Nurse executives say clinical experience matters in top healthcare jobs.
The way hospitals make money is changing. Government and insurance companies only want to pay for quality results, so now there’s more talk about making sure healthcare executives have clinical experience. Some say the person in the top spot needs to be a good leader and also an expert in the core business of healthcare.
Registered nurses commonly make the jump from staff nurse to manager and, eventually, Chief Nursing Officer. The next leap—to Chief Executive Officer—is a lot more rare.
One estimate suggests that a physician leads only five percent of hospitals. We didn’t find a good count on the number of RNs leading medical centers around the country, but we’ll get to the reasons behind that in a minute.
Kelly Doyle is CEO of Rothman Orthopaedic Specialty Hospital; she has lead the small for-profit organization in the Philadelphia suburbs since 2011. One of her first roles was to help the physician-owned hospital gain accreditation with the Joint Commission.
Asked why there aren’t more nurse CEOs, Doyle said you can’t overlook the fact that the vast majority of nurses are women.
“Women have to take a time out and raise their families,” she said. “If I had babies in my 30s, would I be sitting here? I don’t know.”
Doyle had her children young, and by the time she was in the prime years of career advancement—her kids were older. Hospitals never close, but in her 30s, Doyle says, it was easier to put in the long hours that healthcare management requires.
Then there’s this: “Nurses aren’t trained in finances, nurses are trained in patients, patient care and safety,” Doyle said.
A lot of what Doyle needs to know as a CEO, she learned on the job. Soon after her promotion, she booked a two-hour lunch with a mentor.
“And I took the financials with me, and I just asked him a lot of questions, and I tape recorded it and I listened to that recording over and over again,” Doyle said.
Today, she has an answer when a board member asks: Why are supply costs up? What’s happening with salary-wage benefits?
They also don’t teach facilities management courses in nursing school.
But when a recent storm dumped two feet of snow on the Philadelphia region—and the lights went out in Rothman’s hospital café—Doyle gathered her management team to prevent that from happening again.
“My job is to care about everything as a CEO,” Doyle said.
“The CEO is doing things like figuring out: ‘Are we going to float a bond, or not float a bond?’ Or ‘how are we going to recruit physicians from Mt. Sinai so we can be the center of dermatology, rather than them being the center of dermatology,'” said Christine Kovner, a professor at New York University’s college of nursing.
Nursing students are so focused on clinical skills, there’s not much time for management training, Kovner said, and lots of nursing schools offer just one or two classes in leadership.
“At least when I’ve taught that course, they just want to make sure they don’t mess up the IV,” she said.
The education you need to run a multi-million dollar business is not the same skillset you need to be able to react quickly in an emergency situation when someone suddenly starts bleeding, Kovner said. There are nursing leadership programs around the country—for mid-level managers—but registered nurses who lead entire healthcare organizations often first return to school for a business or administration degree.
Most top leaders in healthcare are marketing and finance types. That makes sense: bottom line, running a hospital is a business. In crowded healthcare markets like Los Angeles and New York, where there’s a big name medical center every few blocks, there’s lots of competition for customers, or patients.
In order to stay solvent—and stay open to offer good care, hospital leaders need to worry about attracting cases that are well reimbursed, said Richard Webster, an RN and president of Thomas Jefferson University Hospitals.
He oversees nearly 8,000 employees and about 900 patient beds across three hospitals in Philadelphia.
So what’s a hospital CEO’s biggest headache? Webster said in recent years there are many more outside requirements “almost dictating how we need to provide care.”
“Trying to meet certain metrics—that may not actually impact patient care–but are required by insurers and regulatory agencies, is certainly one the biggest challenges I experience in my role,” Webster said.
‘You can’t study that’
These days, a tailored, navy suit is Webster’s regular uniform, but he says he has scrubs in a closet somewhere just in case. It’s been a long time since Webster got his hands dirty, but he started his career as a staff nurse at the bedside.
“You can’t study that, you can’t read that,” Webster said. That clinical knowledge boosts his credibility as an executive, he said.
When a doctor comes in with a pitch for a cool, new piece of equipment, Webster weighs how that purchase might improve healthcare and how much it will cost.
“Physicians feel comfortable that someone who’s done direct patient care is making the decision,” Webster said.
When he was first promoted into a job away from direct patient care–to lead a profit center within the hospital—that was the first time Webster began working with colleagues in marketing and finance to capture more market share and focus on the “patient experience.”
When you look up Richard Webster’s bio—RN for registered nurse—is the first of many letters listed after his name.
Pamela Cipriano, president of the American Nurses Association, says some other nurse executives choose to leave RN off their resumes. Some administrators have let their nurse license lapse, but others intentionally leave the title behind, she said.
Cipriano says she’s heard this reason: “‘Well, I don’t want to put RN after my name because some people might not think that I know as much about business, or that might be a detractor when I’m competing with others in the C-Suite, especially men in the C-Suite.”
She says that’s disappointing. It also makes it hard to count up the nurses who are chief executive officers, chief operating officers, board chairs and presidents.
“We wish we had more data about how many nurses are moving into those executive positions,” she said. But anecdotally, Cipriano says she’s noticing more nurses taking over the top spots in healthcare.
Christine Kovner offered another anecdote that might help explain why more nurses don’t lead healthcare organizations.
Kovner was caring for her three-year-old grandson when he cut his finger. As the two went to look for a Band-Aid, she said to him: “‘You know Zachary, Nona’s a nurse.’ He put his hands on his hips and he said: ‘My mother’s a doctor.'”
Kovner’s daughter is actually a Ph.D., not a physician—but no matter—in young Zach’s mind, doctors clearly ‘outrank’ nurses.
Kovner says attitudes about who’s supposed to be at the top of the healthcare heap are ingrained and passed on early—even in a time when lots of professionals are emphasizing an inter- and trans-disciplinary approach, where clinicians –-whatever their specialty– work as a team.
“Let me just correct one notion, nurses almost never report to physicians [in a large hospital setting],” Cipriano said.
And–it seems—physicians do not typically report to nurse executives.
At Jefferson, the chief medical officer is part of president Richard Webster’s management team, but the top physician at the hospital reports to the CMO of the parent company Jefferson Health.
At Rothman Orthopaedic Specialty Hospital, CEO Kelly Doyle is in charge of about 150 staffers—but that count does not including the physicians.
“I don’t tell the doctors what to do,” Doyle said.
A typical day
About once a week, she’s in by 6 a.m. as the first surgeries of the day begin. Doyle—who’s just five feet tall–changes into comfortable blue scrubs to say ‘hi’ to the surgeons, but she never kicks off her four-inch suede pumps.
“I’ve been known to wear heels in the operating room,” Doyle said.
As Doyle tours the surgery suites, she’s thinking about volume.
There are 20 cases on the schedule the day I visit. Spine, shoulder, elbow and ankle surgeries are Rothman’s bread and butter.
As she watches an operation, Doyle is making sure the staff uses hardwired habits to prevent medical errors. Part of an executive’s job is to make a profit– and that only happens, Doyle says, if people are getting quality care.
Sports medicine surgeon Christopher Aland says he and other physicians trust an administrator–just a bit more–if that person has experience working directly with patients.
“The MBAs don’t get it. They’ve gone to school, they’re brilliant, smart people, but they haven’t been in the pits,” Aland said.
“I started my career in nursing,” Doyle said. “If there is a nursing mailroom, I essentially worked my way up through it.”
Savvy shoppers can get their shoulder surgery at one of the big academic medical centers in Philadelphia–just 25 minutes away. So, one of Doyle’s tasks is attracting top doctors to her small 24-bed hospital–and to get patients to follow their doctor to the suburbs.
There’s no emergency room or intensive care unit at Rothman—so part of the hospital’s business model is to only take-on patients who have an orthopedic problem–but who are otherwise healthy.
You can’t use Medicaid at the specialty hospital–and some people pay more because their insurance carrier considers the hospital out-of-network–but parking is free and you get a guaranteed private room.
As CEO, Doyle gets two big reports cards each month: patient satisfaction scores and the number of cases that come through the door.
In the last year, she says volume has increased by more than 20 percent—partly because she and the other Rothman leaders negotiated new reimbursement contracts with the “Blues” branded insurance companies. Patients with health coverage through Independence Blue Cross—for example–now pay in-network rates when they get care at the specialty hospital, Doyle said.
It was an executive win.
There’s a national movement to get more nurses appointed to all kinds of trustee boards—community, corporate, governmental, and healthcare. The goal is 10,000 nurses by 2020.
Supporters say that change could make a significant difference to hospital leadership around the country.