Blurring the Lines: Rethinking Leadership in Healthcare

One of the things I’ve learned from working in healthcare for most of my career is that credibility matters. So does expertise. But increasingly, the problems healthcare leaders are trying to solve don’t respect the organizational lines we’ve drawn around that expertise.

That’s what made my conversation with David Sylvan so interesting.

David is Chief Strategy, Innovation and Marketing Officer for University Hospitals, which means his own role crosses three functions that are often separated in healthcare organizations. When we spoke before the podcast, he used a phrase that immediately caught my attention: “blurring the lines.”

Healthcare needs structure for very good reasons. We have specialties, subspecialties, licensure, credentialing, scope of practice, reporting relationships, departments and clear accountability. But David’s point is that those necessary boundaries can become a problem when “stay in your lane” turns into an organizational mindset.

Think about the challenges health systems are dealing with right now: access, affordability, consumerism and, of course, AI. None belongs entirely to marketing, IT, clinical leadership, operations or strategy. Solving them requires people who can move across functions without losing respect for the expertise within them.

David and I spent a lot of time talking about what that looks like in practice. A big part of it comes down to curiosity and trust. You don’t walk into somebody else’s area and tell them how to do their job. You ask smart questions. You listen. You understand what you don’t know. And over time, you build the social capital that gives you more latitude to challenge assumptions and bring people together differently.

I especially liked David’s concept of “bounded ambiguity.” Organizations need clarity around the things that absolutely can’t be ambiguous, but innovation often happens in the spaces that aren’t so clearly defined. The trick is giving people room to explore those spaces without creating chaos.

AI makes all of this even more relevant. A clinical AI tool can simultaneously be a clinical, technology, workflow, patient safety, legal and data issue. As David put it, asking who “owns” AI may be the wrong question.

This episode ultimately became a conversation about much more than organizational silos. It’s about how healthcare leaders can preserve the expertise and accountability their organizations need while creating enough flexibility, trust and curiosity to solve problems that simply don’t stay in one lane.

Why Listen?

If you lead people, strategy, innovation or growth in healthcare, David offers a useful way to think about organizational boundaries and when they help or hinder progress. You’ll hear:

Why AI is simultaneously breaking down existing boundaries and creating entirely new questions about ownership, judgment, data and accountability.

Why healthcare needs clearly defined lines of expertise and accountability, but also leaders who know when and how to cross them.

How curiosity and smart questions can help leaders build credibility and social capital across departments.

Why David looks for a combination of healthy skepticism and relentless curiosity when identifying people who can contribute beyond their core expertise.

How “bounded ambiguity” gives teams room to innovate without sacrificing accountability or creating organizational chaos.

Key Insights and Takeaways

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Note: The following AI-generated transcript is provided as an additional resource for those who prefer not to listen to the podcast recording. It has been lightly edited and reviewed for readability and accuracy.

Stewart Gandolf (Healthcare Success): Welcome to the Healthcare Success Podcast. And today it is my pleasure to introduce David Sylvan, who is Chief Strategy Innovation and Marketing Officer for University Hospitals. Welcome David.

David Sylvan (University Hospitals): Thank you very much for having me. Looking forward to the conversation.

Stewart Gandolf (Healthcare Success): So, David, one of the things we talked about offline was the idea of blurring the lines. And what does that mean to you? Because I thought that was such a compelling idea.

David Sylvan (University Hospitals): You know, for me, Stewart, it's the notion of not ignoring organizational structure, but refusing to allow structure to either inhibit or constrain collaboration or accountability or problem solving. It's navigating complex organizations without being constrained by boundaries. So that it's that notion of fluidity across functions, across disciplines, even reporting lines. And I think we'll get to that in a while. As well as areas of expertise, not merely confining potential solutions to well-defined problem statements into a specific area of expertise, but being sort of cross-functional. Organizations in my mind, and this does refer to the notion of blurring the lines, complex organizations need clear structures. This is healthcare and you can understand the importance of that. But the hardest problems really respect just structure. They want leaders in my mind who can blur the lines, move comfortably across functions and disciplines and create shared ownership for problems that don't necessarily need to be along within one domain.

Stewart Gandolf (Healthcare Success): That totally makes sense to me. And I think in healthcare, things can get so organized and so siloed that it can be very difficult to get things done. And particularly in today's world where we have AI and so many different things happening all at once, we need leaders who have the flexibility to see the bigger picture, right? it's super important. And when we think about it, healthcare is an industry that's built around specialization, right? So we have specialized you know, we don't just have orthopedic surgeons, we have hand surgeons or pediatric surgeons or neurosurgeons with a different specialty. But the idea is we have deep specialization within each profession, each specialty and subspecialist, right? We don't just have ophthalmologists, we have retinal specialists. So then of course we have CEOs, we have marketing people, we have other caregivers, we have, you know, the maintenance staff, everybody along the hospitals are very complex systems and everybody has clear defined areas of authority. So when we as we talk about that, the idea of staying in your lane, is that a a point is that a common thing that you had to overcome as you've journeyed into healthcare? And is that a powerful cultural force? Like how does that work in a health system in particular?

David Sylvan (University Hospitals): Yeah, your preamble was spot on. Healthcare, we deliberately design and construct around boundaries. Specialties, subspecialties that you mentioned, but it's further delineated by training and licensure and credentialing and scope of practice and privileges, et cetera. That creates hierarchies and that creates boundaries to communication flow. And of course, many of these boundaries should exist for very good reasons. You want clarity around who is qualified for and accountable for specific decisions.

The problem arises when a principle designed to protect expertise and accountability migrates into broader organizational ethos, culture, and it becomes almost a constraint on collaboration and innovation and problem statement. “Stay in your lane.” “This isn't my department.” “That's a clinical issue.” “That's an IT issue.” “Operations owns that.” And yet, virtually every—this is my philosophy. Every major challenge facing healthcare now, affordability, access, AI, consumerism cuts across all of these lanes almost by definition. There isn't a single discipline who owns the problem and the processes and possesses all of the capabilities to solve for it. So healthcare needs lines, but it also needs leaders who have the capacity, the bandwidth, the social capital to appropriately cross their lines. These lines, the goal isn't elimination. It's blurring where collaboration matters and sharpens them where accountability is needed.

Stewart Gandolf (Healthcare Success): It's funny, it reminds me of I don't know why, but it goes to a kid's game when we used to all throw a football in the middle of the field and someone would grab the ball, get tackled, and the next person would grab the ball. But sometimes that ball would be sitting there in the middle of the field, everybody's afraid to pick it up. And that can happen in healthcare, right? We just if if we've been tackled so many times by trying to do things outside of the norm, eventually it hurts and we just stop doing it. And that could be a real problem. Your role I one of the things I thought was also interesting when we spoke about that your role combines strategy, innovation, and marketing and your career has crossed a bunch of different traditional boundaries. You know, how did you develop a career where you are in all those categories? And what have you learned in operating at the intersection of these things that you might have missed had you not stayed within a single discipline?

David Sylvan (University Hospitals): You know, I think the, whether I was stubborn or naive, I always believe that all knowledge is fungible and this opportunity to be able to not necessarily reinvent, but to amplify the assumption of knowledge that you've gained up to a certain point and perhaps parlay that into a into a new focus and a new industry. I've always found that fascinating. I was ironically fortunate to have embarked upon this journey, the healthcare journey, as a student, as a true outsider. I had no formal training when it came to healthcare management, but was quickly able to compensate for that purported deficit with people I trusted and those people who did have the aforementioned. Many of those are recruited and hired. So that trust factor was somewhat baked in from day one. It was innate to those relationships. It sounds trite, but the ability to ask the stupid questions, “why do we do it that way?”, enabled me to tease out rigidity and in some case stubborn resilience to change. especially if that change emanated from outside of the industry which at times is seen as an antibody.

Stewart Gandolf (Healthcare Success): So one of the things that I've noticed from talking with other health system leaders is the importance of building essentially alliances or building trust within the organization in order to get anything done at all. Any secrets on that? Because you know you came in again without healthcare experience, you had to build credibility quickly. And again, it's night and day in my experience, the difference in somebody who gets credibility and who doesn't inside of a health system.

David Sylvan (University Hospitals): I think it comes down to social capital. Don't be prescriptive. Don't be presumptive. Be curious. Hear and heed. And then the manner in which you either rearticulate the problem statements or you perhaps propose a pathway or markers towards achieving an outcome, I think needs to be done gently and I think needs to be done with respect for the expertise sitting in front of you and the expertise that's come before you. It's not always a pure democracy as you can well appreciate Stewart, but I think enabling people to feel like they're seen and heard goes a long way when it comes to building trust. in that way, you begin to build your reps and you begin to build your reputation around someone who is part of a potential solution in a team setting versus someone who's going to be dictatorial or prescriptive.

Stewart Gandolf (Healthcare Success): For sure. That totally makes sense. And, you know, having worked in healthcare for most of my career, I think it is a balance. You need to listen. but also I always tell people in my team and with others, it's about credibility, credibility, and credibility. So you need to be able to know more about your given field than the the the audience of people you're talking to, but you have to do it in a way that helps them see the light. and minimizes friction. A lot of times you can get into, you know, silly things that take us way off court over who's right. Whereas if you plan your discussions carefully, it can obviously help.

So to switching a little bit to talking about hiring people and you you know, the people that have the capability of working within a system like healthcare. And I like that you call them “and people,” people who have a core capacity, a core expertise But they also can contribute beyond that, sometimes in ways that haven't even been defined yet. How do you find that? How what do you look for in people? Because by the way, I love that. I try to do that too. And but I'd like to hear your comments and I'll probably throw in a few as well.

David Sylvan (University Hospitals): It sounds trite, maybe even Pollyanna-ish, but you need to look for people who exhibit a combination of healthy skepticism and relentless curiosity. I have a simple tell. Probably sounds a little silly, but it's never failed me. And it's a subtle factor that, for me, exposes the “and” folks. Let me just clarify one element before I tell you my reveal. Not everyone needs to be or has to be a crossover player. And in fact, we made mention of this earlier. More often than not, organizations need professionals who are indeed subject matter experts and who have honed their craft. They are needed in their lane lines. They own those domains. And for the betterment of all, that's where they need to reside. In the broader innovation space, however, you need a healthy dose in my mind of cynicism and even skepticism. So what I look for in an initial conversation is the person who doesn't have a poker face, the person who perhaps adopts a quizzical look or furrows their brows when I describe an existing workflow or process map. That person is wondering to themselves, “why do they do it that way?” That's my tell.

Stewart Gandolf (Healthcare Success): Very good. You know, it's funny because some people are better at this than others, clearly. And earlier in my career, I assume 'cause I love doing stuff like that, David, to me it's just that's play to always innovate and bring in new ideas. And, you know, when I first started I thought, “you guys just figure out your job.” You can't do that. That doesn't work. that was naive, you know, thirty old me thought everybody could just figure it out. No, you can't. And some people need more help than others. But there are some people just gravitate toward that. And, you know, one of the things we talk about in our company culturally is I have never said out loud to anybody, we do this because we've always done it this way. We just have never done that. Not once in 20 years of owning our agency. And I think that mindset is helpful. And the idea of the “and” really caught my attention because, you know, the the sort of creative side, the the wonder side of my personality has to be balanced a little bit with you can't just have chaos. Like we the people can misinterpret that and suddenly everybody's doing everything. It's like, no, no, no, no, we didn't say that. We do have to get the job done. But the idea of balancing that I think is super exciting.

And then so you know using that to bridge to our next topic here, when we spoke, you talked about “welcome to ambiguity”. And you know, most people say that they're, you know, organizations and people say they're they want innovation, they want entrepreneurial people. But I don't know, David, in my experience a lot of people slap that down. So how do you create that ambiguity for people to, you know, cross-pollinate without ca causing the chaos that I was alluding to a few minutes ago?

David Sylvan (University Hospitals): For most people, ambiguity is uncomfortable. I would have counted myself in that descriptor for a good part of my career. And I'll talk to why that morphed. it's about creating intentional ambiguity at the boundaries, if you will, Stewart, but adhering to the sacrosanct nature of clarity at the core.

Organizations by their very nature try to eliminate ambiguity. Things are difficult to measure when they're ambiguous and they aren't linear. And that creates, that spawns reporting lines, job descriptions, budgets and decision rights, and then the worst of all, committees, death by committee. All of that creates necessarily necessary order. But innovation, as you know, happens in the spaces that aren't clearly defined between departments at the co-phase, between disciplines and mandates and ownership.

So it isn't a binary factor of choosing between structure and ambiguity in my mind. It's deciding when to toggle one up and one down. It's around the destination, what dose and what percentage of each in terms of guardrails and accountability would allow us to get to that destination with the willingness to accept indifference with regard to where the solution might come from. So it's this notion of bounded ambiguity, if you will.

People know what matters. They know what rules can't be violated and what lines can't be crossed. But they have permission to challenge assumptions, to assemble unconventional teams, and to perhaps pursue a pathway that isn't constrained by an org chart. Ambiguity without any type of rule factor is chaos and obviously you want to be in a position where you avoid chaos. Great organizations are clear about what must not be ambiguous and they are deliberately ambiguous about everything that doesn't need to be, in my mind.

Stewart Gandolf (Healthcare Success): Makes sense. So you when you're talking about avoiding chaos, how do you as a leader of a department with people reporting to you, give them the support, the coaching, the air cover they need so they can, you know, do things with the appropriate amount of latitude and not have to ask for permission every t you know, on everything, basically.

David Sylvan (University Hospitals): Yeah, comes down to, in my mind, comes down to trust. And that comes with time and situational at bats. Trust isn't established as a, you know it is not a day one permissioning to break the mold and start again. It's a time and circumstance bound, slowly letting out of more of the line, so to speak. And with each action and with each outcome analyzed and assessed, a goal of allowing, even encouraging recoverable and manageable mistakes.

It's probably trite now, but the idea of sanctioning failing forward does have validity and when a team member sees that you have their sixes, they're empowered to then bring intentionality to work every day with that notion of air-connect cover. Anyone on any of my teams can press the red button to stop the production line and that's mandated and we're all. required to listen and heed regardless of rank and hierarchy. That's not to say everything is democratic. That would be naive, but every voice matters. And when team members see manifestations of that, they tighten their circle of wagons around that as a team ethos.

Stewart Gandolf (Healthcare Success): So I would love as we go forward with the rest of this interview, David, to talk about and to the extent that you can, without naming people or you know, I think this is too confidential, but some anecdotes of real world cases just to bring the discussion to life. So, you know, one of our things we talked about before is like, “Well, you're not a clinician, how do you know that?” So, you know, like what are some of the resistance that you face, whether it's that sort of a discussion or any other that you have to overcome? And inspiration from, you know, real life events can make it even better if you can think of any offhand.

David Sylvan (University Hospitals): Yeah, know, this whole notion of it's, “that's not your domain.” know, every, this is where organizational judgment becomes as important as courage in my mind. If you're gonna be a change agent and you're gonna challenge every boundary, you won't be a change agent for long. That's I think called an irritant. The opportunity is to prove that the boundary perhaps is wrong and that you can make the organization better by crossing and collaborating a little bit more intelligently.

And then this, you know, it gets back to how people feel seen and heard and respected, Stewart, this notion of leading with curiosity rather than just rank or jurisdiction. Instead of saying, “well, here's what you should do,” I think it's more a notion of, and I encourage my team to say, “help me understand why we do it this way” and that creates permission to perhaps enter someone else's territory.

I get reminded often that I'm not a clinician. More so when the stakes are higher and the magnitude of the decision or the conclusion that we're aiming to reach has more potential impact. But credibility matters enormously and you don't need to be a clinician to ask an important question about clinical care. But you do need to have enough humility to recognize where your expertise starts and ends. The best boundary crossers I've met are rarely, rarely adept at knowing what they don't know. And they bring in people around them and that distinguishes then between the resistance to those that contain the information and the resistance that you'll experience from those who want to protect turf. So know when to push, read the room, heed expertise, respect expertise, but be credible in the manner in which you challenge and you propose. Perhaps there might be an alternative pathway versus worth consideration.

Stewart Gandolf (Healthcare Success): So you said two things in the last couple of comments that I want to underscore. One was the idea that you have to build trust over time. And I feel like in our society today, especially if you're younger in our is because I talk about this a lot on this podcast, that change is happening with faster and faster acceleration. And so from you know, these are different, not just different cultures coming up if you're new into healthcare or new into your career. But it's really easy in this world of technology to forget the human trust element. And that doesn't go away. And there's times where, again, we talked earlier about credibility. Without taking the time to build that trust, it's gonna be really difficult. And then you're going the wrong direction.

And then number two, you stumbled into something that or referred to something that I talk about a lot. I used to do workshops around the country literally hundreds of times with doctors, and I found that they've Doctors think you're smart when you ask smart questions. And so does everybody else too. But asking smart questions is just so valuable. And nobody does that. Everybody wants to hear themselves talk, but a question asking is such a powerful, powerful skill.

So as we're pivoting here, the another thing that you know it's on that note, I guess to build upon that thought is AI is changing everything, you know, even faster, right? Technology, clinical care, strategy, marketing. consumer experience. So how does AI help blur the lines and make this even more important? Are there s whole new sets of boundaries we haven't figured out?

David Sylvan (University Hospitals): I think it's both. And I think that tension is exactly what makes AI such a potentially profound organizational change factor, change element. AI makes the ability to blur lines more important because AI by its very nature doesn't respect organizational architecture or hierarchy, especially any of that that was built before it existed.

A clinical AI tool is a technology issue, it's a clinical issue, it's a workflow issue, it's a patient safety issue, legal issue. So almost asking who owns AI is the wrong question, you know, in and of itself. But it is creating entirely new boundaries that we haven't fully defined. When does human judgment end and machine judgment begin? And are we comfortable with that? Not just from the perspective of the relinquishing of credibility, but risk implications. Who adjudicates accountability when the two run afoul of each other or disagree? What decisions should we relegate?

God, there's a whole topic around data. Who owns the data? Who does the algorithm validation? So AI will play a role in simultaneously dismantling old boundaries and perhaps even in inventing new ones. Blur the interfaces and but sharpen the accountability perhaps is where AI is going to come into play. But your workforce has to be AI literate. There shouldn't be this, we can only police and adjudicate the quality of the output if we're actually conversant with the tools and literate with the tools, and the human stays relentlessly in the loop. So this is a… watch the space, so to speak, because it's ever evolving. I think we're living in six-week cycles,

Stewart Gandolf (Healthcare Success): For sure. So as we get closer to the end here, one of the things that comes to mind is this idea of silos. And you know, again, you I'm not I own an agency, not a health system, but even with us with forty some people, silos are amazing how they can take hold. And I'm assuming you've probably worked with CEOs that have complained about silos, you know, causing confusion with an organization. So if you were talking to a CEO or department head who's thinking “How do I break these silos down?” What would you tell them? Where would the where should they start?

David Sylvan (University Hospitals): I think, yeah, I think you have to show and not tell. I think, for example, I was put in the fortuitous position when I was asked to assume the responsibility for system strategy. One of my stipulations and requests was to bring the innovation function along for the ride. use the disciplines and the processes and the engine and the methodologies that we had honed within the innovation space to help to inform how strategic decisions should be made.

Now that sounds good on paper. That only really takes life when you actually blend the people together. You actually put people, you take people from one seat and you purposefully put them in another seat with that permission to once again reclaim that curiosity and that desire to understand the why.

It happened again in my case when I was asked to assume the marketing responsibility role. And for me, that was a great opportunity to pull people out of the marketing back room, if you will, put them at the forefront of opportunities in a cross-functional sense, and have them lead solutioning when it comes to a domain that would ordinarily have resided somewhere else. Then you're able to say to your CEO, “you see, this is what it looks like an action,” the force multiplication, the whole is greater than the sum of the parts, whichever moniker you want to use. But I think it's not conceptual. It's a “show me” type environment. Show me what it looks like when it works. And that then reveals the opportunity to disband the silos because you can see in action what doing that will imply.

Stewart Gandolf (Healthcare Success): So the last question I have is intriguing to me. When you get into marketing with hospitals, and I often say if you know a hospital, you know one hospital. If you know a health system, you know a health system. And you know, there are some hospitals and health systems where marketing doesn't have a seat at the table, or strategy is a separate department entirely, or innovation is a separate department. So I guess what I'd love to know from your standpoint, working in these three categories of strategy, innovation, and marketing, what I guess as you've gone you know, from maybe the strategy side to the marketing side too, what has surprised you? What what is just different than you expected? Maybe lessons that you had learned before were wrong or vice versa. Maybe team members you're working with have just never thought about things in the same way in a holistic sort of way.

David Sylvan (University Hospitals): I think it's about permissioning. I think the opportunity for an individual to flex into, to become that and person that we mentioned earlier and to glean the recognition for that contribution, I think is very empowering. When someone's able to look at you and appreciate and respect your contribution to an opportunity where ordinarily you might not have been invited to that room, that's very empowering. People then tend to want to show up and do that again because of the affirmation that that implies.

You know, for me, lessons learned, things that I didn't know I didn't know before coming into healthcare specifically was, this is about the human being. This isn't widgets, this isn't products, this isn't throughput. And it was 11 or so years ago that this notion of human-centered design really took hold for me. it's the, you know, it used to be for me, “it's the product, stupid.” Well, it's not. It's the person, it's the people, whether they are the people we serve or the people we serve with, the ability to put people in a position where voices are heard and opinions are respected. And again, not necessarily with this notion of universal acceptance, but with the right type of pushback, pressure testing and challenging in a respectful way. I think that puts people in position where they feel like they are part of something bigger, part of something greater. And that's exactly how I feel.

Stewart Gandolf (Healthcare Success): Outstanding. David, it's been a pleasure working with you today and thank you for joining our podcast. any last words or advice before we wrap up here?

David Sylvan (University Hospitals): Stewart, I appreciate you having me. I think healthcare is under duress, and I think we're all going to have to lean into being part of the solution versus merely lamenting the problem and some of that is going to be elements that we can impact as individuals, some of these are going to be legislative, but be participants and not passengers in both your individual journey and the journey of that of your community I think is an important mantra that I live by.

Stewart Gandolf (Healthcare Success): I love it. Thank you for your time.

David Sylvan (University Hospitals): I appreciate you. Thank you, Stewart.