It Takes Two: Can Dyad Leadership Provide a Durable Pathway in Healthcare's Brave New World?

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As the healthcare landscape continues its tectonic shifts, the old pillars—siloed organizations, unchallenged leadership, see-through accountability—are starting to totter. In their place new models are emerging, like the dyad, which pairs a respected physician leader with an accomplished administrative head to enable hospital systems and medical practices to more effectively manage their complex operations and, as importantly, stay ahead of change.

When three cardiovascular practices joined forces nine years ago to become Piedmont Heart Institute, leaders knew their success would lie in getting the structure right. “We realized we wanted to be a physician-led organization,” recalls Katie Lund, RN, MBA, senior director of clinical integration for Piedmont Healthcare, which includes seven hospitals and 26 cardiology offices across metro-Atlanta and North Georgia. “But we also knew that being a good physician doesn’t necessarily make you a good administrator. So we groomed our physician-leaders and paired them with administrators, and now we have more and more physicians moving into leadership roles within our dyads.”

Piedmont is hardly an outlier. As hospitals and other medical organizations are being redefined by integrated provider networks and the movement from volume to value, they are realizing that entrenched leadership models are sorely outdated. The days of easing physicians with the most years of practice into top-tier posts of authority are over; temperament, training and vision will be essential to bringing positive change to the entire organization. By pairing clinical and administrative leaders whose skills, expertise and credentials complement each other, dyads are carving a pathway into a new era of quality-based, team-driven care. “I believe they’re essential today to survival,” declares Cathie Biga, RN, MSN, president and CEO of Cardiovascular Management of Illinois and a former hospital CEO. “Leadership responsibilities are bigger than any one individual, and dyads allow you to pull together the best of both worlds and help ensure that people are operating at the top of their license.”

While no firm numbers exist on the number of dyads across the country, the Advisory Board Company cites a 2015 survey that found 46 percent of service line leaders and 32 percent of medical directors in hospitals are involved in dyads. The movement is clearly spreading as hospital systems adapt them to clinical service lines, such as cardiology, orthopedics and oncology; to improvement initiatives in areas like quality, finance and patient outcomes; and to regional or national networks of providers. Catholic Health Initiatives (CHI), for one, has moved to service line dyads at many of its 105 hospitals across the country as well as at its clinical practices. “I’m hearing of dyads popping up everywhere as people come to realize that what we’ve been doing in healthcare hasn’t worked,” asserts Kathleen Sanford, DBA, RN, senior vice president and chief nursing officer for CHI, and co-author of the book Dyad Leadership in Healthcare (2015). “We have tribes of people out there who have worked for years in parallel thinking they know each other, but really don’t. Now they need to cross over and become one big tribe centered around what is best for the people they care for.”

Cathie Biga, RN, MSN, Cardiovascular Management of Illinois
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Challenges Abound

But, Sanford hastens to add, converting to a dyadic structure can be a daunting task. “Many clinicians who get involved are astonished at how much hard work it is,” she acknowledges, while adding none of the dyad partners she interviewed for her book said they would ever go back. For a dyad to succeed, according to participants in the field, hospitals must be committed to redrawing many of the traditional lines of power and control and be willing to openly welcome a new culture where shared decision-making and accountability are paramount. Physicians, for their part, must be willing to unload any biases they hold (be they gender, race, cultural or assorted others) and relinquish some of the autonomy they’ve enjoyed in the past to a team-based approach. They also must have a passion for communicating (and, when necessary, for sharpening their communication skills), particularly with their administrative partners. Therein lies one of the biggest challenges facing any nascent dyad: ensuring their clinical and administrative heads are respectful of each other’s background and skill sets and able to work seamlessly together—the antithesis of a shotgun wedding.

“You can’t just throw two people together and call it a dyad,” emphasizes Sanford, who is a partner, along with the chief medical officer of CHI, in a dyad responsible for medicine and nursing practice across the entire CHI system. “They must understand it’s going to change their perceptions of power and that they need to have the right conversations if they’re going to work well together. That’s the only way a true dyad can work over the long run.”

Biga suggests that many, if not most, healthcare organizations today operate in a dyad-type setting, though they may not call it that or employ it to its full potential. “If you look at a cath lab or noninvasive imaging department, for example, they almost always have an administrative leader and a physician-medical director,” she points out. Even so, healthcare systems flying true dyad colors—like clear-cut divisions of power along with tailored values, culture and strategic plan—appear to be far less ubiquitous. 

CQO, chief quality officer; CMO, chief medical officer; VPMA, vice president of medical affairs; CMIO, chief medical information officer. Source: Advisory Board. https://www.advisory.com/research/physician-executive-council/prescripti.... Accessed Oct. 25, 2016; reprinted with permission.
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Role of the Physician Leader

While dyads embrace the notion of co-equal partners in something of a “work marriage,” the physician is the point person in many critical areas. Among his or her responsibilities: ensuring quality across all areas of patient care; encouraging teamwork among physicians; nurturing a culture of open peer review; minimizing variation in the way care is delivered; establishing metrics and guidelines in sync with an industry moving to value, appropriate use criteria and bundled payments; and serving as a visible champion for change. Says Biga, who advises healthcare systems on integrating their physician groups and managing integrated practices, of the pivotal role of physicians: “They’re at the table helping to make decisions about staffing, capital and financing, and they’ll be your best friend and ally when the budget is completed and you have to go out and sell it to the troops.”

For a dyad to run smoothly, however, the physician must be in lockstep with his or her partner—who may hold a nursing and/or business degree—on shared decision-making and accountability. The administrative member will typically be immersed in operating, financial and market share performance from a strategic perspective. Seldom should the physician-leader be pulled into everyday problems and issues; these are more efficiently handled by subspecialty managers, councils or teams that report directly to the administrative head.

“We work together as a team to create a better product that looks at everything from the whole perspective,” says Thomas Deering, MD, chief of Clinical Centers of Excellence and the Arrhythmia Center of Excellence at Piedmont Heart Institute, and partner with Katie Lund on a dyad focused on Value. (Among Piedmont’s other dyads are Strategy, Research & Education and Information Technology.) “We learn from each other so that I become more administrative and my dyad partner becomes more clinical and understands the subtleties a little more,” Deering says.

A productive partnership can help quell another concern sometimes voiced over dyad rule: Who’s really in charge? Jennifer Zelensky, executive director at Providence Heart and Vascular Institute in Oregon and a dyad co-leader, maintains that she and her physician partner are “reasonably interchangeable,” adding: “He can go to certain meetings and I can go to others and people know that we’re in sync. If an issue arises over medical quality, he’s much more the lead, whereas if it’s about budget or long-range financial plans, it’s clear I’m on-point.”

Sources: Essentia Health Fosston, 2015; Society for Cardiovascular Angiography and Interventions Cath Lab Leadership Boot Camp, 2016.
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Creating a Career Pathway

Experts in the field agree that rigorous training and education are vital to any effective dyadic leadership program. The longer range goal is to carve out pathways for young professionals who want to pursue career opportunities outside traditional clinical practice. As a report in Physician Executive put it, “Administrative medicine will be a career goal for sure. Training for these roles will require formal graduate education, including graduate management degrees” (2010;36[1]:14-9).

Piedmont Heart Institute is helping to point the way through its Physician Leadership Academy. The mini-MBA type program, offered in collaboration with Georgia State University, is designed to teach physicians business and leadership fundamentals, from reading financial reports to understanding human resources issues to driving improvement across an organization. “We learned many business and administrative techniques, but we also learned a lot about ourselves—how to assess our strengths and weaknesses and the impact they can have on the entire program,” comments Deering. The success of the Physician Leadership Academy resulted in opening its doors to administrative leaders at Piedmont Heart, and it now offers a course in which clinicians and managers learn side by side.

Even when dyads lack an organized training platform, they invariably encourage or require their leaders to continue their learning through MBA or other degree-granting programs. Some healthcare systems, like CHI, have leadership coaches to help dyad chieftains sort out difficult issues and challenges, such as making sure they’re both reading from the same playbook. “It’s important that they talk things through and agree on what their goals are because partners don’t always hear things the same way,” says Sanford.

Jennifer Zelensky, Providence Heart and Vascular Institute, Oregon
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The Dyad as a Tool for Change

Despite potential pitfalls and growing pains, the properly executed dyad model can yield considerable dividends in terms of clinical quality, patient outcomes and financial performance. Providence Heart and Vascular Institute, Oregon’s largest provider of cardiac services through eight hospitals and 17 clinics, uses its service line dyad to drive improvements in clinical areas such as cardiology and vascular surgery. At the helm of the initiative is dyad co-leader Dan Oseran, MD, an electrophysiologist and chair of the Institute’s Quality Council who regularly convenes physicians in areas targeted for improvement to conduct in-depth case reviews. “It really makes a difference because it gives us the chance to question clinical practice at a much deeper level,” explains administrative partner Zelensky. “Everyone is expected to speak up and say, ‘I would have done it this way.’”

When Piedmont Heart wanted to reduce its heart failure readmission rate, it created an Institute-wide initiative that relied on a dyadic structure of physician champions/administrative leads across a host of work streams. And thanks to new standardization practices in areas like patient disposition, physician documentation and patient/physician/nursing education, Piedmont Heart was able to cut its rolling readmission rates from 23.7 percent in September 2014 to 18.7 percent in December 2015. Another dyad-directed program known as the Acute Coronary Syndrome Pathway expects to save several million dollars at one Piedmont hospital alone. That effort, still in its early stages, is engaging both physician and administrative staffs to develop up-to-the-minute guidelines on how to treat patients entering the hospital with conditions like chest pain. “Instead of having 20 doctors doing it 20 different ways, we want to narrow that clinical variation, without eliminating it altogether,” says Deering, who is the clinical lead on that program. Once the new operational steps are put in place, he envisions a reduction in errors, better communication among member of the clinical teams as well as with patients and their families, and decreased costs through the avoidance of unnecessary tests and more standardized treatments.

Kathleen Sanford, DBA, RN, Catholic Health Initiatives, Co-author, Dyad Leadership in Healthcare
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Flexible Model for the Future

Like any thoughtful model, the leadership dyad continues to evolve as new converts learn from and build on the experiences of earlier adopters. One hybrid that’s gaining currency in some healthcare quarters is the triad. As the name suggests, a triad adds a third partner to the dyadic leadership mix, usually a nurse, pharmacist, radiologist or finance expert. CHI is experimenting with a number of those variations at its hospitals across the country. “If it’s a pharmacy triad, it means we’re trying to get a better handle on pharmacy costs and value—making sure we’re not overpaying for expensive drugs that don’t add anything to patients’ lives,” notes Sanford. She explains, however, that the third triad partners at CHI are not true co-equals since their team contribution is confined to their specific area of expertise. “Dyads are much more of a movement right now than triads,” she confirms, “but they’re something that people are willing to try. And that’s a good thing.”

Regardless of form, it seems safe to assume that leadership dyads and any offspring will continue to gather steam in a healthcare environment that not only encourages change, but makes it almost mandatory. Traditionalists who demand to know, “Why can’t doctors just practice medicine and administrators just mind the store?” are finding their voices have a decidedly hollow ring. As dyad administrator Lund puts it, “Most people are going in the direction of dyads and should be because, in the end, everyone is better off having these leaders at the table.”