Rural Network Leadership

This article was written by Tim Size, Executive Director, Rural Wisconsin Health Cooperative (RWHC) for the “Networking News” monthly newsletter. The Network Technical Assistance Project is funded by the Federal Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services through a contract to Rural Health Innovations, LLC, a subsidiary of the National Rural Health Resource Center.

This article is abstraction from "Leadership Development for Rural Health" by Tim Size

Leadership is the capacity to help transform a vision of the future into reality.

The significant challenges we face today in healthcare require a form of leadership that is less authoritative and more collaborative. Ronald Heifitz and colleagues at the Stanford Graduate School of Business say it very well. These 'problems require innovation and learning among the interested parties, and, even when a solution is discovered, no single entity has the authority to impose it on the others. The stakeholders themselves must create and put the solution into effect since the problem is rooted in their attitudes, priorities, or behavior. And until the stakeholders change their outlook, a solution cannot emerge.'[1] It is important to not confuse being collaborative with endless stanzas of singing 'Kum By Ya;' collaboration frequently requires strong external catalytic action.

In Leadership Is an Art,[2] Max Depree offers a model for employer-to-employee relationships based on his experience that productivity is maximized by designing work to meet basic employee needs. His vision of the art of corporate leadership brought employees into the decision-making process. DePree's experience is primarily within the world of the Fortune 500, but many have found him to offer a useful framework for non-profit and public sectors.

While DePree was a successful leader of a Fortune 500 Company, some may describe him as impractical, a common descriptor thrown by the 'pragmatists' at 'collaborators.' Robert Greenleaf offers a suggestion that may be helpful in thinking through this dilemma: "For optimal performance, a large institution needs administration for order and consistency, and leadership so as to mitigate the effects of administration on initiative and creativity and to build team effort to give these qualities extraordinary encouragement."[3]

As the executive director of a cooperative of rural hospitals for more than 35 years, it is easier for me than for many to see rural health through the lenses of collaboration, the opportunities it creates, and the threats it endures as a model for organization and community work. We have adopted and adapted DePree's eight leadership principles as a guide for both our internal and external relationships.

To illustrate these leadership principles, the following is as described in the article Managing Partnerships: The Perspective of a Rural Hospital Cooperative. [4]

1. There Is Mutual Trust
Develop relationships based primarily on mutual trust so that the cooperative goes beyond the minimum performance inherent in written agreements. "While responding to a rapidly changing market in 1984, the implementation in six months, from scratch, of a rural-based health insurance company in Wisconsin was only possible due to the prior existence of a basic level of trust among the key actors."

2. Commitment Makes Sense
Participants may join a cooperative to explore its potential; they remain only if they perceive that they are receiving a good return on their investment of time and money. "RWHC offers a broad array of shared services from which hospitals pick and choose according to their individual needs; commitments are made because they have been structured in a way that attempts to maximize the 'fit' for each individual participant."

3. Participants Needed
Each organization must know that it is needed for the success of the cooperative. "It is a major mistake to ever take for granted the participation or commitment of any member. The RWHC communication budget is ample testimony to the importance of early and frequent communication and consultation."

4. All Involved in Planning
The planning is interactive, with the plan for the Cooperative being the result of, and feeding into, the plans of the individual participants. "One theatrical but powerful example of ignoring the need for local input and preferences involved the Cooperative within months of its incorporation in 1979. Two regional health planners were practically driven from the bare wood stage of Wisconsin's historic Al Ringling Theater after their presentation of a unilaterally developed plan for local consolidations and closures. The plan was not implemented and did not contribute to further discussion of how rural healthcare in southern Wisconsin could be improved."

5. Big Picture Understood
Participants need to know where the organization is headed and where they are going within the organization. "RWHC has a motto: 'Say it early and keep saying it.' A number of RWHC's more significant initiatives, such as improving rural hospital access to capital, various quality improvement projects, and advocacy for major education reform within the University of Wisconsin's health professional schools has been multiyear if not indefinitely long efforts."

6. Participants Affect Their Own Future
The desire for local autonomy needs to be made to work for the Cooperative through the promotion of collaborative solutions that enhance self-interest. "When RWHC began operations, many observers were highly skeptical about whether or not it would last, let alone make any real contribution-that rural hospitals' traditional need for autonomy would prevent any meaningful joint activity. Some shared services have been undersubscribed as hospitals have chosen local options when, at least from the perspective of RWHC staff, a cooperative approach offers a better service at a lower cost."

7. Accountability Up Front
Participants must always know up front what the rules are and what is expected of them. "Discussions at RWHC board meetings are frequently comparable to customer focus groups and equally valuable. Participation in all Cooperative shared services requires a signed contract, not so much as to permit legal enforcement, but to ensure that all parties in the partnership have thought through upfront the expectations of all the participants."

8. Decisions Can Be Appealed
A clear non-threatening appeal mechanism is needed to ensure individual rights against arbitrary actions. 'The use of the cooperative strength of RWHC hospitals has been used to enforce an appeals process in a variety of circumstances, including a potential breach of contract by a large health insurer; individually, few could have justified the necessary prolonged legal challenge to enforce the contract but through concerted joint inquiry into the legal options available, further legal action became unnecessary."

In summary, leadership is the capacity to help transform a vision of the future into reality. Individuals who can and will exercise leadership are like a river's current-a part past where we now stand, a part yet to come. We have an ongoing need to remember and to look toward the next 'generation.'

The full text of this article is available at Leadership Development for Rural Health

About
RWHC has been providing affordable and effective services to healthcare organizations since 1979. RWHC is owned and operated by thirty-nine (39) rural acute, general medical-surgical hospitals. The Cooperative's emphasis on developing a collaborative network among both freestanding and system affiliated rural hospitals distinguishes it from alternative approaches. RWHC offers a variety of programs and services to its members as well as to other clients across the nation. RWHC is a current Rural Health Network Development Grantee of the Health Resources and Services Administration, Federal Office of Rural Health Policy. RWHC staff served in early leadership roles and continues to be an active member of NCHN (National Cooperative of Health Networks).

[1] Size T. Special Issue of the North Carolina Medical Journal: Contemporary Issues in Rural Healthcare (in honor of James D. Bernstein), January-February Issue 2006.

[2] Heifitz R, Kania J, Kramer M. Leading Boldly. Social Innovation Review. 2004;Winter:25.

[3] DePree M. Leadership is an Art. New York, NY: Dell 1989.

[4] Greenleaf RK. Servant Leadership. New York, NY: Paulist Press, 1977:60.

[5] Size T. Managing partnerships: The perspective of a rural hospital cooperative. Health Care Manage Rev 1993:18(1):31-41.