Written by Chris Westfall and originally featured in Forbes

In 2022, turnover rates for segments of the healthcare industry ranged from 19.5% at hospitals to 65% for at-home care providers to 94% at nursing homes. According to a new report from software company Oracle, this level of turnover puts a huge financial and logistical burden on healthcare providers. Turnover in hospitals can cost up to $85,000 per clinician – and this number does not factor in future revenue for lost replacements, lost productivity, and other intangibles that hit the bottom line. While COVID-19 put additional stress on the healthcare labor force, the healthcare staffing crisis existed long before the pandemic. “There is an urgent need for healthcare organizations to proactively address the root causes of turnover, develop retention strategies, and invest in creating a supportive and engaging work environment,” explains Brian White, the CRO and Co-founder of software provider, Doorspace

Healthcare jobs are notorious for long hours and erratic schedules, and many are considered “deskless” jobs, meaning workers spend much of their time on the move. In fact, it’s estimated that nurses in hospitals walk about five miles a day. Hospitals operate at the intersection of high tech and high touch, when it comes to retention. “We focus on initiatives that are proven to be effective rather than continuing to invest in solutions that look good on paper but provide little, if any, real-world impact,” White says, referencing his company’s employee relationship management (ERM) software. But tech isn’t the only tool in the box, when it comes to keeping hospitals humming.

Focusing on impact and retention is David Schreiner’s business. Schreiner, a PhD, is the CEO of Katherine Shaw Bethea (KSB) Hospital in Dixon, Illinois. With nearly 1,000 employees, Schreiner leads an 80-bed rural facility 100 miles west of Chicago. While overall industry turnover stands at approximately 18%, Schreiner says his numbers hover around 11%. How is he tackling the challenge of retention in his hospital?

“Before our conversation today,” Schreiner shares from his office, overlooking the Rock River at sunrise, “I sent out six emails: three for work anniversaries, three for birthdays. We have an integrated reminder system so that we can stay connected with our team.” From high tech to high-touch, connection is the key, Schreiner says. “We have to earn the right for people to stay here. That means connecting with employees where they are, and recognizing their journey and their milestones,” he says. Here’s how Schreiner is making sure that those connections create better patient care:

1. Maintaining Gratitude: how well are you doing, as a leader, when it comes to expressing your appreciation? Schreiner is writing a book, published by Forbes, called Be the Best Part of Their Day. Launching in early 2024, the book identifies 15 leadership pillars (based on both his doctoral research and personal experience). According to Schreiner, it all starts with gratitude. “Leaders need to talk about [appreciation] every single time we get in front of our teams.” In healthcare, as in any business where caring and service are front and center, the key theme is the meaning of the work. That focus on individual impact is key to avoiding platitudes, when expressing gratitude. On a human level, we all see the value of appreciating others. Schreiner explains, “We have a local community college that pumps out 20 x-ray techs every year. It used to be a case that 15 of those would have to take part-time jobs until something opened up. Now they’re placed before they graduate.” It’s no secret that the current job market When employees understand that they have more options, leaders need to understand how to value the employees that choose your organization over others.
2. Transparency: With nearly 1,000 employees, the hospital doesn’t always lend itself to personal interaction with the CEO – but Schreiner goes out of his way to create a personal touch, inside a promise delivered. “When I get to meet with employees in the first hour of their first day at KSB Hospital, I give them my cell phone number. And I say, if within six months, KSB hospital isn’t the best place you’ve ever worked, please call me and talk to me about it.” When asked how often his phone rings, he replies, “Never. But I wish it would.” More than just a folksy offer, or a bold claim of an informal employee engagement survey, Schreiner means what he says. Walking the walk – and taking the tough calls – is part of transparency. What can you do, as a leader, to let people know that you possess that most valuable and rare leadership ability: the willingness to listen? For extra credit, consider how you might personalize your answer – and show that you mean what you say.
3. Do the Do-Able: If you improve just 1% per day, in 73 days you will double your results. Leadership, according to Schreiner, happens one step – and one conversation – at a time. “My journey started at a place where I felt like I was underdelivering. I was not engaging in the way that I wanted to with the people that matter the most.” The impulse led him to his doctoral research into advanced leadership, as a means to identify what was missing. In his journey, he recognized the importance of adding one thing at a time, instead of trying to arm wrestle the known universe. Can you relate? Does your leadership style feel like a scene from Everything, Everywhere, All at Once? Inside the frenzy of meetings and obligations, take the win for what you’re already doing right. From a place of encouragement, expand your possibilities. Schreiner calls his approach “Appreciative Inquiry” – offering a new kind of AI that doesn’t cause all of Hollywood to go on strike. “I wanna celebrate what’s already good, and from there: What are one or two or three of the things that are still outstanding that you might be willing to try?”

At its core, leadership is about humanity: connecting with people in a way that drives results. For effective leaders, those results come from appreciation, transparency and process. Leaders, and employees, have to realize that profitability and humanity must co-exist – one supports the other. When turnover can cost as much as 200% of a single workers’ salary, retention in healthcare is a profit-sucking obstacle for everyone – driving up healthcare costs, and reducing the quality of care. More than perhaps any other arena, healthcare is a people business. But hospitals are just one example among many, where people are making a difference. Maybe you’re not healing the sick or bringing babies into the world at your office, but anything of any value happens with the input of other human beings. At least, for now anyway. When you get right down to it, business exists for people, and with people, and because of (wait for it) people. In an era where the entire knowledge of the human race is just one prompt away, the information that leaders need isn’t coming from a ‘bot. We are already well-equipped to be better human beings. And in that regard, leadership is simply putting humanity into practice.

Imagine this.

As your health system’s CEO, you finish a meeting with a physician, stand to walk them to your office door, and present them with a handheld tablet on which they determine your compensation. The choices are 0%, 10%, 20%, and 25%. The process repeats throughout the day as you meet with your Board Chairman, a Vice President who reports to you, a housekeeping employee, and your Administrative Assistant.

As a servant leader, your organization has determined a portion of your compensation will be similar to that of a server in a restaurant. To keep the math simple, if you earn an annual salary of $100,000, your base pay will be reduced to $80,000, and you will have the opportunity to “make it up” through service to your key constituents. If you meet or exceed expectations, a generous gratuity will be granted. Leave them wanting, and no tip is given.

Non-profit leaders see themselves as stewards of the organizations who seek to grow the resources and reputation of the organizations entrusted to them (van Dierendonck et al., 2017). Servant leaders focus on the development of their followers.

Authentic leadership and servant leadership are closely aligned. Eva suggested that “servant leaders are authentic not for the sake of being authentic, but because they are driven either by a sense of higher calling or inner conviction to serve and make a positive difference for others” (Eva et al., 2019, p. 113). When considering the context of leadership in rural medicine, authentic leaders and servant leaders conform nicely to the space. Authentic leaders need and take opportunities to interact with their constituents. Servant leaders view hospital leadership as an opportunity to serve multiple constituents.

Let’s go back to that meeting with the physician. This doctor came to speak with you about her compensation. She feels she should be paid for taking call above and beyond the one-in-three medical staff bylaw requirements. You listen intently, processing the broader organizational impact of such a move. A commitment is made to consider the request and get back to her.

The handheld is offered. The physician looks you in the eyes and chooses 10%. You receive this message: “you heard me, now what are you going to do about it?”

How might this instant application of a gratuity impact your engagement? Would your decision be affected? Would the tone of your voice and your listening practices be modified in a more remarkable attempt to show interest and concern? Remember, when you return to this physician to report your decision, the handheld device will be presented for another gratuity round.

Gratuity is “something given voluntarily or beyond obligation, usually for some service” (Merriam-Webster, retrieved June 22, 2022). Leaders provide service in every interaction, and the concept of instant feedback is thought-provoking. A leader might claim they have little control over the mindset, agenda, or temperament of the people they serve, rendering the concept of tipping each encounter unfair. A server in a restaurant has no control over parking, the table where customers are assigned, the temperature of the food, or prices. Yet they are subject to the discretion of those they serve.

Why not leaders?

Peter Northouse describes servant leadership as the caring principle, with leaders as servants who focus on their followers’ needs to help these followers become more autonomous, knowledgeable, and like servants themselves (Northouse, 2018). (p. 24). Eva et al. (2019) expanded Greenleaf’s definition by including the success and prosperity of the broader community.

Some of the world’s leading corporations have adopted servant leadership practices, including Starbucks, Southwest Airlines, Ritz-Carlton, Marriott, and Intel (Eva et al., 2019). In the seminal work on servant leadership, Greenleaf (1977) stated, “Servants by definition are fully human. Servant leaders are functionally superior because they are closer to the ground—they hear things, see things, know things, and their intuitive insight is exceptional. Because of this, they are dependable and trusted.”

As servant leaders, we are motivated for reasons far beyond financial returns to care for those we serve. I interviewed CEOs, board chairpersons, hospital executives, physicians, and staff members at five health systems to determine effective engagement methods. Three themes emerged from the research.

This qualitative research determined that all three best practices for engagement must be implemented.

Engage and Connect at a Personal Level

Ask great questions and generate positivity

• Develop outstanding listening skills and practice them regularly
• Be accessible and show an interest in member concerns
• Find ways to express gratitude
• Find ways to interact through rounding

Engage with Intent through Various Mediums

• Find a rhythm of regular communication with key constituents
• Be transparent with high frequency
• Use multiple channels to communicate your message
• Look for ways to overcome engagement challenges
• In times of crisis, be intentional in communicating differently

Be Mission-Focused

• Keep the focus on the mission and know your audience – be prepared
• Vocally support team members and encourage healthy debate
• Ensure team members feel informed and included
• Build a structure to support key leaders
• The Executive is part of the community – get involved

If your compensation depends upon the evaluation of others defined at the moment of interaction, these best practices give you the best chance of reaching and exceeding your previous salary.

And who is to say our compensation and career success do not, directly and indirectly, revolve around how we engage with our key constituents?

References

• Eva, N., Robin, M., Sendjaya, S., van Dierendonck, D., & Liden, R. C. (2019). Servant leadership: A systematic review and call for future research. The Leadership Quarterly, 30(1), 111–132. https://doi.org/10.1016/j.leaqua.2018.07.004
• Gratuity Defined. (n.d.). Merriam-Webster. Retrieved June 21, 2022, from https://www.merriam-webster.com/dictionary/gratuity
• In-text citation
• Greenleaf, R. K. (1977). Servant leadership: A journey into the nature of legitimate power and greatness. Paulist Press.
• Northouse, P. G. (2018). Leadership: Theory and practice (8^th ed.). Sage Publications.
• Schreiner, D. L. (2022). What CEO practices help rural hospitals engage constituents in volatile, uncertain, complex, and ambiguous times?
• van Dierendonck, D., Sousa, M., Gunnarsdóttir, S., Bobbio, A., Hakanen, J., Pircher Verdorfer, A., Cihan Duyan, E., & Rodriguez-Carvajal, R. (2017). The cross-cultural invariance of the servant leadership survey: A comparative study across eight countries. Administrative Sciences, 7(2), 1–11. https://doi.org/10.3390/admsci7020008

Published in The Governance Institute, December 2021

I tell our senior leaders that we have twelve Super Bowls every year. These big moments are when we get together to have hospital board meetings, and I want each one to be special for everyone involved.

Board members want to make valuable contributions to the organizations and communities they serve, and rural hospital CEOs want their board members engaged. What is important to board members, and how do we, as executives, show them the love they deserve?

I came up with a novel idea:  Ask them.

I surveyed the eleven board members from the independent, rural health system I serve and received input from six. I did not finish at the top of my class in my doctoral program statistics class, but I’m going with the basis that a 54% response rate is pretty solid. I asked four questions:

1. Think of a time when you felt fully engaged as a Hospital board member. Describe in vivid detail what was going on at the time. What was it about the moment?

• When thinking of our board meeting agenda, do certain items catch your attention?  Describe a category(s) you find interesting and why.

• Is there anything about your board work that is a de-energizer for you? Do certain topics leave you feeling less engaged?

• What could I do to increase your feeling of engagement and accomplishments as a Hospital Board member?

The answers funneled towards five themes that may help to lead your board members with love.

Make Sure All Voices Are Heard

Break into small groups and tackle a complicated topic. Ask the question from a curious perspective. Have each group elect a spokesperson and reconvene the full board and share key takeaways. Small groups offer some of our quieter members the opportunity to express their opinions in a safe manner.

Connect Board Members with Employees

Any chance to connect board members with those closest to our patients is a win. Invite them to serve lunch at Hospital Week and bring board members in as participants in staff retirements and other celebrations. Ask key hospital personnel to present information at board meetings and allow board members to ask questions and express gratitude for the work. This practice represents a growth opportunity for the employee as well. Board education has a role in many of our board meetings. Bring internal talent onto this stage.

Connect Board Members with Each Other

Our board meetings finish with a roundtable chance for each member to share something personal or professional. We call this segment “Inquiring Minds.” New grandchildren, job accomplishments, patient stories, and times when something they learned at a hospital board meeting was operationalized in their own business have all been topics of conversation. This process takes less than ten minutes and helps to personalize the experience.

Balance Out Heart Versus Head Agenda Items

Some of us are numbers people, while some of us feed on emotion. Find a balance during your board meetings to connect with both kinds of board members. If the meeting needs to be finance-heavy, find a way to weave in an appreciative inquiry moment, inviting board members to dream about the organization’s future. If a portion of the meeting needs to address hospital billing issues, balance the topic by asking members what it might feel like to have a near-perfect billing experience with hospital and physician services.

Find A Way To Close The Loop On Key Issues

Here’s a quote from the survey that caught my attention:

“The board hears a lot about strategic partnerships when we are considering the opportunity or first entering into them, but we hear little about how those partnerships are progressing until there is an issue that causes us to exit the strategy. We often invest a substantial amount of money in infrastructure to accommodate a partnership, and it would be beneficial to know how successful these initiatives are periodically.”

When the board makes a key decision, create a placeholder three months or six months away that provides the board with an update on how that decision is progressing. Good or bad, close the loop, reevaluate the decision, and learn from the process.

Closing Thoughts

A high level of engagement between hospital board members and senior leadership contributes to organizational success. Positive engagement is wonderful when things are going well and our health systems are firing on all cylinders. I suggest engagement is even more important in challenging times when CEOs need support, advice, and love from the board members they are blessed to serve.

Building positive connections with our hospital board members has proven to be one of the most rewarding aspects of my career. Try one or more of these suggestions, and let me know if and how the change impacts the meetings with this most important constituency group.

I believe all Americans deserve access to a medical professional to make them feel better when they’re sick or hurt. In my experience, that access feels even more important when the hurting person is my spouse, a young child or an elderly parent. In situations like these, should healthcare be considered an inalienable right? I say yes.

More proactive services – such as wellness programs, mammography tests and annual physicals – are important, too. Are these rights? And, if so, who should pay for services?

Some politicians argue the government is responsible. “Medicare-for-All,” which continues to pick  up some momentum this election cycle, is built on the premise that healthcare is a right. The proposal would replace private insurance, Medicare and Medicaid.

According to an article on Politifact.com titled “Medicare-for-All: What it is, and what it isn’t,” “Medicare for All would be a single, national health insurance program that would cover everyone who lives in the United States… It would pay for every medically necessary service, from routine doctor visits to surgery to mental health to prescription drugs. Dental and vision care are part of the package, too.”

Studies have shown that so-called “social determinants of health” – things like access to healthy food, shelter, safety, education and clean air – have a huge impact on a person’s wellbeing. Should these be included under things that are “medically necessary”?

Is it one person’s right to live in a large house with acreage while others live in more modest settings? If everyone has the right to be educated, does that include primary school, undergraduate, graduate and doctoral studies?

If public transportation is not available in certain areas, should the government provide automobiles to citizens that live in those places?

The Congressional Budget Office estimates the cost of Medicare-for-All at upwards of $34 trillion. That’s “trillion” with a “T”. A suggested method of payment would come in the form of new taxes, perhaps increasing taxes by as much as 20 to 25 percent (The Atlantic, October 2019).

My area of expertise is in healthcare, and I intentionally veer somewhat out of my lane to challenge you to think about what Medicare-for-All might look like if our elected leaders are encouraged to continue down that path.You may have noticed that I’ve posed many more questions than answers. Here’s what I know: America’s community hospital’s are fighting every day to make needed services available to the people in the communities we serve. Hospitals are fighting to keep down costs, regardless of whether the entity paying is the employer, the government, or the patient. The healthcare payment process, as it exists today, is inappropriately complex and confusing and adds unnecessary costs for everyone.

I believe we owe it to our patients to work within today’s framework to find realistic solutions, rather than overhauling the entire system. I also believe healthcare is an inalienable right, which is why many hospitals are holding more open-to-the-community health programs, seminars and health events than ever before.  But I’m particularly proud of the great work the hospital community is doing to educate and improve the services offered to our communities, especially in rural areas,  in hopes of keeping our friends and neighbors out of the hospital and free from the high bills that our current system requires.

It may not be a perfect, immediate solution. But I believe we are making a difference in people’s lives,  and I’ve yet to see a realistic federal proposal that fixes our problems any better.

The COVID-19 pandemic is surging across our country, and true heroes are emerging. America’s healthcare workers are tirelessly caring for those patients that exhibit symptoms of the virus (fever, dry cough, or shortness of breath).

When I see our team members staffing a drive-thru screening clinic dressed in full personal protective equipment, it reminds me of firefighters running into burning buildings.

These people are heroes.

I witness our physicians, nurses, and technicians caring for our patients, knowing that their personal risk of exposure is exponentially higher. These people understand the risk and still come to work every day because they care about their patients.

These people are heroes.

Housekeepers clean dirty rooms. Maintenance workers fix what needs to be fixed, regardless of the location. Supply chain professionals work tirelessly to make sure the scarce supplies are obtained and distributed. Dietary workers feed not only our patients but our hungry, tired, staff members as well.

These people are heroes.

Lab Professionals do their jobs, Radiologic Technologists continue to perform their examinations, and Respiratory Therapists will continue to be key performers in the COVID-19 drama.

Nurses, Nurse Aides, and Medical Assistants in our physician offices are often the first point of contact in communication with our patients. They answer the phones, provide advice, schedule appointments, and care for our patients in the clinics.

These people are heroes.

All of them know they signed up for, and they do run towards the danger because that is what they were trained to do. And they still worry about taking home the virus to their own family members.

They go home exhausted and frustrated that they didn’t do enough and worried that they made a mistake.

And they come back the next day and do it again.