Being a CEO in healthcare is a roller coaster of shared highs, personal failures, and never-ending bad publicity.
Done right, these leaders rightfully distribute the credit for success among an army of compassionate and competent workers, and personally take responsibility for poor performance – which can literally be a matter of life and death. On the other hand, those leaders who take the selfish route, absorb all the credit and direct all the failure to others. The former tend to receive little attention while the latter get noticed, putting all healthcare CEOs – toxic and uplifting alike – in a negative light. Simply put, the pay is good, but the pressure coming from all directions is extreme, often driving out the leaders that hospitals and health systems need most.
To shed light on the barrage of challenges facing CEOs, and to help stakeholders correctly separate the good from the bad, we’re combining our unique expertise – one author, Brian Spisak, is an organizational psychologist and consultant focused on leadership and workforce issues while the other author, Michelle Oxford, is a healthcare CEO with years of experience – to establish a science-backed, yet practical understanding of leadership hurdles in healthcare. Together, in the form of a Q&A, we’ll provide a framework for understanding the multilevel problems healthcare CEOs must solve and provide real-world examples of best practices.
Meta-Leadership in Healthcare
Brian:
I’m a research associate at the National Preparedness Leadership Initiative (NPLI) at Harvard University. One of the core frameworks the NPLI developed is “meta-leadership.” A key element of this perspective emphasizes the multi-dimensional nature of leadership – i.e., leading up to superiors, down to team members, across to peers, and beyond to external stakeholders – particularly in crisis situations or when managing complex challenges that require broad coordination.
When leading up, decision-makers must work to influence those in higher positions of authority. It involves effectively communicating challenges and solutions up the chain of command, advocating for necessary resources or policy changes, and ensuring that senior leaders are informed and engaged in a way that supports the organization's goals.
For healthcare CEOs, leading up might involve interacting with the hospital's board of directors, government health agencies, and other regulatory bodies. It's about effectively communicating the needs and challenges of the hospital or health system, advocating for necessary resources or policy changes, and keeping these higher authorities informed about the hospital's performance and strategic direction. This could involve negotiating for funding, presenting progress reports, or discussing compliance with healthcare regulations.
Michelle, can you give me an example of challenges when leading up as a CEO in healthcare? What’s a situation where you had to lead up, what was the challenge, and how did you solve it?
Michelle:
The Situation
After a transfer of 53% majority ownership to an entity which was new to healthcare, and specifically hospital ownership, the learning curve was steep, and education and training fell to me as the CEO. The new investor owner had significant experience in a multitude of businesses/industries and was extremely successful however the nuisances of a hospital, especially one in California were foreign. Often, my recommendations were not received well due to the Dunning-Kruger effect, a cognitive bias in which people wrongly overestimate their knowledge in a specific area. They believed, “past performance predicts future performance, what could be so different and difficult with a hospital?”
The Challenge
We began to embark on a financial turnaround of the organization. A new CFO was selected and reported directly to the majority owners. He had an impressive resume and was extremely knowledgeable in finance and accounting. I was excited for fresh eyes. During our first budget season together, I provided my assumptions for volume, staffing, cost containment, etc. I had an impressive Earnings Before Interest, Taxes, Depreciation, and Amortization (EBITDA) figure in mind based on prior year volume and our aggressive growth plans. Upon receiving the draft budget, it was showing a significant loss. I reviewed the line items several times, thinking “something is off, what is wrong?”
Our CFO’s experience was in the hospitality industry and did not have hospital related budgeting experience. Most recently, he served as CFO for a high-end French restaurant which was also an exclusive and famed macaron patisserie. While trying to decipher what went so terribly wrong with my assumptions, the lightbulb switched on and I said aloud “macarons!”
The Solution
Again, with the Dunning-Kruger effect, he didn’t know what he didn’t know, and I uncovered, now obviously, he calculated using an incorrect method for hospital budgeting. A 25% increase in macarons simply needs a proportional increase in almond flour, egg whites, sugar, and so on, and is easily managed by a straight line budget. However, this approach is not a suitable method for hospitals, which require a flexible, incremental budgeting process to account for all the variables.
I quickly called a financial consultant that knew our facility asking for his per diem rate to assist with training the new CFO and help to fast track a budget to the board of directors. The cost of the special project with a consultant was thoughtfully presented to the new investors, along with the EBITDA figure, and approved. The following year, the learning curve was resolved and the budget process was seamless. I have never looked at a macaron the same.
Brian:
Great! It seems the key was clear and effective communication when leading up, especially when dealing with stakeholders who may lack specific domain knowledge. This case highlights the critical need for leaders to actively engage in educating their superiors or investors to ensure strategic alignment and effective decision-making.
To continue our meta-leadership journey, decision-makers must also figure out how to best lead down by effectively guiding subordinates. It includes providing clear direction, support, and feedback to ensure that teams are motivated, aligned, and effectively working towards common objectives. Leaders must be adept at managing performance, developing team members, and fostering a positive and productive work environment.
This aspect is crucial in managing healthcare workers, including doctors, nurses, administrative staff, and support services. Healthcare CEOs must inspire and motivate this diverse workforce, ensuring they understand the organization’s mission, vision, and values. This includes fostering a positive work culture, addressing staff concerns, providing professional development opportunities, and ensuring patient care standards are upheld. Effective communication, empathy, and the ability to address diverse needs and challenges are key skills in this area.
Michelle, what’s a situation where you felt pressure to lead down the hierarchy? How did you address the challenge and improve outcomes?
Michelle:
The Situation
Running a hospital is tough, which is one thing I know for sure – high stress, long hours, personality dynamics, financial constraints, competing priorities, and burnout just to name a few challenges. Culture plays a big role in the health of any organization and often it takes just one individual to break the chain of momentum of positivity.
The Challenge
As CEO, I worked hard to create a culture of kindness, civility, mutual respect but always had a few difficult people. It felt like a game of whack-a-mole with toxic individuals bubbling to the top no matter how hard we tried to coach and mentor kindness and a positive work culture. The biggest element of a toxic employee is they can suck others in and multiply. Also, if one toxic person complains an entire shift, it can certainly impact the mental health of those around them.
The Solution
I had recently heard the term “Energy Vampire” and used it in a presentation to front-line staff during employee forums. I didn’t speak specifically of a person or a unit, I simply stated that if we have any energy vampires, they will take a toll on others – the collateral damage is that co-workers leave the hospital mentally drained and exhausted praying tomorrow they are assigned away from this toxic person. I then concluded that part of my presentation with a request to be mindful of how you show up and moved on to the other topics.
Over the course of the next few days, the most amazing thing happened. The handful of individuals I was specifically concerned about came to administration one by one requesting a meeting with me. I had a similar conversation with each. They all stated that they enjoyed the employee forum and would cautiously ask, “when you used the term ‘energy vampire’ were you talking about me?” To which I would reply, “why would you think I was talking about you?”
The response was different versions of “sometimes I’m frustrated, and I do spend my days on a negative track venting, I guess venting makes ME feel better.” I replied, “if you think you negatively impact your coworkers, physicians, and even patients, then it’s a problem.” There was some defensiveness (and excuses), but by the end of our conversation, the conclusion was no one wanted to be an energy vampire.
I suggested we bring the best version of ourselves to work and cultivate positivity and I was most grateful for the self-awareness that occurred once the issue was pointed out. I observed over the next several months more positive interactions occurring throughout the facility leading to fewer rounds of whack-a-mole with vampires.
Brian:
Thanks for sharing this case. It illustrates the power of prompting self-reflection and behavioral change among team members. Leaders can take from this the importance of fostering an environment where self-awareness is encouraged and constructive feedback is framed in a way that motivates individuals to reflect on how they impact their team. This approach builds a culture of positivity, mutual respect, and continuous improvement within the organization.
Another aspect of meta-leadership is leading across. This refers to working with peers and colleagues at the same hierarchical level, both within and outside one's own department or organization. It emphasizes the importance of building strong peer relationships, facilitating collaboration, and leveraging lateral connections to share resources, information, and best practices. This is crucial for coordinating efforts and solving problems that cut across organizational boundaries.
In a healthcare setting, leading across involves working with peers and leaders in different departments or units within the hospital, for example. This could include coordinating with heads of various medical departments, IT, finance, human resources, and other support services. The goal is to ensure cohesive operation, facilitate interdisciplinary collaboration, and optimize resource allocation. It's about breaking down silos, encouraging interdepartmental communication, and fostering a team-based approach to healthcare management.
Michelle, can you recall a situation where you had to lead across? What barriers did you experience and how did you address them?
Michelle:
The Situation
The Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted in 2009 and played a key role in the adoption of electronic health records (EHR). Hospitals and physician offices were scrambling to implement electronic medical records and to learn about, and adapt to, this changing landscape. In 2010, early in my hospital career journey, I was invited to a meeting with a guest speaker who was an expert in the field. The presentation was extremely informative, and the presenter repeatedly used a word I had never heard of, nor did he define the word – “interoperability!” I scanned the room, and everyone was following along with the presentation, nodding and agreeing, no questions asked. I left the meeting wondering how my colleagues in the room were familiar with the concept of “interoperability,” yet I was not?
The Challenge
Frustrated with my gap in knowledge, I went to one VP and asked, “what is interoperability?” to which he responded, “I have no idea, first I heard of it.” I asked him why he didn’t ask a question, and he looked at me and raised his eyebrows – which was all the answer I needed. Later that day, I drove to a sister hospital and asked a VP there, “what did you think about that meeting and what is interoperability?” He replied, “no clue.” When I asked him why he didn’t ask a question, he replied with an eye roll, simply saying “I wasn’t going to ask a question.” Essentially, the group didn’t ask questions for fear of being seen as incompetent in the subject, same as me.
The Solution
This early experience shaped how I view the importance of speaking up and asking questions. That day, a room full of stakeholders missed the opportunity to learn from an expert and master interoperability (or at least gain valuable insights).
Curiosity and continuous learning are key elements of great leadership, and I now pride myself on asking questions. If you pay attention, you’ll notice in large group presentations that during the time for Q&A there’s often a long pause then one brave hand is raised, and that usually spurs more questions. Lead by asking questions, your colleagues will follow, and it’ll inspire a culture of learning. In my opinion, the one with the brave hand raised is usually the smartest person in the room.
Brian:
Another fantastic example! This case exemplifies the value of fostering curiosity and continuous learning. Leaders must not only be willing to admit their own uncertainties but also actively promote an environment among their peers where asking questions is seen as a strength, not a weakness. This approach sets a precedent for encouraging a more informed, engaged, and adaptive leadership team.
The final aspect of the meta-leadership framework is leading beyond. This dimension extends the concept of leadership to include external stakeholders, partners, and other entities that are not part of the organization's formal structure. It involves engaging with the broader community, other organizations, government agencies, and any relevant parties to build alliances, foster collaboration, and create synergies towards achieving shared goals, especially in response to complex challenges or crises.
For healthcare CEOs, leading beyond means engaging with the broader community, patients, highly skilled and desirable external talent, vendors, media, and so on. This includes building relationships with local organizations, patient advocacy groups, and the media to enhance the organization's public image and community engagement. It also involves staying attuned to the healthcare needs of the community, shaping public health initiatives, and responding to external trends and changes in the healthcare industry and labor market. Leading beyond is essential for maintaining public trust, securing community support, attracting talent, and enhancing the hospital's reputation.
Michelle, as a CEO, how does the need to lead beyond manifest? What’s a good example from your experience?
Michelle:
The Situation
During one of my early positions in healthcare, I was responsible for physician recruitment, and looking back, I learned a valuable lesson about the importance of transparency. As we were wrapping up a physician contract, we met with several hospital leaders. The physician was sharing his vision for the program, best practices, and extensive list of operational expectations. Then, something surprising happened, the very tenured CEO agreed to the candidate’s entire list of expectations!
The Challenge
Leadership told him everything he wanted to hear, but I knew we couldn’t deliver on half of it. After the meeting, I asked the CEO a simple question, “why did you say we can do all of that, we can’t.” The response back was, “don’t worry, once he signs there is not much he can do about it, physicians are naïve.” What I observed is that this particular leader treated physicians as commodities. However, I didn’t share their mindset, and I also predicted that this lack of transparency upfront would eventually lead to unkept promises, resentment, and mistrust.
The Solution
Several years later, I was in my first CEO role making the final decisions on a contract with a physician sitting across from me. He had a list of requests that my hospital could not deliver. I listened, took notes, shared what we could and could not accomplish, and then provided him the why behind each.
He looked at me, tilted his head sideways and said, “you are the most transparent administrator I have ever met.” I thought to myself, oh no, maybe the approach I witnessed years ago of telling a prospective new physician what they want to hear was what this current individual sitting across from me wanted. To test this hypothesis, I responded with a question, “is that a good thing or a bad thing?” He replied, “it’s fantastic, I know where I stand with you and it’s a rare thing.”
This lesson has shaped my interactions with all stakeholders, especially during conversations with different perspectives and priorities. Coming together with transparency, even when it’s not something the person across from you wants to hear, will lead to collaboration and will always check two essential boxes for any healthy relationship, trust and respect.
(Side note: Years later, the physician who was promised the world back at my prior job eventually ended up leaving for a competing hospital system, taking his robust patient list with him.)
Brian:
Another fantastic example and a great way to conclude our exploration of meta-leadership! Here, the key was indeed trust through transparency when leading beyond to external stakeholders. Leaders must focus on the long-term value of honesty when building (external) relationships and establishing sustainable success. It contrasts sharply with short-term gains from misleading promises, showing that integrity in leadership fosters lasting and productive outcomes.
The Bottom Line
Collectively, these are very compelling examples of the multilevel pressures healthcare CEOs face and the opportunities they have to create innovative, high-impact outcomes. The four dimensions of meta-leadership – leading up, down, across, and beyond – underscore the importance of a versatile approach to leading. The framework shows that effective CEOs navigate and influence a wide range of relationships and structures, both within and outside their organizations. By mastering the art of leading in every direction, CEOs can more effectively mobilize collective action and drive positive outcomes for providers and patients in complex and dynamic environments.
About the Authors
Brian R. Spisak, PhD is an independent consultant focusing on digital transformation and workforce management in healthcare. He’s also a research associate at the National Preparedness Leadership Initiative (Harvard T.H. Chan School of Public Health, Harvard University), a faculty member at the American College of Healthcare Executives, and the author of the best-selling book, Computational Leadership: Connecting Behavioral Science and Technology to Optimize Decision-Making and Increase Profits (Wiley, 2023).
Michelle Oxford, MBA, FACHE is an executive leader with 20 years of experience in healthcare and the former CEO of Bakersfield Heart Hospital. Her facility maintained the highest “would recommend” scores in the market during her tenure and obtained a Leapfrog A score during the pandemic. She is also a fellow of the American College of Healthcare Executives.