Today marks the 63rd anniversary of Harper Lee‘s “To Kill a Mockingbird” (1960) — a novel containing truths so universal that they bear repeating in 2023.
“You never really understand a person until you consider things from his point of view … Until you climb inside of his skin and walk around in it.”
“I wanted you to see what real courage is … It’s when you know you’re licked before you begin but you begin anyway and you see it through no matter what. You rarely win, but sometimes you do.”
“People generally see what they look for, and hear what they listen for.”
“The one thing that doesn’t abide by majority rule is a person’s conscience.”
“Sometimes the Bible in the hand of one man is worse than a whisky bottle in the hand of another … There are just some kind of men who — who’re so busy worrying about the next world they’ve never learned to live in this one, and you can look down the street and see the results.”
HBO’s critically acclaimed series Succession recently concluded its fourth and final season with a crescendo of family dramatics and falls from grace. If you haven’t seen the finale, bookmark this article for later. It contains spoilers.
Succession, for those unfamiliar, centers on the uber-wealthy Roy family, majority owners of the global media and entertainment subsidiary Waystar Royco. The plot revolves around the bullishly Machiavellian patriarch Logan Roy and his four adult children, each of them seeking (a) control of the family business and (b) their dad’s approval.
During its run, the show’s endless infighting and fascinating archetypes captivated viewers. But the 39-episode series also provided enduring lessons in dysfunctional leadership, which apply directly and saliently to U.S. healthcare.
As with Waystar Royko, the institutions of medicine (hospitals, medical groups, insurers, pharma and med-tech companies) need excellent leadership just to survive. With millions of dollars and hundreds or thousands of jobs resting on the decisions of top administrators, any major flaw can prove fatal—erasing decades of organizational success.
In any industry, poor leadership can undermine performance and threaten livelihoods. In healthcare, poor leadership puts lives at risk. Here are five dangerous types of leadership personalities, each inspired by a character from Succession:
1. Connor Roy: the delusional leader
In the show’s second season, Connor, the eldest and oft-forgotten son of Logan Roy, launches his U.S. presidential campaign on a “no-tax” platform. When the eve of election arrives, he’s polling at less than 1%, yet he refuses to step aside, still convinced he is capable of doing the job.
Like Connor, healthcare’s delusional leaders overestimate their abilities. Their ideas are unrealistic and their vision for the future: pure fiction. But no matter how outlandish their outlook, delusional leaders will always find apostles among the disenfranchised who, themselves, feel undervalued and overlooked.
When confronted with the harshness of reality, deluded leaders and their followers double down, insisting that everyone else is myopic. “Just follow and you’ll see,” they demand.
Unless senior executives or board members step in to relieve this leader of power, the organization will be as doomed as Connor Roy’s bid for presidency.
2. Kendall Roy: the narcissistic leader
On the surface, Kendall is by far the most capable and experienced candidate to succeed his father. He’s a smart and articulate heir apparent who appears up to the task of CEO.
But underneath the gold plating, his every action is reflexively self-centered. As such, when the time comes to sacrifice something of himself for the good of the company, he freezes and falters, his decisions corrupted by the compulsion to put himself first.
Like Kendall, healthcare’s narcissistic leaders bask in praise and blind loyalty. They reject and punish those who provide honest feedback and fair criticism. Their obsession with status and self-importance blinds them to long-term threats and opportunities, alike.
Unlike delusional leaders, who fail because their vision cuts against the grain of reality, the narcissistic leader’s passion for winning may advance an organization—in the short run. Long-term, however, their flaws will be exposed and weaknesses manipulated by seasoned competitors.
Across four seasons, Kendall can’t fathom that anyone else might be a better choice to run the company. As a result, he underestimates a rival CEO who’s seeking to acquire Waystar, and he overestimates the loyalty of his siblings. In the end, he’s left hopeless and broken.
3. Roman Roy: the immature leader
Roman, the youngest Roy, is brash and witty, but also unpredictable and unrestrained. His penchant for foul language and cutting insults make for good television, but they’re the telltale signs of insecurity and immaturity.
Like all immature leaders, Roman is addicted to novelty and excitement, often acting without regard for the consequences. He’s fast-talking and loud, which makes him likable enough for many to overlook his incompetence. But he’s incapable of filling his father’s shoes.
Immature leaders get promoted before they’re primed and polished. They often lack boundaries and excel at the sport of making others uncomfortable. At times, they seem more interested in causing a scene than creating results. They chase big ideas—if only for the adrenaline rush—but can’t accurately calculate whether the risk of failure is 20% or 80%. This makes them very dangerous as leaders.
4. Shiv Roy: the political leader
In a world of deluded and despotic men, Shiv comes across as the voice of reason. Smart and strategic, relaxed and composed, Shiv carefully cultivates new allies but never establishes an identity of her own. This makes her an excellent political consultant (the job she has) but a poor candidate for CEO (the job she wants).
Political leaders are better at advancing within an organization than advancing the organization itself. Like chameleons, these leaders change with the scenery, shifting alliances and values as organizational power waxes and wanes. While they’re busy focusing on rumors and relationships, they fail to muster real-life business acumen and experience.
Colleagues rarely respect those who play organizational politics. Once political leaders have accrued enough power and advanced their careers to the max, their shallow alliance and inability to drive performance leaves them stranded at the top—with nowhere to go but down.
5. Tom Wambsgans: the compromised leader
Not technically a Roy, Tom is Shiv’s husband and an eager aspirant for CEO.
Once appointed head of Waystar’s struggling cruises division, Tom conceals damaging information to protect his father-in-law. He is a willing henchman, ready to sacrifice his ethics for a shot at the corner office.To advance his interest, Tom repeatedly compromises his integrity, first with Logan, then Kendall, and eventually Lukas Matsson, the incoming global CEO who completes the hostile takeover of Waystar.
In what proves to be Tom’s final interview for U.S. CEO, Matsson asks him whether he will be willing to play the role of “pain sponge,” absorbing any negative fallout the company may experience. After he responds positively, Matsson tests him further by mentioning that he’d like to have sex with Shiv. While viewers squirm in their seats, Tom doesn’t object. For him, every compromise is simply a means to an end.
Compromised leaders are skilled at making promises. They seek support by vowing to fulfill wants and palliate pains. Depending on who these leaders aim to please, they’re willing to slash budgets or raise salaries, regardless of the financial impact. Ultimately, they’ll do anything to keep people happy, even if they have to sink the business in the process.
The three attributes of excellent healthcare leaders
In the final season of Succession, Logan tells his offspring, “I love you, but you are not serious people.” He is both accurate and accountable. Logan was not a serious father and, as a result, his kids were poorly equipped for life and leadership.
The healthcare industry is replete with stories of once-successful institutions falling on hard times under poor leadership. Although there’s no one way to run an organization, all great healthcare leaders share three characteristics:
1. A clear mission and purpose
Leaders have three jobs. They must create a vision, align people around it and motivate them to succeed. To accomplish these tasks, executives may use carrots and sticks, incentives and disincentives, or positive and negative reinforcement. But these tactics will fail unless they reflect a clear mission and purpose.
Years ago, former CMS administrator Don Berwick started a program with an audacious goal of maximizing patient safety and preventing unnecessary deaths. He called it the 100,000 Lives Campaign. And when he spoke of the program, he leaned hard on its righteous mission. Instead of presenting metrics and statistics, he talked about the weddings and graduation ceremonies that parents and grandparents would attend, thanks to the program and the people behind it. Even hard-weathered clinicians in the audience had tears in their eyes.
Financial incentives drive change in healthcare, but rarely achieve the outcomes intended. Everyone engaged in the 100,000 Lives Campaign knew exactly what they needed to accomplish and were motivated to do so.
2. Experience and expertise
Bold ideas and glittering promises always capture attention. Words are powerful and relationships can take aspiring leaders far. But when it comes time to turn big plans into action, there is no substitute for a leader who has been there and done it well.
Exceptional performance, not promises, separate great leaders from the rest—and success from failure. In every industry, past performance is the best predictor of future success. Of course, poor leaders can get lucky and even great ones in bad circumstances may fail. But the odds always favor those who have achieved recurring success throughout their careers.
3. Personal integrity
Emerging leaders can work on their weaknesses. Coaching, training and even therapy can help them quell maladaptive behaviors.
But everything changes when an emerging leader becomes the head of an organization and faces a crisis. As risks and pressures intensify, people tend to fall back on approaches and habits they learned in the past, particularly problematic ones. Whenever tested, the Roy children did exactly that.
After Logan’s death early in the final season, the fatal flaws of each Roy child came into clear view. As a result, the Waystar board made the safest choice for successor: none of the above.
Like a true Shakespearean tragedy, the flaws of the characters in Succession exceeded their abilities.
In healthcare, that’s a guaranteed prescription for failure.
On October 1, 1908, Ford produced the first Model T automobile. More than 60 years later, this affordable, mass produced, gasoline-powered car was still the top-selling automobile of all time. The Model T was geared to the broadest possible market, produced with the most efficient methods, and used the most modern technology—core elements of Ford’s business strategy and corporate DNA.
On April 25, 2018, almost 100 years later, Ford announced that it would stop making all U.S. internal-combustion sedans except the Mustang.
The world had changed. The Taurus, Fusion, and Fiesta were hardly exciting the imaginations of car-buyers. Ford no longer produced its U.S. cars efficiently enough to return a suitable profit. And the internal combustion technology was far from modern, with electronic vehicles widely seen as the future of automobiles.
Ford’s core strategy, and many of its accompanying products, had aged out. But not all was doom and gloom; Ford was doing big and profitable business in its line of pickups, SUVs, and -utility vehicles, led by the popular F-150.
It’s hard to imagine the level of strategic soul-searching and cultural angst that went into making the decision to stop producing the cars that had been the basis of Ford’s history. Yet, change was necessary for survival. At the time, Ford’s then-CEO Jim Hackett said, “We’re going to feed the healthy parts of our business and deal decisively with the areas that destroy value.”
So Ford took several bold steps designed to update—and in many ways upend—its strategy. The company got rid of large chunks of the portfolio that would not be relevant going forward, particularly internal combustion sedans. Ford also reorganized the company into separate divisions for electric and internal combustion vehicles. And Ford pivoted to the future by electrifying its fleet.
Ford did not fully abandon its existing strategies. Rather, it took what was relevant and successful, and added that to the future-focused pivot, placing the F-150 as the lead vehicle in its new electric fleet.
This need for strategic change happens to all large organizations. All organizations, including America’s hospitals and health systems, need to confront the fact that no strategic plan lasts forever.
Over the past 25-30 years, America’s hospitals and health systems based their strategies on the provision of a high-quality clinical care, largely in inpatient settings. Over time, physicians and clinics were brought into the fold to strengthen referral channels, but the strategic focus remained on driving volume to higher-acuity services.
More recently, the longstanding traditional patient-physician-referral relationship began to change. A smarter, internet-savvy, and self-interested patient population was looking for different aspects of service in different situations. In some cases, patients’ priority was convenience. In other cases, their priority was affordability. In other cases, patients began going to great lengths to find the best doctors for high-end care regardless of geographic location. In other cases, patients wanted care as close as their phone.
Around the country, hospitals and health systems have seen these environmental changes and adjusted their strategies, but for the most part only incrementally. The strategic focus remains centered on clinical quality delivered on campus, while convenience, access, value, affordability, efficiency, and many virtual innovations remain on the strategic periphery.
Health system leaders need to ask themselves whether their long-time, traditional strategy is beginning to age out. And if so, what is the “Ford strategy” for America’s health systems?
The questions asked and answered by Ford in the past five years are highly relevant to health system strategic planning at a time of changing demand, economic and clinical uncertainty, and rapid innovation. For example, as you view your organization in its entirety, what must be preserved from the existing structure and operations, and what operations, costs, and strategies must leave? And which competencies and capabilities must be woven into a going-forward structure?
America’s hospitals and health systems have an extremely long history—in some cases, longer than Ford’s. With that history comes a natural tendency to stick with deeply entrenched strategies. Now is the time for health systems to ask themselves, what is our Ford F150? And how do we “electrify” our strategic plan going forward?
Writing for Forbes, Sachin Jain, president and CEO of SCAN Group and Health Plan, argues that “toxic positivity,” or the idea that one should only focus on what’s going right rather than identifying and working on the underlying causes of a problem, is rampant throughout the healthcare industry and offers a few ideas on how to fix it.
Toxic positivity in healthcare
Jain writes that toxic positivity is a “somewhat understandable reaction to seemingly insurmountable obstacles, which perhaps explains toxic positivity’s ascendancy in the healthcare industry.” But now, toxic positivity is “bleeding into situations involving challenging but fully solvable problems.”
For example, Jain writes that nearly every company in the healthcare industry eventually pays a marketing agency to craft “glorious-sounding mission statements” that are then used by leaders whenever they are confronted with their shortcomings.
“Your health system just christened a new billion-dollar hospital, but is unleashing bill collectors on the indigent? Our mission is clear: Patients first!” Jain writes. “Your startup appears to be serving only the wealthiest and healthiest retirees, while pulling no cost from the healthcare system? We’re proudly committed to doing right by seniors by offering value-based care!”
Jain clarifies that he doesn’t believe all healthcare executives are cynically trying to avoid hard issues. Rather, they are “often too far removed from the front lines of the system, and even their own companies’ patient-facing operations, to witness the flaws.”
Often executives don’t notice the flaws in their health systems until a loved one needs help, Jain writes. “Only then do the industry’s leaders confront the reality that, at a person’s most vulnerable point in life, healthcare companies often treat you like a consumer … instead of just taking care of you.”
Without that reality check, it’s easy for executives to rely on their lofty mission statements and value propositions, and to “see their companies as distinct from, rather than intrinsically connected to, the industry’s biggest issues,” Jain writes.
How to fix toxic positivity
One simple intervention won’t fix toxic positivity in the healthcare industry, Jain writes, but companies can start by talking about their flaws.
“In a perfect world, the healthcare industry would commit to a culture of relentless interrogation of its flaws as a means of driving to better results,” Jain writes. Healthcare leaders need to “stop hiding behind company mission statements and ‘just-so stories’ about their impact and start speaking publicly about the steep challenges we each face as we fall short of fulfilling our specific corporate mission,” Jain adds. That means publicly addressing issues at events and discussing strategies for addressing them.
Private behavior within a company can also help reverse toxic positivity, Jain writes. Leaders should continue celebrating the accomplishments of frontline healthcare providers, but they should also “bring a critical eye to their operations and demand — not just encourage — that their colleagues help them uncover ways they can individually and collectively do better.”
That means asking questions like, “If our organization disappeared tomorrow and people were forced to find their healthcare insurance or services or devices elsewhere, would anyone be truly worse off and why?” Jain writes. If your company doesn’t have an answer for that, then you should work harder to increase your replacement value and drive competitive differentiation.
Addressing toxic positivity also means addressing the flaws in value-based care and having “honest, authentic conversations about what works and what doesn’t and why,” Jain writes. “About whether companies that proclaim to improve care are merely benefitting from arbitrage opportunities in reimbursement systems or are actually, meaningfully improving service to patients.”
Executives need to stop treating the healthcare industry like all other industries and “call BS on the idea that it’s somehow okay to be financially successful without making an actual difference in anyone’s lives,” Jain writes.
The healthcare industry needs to welcome thoughtful, critical, and reflective voices to every table, Jain writes. “Because nothing — absolutely nothing — will actually get better without them.”
There is no shortage of challenges to confront in healthcare today, from workforce shortages and burnout to innovation and health equity (and so much more). We’re committed to giving industry leaders a platform for sharing best practices and exchanging ideas that can improve care, operations and patient outcomes.
Check out this podcast interview with Ketul J. Patel, CEO at Virginia Mason Franciscan Health and division president, Pacific Northwest at CommonSpirit Health, for his insights on where healthcare is headed in the future.
In this episode, we are joined by Ketul J. Patel, Division President, Pacific Northwest; Chief Executive Officer, CommonSpirit Health; Virginia Mason Franciscan Health, to discuss his background & what led him to executive healthcare leadership, challenges surrounding workforce shortages, the importance of having a strong workplace culture, and more.
HENRY KOTULA 