Professor Linda Hill first met Tom Mihaljevic (GMP 15, 2013) when he came to campus to participate in a fireside chat that Hill unexpectedly wound up facilitating. At that time, he was the CEO of Cleveland Clinic Abu Dhabi, and the pair found they had a lot to talk about—between Hill’s interests in leadership, innovation, globalization, digital transformation, and the health care sector and Mihaljevic’s path from cardiac surgeon to leader of one of the world’s most esteemed medical centers. That initial conversation led to many more and a series of three case studies that were possible, Hill says, only “because there was so much to learn from Mihaljevic and his colleagues.”

“What Tom really cares about is people, and that shows up in everything they do at Cleveland Clinic, from the caregivers to the patients and the community,” says Hill, who also chairs the Leadership Initiative at HBS. What these three cases illustrate is the mindset, talents, and courage it takes for leaders to make the tough choices required to live their intentions and values.

This particular case finds Mihaljevic in his fourth year as president and CEO of the entire hospital system at the end of 2022, looking back at its heroic response to the pandemic. Still, it took a toll on the organization’s 77,000 caregivers, and the hospital would not meet its performance targets for the second year in a row. They had recently transitioned the performance management system from KPIs to OKRs. The dilemma in the case centers on how much of a stretch Mihaljevic and his team should build into the 2023 targets.

Sweet Spot
“I’m an organizational anthropologist, so I like to deep dive into a context and conduct ethnographic research that can take years to complete. I look for leaders who are willing to let me stick around to see how their organizations evolve over time. Tom and his colleagues at Cleveland Clinic have been willing to let me do that. When I first spoke with Tom, he was the CEO of Cleveland Clinic Abu Dhabi. By the time I got around to researching our latest case, he was the CEO of the entire enterprise or ‘mothership,’ as they call it in Cleveland.”

Symbiosis
“One of the purposes of this case is to look at globalization and how to get the global/local balance right. We see first how the core business operates and then learn of the leadership challenges and opportunities in Abu Dhabi. We ask questions like, What should the relationship be between the mothership and the field location? Who should have decision-making rights about what? How do you share resources across locations? Tom knew they couldn’t simply cut and paste the culture from the main campus to Abu Dhabi. They had to develop the contextual intelligence and partnerships required to adapt to an entirely new ecosystem if they were to scale and have impact.”

In Full Measure
“In this case we wanted to write about the impact of planning and performance management tools—and going from KPIs to OKRs, to drive innovation and agility. Cleveland Clinic was very forthcoming about both their implementation strategy and tactics. They shared their challenges in embedding OKRs into their operations, as well as their actual leadership and enterprise scorecards.”

Pulling Threads
“An underlying theme in this case is how to attract and lead a diverse workforce. In helping students understand how to build inclusive cultures, my preference is to thread that theme throughout the course of a semester. They encounter diverse case protagonists in a range of settings across the globe. And they see what it takes for leaders to build organizations in which everyone can bring their best self to work.”

Show and Tell
“The toughest challenge in case writing is deciding what to show and what to tell. The decisions should be based on what you want students to grapple with and analyze for themselves. Since we want them to focus more on the implementation of a new performance system, we tell them what the system is and show them how they implement it—that is, the choices Tom and his colleagues make in rolling out the new system and their impact. In analyzing the how, the students also glean insight into how the move to OKRs is more aligned (or not) with building an innovative culture.”

On Second Thought
“I think beauty is in the detail, so my cases are always too long. After teaching them a few times, I always abridge them. The first few times I teach a case, I see where people gravitate naturally. I take detailed notes about how the students make sense of what they’ve read. You also must teach a case in a few different spots in a course to figure out where the material is best placed. For example, this one would teach differently if placed next to another about leading an organization in a new market, as opposed to one about transforming organizational culture. That is what I love about case method teaching: It is truly a discovery process, not only for the students but also for the faculty.”

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