Creating a successful dyad model requires staying ‘in sync,’ finding balance, and great listening, says the CNO-CMO partnership.
If nurse leaders in the LifePoint Health system need guidance, they don’t automatically go to Michelle Watson, senior vice president and chief nursing officer (CNO); they also can get the information they need from Christopher Rehm, MD, senior vice president and chief medical officer (CMO).
That’s because Watson and Rehm together oversee all clinical, quality, and patient safety initiatives through a singular clinical lens—a dyad leadership model.
LifePoint, a Brentwood, Tennessee-based private healthcare network operating 63 community hospital campuses, 30 rehabilitation and behavioral health hospitals, and more than 170 additional sites of care in 30 states, adopted the dyad leadership model in early 2020, right before the COVID-10 pandemic ramped up.
Watson and Rehm spoke with HealthLeaders about how the dyad works, its challenges, and its benefits.
This transcript has been lightly edited for length and clarity.
HealthLeaders: Can you explain how LifePoint came to adopt this model?
Christopher Rehm, MD, CMO: We have preached in our quality program that healthcare is a team-based sport, and we need everybody to be engaged and everybody to be involved. Our direct supervisor is Victor Giovanetti, the executive vice president for hospital operations, and Victor’s vision—and Michelle and I are totally aligned with this—was if the CNO and CMO of the company worked in a dyad, that would be an example for the rest of the organization—nurses, physicians, and then extrapolate on across the line, whether it’s techs, aides, physical therapy, occupational therapy, etc., [showing] that the entire team is a team and not a hierarchy, where the physician writes the orders the nurses execute the orders. That’s not what leads to success and high-quality and safe care.
Victor came to the two of us and said, “You’re the CNO and CMO, and I want you to work in a dyad,” and it’s for a number of reasons, but I think at its core, it was to reinforce that everybody has a seat at the table and everybody’s voice matters. It’s the hierarchy that frequently shuts down conversation, that keeps people from speaking up, that can be intimidating to new team members, and the dyad is representation of how we break down those barriers.
Michelle Watson, CNO: It’s common for any hospital or any healthcare system that there’s the work of the nursing staff and the nursing leaders and then there’s the work of the physicians and the medical staff. The dyad model has brought those two together and with Christopher and I, it is the vision of one clinical voice whether it’s the nurse or the physician, that has been a part of what that dyad model is meant to represent. It’s one clinical voice driving quality and safety across the organization.
HL: How has the concept of the dyad trickled down within the organization?
Rehm: Prior to Michelle and I being in the dyad, at the HSE [health, safety, and environment] level there would be calls where we would pull together the CMOs on a monthly call, and Michelle would pull together nursing leadership on a monthly call. When we came together in our dyad leadership model, we then brought the CMOs and the CNO council together in a single monthly cadence because we’re working on the same issues and if there is an issue that’s specific to nursing, that impacts the entirety of the hospitals, so the CMOs need to be at the table, engaging in dialogue, etc., and if the CMOs are working through some challenge, that’s important to nursing as well because they are practicing together in the facility.
That reinforcement, the dyad, and that monthly call has brought our facility CMOs and facility CNOs closer together. At our facilities that have a CNO and a CMO, we’ve asked them to work in a dyad as well—not an org structure like ours, but to functionally work in a dyad. And they are saying that is trickling down all the way to the front line where it’s just a better dialogue and culture between the practicing physicians and the nurses.
HL: Please explain exactly how the dyad works there at LifePoint.
Watson: For two years, during the pandemic, if you were to look at our calendars, 80% of our calendars were exactly the same. We were in every meeting, every call, together from early in the morning to late at night. That forced us quickly to become aligned in how we think and how we strategize. It also modeled to the field that nurse-physician alignment in making those decisions collectively.
Even though we’ve moved past the pandemic and we’re getting back to normal operations, we still have that very same approach. We’re not so focused on COVID, but if you look at our calendars now, about 60-75% of the time, we’re on the same calls. We are intentional and stay connected … so that if Christopher is primarily taking the lead on, say a technology platform discussion, and he has to be out, I can step in and represent the dyad in Christopher’s absence. If I’m taking the lead for something that’s more clinical or operations, by keeping Christopher informed he can quickly step in for me if I need to be out. That’s the beauty of the dyad, but there has to be a lot of intentionality around staying connected.
Rehm: We tried to overtly reinforce that first year by purposely picking what we were going to report out at meetings [Rehm would report on nursing matters; Watson would report on physician matters] so that it would drive home that we really are in a dyad. That was key to drive how we continue to work today. We make sure we’re bringing our different perspectives to those areas that historically were in the other’s role.
HL: What are some of the challenges of a dyad model that you’ve encountered in this last year?
Watson: One of the biggest challenges would be for the two of us to always stay in sync. We’re pulled in so many different directions and we’re not on the same calls together, so being intentional to stay in sync and then finding the balance in that and making sure that you have an equal voice between the CNO and CMO, because sometimes it can get heavily weighted one way or the other.
Rehm: That first year as we were figuring out the dyad, we didn’t want the business to be challenged by others asking, “Do I need to call Michelle?” or “Do I need to call Christopher?” or “Do I need to call them both?” We wanted to make it easy for everybody else by not forcing them to think about it. We want them to think about us as the dyad, and it doesn’t matter which one of us you invite.
HL: You’ve touched on some benefits of this model. What are some others?
Rehm: No single person has all the answers, and no single person is necessarily going to be able to analyze every challenge, every opportunity, from every angle. Michelle and I do not have exactly the same view of every everything we should do, but with the right kind of understanding of how we work together, to every decision we bring a multitude of perspectives. Her background is different than my background and in an open dialogue, we explore every challenge more broadly and more deeply than if either one of us was doing it individually. We bring experiences, we bring an open mind, we’re great listeners, and we end up with better decisions because of that.
Watson: One of the great benefits is between the two of us, we bring such a broad view of quality clinical operation. As a CNO, I would only bring my view from hospital operations nursing leadership quality. Christopher brings a different view from his background as a physician, so it’s bringing the two together and being open to listen—to each other, to your teams, and to what the organization needs. That broader view has really helped us a lot.
HL: Is this dyad model workable for any and all health systems?
Watson: It is workable in any healthcare system, but it can have its own challenges. The important piece is having a CNO and a CMO who have a shared vision and a shared mental model of team-based care because that’s really what it’s about: driving high-quality performance at the bedside through a team-based model. It is doable, but there has to be a lot of intentionality between the CNO and CMO.
Rehm: There are potentially CNOs and CMOs who would struggle working in this model. You have to have the right characteristics as the CNO, CMO to function a dyad and not have it be something that doesn’t work well, but that I don’t think that’s a system challenge. You have to have the right people in the roles to function in a dyad.
Carol Davis is the Nursing Editor at HealthLeaders, an HCPro brand.