Today’s Medical School Dean: What Boards Need to Know
Academic health systems continue to evolve and expand, driven by the need to capture market share and increase clinical revenues to support varied activities within...
Academic health systems continue to evolve and expand, driven by the need to capture market share and increase clinical revenues to support varied activities within the tripartite mission. Business models that promote clinical growth through mergers, acquisitions, and new construction force medical schools to re-evaluate and reimagine their roles within massive, matrixed organizations.
Medical school deans sometimes find themselves in unfamiliar territory in such systems. Most take on new responsibilities (some as system CEO) and become increasingly interdependent among a team of leaders overseeing the key components of the system, ranging from community-based hospitals and clinics to virtual and home-care offerings to insurance plans.
Many deans welcome change and growth, of course, and strive to adapt to the situation they are presented with. The system’s board of directors can support their dean’s success. It is incumbent upon each board to understand their unique situation in order to fully appreciate their dean and that individual’s priorities, pressures, and ability to lead. This is especially true when the institution recruits a new dean. While the board may not always have a say in dean selection, it must appreciate the kind of person who will thrive in the role and deliver on their organizational imperatives, today and in the future.
Know Your Snowflake
The job of the medical school dean has experienced a two-century evolution, from that of “guild master” to “resource allocator” to “CEO” to the current “System Dean.” Today’s dean is a team player, often within a large universe. The authors of an article in The Permanente Journal explain, “The dean is no longer the final arbiter of the mission and vision of the medical school enterprise, including its clinical relationships (hospital and practice plan). Rather, the dean is a negotiator within a broader health system that will heavily influence or make the final determination of priorities for the school.”
As with snowflakes, no two academic health systems are alike. Two decades ago, Academic Medicine published an article codifying eight organizational models for medical school–clinical enterprise relationships according to the prominence of the clinical enterprise, the degree of clinical–academic integration, and the authority of the chief academic officer (typically the dean). Currently, AAMC maintains a database of medical schools categorized by organizational characteristics, including type of ownership (private vs. public), financial relationship to the parent university, community-based status, research intensity, and practice plan structure. We encourage board members to familiarize themselves with both resources to grasp the sheer diversity of organizational dimensions and how their institution contrasts with others.
Another defining factor across organizations is the position of the dean in relation to the health system CEO. Consider the following reporting relationships:
- Dean and CEO have equal billing
- Dean sits above the CEO
- CEO sits above the dean
- Dean and CEO are one and the same (i.e., dual role)
- Dean has no role in the system (i.e., school and system may share names, facilities, and resources but operate mostly autonomously)
Variations on these basic frameworks exist, and many deans take on additional titles and other duties as assigned (for example, as head of a physician/faculty group practice). The point is that each board must understand what makes its organization unique to establish its expectations for what a dean can accomplish and how success in the role is defined.
The following are other variables that come into play:
Mission balance: Every academic health system must meet its educational, research, and clinical obligations, and yet the relative balance or imbalance of these aims will dictate a dean’s priorities and ability to succeed.
Business state: Institutions have differing degrees of maturity and business imperatives. Drawing upon the STARS model made popular in Michael Watkins’ book, The First 90 Days, each organization likely belongs to one of the following camps: start-up, turnaround, accelerated growth, realignment, or sustaining success. Where the organization finds itself largely determines the dean’s agenda and competencies required for success. In a start-up situation (i.e., a new medical school), a dean must be an individual who, as Watkins suggests, loves building from scratch, thrives as the rules are still being developed, and brings others on board for an uncertain (but hopefully rewarding) ride. Similarly, a dean focused on growth or realignment will carry a toolbox much different from that of a sustainer.
Desired business state: As Watkins points out, every organization must have an eye on where it is headed. A leader who “got us here” may not “get us there.” One school we have worked with was part of a major merger to integrate with statewide health sciences institutions and the area’s largest integrated delivery system. This created the need for an entirely different dean, one who would thrive as a bridge-builder and visionary for an organization that had suddenly become a key cog within the region’s major healthcare player.
Agenda and time allocation: The board must have realistic expectations for how a dean devotes their time. A dean who serves as system CEO or supervises the CEO should preoccupy themselves with commensurate executive-level activities: orchestrating strategy sessions and business dealings; engaging donors, legislators, and media members; and serving on industry committees and state/federal agencies. A dean positioned below the CEO is free to engage in more traditional academic- and research-focused pursuits: communing with faculty and students, overseeing research and securing extramural funding, connecting with advocacy groups and community organizations (town-and-gown activities), and even making the rounds of the hospital wards to check in on residents.
Board engagement: The structure and scope of the dean’s role determines the extent of their interaction with the board. If the dean sits atop the system structure, they should have a standing item on the board agenda and, in fact, serve as an ex officio member and committee participant; if the dean reports up to the CEO, the system board may have infrequent engagement with the leader (e.g., the occasional report on the state of the medical school and its affairs).
Dean-like Competencies
The factors above all enter into dean success, as do the leadership qualities of the individual in the role. The competencies required to lead within academic medicine continue to evolve, pushing deans to exhibit skills well beyond those of traditional, academically oriented leaders. We believe the following competencies are essential for deans today. In our dean recruitments, clients prioritize these qualities and include them on position specifications. (We illustrate our points with phrases copied from recent job specifications.):
Mission focus: Every dean must have an unwavering support for, and deep knowledge of, the educational, research, and clinical missions of the medical school. Although it sounds obvious, it is important to remember that the dean is ultimately responsible for the accreditation of the medical school, and therefore should be well-versed in how these mission areas work both individually and holistically to ensure ongoing compliance with accreditation standards.
Fundraising and financial/business savvy: Depending on the scope of the role, the dean may be the system’s Fundraiser-in-Chief. At a minimum, the executive must “actively engage in fundraising and philanthropic support as a key priority,” especially regarding extramural research funding. Today’s deans must prioritize the “fiscal soundness” of their domain and prioritize the greater system’s business interests.
Diplomacy: Among many stakeholders holding conflicting priorities, deans must be conveners and consensus-builders. One dean profile outlines the “critical responsibility” of the dean to facilitate “productive relationships” among academic departments, with clinical partners, with researchers, and especially with top system leadership and the board.
Strategy and vision: Today’s deans can expect to participate with their boards and executive peers in strategic planning for the medical school, medical center, and health system, reflective of the “synergistic and mutually dependent relationships” between the entities. Institutions seek a “strategic thinker with the ability to build systems and structures to support innovation.” This can include master planning and oversight of new facilities or the construction of entirely new campuses.
Recruitment and retention: Each dean must bring others into the fold and keep them there. “The dean will aggressively recruit high-caliber, diverse faculty and leaders and ensure resources, support, and mentoring are in place to retain critical faculty and staff at all levels.” Today’s dean “oversees the development of a workforce plan to attract and retain faculty, other care providers, staff, and trainees to meet current demands and fuel expected growth.”
Leadership: A dean must exhibit “a leadership style that is transparent, visible, and instills trust, credibility, and confidence”—placing an absolute premium on people skills and authenticity when interacting with constituents including administrative colleagues, research and teaching faculty, staff, learners, and hospital partners.
These qualities reflect the expanded skillset required of deans today, one that does not diminish the importance of the individual’s academic bona fides but puts them into a broader context. The implication—the elephant in the room, perhaps—is that a dean’s curriculum vitae (CV) is but one of numerous essential components required of the executive. For deans in CEO-like roles, the ability to lead, strategize, recruit, and so forth may take precedence over academic credentials.
Supporting Your Dean
With so many variables involved in their success, deans deserve support. Boards can take to heart the following advice:
- Understand the academic/research enterprise within the broader system context. As a governance best practice and part of their own development, board members can educate themselves on the nuances and challenges of today’s medical schools within burgeoning systems and then embrace what makes their school special.
- Establish clear expectations for board–dean engagement. This includes maintaining a set schedule for the dean’s board meeting attendance, regular in-person or virtual meetings with the board chair, service on committees (e.g., academic affairs, finance), and more. In general, a board should establish a framework for a strong and evolving relationship with the dean. Use your dean as a resource both informally and at regular board meetings to provide regular updates on accreditation and the school’s successes and opportunities, and to provide a “heads up” on developments in the local and national healthcare environment.
- Be vocal in support. It’s important for the board to let the institution and its stakeholders know that it has the dean’s back, in its regular correspondence with internal and external stakeholders and certainly during a crisis or challenging period.
- Invest in the dean’s success. Ensure the dean has the necessary resources to do their job and develop as a leader. This includes enabling a budget to hire a full leadership team and maintain adequate faculty and staff. Encourage the dean’s professional growth through leadership development programs or via a coach or consultant.
- Prioritize succession planning. Common practice in the corporate world, succession planning is “one of a board’s core responsibilities; yet it is often postponed, only to be taken up when transition (driven by retirement or performance) is required.” The board should view succession planning for the dean as a strategic imperative that supports the incumbent leader’s professional growth and paves the way for the inevitable changing of the guard.
Much is asked of today’s medical school deans. Each academic health system board can appreciate the responsibilities and rigors of the job at their unique institution and go out of their way to support their dean’s daily pursuits and ongoing development as a leader.
