Introduction and Background:

Although the origin of health care administra-tion as a recognized profession can be argued, itcan be traced in one context to the first gradu-ate program in Hospital Administration offeredat the University of Chicago in 1934. Prior tothat time, the health care administrator, here-inafter referred to as HA, was frequently referredto by title as hospital administrator, superin-tendent, executive director, or by the professionsuch as M.D., Medical Doctor. This paper is notintended to limit the discussion to hospitaladministration. On the contrary, there are ruralhealth administration opportunities in a widevariety of fields.

Today, though there are recognized, accredit-ed schools of Hospital Administration, many ofwhich have adopted a broader description forthe degree, e.g., Health/Health CareAdministration, there are no absolutes, unlessspecified by the organization, with respect tothe academic preparation of the person who isthe number one administrative officer of anyparticular health care organization. He or shecan be of any background, is not necessarily acollege graduate, or, if so, may come from anyvariety of fields of education due primarily to thefact that this position is not registered, norlicensed, nor required by state or federal regula-tion to be other than “qualified” by training orexperience. The challenge for the future of ruralHAs is complex and requires more of an assess-ment of appropriate skills and characteristics oftomorrow’s leaders for academics and govern-ing boards as well as practitioners in this posi-tion as opposed to whether we have a “short-

age” of qualified practitioners given thereappears to be no shortage of applicants, (quali-fied is in the eyes of the employer), for any HAposition in America.

Issues:

Defining a qualified HAThe background of practicing health careadministrators is varied and atypical involvingnumerous variables. Among them is the size ofthe facility. There may be a correlation withacademic preparation/requirements of theorganization and size of the organization. Thesmaller the facility, the more likely it is that theorganization will not have a hard-line require-ment for an advanced degree in health careadministration, but this is not always the case.There are those organizations that may, due to avariety of reasons such as previous occupants ofthe position, culture, or history, that may wantto consider other than a “classic” candidate, i.e.,a graduate of a hospital or health care adminis-tration program and may, for example, prefer agraduate of the business school, perhaps abehavioral program or an individual with a clini-cal background.

Complexity of the organizationNot all small and rural health care organizationsare identical even with essentially the samedescription, e.g., Critical Access Hospital,County Health Department, Rural Health Clinic,Federally Qualified Rural Health Clinic, and agrowing number of health care networks requir-ing yet additional skills and experience amongothers. They differ in scope and complexitywhich may affect both recruitment and reten-tion. These factors must be considered in the

National Rural Health Association

Issue Paper

Title: Subtitle

May 2007

National Rural Health Association

Issue PaperRecruitment and Retention

Of a Quality Workforce in Rural AreasA series of Policy Papers on The Rural Health Careers Pipeline

Number 10: Health Care Administration

NRHA Issue Paper May 20072

recruitment of the candidates making descrip-tion of the organization a pertinent part of thescreening and selection process.

Governing board understanding of theneeds of the organization and related issuesA critical issue in the recruitment and retentionof the HA is the governing board of the organi-zation which is ultimately charged with both.The governing board of most voluntary, not-for-profit organizations has two major responsibili-ties: the hiring and evaluation of the HA and thelegal, fiduciary responsibility for the organiza-tion. In the former, given there generally isn’t alicense or regulation governing the HA positionother than cited above or referred to by “quali-fied” or “recommended,” the board is not limitedto specific criteria.

Many board members of rural organizationshave limited experience with hiring executivelevel professionals. Most small and rural organ-izations do not have succession plans in place.The selection or replacement decision can beinfluenced by other factors such as organizationrelationships, emotion, influence of select boardmembers, physicians, community leaders, sup-port for other officers of the organization whoare in place, e.g., the chief nurse executive, chieffinancial officer, human resource director, headof laboratory, etc., all of whom can be “quali-fied” or “deserve a chance.”

Boards may feel they can identify their HAcandidates without resorting to using outsideresources such as a professional recruiter due tocosts or other reasons.

Criteria other than education, experience, andskill sets can be often overlooked. Fundamentalquestions of character, personality, cultural fit,community relationships, are often cited as veryimportant to the success of the CEO in selectionand retention.

To contract or not to contract is also debat-able. There are those who would argue that theHA contract is as good as his/her previous day’sperformance. Also, it can be easily argued thatthe HA’s performance and ability to take riskscan be directly related to the “confidence”he/she has with support for his/her decisionsparticularly if there is less than a desirable out-come of a particular decision.

Boards will continue to be challenged indefining and selecting the “right” person to fulfillthe leadership roles as we are experiencingmore frequent turnover in many organizationsand the aging of the workforce is affecting HApositions as well.

Academic preparationWhat is the right curricula for an HA? This isanother debatable topic. What courses areimportant now and for the foreseeable future?Will they differ dramatically? Who shall decide?Forti & White (2001) reported that 27 percent ofstudents who were exposed to rural internshipsaccepted positions in rural health care facilitiesupon graduation and most of them were still inthose positions five years later.

“Fair”, i.e., adequate compensation andbenefitsCertainly not unique to the HA profession inrural health care organizations, but equallychallenging for recruitment and retention arecompensation and benefits. As with manyorganizations, the larger the revenue base ornumber of employees, the larger the salary andgreater the benefits, (again with exceptions)which could be argued is even more striking forthe rural HA. He/she has most of the sameresponsibilities and demands with fewer admin-istrative or management resources to delegate.It can be argued that he or she must be even“more qualified” to be an HA of a rural healthcare organization.

Recognition of the variability of environ-ments and expectations of the HAThe environments in which HAs practice varywidely and the skill sets/competencies will varyin number, strength, and intensity. Administra-tion is a health profession and Area HealthEducation Centers (AHECs) may wish to consid-er facilitating rural placement of students inhealth administration programs.

Similarly, Federally Qualified Health Clinics(FQHCs) and Rural Health Clinics (RHCs) face adifferent environment from hospitals, long-termfacilities, etc., making it imperative that furtherresearch and evaluation are in order to deter-mine the “right fit.”

More organizations are seeking and havebecome part of a growing number of health care

NRHA Issue Paper May 20073

networks to achieve a number of tangible andintangible benefits from the development ofbuying groups, Group Purchasing Organizations(GPOs) to the opportunity for sharing and seek-ing solutions to common issues and challenges.

Recommendations

The NRHA supports the following policy recom-mendations:

• Develop guidelines of academic/experi-ential/skills/character/personality, corecompetencies, and tools to assist gov-erning boardsThe ultimate “success” of a particular HA orhis/her organization in itself begs multipledefinitions and descriptions. What is likely tohave more success is to recommend to anumber of nationally recognized organiza-tions whose members are HAs e.g., theAmerican Hospital Association (AHA),American College of Healthcare Executives(ACHE), National Rural Health Association(NRHA), American Public Health Association(APHA), and perhaps the Office of RuralHealth Policy (ORHP) to commission a projectwherein a short “workbook” is created forgoverning boards of rural health providersthat would specifically address their roles andresponsibilities in the recruitment and reten-tion of their executives. Included may be theneed for a set of competencies for HAs.

An effort to develop an understanding of sucha core set of competencies was written in theJournal of Healthcare Management, 2005. Thisstudy described an approach that used a pur-poseful sample of American College ofHealthcare Executives (ACHE) affiliates whorepresented different geographical regionsand health industry segments to construct aframework composed of critical health careissue clusters. A panel of health care execu-tives then specified five sets of entry-levelbehavioral competencies that would berequired to address the clusters of criticalissues. Although the behavioral competenciesidentified by the executives in this study wereanchored to a framework, their empiricalassociation with performance was not tested.

Generally speaking, competencies mayinclude among others: structuring and posi-

tioning health organizations to achieve opti-mum performance; financial management;leadership and interpersonal communication;quantitative skills; legal and ethical analysis;health policy; population health; and outcomemeasures. Additionally, they may include pro-grams and courses in annual meetings andother opportunities for practitioners in thefield to earn continuing education credits.

• Identify sources of funding for a ruralexecutive internship for college studentsto increase their interest in working in arural facility.

• Encourage better representation of thecommunity in rural health organizationleadership positions.As our rural communities continue to diversi-fy, so should our efforts to diversify our lead-ership. NRHA leadership should avail itself ofthe resources found within the Institute forDiversity and similar efforts to promote thisrecommendation.

• Advocate for reauthorization and rein-statement of funding for the Health CareAdministration Traineeship as part of theTitle VII health professions training.

Summary

The recruitment and retention of qualifiedHAs is extremely complex relative to some otherrural professions, e.g., technologists or otherlicensed or registered health care professionals.Nonetheless, the importance of training andretaining leaders of health care organizations isof paramount importance with increasingdemand for services and diminishing resources.These HAs will be instrumental in setting thecourse for the future of health care policy, pro-gramming, access, and delivery of health careservices to the rural population.

A major strategy to ensuring adequate prepa-ration and retention is the need for guidelinesand tools to assist interested and responsibleparties in making the right selection and devel-opment of retention programs.

www.NRHArural.org

Administrative Office521 East 63rd StreetKansas City, MO 64110816/756-3140

Government Affairs/Policy Office1600 Prince Street, Suite 100

Alexandria, VA 22314703/519-7910

Contributing Authors

This policy paper was prepared for the National Rural Health Association by: D. David Sniff, EstherForti, and David Hartley

www.NRHArural.org

Administrative Office521 East 63rd StreetKansas City, MO 64110816/756-3140

Government Affairs/Policy Office1600 Prince Street, Suite 100

Alexandria, VA 22314703/519-7910

References

Ackerman, Ken. et.al. (2004) Governing Executive Compensation: Demystifying the Board’s Role, a Guideto “Getting it Right.” Clark Consulting Company. 9 pp.

Forti, E.M., & White, A. (2001). A rural service-learning model for health administrators. The Journalof Health Administration Education, 19, 403-416.

Klegon, Doug, Garman, Andy, and Keene, Pamela A. (2004) Succession Planning Routinely Done by21% of Freestanding U.S. Hospitals, a study by ACHE.

Metzler, Chris J. (2007) Strategic Diversity Recruiting Workshop, UWM School of ContinuingEducation, Ithaca, New York

Moscovice, Ira and Elias, Walter, (2003). Networking for Rural Health, Using Rural Health Networksto Address Local Needs. Academy Health. 48 pp.

Robertson, R and D Cockley. (2004). Competencies for Rural Health Administrators. Journal of HealthAdministration Education. 21(3):329-341

Shewchuk, Richard M., O’Conner, Stephen J., Fine, David J., (2005). Building an Understanding of theCompetencies Needed for Health Administration Practice. Journal of Healthcare Management. Volume50 Number 1.

Weil, Peter. (2006). Via email. (pweil@ache.org)