Presentation delivered by Debra Harrison, Emeritus CNO, Mayo Clinic at the marcus evans National Healthcare CNO Summit 2018 held in Orlando FL

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The Dyad and Triad: Shifting
and Sharing Power
Debra A. Harrison, DNP, RN, NEA-BC
Emeritus CNO, Mayo Clinic in Florida
Executive Coach, MEDI Leadership

2. Confidential
Nursing in the 1970’s

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Images of Nurses
In the early 1900s,
nurses had a
distinct
stereotype:
feminine, middle
class, Christian
and white.
Angels of
Mercy
Gibson
Girl

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When stereotypes don’t fit….
Jacksonville’s first
hospital for African
Americans was
Brewster Hospital,
which dated from
1901.
Angels of
Mercy

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Images of Nurses
Nursing - a distinctly female profession in
the 1920s and 1930s. The heroic work of
nurses during World War II shifted public
perception in the United States.
In the 1950s and 1960s, television
shows helped to cement the
stereotype of the sexy nurse.

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Images of Nurses
By the 1980s, nurses were actively
trying to attack the media images of
nurses and for the most part have
been successful. United States.

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Images of Nurses Today

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Nurses Ranked #1 Most Ethical
Profession By 2017 Gallup Poll

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Images of Nursing Executives
Maureen Swick, PhD,
MSN, RN, NEA-BC,
Carolinas HealthCare
System Nurse Executive
Jane Englebright, RN,
PhD, CEBP, FAAN, Chief
Nursing Executive and
Senior Vice President at
Nashville, Tennessee-
based HCA
Linda Burnes Bolton,
DrPH, RN, FAAN
Vice President for
Nursing, Chief Nursing
Officer, and Director of
Nursing Research at
Cedars-Sinai
Leah A. Carpenter,
RN, MPA
Administrator and
CEO, Memorial
Hospital West in
Pembroke Pines, FL.

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Health Care Transitions
7 Healthcare Trends to Watch in 2017
1. MACRA
2. Future of ACA
3. Healthcare Costs
4. Technological Advancements
5. Reorientations in
pharmaceutical industry
6. Increased partnerships and
collaborations
7. Achieving higher value with
lower costs
CVS to Buy Aetna for
$69 Billion in a Deal
That May Reshape the
Health Industry

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Nurse Executives….
We ARE the center of U. S.
Healthcare transformation!
Our time is now.

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Objectives
• Discuss the dyad and triad leadership models and
their relationship to System transformation
• Examine the benefits and challenges of the
models
• Define leadership behaviors needed to create
effective partnerships
• Examine the dynamics of shifting power and
sharing power

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Defining dyad and triad leadership
Dyad
Triad
a partnership where an Administrative
or Nurse Leader is paired with a
Physician Leader, bringing together
complementary skills and expertise
bringing all three together as partners –
Nurse Leader, Physician Leaders and
Administrator - for complementary skills
and expertise

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Examples of Models
• Mayo Clinic
• Catholic Healthcare Initiatives (CHI)
• Texas Health Resources
• Others?

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Dyad Leadership is trending up

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History and Culture:
• Patient Care
• Coordination of care
• Collaboration
• Patient Service
• Teamwork
• Shared Decision
Making
• Positive Work
Environment
• Administrators want
to cut staffing
• Doctors have big egos
History and Culture:
• Practice
good/excellent
medicine
• Autonomy is central
• Know the answer
• Lead the team
• Suspect
administration
(behind all the bad
things)
• Nurses take orders
History and Culture:
• Run the business
• Strive for
efficiency
• Nurses are
expensive
• Doctors are
demigods or divas
• Meet the budget
• Everyone’s
important, not
just nurses and
doctors

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This should be easy!

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Benefits of a Partnership Model
• Supports shift to value
• Improves accountability
• Increases credibility with front line staff
• Reduces silos
• Allows for different perspectives
• Leverages each other’s strengths
Leading together – differently.

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Challenges of a Partnership Model
• Tendency to take a “divide-and-conquer approach”
• Cultural baggage
• Employment relationship with physicians
• Financial challenges
• Communication triangulation
• Potential ambiguity re: authority

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Evaluating Leadership Effectiveness
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Criteria of Effective Leadership Operations Dyad/Triad
1. Speed of decision making Quick Moderate to slow
2. Implementation of change Moderate to slow Quick
3. Executive Power Centralized Shared
4. Trust of Administration Weak Strong
5. Stakeholder engagement Poor Good
6. Role clarity Clear Mixed
7. Communication and
coordination of decisions
Good Good
8. Rapid cycle/Point of care
innovation
Poor Good

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Shared Physician Executive Nurse Executive Chief Administrator
Managing the business of
the organization/system
Providing nursing staff
supervision
• Performance review
• Discipline
• Recruiting, on-boarding
• Nursing Engagement
Providing medical staff
supervision
• Performance review
• Discipline
• Recruiting, on-boarding
• MD engagement
Developing operational
goals, priorities,
responsibilities
Fostering group culture and
supporting mission, vision,
values
Creating, implementing, and
monitoring nursing practice
guidelines
Creating, implementing,
and monitoring clinical
practice guidelines
Managing group financial
functions – budgeting,
accounting, I.A., taxes
Promoting, monitoring and
reporting group and
individual performances
• Quality of care
• Patient safety
• Patient experience
• Operational efficiency
• Operating budget
Driving new and innovative
and staffing model
initiatives; supporting and
leading population health
initiatives, etc.
Evaluating new innovations
in care delivery (e.g.
population health) and
surgical procedures
including technology
advances
Managing and developing
human resources consistent
with organizational
guidelines, established
contracts, and legal
requirements
Developing internal and
external organizational
relationships
Coordinating supervision of
clinical support services e.g.
RT, PT, Pharmacy, Dietetics
Evaluating clinical outcomes
(effectiveness and
efficiency)
Coordinating necessary
support functions –
marketing, IT, financial,
supply chain
Developing or
implementing strategy and
associated action plans
Supporting Physician and
Administrative Member
Supporting Nurse and
Administrative Member
Supporting Physician and
Nurse Member

23. Confidential
Don’t Underestimate History and
Culture
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24. Confidential
How do you own your executive role?
• Identify skill areas needed

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Executive Leadership Competencies
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How do you own your executive role?
• Identify skill areas needed
• Coaching, mentors, sponsors
• Value different perspectives
• Learn to leverage strengths in others
• Collaboratively create solutions
• Learn and unlearn

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Every day you must unlearn the ways
that hold you back.
- Leon Brown
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How do you own your executive role?
• Identify skill areas needed
• Coaching, mentors, sponsors
• Value different perspectives
• Learn to leverage strengths in others
• Collaboratively create solutions
• Learn and unlearn
• Be courageous
• Own your Power!

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Six Types of Power
• Positional Power
Sources
– Legitimate Power
– Reward Power
– Coercive Power
• Personal Power
Sources
– Referent Power
– Expert Power
– Information Power

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Responses to the Use of Power
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Compliance Resistance Commitment
Position Power Personal Power

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Dynamics of shifting power and sharing power
NOT Administrators inviting
the Physicians and/or Nurses
to their table….
NOT the Nurses and
Physicians inviting
Administrators to their
table…
(or Physicians taking over)
RATHER – Creating a NEW
Table
• With nurse leaders
• With physician leaders
• With administrative
executives

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Strategies to Own Your Power
• Take control of your image
• Increase access to information
• Seek skills and resources to increase your personal
power
• Build your capacity for decision-making and ability to
take action
• Embrace formal executive coaching as a way to reinforce
the behavior changes needed
• Build supportive networks among
peers and professional resources

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Questions?

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References
• Baldwin, K., Dimunation, N. and Alexander, J. (2011). Health Care
Leadership and the Dyad Model. Physician Executive Journal,
37(4):66-70
• Elwood, S. (2016). How to promote effective physician partnerships.
Presentation at Trauma Nurses Association. Retrieved from:
http://www.traumanurses.org/_resources/documents/events/Sean.Elw
ell.Presentation.pdf
• Fabrega, M. (2018). 50 Ways to Increase Your Personal Power.
Retrieved from: https://daringtolivefully.com/increase-your-personal-
power
• Kornacki, M.J. (2017). Three Starting Points for Physician Leadership.
NEJM Catalyst. Retrieved from: https://catalyst.nejm.org/three-
starting-points-physician-leadership/
• Larson, L. (2017). The Rapidly Evolving Role of Nurse Executives.
Hospital & Health Networks (H&HN). Retrieved from:
https://www.hhnmag.com/articles/8029-the-rapidly-evolving-role-of-
nurse-executives
• McWilliams, T., (2018). Mastering Dyad Management. Retrieved from:
http://hsgadvisors.com/thought-leadership/articles/mastering-dyad-
management/
• Oshiro, B. (2016). The Best Way Hospitals Can Engage Physicians,
Nurses, and Staff. Health Catalyst.com. Retrieved from:
https://www.healthcatalyst.com/the-best-way-hospitals-engage-
physicians-nurses-and-staff

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References (cont.)
• Pawar, M., and Kasti, M. (2016). Dyad Leadership Development:
Risks, Challenges and Solutions. Retrieved from:
http://www.ashhra.org/conference/2016/files/2016%20Presentations
%20for%20Website/01_M11.pdf
• Sandford, K. (2017). Dyad Leadership: Solving Problems, Creating
Advantages for Health Care Systems. Voice of Nursing Leadership,
AONE, 15(6), 8-10.
• Shute, D. (2017). Clinicians in the C-Suite. HealthLeaders. May issue.
Retrieved from: http://www.healthleadersmedia.com/physician-
leaders/clinicians-c-suite
• Smoldt, R.K, and Cortese, D.A. (2015). 5 success factors for
physician-administrator partnerships. MGMA Connections Plus.
Retrieved from: https://www.mgma.com/practice-resources/mgma-
connection-plus/online-only/2015/september/5-success-factors-for-
physician-administrator-partnerships
• Trandel, E. (2015). Advocating for dyad leadership at your
organization? The Advisory Board Company. Retrieved from:
https://www.advisory.com/research/physician-executive-
council/prescription-for-change/2015/03/dyad-leadership-slides
• VanDriel, M.K., Bellack, J.P., O’Neil, E. (2012). Nurses in the C-Suite
Leadership Beyond Chief Nurse. Nursing Administration Quarterly, 36
(1), 5–11.

37. Confidential
Debra Harrison, DNP, RN, NEA-BC
Emeritus CNO, Mayo Clinic in Florida
Harrison.debra@mayo.edu
MEDI Leadership- Executive Coach
Cell – (904) 616-1179
dharrison@medi-leadership.org
www.medi-leadership.org
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