Health care leaders--it is time to step forward.

Bruce Vladeck's timely and interesting article clearly makes the point that it is indeed time for health care leaders to step forward as they consider the relationship between health care organizations and the communities they serve. I must acknowledge that my review of this work is influenced by my own personal experience and background in hospital administration and, for the most part, I tend to translate health care organization into hospital. In my view, the author captures well the sense of complexity in health care management today. He makes a number of points about this, but one is particularly significant, and that is the matter of public expectations of health care providers. These expectations are increasingly more difficult to match with performance. Institutions are asked to have the best of technology and medicine available but at prices low enough to quiet critics. Vladeck says these expectations become the boundaries in which health care organizations must function. My own view is that these limits are tightening and the freedom to plot our own course is being reduced, largely because we have not been able to deal with the cost issue as a part of our freedom to shift plans, change programs, implement new technology, etc. As we in health care wrestle with problems of meeting community needs we are troubled by the question of who defines or determines these needs. Indeed, hospitals may well see their core technology or services in the decade of the 1990s begin to shift from acute care, medical-surgical services, to more of emergency and primary care, clinics, prevention, education. Research and development, especially in the area of genetics, increasingly seems to indicate that we may move from centralizing major technology in large centers such as hospitals into smaller operating units with machines that will fit quite well in these new or different facilities. I agree with the author that health care leaders will have to know what their institutions' core activities are or should be and they will have to focus on them in order to build up and outward from them. Vladeck writes about the characteristics of successful leaders and suggests that leadership is not readily visible at the superficial level. While this may appear rather obvious in general terms, I am often reminded that leaders do have a certain air about them, a certain "look." This may be affected by posture, attitude, demeanor, intellect, etc. My thought is that the self-confidence and strong sense of purpose that routinely accompanies leadership does show up in people's appearance, and it can be detected. Styles of management certainly change over time, but the basic qualities of leadership seem to be very consistent. As I reflected on the article and health institutions' responsibilities to their communities, I was reminded that some time ago I read that hospitals' roots do lie in societal issues. We began as almshouses and have grown into technological palaces. In our own country as we have moved forward from the eighteenth century to the beginnings of the twenty-first, we find that hospitals are still the recipients of society's failures and that there still remains the serious debate as to whose responsibility it is to pay for the health care of those who suffer as a result of chemical addiction, improper diet, inadequate housing, and other less-than-healthy lifestyles. The article places heavy emphasis on institutional mission, goals, objectives--and appropriately so. Increasingly we hear today that hospitals, for example, must get back to basics, that the days of diversification are gone. We see complex corporate organizations being reduced and simplified. Also, the quality factor is emerging as well as a renewed awareness of our "customers." Indeed, in some ways hospitals are following patterns being set by American business and industry. Vladeck underlines the issue of goals and mission when he talks about the specific attributes of leaders. …