BY: ANDREA COLEMAN, FACHE
In organizations with the power to persist through turbulent eras, one finds leaders who live as if they were stewards of a legacy — the culture, mission, and founding spirit of the organization. These legacy leaders may be physicians, administrators, chief executives, or board members, but they all have the ability to weave a thread of constancy through times of peril.
Five attributes characterize legacy leaders: Their work is a vocation, they possess a moral code, they are committed to stewardship, they have a bias for building, and they instill hope. Legacy leaders stay with one organization a very long time, patiently removing obstacles to worthy accomplishments.
Because the profession of healthcare is at heart a vocation, not a business, we must pay attention to the kinds of leaders we place in our healthcare institutions. To carry out their responsibility of transforming healthcare delivery, boards of directors must hire legacy leaders, manage their business focus, carefully evaluate executives, enhance mechanisms for board evaluation, and raise the bar for decision making.
When I began as a young manager in healthcare, 20 years ago, managed care was yet to come, President Carter's cost caps were considered a grave crisis, and governing bodies were just beginning to implement strategic planning. That era now looks like a golden age of healthcare compared to the present, but there were ample challenges and struggles: resolving conflicts between boards of trustees and doctors, developing primary and ambulatory care, and pioneering the first multi-institutional systems.
Today's challenges are different. A deep anxiety afflicts healthcare institutions as economic forces drive buy-outs, mergers, and acquisitions. In many cases of realignment, a chasm develops between stakeholders in the organization: trustees, managers, employers, physicians, and the community. The original transcendent purpose of the organization — its mission — may be lost.
In organizations with a power to persist through turbulent eras, one finds leaders who live as if they are stewards of a legacy — the culture, mission, and spirit of the founders that permeates the organization in the present. In healthcare, these legacy leaders may be physicians, administrators, chief executives, or board members. They may be long-term department managers or key employees, but they have one characteristic in common: They weave a thread of constancy through times of peril. This article describes characteristics of legacy leaders, and the loss we face if we do not demand this kind of leader at the helm, in the boardroom and on our management teams.
Characteristics of Legacy Leaders
Five attributes characterize legacy leaders.
Their Work Is a Vocation Legacy leaders often unconsciously develop a central theme in their lives for many years before they recognize it. As a leader becomes aware of a purpose that resonates for her, this deepening conviction will make her leadership have increasing impact.
But having a defining purpose in one's life is not sufficient in itself. A leader's purpose must be transcendent; it must elevate others to become more than they are and inspire them to sacrifice for the common good. That defining purpose must also be accompanied by constancy of purpose. A leader who is mercurial, or who embraces the fleeting over the enduring, will have a utilitarian value for an organization at certain moments in its history. However, such a leader is not likely to leave a legacy.
They Possess a Moral Code A legacy leader possesses a personal moral code which, over time, will dominate the organization's moral behavior. The leader's moral code will be reflected throughout the organization, from thoughtful and informed decision making, to the development of reliable, respectful relationships with the medical staff, to an obsessive attention to quality and service to customers.
The leader's moral code breathes life into the institutional mission, and if it is inconsistent with the stated enterprise purpose, the latter will erode. Eventually, the organization will become morally bankrupt.
A legacy leader's behavior is rightly centered on correct decision making. However, his or her personal behavior, and the work of making decisions with and through others, are centered in respect for the individual. Ultimately, the moral purpose of the organization is embodied in the daily behavior of the leader. The leader who leaves a legacy derives personal and professional satisfaction from relationships with individuals, in balance with satisfaction with results.
Legacy leaders have private and public integrity. Few of them use depersonalized language — "volumes" rather than patients, "markets" rather than communities, and "workforce" rather than employees. The constant presence of depersonalized business language in an organization that has a mission other than returning shareholder value is a cardinal sign that the mission is no longer the raison d'etre of the leaders.
They Are Committed to Stewardship Legacy leaders understand the nature of not-for-profit institutions within a community and respect the covenant inherent in their tax exemption for the social good. They understand that tax-exempt status is not so much a business proposition as it is a legacy from past citizens, who founded the mission. Therefore the leader is the current steward of a concept crafted by individuals who were dedicated to community well-being. The legacy leader uses this stewardship to inspire stakeholders with a sense of unchanging purpose. Legacy leaders reach for inspiration, articulate the purpose and meaning of the work of the organization, and, in doing so, elevate the values and behaviors of others.
They Have a Bias for Building Legacy leaders are generally builders, and their building may manifest itself in physical facilities or in defining a new system of care that improves on the old. It may show itself as a new capacity in the organization that will enable it to survive — perhaps a new core competency. Because the work of transforming large institutions is long and arduous, legacy leaders stay with one organization a long time, patiently removing obstacles to worthy accomplishments. I am reminded of the legacy leaders in healthcare who are quietly building the new fundamentals of tomorrow's performance, amidst an industry mindset that is aglow over "focused factories" and is bearish on the value of integrating care. A few leaders will persist and design a system of care that will replace the discontinuous, fragmented, and idiosyncratic care system we have today.
They Instill Hope Legacy leaders instill hope and optimism. Hope is always a transcendent element of hard-won victories. Leaders with hope refuse to give up on solving apparently unsolvable conflicts and refuse to settle for short-term success. It is more than vision, which, while necessary, is not quite the language of motivation. It is vision with a "why," or purpose, attached. Those who nurture hope nurture dreams, and these leaders nurture the development of individuals to uncommon accomplishments.
A Broken Institution
Why must we consider anew the kinds of leaders we are placing at the helms of our healthcare organizations, HMOs, hospitals, systems, and physician settings? First, because the profession of healthcare is at heart a vocation, not a business. From earliest times, healing has been one of the most revered roles in human society. It encompasses covenantal relationships between healers and patients, and, more recently, between health institutions and communities. The foundation of tax exemption for hospitals and other charitable bodies is the confidence that those organizations will be good and do good, first and foremost.
Today, it is fair to say that the profession of healing is tarnished, and the public's faith in institutions of healing is gone. The relentless lobbying of industries for their members' interests rather than for those of patients, the outrageously high salaries of some HMO executives, and the replacement of mission language with business language in the conference rooms have eroded faith in the profession of healing and the organizations that provide it. This is why we need leaders, including trustees, who can exercise restraint, hold a steady course, pursue vision with conscience, and refuse to alter core values even as they pursue necessary transformation.
Second, the pressures of the environment in many communities have pitted institution against institution, revealing the unpleasant machinations of corporate warfare to increasingly wider audiences. An obsession with business results has replaced discussion of people served and institutional mission. However, good business practices and efficient financial performance are not the problem. Few would argue that a margin is needed to sustain a mission. It is the subtle loss of the reinforcement of core purpose that is problematic. When the business of the enterprise dominates all discussion, in a remarkably quick time many others will perceive that business is the mission. Implicit values will erode, affecting patients, physicians, employees, and, ultimately, the organization. As an example, a challenge to tax-exempt status is a clear signal that civic leaders no longer have faith in the covenant underlying the not-for-profit mission, but believe the institution has primarily a business purpose.
Third, our work is unfinished. In the future, the American hospital enterprise will be looked on as a significant organizational achievement in the history of medicine, evolving complex operations to organize the ever more complex discoveries in contemporary medicine. But our crumbling cities, the ranks of the poor, a population that overindulges in unhealthy behaviors, the victims of HIV, and the millions of children without healthcare remind us that the work of healing is unfinished. Ultimately, we must have leaders who have a calling to address the next generation of health problems, who at their core want to improve community life.
We do not need more business leaders. Instead, trustees must find and retain talented and gifted individuals who bring their souls into their work, whose achievements are due to their calling to do good and their leadership qualities. The delivery of healthcare cannot be separated from moral purpose; none of us would want to get our healthcare from such a system.
The Role of Governance
The board of directors has the ultimate moral and legal responsibility for its trust; it governs on behalf of those served. The board selects leaders, reinforces core values, and must itself demonstrate values that promote legacy leadership. If trustees are to transform health delivery without losing the soul of the profession, they must follow five steps.
- Hire a legacy leader. Avoid individuals on their way to other places, who do not indicate a desire to remain in a community for a long time. Look for patterns in individuals' backgrounds that suggest frequent changes in role, and look for achievements that took more than three years to accomplish.
- Manage the business focus of the board. Often a board is dominated by business leaders. Their expertise is needed and valuable. However, a lack of board training or reinforcement of mission accomplishments can unintentionally reinforce an emphasis on fiscal results alone. Chief executives understand who their "boss" is; if fiscal results are all the trustees value, mission purpose will erode.
- Evaluate the leader correctly. Does periodic evaluation of the chief executive measure only achievement of annual objectives, or does it also measure progress on large-scale and long-term achievements? The transformational work required of chief executives and their teams to redesign the healthcare system cannot be completed in 12 months. Instead ask: "What truly consequential achievements has this chief executive envisioned, and what progress is occurring that indicates we will leave a legacy for the future?"
- Enhance board evaluation. Does the system for measuring board effectiveness include measures of mission effectiveness? Does the board fully appreciate the depth of mission expression in the organization, through people, programs, and service delivery? How can the board institute a mission effectiveness system, in concert with the chief executive, which assures that core values, policies, and behaviors are a constant in the organization, regardless of organizational challenges and transformation?
A balanced scorecard approach, which has measures of employee knowledge of mission, the quality of physician and caregiver relationships, and the presence of staff commitment as well as fiscal integrity, is essential. One faith-based organization for which I worked always included in its annual employee satisfaction survey the following question: "How well do you know our mission?" followed by "How important is this mission to your work?" Ninety-five percent of employees (90 percent of whom did not share the organization's religious orientation) routinely responded positively to both questions. These two questions were viewed as important benchmarks in the organization.
- Raise the bar for decision making. When proposals and plans are brought before the board, trustees' analysis must include a thorough consideration of their possible effects on mission, any attendant ethical issues, and the effects on marginalized patients or employees.
Ms. Coleman is vice president, Community Health Improvement and System Integration, Inova Health System, Falls Church, VA.
LEAVING A LEGACY
A venerated administrator retired after more than 15 years at the helm of her hospital. She had been an activist administrator and a determined protector of the institution. She led the organization through times of too little cash, when gifts of food from area farmers were frugally used to make the evenings' dessert for the patients. When I arrived, to my surprise, I found her, in her retirement, working in the laundry. She folded sheets and pillowcases for four hours every day. Not surprisingly, we had an excellent laundry, with long-term employees who understood that they were essential to the mission of the organization. Through her example, she ennobled the work of every employee, many of whom performed the unglamorous, yet necessary, tasks associated with patient care.
The entire organization reflected the impact of this leader. Her legacy was evident in the high level of employee satisfaction, mission effectiveness, community support, and exceptional quality and service for which this organization was known.
Copyright © 1998 by the Catholic Health Association of the United States
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