Staying Power: How CEOs Can Lead Through Uncertainty

Translating big-picture long-term strategies into day-to-day processes that point toward success requires CEOs who recognize the humanity of the workforces they lead.

This article appears in the July/August 2019 edition of HealthLeaders magazine.

How a CEO handles the tension between long-term strategies and nearer-term needs will determine whether that CEO succeeds in implementing solutions that stick.

Those who stare too intently at the horizon may lose their footing as the landscape shifts. Those who focus exclusively on day-to-day tasks risk having their accomplishments rendered obsolete by the industry's constant churn. The CEO with staying power, however, imagines a future that might be, enacts a concrete plan to get there, and readjusts as circumstances change.

That means defining an inspiring big-picture strategy, one that's rooted in the healthcare industry's present realities but anticipates what's to come. It means driving missional alignment around that strategy, so the people and processes at every level of the organization are oriented around the vision. And it means investing in the organization's culture, so stakeholders know their contributions are valued.

One executive who is well-acquainted with this complex balancing act has been a familiar face at Yale New Haven Health in Connecticut for the past four decades. Marna P. Borgstrom, MPH, joined the organization in 1979 as a junior administrator for Yale New Haven Hospital, climbing the ranks from a post-graduate fellowship through staff and management posts that led her ultimately to the C-suite overseeing an academic health system with more than $5 billion in annual revenue. Borgstrom has been CEO of both the hospital and health system since 2005.

Rising to the top executive spot from within an organization means the people you work with will remember your successes and shortcomings alike. But internal promotion also comes with a more intimate appreciation for how the C-suite's edicts ripple from top to bottom through an organization, Borgstrom says.

"It's really one thing to come up with an idea and a plan, and it's another to understand what it takes to execute it … especially in a large complex organization," she says. That's why the fundamental task of a CEO with staying power is to muster a team and set a direction.

"It helps immensely if you can get people to share your vision and to want to support it. Then you can do almost anything," Borgstrom says. "But if you haven't treated people well or you haven't engaged them, they can throw as much sand in the gears as they want and make it very difficult to do what you need to do."

Strategizing amid uncertainty
 

Yale New Haven Health announced a partnership five years ago with Dallas-based for-profit hospital operator Tenet Healthcare. The organizations said they would remain independent from one another but establish a comprehensive delivery network within Connecticut, with plans to expand regionally.

When she first suggested that such an esteemed nonprofit consider collaborating with a for-profit company, Borgstrom says she half-expected board members to balk.

"I was somewhat thinking that they might drum me out of the room and say, 'Have you lost your mind?' " she says. "They didn't do that."

As they talked through each organization's values and objectives, it became clear that Yale New Haven Health and Tenet had a lot in common, that the strategy made sense, and that their arrangement could enable the academic nonprofit to expand its influence without having to go on an extensive buying spree, Borgstrom says.

"You don't have to own everything to create a broader geographic footprint," she says.

Borgstrom rallied the board's support. But the proposed collaboration fell through anyway. Tenet backed out in 2015 under pressure from the demands of state officials.

"What got in the way were largely politics and regulatory overreach in the state of Connecticut," Borgstrom says. "We worked really hard on that for a year and a half or more, and the state just overreached—and Tenet did what they should have done, which is to say, 'Look, this could have been a great collaboration, but we're walking away.' "

Leading amid uncertainty requires a deep sense of humility

Had she pushed for the Tenet deal with absolute confidence and demanded there be no doubt in it as Yale New Haven Health's strategic path forward, then running into a dead end might have spelled trouble for Borgstrom's leadership standing within the organization.

By explicitly acknowledging her own limitations, however, Borgstrom leaves room to redirect and recalibrate as needed. After all, the CEO with staying power leads competently and confidently while tempering their messaging with a humble recognition that their capabilities and knowledge are finite.

"When I go out and share something, I share it with as much confidence as I can, but I also acknowledge that we're going to be right on some of it, and we're going to be wrong on some of it," she says. "The real power of leadership is the ability to be introspective and flexible enough to go back and correct what's not on track and to ask for help."

That's not just true on a deal-by-deal basis. It's true for the healthcare industry as a whole, which is transforming through a combination of market dynamics and regulation into an end product that is not yet clear, Borgstrom says.

"What's really hard for all of us right now is to develop plans and strategies to go where we think healthcare should go but to recognize that we have to do that successfully in the context of the current business model," she says.

Although it remains unclear precisely how Yale New Haven Health will be paid five years from now, Borgstrom says the organization is guided by a value strategy that expects to succeed based on improving quality, safety, and patient experience, plus increasing efficiency.

Steve Narang, MD, CEO of Banner–University Medical Center in Phoenix, says tolerating failure and maintaining high standards are not mutually exclusive. The two ideals must be modeled, he says, from the top of the organization. That means CEOs must remain vulnerable and acknowledge their mistakes. (Update: Narang became president of Inova Fairfax Medical Campus in Falls Church, Virginia, in July.)

"Frankly, there's strength in being wrong," Narang says, "because that is probably going to spark questions that will get us to a right answer."

Leading amid uncertainty requires constant cross-silo communication

Before taking the CEO job at Banner–UMC in 2013, Narang was chief medical officer for a children's hospital in the Banner Health system. Narang says his job as CMO was to translate clinical care needs for his nonclinician colleagues in the C-suite.

"One of the reasons I took the leap from the bedside to leadership was I was very passionately focused on finding value at the intersection of clinical care, finance, and operations," he says. "I felt like healthcare had created artificial siloes."

"My focus wasn't to stay in one swim lane," he adds. "I felt like, as chief medical officer, my job was to navigate those three swim lanes, so the patients experienced high-value and compassionate care."

His paradigm as a CEO has been essentially the same as it was when he was CMO, he says.

"I don't look at it as a different title," he says. "That's what I do every day."

In this sense, the CEO with staying power constantly communicates each stakeholder group's evolving needs and expectations to the other groups, so everyone can see how their work intersects with the overarching strategy.

To keep himself focused on long-term strategic goals without losing sight of more immediate needs, Narang adopted what he calls "a 5:2 model," which he picked up decades ago from a fellow physician leader. The tactic calls for Narang to identify five longer-term "transformational" objectives for the coming one to three years and two shorter-term objectives to tackle in the next one to three months. He posts them on his desk, where he and his close team members see them every day.

"This 5:2 mantra, I think, keeps my team balanced and, personally for me, it keeps me specifically focusing on what I can control," Narang says.

Leading amid uncertainty requires a value-based compass

While other markets may be farther along the road to value-based care, Narang says providers in the Phoenix market are still generally competing for inpatient commercial volumes in a decidedly fee-for-service model.

"I call that a 'red ocean,' " he says, likening healthcare providers to sharks that circle when there's blood in the water.

"When you really think about it, what's the value equation in that model?" he adds. "Who's actually winning in that model?"

Narang says he and Banner Health—which enjoys about 40% of the inpatient market share in Arizona's most populous area, Maricopa County—are not terribly fond of this "red ocean" approach to competition. They would much prefer to navigate toward a "blue ocean" strategy that delivers greater value at a lower cost by coordinating care among hospitals and other care sites, with the helpful influence of academic medicine, he says. (The metaphorical ocean is blue in this case, Narang says, because there's not really anyone there yet, since there isn't a reliable source of value-based payment.)

"The only way to do that is to invest in infrastructure that today may not bring more market share or '
margin,' " Narang says.

If healthcare organizations are like ships at sea, then the CEO with staying power is one who steers confidently toward a destination port that's still under construction, relying on a value-based compass to guide every course correction even before a return on investment is proven.

That's why Banner partnered with the University of Arizona to restructure around its value-based mission. Rather than clustering around physician specialties, in 2015 the organization began rolling out institutes that specialize in particular conditions, such as diabetes. Thirteen such institutes have been launched thus far, says Narang, likening the structure to a complex startup environment.

"The institute structure essentially says we're going to organize our care around the condition of patients, not around the physician specialty, not providers, not insurance companies, but around patient conditions," he says. "And we're going to attract anybody who's excited about improving value for that condition to participate in the institute. You can be a physician. You can be a therapist. You can be a nurse. You can be someone in finance. But your focus is to improve value for that condition."

Partnering with key system leaders to integrate Banner's institutes with service lines across Maricopa County is one of the five longer-term objectives on Narang's 5:2 list.

Top-to-bottom alignment
 

John Nguyen, chief marketing officer for St. Louis–based SSM Health, hailed a taxi on his way home from the airport, making conversation with the driver, who asked where he worked.

"SSM Health," Nguyen told the driver.

"Oh, you're the guys that are buying up everything around town," the driver replied.

"No, we're not buying anything," Nguyen said, laughing as he recalls the conversation. "It's just the new signs."

Driving around the St. Louis area, it's increasingly tough to miss SSM Health's physical presence. The number of facilities prominently featuring the Catholic health system's name and logo has risen in the past few years, as part of a coordinated rebranding effort to make the organization's footprint in the community more consistent and apparent.

While there had been some merger and acquisition activity over the years contributing to the patchwork of brands belonging to SSM Health, most of those brands stemmed from the way the ministry was founded, Nguyen says. The Franciscan Sisters of Mary were itinerants who traveled wherever they saw a need, opened a new healthcare facility, and named it after significant historical figures, such as St. Francis or St. Mary.

With care delivery sites scattered across four states, SSM Health's various regions often acted independently of one another. That was the case until about five years ago, anyway, when the system's leaders decided to reconfigure it from a holding company to an operating company and realign each of the regions to report directly to SSM Health's centralized office as part of an effort to increase effectiveness and reduce waste, variation, and unnecessary duplication, Nguyen says.

"That was a very big change for the organization," he says, "and I'd be lying if I didn't say we're still on that path today."

The marketing and communications team consolidated its market research functions, condensed 70 separate websites into two, and brought about 300 distinct brands under the single SSM Health umbrella, Nguyen says. As the system linked its disparate components together in the minds of consumers, the public's unaided awareness of SSM Health's brand rose 34%, he says, citing custom research conducted by a third party.

This metric of unaided or "raw" awareness—in which respondents are presented with an open-ended prompt to name a health system and researchers count the number of times SSM Health is mentioned—is a good starting point for the system to track its progress. The next step, Nguyen says, is tracking how well that brand resonates with the public.

Missional alignment is a two-sided endeavor

Consistency in external brand identity clearly isn't the only type of alignment CEOs with staying power need. Internal consistency of process and mission are just as important. These external and internal initiatives can be two sides of the same coin, Nguyen says.

"A brand, more than just a campaign, is how we galvanize ourselves to that [mission] internally as well as externally and make sure that the experience is hardwired into the services we provide and to how our employees are positioned to do the work," he says.

As SSM Health conducted market research with the public, it asked its own employees what sets the system apart from others. Nguyen says researchers tested a variety of positioning statements both externally and internally and found one sentence, in particular, was positively received all around: "We get to know you better as a person, so we can treat you better as a patient."

That research, combined with a reflection on SSM Health's heritage and mission statement, led Nguyen's team to develop "The Healing Power of Presence," a unifying campaign designed to articulate and reinforce SSM Health's identity for employees and the public alike.

At its core, this type of messaging is about talking to people, understanding their lives and what they are trying to achieve, then boiling that down in a way that resonates with individuals, Nguyen says. If it doesn't reflect the reality of the health system, then it's meaningless, he notes.

"I can make a great campaign and put it out there, but unless there's some passion around that as an organization, that really doesn't mean anything," he says.

If you hope to align a large or complex organization with senior leadership's strategic vision, then you must communicate in a way that empowers managers to act as surrogates for the message. That's why SSM Health published a booklet by CEO Laura Kaiser outlining her vision, then followed it up with weekly communications from her reinforcing that strategy, Nguyen says.

SSM Health also rolled out a formal communications training module for all managers in 2017. The training teaches how communications flow through the health system, what the manager's role is in relaying messages to his or her team, and how to facilitate discussion and feedback, Nguyen says. The training includes a practicum component, so all managers know not only what tools are available but also how to use them.

There will always be some level of variation in a health system as big as SSM Health. The goal in communicating and reinforcing strategy throughout an organization is to get the big things right, so all team members can orient themselves around those priorities, Nguyen says.

"When it comes to communications, it's not the same as clinical practice," he says. "If there's a little gray area in the details, that's OK. We have to make sure the core messaging is right: How is this attached to our mission? Why are we doing this? Why is this better for people? Why is this better for the communities we serve? Why is this better for our organization?"

Alignment isn't just for large organizations

The need for missional alignment isn't unique to large health systems. Individual hospitals, too, can benefit from leaders who keep stakeholders laser-focused on big-picture long-term goals while they handle the day-to-day operations more quietly.

Lee Domanico is CEO of MarinHealth, which includes MarinHealth Medical Center (known until recently as Marin General Hospital) in Greenbrae, California. The hospital opened more than 60 years ago, then became part of a health system in the 1980s that merged in the 1990s with Sacramento-based Sutter Health. After years of controversy over who should pay to renovate the aging facility, Marin General Hospital regained its independence from Sutter in 2010.

The newly independent hospital needed to supplant the operations systems that Sutter had provided, and it had only about a week's worth of operating cash on hand when it broke off, so Domanico and his team spent nearly three years building public confidence in their mission, ultimately persuading taxpayers to pass a bond measure to pay for the new hospital.  

"While we were improving finances, stabilizing the organization, we had our eye on the long-term prize for us, which is opening a new hospital," Domanico says. "To do that, we not only had to stabilize financial performance because we were ultimately going to have to borrow for the long-term debt. We had to build public confidence because most stakeholders felt we weren't going to make it."

The key to building trust, both within an organization and with the public, is relatively straightforward, Domanico says.

"You tell people what you're going to do, and then you do it," he says. "Then you tell them again what you're going to do, and you're going to do it. And each time when you do what you said, a few more people will sort of believe, 'Well, OK, maybe this could really happen.' "

Cultivating a conducive culture
 

About a decade before his move to Marin General Hospital, Domanico took the reins at the Allegheny Health, Education, and Research Foundation (AHERF) in Philadelphia, which was trying to emerge from its $1.3 billion bankruptcy, one of the largest failures in nonprofit healthcare history.

Domanico knew when he arrived that AHERF personnel had taken pay cuts, that physicians had lost their research funds, and that the organization had been barraged with negative publicity. "And that all takes a toll on the psyche of the stakeholders, the physicians, the employees," he says.

"While we went through every line of the profit-and-loss statement to turn it around, what was needed was empathy and a recognition of what the people had been through," he adds. "We adopted a theme of 'Let the healing begin.' "

The CEO with staying power knows that even the most carefully crafted strategies with the proper processes in place will fail if the organizational culture has soured. That's why Domanico and his team fought on two fronts, both correcting the errors of their predecessors and absorbing the frustrations of those whom their predecessors harmed.

"While we were working on cutting overhead and all the technical aspects, we really had to give people a chance to vent—there was anger about what had happened—and really allow for the healing process culturally while we were technically doing what we needed to do to right the ship," he says.

Making a financial turnaround permanent requires that leaders identify and capitalize upon the organization's intrinsic advantage, Domanico says. But equally important is the need to build confidence among the organization's stakeholders and reinvigorate their belief in a better future.

"That's very nuanced and certainly very different from one organization to another," he says.

Beyond making stakeholders feel heard, leaders need to actually hear them. That's why Domanico's team rolled out a Studer Group–inspired assessment to track employee sentiment quantitatively over time. Tenet Healthcare acquired AHERF's entire Philadelphia operations in 1998. At first, the organization ranked near the bottom of Tenet's 11 regions, but it climbed toward the top within about two years, as stakeholders increasingly believed a turnaround was underway, Domanico says.

"While we were improving finances, stabilizing the organization, we had our eye on the long-term prize for us, which is opening a new hospital."

—Lee Domanico
 

Narang, at Banner–UMC, says his team asks employees six to eight questions on organizational culture in a survey every six months, such as "Do you feel inspired to work every day?" "Does your leader inspire you?" and "Does the culture make you want to work here a long time?" The hospital generally sees a response rate above 85%, he says.

Borgstrom says Yale New Haven Health similarly conducts a biannual employee engagement survey through Press Ganey, plus occasional "pulse surveys" in between.

Don't neglect qualitative feedback

While aligning team members around your strategy generally means communicating your vision to them, fostering a conducive culture should also entail soliciting stories from them.

The CEO with staying power doesn't settle for quantitative feedback alone but listens to employees' qualitative feedback as well. That can help to spark a problem-solving culture not only within the C-suite but at all levels of the organization. It tells stakeholders that their input is valuable and encourages them to identify shortcomings and propose solutions that might otherwise be tucked outside the CEO's line of sight. Borgstrom says Yale New Haven Health's hospitals and physician practice foundation host regular open forums. While workers might be a bit reserved at their first or second forum, she says they tend to open up more as the events become routine.

"Stories are very powerful," Borgstrom says. "When somebody is willing to speak up and describe something that was an issue or problematic for them or share [a success story], that's really powerful."

Yale New Haven Health has participated, furthermore, in a Barrett Values Centre survey of health system employees, as well as full-time faculty and community-based medical staff, says Borgstrom. The survey asked people about their own individual motivations, how well the organization aligns with the individual's values, what an organization would look like if it aligned with the individual's values, and what the gap looks like between Yale New Haven Health and that ideal system.

Researchers used the responses to give the C-suite a better sense for how well the status quo matches the workforce's values and how leaders might chart a path forward, a useful tool for healthcare executives seeking to lead through uncertainty. The fundamental task of a CEO with staying power, after all, is to muster a team and set a direction.

"If people's values are intuitively aligned with the organization's," Borgstrom says, "you're going to get more engagement, you're going to get more participation, you're going to get more innovation."