Navigating leadership crisis — The County Health Department: The Hatfields and the McCoys
I received a call from the chairman of the board, Lynn, of a county health department. She advised me that there was a significant mess, and she desperately needed my help getting things sorted out. I asked for the broad-brush overview. She said the board was deeply divided, uncertain about the facts, and chaos was ruling. The county could not afford to have the health department be dysfunctional. There was no hospital in their county, and the citizens relied upon the county health department for most of their primary care.
Lynn told me there had been a mass resignation almost a month ago. Four of the six nurses on staff had resigned without notice, leaving patient care to suffer. It was unclear exactly why the resignations had occurred, but obviously something very wrong had happened. There was an informal but specific allegation that the executive director, Sharon, fired the director of nurses, Hannah, and replaced her with the executive director’s future daughter-in-law. The general allegation was that Sharon lacked the skill and judgment to effectively operate the county health department. Lynn realized that the department was on the verge of collapse and that the state department of health could step in and shut them down. Worse yet, due to the shortage of staff, quality patient care was being threatened which could produce conditions which could precipitate lawsuits and bad PR. My experience told me she was correct and that the direction the health department was going was extremely serious.
I told her that I preferred to draft a thorough proposal first. A detailed scope document would minimize confusion and misunderstanding. Within it, I would identify the present situation and document my understanding of the context of the case The next element of my proposal would be an articulation of my objectives and the assumptions, as well as a section specifying the work delineated in my plan of action. The final section of the proposal would be entitled “Time, Staff, and Costs.” In addition to detailing my timetable for starting and finishing a project, my proposals always include who, if anyone besides myself, will be working on the case as well as the fee I intend to charge. Lynn appreciated my intention to be orderly and specific but said the situation was so dire that I needed to be there tomorrow. Understanding, I told her that I would work on the proposal that day, and if she approved it, would change my schedule to meet with her the next day, long drive not withstanding.
I have found that because most of my work is addressing a crisis, my clients don’t care or worry too much about my fees at the beginning, or even about my understanding of the situation. They just want me to intercede as quickly as possible. I always go back to that first management tenant of never making a bigger mess than the one in which you find yourself. I’ve also found that once things settle down, the scope of my work and fees will then become a focus of conversation. The last thing I want or need, or my clients’ want or need, is for me to contribute to the chaos or their pain, I need to come into the case with clarity and purpose, so I insist upon drafting thorough scope documents and having the client approve my work plan in writing.
With these documents in hand, Lynn and I met at the health department. I discovered she was a retired nurse who seemed honest, sincere, and very credible. Agreeing to my proposal, she signed the engagement letter formally authorizing me to enter the case. She told me her version of the entire situation, admitting that several holes existed in her understanding of all the aspects and elements of the mess. My work plan, directly from my proposal, included:
Step 1. The consultant will interview, by phone or in person, all members of the board and obtain their insights about the problems in the organization from the board’s perspective.
Step 2. The consultant will meet with and interview the staff persons making allegations or expressing concerns regarding what is happening at the health department.
Step 3. The consultant will meet with and interview the staff person or persons about whom allegations have been made against to gather perspectives on incidents. Additionally, instructions will be provided to assure that no retaliation for the allegations occurs.
Step 4. The consultant may interview past employees to gather their perspective on matters present at the health department.
Step 5. The consultant will analyze and synthesize the information and insights gathered from the interviews and form an opinion regarding the severity of the situation and the appropriate steps to address the current organizational climate.
Step 6. The consultant will provide an oral report of findings with conclusions and recommendations for an appropriate response to the findings to the board for their consideration.
I began by making appointments and then speaking with the other six board members, five women and one man. The man was a pharmacist in town, one of the women was the wife of the local veterinarian, and another woman was an accountant in town. The other three women on the board were high school educated and otherwise unremarkable. The mayor of the town appointed all board members for multi-year terms.
As I interviewed each board member to ascertain his or her assessment of the situation, I found myself recognizing the difference between formally educated and less educated people. It would be interesting to see if this experience mirrors or contradicts your own view if you have ever considered the matter yourself. My view is that people who do not have a formal education tend to view things as black and white, this way or that, right or wrong. People with a formal education beyond high school tend to see things more in shades of gray. Not trying to be elitist but practical in viewing the differences, I have found people with a formal post-secondary education tend to look at problems and see four or five different alternatives. Then they identify the best one. On the contrary, people with only a high school education tend to look at the same problem and see the one right or the one wrong alternative.
I’m reminded of a movie from early 1992 called A River Runs Through It. You may recall the movie was somewhat about fly-fishing, but there was a very salient theme that I identified. Remember the part in the movie where the father, who was home schooling his son, gave his son the assignment to write a paper? I do not remember the subject of the paper, but I do remember that after the son wrote it and turned it into his father, he read it and told his son to go back and rewrite it. The son dutifully rewrote the paper and again gave it to his father. Once again, his father read the paper and advised his son to rewrite and resubmit. For the third time, the son rewrote the paper and gave it to his father. His father was finally satisfied with the paper, and in front of his son, he crumpled it up and threw it away. Then he told his son that he could now go fishing. What that scene revealed to me was the essence of formal higher education. The student is asked to articulate his or her feelings or findings on some subject matter. The professor rejects it and advises the student to try again. The professor again forces the student to rethink and restate his or her position, feelings, or findings to be clearer or more specific. It’s the learning process that is as important, if not more, than the content.
Getting back to the case, the three board members without formal education after high school saw things very differently than the college-educated members. This will unfold more dramatically as this chapter continues. Basically, the board was completely polarized four to three. It was like the Hatfields and the McCoys. The McCoys saw the executive director as a saint. From their perspective, Sharon was a great executive director. The Hatfields saw her as a good person but also as the source of the problems. My job was to get to the bottom of the allegations that would reveal whether the Hatfields or the McCoys were correct.
I got the impression that several board members, the McCoys, did not like me very much. They saw me as an intruder, an interloper, and someone from the big city sticking his nose where he didn’t belong. Funny how that happens. There’s an old expression in the South relating to people from the North moving to the South —they never become Southerners. They say, “Just cause a cat has kittens in the oven, it don’t make them biscuits.” As far as the McCoys were concerned, outsiders were not to be trusted.
After completing the board interviews, I proceeded to interview all current staff members. I found the staff members curiously polarized. About half of the staff loved Sharon and supported her unequivocally, while the other half thought she was a complete idiot as an administrator. I learned that she did terminate the beloved director of nurses, Hannah. I say beloved because all staff members were in agreement that Hannah was highly respected, both as a person and as a medical practitioner. To add insult to the situation, Sharon had then hired future daughter-in-law to become the new director. The future daughter-in-law was a registered nurse with experience in home healthcare, but the nursing staff was incensed that this person was placed in this role at Hannah’s expense. In protest of this action, three staff nurses immediately resigned without notice, plunging the nursing function into chaos and a situation of being severely short-staffed.
Now Sharon was also a registered nurse. She immediately placed herself in the role of one of the nursing staff in an attempt to operate the department. She, her future daughter-in-law, and the one remaining staff nurse worked the home healthcare duties of the health department. Remember that the original nursing department struggled to keep up with four registered nurses and was now operating with three. And Sharon, functioning as a registered nurse, was neglecting her duties as administrator.
To make matters worse Sharon, while at home one evening, literally shot herself in the foot while cleaning a rifle. She blew the great toe on her right foot clean off. Because of the staffing caseload and shortage of personnel, Sharon hobbled on her injured foot and continued to see patients and provide home healthcare instead of resting. As a result, some on the board and in the community saw her as a hero of patient care and a living, shining example of service to the county.
I interviewed Hannah and the three nurses who had voluntarily terminated in protest. Each individual was conflicted about the situation. They knew that their patients were suffering, the health department’s status with the state was precarious, and that they were being demonized in some quarters. They were also resolute in their view that they were right and what the executive director did had been very wrong. Two of the nurses had new jobs lined up and were glad to leave the health department, and Hannah and the other nurse indicated their willingness to come back under the right circumstances.
Working around the staff interviews, I spent a few days examining all the business aspects of the health department’s operations. This included looking at the HR systems, job descriptions, performance appraisal system, policy and procedure manual, and the compensation system. I also looked at the budget and financial controls and was appalled to find that these areas were in a complete state of disarray. It turned out that the only thing that functioned properly was the nursing service.
In my report of findings, I wrote my investigation had substantiated the general allegation that Sharon lacked the administrative skills needed to operate the health department. I also substantiated the specific allegation that she did inappropriately and without cause terminate Hannah. The report stated:
In the financial arena:
The executive director appears not to be very adept at understanding or using financial information. She did not know the amount of the fund balance or the actual amount of the operating budget of the health department. The budget development and operations process is primarily handled by the bookkeeper. Understanding and operating the financial aspects of the department’s budget is a crucial skills set. The ED did not know that the fund balance was in excess of $226,000. She thought it was around $90,000. The ED could not tell me the amount of the health department’s annual budget. She did, to her credit, have an approximate notion of the budget’s monthly total indicating that it was around $54,000 per month. Actually, it was $55,681 per month. She indicated that she reviewed the budget every quarter and started working on the new budget in the final quarter of the year.
Understanding and using financial information in the daily, weekly, monthly, and annual operation of the health department is essential in the current environment. Spotting and reacting to financial trends, monitoring cash flow, management and maximization of investments, management of cash, and accounts payables and receivables is all the domain of the director.
In the leadership, management, and ethical arenas:
Even the staff who supported the ED acknowledged that she was “too nice” and that she tried to be a buddy and tried to please everyone. Feedback confirmed that she approved requests for leave without checking the impact of the absences on the schedule. Her leave approvals left staffing short. Feedback exists from two aides who, for a period of time, had patients and clients who required seven day per week visits. This weekend burden was falling on two aides, and when they asked for help so that they did not have to cover all the weekends, nobody would volunteer to assist with the coverage. They approached the ED for leadership and were told that since nobody wanted to help them, they would have to cover it for themselves.
Another confirmed incident that demonstrated a lack of leadership and management expertise was a situation in which two staffers were engaged in a shouting match in which personal attacks occurred. The ED was present, observed the unprofessional exchange, and failed to call a halt to, or deal with, the situation.
Her supporters and detractors indicated that she was gone too much. It could be said that she was away attending meetings in order to keep up with industry trends and governmental expectations, but much of the feedback indicated that she was away dealing with migraine headaches and recovering from the gun accident. Feedback from several staff indicated that the ED stated publicly and on several occasions that “her give-a-damn button was busted.” This gives the impression of the presence of burnout, which suggests an explanation for the frequent absences. In any case, making such statements doesn’t instill confidence.
The most serious issue to surface was a statement made by a staff person that Sharon pushed Hannah out of her position so that the future daughter-in-law could have the job. I spoke with Hannah and she confirmed that Sharon had come to her and said that her future daughter-in-law wished to come on staff at the health department. Hannah stated to me that she very clearly and precisely told Sharon that she wanted no part of the interview process and would have no role in bringing the future daughter-in-law on staff. From this point forward, Hannah continued, she felt stress and pressure from Sharon. If this happened, and it appears that it did, it represented a serious breach in ethics. Several at the health department perceived that it did happen.
With the hiring and promoting of future daughter-in-law to the position of second in charge, there was a coalition that effectively prevented any sort of accountability at the top. Staff could not complain or voice concerns to Sharon about the future daughter-in-law, and staff could not complain or voice concerns to future daughter-in-law about Sharon. The power of nepotism trumped accountability, which violated ethics principles and created a clear conflict of interest.
Several staff indicated that clients had complaints about the care future daughter-in-law provided and about the accuracy of her charting. These complaints went nowhere because of the future daughter-in-law’s protected status. There was nothing in her personnel record about any conversations, warnings, or investigations into any accusations of wrongdoing. Complaints about the care provided, the care not provided, and the charting completed by a staff nurse are serious. Sharon should have reviewed them and future daughter-in-law should have been formally cleared or formally reprimanded. Neither happened.
I reviewed the staff’s personnel records and discovered several problems. Among them, in every file reviewed, health records were co-mingled with other records. This was a clear violation of US Department of Labor regulations that specify that health-related records on employees shall be held confidential and cannot be co-mingled with any other records. Confidentiality or the lack thereof was a problem in the health department. Feedback confirmed that visitors of staff were allowed to come into the private offices of staff where patient records were clearly visible. All incoming mail was opened, thus allowing for personal records of staff to be viewed by the person opening mail. These examples indicated the lack of attention Sharon demonstrated to preserve confidentiality within the health department.
Another incident occurred and was verified by several staff persons. Sharon received a notice on January 30, from one of the state granters reminding the health department that its first quarter report (regarding the status of the grant activity) was due the next day. This was ignored. Two weeks later, the health department received a notice from the state indicating that the report had not been received and demanding it must be received at the state office immediately. This created a panicked response. The new staff person (responsible for the program) asked Sharon for help and learned that Sharon really did not know the answers nor did she understand the seriousness of the situation. This staff person worked with other staffers who gathered the information and got the report completed and submitted. The staff person had known about the January 30 reminder Sharon had received. Just for “grins” as well as possibly curiosity, the staffer commented to her that she thought it was very strange that the state would demand the report with no notice. Sharon told the staffer that she failed to understand the state’s behavior either. So much for leadership.
This situation raised several “red flags” in the health department:
- This denial or lack of acknowledgement regarding the January 30 reminder memo caused trust issues to be raised. The employee told me that she could have accepted an explanation like “I just completely forgot about the report being due; it slipped through the cracks.” Even an honest “I blew it.” would have been a sufficient answer. Instead, the ED’s choice to omit or deny the truth caused her credibility to be reduced in the eyes of the staff.
- Another red flag related to the ED’s inability to understand the state’s contract and its expectations is that this staff person realized that it is very significant to miss state program deadlines and to “mess with state money.”
There was clearly a mutiny at the health department as evidenced by the polarized staff. The outward signs of the mutiny occurred in November of the previous year. My hunch told me that it really started approximately 12 to 18 months prior. Feedback from several staff indicated that things had not been good at the department for about two years. I was not enamored by all the staff who were the Sharon’s detractors. Even though they were on the right side of the issue, incompetence and incompatibility reigned at a level that could be dangerous to the health department’s operations. Some of them were very credible, but some seemed to be snipers and snakes. These feelings aside, experience with these types tells me that complainers and snipers do not complain nor do they mutiny about nothing. It is always about something. Sharon failed to take the necessary steps to mitigate the discontent. Actually, she did much to foster it. Any of the above transgressions were enough to throw her credibility into question. Taken together, all clearly indicated that her status as executive director was unsalvageable and irreconcilable. I did not wish to see one side “win” and another side “lose.” I saw plenty to convince me that all sides were hurting, patient care could be suffering, and the credibility and reputation of the health department was taking a hit. Changes were required.
- Regarding the health department, it needs proper governance structure, internal leadership and teamwork, and human resources tools to operate the personnel.
- Regarding the community, it needs its health department to settle and operate ethically, orderly and efficiently ASAP.
- Regarding the director, I recommend she step aside and the board conduct a search for a new director.
- Regarding the staff, they need to be managed and held accountable for their performance.
- Regarding the board, you need to manage and educate yourselves regarding your highest and best role as the governing body.
Regarding the board:
- Job descriptions for board member and board chair are needed so that the roles of each are clearly defined.
- A narrowly defined set of bylaws are needed or needs to be updated specifying how the board operates. The board should never allow its meetings to be dominated or captured by staff or public. The board meetings must be structured and disciplined so that it can conduct health department business.
- An annual, or at least every other year, patient/client opinion survey should be conducted so that structured listening can be accomplished.
- A subtle but concentrated PR campaign needs to be undertaken to assure the county leaders that the health department is back under control.
Regarding the executive director:
- She should be replaced.
- An interim director should be recruited and placed so that leadership, management, and healing can occur during the active search for the next director.
Regarding the health department:
Human resources tools need to be designed and put in place. They include the following:
- A comprehensive policy manual
- Job descriptions
- An appraisal program
- A wage and salary plan
- Training on how to use the tools
This was just phase one of this assignment. The board and I had a rather contentious meeting to discuss the report delineated above. In the end, the three board members, the McCoys, voted to reject my report and proposal. The other board members, the Hatfields, chose to accept the proposal and asked me to assist them with phase two which would be the termination of Sharon and the restructuring of the health department. The not so unusual thing was that my investigation and report seemed to have no effect on the McCoys. When confronted with the conclusions, which I had drawn based upon extensive interviews, these board members chose to completely disregard everything, even though the facts were in front of them.
Remember the three to four board member split, as it will become very important as the case unfolds. The three McCoy board members represented the pro-administrator group. Four board members, the Hatfields, accepted my report as corroboration of their assessment of Sharon.
I outlined the work plan I intended to implement in phase two. We agreed that I would stay on site for approximately one to two weeks. My objective was to have as many meetings with Sharon as needed to either terminate her or obtain her voluntary resignation. Additionally, I would dig into the administrative matters that had been neglected during the period of time when Sharon acted as a staff nurse. I suggested one of my associates be considered as the interim executive director. He had the time and the administrative expertise to assure the board and the state that the health department would be operated safely and effectively. While he acted as the interim ED, he could also conduct the search for a permanent replacement. Again on a four to three vote, the board accepted my proposal.
Phase two proceeded fairly smoothly in some ways, but in other ways, it continued to act like the “Wild Wild West.” The home health nursing and patient care demands on the schedule were extensive. Full staff consisted of four nurses and only three were immediately available. Sharon, her future daughter-in-law, and one other nurse were providing the patient care coverage. Bringing back Hannah and the other staff nurse who had left under protest but still available, was under consideration but problematic. The questions remained: Could the decision to roll back the termination of the previous director of nurses be made? Answer yes. Could the decision to roll back the hiring of the future daughter-in-law be made? Answer: questionable. Could the existing nurses work with the terminated nurses? Answer: questionable. The odds that things would work out ranked right up there with winning the lottery. Should that happen, however, the two nurses, Hannah and the self-terminated registered nurse, could replace Sharon and fill the vacant position.
Newsflash — it’s next to impossible to win the lottery! By this time, the registered nurse had taken another job. Hannah agreed to come back at her previous salary but in the role of a staff nurse. On a more controversial note, Sharon agreed to voluntarily resign, but wanted to stay on as a staff nurse for an eight-week period at the same salary. While working, she would use the eight weeks to conduct a job search for her next position. Satisfying the home health patient’s requirements for treatment superseded almost all other considerations. This eight-week contract bought the board two month’s time to recruit and select a replacement staff nurse. This provided yet another example of what a saint Sharon had been! Also, a cool down period was underway which facilitated staff morale and the rebuilding of the health department.
So this is where we stood two weeks into phase two: Sharon had resigned, signed the hold harmless waiver, and accepted a time-specific contract in which she acted as a staff nurse. Patient care needs were being satisfied, and the state was cautiously happy. I was working on job descriptions and developing a policy and procedure manual for the health department, and my recommendation for the interim executive director had been accepted. The chairman of the board had already interviewed him by telephone, was satisfied with his credentials, and ready to approve his formal start the day after the upcoming board meeting.
The board meeting was scheduled, the interim ED had been selected, and all that remained was the formal authorization to proceed – or so I thought. The media had been all over the story for the previous two months, and the community had attended the board meetings over the past several months and been quite vocal in their support for or against Sharon and the board’s actions. Sharon’s two brothers had actually stopped by the health department on one occasion and threatened me. I assured them that the situation with their sister was well under control and operating to a great extent in her favor and instructed them to communicate with her for confirmation. I further communicated to them that if they threatened me again, I would press assault charges — the big oafs.
The board meeting rolled around and brought some surprises. The media was there, the community was there in mass, and Sharon’s brothers were there. Staff members were present, as well as the interim director and myself. None of these were surprises. I asked one of the staff to call the county sheriff and ask that he be present at the meeting for crowd control. He arrived, took out his gun in clear view, and took a seat. What was a surprise was that Lynn, the chairman of the board, was not present. She had been called out of town due to a last-minute family emergency. The vice chair, a pharmacist by training and a rather fragile looking little person physically, convened the meeting. As soon as he had called the meeting to order, one of the board members, a McCoy, immediately began a verbal attack on his character. I halfway expected an attack on me. Even though I had accomplished all of the goals specified in the proposal for phase two, I never expect a pat on the back, but rather someone to be there with a kick to my derrière. What I did not expect was the personal attack of one board member on another.
It was a brutal attack. A second member of the McCoy group picked up the club and continued the attack on the pharmacist. It seemed to come out of nowhere, but I finally figured out what was occurring. What the McCoy clan of the board was attempting to accomplish, through this diatribe, was to get the vice chairman to become so incensed or embarrassed that his fight or flight reflex would overtake him, and he would resign on the spot. If he did resign, that would leave five members present at this board meeting and they would represent a 3 to 2 voting bloc. With this majority, the McCoy clan could vote to terminate the consultant’s contracts and reinstate Sharon. Talk about political drama! I had to admit it was a pretty savvy move by the McCoys. I interceded to the greatest extent possible, but was shouted down by the McCoys and told that because I was not a board member, I did not have the right to speak. I whispered in the pharmacist’s ear to remain calm and to remain seated. It took all of his will and all of my effort to keep his backbone erect. I practically ordered this board member to do nothing, stay strong, and allow the attack to roll off his back. This was an attempted coup, and he could defeat it by letting them run out of steam and simply thank them for their comments. By ignoring the content, he could sidestep the context and win this battle.
The pharmacist stood firm, and the coup failed. Fortunately, the sheriff was present to maintain order in the public gallery. It was all pretty exciting but when I stop to think about it, it was pretty depressing. The McCoy members embarked on an exercise that would basically rip at the fabric of the whole organization. Remember how important the health department was to its patients and the county in general. The McCoys’ actions would have served to return the department to total chaos, which could only have resulted in patient care breakdown and forced the state to step in and either take it over or shut it down. Everything that I had accomplished, and they had paid for, would have been undone.
In the end, the interim executive director’s contract was approved, and the plan that I had established was carried out. I was vilified by some, and recognized by almost none. Lynn appreciated my work, but by not being at the meeting, she was left “rolling her eyes” at the thought of what could have happened. This had been a close call due to her unexpected absence; it could have all come crashing down. The interim executive director conducted an effective search and within three months a qualified, competent, and experienced ED was selected. The Hatfields and the McCoys still existed, side-by-side, on the board. As the health department settled down and became functional, the media and the community also calmed down and normalcy returned, as it should. The steady state of any organization should be peace. My role had been that of a wartime officer, so I was just as happy to leave that health department, as the McCoys were to see me go.