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The Benefits and Challenges of Leading a Rural Health System

Analysis  |  By Melanie Blackman  
   September 01, 2022

Dartmouth Health CEO Joanne M. Conroy, MD, shares insights into what it's like to lead a rural academic health system and how rewarding she finds her position.

Editor's note: This conversation is a transcript from an episode of the HealthLeaders Podcast. Audio of the full interview can be found here and below.

Joanne M. Conroy, MD, has served as president and CEO of Dartmouth Health (previously Dartmouth Hitchcock Health), New Hampshire's only academic health system, since 2017. Her career has come full circle, as she graduated from Dartmouth College in 1977.

The health system serves rural communities in New Hampshire and Vermont through six hospitals, a visiting nurse and hospice program, and numerous clinics, and operates in partnership with the Ivy League university.

Additionally, Conroy is the American Hospital Association chair-elect designate and will become chair of the AHA in 2024.

During a recent HealthLeaders podcast interview, Conroy shared insights into the benefits and challenges of leading a rural health system, described her 4 tenets of leadership, and offered advice for future leaders.

This transcript has been edited for clarity and brevity.

HealthLeaders: What is Dartmouth Health's role in serving communities across New Hampshire and Vermont?

Joanne Conroy: When we think about the communities we serve, it's not just the patients we serve, but those communities that the patients live in. We realize that in rural parts of the country, your zip code has a lot to do with your healthcare, and so when we think about serving communities, it's not just addressing the healthcare needs of those patients we serve, but understanding and trying to mitigate the environmental and social factors that lead to poor health.

We have a fabulous population health group that has a broad definition of population health, and they've done an analysis on longevity according to zip code. [They found] you can live in Claremont, New Hampshire, and your anticipated lifespan would be 15 years less than if you lived in Hanover, New Hampshire. There are many reasons why those are less healthy environments for people to live in and bring their families up in. Those are the things that we're focusing on addressing; the issues that are associated with simple things like appropriate housing, access to fresh food, even how the communities are addressing opiate use disorder; all of those have an impact on communities and the health of the people that live in them.

We are the most rural academic medical center, so our reach is really broad. Not only are we serving patients all the way up to the Canadian border, but we serve many patients from rural areas of Vermont as well. We only have 170,000 people within a 30-mile radius. I think the second most rural academic medical center is Mayo Clinic in Minnesota and they have about 230,000 people within a 30-mile radius, which is how the degree of your rural nature is determined.

With it comes great opportunities to use telehealth, to provide services to our neighboring hospitals that are not part of our network in a way that allows them to be financially strong and sustainable so they can continue to serve those communities. In essence, when you serve rural communities, you serve through other members of those communities: other hospitals, other organizations, other nonprofits. That's how you're effective in delivering care in rural America.

HL: What are some of those challenges that your organization is facing due to being a rural health system and how are you addressing those as CEO?

Conroy: Recruiting people to come work in rural America has been tough for years. Here are a couple of things that we have done:

1. Understanding the barriers for people to move to rural areas that we serve. Sometimes it's housing and being able to access and identify housing for an individual or their families.

2. Transportation. We support a number of public transportation systems because they move our employees around and they move our patients around as well.

3. Creating a spectrum of experiences for the providers [and] clinical staff so they see the whole continuum of how we provide care to patients. Our hospitalists [provide care] at our academic medical center where it can be super intense, especially as we've gone through the pandemic. But they also provide inpatient services at our critical access hospitals. People can get a little bit of a breather from the intensity of the academic medical center to take care of people in a smaller hospital that may be focusing on surgical throughput or caring for people with low acuity concerns in the community.

The same opportunity is there for our nurses. They can move up the career ladder by working in several different rural environments. They don't have to leave the system to advance their career, because we're so widely distributed.

HL: Earlier this year the health system rebranded as Dartmouth Health. Why was there a rebrand and what was the three-year strategic plan behind the new name and logo?

Conroy: It shouldn't have taken three years, but we were doing it in the middle of a pandemic. Many people would say, 'Why didn't you just stop?' but we felt that we had changed so much as a system over the last five to six years that we needed to reintroduce ourselves to the community.

Part of the new brand was spending some time thinking about who we were in the community and comparing ourselves to other organizations across the Northeast. Our NCI-designated cancer center has the highest patient engagement scores of any NCI designated cancer center in the country, our children's hospital is the only one in the state, [and] we're the only academic medical center in the state. The innovations and the care that people can get here at the academic medical center are truly extraordinary and they can access that care from anywhere [and] from the communities in which we have facilities.

As we thought about who we were, we said we were world-class institutions that were woven into the fabric of our communities, and that's part of delivering rural healthcare. There's no anonymity. When I go to the supermarket locally, you're going to have a conversation with people who either receive care in your facility or work in your facility. And sometimes, frankly, you solve some pretty big problems in aisle three of the co-op.

That's the beauty of living in a rural environment when you're so close to the people you serve, and we felt that talking about ourselves as part of the community was important. It's different when you're delivering care to your friends and neighbors, rather than people that you might never see again in a more urban environment.

HL: What has your career journey looked like so far?

Conroy: Well, I never thought I would end up here. I was a 1977 graduate of Dartmouth College, one of the first classes to be co-ed here, and it was a great experience. I was a full scholarship student and worked at a local restaurant for three of the four years here, which allowed me to pay for everything that the scholarship doesn't cover that's part of your education.

I left here never thinking about coming back, and moved to South Carolina. My subsequent moves, though, actually kept bringing me further and further north. I was working outside of Boston when somebody called me about the job [at DH]. I applied, and it's interesting, during the interview I realized that this was an opportunity for me to pay back a debt that I had to this broad community that had supported me in my education. I am not sure that I would have been able to achieve what I've achieved in my life without a full scholarship, as well as an incredibly supportive community that became my friends and neighbors while I went to undergraduate here in Hanover.

Sometimes you feel like your career goes full circle and so it seemed like exactly the right move.

HL: How would you describe your leadership style and how has it evolved over your career?

Conroy: As you go through your leadership experiences, you start to depend on more than facts. You depend on your gut, and there is something about your intuition which can't be ignored as a leader.

I give a lot of leadership talks, and I've got four tenets that I use all the time:

1. Authenticity. You need to be an authentic leader. That means people feel like you're not manipulating them, that you are being honest and straight with them. Part of that is being a little bit vulnerable, which is always great when a leader can do that with great authenticity.

2. Integrity. All of us need to commit to things. And if we can't deliver on them, we have to tell people why and when they can expect us to deliver on those promises.

3. Responsibility. We all make choices, and you have to be accountable and responsible for those choices you make; they get you to where you are.

3. Being committed to something bigger than yourself. That's what healthcare is all about. People who come here for a financial or reputational gain are probably in it for the wrong reasons. There's nothing that sustains leaders more in healthcare than looking at the impact you have on the lives of everybody that you work with and care for.

HL: What advice do you have for aspiring healthcare leaders who are curious, but maybe wary, of serving in leadership roles for rural institutions?

Conroy: I would advise them that it's an important part of their leadership training to understand rural healthcare. 20% of the people in the US receive healthcare in rural health systems, so it's not like we're an anomaly.

In rural systems you know everybody, and it's a great way to learn how to get things done. And it's not always because you've figured out the answer to a problem, but it's because you develop relationships. You can appreciate the challenges that people you're working with are facing because they are your neighbors. You learn a lot about how to create win-win solutions, how to lead authentically, and [how to] create coalitions within your community to improve health. All those skills are incredibly important and translatable to a higher density environment.

Sometimes it's hard to get those experiences in an urban or a busy suburban environment where you don't necessarily know everybody. I can tell you that first couple of weeks I was here, I received a call from the governor of the state to welcome me and introduce himself. That doesn't happen in a lot of large sites. And there are a lot of benefits of really spending part of your career in rural healthcare.

“When we think about serving communities, it’s not just addressing the needs of those patients we serve, but understanding and trying to mitigate the environmental and social factors that lead to poorer health.”

Melanie Blackman is a contributing editor for strategy, marketing, and human resources at HealthLeaders, an HCPro brand.

Photo credit: Joanne Conroy, MD, President and CEO, Dartmouth Health. Photo courtesy of Dartmouth Health.

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