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Happy Thursday, Hospitalogists.

Last month at Vizient's Connections Summit, I got to sit down with 3 leaders who have spent a combined 82 years at their current organizations:

• Dan Lundergan, CEO of University of Utah Hospitals and Clinics, who recently took on a system CEO role as well. He's been at Utah for 52 years starting with the laundry room.

• Regina Cunningham, PhD, RN, CEO of the Hospital of the University of Pennsylvania (HUP) and the 1st nurse to run it in the hospital's history. She's in her 10th year in the job and 15+ at Penn overall.

• David Levine, MD, Vizient's chief medical officer, an emergency physician who ran the ED at Cook County Hospital and now oversees Vizient's Quality and Accountability rankings, part of the org for the past 15+ years.

Huge thanks to the Vizient team for the hospitality, for wrangling 3 very busy executives into one room, and for the opportunity to have these conversations at all! Let’s dive in.

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See It In Action

From the Laundry Room to the Corner Office. Leadership Lessons From 3 AMC Leaders.

I told the group up front a simple truth: I'm not a gotcha journalist. I'm after knowledge and shared best practices from the people who actually run these places. All 3 delivered in a major way. And if you want to be a part of the conversation moving healthcare forward, not part of ‘gotcha’ journalism encompassing much of healthcare media these days, I’m your guy.

Something worth keeping in context for the whole conversation with these extremely long-tenured individuals is…the average healthcare CEO lasts 3-4 years. Hold that number next to the 82 combined years these leaders represent. Dan's phrase for what these 3 have built is stability through change, and this is a great overarching concept for the conversation at large.

Executive Summary:

• Leadership longevity is a competitive advantage in academic medicine. Based on Vizient top-performer research, hospitals that fall out of the top of its quality rankings often do so after a CEO change, and the smoothest successions come from someone mentored internally.

• Gotta have the culture and trust. Before teams follow you into anything new, they want to know whether they're going to be okay. It’s on you to provide that safety and transparency.

• Clinician CEOs have to learn the revenue side, or, more generally…humble yourself to understand your ‘weak’ spots. Regina met weekly with an internal tutor on contracts, payers and case rates during her 1st year in the job.

• You can't be good at everything so learn to delegate and partner. HUP built its strategy around high-acuity services like its ~1,000 solid and liquid organ transplants a year, and said no to plenty of reasonable requests along the way.

• System-ness starts in accounting. Utah is moving its School of Medicine from cash to accrual accounting under a new system CFO, 1 of 9 initiatives running at once.

• AMCs shouldn't try to out-consumer the consumer players. Dan wants Utah to be the coordinator and information hub that makes the "100 doors" smaller.

On Leadership: Nobody leads alone.

A nurse in the corner office

Regina is the 1st nurse CEO in HUP's history, at a hospital that opened in 1874 inside an organization that's been around for more than 250 years. She also wasn't tracking for the job. At all. (which probably made her the best option).

She knew early she wanted to be a nurse, and she wanted oncology specifically after going through Hodgkin's disease with her grandmother. Nobody encouraged new grads to specialize back then, so she spent 4 years with surgical patients at a general hospital across the street from where she lived in New York City, then moved to Memorial Sloan Kettering. That's where she got hooked on the question she's chased for the rest of her career:

"How do you drive outcomes, and what is it about the practice environment that you need to think about in order to have people do the best work they can do?"

From there, she knew her path. graduate school at NYU, a run of progressively bigger cancer leadership roles in New York, and then Penn about 15 years ago, where she'd done her doctoral work. Cancer program, then chief nurse at HUP, then chief nurse for the whole system as an SVP. She was content.

Then her boss told her he was retiring. "I think you might want to think about this because you're very good at it."

She hadn't thought about it at all. They went back and forth on the pros and cons, she said yes, and year 1 was "really challenging." She had a learning curve in certain areas while holding complete mastery in others, and she grappled with how to get up to speed on everything.

"In the beginning... you're fumbling all the time, and you're just trying to learn everything, but then you get good at it, and then it becomes like really fun."

Her hardest adjustment was becoming the person where the buck stops. Month-end financials, any risk that materializes anywhere in the hospital, all of it lands on the CEO. I couldn’t help myself and made the sports-guy comparison: the head coach gets fired even when his team fumbles 6 times. Regina responded with a smirk and said: "I wouldn't want to be a coach." I agree; that’s a different level of responsibility (and I can remember when people wanted to fire Steve Sarkisian in year one (ONE!!) after our historic loss to Kansas, but I digress)

But she pairs the buck-stops-here line with a caveat she repeated all hour: "Nobody leads alone." You inherit a team, that team makes or breaks the work, and building the right one deserves an outsized share of a new CEO's attention.

Regina’s 3 moves for a Successful CEO Transition

Like I mentioned, CEO longevity and executive turnover was kind of thematic and present throughout my entire conversation with the 3. So if you're being mentored or prepared for the top job, you usually get stretch assignments. In Regina’s case she didn't, so she built her own on-ramp in real time. Here wer 3 things she did I thought were super impactful:

• Be curious. Ask more questions than anyone expects. Year 1 for Regina included a big lawsuit involving one of the hospital's physicians (not a malpractice case), and she was meeting with lawyers constantly. One day they told her, "[the former CEO] never asked us this many questions." She replied "Yes, but I really want to understand." (I assume nobody billing by the hour minded.)

• Stop taking resource requests one meeting at a time. Leaders kept coming in with individual asks for a recruit, a program, some equipment. All of it made sense on its own. She decided she couldn't work that way and started sitting down with key leaders to plan 1, 3 and 5 years out, lining up recruitment with financial cycles, capital and equipment.

• Remove your ego from the equation. As system CNO she ran a huge budget, but only the expense side: labor and supplies. So she asked a colleague who knew the budget inside and out to teach her the revenue side (contracts, payer issues, special service arrangements), meeting every week. "I don't know as much as a CFO for sure... But I wanted to learn the details, so I feel that I had command of it."

Plenty of clinical executives can tell you their labor cost per adjusted patient day off the top of their head. Far fewer can walk through how their biggest commercial contract actually pays for a heart transplant. Command of the revenue side is a potential gap between a great clinical leader and a CEO, and Regina closed it intentionally, recognizing this gap. She owned it.

82 years of tenure in a 3-year industry

Back to that 3-4 year average. Regina's in CEO year 10.

Dan’s at 52 years with the University of Utah (go Utes).

And he started with laundry.

"I'll just say that's a credit to the organization to believe in people," he told us. I asked the obvious follow-up about what the best fabric softener was. He didn't have a recommendation (ridiculous), but he did point out there were no gloves and no masks in the laundry back then. "I’m surprised I'm still living," he joked.

From the laundry he worked his way up to CEO of Hospitals and Clinics and, more recently, a system CEO role. His fam remained as the anchor through all of it: his wife and 3 boys, and a belief that an organization should behave like a family that treats each other with respect and dignity and integrity.

Then, last but not least to the party, David's path took a different shape from the others. Northwestern for med school, emergency medicine training in Boston, then his "dream job" at Cook County Hospital. A chairman who ‘loved to be bad cop’ pulled him into administration as associate ED medical director with a promise straight out of the Palm Pilot era: do it for a year and you can come back. Years of experience elsewhere later, Vizient recruited him and he planned to stay maybe 3 or 4 years.

It's been 15.

So what…all of these individuals stuck around their respective organizations rather than jetting. Who cares? What does it matter in today’s day and age when tenures are so short and everyone just wants to get their bag?

In healthcare, more than any other industry, longevity of people is a qualitative, decisive factor in creating the right culture for the broader organization. Transparency, adaptability to change, and transformation efforts all translate into better patient care and higher quality and financial results.

Things move at the speed of trust. I’m almost POSITIVE you have heard this altruism before. Right?

Dan's answer starts with what teams across the University of Utah need to be successful: stability, plus "the excitement and curiosity of innovation." Underneath the org chart, people are asking a handful of quiet questions which really gets down to the psychological core of…’am I valuable as a human?’:

"Am I going to be okay? What impact do I have? Am I empowered? Do I have a voice? Am I being listened to?"

Answer those, and you have the platform to be able to now move the organization forward. To be fair, Dan steel-manned the other side right away with a caveat: new leaders can still bring great ideas from other organizations, and the right answer is a blend. But overall, the CEO sets the culture and this combined ability to communicate between old and fresh ideas and people.

Regina framed the executive churn problem as footing for an organization.

When CEOs turn over every few years, it's really hard to get your footing and an erratic environment has people worrying about what's coming instead of doing their best work. Regina had a great one-liner on stewardship of being the CEO of the organization: "I stand on the shoulders of giants, but I have my responsibility and obligation to ensure for the next generation."

I knew this interview is a good one when they started talking amongst themselves rather than answering my questions individually. All 3 eventually landed on the same word: trust. I asked Regina how she balances trusting her executives to run their domains against her own conviction when she feel something's off. Her answer was a high-reliability, feedback-rich environment where people feel psychologically safe enough to course correct, plus a CEO willing to have the correcting conversation "as quickly as possible." Done authentically, people take it well. "Most people, when you correct or give feedback, they're thankful."

That one landed for me. It's how I try to run Hospitalogy with all of you: tell you what I think, communicate directly, skip the hand-holding, and be authentic.

David brought a more analytical approach with numbers to back up a qualitative trust fall exercise. His team runs Vizient's Quality and Accountability Ranking, which weights mortality, safety, effectiveness, efficiency, patient-centeredness and equity into a balanced scorecard. He's quick to say every one of those metrics is a proxy. "Quality really starts in the lens of the patient and the community you're trying to serve…we're just at the cusp of honestly measuring quality now."

When Vizient studies what separates top performers, the secret sauce comes down to a shared sense of purpose, collaboration and accountability. And when you look at who stays on top:

"I've definitely seen the ones that have come to the top and fall, and then not stayed at the top. A lot of times, it correlates very much with a leadership shift at the CEO level. Not always."

In his experience, the smoothest transitions go to someone who's been mentored to be next in line.

A lot of boards treat a CEO search like a reset button. David's read is that the reset often costs you, and the cheapest insurance is a successor you've been developing for years.

On Strategy…You can't be good at everything.

Acuity is the strategy

When I asked Regina what clicked once she learned hospital economics, she pointed to how tightly operations, strategy and revenue connect. HUP's strength is high-complexity, high-acuity care: interventional cardiology, cardiac surgery, and solid and liquid organ transplant. On transplants alone, HUP does about 1,000 a year combined. A huge differentiator for her organization and an area she thinks often about doubling down on.

That focus drove a lot of early no's. When she stepped into the role, people came asking to open more rehab beds and more medicine beds. Her answer was no.

"You can't be good at everything, and other people can be good at other things."

This is intentional strategy - differentiating into a high acuity offering that is brand boosting and not easily replicable. An AMC's infrastructure for a transplant or cardiac surgery program can't be replicated by the community hospital down the road, payers know it, and higher acuity, of course, carries a higher case rate. Plenty of hospitals can staff a rehab unit. Capital spent there is capital not spent on the services only you can deliver.

Health System Evolution rather than Transformation

Dan doesn't like the word transformation. "I think transformation kind of conjures up a little bit of thinking things are not working well now." He prefers evolution. Or revolution. Either way, you start by acknowledging what's already working.

What Utah is evolving toward is the concept of system-ness. Historically, the School of Medicine ran on a parallel track to the hospitals and clinics. So did 18 clinical departments, the basic science side, and a handful of deans (dentistry, pharmacy, nursing). Getting all of that into "system thinking" means rethinking autonomy, and the role of the department chair is changing in real time.

Dan's most concrete example was the accounting. Hospitals and clinics run on accrual accounting with a monthly close. Utah's School of Medicine ran on cash accounting, which Dan described as "pretty loosey goosey." (I’m sure every CFO reading that just felt a horrifying chill down their spine.)

Now everyone is moving to accrual, which raises its own questions, like who the finance people embedded in each department report to going forward. And that's 1 of 9 initiatives running at once, on top of federal and state policy pressure and AI, at the University of Utah.

Then there's the university itself. Athletics "used to be the top dog in terms of money," Dan said, and now it's "knocking on our door," with the broader university hunting for efficiency and functional alignment across main campus and health sciences. Apparently the House settlement bill had to land somewhere.

I asked whether the football program was hitting up the health system for NIL money. I was kidding. Mostly. (I also may have brought up Michigan poaching Utah's coach. Couldn't help myself.)

Through all of it, Dan's focus is what teams need from leadership. Change always comes back to "how does it impact me, or how does it impact my teams?" His reassurance comes with a caveat attached: "It's going to be okay. You're not going to lose your job. But your job may change." People watch leaders for tells ("Are you nervous? Are you talking different?"), so he's deliberate about it. "You say what we know, and what we don't know."

Regina pointed out that AMCs across the country are going through the same struggle, and the delivery matters as much as the plan. "If we run around with our hair on fire, our teams are going to be like, 'What's going on? This feels so crazy.'"

Inside the hospital, she treats it as a daily tension between performing and transforming - a simple but nice framework to think about it day-to-day.

• Performing is delivering today's care against the balanced scorecard.

• Transforming is asking what tools and resources would let the team do it better tomorrow, from driving the CLABSI rate down to using AI to strip out the non-value-added work that burdens clinicians every single day.

"You have to be little ambidextrous with perform-transform."

Dan added the ultimate importance to keep blocking and tackling (gotta keep the football metaphor going). You can't get lost in all these initiatives and quality and patient experience can't slip while leadership is "swirling up" on governance and finance. He credited Dr. Kencee Graves (who was also in the room and should have joined in on the conversation!!) with leading Utah's push on psychological safety, so teams keep a voice while everything moves.

David agreed medicine has always evolved. It's just evolving faster now:

• Outpatient migration;

• A wave of new oncology drugs (and the associated cost and utilization management);

• GLP-1s, touted for a growing list of indications beyond weight loss;

• AI and ambient listening, where his question is what the freed-up time buys: more patients, or more time with each one, better diagnoses, and better physician engagement and retention

Shrink the 100 doors

My last question went to Dan. GLP-1s, direct-to-consumer, longevity, everybody using AI. How much does an AMC need to respond on access and the front door, and how much should it lean into what only it can do?

He pointed back to a piece I wrote on the 100 front doors (talk about a flattering moment - love to see it). Then he got blunt:

"We're not going to compete with the consumer base. That's just end of story."

So in Dan’s mind you’re never going to outcompete more consumer-forward companies. But what Utah can do is coordinate. If a patient goes to Hims & Hers or an independent site and Utah has them in MyChart, the open question is whether stitching that data back together is the patient's job or the organization's. Dan wants Utah to be "an information driver" that stays in the game enough to provide continuity. "From a coordination of information and delivery of care, those doors have to start getting smaller."

I'm with him, and it ties straight back to Regina's "you can't be good at everything." Hims & Hers, Function Health and whatever longevity clinic just opened in your market will win on convenience. An AMC wins on complexity, and on being the place where all of that outside data finally lands in one chart. Be the hub the spokes route back to. But regardless, this tension and friction between health systems and consumerism will continue. Some health systems will forge ahead and want to own the consumer layer. Others will be content to collect the downstream from a more fragmented system. Even more question every day whether they’re becoming a ‘ghost kitchen’ of downstream proceduralists. Over time, the role of the health system will evolve, and strategies will diverge among those with the means to capture the highest acuity of care versus devote time to transforming into an integrated care delivery vehicle.

Practicing what she preached

With about 2 minutes left, Regina circled back to the 2 things she thinks matter most: listening to your teams, and empowering them. "You're unleashing large numbers of people to do this really good work," she said, and she called it a key driver of performance at Penn.

Then she had to leave early. One of her team members was presenting at 1, and the co-presenter had dropped out at the last minute. "I want to make sure I'm there to support her."

So she walked out of a room full of executives to go do exactly what she'd just described.

Average CEO tenure in this industry is 3-4 years. Spend an hour with these 3 and it's pretty clear why theirs isn't.

Thanks again to the Vizient team for making this happen, and to Regina, Dan and David for their time. (Dan, thanks for reading. That's the highest honor.)

As for me, I’ll be doing my laundry tonight!

TOP READS AND RESOURCES

• Trilliant Health released its annual report on trends shaping the health economy. It argues the U.S. health economy is a "tragedy of the commons." Each stakeholder acts rationally in its own interest, and the combined result is collective failure. The report says no stakeholder is organized around producing health rather than revenue.

• Nurse turnover risk peaks in the first 12-18 months, yet many clinical ladder programs can limit early-career participation. A new AONL and Laudio Insights report shares redesign strategies from nurse leaders to help you enhance your approach to ladders.*

• Lawmakers urge CMS to “roll back proposed Medicare payment changes that would bar remote patient monitoring programs from using third-party clinical staff. The lawmakers argue that the proposal could significantly reduce access to remote monitoring for Medicare beneficiaries, particularly rural patients and those served by small, independent physician practices and hospitals.” Read more from Fierce Healthcare.

• A new KFF Health Tracking Poll looks at how healthcare and affordability are shaping the 2026 midterms. Results show 6 in 10 voters worry about affording healthcare, tied with gas prices as the top economic concern. About half (47%) say it's "extremely important" for candidates to discuss health costs, second only to cost of living (62%).

*This read is brought to you by one of my brand partners who help make this newsletter possible!

MISCELLANEOUS MADDENINGS

If you’re around the Texas-OU game this weekend, I’ll be there. Of course besides the Fletchers Corn Dog and whatever won best dessert (though I‘m always a sucker for the fried cookie dough), I’ll be considering whatever won best in show this year. There’s always something crazy. Like fried pizza (but the year I tried that it was really not worth the calories). Anyway, I’m actually terrified of playing OU this year. I think everything is lined up for us to have an ‘easy win’ which is the exact setup where we go in feeling entitled and get hit in the mouth by a team with nothing to lose. It’s going to be a close, low scoring affair and despite the fact that OU seems to be playing like a middle school team on offense and has injuries galore, something is bound to happen in this game. Still, ‘Horns figure it out and come out on top (of course). Hook ‘em.

Thanks for the read! Let me know what you thought by replying back to this email.

— Blake