Every chief medical officer (CMO) remembers the healthcare workforce crisis during the COVID-19 pandemic; some are still struggling with it, and many are bracing for workforce shortages in the future. About 40% of registered nurses, licensed practical nurses, and licensed vocational nurses plan to leave nursing within the next five years, according to the 2024 National Nursing Workforce Study.
The challenges of delivering safe, high-quality care with too few — or inexperienced — nurses test the resilience and coordination of clinical leadership teams. That’s why a close, collaborative relationship between the CMO and the chief nursing officer (CNO) is not just helpful, but essential, says James L. Hill, Jr., MD, MBA, CPE, FASA, FACHE, chief operating officer and former CMO at University Hospitals Parma Medical Center, the largest community hospital in the UH Health System.
“The CMO and CNO partnership was critical,” he says, recalling his dual role as both CMO and COO during the height of the pandemic.
As Hill and other clinical leaders shared their perspectives on dealing with nursing shortages with Physician Leadership Journal, one message stood out: The CMO/CNO relationship needs to be rock-solid before a crisis so the clinical executives can lead their teams — and protect their patients — when a crisis hits.
“Do not underestimate the investment that you’re going to have to put into that relationship,” warns Janice Walker, DHA, MBA-HCM, NEA-BC, BSN, RN, a system chief nurse executive previously serving Baylor Scott & White and Advocate Health. “That relationship has to be built on every single day.”
DIFFERENCES AND CHALLENGES
Reaching top leadership positions, CMOs and CNOs share the drive to work hard and be the best they can be. Beneath those shared attributes, however, they are physicians and nurses with inherent differences in training and the nature of their work.
“We come from different training models,” says Dani Hackner, MD, chief clinical and academic officer at Southcoast Health, a three-hospital system serving southeastern Maine and Rhode Island.
Nurses are trained to work collaboratively while physicians are trained to take responsibility for their patients’ outcomes. And, day in and day out, nurses work in groups while physicians operate more autonomously.
“They tend to be in two different silos,” says Anand Budi, MD, CMO of Meritus Medical Center in Hagerstown, Maryland. Those silos can support us-vs.-them thinking. “That can create an environment where, for example, if a physician is not being polite or professional to the nurse, that spreads like a wildfire among the entire group of nurses,” Budi says. “And vice versa.”
While physicians and nurses know a lot about patient care, they do not always understand one another’s professional lives. “Physicians at times think they understand what nurses do and they do not,” Walker says. “And we nurses think we understand the pressures physicians are under and we do not. Just because you have worked beside each other for years and years and years does not mean you truly understand how others are educated, how they think, the accountability they have.”
These differences present challenges to navigate in the working relationship between CMO and CNO and in the management of the respective physician and nursing staffs for which they are responsible.
In the past, Budi has seen situations in which the CNO and CMO always pointed the blaming finger at one another’s staff when problems arose. “That creates an environment of constant tension,” he says.
It doesn’t have to be that way. When a provider complains to him about a nurse, Budi notes that the nurse is with the patient throughout the day, compared to the physician’s relatively brief interactions. “I say ‘try to listen to what they are saying, listen to their reason for their concern and it works better,’ ” he explains.
In turn, the CNO he works with shares his approach to problems. “What I really like about working with my chief nursing officer is the collaborative effort,” he says. “If a patient complaint needs attention, we meet with the patient or the family together to discuss the situation.”
WHAT YOU NEED FROM EACH OTHER
Training differences aside, the success of healthcare leadership dyads and triads rests on the ability of the individuals to work together. “Things can go off the rails in dyads when you lose sight of the person across the table,” Hackner says. “You can frequently get through a difference in perspective if there is respect and understanding, patience and persistence in working at the relationship. But if those are missing, it becomes a very difficult divide.”
He works in a dyad with Southcoast Health’s system CNO. Together, they work with associate CNOs and site-specific medical directors at the system’s three hospitals. They have standing meetings — daily, weekly, and monthly — with other Southcoast leaders or just among themselves to manage their various responsibilities and stay connected.
“Frequently, I’ll just pop in to see my dyad, or she will pop in to see me,” he says. “We will talk about an ad hoc issue or check in with one another, and I consider that open-door approach even more important than the formal meetings.”
As COO at UH Parma, Hill participates in a leadership triad with the hospital’s CMO and CNO. Having served as CMO and COO concurrently, he brings a unique perspective on how to optimize this model. “We don’t need rigid, scheduled triad meetings anymore,” he says. “We’re in near-constant communication — quick texts, five-minute huddles.” It’s an ongoing conversation.
“Each leader needs to manage their area of expertise,” he continues, “But we maintain visibility across all domains. That transparency allows each member to contribute insights others may not have considered.”
Effective working relationships require humility and vulnerability from each leader. “I take help and coaching from the chief nursing officer all the time,” Budi says. “Even though she is much younger than me, every day is a learning experience for all of us in life and especially in healthcare.”
The primary success factor for dyad or triad leadership, Walker says, is that each individual shares “a deep-rooted understanding that that relationship must be arm-locked.”
That requires knowing one another on a personal level — family dynamics, educational background, where each person is in their career trajectory — and knowing one another’s professional challenges.
In her most satisfying dyad leadership experience, Walker was paired with Alex Arroliga, MD, CMO, of Baylor Scott & White Health to oversee about 7,500 physicians and 16,000 nurses at 51 hospitals and more than 1,000 care sites. Their leadership was so effective during the pandemic that they were the first dyad to be recognized on Modern Healthcare’s list of the 50 Most Influential Clinical Executives.
One of their important habits, Walker says, was sharing their biggest professional concerns on a daily basis. “He would say, ‘What are you most worried about today, Janice?’ ” she recalls. “And then I’d say, ‘Well, Alex, what are you most worried about?’ Sometimes it was the same thing for both of us, and sometimes it was a shock to know what he was most worried about. But that helped build the trust that we were in this together.”
WHAT YOUR STAFF NEEDS TO SEE
CMOs and CNOs must have the respect of all the clinicians they work with, and that requires high visibility as a leadership team.
“It’s great when you can get everyone together, but it’s important to at least get two [leaders],” Hill says. “When the staff see that, they realize that there’s a common vision that’s going to propel the organization forward.”
High visibility and approachability allow CMOs and CNOs to learn about the challenges staff are experiencing. “You cannot wait for problems to implode and come knocking at your door when you’re sitting behind the desk in the executive suite,” Walker says. “If you are visible and approachable, people will bring you their biggest burdens so you can work on them before they fester and become much harder to unravel.”
CNOs and CMOs must demonstrate respect for each other’s sphere of influence. “When you are in front of interdisciplinary audiences, you cannot just lean to the nursing side or to the physician practice side,” Walker says. “You have to use words that make everyone in the audience feel that ‘We are in this together, and we are one big team, and we are going to take care of patients together.’ ”
Consistently demonstrating that single vision requires actually having it. “Where you can get into trouble is when you have people who aren’t talking to each other and their goals are maligned,” Hill says. “You need to make sure that all the members of the triad are communicating with each other so much that, at least in our organization, there are very few things that I do that my CNO or CMO are not aware of.”
HOW TO NAVIGATE STAFF SHORTAGES
Like many hospitals during the pandemic, University Hospital Parma saw many of its experienced nurses take travel-nursing opportunities, leaving the hospital short-handed. The biggest challenge was night shifts. “We had a lot of new nurses on nights who weren’t as familiar with the organization as our day shift staff,” Hill says. “The physicians saw that dichotomy.”
Because of the strong partnership between Hill, who was serving as CMO and COO at that time, and the CNO, he was able to present physicians’ concerns about the quality of care without being perceived as blaming anyone for the situation. “We had to realize that this is a problem that needs to be solved; it was not an individual failing,” he says.
The solution: creating a new role called clinical coordinator. “They served as the eyes and the ears of nursing practice on those floors at night so new nurses could use those people as a resource,” he says. “That definitely paid dividends because we weren’t digging out of a patient care problem first thing in the morning after it had been going on for 12 hours. If there was an issue, we were able to address it in real time.”
While the labor shortage may be seen as a root cause for patient-care issues, Hackner says other issues may be at play.
Although nursing schools are turning out a record number of new nurses, many of them need on-the-job training after they are hired. At Meritus, Budi encourages providers to be part of the solution by helping nurses learn. “Providers tend to focus on one person at a time and move on, which can sometimes create an impression that they are not paying attention,” he says. “We need to develop patience because if we coach them properly, they are going to learn better.”
Hackner points out that what may be blamed as a staffing challenge may reflect a broader set of training issues that need attention. Because of the limits on resident-physician work hours, the pandemic, and increased use of simulation-based education in healthcare, many younger, recently trained physicians and advanced practice providers (APPs) have had less direct patient contact than their older colleagues.
“Clinicians are coming with diminished face-to-face social skills with team members, so we have opportunities on all sides — this is really multifaceted,” he says. “It is incumbent on us to develop mentorship, onboarding, and proctoring programs, both formal and informal, for physician providers, APPs, nurses, and other disciplines.”
In this milieu, it’s important to recognize that individuals who are not performing at the necessary level reflect a system challenge, not an individual failure. “You have to consider ‘How did the person get there? What are our systems to enhance performance? What are our approaches to ameliorating problems and sustaining high performance in teams?’ ” Hackner says. “In the vast majority of cases, when we encounter performance failures, there are multiple issues — I constantly remind myself of that.”
When patient-care problems surface, Hackner leans into the high-reliability principle of deference to expertise. “Sometimes you really think that, as a leader, you understand a problem, but you may not,” he says. “It’s the person closest to the problem or the patient who understands what went on. So if you don’t take the time to fully explore the problem with staff who are closest to the patient with lots of input, you don’t get a full picture of how we got to a failure point.”
He likes to use hot debriefings immediately after events, followed by cold debriefings a week or so later. “A nonjudgmental, nonpunitive, psychologically safe debriefing often gives us the insight, without the leader’s judgment or conclusions coming in first,” he says. “Let’s get the facts and the feelings first and then move on to how to ameliorate the systems.”
Many health systems continue to face significant workforce volatility. But as Hill says, success doesn’t come from perfect conditions — it comes from strong, aligned leadership.
“When triads work well, it’s not because the environment is easy. It’s because the relationships are solid, the communication is open, and the team trusts each other,” Hill explains.
And that kind of leadership — built before the crisis — makes all the difference when a crisis inevitably arises.