Case Introduction Founded over a century ago, Balewa Health System (BHS) is a faith-based, nonprofit healthcare organization dedicated to improving the health of the people and communities, especially the poor and vulnerable, in the southeastern part of West Virginia. It has grown from a one-building community hospital to a fully integrated 4,000-bed healthcare delivery system. BHS boasts a network of seven hospitals, an advanced imaging center, an urgent care center, primary care and specialty care centers, rehabilitation and therapy clinics, senior health centers, home health and hospice services, affiliated ambulatory surgery centers, and five medical groups. With a total budget of USD 3.5 billion, BHS is a major employer in the area, with more than 25,000 clinical and non-clinical staff. BHS provides more than USD 257 million in community benefit annually. Termination of CEO Benny Edwin Efforts to increase the national ranking of BHS as a national leader in the healthcare industry continue to be hampered, both by persistent low employee morale and satisfaction and by the high turnover in system leadership. In June 2010, the Board of Trustees gave Mr. Benny Edwin, who had served as Chief Executive Officer (CEO) for more than seven years, a one-year contract extension with an expectation that he would engage other high-level executives in creating a culture that valued effective followership. Subsequently, and citing their lack of involvement in the decision-making, several members of the employee union expressed doubts that Mr. Edwin was capable of embracing the values and the importance of effective followership. His contract was terminated within two days, after a five-page letter signed by five senior vice presidents was delivered to Bonnie Wesley, Chair of the Board of Trustees. The senior vice presidents, in addition to echoing the concerns expressed by the employee union, complained that Mr. Edwin had failed to demonstrate an ability to communicate clearly with 3 others, to clarify the goals and objectives of BHS, to embrace shared decision-making, or to serve as a role model for the values of BHS. In announcing Mr. Edwins termination, Ms. Wesley remarked that having completed a comprehensive top-to-bottom review of our organization, it was determined that a change in leadership at this time is in the best interest of all of our key stakeholders, including employees, patients, and providers. The Board believes that this leadership change is necessary to enhance the ability of BHS to recruit and retain talent, improve employee morale and satisfaction, and reclaim its national reputation as a provider of personalized specialty care in the areas of cardiovascular medicine, gastroenterology, geriatrics, nephrology, neuroscience, pulmonology, urology, and pediatrics. Appointment of Dr. Adesuwa Mabel After an extensive five month national search, the Board of Trustees of BHS announced that Dr. Adesuwa Mabel had been selected as the next President and CEO. The Board made its decision after reviewing input from all key stakeholders (i.e., physicians, administrators, and other members, including senior management, department directors, medical staff leadership, and medical staff). Each had the opportunity to evaluate the vitaeincluding experience, leadership attributes, and strategic visionand interview each of the three finalists for the position of CEO. Dr. Mabel brought to BHS more than 30 years of healthcare experience in a variety of different roles. After a distinguished 20-year stint as an officer in the U.S. Army, she enrolled and graduated with a masters degree in healthcare management with a concentration in operations management from the College of Waterloo Rapid, Minnesota, and then completed an administrative residency at St. Marys Hospital in Battle Creek, Florida. In her most recent position as Vice President for Clinical Services at the St. Vincent Health System in Coralville, Texas, where she was on staff during the past 10 years, she focused on using data to improve hospital clinical processes, quality of care, operations, and financial 4 performance. During Dr. Mabels tenure, St. Vincent earned the American Hospital Association Award for Improving Quality of Care at a rate considerably faster than that of other hospitals in the nation. Dr. Mabels appointment as CEO and President at BHS was welcomed and celebrated by both senior leadership and employees because her track record of creating an organizational culture that encourages shared decision-making and rewards exemplary followership stood out and seemed to be just what BHS needed. She assumed her position at a critical time in the history of the organization. Employee morale was low, the overall patient satisfaction rate was below the national average, the financial performance of the system was the lowest among health systems in the region, and the BHS national ranking had fallen by almost 50 percent in critical areas. During her welcome reception, she reassured all key stakeholders that the task of making BHS a nationally recognized provider of care and employer of choice is a responsibility that must be shared by followersas well as by leaders. Within six months of assuming the position, she had established a task force to develop and implement comprehensive leadership and management development and succession plans for the senior leadership of BHS. She had also formulated a strategic financial planning and budgeting process that had a profound impact on the ability of BHS to fulfill its mission. Other important actions taken by Dr. Mabel include giving credit where credit is due, articulating a clear vision for the organization, enabling employees to take bold initiatives, and rewarding exemplary followers. Today, BHS is one of the first health systems in the nation to use data analytics and telemedicine as strategies to improve access to care, to reduce hospital readmission, to increase medical options for patients, and to improve clinical outcomes for patients. By having established new linkages with national and international clinical research centers, BHS is now a national leader in the provision of precision medicine, with a specific focus on cardiovascular and pediatrics care. In recognition of her accomplishments, the International Federation of Healthcare Executives presented her with its Outstanding Leadership Award in 2016. As Dr. Mabel accepted the award, she thanked her senior leadership team for their dedication and commitment to excellence, and she remarked that her success was due largely to her ability to appreciate the contributions of exemplary followers. She also 5 used the occasion to encourage her peers to establish executive management programs aimed at teaching effective followership skills. At the conclusion of the event, Dr. Mabel sat down for an interview with Mr. Jones Amadin, the senior managing editor of Inside the Mind of Exemplary Leaders, a magazine dedicated to highlighting the importance of followership in both nonprofit and for-profit organizations. Dr. Mabel discussed her perspective on followership, describing her method of leveraging the expertise of senior executives to improve not only operational efficiency but also the quality of patient care, employee morale, and financial performance, all of which served to enhance the overall reputation of BHS as an employer of choice. Here are excerpts from that conversation, condensed and edited for clarity. Inside the Mind of Exemplary Leaders Magazine Interview with Dr. Adesuwa Mabel Question: First of all, congratulations on receiving the Outstanding Leadership Award, Dr. Mabel. During your acceptance speech, you attributed your success to your ability to recognize and reward effective followers. Would you mind elaborating on how you became advocate for effective followership? Answer: Hmm. Well, I can say this: as a young officer in the U.S. Army, I learned that followers and leaders exhibit the same traits. In fact, most effective leaders are also exemplary followers. I firmly believe that if a leader does not have followers who are capable and committed to acting in a professional and unselfish manner, he/she cannot be an effective leaderand cannot achieve organizational goals. An organization will fail without effective followers. Followers are a critical part of the leadership process, but their roles in organizational effectiveness are rarely appreciated or acknowledged. My views on followership were reinforced during my healthcare management training. In addition to completing rigorous coursework in finance and operations management, the program exposed its students to excellent case studies on effective followership. 6 Question: Based on your observations, what do you see as the most important characteristics and traits of effective followers? Answer: The characteristics and traits of effective followers are essentially the same as the qualities typically associated with effective leadership. Like an effective leader, an effective follower must be able to place the growth, stability, and success of the organization ahead of personal ambition. As I see it, the most critical characteristics of an effective follower are the abilities to know where and when to articulate specific views on strategic issues, and follow directions to execute the final decision on that issue, regardless of his/her personal views. Question: You said that the task of making BHS a nationally recognized provider of care and an employer of choice is a responsibility that must be shared by followers, as well as leaders. Do you believe that every employee is automatically an effective follower? Answer: No. It takes time to learn the skills required to be an effective follower, just as it takes time to acquire leadership skills. Followership is essentially the flip side of the coin of leadership. All leaders are followers at some pointeither they were before they attained their current position or perhaps they are now followers to someone higher up in the organizational hierarchy or to a governing board. Simply stated, in any organization, each member is both a leader and a follower, depending on the position that he or she occupies. Question: Based on your experience, what do you suppose healthcare organization leaders can do to create, manage, and sustain an organizational culture that values effective followership? Answer: Well, Mr. Amadin, I believe that healthcare organizations share a number of fundamental beliefs and values: the commitment to providing affordable, accessible, and high-quality care; honesty and fairness; and the commitment to treat both patients and employees with dignity and respect. These values and beliefs, which are often codified in organizational mission and vision statements, reflect the beliefs, attitudes, and priorities of everyone in the organization, including the leaders. In order to create, manage, and sustain a culture that values effective followers, a leader must work to align the culture of 7 valuing effective followers in the organization with these values and beliefs. In other words, these values and beliefs must be strengthened in order to transform subordinates into followers. The leaderfollower professional relationship must be based on mutual trust and respect. An experienced leader can enhance this relationship by providing tangible and intangible rewards, by creating a work environment that aligns employees values and skills with organizational values, by engaging followers in shared decision-making processes, and by providing professional growth opportunities for other members of their team. Question: In your opinion, Dr. Mabel, do you believe that there is a business case for effective followership? Answer: As far as I am concerned, I believe that one can make a strong and compelling case for leaders to recognize and reward effective followership. The unprecedented issues and challenges that face hospital and health systems and healthcare professionals make it imperative for leaders to reward effective followership. The demand for servicesacross the delivery systemis increasing, as organizations are pressured to embrace emerging clinical innovation trends and technology, even as they provide precision medicine. To surviveand more, to thrivein this turbulent healthcare market environment, while coping with reduced reimbursement for services, large health systems have eliminated several mid-level management positions. This has forced the remaining mid-level managers to assume the roles, responsibilities, and functions that were traditionally performed by senior executives. This trend, necessitated by increased competition, has forced health systems to promote decentralization of authority and collaboration among units. The ability of any health system to cope with uncertainty in a complex and rapidly changing business environmentwhile meeting patient needsmay depend on how quickly leaders can adjust their leadership styles to enable effective followers to take on leadership roles and responsibilities. 8

Discussion Questions Analyze the case, apply concepts/theories/models from our MGMT 601-Course and the Leadership textbook by Hughes, Ginnet & Curphy (2022) to answer the following questions.

1. What is your assessment of the organization and the organizational culture? In your response, consider the leaders, followers and the situation and touch on what you believe is important to know about each of these aspects of the leadership framework in relation to this organization and what has been presented in the case.

2. What were the leadership styles of Benny Edwin and Adesuwa Mabel? In your response, consider did Benny Edwin succeed or fail in his efforts to achieve the goals of BHS? did Adesuwa Mabel succeed or fail in her efforts to achieve the goals of BHS? Why?

3. What roles do followers play in the success of an organization and effective leadership? In your response, consider misconceptions of followership, and important characteristics that are shared to be effective leaders and effective followers.