When Aidan Hettler showed up for a job interview at the Sedgwick County Health Center in the summer of 2022, he was prepared to tell the hospital’s board that he absolutely should not get the job.
He had been talked into applying for the role by somebody at the hospital, despite having no health care experience to speak of — and he was just 22 years old.
“Unashamedly, I did say in the interview … ‘I don’t have any right sitting in your CEO chair. You do not want this, I promise,’” said Hettler, who graduated earlier that year from Colorado State University with a degree in business administration.
The board of the hospital — a small facility in Julesburg less than a mile from the Nebraska state line — didn’t see it that way, and quickly brought him aboard.
In the 15 months since, Hettler, now 24, has dived into his new role with a gusto, talking to as many people in the organization as he can to learn how it works and seeking out an experienced mentor on his own.
But Hettler acknowledges the fact that he was interviewed at all is a sign of a challenge many rural hospital leaders have faced in Colorado in recent years: immense difficulty hiring and retaining CEOs.
“If it was not difficult to recruit, no, I probably would not have gotten an interview,” Hettler said. “In a normal world, I would have never gotten an interview.”
CEO turnover at critical access hospitals in rural Colorado hit 34% in 2021, according to the Colorado Rural Health Center — much higher than the national average of 16% that year.
While industry experts say the pandemic certainly aggravated many of the factors that drive those numbers, some facilities have been dealing with regular CEO turnover for years.
That’s a problem, because recruiting a qualified executive to a rural community can take months. While patient care continues on, strategic planning and organizational stability can go right out the window as the hunt goes on.
“Those kind of transitions take time. They take resources,” said Jeff Tieman, president and CEO of the Colorado Hospital Association. “If a CEO leaves because of retirement or a CEO leaves because they get a new job somewhere else in the state or somewhere else in the country, it’s not as simple, usually, as just slotting someone into that role.”
Factors driving turnover
Industry experts say that a number of factors are likely responsible for Colorado’s high rate of turnover among rural hospital CEOs, but overall, they say, it’s just a hard job.
Rural hospitals generally operate with slimmer margins, and often have to work under direction of elected volunteer boards. Recruiting medical staff is tough anywhere — but even more so in small, isolated towns. CEOs are highly visible in small communities, for better or for worse.
They don’t have large systems to fall back on for infrastructure or logistical needs, said Kevin Stansbury, CEO of Hugo-based Lincoln Community Hospital and Care Center.
“I think that being an independent rural hospital CEO is one of the toughest jobs in health care,” said Stansbury, who has led the hospital in the town of fewer than 1,000 people for about a decade. “We’re managing board relations. We’re managing community relations. We’re managing the operation of the hospitals.”
During the pandemic those jobs got even harder, as CEOs had to make tough calls about how to handle everything from patient care to staff vaccine policies.
Tieman, of the Colorado Health Association, said he thinks the 2021 spike in departures may have to do in part with executives delaying retirement or putting off changing jobs in order to get their organizations through the toughest part of the pandemic.
“You might call it pent-up or delayed, but I think some of that sort of career movement just got stalled or slowed when we were so busy managing COVID,” Tieman said.
Managing relationships with elected hospital board members can also be a challenge at times.
“It is very plausible, and has happened here, that you get somebody (on the board) that either has an agenda about something or just thinks that they know how to run the hospital better than anybody else and the CEO,” said Steve Young, president of the Melissa Memorial Hospital’s board of directors in Holyoke, a town of about 2,300 people on the northeastern plains.
“Horrendously chaotic”
When a CEO leaves a small rural hospital, it can throw an organization into disarray.
Jennifer Riley, a longtime employee at Memorial Regional Health in Craig who was named CEO in 2022 after a year doing the job in an interim capacity, saw her fair share of executive churn before things stabilized with her immediate predecessor.
For decades the county-owned hospital retained a management company that provided a CEO and CFO. In about 2012, though, the board decided it wanted to move away from that model — but not right away.
“That set off three years of just constant turnover with CEOs because anybody who took the job knew that they weren’t going to be able to stay in the job,” Riley said, adding that the hospital once had five CEOs in between 2012 and August 2016. “It was horrendously chaotic.”
One CEO Riley worked under lasted just two months. Another stayed six months and had “a lot of big ideas that really didn’t have a lot of feasibility,” she said. Among those was a plan for a dialysis center — a heavy lift for the hospital in a town that’s still shy of 9,000 people. Riley and other staffers worked on the project for months.
“That project was really getting close to kind of a ‘go, no go’ situation, when he ended up leaving,” Riley said.
The next interim CEO that took his place immediately axed the plan, Riley said.
CEO turnover also makes it harder to hire new staff or to retain existing employees, Riley said.
“If there’s been a lot of CEO turnover, it causes them to question, ‘Well, why is there a lot of turnover in the CEO? Why have there been six CEOs? What is happening? What’s the problem?’” she said.
Young, who has been on the Holyoke hospital’s board for about 30 years, said getting a new executive in the door can be a lengthy process.
Departing CEOs may give no more than two weeks notice, though Young said it’s more typically a month or so. By the time board members meet, decide what direction they want to take, write a job description and in some cases hire a search firm, half a year may have gone by.
His hospital had a chief executive who lasted about 18 months before departing, then an interim head for about six months before they hired current CEO Michael Hassell about a year ago.
“It just takes awhile to kind of get all the pieces in the right place,” Young said.
In addition to the difficulties inherent to the CEO job, small, rural communities often can’t meet candidates’ family needs, like housing, child care or good jobs for spouses, making recruitment an even tougher task.
“It’s always the thing (of), you want to keep it a small town, you want it to always look like Mayberry,” Hassell said. “But if there isn’t some managed growth, there isn’t a place to live and a place to raise your kids, then you’re going to wither on the vine.”
Growing and recruiting rural CEOs
Given the trend toward high CEO turnover and long hiring runways, Young said board members should do the best they can to plan ahead.
“Succession planning for rural hospitals should be a very high priority,” he said. “If you can avoid that six months of lack of strong leadership from a CEO … that’s a tremendous advantage for a hospital.”
Young also recommended investing in governance training so volunteer board members better understand their roles.
Developing mentorship and educational opportunities could also lead to a better pipeline of potential C-suite leaders.
Hettler, the 24-year-old CEO from Julesburg, said he sought out a formal mentorship with Stansbury, the Lincoln Community Hospital and Care Center CEO. The two met after Hettler was hired and joined the Eastern Plains Health Care Consortium, which Stansbury founded.
“After one of our first meetings, I decided to ask him, just because he seemed very down-to-earth … (and) immediately I kind of felt that connection with him,” Hettler said. “He quickly, without a shred of doubt said, ‘Yeah, absolutely.’”
Each visited the other’s hospital, and Stansbury recommended different topics for Hettler to research like hospital finance and regulation issues. They established a standing phone call where they’d talk about personnel issues, operations and more.
“We still touch base every week,” Hettler said.
Hassell, who is a fellow with the American College of Healthcare Executives, said he is working with the group’s Colorado chapter to try to develop a formal mentorship program. He said he would also like to see colleges and universities that offer health care administration programs give a better grounding in rural hospital management, where everything from staffing to reimbursement models can look radically different than in an urban setting.
“In my health care education … I never heard anybody mention rural hospitals specifically as a career path,” Hassell said. “It’s a very different model and it takes a unique set of skills.”
Stansbury said his hospital and others are trying to invite more young people to work as administrative interns to offer exposure to rural health care.
Hettler said he believes small towns like Julesburg, which is home to about 1,200 people, are alive with opportunities for ambitious young people, and should be given more consideration.
“These communities are more vibrant than you would ever think,” he said. “There’s a lot of heart, a lot of soul, a lot of passion, and I consider it to be one of the greatest coincidences in my life that I ended up living out here.”
