Betrayed Trust Article Review

Betrayed Trust Article Review Order Description Read the attached article and answer each question attached in the other document. APA is extremely important, including headers. There is only one scholarly article required to support the answers. We were told we can take any direction we wish with the paper, as long as it directly pertains to the attached "Betrayed Trust" article. Betrayed Trust Discussion Please answer all discussion questions below and submit to the Drop Box. Use one scholarly article to support either a leadership, ethical or legal issue. Use APA format Page 38 of your text discusses the management functions of: Planningencompasses determining philosophy, goals, objectives, policies, procedures, and rules; carrying out long- and short-range projections; determining a fiscal course of action; and managing planned change. Organizing includes establishing the structure to carry out plans, determining the most appropriate type of patient care delivery, and grouping activities to meet unit goals. Other functions involve working within the structure of the organization and understanding and using power and authority appropriately. Staffing functions consist of recruiting, interviewing, hiring, and orienting staff. Scheduling, staff development, employee socialization, and team building are also often included as staffing functions. Directingsometimes includes several staffing functions. However, this phase’s functions usually entail human resource management responsibilities, such as motivating, managing conflict, delegating, communicating, and facilitating collaboration. Controlling functions include performance appraisals, fiscal accountability, quality control, legal and ethical control, and professional and collegial control. D1. Based on your review of the article, give an example of each function D2. What is the role of a Hospital Board? D3. What potential legal issues were threats to the organization? Were these intentional or unintentional acts? Was it subject to trial in civic or criminal court? D4. The CEO uses a systems theory framework to understand the culture of the organization and to rebuild the organization. Was this the right strategy for the organization? Could it be sustainable after the CEO’s departure? D5. If you were to identify one key element that led to the dysfunction of the organization. What would it be and why? D6. Using this case study give one example of an ethical principle? Why? D7. Based on your leadership style, what would you have done differently? D8. Please list any other leadership and management functions that you identified in the article. Vol. 36, No. 1, pp. 63–80 Copyright c 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Betrayed Trust Healing a Broken Hospital Through Servant Leadership Deborah A. Yancer, MSN, RN An investigative reporter with The Washington Post broke the news of a no-confidence vote by the medical staff of a hospital in the suburbs of Washington, District of Columbia. The chaos that followed created a perfect storm for needed change and offered the rare opportunity for unbridled deep and creative collaboration. Issues the hospital faced as a result of this crisis and subsequent events that tested the authenticity of change are summarized. This article focuses on the approach used by the registered nurse chief executive officer (RN-CEO) to humanize the hospital, viewing it as though it were a patient and leading a clinical approach to organizational recovery and health. The relationship that developed between the medical staff leaders and the RN-CEO was pivotal to the hospital’s recovery and evolved as a hybrid of servant leadership. Outcomes achieved over a 7-year period and attributable to this relational model are summarized. Finally, the RN-CEO shares lessons learned through experience and reflection and advice for nurses interested in pursuing executive leadership roles. Key words: no-confidence vote, recovery, servant leadership, trust MIRACLES HAPPEN, as clinical professionals we know that. We have been blessed to see patients recover when healing was not thought possible and our efforts inadequate to the challenge. Miracles can also happen in the health and recovery of a hospital. When a hospital falls from grace in the eyes of the community it serves, people look for someone to place their trust and confidence in. A building does not engender confidence. But people can. And so when we hold up a leader, confidence in the hospital can be nurtured. But the path to recovery can be long and unpredictable. When trust is betrayed, it is more difficult for people to invest in new Author Affiliation: Independent Consultant, Lincoln, Nebraska. The author thanks the past presidents and other medical staff leaders of Shady Grove Adventist Hospital for their leadership and sage advice as they, along with the author, laid down the path to the future. The author declares no conflict of interest. Correspondence: Deborah A. Yancer, MSN, RN ([email protected]). DOI: 10.1097/NAQ.0b013e31823b458b relationships and risk disappointment again. This is true for each of us and so, too, for people bound together by a common work. A HOSPITAL IN CRITICAL CONDITION In 1999, Shady Grove Adventist Hospital (SGAH), a 268-bed acute care hospital serving a rapidly growing community in the suburbs of Washington, District of Columbia, was the subject of a breaking investigative story in The Washington Post, a reputable national news source. The premise of the article, and the series that followed it, was that patients were dying at SGAH because of poor leadership and the medical staff had issued a noconfidence vote (NCV). Although the source was not named, it was attributed to medical staff speaking on behalf of hospital nurses and staff. Perhaps, more damaging was the slow decline in personal confidence that physicians and staff shared with family and close friends. When the story went public, all those comments added credibility to the concerns. Confidence was lost from the inside of the hospital out to the community. All venues of Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 63 64 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2012 local media carried the story over the intervening months. In fact, for several years, any news about the hospital was prefaced by reference to the troubled time. The good intention of medical staff leaders to herald the need for change spiraled out of control and caused many unintended consequences. Public scrutiny placed an additional burden on all engaged in delivering or supporting care at the already faltering hospital. Everywhere hospital staff and physicianswent in the community they were questioned and subjected to name-calling. The hospital’s staff and physicians were battered in the cross fire of accusations and suspicion. It was a fearful time, with great uncertainty about the future of the hospital. Patients continued to come to the hospital, with newspapers in hand, and challenged even the most basic care processes. Regulatory agencies (The Joint Commission and the Maryland Department of Health) also arrived immediately and conducted concurrent reviews. Temporary management was put in place at the hospital and the parent health system, Adventist HealthCare, Inc, whereas the system board (there was no hospital board at the time) worked to respond to the immediate situation. Conflicts between board members and medical staff were aired in the media. The hospital was subsequently placed on conditional accreditation by The Joint Commission, and its deemed status with the Centers for Medicare & Medicaid Services (CMS) was threatened. Conditional accreditation was a designation that had not been previously used, and its meaning and path to resolution were unclear. Many people in the community misunderstood the designation and believed the hospital had lost its accreditation. Since the hospital had recently achieved the highest Joint Commission rating, the health system formally appealed the decision. Meanwhile, the health system board considered potential management options including affiliation, contract management, or recruitment of new leadership. Interim leadership, with assistance from consultants, worked to stabilize the hospital and set priorities. Efforts during the interim period, while well intended, were in some cases off point, bringing focus and energy to change initiatives inappropriate for a hospital in crisis. For example, work began on the development of a clinical ladder for nursing. Although nurses were interested in the development of a system to recognize their clinical expertise, this work would have no value unless the hospital’s performance and reputation were first restored. Themedical staff leadership, to their credit, took seriously their involvement in selection of the next hospital leader. They articulated what they wanted in a leader and what they believed the hospital needed. The medical staff president and president-elect participated in the selection interviews and pledged their support moving forward. No formal methods for medical staff engagement had existed prior to the NCV. Contact with hospital and health system leadership had been predominately transactional. Meetings were held on an as-needed basis with individual physicians or groups. Distrust had grown as people had different accounts of commitments made, and many described an absence of relationship with administration. The medical staff desired relevant involvement in shaping the future of the hospital. Many barriers existed in the hospital that would need to be overcome, including but not limited to the following: • Significant findings from regulatory agencies with tight timelines for improvement. • Frequent unannounced surveys by discipline-specific and hospital accrediting and regulatory bodies. • Damaged credibility with the community. • Weariness of hospital staff and physicians before the NCV worsened under intense public scrutiny and suspicion of coverup. • Broken trust; people described feelings of deep disappointment and betrayal. • Vacant, consolidated, and eliminated executive and management roles. Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Betrayed Trust 65 • Acting or inexperienced leaders; some had experience only at SGAH and lacked requisite formal education. • No hospital board and limited connection between the community, the hospital, and the health system board. • Communication had been messy, with conflicts and disagreements reported in the media; “no comment” responses to inquiries deepened community distrust. • Hospital financial performance had declined to a loss position; expenses for consultants and interim leadership were unbudgeted. • An entrenched view of the prior leadership, like a mantle, would be inherited by the new hospital leader. • People interpreted responses and actions through the filter of prior experience. • People were reluctant to try again since their prior efforts had gone unheeded. • The uncertain future of the hospital made retention and recruitment of qualified and experienced leaders and staff difficult. Over the next several years, significant internal and external events provided additional challenges to the hospital and tested forward progress (given next). Media coverage of selected (*) events and investigations produced a layering type of impact on the hospital and its people. Keeping hope for recovery alive was perhaps the most important and daunting leadership challenge. • The community was growing rapidly and with it, needs for health care services • Service-line competition was increasing with 4 other hospitals in the service area • Patient boarding and ambulance diversions among county hospitals reached a crisis point* • Significant near misses and sentinel events were self-reported, and the error rate in the hospital appeared to increase as a result of increased reporting* • Members of the community notified The Joint Commission and the State Board of Health of their concerns about care delivery, resulting in additional inquiries and on-site reviews* • An intensive care unit nurse was suspected of hastening the deaths of patients at SGAH; investigations were conducted concurrently by the hospital, the police, and the Maryland State Board of Nursing* • A disgruntled former employee was arrested and sentenced to prison after bringing a concealed shotgun to the hospital in search of his supervisors* • Various threats to the community required hospital attention or response, including: • The Pentagon attack* • Anthrax exposure threat at the Shady Grove post office* • Reports that hospitals were targeted for dirty bombs • Random DC sniper attacks, gunmen arrested in hospital service area* At the time, living the experience, each day was filled with urgent issues and more work to be done than we had staff to satisfy. The environment was dynamic both in the hospital and in the broader community. It was easier to see what was working against, rather than for, the hospital’s recovery. The hospital continued to serve the community and experienced growth in volume and services while doing the difficult work of making changes rapidly and in full public view. For the purposes of this article, we will focus on the collaboration between the hospital president (registered nurse chief executive officer [RN-CEO]) and the medical staff officers (past president, president, presidentelect, secretary, and treasurer). Certainly, contributions from the health system leadership, board members, medical staff, hospital leaders and managers, employees, and volunteers were all critical to the recovery of the hospital and are recognized. RN-CEO, THE NEW HOSPITAL LEADER During the selection process, it had become clear that the next hospital leaderwould need a broad base of health care experience and an ability and interest in providing Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 66 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2012 hands-on, just-in-time leadership. Turning the clinical and financial performance of the hospital would require expert communication skills, a strong personal presence, a sense of urgency, and the ability to inspire confidence. The new leader would become the face of the hospital and would need to be comfortable dealing with adversity and conflict. Motivation for success must be deeply ingrained, and the leader must be mission driven. In June 2000, the newly appointed CEO for Adventist HealthCare, Inc, announced the selection of a new hospital leader (RN-CEO) for SGAH. I had been selected to fill the role. I was living in Tennessee at the time and would make the move to Maryland to assume my duties. I had 25 years of experience as a nurse, with 20 years in progressively responsible hospital executive positions including experience in both chief nursing officer (CNO) and chief operating officer (COO) roles. While most of my experience was in mid-size, private, not-for-profit, faith-based hospitals and health systems, I had served as COO in a large teaching hospital and carried interim responsibilities during organizational transitions. My experience included working at every level within the hospital hierarchy, leading department and division turnarounds, and collaborating with other health system executives during hospital reorganizations, consolidations, and mergers. My leadership perspective had been built upon a systems theory framework, beginning with my education in a baccalaureate nursing program and continuing in my first role as a primary nurse in the intensive care setting. It was in that first role as a nurse that I discovered that work conditions matter and that patients care depends on the effective integration of effort across departments and disciplines. I quickly discovered that clear accountability and the existence of healthy relationships are requisite to good patient outcomes. As a staff nurse, I witnessed horrific patient care as the result of fragmented care processes and the divorce of responsibility from accountability. Within 2 years of beginning practice, I felt a deep calling to directly influence care conditions and moved from a staff nurse role to a unit-level management position. My personal mission in that first management role and every role leading up to my appointment as the president of SGAH was to create conditions where good people could give great care. My motivation for moving from a direct patient care role to a management role was to change what was happening at the bedside. I explored ways of involving staff in decisions about patient care and began implementing staff engagement models. Soon after taking my first position as CNO in 1980, I heard Tim Porter O’Grady speak about Shared Governance. Over the next decade, I served as CNO in 3 different organizations in Michigan, Missouri, and Nebraska: • Introducing shared governance in each organization • Applying learning from the prior experience • Deepening my understanding of the complexity of culture change I learned that improving performance in nursing, engaging and empowering staff nurses, and strengthening effectiveness of nursing leadership contributed to improvements in patient care but in limited ways. To really impact patient care, influence across the hospital was required. During this time, I completed a clinical master’s degree in nursing, an unusual academic path for a nurse executive. A more typical path would have been a master’s in nursing administration or a master’s in health care or business administration. However, by that point in my career, I had significant executive-level experience and had learned business skills on the job. Given my passion for improving patient care, I had chosen to pursue graduate level education in clinical nursing and to further strengthen my understanding of patient care, a hospital’s core mission. I chose to specialize in women’s and children’s health, the only clinical area in which I lacked experience. In this way, I broadened my understanding of clinical specialties. Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Betrayed Trust 67 This combination of clinical education and administrative experience offered a balance in perspective thatwould prove an important advantage. Although this would be my first time in a permanent CEO position, there was confidence that my deep experience in hospital operations, engagement models, success with turnarounds, as well as leadership presence and style would be a good match for the challenges the hospital faced. Many people asked me then and since, why I would be willing to take on such a responsibility and risk failure? As I visited the community and interviewed for the position, I had seen a great community that needed its hospital. This was work worth doing. My decision to accept the position came with a deep sense of calling to help ensure that the hospital would be able to continue its mission of service to the community. I had a strong faith that the outcome would not rely solely on my effort, knowledge, or skill. Like all the work we do in nursing, I believed I could make a difference by joining my efforts with that of others. As a clinical professional, my courage came from that internal well that nurses and other professionals routinely draw upon in providing clinical care. It is what we are prepared to do. THE HOSPITAL AS PATIENT But how should I lead? Where would the work begin? It was like being confronted with a critically ill patient and determining where to put your first effort. I observed that much of what was needed was the exact opposite of what had been happening. For example, the initial response to the media inquiries about care had been “no comment,” a literal fuel for the fire of public scrutiny. From themomentmy appointment was announced, I made myself available and was willing to comment even if the response was “I don’t know, but I will find out.” I was responsive to the hospital’s need for permanent leadership and traveled to the hospital before my official start date to address staffing shortages. Every conversation became an opportunity to learn from people about what had happened and what it meant to them. People described the disappointment and hurt they had experienced. It was important to understand the way people in different parts of the hospital had experienced the gradual breakdown of trust and how that played out, near and distant, to the patient. It was valuable to understand the meaning that individuals and groups made of their experiences and to consider how that would affect their behavior moving forward. All the hospitals problems were rooted in disconnection and broken trust. It took 6 months to begin to see an impact. It was like bailing water out of a sinking boat. There were many small changes, and how something was done, often proved more important than what was done. I looked for opportunities to be responsive in early and meaningful ways to signal a new beginning and that people would be valued and heard. For example, 2 major capital investments were made in response to physician and staff feedback, a new computed tomographic scanner for the high-volume emergency department and an additional emergency generator with wiring mapped throughout the hospital to support critical patient needs. Early on, it was difficult to get people to believe that they would be heard, as these urgent requests had been made before. It was the fragile beginning of rebuilding trust. Like priming a hand water pump for a well, there is no water unless you first pour some in. So, too, with trust, when people have been disappointed repeatedly and trust is broken or betrayed, they stop trying and give up hope of any response. Apathy is a learned response. To change this situation, the leader must gift trust, modeling consistent and continuous behaviors that deepen with repetition so that trust can be reborn one relationship at a time (Table 1). I leveraged my personal and professional experiences with trust betrayal and tragedy. I had learned through these experiences that we cannot control what happens to us but we can choose the response we will give. That became my mantra as I met with individuals and groups. I began to help people look at what had happened, take Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 68 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2012 Table 1. Leadership Behaviors to Rebirth Trust Gift trust Be vulnerable and transparent Use presence and voice Listen to understand Communicate openly and directly Do what you say Admit mistakes Be accountable Lead as an equal lessons from it that could inform their future, and put the history and pain behind them. I used stories from my own experiences to communicate that I understood the pain of broken trust. Trust betrayal, like loss, must be experienced to truly understand it. I was able to recognize wounded spirits and create space for healing to occur. My visibility and availability as the hospital leader was critical, especially in the first 3 years of my tenure. My calendar was filled with face-time and I constantly juggled priorities in response to situations and problems that continually bubbled up. One strategy I used to extend my presence in the hospital was a weekly voice mail. An e-mail was sent to communicate that a new voice mail message was available and staff could call a dedicated phone number at their convenience, from home or work, to hear the 1- to 2-minute message. This simple experiment proved to be a very powerful use of voice and virtual time. It became a best practice, with the following benefits: • Other audiences, including physicians, volunteers, community members, and family of staff, accessed the messages. • People felt connected and that they had a direct line with me as the hospital leader. • Rumors were reduced, and finite energy and attention were better focused. • Reliable direct communication signaled transparency and reduced power games over access to information. • The hospital had a simple and easy way to communicate quickly, making it possible to communicate before information was in the press. • During regulatory surveys, daily reports of progress and requests for changes could be communicated. • Appreciation was expressed for the important work each person was doing to support the care and caregivers, highlighting examples throughout the hospital. • People reported that they felt they knew the RN-CEO, even if they had never met me. (This impact was attributed by staff to knowing the sound of my voice.) Hospitals are complex organizations with interdependencies within and among professional and support staff. I had learned that lesson many times. As a CNO, I had experience strengthening the performance of nursing and still having poor care result. In hindsight, this is not surprising. It would be like setting a broken leg and expecting your patient’s heart to heal. My desire to become a COO and a CEO had been born out of that recognition. To impact patient care and to create conditions where good people can give great care, you must be able to influence the whole organization. My view of the hospital had shifted from an organizational context to a human context. My leadership perspective had been shaped through the interplay of education, experience, and exposure to theoretical constructs over my entire career. I had benefited from opportunities tomakemistakes, to begin again, and to adjust my approach on the basis of situations or new learning. Until, as I began my work as RN-CEO at SGAH, I viewed the hospital as though it were a patient (a collection of humans, with human characteristics). This was not a decision, rather a natural progression that I began to give voice to and be intentional about. I applied a clinical model to leading the hospital and found that knowledge I had gained while pursuing my clinical master’s degree was directly relevant in my role as hospital leader. Family theory could be applied when Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Betrayed Trust 69 using a human construct for the hospital and was remarkably similar to organizational theory. My knowledge and experience as a nurse and as a clinically rooted executive gave shape to a clinical approach that I used to support the hospital’s recovery (Table 2). Just like patient care, leading a hospital through a turnaround requires intuitive skills and the courage to test interventions and pursue other optionswith a sense of urgency. Situations are dynamic and ever-changing, like in any living system. I had to stay close and project confidence that together we could make the difference needed, regardless of the number of problems that surfaced within the hospital or changes that impacted the hospital from the external environment. People seemed to value my nursing background but often referred to me as a “former” nurse. I repeatedly had to correct this misunderstanding. I believe that nurses sometimes add to the public’s confusion by discounting roles that are not involved in direct patient care. We need to give voice to the value that clinical preparation and experience bring to patient care and leadership roles in hospitals. The hospital had difficulty attracting and retaining well-qualified CNOs. In fact, the position had been vacant for some time prior to the NCV. It was unclear whether CNOs were risk averse and put off by the significant challenges at SGAH, or in some way intimidated by an RN-CEO. While at SGAH, I came to understand that my nursing experience should inform my practice as the hospital CEO but I should take care not to eclipse the CNO as the organization’s nursing leader. My role as RNCEO was to be the voice of patients and their families and all who serve them. This was an important role shift for me to understand. Because of my breadth of experience as a nurse and a hospital executive, I was able to do parts of various roles as needed early in my tenure when many important roles were Table 2. A Clinical Approach to Leading Hospital Recovery Continuous use of the nursing process assess whole patient (hospital) sample at the point of care and move outward, checking processes and interfaces continuously learn and teach engage the patient (the hospital people) in the healing process leverage fluency in clinical language (a language of healing) Therapeutic presence and listening personal presence required for relationship to develop create space for listening, listen to understand help people process and mine meaning from the unfortunate experience invite people to have their future be informed by this meaning urge people to leave the wreckage behind and move forward Bring a single-minded focus to mission and set priorities meet people (patients, families, staff, physicians, community) where they are clarify mission “why we do what we do” use Maslow’s hierarchy to prioritize change efforts, delay work until appropriate time minimize use of external resources Author new culture of the hospital position communication as universally available be trustworthy and transparent value all people and help them see their relevance to patients model accountability and build it into processes and systems expect people to lead from where they are, staff and management continually learn and always seek feedback and improvement Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 70 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2012 vacant. I also worked closely with individuals and teams to push for results in short time frames. Although the role did not require that I be a registered nurse, it was the clinical construct that informed my business practice and inspired on-point connections with people. When time was really of the essence, this advantage contributed to the hospital’s success. SERVANT LEADERSHIP, A HYBRID EMERGES Robert Greenleaf coined the term servant leadership with the writing of his seminal essay, “The Leader as Servant,” in 1969. That essay became the first chapter of his book on the same subject in 1977. The second and third chapters of his book were essays written as Greenleaf explored a structural basis for hope in response to great upheaval in colleges and universities that had resulted in significant damage to previously heralded institutions. Greenleaf was seeking a way to make meaning of what happened and to help in the healing process. He asserted that “hope . . . is absolutely essential to both sanity and wholeness of life.”1(p7) In his second essay, “The Institution as Servant,” Greenleaf’s audience was governing boards. He spoke of a tradition passed down from Roman times, primus inter pares—first among equals. The primus continually must prove his leadership prowess among his capable peers to remain primus (first, but not chief). Greenleaf advocated that a leadership team with a primus would be a more effective leadership model for complex organizations than the traditional hierarchical model of a single leader. Furthermore, he asserted that it was not possible for a single leader to know all that should be known or to handle everything at once when organizations faced challenges and organizations suffered as a result. It was not fair to the leader or the organization.1 The visual of the primus next-to rather than over others resonated with my values as a nurse and my experience as a leader launching shared governance with nurses in my prior CNO roles. As I had progressed up the hierarchical levels, I experienced distancing between myself and direct care delivery and the conundrum of desiring direct feedback and communication when less and less of it was proffered. The simple visual, Greenleaf used to diagram the relationship, highlighted the advantage a primus would have standing next to capable peers, firmly rooted in the work of the organization rather than removed from it by layers of management. It is not surprising that communication and trust are so often issues in complex hierarchical organizations. An NCV assigns responsibility for poor performance to a single individual and yet recovery of an organization requires participation and accountability of the whole organization. But what if the leader creates a culture of shared leadership and uses the primus inter pares—first among equals concept as a leadership model? What if, instead of clamoring for control, leaders learn to rotate the role of primus on the basis of need, expertise, or relationship to serve a common good and thereby benefit self-interest? It is not a matter of choosing between self-interest and common interest but rather being compelled by commitment to serve both, but place one before the other. Creating the conditions for such an experience comesmore easily after an NCV. When a hospital finds itself in such a desperate situation that its survival and the future of all that depend upon it is threatened, opportunity emerges. People are willing to make dramatic change and work hard and long if they believe it will make a difference. The most important action I took as the new RN-CEO of SGAH was to ask the president and president-elect of the medical staff to meet with me weekly. We began our first meeting by sharing what we knew and what we had questions about. It was as simple as trying the opposite of a behavior. As an executive, I had too often been put in the position of dealing with physicians who felt they had been misled by the CEO or other executives. So, I took this opportunity to create a relationship based on trust, inviting equal (mutual) expectations, and pledging to always talk in terms of the hospital as a whole organization Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Betrayed Trust 71 with no artificial walls between the medical staff officers and the RN-CEO. We agreed to share all that we knew and to expect that confidences would be named and honored. Furthermore, since trust had been broken, restoring trusting relationships in the hospital and community would require that we partner effectively and visibly. In that first meeting, afterwe each sharedwhatwe knew, I was asked what we needed to do. I still remember the looks of disbelief when I said, “Nothing. We need to first listen to understand.” And so we did. I attended all medical staff department, committee, and general staff meetings including the credentialing committee for the first several years. It was important to create time and space with the medical staff, develop relationship, partner on important issues and build trust. I applied the same leadership behaviors described in Table 1 in my relationships with medical staff. There was a gradual acceptance of my presence at meetings and direct involvement in medical staff issues. This represented a significant change in engagement. The president and president-elect of the medical staff and I had weekly confidential meetings, with very few exceptions over the 7 years we worked together. Each brought what we knew, what we wondered about, and continually shaped common interest, attaching or subordinating our self-interest. As an RN-CEO, I believe my greatest contribution was bringing clarity to common purpose and developing language that resonated and allowed others to see their self-interest served by a greater common good. Together, we created and protected a safe environment where we could consider, disagree, debate, and even argue issues. We developed agreed upon approaches and had the wisdom to yield to one another and even delay decisions when possible to allow additional time for contemplation. Wemonitored progress andmade adjustments as needed to support successful outcomes. We created expectations for accountability across the organization, including the medical staff. Each challenge we faced and traversed successfully deepened our trust and our commitment to the work and each other. Our weekly meeting changed and grew as we felt the need. For example, we decided that the medical staff officers should join our meeting once per month so that perspectives of those leaders could be heard together. We also used our meetings for development of the future medical staff leaders. Additional time was spent one on one between medical staff officers outside our meetings to prepare for succession of roles. The medical staff took care to document roles and responsibilities as they evolved. There were times when we invited individual physicians or department chairpersons to our meetings so that we could either benefit from additional information and input or deliver a message together that would require our follow-up and support. During this 7-year period, the medical staff related directly to me as RN-CEO, an important factor in the recovery and development of the future hospital. The direct relationship and regular interaction of this group was invaluable. There was a safe place where we could argue viewpoints, ask difficult questions, and create space for deliberation. In the end, regardless of the topic, a decision would be made that we all would support. It was not easy, not always comfortable, but very effective. I know that their testament of our relationship influenced staff and physicians who trusted these physicians. In this way, trust grew exponentially outward in the hospital and community, reversing the effect of the confidence and trust once lost. As RN-CEO, there were decisions that could have ended my career because of the political intricacies. Navigating those difficult courses, I relied on the advice of medical staff, both formal and informal leaders, and at times went against my personal comfort. Change sometimes took longer, but together we accomplished good, meaningful change in a way that served the common interest. We were free to learn from each other, to show our vulnerabilities, and to coach each other. The more successful we were, the more successful Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 72 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2012 we became. Over time the relationships deepened such that we could anticipate what the other would do or say. It is what you hope for in every team but rarely experience. So why did it work here? First, I have learned that the general medical staff exhibit different groundings or priorities from hospital to hospital. These medical staff were truly committed to patient care and took their responsibility as a collective seriously. They helped to build the hospital only 20 years earlier and still told stories of planning sessions held in their living rooms. Shady Grove and the surrounding communities along the rapidly growing I-270 corridor mattered to them, both personally and professionally. It was unthinkable that SGAH with so much in its favor could come so close to disaster. There existed a very strong desire for change and to realign priorities to benefit patients. We were willing to place shared leadership ahead of the myth of control (power over each other). We learned how to work next to each other and to model that behavior to the broader organization. This was interesting given the history of RN and MD relationships. In health care, we all have stories of when it has worked well and when it has not. We did not waste energy on control issues so common in teams of leaders, jockeying for position. We were clear on our group mission: Save our hospital and make it the best it can be for everyone, those served and those serving. Beyond that, it was all about relationship, between us and each relationship we would touch. It was about continuity and commitment day to day and into the future, building sustainability. Advice that Greenleaf offered seemed to naturally occur as we developed our relationship. He suggested that whoever has the greatest team building ability and can provide the focus that holds the team together in common purpose should be primus.1 Our mission (stated earlier) provided that clarity. It is ironic that as leaders we continually felt the pull of our constituents (medical staff, administration) against collaboration. We were criticized ifwe appeared to “get too close.” As an executive, I was humbled by the personal sacrifices that medical staff leaders made in service to the hospital and the community. I also witnessed the price medical staff leaders often pay for authentic and engaged leadership: • Suspicion of unfaithfulness to medical staff colleagues. • Any compensation received for leadership duties was usually returned to the group practice. • Personal compensation was often less during a leadership term since the work was considered nonproductive by the physician’s practice partners. • Competing medical staff members or groups were suspicious of intent. • Physician leaders may be punished during and after their term by reduction in referrals (especially true for specialists). The hospital benefited from experienced medical staff leaders remaining engaged. For example, the credentialing committee was made up of mostly past presidents of the medical staff. Care was taken to ensure sustainability of changes by following the required medical staff procedures both for adoption and formalization of decisions including documentation in the rules and regulations and the bylaws of medical staff. This was especially important given the rapidity of change and the fact that voluntary medical staff were carrying out responsibilities usually under the purview of a chief medical officer. Departments met regularly, and quarterly medical staff meetings were held. Medical Executive Committee improved year after year, strengthening clarity of medical staff expectations and creating and enforcing consequences within departments and across the hospital. Physician leaders became expert in important areas such as quality improvement. Best practices were shared, and departments were held accountable for improving clinical quality, peer review, and performance issues including professional behavior. These priorities were strengthened through the practice of continuous learning. Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Betrayed Trust 73 The commitment that medical staff leaders made to partner with the RN-CEO during this period was remarkable. For example, a physician on track to be considered for the office of medical staff president would first serve 1 to 2 years as a department chair in either a medical or surgical specialty, 2 years as secretary or treasurer, 2 years as president-elect, and subsequent to his 2-year term as president would serve an additional 1 to 2 years as past president and chair the credentialing committee. A physician in line for a potential role as president would be committing a decade of his career in medical staff leadership roles. This level of commitment and continuity of leadership played a huge factor in the successful recovery of SGAH andmade it possible for close collaboration with the RN-CEO. The practice of alternating appointment of practicing physicians in the medical and surgical specialties as president further strengthened the performance of the team by ensuring that both perspectives were always represented and by creating a broader base for understanding practice subtleties. Physicians with hospital- and procedure-based practices were not considered for these roles, with the intent of keeping the focus of a community practitioner at the helm of the medical staff. Physicians in leadership roles had dedicated hospital office hours and the hospital provided an administrative assistant to support them. Physician leaders covered for one another and were available to the RN-CEO when consultation or collaborative actions were necessary. A true partnership developed between the medical staff leaders and me. We came to more clearly understand our respective selfinterests. Together, we shaped a common mission that we were each willing and able to see our self-interest served by. Each leading from where we were, others, to achieve that common mission. We lent our credibility and our voice to the achievement of a common purpose. We came to understand and respect the sacrifices of the other for the privilege of serving the common good. We developed genuine respect for knowledge and skills expressed through decisions to lead or follow one (rotating primus) another depending on the skill or connection needed to accomplish work. We agreed to disagree openly (in private) and share confidential information that others would believe perhaps too trusting. Together, we sought the best direction and ways to support it from our positions of influence. All of this happened across a 7-year period without a chief medical officer, with a voluntary medical staff of 1100 physicians with physician peers electing their officers. Together, we developed ways of preparing physician leaders for successively more responsible roles. With rare exception, we met weekly to do the following: • Discuss all that we were facing • Discuss what was known and unknown • Seek advice • Provide perspective • Benefit from a sounding board • Set priorities and strategize • Create a platform to view the hospital as a “whole” organization • Consider the intricacies of work interdependence OUTCOMES ACHIEVED Many important outcomes were achieved from 2000 to 2007, and those attributable to the relational model of servant leadership are summarized in Table 3. Three outcomes required consistent and diligent efforts throughout the hospital and were external measures of the hospital’s recovery and improved performance: • Conditional accreditation was replaced with a full 3-year accreditation in 2001. • Joint Commission on Accreditation of Healthcare Organizations Ernest Amory Codman Award recipient in 2005 for excellence in the use of outcome measurements to improve the quality and safety of care. • Named a Thomson Reuters 100 Top Hospitals Performance Improvement Leaders in 2007 (recognizing year-over-year improvement in 8 quality and financial indicators from 2002 to 2006). Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 74 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2012 Table 3. Significant Outcomes Achieved, 2000-2007, at Shady Grove Adventist Hospital Conditional accreditation replaced with a full 3-year accreditation, 2001. Joint Commission on Accreditation of Healthcare Organizations Ernest Amory Codman Award recipient for excellence in use of outcome measurements to improve the quality and safety of care, 2005 Thomson Reuters 100 Top Hospitals Performance Improvement Leaders award recipient, 2007 (recognizing performance over 5-year period 2002-2006) Launched a hospital operating board (first to be established at the hospital), which included significant physician representation Improved the hospital’s profitability from a 2.3% net loss margin in 2000 to a sustained average net margin of 4% for 2003-2005 Strengthened throughput processes across the hospital producing a significant and sustained reduction in hospital and emergency department average length of stay (ALOS), patient boarding, and ambulance diversions, as well as improving patient satisfaction Raised more than $13 million of voluntary contributions toward the hospital expansion project, with top 4 lead gifts and nearly $5 million contributed by medical staff Negotiated the first hospital-physician joint venture at Shady Grove Adventist Hospital to establish a community-based imaging center located adjacent to the freestanding emergency center Facilitated a shared interventional lab model, including development of comparable privileging requirements across clinical specialties Strengthened roles of voluntary medical staff leadership and developed process for leadership succession resulting in effective leadership of medical staff and interface with administration Implemented hospital-based physician practices utilizing a private practice model with a dramatic impact on quality of care and ALOS, including Intensive care unit intensivists, 2004; Medical hospitalists, 2004; Obstetrics hospitalists, 2005; and Surgical hospitalists, 2006. Collaborated with physicians to craft sustainable solutions by surgical specialty responsive to call burden, increasing physician discretionary time Steadily grew admissions despite space constraints by maximizing use of clinical space by time of day The hospital has continued to perform well since then. Trust was reborn, grew, and has continued to be cultivated by the executive leadership, medical staff, and hospital staff. The hospital was healed from the inside out and, thankfully, the community, though shaken, continued to seek care at the hospital. The story has a happy ending, which is really a wonderful new beginning. The adversity and pain of the NCV and all the chaos that followed it will always be a part of the SGAH story. And that is something to be celebrated. For, as long as the story is remembered, the hospital will never grow complacent again. Adversity can be a blessing when it breaks us open, and we do the hard work of regaining our health. We never take it for granted again. We are diligent and always seeking ways to improve. The physicians and staff have grown through the process and have a vision for the future of the hospital that continues to be informed by their experience and their dreams. The health of the hospital is no longer leader dependent but rather is shepherded by the people of the whole hospital. LESSONS LEARNED The 4 intervening years since I left SGAH have offered me distance and opportunity to reflect on the experience and compare it with prior and subsequent experiences. Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Betrayed Trust 75 Furthermore, I have been able to contrast that experience with my later experience as CEO at another hospital following an NCV. In many ways, the hospitals and communities are very different but conditions leading up to theNCV are alarmingly similar. In this article, we have examined the experience of one RN-CEO partnering with medical staff to lead a hospital beyond an NCV to recovery and notable performance. It is hoped that description and exploration of this case will benefit other leaders as they work to heal hospitals from the inside out. Learning mined from this rich and rewarding experience is organized into 4 sections (to follow): broken trust, exposed; signs of trouble; building a new culture; and recovery of a hospital. Broken Trust, Exposed The CEO serves as proxy for the performance of a hospital. Leadership is not necessarily appreciated or recognized when a hospital is performing adequately or well. However, when performance declines to the point of poor outcomes, quality or financial, the CEO is held accountable. Leadership becomes the focal point for change when an organization is spiraling down. Following an NCV, when the leadership is publicly discredited, confidence is lost for that leader and by association for the entire organization. Regaining confidence takes several years of consistent performance and creation of trusting relationships inside the organization and within the community. When people experience a serious and extended betrayal of trust, they can become jaded and it is difficult to risk trusting again. People either leave or turn inside themselves, their departments, or disciplines. Silos develop or deepen as a mechanism for focusing on what people can do to survive. When the edges of individual work effort can no longer be pulled together by working harder, recognition of the futileness of the situation spreads. People grow weary of seeing the impact these conditions produce for patients and themselves and seek relief. Trust in leaders is completely fractured. A vote of no confidence by the medical staff can result. As independent contractors and people of influence within the hospital and the community, the medical staff are perceived as powerful and capable of calling for leadership accountability. An NCV represents a cry for help without consideration for unintended consequences that may and usually do result. The action is communicated to the board necessitating consideration and action in response. Sometime before, during, or after board consideration, the media and community become aware. Chaos follows that places additional stress on caregivers, in particular. Conditions actually worsen as the hospital comes under heightened scrutiny by patients and families receiving care, as well as public and regulatory agencies. Hospital staff and physicians are further distracted from their work by constant questioning and dealing with the emotional response of patients and families receiving care in a hospital under intense public and regulatory scrutiny. So, conditions grow worse for some period of timewhile the board comes to terms with the situation and what must be done to correct it. The board experiences its own level of stress and is called to accountability by the public. Signs of Trouble The situation can spin out of control when an NCV signals that a change in leadership is required. But even more difficulty comes as the process plays out. Hospital staff and physicians describe signs and symptoms of distress 6 to 10 years prior to an NCV. The decline is insidious and can go unrecognized despite early warning signs including the following: • Declines in collaboration and increases in unresolved conflict among and between hospital staff, departments, medical staff, and administration • Efforts by staff and/or nurses to unionize • Increases in staff turnover • Increases in frequency and severity of errors, near misses, and sentinel events • Declining financial performance Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 76 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2012 • Incomplete, disconnected, or absent work processes • Frequent changes in reporting relationships • Key leadership positions vacant or moved to system level • No or low leadership presence on the site • Poor leadership relationship with staff and physicians • General unrest in the hospital • Presence of oppressed group (victim) behaviors Any of these signs when considered in isolation may not prompt action. Hospital boards need to have processes in place to regularly assess the health of relationships in the hospital. Identifying early symptoms that forecast a path to ill health can result in earlier intervention. What combination of these signs will produce a tipping point? Like a divorce, people are sometimes not aware of trouble in the relationship until one partner suddenly leaves. In retrospect and with assistance, people can usually recognize that therewere signs of trouble brewing that went unnoticed until there was a crisis. An NCV plays out in a similar fashion. For some reason, the signs that eventually add up to a huge outcry go unnoticed and that is the problem. Hospitals are often distracted from their mission of service by contentious, we-they relationships at every level of the organization. This is especially true in hospitals experiencing an NCV. From the bedside to infinity (the board, the community, and everywhere in between), trust is the currency of relationship. Without authentic relationships, we engage in endless permutations of we-they oppositions. These ego-bound behaviors cloud our vision of one another and the work that calls us to be our best selves, to blend our efforts, and to serve a mission we hold in common. Wethey conversations in the hospital signal the presence of dysfunctional relationships. Blaming behaviors serve to further distract people from their work, use precious finite emotional resources, and add to the chaos already erupting. The time between communication of the NCV and selection of a new leader can be protracted. Interim leadership is usually in place for 3 to 9 months and consultants may be engaged to begin work. When the new CEO is appointed, work priorities and methods shift on the basis of the new leaders assessment. The intervening months are very challenging for the hospital staff and physicians and they are weary and often further distressed. The NCV signals a breaking point, yet the action does not bring immediate relief. In fact, intense public scrutiny and fear create significant and protracted distractions for those providing patient care. The 2 sentinel events reported in The Washington Post were no more significant in number or severity than those that occur in other hospitals. So, why was SGAH brought under such scrutiny? I believe it resulted from the meaning ascribed to the events. People assumed that these events were a symptom of a more serious condition. In fact, as a result of the conditions over a period of likely 6 to 8 years, processes and systems had become broken or were missing altogether. As problems were identified and studied, the pattern was evident. Much of the work required to improve conditions and outcomes at the hospital was focused on the detailed redesign or connection of steps in key processes. Building a New Culture Transparency is an antidote for betrayal. But how do you get people to be willing to trust again? It is really all about relationship. You begin where you are. And that means being present with people and listening to their stories. It really would not matterwhat you say as a leader, when relationships are so broken, people will only believe what you do. Fortunately, the remedy is the opposite behavior to that which caused the injury, in every moment of every relationship. The most important overarching requirement for the new leader is to be trustworthy and to be vulnerable and transparent. The leader must be willing to be held accountable, as well as hold others Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Betrayed Trust 77 accountable, and admit, even draw attention to, their own mistakes. She must value the contributions of all and lead from an attitude of equality. Shady Grove Adventist Hospital, a hospital once suspected of covering up wrong doing, became known for its transparency. Such transparency had actually brought additional scrutiny and criticism of the hospital in the beginning but gradually rebuilt public trust. People did not expect perfect performance, understanding that we were human. However, they did expect accountability and that behavior when consistently practiced built confidence and trust. We encouraged people to do their best work, to report any shortfalls, to learn from mistakes, and to focus forward. In a sense, then, the adversity that the hospital experienced strengthened the character of the collective called a hospital. We learned to welcome onlookers, to value their fresheyes, and to see them as a part of our team. We genuinely welcomed feedback. A culture that had once been based on pride and grew to become complacent morphed through the experience of adversity to become a culture never satisfied with its performance, always seeking improvement. A test of relevance to the mission can be made by asking people in the hospital, “Who is involved in patient care?” This question unlocks thinking about individual work within silos and helps people to understand that the relevance of their work comes from those served. Everyone in a hospital is either delivering care or supporting someone who delivers care. Any remaining roles are not needed, as the roles have no relevance to the core mission. This realization can break people out of silos and move them toward embracing the interdependency needed for organizational health and effectiveness. Furthermore, recognition of a single-purpose (mission) and the desire to better serve it go a long way to encourage people to risk another disappointment. When there has been a betrayal of trust in relationships, action or words are assigned meaning on the basis of the filter of past experience. This makes the job of a new leader very difficult. They have knowledge about the broken relationships but do not know what behaviors connect and cause people to flashback to that experience. Therefore, it is important for the new leader to listen, to understand, and to create opportunities to debrief with trusted allies who know the organization and its history. The new leader must model the gifting of trust. When we have experienced betrayal, to trust again, we must first be willing to gift trust and risk disappointment. Our past experiences should inform our future and not limit what is possible. The CEO is held accountable for the work conditions—and should in fact author the culture, as well as live and model it. In my view, this is the single work that must be performed exclusively by the CEO. All other work can be delegated, with the understanding that the CEO retains responsibility and must hold others accountable. The culture when shaped and lived well makes everything else more possible. Care delivery relies on strong and deep currents of culture in a hospital. But this is not work accomplished easily or quickly, especially after an NCV. The CEO must effectively partner with others and live the culture she wants to author. Especially after an NCV, the CEO must author the culture and live it in all her relationships, consistently. People only truly believe what they see. The CEO cannot be in direct relationship with every individual in a complex organization. So, in this way, she can meaningfully shape culture in the hospital by being faithful in the development of her direct relationships. As she creates trusting relationships, the impact ripples out through those people she touches and the people they have relationships with, like a stone thrown in a pond. But culture is sometimes regarded as soft work, not measurable, not connected enough to the bottom line of the hospital. In truth, it is the work that really matters in the ultimate outcome of patient care. We need to rewire our human systems. Culture is the process of changing everyone from the inside out. Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 78 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2012 Corollary to electronic medical record (EMR) development and implementation, culture work requires a common language, engagement, and empowerment of all relevant to the work. Servant leaders canmake amazing contributions to the life of an organization by setting the conditions where people own their work and lead fromwherever they are. The heritage of successfully blending efforts in service of a commonmission is a rich blessing to each subsequent leader. The work of a hospital should not be about the egos of its leaders but rather rooted in the work itself. Culture work cannot be accomplished in a mechanistic way. However, there seems to be more willingness to commit time and money to EMR-like work than to building healthy organizational cultures. That is, until a hospital is broken. Then, time and money are found. But great harm falls upon those served and those serving in the meantime. This is unnecessary suffering. After an NCV, a hospital needs, in effect, a hard reset. We need to wipe filters clean and start again with clear expectations about what we expect andwill honor. Changes must stand the test of time and live beyond the leader. Culture must eventually be upheld by the generations of people who work in that hospital and live in that community. Executives are transient by the nature of their career path with few exceptions of individuals who ascend the hierarchy in a single organization. Recovery of a Hospital Turnaround is a word that has more of a financial connotation and suggests that we are striving to return to a previous place. However, organizations, like people, can never return to a previous state. Recovery is a better word to describe the process a hospital must go through to rebirth trust and restore credibility within the hospital and with the community. Experiences shape us and remain a part of our history. Adversity leaves scars and the stories follow the hospital into the future. But recovery brings the blessing of truly appreciating health, and the complacency that allowed such decline is recognized. So, the trouble that almost cost the hospital its life, in the end, saves it and changes it for good. Leadership must understand this and appreciate the value of this learned experience to the ongoing health of the hospital. People are resilient, especially when they experience transparency and vulnerability in leadership, and are invited to authentic engagement in a worthy work. At SGAH, we worked hard to create an environment where all were valued and encouraged to learn from errors and to constantly seek ways to improve and strengthen processes. We were not perfect, but we were striving continually to improve and to better serve our patients. People were initially angry, fearful, and disengaged. But gradually they accepted that we would always be closely scrutinized as a result of being so publicly discredited. We pledged our best and continually sought ways to evaluate and strengthen results. Living that commitment in every moment of care every day made the difference. During the recovery of a broken hospital, a RN-CEO is uniquely prepared to prioritize and lead change efforts. As an example, at SGAH an intensive care unit nurse was suspected of hastening the deaths of patients under her care. That suspicion was shared directly with family members in their homes by the RNCEO. She shared what was known and not known and pledged the hospital’s commitment to work with authorities to discover the truth and to remain available to the families. This was a valuable use of nursing knowledge and presence that made a huge difference for all involved in a very visible test of the hospital’s recovery. RN-CEOs’ know the implications of sentinel events and near misses and can experience greater stress as a result. They really know what it means to patients, families, doctors, nurses, all who stand close to the action. Like being on the frontline in a war, knowing the people, the circumstances, and seeing the casualties you cannot prevent creates suffering. RN-CEOs understand that rapid change in a large organization is really snail pace in Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Betrayed Trust 79 human terms. That patients and staff will be in harm’s way, until needed change is accomplished. In this way, RN-CEOs’ experience the suffering of direct care providers. Although this knowledge helps a leader better support the caregivers, it is a burden to know the impact on patients and staff in the meantime. Changing a policy or system may take weeks or months to make a decision and longer to effectively implement. The knowledge scale is larger for the RN-CEO since she lives at the epicenter of all that is found to be lacking or wrong with the hospital. Perceived as the most powerful by position, the RN-CEO can do almost nothing single-handed. A bedside nurse has more power over a patient’s care, in a moment, than the CEO. So, to do the best for patients, the RN-CEO must diligently work to create the conditions (culture) where a nurse, physician, or staff member can make the difference that is needed. As clinical leaders, the RN-CEO andmedical staff president of SGAH shone a unifying light on patient care and positioned themselves as servant leaders. In the moments of care, in the office, in public, in private, and in board meetings, the message and actions were the same, choosing common (patients and their families) interest over self (personal or corporate) interest. They were faith-full day in and out over a period of years despite changes in elected leadership roles. In fact, great effort was put intomedical staff succession planning and preparation. Each leader brought different talents and characteristics that were beneficial, and the team blended and supported efforts so that work continued forward. As RN-CEO, I most of all valued the honest and direct feedback I received from the physicians who held office during my tenure at SGAH. I could count on them for the truth, something that is hard to come by as you move up the organizational hierarchy. My commitment to them was the same even if the truth was “I don’t know”; they knew they could count on a response. I learned that individual medical staff members represent a perspective, not one another, and that it was important to have different types of medical staff involved, for example, medical, surgical, hospital-based, procedure-based, and community. The realities of their practices and concerns were dramatically different and I came to understand the important nuances. I appreciated the respectful attitude they displayed toward one another, regardless of specialty, group affiliation, or position on an issue. Of course, there were exceptions as there are in any group of people. I learned new compassion for even the most difficult physicians. I found that in partnership, the medical staff leaders and hospital leadership could create expectations for performance and hold accountable all people who served or supported patients. As the RN-CEO, I experienced something unique and life-changing at SGAH. It was the most difficult and rewarding experience of my career. In fact, I view the recovery of SGAH as my opus, my most important work. If I had to identify one aspect of that experience that made the recovery of the hospital possible, I would point to the medical staff leaders who had the courage to call for needed change and their willingness to keep a commitment to a first-time CEO, to participate in a leadership experiment, and to stay the course through incredibly difficult times. Recently, I read Robert Greenleaf’s second essay again. Thewords literally jumped off the page as though I had the benefit of 3-D technology, the meaning was deeper and richer. His words had not changed but I have. I last read the essay near the time I accepted the position at SGAH. I had written in the margin “try this at Shady Grove” next to the description of primus as an alternative to the traditional hierarchal leadership model. At the time, his message spoke to my heart as a clinician and as a leader. I had a theoretical construct to shape my thinking and I shared it with the medical staff leaders as we began our work. But what evolved as we lay down the path together is a hybrid of the primus Greenleaf envisioned. His model describes fully capable peers. Our collaboration took more trust, since neither physicians nor executives fully comprehend the other’s role. Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 80 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2012 Greenleaf’s words have deeper and richer meaning for me now that I have experienced the miracle of SGAH’s recovery. Our blend of servant leadership made all the difference for a community and its hospital. ADVICE FOR NURSE LEADERS My advice to nurses seeking executive leadership roles is to stay focused on the mission, serving patients and families. Consistently approach your work from the patient and the point of care outward. Always do the best work you can in your current job and trust that opportunity will come as a result. Have the courage to take on new responsibilities as opportunities arise. Use your clinical knowledge to understand human behavior and remember that the organization is a collection of people and therefore has the qualities of living organisms. Remember that peoplewill always givemore of themselves willingly than we could ever require of them, if aligned around a common mission or vision. The most powerful principle is that people are people, including and especially, physicians. Make peace with medical staff colleagues. Practice compassion for difficulties inherent in every role. Be a person of the whole organization. Regardless of how your responsibilities are divided or assigned, always consider the whole organization as your responsibility. Let go of the need to control, instead trust the process and the wisdom that resides in the whole organization. Ask questions and listen to understand. Language matters, so refine your use of language to connect with others and promote healing in every relationship. Leverage your knowledge of clinical language. Like a person, raised to think in and understand a language in their formative years, nurses are fluent in clinical language. Nurses in hospital executive roles do not need others to translate clinical language or subtleties and can more easily and quickly identify leverage points for change as well as intentional deflections and distractions off point. With proper progression of experience, nurses can develop a keen understanding of interdependencies among the disciplines and departments. People do not relate to buildings but rather to other people. Be the face of your department or organization and live the culture you want to grow. Keep your priorities clear, attend to both quality care and financial viability, but remember only one necessarily leads to the other. Quality care and financial viability are married. You cannot have one without the other. And the success for both hinges on which you put first. Quality care requires financial viability, and long-term financial viability is not possible in a hospital without quality care. Remember that people are drawn to a mission of service and must make a living to prosper. People can embrace the connection, but placing mission and care of one another first matters. People will sacrifice for patients and each other, and for financial viability, only when its relevance is connected to mission. When the patient is consistently at the center of our work, there can be no sides and our self-interests are subordinated. REFERENCE 1. Greenleaf RK. Servant Leadership: A Journey Into the Nature of Legitimate Power and Greatness. 25th anniversary ed. Mahwah, NJ: Paulist Press; 2002. Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.