Editor's Note: As Carilion Clinic President/CEO Nancy Agee announces her upcoming retirement, writer Dan Smith shares this previously written piece on Agee's incredible journey through our local health care system.
From Carilion's YouTube page with video below:
Nancy Howell Agee, who has led our organization through more than a decade of transformative change, will step down as CEO Sept. 30, 2024. Steve Arner, who was promoted to president in May 2023, will succeed Nancy and become president and CEO Oct. 1. The leadership transition comes after Nancy’s long and distinguished career at Carilion, beginning as a nurse in 1973. She was named president and CEO in 2011, becoming our seventh—and only female—top executive. Nancy will serve as CEO emeritus through September 2025 and focus on philanthropy, growing partnerships and continuing to develop our health system’s reputation statewide and nationally.
You can watch Agee’s full retirement announcement below:
Nancy Howell Agee, President/CEO Carilion Clinic, was described by one healthcare executive as “a Carilion lifer,” and indeed she is. Quite literally. She was born in April of 1952 at Crippled Children’s Hospital, which later became Roanoke Memorial and now houses her Carilion office on the first floor. Her son was born at a Carilion facility and her father died in one. She earned a nursing diploma at Roanoke Memorial Hospital.
Over the years, Agee has risen to the top echelons of healthcare administration in the United States, recognized widely as one of the most influential women in the field. By all accounts, she has earned every accolade, every promotion. She is the CEO many admire for her humanity, her humility, her honesty, her quick mind, her ability to rapidly evaluate the most complex challenges, and for her fearless decisiveness. Carilion employees adore her; competitors admire her; colleagues seek her counsel.
As a child who had frequent contact with health care professionals because of knee surgeries (she spent nearly two years in a wheel-chair or on crutches), “I saw mostly the good in nurses and doctors who cared so much.” But there was a flip side, especially “with the lack of transparency, the lack of communication with a teen [her], fear of certain types of cancer. I wanted to fix that.”
Her early years were spent in a four-room house in the working-class Virginia Heights section of Roanoke with her mother and father (JoAnn and Billy Howell) and two siblings. Billy worked at the grocery store Mick or Mack, as did Nancy Agee’s beloved grandmother, Reyna Howell. The family later moved to the more upscale Cave Spring area.
Agee’s grandmother, Reyna Howell, was her touchstone. “She worked all her life [as a manager at Mick or Mack grocery stores], but she was always doing something fun. When I look back on it, it was a series of small adventures: getting milkshakes at 10 p.m., chewing ice …” Reyna Howell was the only female manager at Mick or Mack and she owned her own home, which was unusual for a woman at the time. Nancy Agee lived with her grandmother for a while as a child. “We were very close,” she says. “She was my go-to person.”
Dan Smith
Carilion's Nancy Agee
Her career with Carilion began when she was a teen, working as a candy striper. About 40 years ago, Agee was hired as a nurse at Roanoke Memorial and advanced through administration. She was named VP of medical education in 1996 and Chief Operating Officer in 2001, reporting to CEO/President Ed Murphy, who would groom her for his position. In 1985, the Jaycees of Roanoke saw her as a bright light and named her Outstanding Young Woman of the Year. Most recently, recognition for her work has been impressive: beckershospitalreview.com selected her among the 24 leading women in the healthcare world. She was included among Virginia Business magazine’s Big Book Most Influential Virginians. Virginia Lawyers Weekly selected her one of the 40 Most Influential Women of Virginia, 2015.
She has degrees from the University of Virginia and Emory University; postgraduate studies at Northwestern University's Kellogg School of Management and she went to nursing school at Carilion. She was “first in my family to graduate high school,” not to mention college, she says.
Husband Steve Agee, was a Republican Virginia State Delegate from Salem. He now sits on the U.S. Court of Appeals, 4th Circuit in Richmond. Son Zach is a clerk for an appellate judge in Virginia Beach. The family is close, despite physical distances of their jobs. “We love each other and we like each other. The family is a priority,” she says. Zach and Steve “respect that I have my own thing. Each of us has our own interest. At home, we don’t always talk about work.”
Agee is a healthy eater and works out regularly, but she drinks Diet Dr. Pepper throughout the day. It is a drink that is something of a family tradition. “We used to stop on the way to the beach—on those few trips we made to the beach—or to see our family in Tennessee, and get Dr. Peppers.”
Dan Smith
Nancy Agee with her replacement Steve Arner and Chief Medical Officer Patrice Weiss.
Her profession, she says, “is a passion. It started a long time ago. All my life, I’ve wanted to make a difference in health care.”
“I never did” aspire to high management, Agee insists. “I moved into it out of a sense of frustration, getting things done for patients that needed to be done. I gravitated to it more than planned for it.”
Replacing Ed Murphy, an MD and PhD with clinical experience, as president/CEO “was a bit of a surprise. I was flattered and grateful, but I anticipated being an interim CEO until a search was completed.” When Agee was selected by the board of directors, “I said, ‘Are you sure?’”
Murphy says he moved Agee into the COO position when he took over the reins from Tom Robertson at Carilion because she had “the skills to run a complex organization.” He saw “a three-legged stool” in her skill set: the “ability to handle and manage a [large, complicated] health care organization; the ability to manage people and keep the trains running on time; and a good dose of strategic vision. She was a very good fit.”
It wasn’t difficult to convince the board to slide Agee into the boss’ chair upon Murphy’s resignation, he says. “You look at the people all over the country [in that position] and Nancy has elements of all of the [successful ones]. She is a rare individual with an equally strong set of skills [across the spectrum]. She is a rare find.”
Board member Warner Dalhouse, a retired banker who has been on the boards of Carilion and Community Hospital before the merger with Roanoke Memorial, says he and a few others pushed hard for Agee when the vacancy at the top occurred.
Says Dalhouse, “When Ed let it be known he was leaving for New York [to join TowerBrook Capital Partners LP], I was one pushing hard for us not to do a search, to just go ahead and hire Nancy. It was a gusty thing for the board of a large enterprise to do. We had a fiduciary responsibility.”
The vote was lopsided. “I was at a funeral with [former Carilion CEO Tom Robertson] a few days after we appointed Nancy and we were talking about it. I said, ‘Can she run it?’ and he said, ‘She’s been running it for a long time.’”
Robertson says Agee “has a lot of credibility, a clinical background and excellent interpersonal skills. She understands the culture [at Carilion].” It was a matter, he says, “of the right time, right place, right person.”
Murphy, says Dalhouse, “was a visionary, but Nancy ran [the corporation] on a day to day basis. Boy did she ever! We had been losing a good bit of money for several years when Nancy took over and it took her four years [to push Carilion into the black]. Now [in 2015] we are making money.”
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As Chief Operating Officer, “I followed [Murphy’s direction] and made it work,” says Agee. “The COO can disagree,” she says, “but you have to believe. The CEO has to be vigilant and understand what’s going on. You work differently in a $1.7 billion company.”
Murphy was a difficult act to follow, even though finances were in a bind when he left. In 2010, shortly before Agee took over, Carilion reported an operating loss of $45.9 million on revenues of $1.24 billion. The loss continued for a while before Agee righted the ship (the net having fallen 40 percent in the previous two fiscal years). During that difficult financial period, charity care increased by 31 percent at the region’s non-profit health care center, the one that was described by Valley Business FRONT magazine as “the health care organization with big shoulders.”
Murphy began a long transition from a hospital to a patient-focused clinic during his tenure; helped institute a partnership with Virginia Tech and also founded a med school and research institute. Agee calls Murphy “a visionary,” “a wonderful mentor,” “a good teacher” and a man who “dreams big dreams.” She told Virginia Business, “His footprint will be different than mine ...” shortly after she was elevated to CEO.
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Carilion met strong, loud and persistent resistance to its conversion from a hospital-based operation—which is traditional—to the newer clinic system. That system focuses on outpatient care. Murphy instituted the change but Agee has been all-in. Those opposed to the change—primarily physicians—say it creates a monopoly and drives up costs.
For a period during the change, Carilion was losing physicians in trauma care specialties at such a rate that it had to alert the Commonwealth that it wasn’t meeting its requirements as a Level I center. The change in leadership seemed to ease that conflict. Vista Eye Center managing partner John Brisley, M.D., was quoted in The Roanoke Times at the time as saying, "Our sense is with Nancy Agee heading things up now, there really is a new tone and it's a new approach." She moved quickly upon appointment to fill the trauma leadership void, promoting Paul Davenport to VP of Emergency Services.
Dalhouse says, “When she took over, Carilion was in terrible shape regarding the area’s independent physicians [because of the move to the clinic model] and there were a lot of sharp feelings. Ed didn’t really tend to that. She smoothed it over and now some of the physicians who opposed [the clinic change] have joined in. Ed made no real effort to do that.”
The sheer size of the company obviates some of what Agee would like to do. “People say, ‘I wish you would make rounds every day like Mr. [ex-CEO Ham Flanagan] did.’ I do, but we have seven hospitals and 1,000 physicians. Every day I am somewhere, but we have a bigger footprint.”
Early in her tenure, says Agee, she received some valuable advice from a close friend: “Make this your own. You’re not following anybody else’s footsteps.”
The board wanted immediately to “refresh and review our mission. First, how do we get out of the hole? We were deep in the red at the time. I got permission with expectation.” She did not “have a traditional honeymoon. It was time to roll up my sleeves and get to work.” She says Carilion has “a very engaged board,” and has had for a long time.”
The challenge was impressive, but, says Agee, “I love to work and I work hard.” Her days are often 12 to 15 hours long.
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Education has always been at the center of Agee’s interest. “Jefferson College is an enormous asset. It has, what, 1,100, 1,200 students with masters and baccalaureate degrees.” PhDs are on the horizon and that will “be a huge asset.”
She was instrumental in bringing the new doctorate of physical therapy program from Radford University to Roanoke. She established the research-based Innovation Center at Carilion, as well.
Education and health care “are a dual passion” of hers. Centering STEM(H) education in Roanoke is a goal. She directs a nonprofit organization that includes Jefferson College of Health Sciences and the Virginia Tech/Carilion Medical School. She stresses that “we have educated a lot of people who work at the other hospitals.”
The vigorous relationship with Virginia Tech, which accelerated during Ed Murphy’s tenure, presents “the opportunity to do exciting things. You’re just seeing the beginnings.” What Carilion has accomplished, Agee says, “is extraordinary for a region our size. You can get anything here except transplants. That’s a WOW!”
Her work with the Joint Commission board and the American Hospital Association have put her smack in the middle of the conversation on healthcare reform with the people who can make it happen. Cost and quality are her laser-focus issues. She is especially interested in how cuts would affect Medicare and Medicaid.
Agee stresses that “60-90 percent of our payer source [the government] doesn’t pay the cost” of treatment. “We need a vibrant business community to support the kind of health care we want. We need to grow this community better, to grow services. I’m really serious about that.”
As big as Carilion is, she says, “We’re small compared to others. We’re a big fish in a small pond. I wish the pond was much larger.”
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Colleagues and business leaders have been consistently impressed with Agee.
John Williamson, former CEO of RGC Resources in Roanoke, served on the Foundation for Roanoke Valley, Roanoke Economic Development Partnership and RGC Resources Boards with her. He says, “I always found her to be well prepared, incisive in her questions, thoughtful and poised in her comments, and deliberate and prompt in her decisions. She tends to inspire confidence. "
Laurens Sartoris, former President/CEO of the Virginia Hospital & Healthcare Association, has been quoted as saying Agee’s strong relationships make it “a more comfortable exercise in communication when people get along." Sartoris’ successor, Sean Connaughton, calls Agee a “nationally recognized leader and trailblazer who has helped build Carilion Clinic into a renowned provider of exceptional healthcare services.
“She is a Carilion Clinic lifer … overseeing one of Virginia's largest non-profit integrated health care organizations. … Nancy is a tireless advocate for Carilion Clinic, for health care, and for patients. I consider myself fortunate to have ... a chance to know her and work with her.”
Warner Dalhouse says Agee “is an excellent administrator. She is good with the board. Nancy decides the strategy, gets approval and delegates. The people who work with her love that. … Carilion runs like a well-oiled machine. She doesn’t even have to be there.”
Agee, says Dalhouse with emphasis, “tends to the store.”
In a magazine story, Becker’s Hospital Review quoted Agee as saying, “At the end of the day, it's about paying attention. The most important thing is taking care of patients, followed by making sure our staff has a great environment.”
In brief
Nancy Howell Agee
Born: Roanoke Children’s Hospital, April, 1952
Married To: G. Steven Agee, judge U.S. Court of Appeals, 4th Circuit. Son, Zachary S. Agee, court clerk.
Education: Northwestern University (Kellogg School of Management); Emory University, magna cum laude; University of Virginia, with honors; Roanoke Memorial Hospital, nursing diploma.
Title: President and CEO, Carilion Clinic since 2011. Has been COO/Executive VP; senior VP Carilion Health System/Carilion Medical Center and VP medical education. Various management positions at Carilion Roanoke Memorial Hospital.
Professional Affiliations: American Hospital Association board of trustees, board of directors, committees; Coalition to Protect America’s Healthcare Association board; Virginia Hospital & Healthcare Association board member and chairwoman; The Joint Commission board; Virginia Tech Carilion School of Medicine board; Virginia Foundation for Independent Colleges, board; Virginia Tech Foundation board; Virginia Business Council, vice chairwoman; Virginia Business Higher Education Council; Virginia Western Community College Education Foundation board; RGC Resources board; Hometown Bank & Hometown Bankshares Corporation board; Governor’s Advisory Council on Revenue Estimates; Center for Medical Interoperability board; Rockingham Group board; Association of Community Cancer Centers board; Hospice Association of America board; American Cancer Society—National advisory group; ACS Virginia Division board; ACS Roanoke Valley Unit honorary board.
Community Involvement: Taubman Museum of Fine Arts board; Western Virginia Foundation for the Arts and Sciences board; Radford University board of visitors; Foundation for the Roanoke Valley, board; Mill Mountain Theatre board; Roanoke Regional Chamber of Commerce board.
Awards (selected): University of Virginia Outstanding Alumni; Roanoke College – Doctor of Humane Letters; The Taubman Museum of Art – Ann Fralin Award (Community leadership and support of the arts); Palladium Award (Carilion’s highest award for quality); March of Dimes Hall of Fame; Silver Hope Award – Multiple Sclerosis Society, Blue Ridge Chapter; Meritorious Service, American Cancer Society, Virginia Division’s Highest Award; Outstanding Young Woman of the Year, Jaycees of Roanoke Valley; Outstanding Nurse, Virginia Nurses’ Association, District 2; Miss Hope of Virginia, American Cancer Society.