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A Leader’s Notes

The first nurse to serve as CEO of HUP lists the skills every nurse should have to lead in health care.

Careers move by opportunity, the same way science does. No road map exists that you can follow through your career. Every nurse should anticipate forks in the road. My own career serves as an example: I would never have predicted its trajectory. But I took opportunities as they came up; and I still don’t know exactly where I’ll land.

I come from a health care-oriented family. My mother and aunt were nurses, and my grandfather was a physician. But it was my grandmother’s illness that first sparked my curiosity about why people get sick. When I was growing up, she became ill with Hodgkin’s disease. I remember her going for cancer treatments…in those days, the options were quite limited. I remember her being so sick from the chemotherapy and cobalt treatments, and spending most of her time in bed. She died several months after being diagnosed.

When I went to nursing school, I had an interest in cancer and wanted to specialize in cancer nursing; but many people recommended at graduation not specializing so early. So I first became a surgical critical care nurse in New York City. A job was available in a hospital directly across the street from where I lived, so I went to work there as a matter of convenience. It turned out to be a great beginning. I was exposed to patients undergoing complex surgical procedures and had the opportunity to really learn a lot. After a couple of years, I was promoted to senior staff nurse, a wonderful opportunity for a young nurse; in those days there were no formal career ladders.

Still, I yearned to specialize. Being in New York City, I went up the street to Memorial Sloan Kettering. That was the place to go if you wanted to be a cancer nurse. I started out working in medical oncology, and it was a transformative experience. When you get into this field, you either love it or you leave; it’s a very intensive kind of nursing. I loved it.

At Sloan Kettering, I became interested in the organization of nursing service, the way it was delivered, and how these factors affected outcomes. This in turn got me thinking about how nursing drove outcomes—an important revelation for me. This led me to another fork in the road. Should I focus on clinical work for graduate school, or on administration? Because of the experience I had at Sloan Kettering, I decided to go the administrative route and chose to do my graduate work at New York University.

After that I followed a fairly traditional administrative trajectory. I went into a nurse manager role, becoming a clinical director and then chief nursing officer. My first CNO role was in a small free-standing cancer center. It was a new program, and I was its first CNO. I had an opportunity to learn about how cancer centers work and how they are funded. I learned about the cancer research enterprise and the role that plays in a cancer center. While there, I decided to pursue a doctorate. After looking carefully for a faculty match, I found one at the University of Pennsylvania School of Nursing. Dr. Ruth McCorkle, an internationally renowned cancer researcher, became my mentor. My dissertation was a secondary analysis evaluating the effect of advanced practice nurses on clinical outcomes in patients undergoing radical prostatectomy—a common procedure in those days, prior to robotics. Dr. Terry Richmond served as my dissertation chair; she was another important mentor.

When I finished my doctoral work I was recruited back to Mt. Sinai, taking a leadership role in the cancer center where I worked on developing a number of aspects of the cancer program. It entailed aspects of cancer nursing, cancer operations, cancer research, and cancer financing. I liked this broadening of responsibilities beyond nursing, and I was very satisfied professionally in that role.

A few years later, I received a call from Phil Okala at Penn’s Abramson Cancer Center. He had an interest in developing a nursing leadership role there and I was ultimately recruited into that position. It was another fork in the road. I hadn’t anticipated it at all. Leaving New York City, my home for a long time, was a big change. I don’t regret it.

After I had served a couple of years in the Cancer Center, Dr. Victoria Rich, HUP’s chief nurse, announced her retirement. I applied and was selected for the position, moving from an all-cancer world into a much broader context, with many specialties that I hadn’t had experience with. Here was another big fork in the road, and that first year brought a very steep learning curve.

I moved from there to become the system-wide chief nursing executive. This gave me a chance to work with other chief nurses across the Penn Medicine System, and to collaborate on identifying ways we could help position nursing to drive value for the system. Finally, last April I became CEO of HUP. Another fork in the road: it wasn’t something I was necessarily working toward. It was an opportunity that presented itself. I thought long and hard about it, with some guidance and direction from people who had been mentors for me. And that is how I got to where I am today.

While I hadn’t planned for any of these forks in the road, I had picked up leadership skills along the way. They gave me the preparation and confidence to meet the challenges as they came. I’ll share some of the skills that I think have been important along the way.

Constantly hone your professional knowledge.

Health care is moving from a fee for service model to a VBP—value based purchasing—model. Quality matters in this new world. It’s not just how much volume you do; it’s about how well you do it. You need to have an understanding of what drives quality. What are the factors and outcomes you need to understand that are meaningful to patients? I typically define “value” as outcomes that matter to patients, over the cost of delivering those outcomes. Clinical knowledge is a major advantage in this world. Therefore, it’s important to stay abreast of knowledge development in your areas of interest. At the same time, we need to read broadly, not just in the health care space. Many factors influence the contexts you work in and it’s important to have an understanding of what’s going on in the world.

Besides reading, take opportunities to gain experiential knowledge. Stretch assignments will frequently come up in your work, with new opportunities. Raise your hand. Take a risk. We learn a lot through experiences. And validate your understanding through experts in your field. All of these factors will help you develop as a thought leader—someone others will want to follow.

Take time to think (and talk about what you’re thinking).

As leaders we need to ensure that we are taking time to think and are articulating how we are thinking about things. When Einstein was asked what was the most important factor in his thinking about relativity, he said it was figuring out how to think about the problem. We’re often faced with increasing complexity at work, especially in academic medical center environments. We need to get our heads around the challenges in the clinical work environment today. Nurses are incredible doers. We love to do things. As a result, we don’t step back and look at our practice and think about how things are working often enough. We have opportunities to do this more systematically.

We should share how we are thinking about things with others. Not only can you help shape the thinking of other people, you can all come to a higher understanding.

Develop clarity.

What is clarity? It’s an ability to see through messes and contradictions to a future that others cannot yet see. This entails being clear and precise about the direction your team or practice needs to go. Finally, clarity means putting matters into context. When you do this, people will look to you as a leader. They want to know what things mean, why it’s important to them, and how they can contribute.

Change the status quo.

Warren Bennis, a pioneering leadership scholar, said: “The manager accepts the status quo. The leader challenges it.” When is the last time you asked, “Why do we do it this way?” Don’t let yourself be complacent with current thought. Come at things with a beginner’s mind. Be bold. This can be daunting, particularly at an institution steeped in tradition, where people have done things the same way for 100 or 150 years. It takes courage to drive toward the future.

Cultivate your learning agility.

Learning-agile people can process new information and situations faster than others. They can adjust on the fly to changing situations. Some of the literature points to the ability of learning-agile people applying what they know to situations that are different. This becomes especially important when you think about the unstable context of our world today. The military describes it with an acronym, VUCA. It stands for Volatility, Uncertainty, Complexity, and Ambiguity. That’s the world we live in. It requires the ability to be flexible and nimble, to turn on a dime. Flexibility in turn demands openness to information, and the ability to apply insights, even from a misstep. These are the traits of people who succeed in a VUCA world. They are comfortable learning from their mistakes, dissecting them, and changing their behavior. You see the most successful athletes doing this. They also take risks. Michael Jordan says you miss 100% of the shots you don’t take. So think, what do you have to lose?

With agility comes innovation. In any situation, ask yourself, “How could I approach this differently?” You might come naturally to a solution. But we do best when we look for alternative strategies.

And when things don’t go so well, avoid getting defensive. Work is not your personal reality show. You should not take things personally. Step away and take the opportunity for feedback.

Some of the best feedback will come from your own thinking. Become more reflective. Constantly ask yourself, “What could I have done better?”

Use data as a strategic asset.

Data serves as a key driver in understanding and decision making. You can use it as a power tool of leadership. It becomes significantly easier to justify a course of action when you have compelling data. I use it every single day, and I ask others for data to justify their recommendations.

To use data effectively, become knowledgeable about the sources at your institution, such as financial and administrative data. In addition, EMR (electronic medical records) are huge repositories of data. While they can be difficult to access in meaningful ways, understanding what they contain is important. You need to know what particular metrics you should understand and measure over time. If you’re doing a project, be sure to acquire data relevant to that particular project. Partner with other resources such as IT, data science, analytics, and nurse researchers. Benchmark using national data; or benchmark against yourself over time. It’s critical for tracking return on investment.

To use data as a strategic asset, though, you must put it in context. Tell a story with it. No one can tell stories about data the way nurses and clinical teams can. The work nurses do is so compelling, when you combine the stories nurses tell with data, it has a very powerful impact.

Capitalize on the power of collaboration.

The volume and complexity of health care knowledge today is substantial and the locus of control for critical aspects of management is spread across a broad number of decision makers. Collaboration is essential to getting things accomplished and driving outcomes. Know who the key stakeholders are, not just the obvious ones.

Build collaborative skills, particularly your ability to foster relationships. They lie at the heart of collaboration. Build trust in those relationships by keeping your promises.

With any team you’ll find different perspectives that can lead to disagreement, but these can also be a source of strength. Be the leader who finds common ground; connect your priorities to those of others. In other words, represent their interests, not just your own.

Understand the importance of intangibles.

People often refer to intangibles as “soft” skills. I believe that when you acquire and use them correctly, they turn out to be quite powerful, and not so soft. In particular, emotional intelligence is a sine qua non for any leader. I wouldn’t leave home without it. Ensure that you are self-aware and have control of your emotions. Listen to them, and get feedback from others. No effort comes without error. Allow yourself to be wrong, failing and moving on.

Communicate, communicate, communicate.

You can never over-communicate. It helps you advance your work faster and increase its impact. Yet, communication is complicated. We may think we’re communicating with people even while they fail to hear what we say to them. One solution is to speak in a language they will understand. Tailor your messages to your audiences—not just in terms of their professions or specialties but in terms of their working styles. Communicate systematically by developing a formal communications plan. At the same time, capitalize on every opportunity to communicate. At every change or crisis or misstep, bring people back to the center. Remind them of the priorities your group must focus on.

All this takes courage.

The word comes from the Latin cor, meaning “heart.” We have no clear roadmaps for the future of health care. Having the ability to make mistakes and change your course in the face of uncertainty takes heart. This courage, more than anything, lets you lead the way.

– Regina Cunningham 

Apply it

Learn what it takes to be a health care leader at the Nurses on Boards Coalition. In addition, Best on Board offers courses on leading health care organizations.