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Summary
To get a perspective on how the mission role has evolved over the past few years, the Catholic Health Association surveyed a sample of mission leaders at Catholic acute care facilities throughout the United States.

Most respondents (86 percent) were women religious, and the majority had advanced degrees in some area of religious studies. They indicated that an ideal education for a mission leader would include preparation in theology, ethics, or spirituality, as well as business or healthcare administration.

The majority of mission leaders answering the survey ranked themselves high in their ability to influence their organization's chief executive officer. They consistently identified their key role as integrating values and mission into the daily life of the organization.

The majority of respondents (95 percent) said they were responsible for mission in acute care. Other important areas of responsibility included home care, hospice, long-term care, and outpatient care. Most respondents reported extensive involvement with the ethics function at their facilities, and they also had an active and vital role in continuous quality improvement efforts.

Mission leaders felt their skills uniquely qualify them to assist organizations making the transition to integrated delivery. Their experience in collaboration, communication, and team building can be crucially important as organizations adjust to the demands of a new delivery system.

As the push for reform intensifies, healthcare chief executive officers (CEOs) are assessing and redefining the roles various healthcare professionals will play in a changed healthcare system. Reviewing the role of the mission leader is a particularly urgent task. Mission leaders' unique position makes them sensitive to their organization's culture and a tremendous asset to CEOs who must lead in a time of change.

How has the mission role evolved over the past few years? How is it viewed within the healthcare organization? What kinds of skills, qualities, education, and experience make an effective mission leader? And what new skills and qualities will they need to meet the challenges of healthcare reform?

Survey Respondents
To capture a "snapshot" of mission leaders' role and function in Catholic healthcare, in fall 1993 the Catholic Health Association (CHA) mailed surveys to 85 full-time mission leaders at acute care facilities throughout the United States. Mission leaders were asked questions regarding time spent in their present position, previous similar positions, reporting arrangements, decision-making authority, and a variety of other factors. Sixty-three leaders returned the survey, a 75 percent response rate.

Respondents represented institutions from 27 states, about half of which were in the Midwest and the other half divided evenly between the South, West, East, and Northeastern regions of the United States. Institutional bed size ranged from 100 to 500 beds, with the majority in the 200- to 300-bed range. Eighty-six percent of the respondents were women religious, 80 percent were members of the religious congregation that sponsors their institution, and 10 percent were laypersons (4 percent did not indicate their status). Ninety-seven percent were Roman Catholic.

The majority of respondents have master's degrees, mostly in some area of education or religious studies such as theology, spirituality, or biblical studies. Many of them also have bachelor's or master's degrees in nursing. They indicated that an ideal education for someone in a mission position would include preparation in theology, ethics, or spirituality. Respondents also recommended that mission leaders have some preparation in business or healthcare administration.

Impact and Responsibilities
The Mission Leader and the CEO The mission leaders were asked to provide a self-rating, on a scale of one to five (one being high and five being low), of their ability to influence the CEO in decision making. About 55 percent gave themselves either 1 or 2, whereas 38 percent gave themselves 3 or 4. (Seven percent did not answer.)

Respondents were also asked how they are viewed by their organizational CEO. Most indicated that, overall, the CEO values the mission role highly, views them as influential within the organization, and is supportive of their work.

Organizational Role When asked to describe how they view their own role as leaders within the organization, many respondents said they believed they were influential, describing themselves as catalysts, tone setters, direction setters, and question raisers. Respondents frequently highlighted their purpose of integrating values and mission into the organization's daily operations. They saw themselves as facilitators, resource persons, educators, and visionaries. Many respondents underscored the importance of leading by example or being a visible symbol of commitment to Gospel values.

Nearly all the survey respondents report to and are directly accountable to the organizational CEO and are considered regular members of the executive management team or administrative council. They also keep the sponsor informed through direct discussions, periodic reports, and communication through the CEO. Only 7 percent reported that they do not participate in making major decisions such as budgeting, planning, staff reduction, and joint ventures.

The mission leaders stated that they supervise a wide array of professionals, mostly in pastoral care and chaplaincy services, but sometimes in patient relations, community health services, and other departments. Twenty-seven percent reported having no support staff. Those who do have a support staff person usually share the employee with some other manager(s). Most of the mission leaders reported earning what could be considered middle to senior management salaries. About 64 percent earn between $40,000 and $69,999 per year. Another 17 percent earn salaries above $70,000.

Responsibilities Most survey respondents were responsible not only for acute care (95 percent) but also for mission in other areas such as home care (35 percent), hospice care (25 percent), long-term care (20 percent), and freestanding outpatient centers (13 percent).

The mission leaders indicated that their primary responsibilities include performing administrative duties and conducting meetings. They are also involved in developing and implementing programs; consulting on sponsorship, mission, ethics, Church teaching, and theology; directing education and orientation activities; and performing activities related to leadership or management development. Other responsibilities include group facilitation, staff support, policy development, advocacy, and social accountability and community needs assessments.

Respondents indicated extensive involvement with the ethics function within the organization. Sixty percent serve on the institutional ethics committee, and 43 percent are responsible for organizing and facilitating committee activities (e.g., developing agendas, securing resources, being a communication channel). Eighty-one percent of the mission leaders are responsible for the ethics function within the organization. Forty-one percent said their organization employs an ethicist, and 56 percent reported that it does not. However, of those which do not, 29 percent use an ethics consultant.

Mission leaders are also taking an active and vital role in continuous quality improvement efforts (CQI). Nearly all (95 percent) reported that their organization is involved in CQI, and the vast majority of these efforts have been initiated within the past two years. Most of them reported involvement in education and preparation for quality improvement through activities, workshops, and seminars encompassing several days. A majority of respondents mentioned serving on the organization's quality improvement committee, council, or task force. Several of the mission leaders are personally responsible for continuous quality improvement within the organization, and a number of them described themselves as trained facilitators and resource persons for CQI.

Leadership Development and Board Involvement About 69 percent of the mission leaders reported that their organization has a leadership development or leadership formation program. Respondents said they participate as active resource persons, developing modules or components related to mission and values for leadership development education.

Mission leaders also reported being actively involved with their board of trustees. Most of them (73 percent) give reports or updates on mission-related activities to the board at regular intervals, and 61 percent attend all board meetings. Many of them (30 percent) serve on board committees dealing with mission or mission-related issues, and about 20 percent are responsible for special education or reflection for board members.

The Mission Role in Integrated Delivery
Most survey respondents (91 percent) said that their organization has been involved in collaborative meetings or discussions with other hospitals or organizations within their community. About half of those whose organizations are involved in such activities reported serving as team members, resource persons, and members of committees that plan collaborative activities. These ongoing or continuing collaborative activities include community outreach, prenatal and maternal care, migrant worker outreach, ethics education programs, parish nurse services, and care of the poor.

About half the mission leaders said their organization is involved in a joint venture, management arrangement, or merger plan with organizations that are nondenominational or of other religious denominations. These arrangements include various managed care or insurance plans; health maintenance or preferred provider organizations; and shared magnetic resonance imagers, lithotripters, rehabilitation services, prenatal care, cardiac catheterization, outpatient services, and clinics for the indigent.

Making Transitions
Key Roles Respondents saw the mission role as vital in preserving Catholic identity as reform prompts providers to work with other healthcare organizations. They saw their primary function as helping the CEO preserve Catholic identity and values in a time of tumultuous change. The respondents believed the mission leader could promote collaboration and cooperation and also teach and advocate for Gospel values. They thought mission can and should be part of every facet of healthcare delivery and its reform, playing an integral role in policy and program development. Respondents indicated some of the key activities of the mission role were to raise consciousness about and be champions of Catholic mission and values. Promoting social justice and raising necessary ethical questions were also identified as important aspects of the mission leader's job.

A few survey respondents expressed uneasiness about the possibility that, as Catholic healthcare organizations are swept along by healthcare reform, mission and values will be lost in a tide of concerns about payment issues, legal restrictions, and control. As one respondent wrote, "I worry that, in our rush to be part of things, we won't take the time to ask crucial questions about the impact of our activities on our mission and values." At the same time, they emphasized that the mission role, by promoting networking, collaboration, values integration, and shared support and advice, is ideally suited to addressing CEOs' concerns about maintaining those values.

Many respondents pointed out that the mission role includes ensuring access to healthcare for the poor, meeting unmet needs, and being responsive to true community needs. Although healthcare reform promises insurance coverage for the underserved, problems with access to healthcare will most likely continue. Many mission leaders are already active in assessing community needs and finding ways for the healthcare institution to work with the community to best serve those needs. It can be the mission leader's role to make sure that people's needs remain at the center of the integrated delivery system and that Gospel values drive changes in the organization's healthcare delivery efforts.

Skills and Qualifications The survey asked mission leaders to indicate what they thought their role would be as healthcare reform progresses. Respondents were asked what kinds of skills and education would best equip the mission leader to meet tomorrow's challenges and enhance the future of Catholic healthcare. They were also asked what a mission committee or CEO should look for in an individual seeking a mission position.

Survey respondents were asked to rate a number of qualities and skills according to their importance for an organizational mission person. The qualities included the ability to:

• Facilitate collaboration
• Keep mission in focus and ask values-based questions
• Educate
• Raise consciousness
• Promote networking
• Articulate spiritual and religious issues
• Be an advocate for Catholic values and for true community needs
• Be a support and resource to the CEO

"Skills for Mission Leaders" (at the end of this article) lists specific skills respondents thought were important for mission leaders.

Some Implications of Change
With change occurring so rapidly in healthcare, it is more crucial than ever to probe some of its implications and clarify the future direction of the Catholic healthcare ministry. As healthcare delivery is streamlined and restructured into integrated delivery networks, Catholic healthcare leaders can perhaps best keep their goals and purposes in focus by taking the time to rearticulate their organization's mission.

The integrated delivery setting demands a new way of thinking about healthcare and about sharing power and control. Today's Catholic healthcare organizations may or may not be leaders of the integrated delivery network within which they serve, and healthcare leaders may thus have fears about losing autonomy and control. Mission leaders can use their skills and their own example to enable others to collaborate. They can help develop criteria for collaboration and even assist in the negotiation process. Healthcare organizations, traditionally the originators and controllers within the community, will need to learn to share power. In such a setting it will be necessary to acknowledge everyone's contribution, to seek information in nontraditional ways about healthcare needs and existing resources within the community, and to share credit for successes and responsibility for failures.

The mission role will be crucial to maintaining Catholic identity in a rapidly changing environment. For example, the continued move toward regional delivery networks could lead to the development of a "regional mission leader." By putting their skills to work on a regional basis, whether in an integrated delivery setting or other shared community activities, mission leaders can become an invaluable support to the CEO in a difficult time of transition.

Integrated delivery and community-based healthcare delivery also focus on wellness, preventive care, and holistic approaches to health, as opposed to acute or urgent care. The mission leader can be influential in creating an external and internal culture of healing that recognizes the connection between a healthy mind, body, and spirit.

Part of mission leaders' role is to support and educate their organization's employees. Mission leaders typically are involved with human relations issues within the organization. They call attention to issues of human dignity and justice in employment conditions, involve people in decisions about their work situations, and enable all employees to contribute and have their contributions acknowledged. The mission leader can also help identify and assess the organizational culture and seek ways to enhance Gospel values within it. Finally, the mission leader can help staff cope with change and can work to build a values-based culture not only within the organization's walls, but in its ministry with the community.

Healthcare reform will bring painful issues like employee layoffs and organizational restructuring. The mission leader can point to justice issues involved in such decisions and can be a resource and support for people who lose their jobs. In such a situation the mission leader might work with human resource staff to develop guidelines for layoffs and downsizing, find ways to improve morale, develop communication channels, and involve staff in the change process. Since the mission leader is responsible for promoting spiritual as well as physical healing, he or she can also help employees cope with layoffs by developing rituals that let them express their anger, fear, and hope.

As organizational mergers become more commonplace, the mission leader can assist in the integration of organizational cultures along ecumenical lines. For example, in a merger between Catholic and Baptist organizations, Catholic mission should be kept in focus, but shared goals, visions, and common ground can also be stressed. Statistical and anecdotal evidence suggests that, in a significant number of failed organizational mergers, a clash of organizational cultures, rather than financial or market factors, was the cause (see Susan Cartwright and Cary Cooper, "The Role of Culture Compatibility in Successful Organizational Marriage," Academy of Management Executives, vol. 7, no. 2, pp. 57-70; and G. A. Walter, "Culture Collisions in Mergers and Acquisitions," in P. J. Frost et al., eds., Organizational Culture, Sage Publications, Beverly Hills, CA, 1985). Mission leaders can evaluate these issues and help develop guidelines and policies, as well as symbolic rituals and celebrations, that will enable workers to make the psychological and emotional adjustments needed to cope with massive change. By assessing the organization's culture and, in a sense, acting as organizational facilitator to promote the changes, the mission leader can help develop a values-based culture and assist the CEO in preventing the formation of a culture plagued by fear and resentment.

A Unique Opportunity
As healthcare reform moves providers toward community service and integrated delivery, mission leaders have a unique opportunity not only to strengthen Catholic healthcare by keeping the focus on mission and values, but also to employ their skills as change agents, educators, and collaborators. Despite inevitable conflict and tension, the mission leader's ability to facilitate change during a time of healthcare reform will be exceedingly valuable to the organization and its CEO. Now is the time not only to ensure that the commitment to Gospel values is maintained, but also to strengthen this commitment.

Sr. Stanley is senior associate, mission, Catholic Health Association, St. Louis.

MISSION LEADERS' TRANSITIONAL ROLE

• Help rearticulate mission, values, and philosophy.
• Be involved in developing a shared vision.
• Influence decision making. Have a "seat at the table."
• Represent Catholic perspective: Gospel values and ethical tradition.
• Assess and foster values-based organizational culture. Help organization deal with change.
• Be involved in strategic planning.
• Facilitate networking. Remove obstacles to collaboration.
• Raise value questions and justice issues in employee relations.
• Advocate for and highlight needs of the poor and disenfranchised.
• Develop symbols, rituals, and celebrations to deal with change or highlight Catholic mission.
• Be a visible symbol of commitment to the healing ministry of Jesus.
• Promote the spirituality of healing and wholeness.

SKILLS FOR MISSION LEADERS

Overall Skills

• Interpersonal skills
• Ability to work as a team member
• Understanding of the Catholic healthcare ministry
• Knowledge of Scripture and spiritual issues
• Knowledge of sponsor's charism
• Organizational development skills
• Listening and oral communication skills
• Adult education skills
• Written communication skills
• Ability to lead and facilitate groups
• Knowledge of current issues in clinical and corporate ethics
• Administrative, public speaking, and conflict-resolution ability
• Ability to develop rituals and symbolic celebrations

Crucial Skills for This Transitional Time

• Willingness to live with ambiguity
• Creativity
• Ease with risk taking
• Energy to forge new relationships with different traditions

RESOURCES FOR MISSION LEADERS

Mission leaders can use A Perspective on How to Approach Catholic Identity in Changing Times (Catholic Health Association, St. Louis, 1994) as a useful tool to educate themselves, board members, and managers. (The text will be published in April 1994 Health Progress.) It provides practical guidance on retaining a strong Catholic mission as new healthcare models emerge, advice for the prenegotiation and negotiation process, and help in evaluating partnering arrangements. The document also shows providers how to ask focused questions to articulate mission and values, reflect on ethical issues, clarify community needs, and assess the compatibility of their vision with that of an integrated delivery network in which they might participate.

Healthcare and mission leaders will also find CHA's A Handbook for Planning and Developing Integrated Delivery a helpful resource as they become involved in integrated delivery. This document highlights the importance of maintaining Catholic identity and values and discusses mission integration and the mission role within the context of integrated delivery.

To obtain copies of these books, call Dottie Freitag at 314-253-3458.

Copyright © 1994 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.