Triad leadership has become a foundational way of operating across hospitals and health systems. There’s no doubt the triad is a powerful idea: you bring together a physician leader, a nursing leader, and an administrative executive to jointly lead care delivery. When these leaders work well together, they create alignment between the organization’s clinical quality, workforce stability, and operational performance. This sets an incredibly strong foundation for success, sustainability, and patient outcomes.
However, like any leadership model, successful leadership triads depend on more than structure alone. Many organizations implement a triad without fully defining how this leadership structure should function on a day-to-day basis. That’s where opportunities are missed. Without clear alignment, communication, and shared accountability, even well-intentioned triads can struggle to operate at their full potential.
The good news is that these challenges are highly solvable. When designed with intention, actively managed, and continuously refined, triads are the leadership structure best prepared to meet the current (and future) moment of the healthcare sector, as each organization’s complexity increases well beyond the capacity of any individual leader.
Based on the findings from a recent industry pulse survey, conducted by Kirby Bates Associates in partnership with Jackson Physician Search, we’ve identified four fundamental practices that consistently show up in the highest-performing triads. Those practices relate to alignment, communication, psychological safety, and shared accountability. Here, we’ll walk you through what a triad needs to excel in each of these areas, and what comes next.
1. Start with Intentional Alignment
Every leadership triad starts with the best intentions. Naturally, healthcare organizations only pursue triad leadership when they’re actively trying to improve their operations. However, things can fall apart quickly without alignment.
This stems from the triad over-emphasizing a single priority, often clinical outcomes. The point of a triad is balance and compromise. Prioritizing one area (clinical outcomes) fails to account for workforce sustainability or an organization’s financial viability.
If a triad doesn’t balance those concerns, they’ll hit a wall. Nursing leaders will push back on staffing constraints and concerns, administrative leaders will raise financial concerns, and physicians will feel that they’re being blocked from moving their priorities forward. This is common, and it’s not a failure. However, it does signal that the triad wasn’t truly aligned from the start.
Define Success For Each Domain
To get your triad off on the right foot, prevent misalignment by getting crystal clear on what success looks like in each leader’s domain.
- What does success look like from a clinical perspective? Talk about quality metrics, such as complication rates, readmission rates, and infection rates.
- What does success look like from a nursing workforce perspective? Assess nurse vacancy rates, turnover, and your organization’s degree of dependence on agency staff.
- What does success look like for the organization’s operations and finances? What are reasonable targets for your OR utilization, average length of stay, and margins?
Getting aligned on success metrics matters. However, your triad also needs to align on how decisions are made. Not every decision needs to go to committee; that’s not what a triad operating model is for. The vast majority of decisions each leader will make can be handled independently, as they are in a traditionally siloed approach, but shared decisions must be explicitly defined. These decisions can generate conflict and tension. That’s to be expected and is a sign your triad is moving in the right direction. Your triad simply needs to assure that processes are in place so disagreements can be resolved quickly and completely.
Without this alignment — a high degree of clarity on what success looks like, how decisions are made, and which decisions are shared — your triad will be at risk of returning to traditional hierarchies.
2. Effective Triad Communication Can’t Fit In A Monthly Meeting
Have you ever met with an old friend and felt like you spent so much time catching up that you never really got into the free-flowing conversations you had with them in the days of yore? It’s not a bad thing, per se, but it does tend to tell you that you’re not as close as you could be.
The same thing can happen in leadership triads, and this is why you can’t settle for monthly meetings. When the cadence drops to once a month, meetings become a forum for updates, rather than a platform for decisions. Your triad becomes so mired in catch-up and status reports that you can’t devote time to immediate concerns or plan for long-term goals. Not to mention, when the challenges facing your hospital can change on a weekly basis, meeting just once a month will render most of the triad’s updates irrelevant.
Tips For a Better Triad Meeting Cadence (MOVED TO NEW PAGE)
To get the most out of a triad, communication needs to be designed to happen early, often, and regularly. That said, more meetings doesn’t equate to better outcomes. Your triad communications should therefore have two critical parts:
- Regular (almost daily) check-ins: These don’t need to be scheduled calls or take up time on the calendar, but pulse checks throughout the week can keep your triad aligned, clear on goals and priorities, and up-to-date on the status of various initiatives.
- Weekly triad meetings: When status reports can be shifted to daily check-ins and project management dashboards, these meetings can be used for high-impact decision-making and agenda-free collaboration.
With this approach, you can improve communications without bloating calendars.
How to Make Triad Meetings More Effective
The first step to better triad meetings is to hold them regularly — at least weekly, as mentioned earlier. By increasing their cadence, they cease to be consumed by passive updates and siloed reporting that defies the purpose of the triad leadership approach.
Once your meeting cadence is improved, you can focus on real issues. Let’s take OR utilization, for example: say it’s down, hovering around 60%, and your triad wants to increase it. Use your triad meetings to identify and hammer out:
- Barriers: Is your throughput limited by anesthesia provider availability? Are nurses burned out?
- Tradeoffs and misalignment: Are OR blocks being released too late to be filled? Is your post-anesthesia care unit at capacity?
- Decision making: Should you change your block release rules? Do more procedures need to be shifted to outpatient facilities?
In this example, a triad could try to address it by extending OR hours on a specific day. The nursing leader would coordinate and own staffing, the physician leader would organize surgeons, and the administrative leader would own the cost analysis. By piloting an approach like this, each leader has clear responsibilities that align with both their domain expertise and the hospital’s broader goals.
To reiterate, when a triad’s communication enables them to quickly find and agree on solutions, a discussion like this could take place in a single meeting. If a triad meets once a month, it simply won’t have the time to go deep enough to find solutions.
3. Create Psychological Safety by Design (MOVED TO NEW PAGE)
Triads bring together leaders with different incentives and levels of authority. In hospitals where triad leadership fails, a common thread is the assumption that those hierarchies will naturally dissolve once the word ‘triad’ is waved in their direction. They don’t. The triad’s diversity is both its strength and its weakness, and healthcare organizations see the most success when they understand and acknowledge that challenge, rather than trying to work around it or ignore it.
However, because those hierarchies stay intact, psychological safety is imperative for a triad’s success. Without it, the triad will become performative and regress to the traditional hierarchical leadership models. Here’s what can happen in a leadership triad that lacks psychological safety.
Triads That Are Unsafe Psychologically Risk Unsafe Practices
Imagine that a hospital administrator is considering increasing their nurse-to-patient ratio to manage their ever-rising labor costs. It may be possible under the right conditions. Still, the nurse leader is concerned about an already-lean staff’s risk of burnout, and the physician leader is concerned about long-term complications that could arise if nurses are spread thin. However, because this triad lacks psychological safety, the physician and nurse leaders either don’t speak up or water down their concerns. Thus, the administrator proceeds as planned. A month later, the administrator sees an increase in length of stay that consumes their projected labor cost savings.
Conversely, in a psychologically safe triad, the nurse and physician leaders are comfortable pushing back: “We’re already pushing staff toward burnout, and I think we’ll see more turnover if we increase their workloads,” or “I’m worried that’ll only lead to longer stays. What else can we try?”
The key to this is each member of the triad understanding that, like a suspension bridge, tension is harnessed to strengthen decisions, rather than weaken them. In our nurse-to-patient ratio example here, the triad might realize that reducing nursing staff isn’t a viable option. However, with the physician and nurse leaders understanding that they need to support the administrative leader’s financial goals, they work to find a solution, such as targeting a specific unit, assessing downstream impacts like length of stay first, or taking a more holistic look at how their care teams are currently designed.
Build Psychological Safety By Establishing Norms And Expected Behaviors
Just as a triad’s impact doesn’t magically materialize by calling it a leadership triad, psychological safety doesn’t simply appear because you want it to. It takes work. That said, establishing norms and expected behaviors when your triad is still nascent can help foster that psychologically-safe environment.
This step is vital for a triad’s longevity. To return to the suspension bridge metaphor, the norms and behavioral expectations your triad establishes early are akin to the anchorages, buried deep underground, that bear the load of the tension. Without clear norms, it’s too easy for a triad to slip back into traditional, hierarchical patterns — and effectively collapse.
Each triad’s needs will vary, but the best triads report success when they establish norms like:
- Challenging ideas rather than individuals
- Bringing up concerns early
- Not tolerating unilateral decisions
Individually, leaders can build trust and cultivate psychological safety, even when things aren’t going well, when they do things like:
- Being upfront about what they don’t know
- Admitting when they’ve made a mistake or fallen short in some way
- Inviting other leaders to challenge their ideas
Psychological safety isn’t just a buzzword to toss around. It’s a prerequisite for your triad’s success.
4. Tie Goals to Shared Accountability
Lastly, when a leadership triad is aligned, communicates freely, and its members are psychologically safe, it can approach its ideal form. However, there’s still one crucial element that distinguishes the most effective triads from those struggling to see results: connecting goals to shared accountability.
When goals are arranged traditionally around roles, results are siloed, and positive outcomes for one leader might come at the expense of another. For example, the administrator who increases nurse-to-patient ratios to control staffing costs might achieve their goal of reducing costs (at least, in the short-term). However, it would likely create issues for the nursing leader and physician leader, who would be forced to deal with downstream impacts of such a change, such as nurse burnout, complications, and longer stays.
Effective triads escape this cycle of siloed goals that drive results that only create more issues later by sharing their goals, so each leader succeeds only when the other two succeed. When each member is accountable for quality outcomes, workforce metrics, and financial performance, there’s a paradigm shift in how decisions and compromises are reached, and the triad becomes a leadership team, not just a group of leaders.
Triad Leadership Works When You Work For It
Triad leadership is not a fad. The results from our industry pulse survey make it clear that triads are here to stay as the complexity of challenges facing healthcare organizations rapidly outpaces what any individual leader can manage. That said, triad leadership is not easy to implement. Here, we’ve covered the basics of what your organization’s leaders need to focus on to establish a strong foundation that will actually support your triad.
Intentionality, excellent and regular communication, trust, and shared accountability will prime your triad for both success and longevity. Without these fundamentals, triads will be little more than an aspiration, and your organization will inevitably revert to traditional hierarchies, siloed decision-making, and an endless cycle of problems and reactions.
As you can imagine, building an effective triad doesn’t stop there. As a triad develops and clinical leaders increasingly need to account for financial considerations, and administrators increasingly need to account for clinical impacts, leaders face an immense need for development.
In our next article, we’ll dig deeper into the principles that sustain triads over the long haul: relationship-building, leadership development, and a high degree of adaptability.
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