“Servant Leadership” in Healthcare: A Natural Fit

Have you ever had a manager who nearly always put your needs (and others’ needs) at the forefront? Did you feel that when you conversed with them, your voice was truly heard and that your manager took a genuine interest in your problems, your goals, and your aspirations? Were they quick to give credit to the team for reaching milestones and goals, while taking responsibility for failures without pointing fingers? Did they successfully strike a balance between core institutional mission and vision, and the growth and well-being of employees? Did your manager make you feel like you were much more than your role as an employee?

If a specific person from your past or present came to mind during this exercise, you’ve met a servant leader. In this overview of “servant leadership”, I will:

• Define servant leadership;
• Discuss the ten major characteristics of a servant leader as set forth by Larry C. Spears;
• Illustrate the transformational power of servant leadership in our own field (healthcare); and, in doing so…
• Leave you thinking about ways servant leadership can transform your own field.

What is Servant Leadership?

While the basic tenets of servant leadership have been around for eons (think the “Golden Rule”), Robert K. Greenleaf coined the term in his 1970 seminal work, “The Servant as Leader”¹, in which he defined servant leadership in the following manner:

“The servant-leader is servant first... It begins with the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to aspire to lead. That person is sharply different from one who is leader first, perhaps because of the need to assuage an unusual power drive or to acquire material possessions...The leader-first and the servant-first are two extreme types. Between them there are shadings and blends that are part of the infinite variety of human nature.”

He then expounds upon the “best test” measurement of servant leadership:

“The difference manifests itself in the care taken by the servant-first to make sure that other people’s highest priority needs are being served. The best test, and difficult to administer, is: Do those served grow as persons? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants? And, what is the effect on the least privileged in society? Will they benefit or at least not be further deprived?”

When I first read this definition of servant leadership, I was taken by its width and breadth. Never before had I come across such an all-encompassing definition of leadership. The altruism inherent within its very core is not only difficult to implement, but lacking in many of our institutions today. And to make oneself accountable to not only the staff and the institution, but also to the community at large, right down to the least privileged in society? It is a tall task, but what a standard to set for ourselves and for our institutions to try to live up to on a daily basis!

It’s helpful to continue our definition by discussing some major characteristics of servant leadership.

Ten Characteristics of a Servant Leader

After years of studying the tenets of servant leadership, Larry C. Spears elucidated ten characteristics that he felt were synonymous with all servant leaders.² These include: listening, empathy, healing, awareness, persuasion, conceptualization, foresight, stewardship, commitment to growth of people, and building community.

Let’s briefly touch on each of these characteristics:

Listening means not just passively hearing someone, but really leaning in and trying to understand where they’re coming from. This speaks to Habit #5 of Stephen Covey’s Seven Habits of Highly Effective People: “Seek First to Understand, Then to Be Understood”.³

Listening is a natural segue into Spear’s second characteristic, empathy. We need not go through the same trials as someone else to empathize with them, because we can connect emotionally to what’s happening. Empathy is being fully present with another. It is my assumption that everyone who has worked with patients has a solid capacity to listen to patients and empathize with them.

Healing, the third characteristic, is simpler than it sounds. We don’t have to solve everyone’s problems. Sometimes just sitting with them and bearing witness to their pain is a healing gesture in and of itself. Healing, in this sense, is deeply tied to both listening and empathy, and is another characteristic that is deeply and naturally ingrained in our profession.

Awareness works on two levels: general and self-awareness. Knowing oneself is the beginning of the quest to know others. This speaks to the popular idea of “EQ” or the emotional intelligence quotient⁴ in the sense that people with a high level of EQ are both acutely self-aware and aware of those around them. Greenleaf called awareness a “disturber and an awakener”³, which may strike a chord with those who have practiced the art of awareness. It is not easy to live with a constant awareness of our own and others’ potential motives. But greater awareness leads to a greater, more in-depth understanding of ourselves and those whom we serve.

Persuasion is another characteristic of servant leadership. To be persuasive, a servant leader must have a great dream. The difference between coercion and persuasion by a leader is this: with coercion, you have convinced the led to do what you ask when you are present. With persuasion, they will do what you ask even when you are not present, because they believe in the shared vision.

Conceptualization is a characteristic that is difficult for busy leaders, because so often they are mired in putting out daily fires to the detriment of holding fast to the organizational vision. The servant leader keeps both the daily and the long-term perspectives in balance. Conceptualization includes not only the ability to interpret the vision on a daily basis, but also inspiring staff to build upon that vision and help shape it. Articulating vision and mission in both words and deeds helps the staff to find meaning in their work.

Greenleaf called foresight “the lead that the leader has”³ and wrote that once leaders have lost foresight, they are no longer leading; they are simply reacting to events. Great leaders will have one foot in daily reality and one detached from the everyday world, taking in a bird’s-eye view of the lessons of the past and the possibilities of the future.

Stewardship means holding something in trust for another, doing what is right for the whole. It brings a shift in focus from personal gain to the greater good. A servant leader who has harnessed this idea of stewardship effectively need not worry about what will happen to an institution once they have left; the torch will keep burning for generations to come.

Commitment to the Growth of People is built around the idea that people have intrinsic value beyond what they contribute as workers. Servant leaders are deeply committed to the ongoing development of their people, not just regarding their work skills but also as human beings.

The final characteristic of servant leadership is Building Community, which includes micro and macro levels. Establishing little communities of care within organizations where staff at all levels can have a safe place to express themselves is one way to build community in today’s hectic, impersonal business environment. Reaching out to the local community is important as well. Encouraging and celebrating volunteerism is a great way to build community both inside and outside of an institution.

These ten characteristics of servant leaders are by no means exhaustive, but they do give us a great springboard from which to start developing our own servant leader skills.

Servant Leadership in Health Care

Let’s discuss servant leadership in the healthcare environment. Many people go into healthcare for altruistic reasons that have to do with serving others, which is a big reason why healthcare is such a natural fit for servant leadership. Servant-led hospitals not only have more content employees, but also happier patients who are cared for more personally and thoroughly.

One great example occurred in one of America’s best known and most respected hospital networks, the Cleveland Clinic. The Clinic consistently lands within the top 5 institutions in the United States for healthcare excellence.⁵ Yet despite its stellar reputation and excellent clinical results, back in 2008, the results of their first HCAHPS survey indicated they failed miserably in patient ratings.⁶ The HCAHPS, or Hospital Consumer Assessment of Healthcare Providers and Systems, survey was developed by the Agency for Healthcare Research and Quality (AHRQ) in response to the Centers for Medicare & Medicaid Services’ (CMS) request for a survey that supports the assessment of patients’ perspectives on hospital care. The purpose of the HCAHPS is to uniformly measure and publicly report patients’ perspectives on their inpatient care. More importantly, on a fiscal level, these surveys are directly tied to Medicare reimbursement.⁷

Around this same time, a Gallup Q12 survey the Cleveland Clinic sent out to its staff revealed more dismal results. Over the next five years, with the help of their chief of human resources, who is a servant leader, the Cleveland Clinic set about the task of increasing employee engagement and patient satisfaction. It was not universally accepted from the outset; however, with each small victory, people began to realize that this was not just another fly-by-night management technique to boost ratings. There was real buy-in from top management in seeking to create a better institution, not just by hiring the best and brightest talent, and buying the newest technologies, but in their commitment to reaching out to staff and patients and asking them what they could do serve them.

Many programs were instituted during the following years that greatly benefited both staff and patients. The Clinic worked hard to improve their patient experience, guided by the 27 items on the HCAHPS survey. They also implemented employee development and recognition programs. What they found was that servant leadership principles do work in the real world. The difference between the 2008 and 2013 surveys were astonishing⁶:

• The Gallop Q12 results on employee/caregiver engagement were in the 43rd percentile in 2008, yet the Cleveland Clinic ranked in the 87th percentile in 2013;
• The ratio of engaged to actively disengaged employees went from 2.57 to 1 in 2008, to 10.2 to 1 in 2013 (higher than the ratio, which constitutes a “world class” organization);
• Finally, the HCAHPS results from the patient surveys improved from less than the 30th percentile in 2008, to over the 80th percentile in 2013, where it has remained.

This is the power of servant leadership when there is true buy-in from the top in an effort to put serving others at the forefront, and not just patients, but also staff. As a healthcare worker, I believe that giving anything less than our absolute best care is simply not enough. Institutions who want to serve their patients at the highest level need to also think about serving their employees well. Southwest Airlines, a servant-led organization, has two groups of customers: “internal” and “external”, their employees and their paying customers, respectively. By serving their “internal” customers to the utmost, they can rest assured that their “external” customers are given the highest level of respect and service.⁸

There are many other examples that illustrate the power of and pressing need for servant leadership in healthcare. Trastek et al⁹ and Yancer¹⁰ also offer two illuminating accounts of servant leadership in healthcare. But I wanted to show this one telling example at the Cleveland Clinic to illustrate the positive effects of servant leadership in one of the most revered healthcare organizations in the United States.

Servant Leadership in the Medical Field and Beyond

Think about your own institution for a minute. We are all struggling with mandated changes in how we go about our daily tasks (such as EMRs and other documentation changes) and in caring for a greater number of patients with chronic illnesses, all while we are in the midst of a shortage of just about every healthcare worker category.¹¹ Think about how your own workplace would be different if the servant leadership concept was developed and adopted. Imagine how working under a servant leadership philosophy would change the game for everyone involved.

When he was a college student in the 1920’s, Greenleaf and his colleagues were challenged by a professor who felt that the large institutions of America were not serving individuals and the greater society as they should. Answering that professor’s challenge, Greenleaf chose to pursue his career at one of the largest institutions in the world and he quietly sought to change it from the inside out. He continued his quest to be a servant leader for almost 35 years with AT&T and for almost three decades after his retirement, founding what is today called the Robert Greenleaf Center for Servant Leadership.

Many Fortune 500 companies have sought consultation with the Center and have watched their own firms grow not only in reputation and employee and customer satisfaction, but also in financial success. More and more courses and programs are being created in colleges and universities that teach the philosophy of servant leadership. Greenleaf created a spark that turned into a fire which, thankfully, continues to burn to this day. It is of special interest in healthcare, as many medical professionals seek careers in the medical professions out of an innate desire to serve.

I can think of no better philosophy — in healthcare, business, education, religion, politics, and in life — than servant leadership to begin to heal our patients, our society, and ourselves.

Servant Leadership in Daily Practice

The tenets of servant leadership strike a chord with many managers in the medical profession. The concepts are easy enough to understand and the principles make intuitive sense; but without putting them at the forefront of our daily routine, these tenets are likely to fade quickly. Hunter suggests budding servant leaders can begin with the three F’s: Foundation, Feedback, and Friction.12 Foundation involves setting the standard for both the leader and the team, and usually involves two questions: (a) how am I supposed to behave? (b) what happens if I don’t behave that way? Once the leader understands this vision of excellence and accountability, they are better able to relay it to the staff by modeling the behavior that is expected of them.

Feedback and self-assessment are important tools used to identify where we may be deviating from the high standards of servant leadership, or where there are gaps. Friction refers to the “healthy tension” that is needed for growth and behavior change, and it naturally follows feedback. It is, in fact, caused by that feedback.

Servant leadership does not mean being “soft” or “a pushover”. Sometimes it means holding others accountable to the extent that you may become very unpopular with them. Herein lies the crux of servant leadership: it is not about improving your own comfort or circumstances, but it is about improving those whom you serve and putting their needs ahead of your own — staff, institution, and beyond.

A common misconception about leadership training is that an intellectual push into any leadership endeavor is enough. How many new members of management teams are sent to classes, courses, seminars, or other information sessions on leadership, only to come back to the workplace with new information and insight on leadership, but no roadmap on what to do with what they have learned?

Though the tenets of servant leadership can be particularly powerful, these tenets will amount to nothing unless they are put into daily practice. These concepts do not only apply to those who are currently in or working toward management positions, but are available to everyone who serves anyone, from staff to physicians, to any other medical worker; even those who do not partake in direct patient contact.

One of the Cleveland Clinic’s mantras during their struggle to reengage their employees was “We are all caregivers”.¹³ This meant that everyone had a voice and everyone was a valued member of the team, whether they had an alphabet of letters after their name or none, whether they worked on patients, with patients, for patients, or simply around patients, everyone affected patient satisfaction, whether directly or indirectly.

So, how does one begin this journey? The best place to start is to make an effort to develop the ten characteristics of a servant leader. We have many opportunities to do this every day in the medical field, especially regarding listening, empathy, and healing. We can do this with patients, their families, our coworkers, and anyone we come across. Taking an extra few seconds to smile or look people in the eye while they are speaking, and to acknowledge that you are hearing their concerns, can go a long way to start building relationships rather than just coexisting in the same space for ten or twelve hours per day. A high degree of emotional intelligence is helpful in this realm. The good news, according to Goleman and others4, is that EQ is not fixed like IQ, so it can, indeed, be developed. Being mindful, rather than reactionary, in our dealings with others is a huge step in the right direction. Hunter’s “F”s of feedback and friction are useful in measuring success.

The journey into servant leadership is not an easy one and there is no “final destination”, as we are all human. We make mistakes in judgment, we sometimes lose our cool, we all have good and bad days. We take one step forward, we fall back two steps; we work hard to make progress over days, weeks, months, only to derail in one weak moment. This is the human condition and it is inextricably bound to our growth not only as leaders, but as human beings. However, the more self-aware we become, the more we are able to check ourselves when faced with crises. If we work on taking little steps daily to build our servant leadership skills and develop the ten characteristics of servant leadership, we become more and more apt to respond to the bigger issues more effectively as they arise. Remember, true lasting change does not come quickly or easily, but it is well worth the effort for everyone. 

Lisa Dittrich, MSEd, RCIS, can be contacted at dittrl@mmc.org.

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