This is What Failed Leadership Looks Like

 

On June 11, the registered nurses of SSM St. Mary’s Hospital in Madison, Wisconsin voted to unionize in a vote of 511 to 63. The Service Employees International Union (SEIU) will now represent the nearly 900 nurses who practice at St. Mary’s in negotiations for wages, benefits and working conditions. In a statement to the press, a St. Mary’s nurse said the nurses want to “make sure the profession we love is sustainable.”  She went on to say “…we need full staffing, resources, and support. With our union, nurses will be part of the conversation and what we say will matter.”   The SEIU also issued a statement calling this the “largest private sector union election in recent Wisconsin history.” It took a little more than a decade for the St. Mary’s Nursing Organization to fall from national recognition for excellence to this sad day. Corporate management will undoubtedly have all sorts of excuses for why this happened. To the extent they accept any management responsibility, the highest-level executives will blame those managers who work closest to the point of care, whose hands they tie with decisions that become barriers to doing the organization’s best work. There is only one truth. This is a leadership failure.

 

The St. Mary’s story is very personal to me. I arrived there in 1991 having been hired as the Vice President for Patient Care. St. Mary’s is part of SSM Health, based in St. Louis and operating health care facilities in Wisconsin, Illinois, Missouri, and Oklahoma. What has become one of the largest health systems in the country with $13 billion in annual revenue, started as the selfless work of a group of nuns who emigrated from Germany to the United States. St. Mary’s opened in Madison in 1912.

 

When I arrived at St. Mary’s, it was the only non-union hospital in Madison. SEIU represented the nurses at the other two hospitals. I immediately set out to see what I could learn about the organization by attending staff meetings in every area of the hospital for which I was administratively responsible. In every meeting I asked the nurses to tell me the best thing about practicing at St. Mary’s. I received the same spontaneous response many times over: “Patients have always come first here.” 

 

This may seem like the obvious answer to those unfamiliar with the evolution of health care systems in the United States, but it was, in fact, an uncommon response. In the early 1980’s, the cost of health care became a national priority and massive changes, particularly in how health care was reimbursed, were underway. By the 1990’s many nurses, physicians and other health professionals who lay hands on patients had become cynical as they perceived the focus had shifted from patients to money.

 

Hearing the nurses speak so lovingly about patients remaining the priority at St. Mary’s was both thrilling and sobering. It was clear to me that I had better not jeopardize that which made St. Mary’s special as I undertook my new responsibility.

 

I stayed at St. Mary’s for twenty-two years and, together, we built something that was unsurpassed in health care in this country. As I reflect, there were a number of things that were pivotal in all we achieved.

 

In 2000, under the leadership of CEO Sister Mary Jean Ryan, the system set out to rewrite its mission tapping into more than 3,000 employees for input. The goal was to create a guide stone for the organization’s work to replace the flowery but meaningless prose that hangs on the walls of most organizations and is easily forgotten. The resulting mission was elegant and meaningful. “Through our exceptional healthcare services, we reveal the healing presence of God.”  We pushed ourselves further to give the mission the meaning that would truly guide our work and went on to define “exceptional health care” as exceptional clinical outcomes, exceptional patient and family satisfaction, exceptional employee and physician engagement, and exceptional financial performance (which flows naturally from the previous three). These were things we could measure ourselves against.

 

I made more mistakes than I could possibly count in the process of developing into an effective healthcare administrator and the most important things that I learned along the way were critical to enabling the organization to do its best work.

 

The most important insight an organization’s leaders can have is understanding what their job is. Too many try to control the organization’s outcomes by trying to control everything that goes on within the organization. This is neither possible nor desirable.

The role of executive leadership is to position those who do the organization’s work with the information, skills, tools, resources, and authority they need to achieve performance excellence. They are the ones who manage the organization’s outcomes. Leaders who truly understand and embrace this truth execute their roles in a manner unlike most.

 

Meaningful voice for employees is not asking for opinions and taking them under advisement. It is the authentic ability to influence that comes with authority and responsibility for the work one does. We built a system of professional governance within the Nursing Organization of St. Mary’s. Twice every month I spent the morning at a leadership table with the clinical nurses whose peers had selected them to lead the work of defining practice, improving quality, and ensuring competence. These are the accountabilities that come with the license to practice the discipline, and, at St. Mary’s, they were owned by the clinical nurses. The management team and I taught the nurses about the finances of health care by simplifying the monthly financial statements and sharing them with all nurses. They understood the resource realities of the business just as they understood their budgets at home, and were always concerned with making the best decisions in the context of these realities. This partnership between clinical practitioners and the organization’s management produced amazing results for our patients, our organization, and our community. We became the 50th Magnet recognized nursing organization in the country in 2002 out of about 6,000 hospitals. This is the highest recognition a nursing organization can achieve for excellence in practice and excellence in the practice environment. It requires the rigorous production of evidence through an application process to the American Nurses Credentialing Center, and a multi-day site visit to verify what has been claimed in the application. Redesignation is required every four years. After two successful redesignations and my departure from the organization, corporate leadership allowed the Magnet designation to lapse.

 

Staffing days helped keep the gap narrow between clinical practice and administration. One day every month I would wear scrubs and spend the day shoulder to shoulder with the team on a patient care unit. Though many years prior I had been a critical care Clinical Nurse Specialist, I was no longer a clinician.  As an administrator, I had two objectives. I wanted to make sure I understood what patient care had become. Stays were shorter, patients were sicker, and it would be dangerous to make resource decisions without understanding the challenges the care team dealt with every day. I also wanted to observe firsthand the impact of the administrative decisions we were making. I wanted to assure myself that “exceptional health care,” the promise of our mission, was realistic with the nurses’ workload expectations. The nurses loved those days. They taught me so much while showcasing their exceptional work. I loved those days. They kept me connected to the only thing that mattered.

 

Seeing is Believing 

 

There are thousands of St. Mary’s stories that are evidence of what it means to live the mission and exercise meaningful voice. Here are two.

 

It was Christmastime and the nurses were caring for a middle school music teacher with terminal cancer. Every year he conducted the school’s Christmas concert and on the day of the concert, it became clear he was too sick to leave the hospital. The concert was very important to him and late in the afternoon his nurses got the idea of bringing the concert to him in our spacious hospital lobby. They got to work and made it happen. That evening the lobby was packed with the students, their families, and many other visitors as the beautiful Christmas music wafting through the hospital drew onlookers from throughout the building.  The beloved teacher conducted his last concert. I didn’t hear about it until the next day. The nurses didn’t ask permission. They knew this loving gesture was as integral to their care as all of the chemotherapy they would ever administer.

 

During one very busy flu season, the hospital was filled to beyond capacity. We overflowed patients in small clusters everywhere we could find room for a bed. This strained our staffing even more than the already high patient volume because safety required a minimum of 2 nurses everywhere we had a patient, even if their condition did not require that level of staffing. One morning I stepped out of the weekly administrative meeting and encountered two nurses. When employees have meaningful voice, they make it their business to think critically and contribute to improving the organization. The nurses reminded me of the 24-bed unit that had been mothballed when we opened the newest wing of the hospital. They suggested if we temporarily reopened that unit for patient care, we would be able to care for many more overflow patients far more efficiently. So true. I returned to the administrative meeting and shared their suggestion. We immediately adjourned our meeting and joined the nurses and other hospital staff to clean, stock, and reoccupy the unit. By late afternoon, the unit was operational.

 

Outcomes Don’t Lie

 

During my twenty-two years at St. Mary’s there were periods of severe nursing shortage in our community and across the country. There was never a time we were not well staffed. Our turnover was very low, and we filled vacancies very quickly. Our clinical outcomes, patient and family satisfaction, employee and physician engagement and financial performance were consistently among the best in the country. This was not the case in our community.

 

When administrators don’t know what else to do, they throw money at problems. It creates an all about money culture and more problems than it solves.

 

In Madison hospitals, it was standard practice to mandate overtime, pay extra shift bonuses and pay sign-on bonuses in exchange for a commitment to stay for a specified period of time. Despite all of this, the University of Wisconsin Hospital typically had to employ about 70 full time equivalents of “agency” nurses – temporary nurses who were paid far more than the employed nurses and had no commitment to the organization. The union could not protect the nurses from these “business practices.”

 

Throughout my entire tenure, we never used a single agency nurse, never paid a

sign-on bonus, never paid an extra shift bonus and never mandated overtime. I shared my belief with the nurses that people who will come for money will leave for money and they agreed. I promised the nurses I would never infringe on their freedom by mandating extra shifts or overtime, and asked them to help out when we needed them if they could. They always came through. On the nights before severe snowstorms nurses would choose to sleep in the hospital to make sure they could make it to work the next day. When I asked a group of new nurses in orientation class why they had chosen St. Mary’s, as was my practice with every group of new hires, one nurse immediately answered, “I wondered why a hospital would have to pay me $10,000 just to stay for a year” (the sign on bonus at UW Hospital).

 

There is a crisis in healthcare leadership

 

The Nursing Organization we built at St. Mary’s over many years was an exceptional and resilient partnership between management and clinicians. It took a lot of bad decisions to destroy it. Early in my tenure, SEIU tried to organize the nurses numerous times and finally gave up. It was clear to me on the day I parted company with the organization they would be abandoning the things we know are most important to follow the path of corporatized health care in America. The nuns are long gone. Bureaucratic corporate hierarchies have moved decision making far from the patients and those who understand the work. Not for profit is a meaningless term in a world that has become all about profit.

 

I have one word for the unionization of St. Mary’s nurses. Heartbreaking. The union will not be able to deliver the joy in work the nurses are starving for, and the union will be invested in keeping the relationship between management and staff adversarial to justify its existence. While at a conference, I once engaged in a spirited debate with a national union leader who believed all nurses should be unionized. At the end of our conversation, she conceded that maybe St. Mary’s nurses were an exception. She left me with a parting comment I never forgot: “They say you get the union you deserve.”  This is what failed leadership looks like.