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If you were to identify one key element that led to the dysfunction of the organization. What would it be and why?

If you were to identify one key element that led to the dysfunction of the organization. What would it be and why?.

If you were to identify one key element that led to the dysfunction of the organization. What would it be and why?

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
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.
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.
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
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
• 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
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
• 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.
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.
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
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
• Applying learning from the prior
• 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.
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.
Table 1. Leadership Behaviors to Rebirth
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
• 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.
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.
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
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.
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
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
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
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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
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).
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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
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.
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.
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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
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
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
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• 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
• 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
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
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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.
Corollary to electronic medical record (EMR)
development and implementation, culture
work requires a common language, engagement,
and empowerment of all relevant to the
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
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
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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
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.
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.
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
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.
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.




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If you were to identify one key element that led to the dysfunction of the organization. What would it be and why?


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