“In healthcare, there has always been this vertical hierarchy. One of the things we’re working on is shifting that to truly horizontal hierarchy; that allows all of us to work ‘together’ as opposed to ‘for’ each other.”
Husnain Kermalli, Chief Medical Officer for Saint Mary’s Hospital, shared his views on leadership and its impact on organizational culture in a recent Connex panel. It was a particularly insightful moment, though that ought not be surprising given St Mary’s status as a nonprofit community teaching hospital. Their mission is communal in nature, so it stands to reason that a more cooperative operating model would naturally resonate with their identity and values. In addition to strengthening their culture, Kermalli argued it also leads to better decision-making outright. “Many times, team members have already thought of a solution that’s going to work [before asking you for guidance,] because they’re the ones who know the process.”
Examinations of non-hierarchical leadership structures would agree with Kermalli. For example, a 2017 meta-analysis into the impact of leadership styles found that flatter hierarchies incorporating transformational leadership were positively related to nursing unit efficacy, and by extension, lower patient mortality rates and higher patient satisfaction. Similar systematic reviews of healthcare leadership models positively linked collective structures with greater overall staff engagement, satisfaction, and performance. Becker’s warned in September of 2024 that rigid hierarchical leadership struggles to adapt flexibly to rapid evolutions in care delivery and organizational needs, especially versus more agile, decentralized models. As discussed in this article by Navindi Fernandopulle, the supportive working environments and appropriate delegation of tasks common in Magnet-designated hospitals even played a key role in those facilities successfully weathering the stress, burnout, and difficult labor conditions of the Covid pandemic.
Such a departure from corporate norms is likely to raise red flags for some readers. As outlined by Fernandopulle, a common criticism of flat leadership structures is the assumption that hierarchy naturally emerges and solidifies overtime. However, not only is such an outcome typically more attributable to a laissez-faire model of democratization, but most proponents of flatter organizational structures don’t dispute the need for clearly identifiable leadership positions. Rather, they simple seek to remove “unnecessary and costly overlaps of accountability”, increasing organizational agility by making decision-makers more accessible to the frontline staff responsible for actual care delivery.
The Buurtzorg Model
One particularly notable example of these principles working to the benefit of providers, staff, and patients alike comes to us from Buurtzorg Nederland, a Dutch non-profit. Buurtzorg translates to “neighborhood care” and is itself an apt way to describe their non-hierarchical model of healthcare delivery.
As explained in this breakdown by Kreitzer et al., this community nursing model was implemented “at a time when the traditional and commercial home care industry was characterized as being costly, fragmented, and populated with caregivers who were overworked and dissatisfied” – which sounds not unlike today’s domestic healthcare industry. The goal was simple: emphasize “humanity” by eliminating “overpaid managers, luxurious offices, and layers of bureaucracy, [giving] teams of nurses the authority and responsibility” needed to effectively deliver care.
This dramatic shift in leadership structure took multiple forms. Teams were now self-directed, determining how best to perform their work as informed by patient needs, their professional experience, and regular staff development. Those same teams were encouraged to broaden their scope of practice, working more closely with general practitioners and other community healthcare providers to deliver more holistic treatments. Closer relationships with patients were encouraged, allowing nurses to account for the environmental, socioeconomic, and even spiritual realities of their patients; this was often made possible by ensuring patients only received care from “3 to 4 nurses” on the team, decreasing overall care fragmentation. On the backend, Buurtzorg Nederland pushed for a straightforward hourly rate reimbursement structure with private and governmental payers alike.
“The fear was that without ‘controls’ and with using highly skilled nurse caregivers, the costs would soar,” primed Kreitzer et al. “The opposite occurred.” Care was typically delivered quicker and more efficiently; overhead was slashed thanks to the low number of administrative and coaching personnel required to support care delivery teams; and employee engagement and satisfaction metrics soared, lessening turnover costs. Since launching their methodology in 2007, Buurtzorg Nederland has replicated their success in more than 850 teams across 24 different countries.
From Proposition to Process
As it turns out, fostering shared leadership doesn’t just support team performance – it can also ease the burden on executive leaders by distributing responsibility more effectively and enabling a more resilient organizational culture. Moving toward this kind of leadership model can be challenging, but by focusing on a few critical mindset shifts and practical leadership behaviors, executives can begin nudging their teams and organizations in this direction.
First, embracing collective responsibility requires a fundamental redefinition of the leader’s role. Rather than operating solely as decision-makers or gatekeepers, leaders must act as facilitators by supporting open dialogue, shared problem-solving, and collaborative ownership of challenges. Kermalli’s co-panelist Shelly Crunk, VP of Finance at AdventHealth, described it well: “Introspection and supportive delegation. I always had a fear of over-delegation, or being absent; there’s a lot of working beside leaders that’s critical.” This shift not only helps alleviate decision fatigue but builds a culture of trust and psychological safety. When teams feel safe to contribute their ideas and challenge assumptions, silos begin to break down, opening the door to greater innovation, faster problem-solving, better care delivery, and most importantly, fewer crises for executives to manage
The second key element is recognizing that shared leadership means everyone needs to be developed like a leader. In democratized teams, responsibilities evolve based on project needs and individual strengths. Leaders can act as guides through this process, using relational leadership strategies like active mentoring and real-time coaching. As co-panelist Geoffrey Hall, CEO of California Rehabilitation Institute, explained, “I try to create space in my schedule to be a mentor to others […] and enough openness with my direct reports that they can give feedback.”.
Supporting this kind of team development means investing in upskilling and leadership capacity at all levels. When team members are equipped to take initiative and make sound decisions, it strengthens succession readiness, boosts morale, and creates a pipeline of high-performing, collaborative leaders – an outcome that benefits the entire organization, including its most senior executives.
A Leadership Evolution Rooted in Purpose
What the Buurtzorg model and the insights from our panelists make clear is this: reimagining leadership as a shared, relational practice is a pragmatic evolution of healthcare administration. This shift doesn’t mean eliminating structure or accountability, but rather, removing the friction caused by redundant oversight and slow-moving hierarchy. In their place, leaders can cultivate agile, empowered teams where responsibility is distributed more sustainably, where innovation rises organically from those closest to the work, and where everyone – senior leaders included – has more opportunities to find their center.
Transitioning to a non-hierarchical leadership model doesn’t happen through declarations alone. It starts with executives modeling new behaviors, delegating supportively, listening more than directing, mentoring consistently, and championing growth at all levels. These are not just soft skills but strategic levers that, when pulled with intention, create healthier organizations. And in that model, leadership wellbeing is no longer an occasional side effect. It becomes the outcome.
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