Carilion Clinic President and CEO Nancy Howell Agee is nothing if not a visionary leader. The former nurse led her organization, based in Roanoke, Va., through a change to an integrated delivery model during one of our nation’s worst recessions. It became one of the most innovative and collaborative health care systems in the country. Now, Agee is preparing to assume her yearlong role as chair of the American Hospital Association board of trustees. As she mentions in a discussion with H&HN Digital Editor Genevieve Diesing, being in the C-suite can be isolating — and the health care field is changing rapidly — but her commitment to patients, innovation and affordability keeps her at her best. Oh, and so does her dog.

On being a candy striper at a young age

Since I was about 5 years old, I wanted to take care of things, take care of dogs, take care of people. I did have a health issue: I had major surgery on my knee when I was about 15. It was serious, but it wasn’t life-threatening. I was hospitalized and on crutches and in a wheelchair for the better part of two years. That was life-changing. And I wanted to be like those people who helped me. They were so wonderful and great caregivers. I think those early experiences all coalesced.

On her early roles as a hospice and surgery nurse

I started out as a med-surg nurse. Frankly, I liked taking care of surgical patients better than other patients, I think because it was more predictable. I could actually make patients better more quickly; I received gratification out of that. And the patient would leave, and then I would take care of the next patient. Oddly, and I don’t even know how this happened, I developed a real interest in taking care of patients with cancer. And then, advisers — who were different from the leadership of the hospital at the time — suggested that we ought to have some specialization in oncology. And, it just so happened that an oncologist was moving to town. We worked with this physician and, after I returned from graduate school, we received a cancer grant. I was the lead administrative director of the grant, and through that process, we developed hospices for all four hospitals in Roanoke.

On working through the recession

Ten years ago, right before the recession started, we decided to change Carilion’s operating structure and become more of an adaptive clinic delivery system with a lot more employed physicians. [Carilion Clinic previously was known as Carilion Health System.] We put physicians in leadership roles, significantly expanded our campus and hired about 350 new doctors. We made some sweeping changes that cost a lot, all of which were planned and thoughtfully done, but without the notion that we’d be heading into a recession. Yes, it was a struggle. Our operating margin went negative, but our board was great. They saw the vision. They believed that this was the right approach. In the meantime, we built Virginia Tech Carilion School of Medicine and Research Institute and grew our relationship with Virginia Tech, and 10 years later, it looks like, ‘oh, that was a great idea,’ but as you’re going through it, it felt a little more tenuous.

On changing times

I think that in today's world, health care is a team sport. And that doesn't mean five people working simultaneously but in parallel. It means working together, and no one person — whether it's a nurse, a physician, a dietitian or therapist — knows everything. Your voice is important, but distilling what needs to be done in short order is difficult. That’s another big change that I’ve seen. We used to have more time to think about the patients' needs; we had longer lengths of stay; and information wasn’t coming at us quite as quickly. In hindsight, that's a luxury. Now, we have to distill information and then find ways to communicate thoughtfully in real time. I think that’s the trick, that nurses and therapists and physicians need to figure out how they can communicate well with each other. The other difference that I've seen is that we used to have one physician basically in charge, and now you have a hospitalist and multiple other providers, so handoffs become even more important. Communication and working together as a team couldn’t be more important, and, yet, it’s pretty tough to do.

On being the first in her family to graduate from high school

My parents really instilled in me a strong work ethic, a respect for others and an expectation that I would do well. The other really important person in my life was my grandmother. I lived with her for a while as a child, and she was a very strong person who went out in the workforce when [most] women didn't do that. She managed a large grocery store. And I’ve laughingly said that she’s taught me some important skills like crocheting and playing poker. But, you know, she also showed me you can do whatever you want if you are determined enough. I don’t think they or I ever imagined that I would be a CEO of a health system. But they had high expectations and believed in me.

I had some great friends, too, who encouraged me, and I had an important physician mentor. When I mentioned that cancer grant, we worked on that grant together. He just pulled me under his wing and gave me all sorts of opportunities.

On staying in her home state of Virginia

As a matter of fact, I had accepted a job in Atlanta. I went to Emory University. I loved Emory, and I loved working there. But my father was quite ill, and I felt that I should come back. It wasn’t my intent to come back and stay, but I did. It worked out. I met my husband, and it was sort of 'here we go!'

On courage

When we decided to adapt to a clinic model, to adopt a new model of health care delivery for our region, that took courage. It was a little bit like stepping off into the great unknown, and that was tough. As the chief operating officer, I had to lead the transformation as well as make sure our day-to-day operations were running smoothly. It was a hard time, and there were moments when you thought, ‘Maybe this isn’t the right thing’ or, ‘We’ve gone too fast.’ It was tiring. In hindsight, it was the right thing to do, but it was a hard thing to do.

On her new role as AHA chair

We have such a great board and such amazing staff and leaders for the AHA. And this is a strange time, unlike any other. There is also the backdrop of drama with the Affordable Care Act and whatever Congress is going to do. What I would like to focus on is turning the dial a little bit to ‘What are we for, what are we against?’ And what we’re for is affordable access to high-quality care — what can we do to be a part of that initiative, and how can we serve as a catalyst for change? We’re only a part of health care costs; we’re only a part of health care innovation. How do we create partnerships with others? I think it’s a long-term effort and it’s multilayered, multiyear. That’s the work that I would like to do going forward.

On strategies for change

One of [my] strategies is not simply to listen to ourselves but to bring in disparate ideas, thoughts from others, and learn. Open ears, open eyes. It’s not enough to just worry about a patient’s bill or to be more efficient — all those things you need to do, but that’s not material change. How do we step back, get upstream, how do we — I don’t know how to do this — but how do we get rid of the waiting room altogether?

How do we make material change that pays attention to both the patients’ and consumers’ needs? How do we help providers function? Another strategy is understanding technology and how it can be helpful. Health care is the only industry in the world in which the care has cost us more as technology has improved, not less. So, how do we embrace technology more, and how do we use it?  

On where the field will be in 10 years

We’ll see many more technological advances at the individual level. I think we’ll do a lot more care and delivery in the home. Those so-called wearables will create a whole different environment in which we both monitor and provide health care. So, I think our delivery system is in for a fairly major change. I will say that the opioid crisis is real. The fact that our country has an aging population, the fact that we have a shrinking middle class, the fact that we have more people in poverty are issues that have a huge impact on health care delivery, on health care outcomes.

In 10 years, a lot is going to change. What’s not going to change is our devotion to patients and doing our best to help people have the best possible health outcomes.

On the challenges of being a CEO

It’s always hard to give the boss bad news. That’s not easy. In that way, you can really set yourself up to be pretty isolated in the C-suite. Then, you stop understanding what’s really going on. With seven hospitals and 48 practice sites, how are you going to understand what’s happening? You have to get out. And you have to understand that, as hard as you try, you’re not going to hear everything. You hope that you’re open enough and available enough that you begin to understand what the issues are.

There isn’t someone else to say, ‘This is how you do it.’ And you have to find a safe environment to brainstorm. Because people think if you’re just talking, that must be what you’re thinking and, therefore, that must be what’s going to happen or what you’re going to do. That was a surprise to me. And that still catches me off guard.

Advice to women in leadership

Three pieces of advice: Be curious. I want to emphasize that. Find out what people are thinking. Find out what resources you have, educate yourself and learn disparate pieces, so you can work together. Also, put yourself in places that are outside your comfort zone. For example, some people are only comfortable talking in small groups, some are more comfortable with a large audience, and some don’t like conflict. Know yourself and stretch into the areas where you need improvement. This requires a mentor and good feedback. Last, lean in. Find ways to get into new positions and find new opportunities. Say 'yes.' It is surprising to me how many people don’t offer themselves up, so they get passed over when they’re probably very capable.

A lean-in example that I think helped my career — and it wasn’t planned — is to volunteer, to serve. I volunteered and quickly became involved in ways that were unexpected to me, and I joined committees and got on boards. Also, I met business leaders from whom I learned a lot. That’s easy to do. Organizations are always looking for good volunteers, but they may not come asking for them. You have to put yourself in that position.

On the main lesson she has taken away from her career

Get a dog. No, I have a great husband, a great son and great support staff. I am so lucky. It’s not said often enough, but family really is your first priority. And without that touchstone [you’re missing out]. They are the people who will say, ‘You really screwed this up!’ They’re really going to give it to you, and they’re going to be there again tomorrow.

On the other hand, a dog, he’s going to love you ... 

I was gone last week in San Diego, and when I got home [my dog] was just crazy. And when I get home tonight, he’ll be crazy and excited. It doesn’t matter if you’re gone 10 minutes or two weeks, [dogs] love to see you. There’s a lot you can learn from a dog.

On her hobbies

I never really learned to cook, as my family will tell you. But it’s sort of fun. It’s just chemistry. I’ve become very faithful to the Food Network, especially the show Chopped. [Cooking] goes in spurts; I try to do it consistently, and then life happens.

I love to bake. The precision of it makes sense to me. But I don’t bake much because it’s hard not to eat all of it. All the things you bake are going to be bad for you, I think. It’s really hard right now because peaches are in season. I think, ‘Oh, I’ll make a peach cobbler.’ And then I think, ‘No, I’ll just have them fresh,’ and it’s the good cop, bad cop inside my head.

On working with patients

I really love patient contact. When I’m thinking through something or feeling particularly stressed, you’ll find me sitting on a patient’s bed and just talking to him or her. That is my true heart. I interact with patients a lot, but especially at those more vulnerable moments of my life.

On gratitude

Something I do every week is write thank-you notes. We send out letters to patients’ families, and I sign all of them. There are usually hundreds, and I write notes on them. And does anybody even know [that I write those]? Maybe not, but I know. I’m always touched when a family member of an employee who died or retired comes back and says, 'On our refrigerator is your note.' It matters.

On what she’s most proud of

I have to say, I’m most proud of our staff. They’re talented, caring and resilient. That’s really our North Star, what’s most important. I’m proud of a lot of other things as well: certainly our relationship with Virginia Tech, Jefferson College, our ability to innovate, our nimbleness, our quality score, the work that we’re doing — especially in the ambulatory space — to help patients stay out of the hospital. There are myriad things that I think we do well. But in the end, it’s all because of great staff, very focused with great leaders, great physician leaders, nursing leaders — the whole team. It’s a credit to them that we’re able to do what we do. And quite honestly, maybe even more important, we’ve got a great board that expects us to innovate, expects us to do the right thing.

The Agee File

Agee’s resume is dizzyingly full of honors, board duties, community activities and professional accomplishments. Agee and her husband G. Steven Agee, a federal judge, have a recently married son, Zachary S. Agee. While there simply isn’t space to list all of her accomplishments, we’ve included a brief overview of her education, professional experience and field recognition.

Education 

Northwestern University, Kellogg School of Management, postgraduate studies

Emory University, master of science in nursing

University of Virginia, bachelor of science in nursing

Roanoke Memorial Hospital, diploma in nursing, 1973

Experience

2011-present: Carilion Clinic, president and CEO,

2001-11: Carilion Health System/Carilion Clinic, chief operating officer/executive vice president

2000-01: Carilion Health System/Carilion Medical Center, senior vice president

1996-2000: Carilion Health System/Carilion Medical Center, vice president, medical education

1973-96: Carilion Roanoke Memorial Hospitals, clinical and management responsibilities

Boards

Agee has served on the boards of numerous organizations, including the American Hospital Association, the Coalition to Protect America's Health Care, the Virginia Hospital & Healthcare Association, the Joint Commission, the Virginia Tech Carilion School of Medicine and the Virginia Business Council.

Honors

  • Top 25 Women in Healthcare, Modern Healthcare, 2017
  • 50 Most Influential Virginians, Virginia Business, 2016
  • 100 Most Influential People in Healthcare, Modern Healthcare, 2016
  • University of Virginia Outstanding Alumni, 2015
  • Roanoke College, doctor of humane letters, 2015
  • The Taubman Museum of Art, Ann Fralin Award (community leadership and support of the arts), 2013
  • Palladium Award (Carilion’s highest award for quality), 2012
  • March of Dimes Hall of Fame, 2012
  • Silver Hope Award, Multiple Sclerosis Society, Blue Ridge Chapter, 2008
  • Meritorious Service, American Cancer Society (Virginia Division’s highest award), 1994
  • Outstanding Young Woman of the Year, Jaycees of Roanoke Valley, 1985
  • Sigma Theta Tau (Honor Society of Nursing), induction, 1980
  • Outstanding Nurse, Virginia Nurses Association, District 2, 1977