Overview / Executive Summary

Client Name & Industry: Cleveland Clinic, Healthcare & Academic Medical Center

Engagement Focus: Leadership Development, Culture Transformation, Employee Engagement

Location: Cleveland, OH (with operations across the U.S. and globally)

Third River Certifications/Tools Used

• Serving Leader Framework

• Leadership Cohorts

• Serving Leader Advisor Training

• Serving Leader Toolkits

Timeframe

2008 – 2013

Top-Level Results or Transformation

• Employee engagement surged (43rd to the 87th percentile) nationally over a 5-year period.

• The ratio of engaged to actively disengaged employees increased from 2.57:1 in 2008 to 10.2:1 by 2013, surpassing Gallup’s “world-class” benchmark of 9.57:1.

• Four of the lowest-scoring Gallup Q12 items saw the greatest year-over-year improvements, including:

• Recognition/praise in the last 7 days

• Perception that opinions count

• Support for development

• Having a best friend at work

• Patient satisfaction scores (HCAHPS) improved significantly across all major categories, aligning with engagement gains and boosting Cleveland Clinic’s national reputation.

• Over 400 directors completed serving leader training; more than 100 Serving Leader Advisors were trained and deployed enterprise-wide.

• 43,000+ employees participated in Cleveland Clinic Experience program, reinforcing a system-wide culture of empathy and service.

• Cultural change contributed to Cleveland Clinic maintaining or improving U.S. News & World Report rankings, including a #4 overall hospital ranking and #1 in heart care for 19 consecutive years during this transformation period.

Client Background

Cleveland Clinic is one of the most respected academic medical centers in the world, known for clinical innovation, cutting-edge research, and consistently top-tier outcomes. With more than 44,000 employees, including 3,100 physicians and 11,000 nurses, the organization operates a vast network of hospitals and health centers across the U.S. and internationally, including facilities in Florida, Nevada, Canada, and Abu Dhabi.

At the heart of Cleveland Clinic’s mission is a commitment to excellence in patient care, education, and research. Its 167-acre, 44-building main campus in Cleveland is a flagship location that draws patients from around the globe. In 2013, U.S. News & World Report ranked the Clinic #4 overall in the U.S., with 15 specialties in the top national rankings, including #1 in cardiac care for the 19th consecutive year.

Despite this sterling reputation in clinical outcomes, by 2008 the organization faced mounting internal concerns about its workplace culture, employee morale, and patient experience, challenges that threatened to undermine its long-term performance and reputation.

The Challenge

In early 2008, Cleveland Clinic received its first publicly reported HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey results, and the findings were sobering. While patients continued to seek out the Clinic for its world-class clinical care, satisfaction scores across nearly every domain, from staff responsiveness and communication to room cleanliness and discharge information, were well below national averages. CEO Dr. Delos Cosgrove candidly observed, “Patients were coming to us for the clinical excellence, but they did not like us very much.”

This disconnect between clinical outcomes and patient experience was a wake-up call. Compounding the urgency was a policy shift: by 2012, HCAHPS scores would influence Medicare reimbursement levels, making patient satisfaction not just a reputational concern, but a financial one.

Internally, Cleveland Clinic leaders were also facing signs of employee disengagement and cultural stagnation. A Gallup Q12 employee engagement survey conducted around the same time revealed that the Clinic ranked in just the 44th percentile compared to other hospital systems. Perhaps more revealing, the engaged-to-disengaged employee ratio sat at a concerning 2.57:1, far from Gallup’s “world-class” benchmark of 9.57:1.

Feedback from informal listening sessions echoed these concerns. Many employees, especially those in non-clinical or support roles, felt undervalued, unseen, and disconnected from the organization’s mission. Leadership culture was perceived as top-down, hierarchical, and transactional.

Cleveland Clinic recognized that transformational cultural change was needed, not just to improve engagement scores or patient ratings, but to realign the organization’s values with its operational reality. That’s when the Clinic engaged Third River Partners to help catalyze and lead this transformation through a bold new leadership approach grounded in Serving Leadership.

Our Approach

Third River Partners was engaged at a pivotal moment in Cleveland Clinic’s organizational journey. With clinical excellence well established, the institution recognized a growing imperative: to cultivate a leadership culture that could elevate employee engagement, restore a sense of shared mission, and dramatically improve the patient experience. That meant rethinking how leadership was practiced across every level of the enterprise.

To meet this challenge, Cleveland Clinic partnered with Third River Partners to implement a research-grounded, values-based framework: The Serving Leader® Model – a proven methodology detailed in the bestselling book The Serving Leader by Ken Jennings and John Stahl-Wert.

Rooted in more than a decade of real-world research, the Serving Leader model offers more than just inspiration. It is a science-informed, action-oriented blueprint for building high-performing, mission-driven teams. It draws on data from thousands of organizations and distills that learning into five powerful, repeatable leadership actions:

• Upend the Pyramid: Leaders serve those they lead, removing obstacles and creating clarity.

• Raise the Bar: Leaders set high expectations and empower others to exceed them.

• Blaze the Trail: Leaders teach, coach, and equip teams to go further than before.

• Build on Strength: Leaders identify and elevate the unique strengths of others.

• Run to Great Purpose: Leaders connect everyday work to a meaningful mission.

Third River Partners brought this framework to Cleveland Clinic through a multi-tiered engagement strategy:

1. Executive Buy-In and Cultural Framing

Third River Partners worked in close collaboration with Cleveland Clinic’s senior leaders to “socialize” the Serving Leader concept. Recognizing that many leaders—particularly physicians—were skeptical of the term “servant leadership,” Third River reframed it using the more empowering and active term “Serving Leader”. This shift allowed leaders to embrace the philosophy without compromising their identity as high-accountability professionals. One-on-one coaching and small group sessions were conducted with members of the executive team and the 65-member Strategic Council. These efforts built trust, generated honest dialogue, and ultimately led to full endorsement from the CEO and key operational leaders, an essential foundation for scaling the effort across the enterprise.

2. Large-Scale Leadership Development

Once executive alignment was established, Third River facilitated a one-day Serving Leader experience for over 400 directors across the organization. These sessions introduced the five Serving Leader actions – i.e., Upend the Pyramid, Raise the Bar, Blaze the Trail, Build on Strength, and Run to Great Purpose – with practical tools, peer reflection, and Cleveland Clinic-specific case examples. The goal wasn’t just education. It was a transformation in how leaders thought, behaved, and engaged with their teams. Serving Leader language and behaviors were simultaneously embedded into Cleveland Clinic’s broader leadership competency model, aligning training, performance expectations, and daily interactions.

3. Internal Capacity Building and Reinforcement

Third River’s philosophy emphasizes sustainable, embedded transformation, not consultant dependency. To that end, the firm helped Cleveland Clinic build internal infrastructure to support long-term change:  

• SL Advisors Program: Over 100 leaders were selected and trained through an intensive 8-day program to become internal champions and peer coaches of Serving Leadership within their departments. 

• Serving Leader Toolkits: These practical, on-the-ground resources equipped managers with ready-to-use tools, language, and exercises to bring Serving Leadership into daily practice. 

• Coaching and Community of Practice: Ongoing coaching and quarterly cross-functional gatherings allowed leaders to share wins, troubleshoot challenges, and continually refine their implementation.

4. Integration with Organizational Strategy

Unlike many leadership programs that live in isolation, Third River worked closely with Cleveland Clinic to integrate Serving Leadership principles into strategic projects and initiatives. For example:

• Continuous Improvement (CI) teams infused Serving Leader practices into their methodology.

• Regional hospitals redesigned management councils around Serving Leader meeting formats.

• Physician leaders were coached in Serving Leader principles to support care model redesigns.

This approach ensured that Serving Leadership became a strategic enabler, not just a soft-skills training, but a culture and performance driver woven into the fabric of how Cleveland Clinic operated.

Implementation

The implementation of the Serving Leader model at Cleveland Clinic was designed as a phased cultural transformation effort—carefully introduced in tandem with the organization’s broader “people strategy.” The engagement began with Cleveland Clinic’s executive team, where Third River Partners introduced the foundational concepts of Serving Leadership using accessible language and evidence-based tools. This included replacing the term “servant” with “serving” to align with the leadership culture of high accountability and excellence, especially among clinical and physician leaders.

Initial work focused on building trust and alignment among the Clinic’s top 30+ executives and its 65-member Strategic Council through coaching and structured dialogue. Once executive sponsorship was secured, Third River facilitated a one-day Serving Leader initiation program for more than 400 directors across the organization. These sessions were immersive, practical, and tailored to each leader's context, helping them translate the five key behaviors of Serving Leadership into day-to-day practice.

To scale the transformation, Third River supported the Clinic in creating an internal capacity-building engine:

• A leadership competency framework was developed and aligned to serving leader principles across domains like empowerment, values-driven management, talent development, and relationship-building.

• Serving Leader Advisors were selected and trained through a rigorous 8-day program to provide peer coaching and reinforce SL practices within their own units.

• Practical implementation kits such as “SL in a Box,” a robust Serving Leader Toolkit, enabled frontline managers to reinforce and replicate key behaviors across departments.

Serving Leadership became a common language embedded into performance reviews, talent development strategies, and operational improvement efforts. A Community of Practice was established to enable leaders from across the system to share learnings, compare project outcomes, and develop new applications for Serving Leadership within their teams.

This work was deeply collaborative. Third River Partners remained closely integrated with Cleveland Clinic’s internal teams, adjusting pacing, content, and coaching formats to reflect ongoing feedback, leadership changes, and cultural nuances. Over time, Serving Leadership was no longer seen as a “program,” but as the default posture of leadership across the enterprise.

The Results

Quantitative Results:

Cleveland Clinic experienced a dramatic shift in employee engagement and patient satisfaction over a five-year period. According to Gallup’s Q12 engagement survey, the organization leapt from the 43rd to the 87th percentile nationally. Even more striking was the improvement in the engaged-to-actively disengaged employee ratio, which rose from 2.57:1 in 2008 to 10.2:1 by 2013—a level Gallup categorizes as “world class.”

This increase was particularly evident in the four lowest-scoring areas from the original survey, all directly linked to leadership behavior:

• Recognition and praise for good work

• Perception that one’s opinion counts

• Support for professional development

• Relationships and sense of connection at work

All four saw the largest gains in engagement scores year over year, signaling a widespread cultural shift.

At the same time, HCAHPS patient satisfaction scores, a critical driver of Medicare reimbursement, rose steadily in parallel. Though multiple initiatives contributed to this trend, internal leaders and frontline staff consistently cited the Serving Leader approach as a key enabler of improved caregiver engagement and patient responsiveness.

Qualitative Outcomes:

The language and tools of Serving Leadership became deeply embedded in Cleveland Clinic’s day-to-day operations. Cross-functional teams began referencing Serving Leader principles in performance improvement projects, including:

• Empowering ICU staff to speak up through the “Silence Kills” initiative

• Redesigning Pharmacy operations for efficiency and collaboration

• Reimagining regional hospital councils using Serving Leader meeting formats

• Embedding Serving Leader coaching into the development of the new “Patient Centered Medical Home” model

One manager described the shift as “viral,” with leaders at every level spontaneously applying Serving Leader principles to complex challenges across clinical, administrative, and technical domains.

Impact

The impact of Third River Partners’ work at Cleveland Clinic extended far beyond improved survey scores—it represented a deep and lasting transformation in how leadership was understood, practiced, and measured across one of the most complex healthcare organizations in the world.

By embedding the Serving Leader® framework at every level of the organization, from executive leadership to front-line supervisors, Cleveland Clinic catalyzed a shift from transactional, command-and-control management to a more relational, purpose-driven model of leadership. This shift helped address systemic challenges in employee morale and retention, while directly improving patient satisfaction, operational performance, and internal collaboration.

Several indicators demonstrate the breadth and durability of this impact:

1. Culture Change Became Self-Sustaining: What began as a targeted leadership development initiative grew into a self-propelling movement. Leaders across the system organically integrated Serving Leader behaviors into daily decision-making, team development, and performance initiatives. As one senior HR leader described, “It is no longer just a leadership program; it’s a way of working and thinking across the enterprise.” This shift wasn’t just philosophical. It created visible ripple effects in organizational behavior, reinforcing the idea that leadership is about enabling others to thrive in service of a greater mission.

2. Strategic Alignment Deepened Across the System: The Serving Leader model offered Cleveland Clinic a common language for leadership at scale. Its core actions were embedded in strategic projects, from care model redesign to performance improvement initiatives, creating alignment between clinical excellence and organizational culture. In one example, the Continuous Improvement Team integrated Serving Leader principles directly into its methodology, reinforcing accountability and service across improvement efforts. Serving Leadership became a “platform for unity” across silos, elevating both clinical and non-clinical leadership practices with a shared purpose.

3. Tangible Workforce Gains with Enterprise-Wide Impact: From 2008 to 2013, Cleveland Clinic saw a dramatic transformation in employee engagement:

• The Gallup Q12 percentile rank rose from 43rd to 87th nationally

• The ratio of engaged to actively disengaged employees grew from 2.57:1 to 10.2:1, surpassing Gallup’s “world-class” threshold

• Four key items on the Q12 survey related to recognition, support, input, and workplace relationships saw the greatest year-over-year gains

These results represented not just statistical improvement, but a shift in how caregivers felt seen, valued, and supported, at scale.

4. Patient Experience Improved in Parallel: As employee engagement rose, so did patient satisfaction. HCAHPS survey scores improved across nearly all domains, including communication, responsiveness, room environment, and discharge information. These improvements helped align Cleveland Clinic’s operational culture with its reputation for clinical excellence, and bolstered financial outcomes as patient satisfaction became tied to Medicare reimbursement. Notably, the upward trajectory of patient satisfaction closely mirrored the rise in engagement, confirming the well-researched link between caregiver experience and patient outcomes.

5. Internal Capacity Was Built for Future Transformation: One of the most durable outcomes of this engagement was Cleveland Clinic’s internal capacity to sustain and scale culture change:

• More than 100 Serving Leader Advisors were trained and embedded across departments

• Tools like SL in a Box and the SL Toolkit equipped managers to lead culture-building efforts independently

• A quarterly Serving Leader Community of Practice continues to connect leaders working on transformation initiatives using SL principles

As one operational leader put it, “The Serving Leader model didn’t just teach us new skills. It gave us a framework we could own, evolve, and lead with across the entire system.”

6. A Recognized Model for Values-Based Transformation: Today, Cleveland Clinic’s Serving Leader transformation is frequently cited in leadership literature and healthcare management forums as a blueprint for aligning leadership culture with enterprise goals. The partnership with Third River Partners demonstrated that purposeful leadership at scale is not only possible, it’s measurable, replicable, and essential in mission-driven environments.

Key Takeaways / Lessons Learned

Several factors contributed to the success of this engagement, offering valuable insights for other complex, high-performance organizations:

1. Start with Alignment at the Top and Build from the Middle

Third River Partners invested early in building senior leader buy-in but did not stop there. By focusing on director-level training and equipping mid-level managers with practical tools and coaching support, the firm ensured that culture change was not isolated at the top. It was modeled, replicated, and reinforced in every tier.

2. Use Language That Resonates with the Culture

By reframing “servant” leadership as “serving” leadership, Third River honored Cleveland Clinic’s performance-driven environment while inviting leaders into a more relational, purpose-driven leadership model. This linguistic shift made the concept more actionable and acceptable in a highly clinical, physician-led environment.

3. Embed, Don’t Bolt On

Success wasn’t due to a stand-alone training program. Serving Leadership was woven into competency frameworks, performance management systems, coaching infrastructure, and improvement projects. The approach became embedded in “how we lead here,” not just something learned in a workshop.

4. Leadership Transformation Drives System Transformation

The improvements in employee engagement and patient satisfaction were not incidental. They flowed directly from a renewed leadership culture—one in which caregivers felt seen, valued, and trusted. In healthcare settings, especially, this emotional connection to purpose is essential for delivering exceptional outcomes.

About Third River Partners

Third River Partners equips mission-driven organizations and their leaders to align teams, accelerate impact, and grow sustainably. Through leadership certification programs, team alignment strategies, and fractional support, we help leaders serve well and scale wisely.