CMS) rating on health plans
This grid is an example of quality scores of health plans represented above, before, after during
merger. Without disclosing the names of the plans or groups that comprised the plans example of
ratings is displayed. More research is needed to correlate level of impact that leadership directly
had as scores are retroactive to results from years prior and involved. However, a 5-year analysis
does somewhat resemble results. Note, that 2021 and especially 2022 may have been impacted
by the Pandemic. The results above would reflect somewhat activity of even those who retired,
demonstrating results which may have been impacted during their tenure. Quality ratings (“star
ratings”) are ratings of health plan quality shown on a scale of 1–5, 5 being the highest depicting
quality. Each plan has an overall rating which is based on scores for member experience, medical
care and plan administration. While a 5 is the goal, it is very difficult to attain. Hospitals and
provider groups use similar ratings as well as nursing homes.
(https://data.cms.gov/provider-data/topics/hospitals/overall-hospital-quality-star-rating)
Abstract (if available)
Abstract
While health system mergers have become a trend, debate over their success and high failure rate continues. This study was aimed at identifying why some leaders are more effective than others when leading transformation and healthcare industry mergers. The researcher collected quantitative and qualitative data to examine the attributes of successful health system leaders at the helm of mergers. A transformational leadership theory lens was applied when examining the problem. Purposeful sampling was conducted for an intra-method interview study utilizing closed-ended survey-type questions, followed by a series of open-ended interview questions to identify leaders’ underlying attributes. Ten senior executives completed the survey, and nine participated in the interviews. The analysis compared self-reported quantitative survey results revealing transformational and transactional leadership attributes. Comparative analysis suggested that the leaders who participated in this study successfully led health system mergers and possessed transformational leadership attributes. Emerging themes among all participants were trust, communication, vision, cultural intelligence, and human capital.
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Vukotich, Gordana
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Core Title
Health system mergers: the significance of leaders
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Organizational Change and Leadership (On Line)
Degree Conferral Date
2023-05
Publication Date
08/15/2023
Defense Date
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