In health care today, a struggle has emerged between two leadership
models--"operations" and "dyad."
The operations model is the traditional and most-effective model of
leadership in most business settings. The management structure is based
on a team of supervisors, managers, and directors working together under
the leadership of a vice president to coordinate and implement
The operations arm of an organization creates the superhighway of
information flow. The explicit reporting, structure allows for
unambiguous authority and straight-forward decision making. In essence,
the supervisor reports to and is evaluated by their manager; the manager
reports to and is evaluated by their director or vice president, and so
The organizational structure creates the traditional pyramid.
Implementation of organizational initiatives is simple because those
below on the hierarchy are not typically empowered to reject direction.
In some ways, the simplest and most extreme example of the
operations model is a structure with no middle management--the
supervisors at the department level report directly to a vice president
who has full authority. The "command and control" structure in
the military is another obvious example. Orders are accepted
unquestioned and then implemented.
One key drawback of the operations model is that, other than the
chief medical officer, physicians hold no formal leadership roles. In
addition, in most health care organizations, physicians are no longer
owners but employees.
In this sense, they should behave as all employees and recognize
their relative position within the organizational hierarchy. In the
operations model, they would be excluded from positions of legitimate
authority and influence unless they held title.
For these reasons, the dyad model makes sense in health care.
The definition of "dyad model" varies across health care
organizations. In most health care systems, it appears that the
operations model remains intact while the vice presidents are partnered
with physician champions, who provided support for their
At Fairview Red Wing Health Services (FRWHS), we developed a
cross-sectional representation of the ambulatory and hospital service
areas and formally partnered an elected physician lead in each with an
Why health care leadership is different
Health care in essence is a sacred act of healing the ill and
injured. Health care providers often speak of a calling--a desire to
help those in need. The true understanding of this comes only through
caring for others.
Unlike business, where individuals enter the organization in
leadership positions after completing a bachelor's degree, the
infrastructure in health care relies on the identification of
individuals with clinical experience who demonstrate leadership
potential. It is essential that leaders in health care bring an
understanding of both the clinical world and the organizational world.
Integrated delivery systems require trusting partnerships between
caregivers. Because physicians hold a different status than nurses, the
need for trust and communication is essential. When trust is engendered,
the partnerships allow for alignment and movement toward shared goals,
both clinical and organizational.
The dyad model provides physician engagement to build that trust.
It opens communication between physician-nurse and
physician-administration in a powerful way.
In 1997, the physician-owned Interstate Medical Center and the
not-for-profit St. John's hospital merged. Fairview Red Wing Health
Services' leadership structure was built on a hierarchical
operations model with a chief operations officer (COO), a chief
financial officer (CFO), and a chief medical officer working together
under the authority of a chief executive officer (CEO). The pyramid
provided effective representation from all departments/work units. The
only physician who held leadership power directly was the chief medical
officer, who was appointed by the CEO.
Governance over the medical staff was granted to a medical practice
committee (MPC). Because FRWHS also employed its physicians, MPC had
both the traditional medical executive role and a management role of
physician activities. In essence MPC held two primary functions for the
First, it provided guiding leadership to administration and the
board as they represented the medical staff in opinion. It was a
sounding board and it offered key feedback and insight regarding the
Secondly, it was responsible to ensure a healthy work
environment--in this, it held the authority to intervene when necessary
regarding problematic physician/provider behavior.
In 2007, when the chief operating officer at FRWHS left the
organization, the CEO decided to implement the dyad model. One of his
imperatives in the process was "defining how to deepen physician
and manager dyads to drive clinical and operational excellence."
Rather than replace the COO, he recruited a chief nursing officer (CNO)
to create an "officer dyad."
Since 2004, each clinical department had elected a
physician/provider lead ("department lead") and the entire
organization was represented operationally by managers/supervisors from
the operations arm (mainly nursing leads).
The "microsystem" (language from the Institute of
Medicine) dyad partnerships were formed between the department leads and
the operations leads in all ambulatory departments and hospital service
"Director dyads" were created with a partnership between
a physician director and a nursing director. The director dyads
represented primary care, emergency department/urgent care,
surgery/operating room, and inpatient areas. The physician directors
were appointed by the CMO and the team was completed with a psychologist
director, forming "medical leadership."
Unlike MPC, medical leadership sat outside of the medical staff
structure. It was an administrative/operations team reporting to the CMO
and, thus, to the CEO. The primary work was around implementation and
follow up of initiatives from MPC with a particular focus on
standardization and accountability within the medical staff. The nursing
directors had a similar structure--they reported to the CNO who reported
to the CEO and focused on the nursing staff.
In truth, most of the work organizationally has occurred through
the director dyads--this structure has allowed the organization to
engage physicians effectively around quality, service and physician
behavior (a Joint Commission point of emphasis). The structured
partnership of physicians and nursing leads has been seen very
positively internally, particularly by the nursing leadership.
The microsystem dyads themselves recently evaluated the 2010
department lead job description. The physicians rated the job
description as a B+ and the nursing supervisors and managers rated the
job description as an A+. The nursing leads expressed intense
satisfaction at having clear, explicit expectations with their physician
The remaining piece in the leadership structure at FRWHS is
"leadership council" (LC). Leadership council holds primary
operational responsibility for the organization. The members are vice
presidents, selected by and accountable to the CEO. Their work is both
strategic and operational.
Leadership council is expected to support the mission, vision, and
promise of the organization and carry out the directives of the board.
The only practicing member of LC is the CMO, who allocates 30 percent of
his time to clinical practice (internal medicine) although the CNO has a
long history of clinical experience as a nurse in multiple settings.
The most important issue around leadership isn't necessarily
what model, but how well does a model succeed. On the surface, this
question may appear simple, but, in reality, there is little objective
criteria to measure leadership model effectiveness in health care. Table
1 provides a comparison of the two models.
In most business settings the preferred model is an operational
one--a pyramid structure with clear lines of authority and
accountability. This structure is efficient and straightforward.
Authority increases as one moves upward and falls ultimately on one
individual's shoulders. The strength of this structure is the clear
lines of accountability--the supervisor reports to the manager who both
directs them and evaluates their success.
Health care, however, has unique differences and a new model, the
dyad model, has taken root. In this model at FRWSH, the operations arm
is partnered at every level with physician leads.
There are many benefits of this model. Foremost, the dyad model
partnership of operations and physician reduces the "us-them"
perspective that plagues many health care organizations. This problem is
so significant that many physician groups continue to maintain their
independence from the health care setting that they practice in.
A classic example of the gulf appears in the hospital setting where
administrators strive to engage physicians in standardized workflows,
especially those that do not immediately improve safety or patient
experience but are based on the need to comply with a governmental or
Without physician engagement, the organization struggles to
successfully implement standardized workflows or, perhaps more
importantly, to rollout new workflows or innovations. In the dyad model,
the time invested up front ensures that the physicians understand the
change and have voiced their opinions regarding a potential change. With
physician leads that are respected by their colleagues, mistrust is
reduced and compliance can be swift.
A second benefit is obvious from the perspective of the supervisor
or manager. In the operations model these individuals are often
instructed that changes x, y, and z need to occur by a certain date.
They are left with the challenge of changing the practice of the
physicians in their work area--physicians who are not informed around
the reasons for the change and may well be mistrustful of
The operations person (often a nurse) needs to create change in
physician behavior but holds no legitimate authority over physicians.
Sadly, the rollout can take an extensive amount of time and generally
the organization creates multiple workarounds to create compliance when
a physician refuses to change (either overtly or covertly).
The dyad model does create financial demands. The organization
needs to invest time and money in the education and training of the
physician leads. This takes them away from their clinical practices and,
therefore, income earning activities.
In our organization, we kept the department leads in practice and
compensated them outside of their clinical time at an hourly rate. The
medical directors had time carved out of their practices due to the
complexity and time demands of the work.
A key challenge in the dyad model is to harness the leadership
potential of the MBA who brings essential perspective and knowledge
around the larger sphere of business and effectively partner them with
the MD who lives intimately in the clinical realm.
If the dyad model is to succeed, the organization must invest
resources in increasing the physician's knowledge and skills around
leadership. This model can create frustration for the MBA who is
accustomed to autonomous decision making.
The process of partnered decision making is slower up front and
physicians are trained to be autonomous decision makers themselves.
In the end, any successful management innovation needs to be an
improvement in delivering value to patients. This means better
financing, quality and service. If it fails to deliver on this value
proposition, the new model will likely fail.
1. Zimmer, DK., Brueggemann, JG. Examining the Dyad as a Management
Model in Integrated Health Systems. The Physician Executive Journal,
36(1): 14-19, Jan/Feb 2010.
2. Institute of Medicine, To Err is Human Washington, DC: National
Act Press, 1999.
3. Institute of Medicine, Committee on Quality of Care in America
Crossing the Quality Chasm: A Now Health System for teh 21st Century,
Washington, DC: National Academ Press, 2001.
Kim S. Baldwin, PhD, is a licensed psychologist and director of
professional engagement at Fairview red Wing Medical Center in
Jack W. Alexander, MD, is chief medical officer at Fairview Red
Wing Medical Center in Minnesota.
Nancy Dimunation, RN, BAN, MHA, is vice president and chief nursing
officer at Fairview Red Wing Medical Center in Minnesota.
By Kim S. Baldwin, PhD, Nancy Dimunation, RN, BAN, MHA, and Jack
Criteria of Effective Operations Dyad
1. Speed of Quick Moderate
decision to slow
2. Implementation Moderate to Quick
of change slow
3. Executive Centralized Shared
4. Trust of Weak Strong
5. Stakeholder Poor Good
6. Culture of Low risk High
consensus and risk
7. Ability to Quicker Slower
8. Ability to make Quicker Unclear
9. Role clarity Clear Mixed
10. Ambiguity Low Medium
11. Communication Good Good
who, when, how
12. Rapid Poor Good
13. Organizational Low High
14. Physician Low High
and support in
the delivery of