Most board chairs and their board members face extremely complex healthcare issues, as well as higher performance expectations in their roles. Collaborating on changes in medical services arrangements is expected, growing market share is a necessity, financing is crucial and ensuring community critical services access is a must. The importance of boards putting their community health first and being mission-focused in moving from volume-to-value-based care has become the basic white waters that boards must navigate.
In most cases, boards have stepped up their game in response to the multitude of challenges confronting their organization. However, most also agree their governance culture and practices still need improvement if they’re going to be a valuable partner in leading their organization through the transformational changes they face.
Where to Begin
Every board annually needs to critically assess, evaluate and determine its strengths and weaknesses in relationship to what it will take to lead their organization. Unfortunately, most boards are not used to having these types of introspective conversations with themselves.
Critical to governance success is conducting annual board self-assessments via facilitated retreats. These events should focus on board performance, action plans for improvement, and establishing educational programs.
Wherever boards are on their journey to better governance there’s no doubt that effective governance begins and ends with their CEO and how he or she views their boards relationship, which can range from nuisance to threat to thought leadership and anywhere in between.
Without CEO support, any board will have a difficult time partnering in leadership because any board action can be snubbed by the CEO as micromanaging or overstepping into management’s domain.
After the CEO, the board chair is the most influential person shaping the board’s effectiveness. It is extremely difficult, if not impossible, to overcome the problems of a weak or overly controlling leadership on the part of the chair.
Keys to Success
A shared balance of organizational power between the Board Chair and the CEO is critical to the success of their partnership.
Managing egos is critical for good governance. When one or both has a big ego, things get out of hand in a hurry in the boardroom.
According to Demb and Neubauer (1992), the following factors build trust between a Board Chair and CEO team:
Characteristics of an Effective Board Chair
The caliber of the board chair enormously influences the quality of governance. It’s not uncommon for non-profit boards members to be unclear about how a board chair is selected.
The selection process many times is either informal or improvised.
The effectiveness of the organization governance depends on the conscientious nomination process for both board members and the chairperson. It must be transparent, understood and inclusive.
The governance committee should poll their board for their thoughts and recommendations:
Chairing a non-profit healthcare organization board demands a huge commitment of time and effort. The opportunity to exercise leadership in one of the community’s most important institutions is priceless.
According to the Great Boards 2016 Fall Newsletter, half of all Board Chairs have no training or mentoring; nineteen percent learn through board progression experience. Most trustees don’t have any healthcare background and an unspecified number of hospital senior leaders think new trustees without healthcare experience take approximately three years to gain confidence in their ability to collaborate effectively.
Dr. Carla Boutin-Foster and colleagues define the medical culture as “the language [slang], thought process, styles of communication, customs and beliefs,” which is used to describe the informal and highly specialized nomenclature and vocabulary used by the healthcare industry. Trying to understand the hospital’s cultural language becomes one of the primary challenges for Trustees when managing their conversations and coming to consensus on decisions.
In a national study on the perspectives of nonprofit board chairs, Nonprofit Quarterly’s fall 2016 edition explored what preparation was done by board chairs and how they see their relationship to the board and other key stakeholders. What they found was a glaring picture of neglect with 51% of respondents doing nothing to prepare to become board chair.
Previously held board officer or leadership position in same institution, i.e., committee chair, vice chair / chair elect has some promise and limitation in preparing an incumbent for the role of board chair.
The majority of board chair respondents relayed that observing the prior chair and asking the CEO for advice was helpful. Coaches, consultants or outside resources were least likely to be considered.
Boards labeled least effective are “rubber stamped” for management recommendations, which provides basic oversight to ensure compliance; boards labeled standard effectiveness requires some thinking regarding proposed prepackaged management recommendations; the highest board performance label requires a governance leadership model that raises critical questions and requires critical thinking from its membership and reporting CEO.
The board chair leadership phenomena has intrigue to it… in the spirit of governance and organizational effectiveness, especially in rural healthcare, how can half of all board chairs assume their role with no or minimal training?
With healthcare changing very rapidly, accommodating long grace periods for board leadership positions is unacceptable. Rural Healthcare key stakeholders, medical staff providers, patients and communities expect their boards to have the skills and competencies to make timely high-stakes decisions, as well understand the best ways to shape and meet their community needs.
Boards in all sectors are being held to a higher standard of performance and accountability. They are expected to be more actively involved in setting organizational strategy, resource allocation, capital financing, investments, conflict management, executive performance, management and succession planning, clinical quality and external relations. It can be quite overwhelming.
Dennis D. Pointer, governance expert, offers this insight, “Boards are as high up in organizations as one can go and still remain inside them. They bear the ultimate fiduciary responsibility, authority and accountability for their organization’s affairs.” A fiduciary is an individual in whom another has placed the utmost trust and confidence to act for their benefit.
Many board development assessments I have conducted conclude that board members are good citizens who don’t have a clear sense of what their obligations are and what type of work needs to be accomplished. Board members role expectations, as well as, their board chair, committee chairs and their CEO roles have not been collectively discussed, understood or agreed on.
Bruce Stickler, Board Chair at the Illinois Department of Public Health, said that expectations for boards and their chairs have changed dramatically, “Board chairs have to be much more active today in every aspect of healthcare change, including collaborative arrangements and community services. They can’t leave the work to the staff; they must provide leadership and direction and be involved.”
What causes board and board chair failures? It’s a board’s tapped out choice in selecting someone who doesn’t understand what governance means and how to exercise it. In my next post, I will cover how this phenomenon can be corrected.
QUESTION: “How do board members get to know their medical staff providers without being perceived as micromanaging or going around management’s back?” This is a question often asked by board members who admittedly say they do not know their medical staff or how to approach them.
A board member shared with me that when she speaks with physicians, it often gets back to hospital administration and is perceived as going around management.
She was lost as to what she should do.
Business is all about relationships, but what if you are not in a relationship with your “rainmakers”?
When presenting on the topic, “How to Improve Hospital – Physician Relationships” at regional board of trustees conferences across the country, I always ask for a show of hands on the question, “How many of your physicians are associated with your healthcare facility because of their relationship with the board of trustees?” At four conferences, with 100 plus attendees at each, I counted only two raised hands.
When the following question was asked at the same regional conferences “…in relationship to the chief executive officers and their executive teams,” only one show of hands was noticed.
And when this question was asked “…in relationship to the nursing staffs” there was no show of hands.
In addition, when I asked, How many trustees had a board-driven policy declaring how they wanted their organizations to deal with their physicians?” – I had no show of hands.
If key physician relationships are strained, fractured, deteriorating or plainly written off, you can clearly understand the reasons why. It may also be why the culture and values in healthcare relationships are deeply rooted with miscommunications and mistrust.
If the truth were known, many boards of trustees would not be comfortable dealing with physicians; hence, they avoid the encounter. While some boards may be at ease speaking with the few physicians they know, other physicians often perceive this contact as favoritism.
Likewise, many physicians do not know who is on the board of trustees of their healthcare organization. In addition and above all, many physicians do not know what board members responsibilities are.
If boards of trustees have not discussed and come to consensus regarding a policy on how they want the organization to deal with their physicians, they can easily be perceived as micro managers or bypassing management when they seek out physicians.
The relationship of the board of trustees with their physicians must be rethought and new strategies developed on how they want their organization to deal with their primary rainmakers.
Discussing and arriving at consensus on the following questions is essential:
A facilitated board retreat with full discussion should center on:
Creating New Relationship Expectations
Developing an explicit written “hospital – physician relationship policy,” describing the working relationship expectations each has of the other will certainly improve individual accountability, communications and trust.
A particular board of trustees, after full discussion amongst themselves, engaged the hospital’s executive team and their medical staff leadership to come up with the following action plans to establish their first ever “hospital – physician relationship policy.
Engaged Physicians: Critical Success Factor
Investing in physician engagement by institutionalizing a collaborative Hospital / Physician Relationship Policy that demonstrates between and among Board Members, CEO, Employed and Independent Medical Providers:
This article is in response to “The Hard Work of Culture” by John Mitchell CEO from Modern Healthcare Online.
The underlying message of John Mitchell’s article (one of the most requested) is both correct and refreshing. Its content signals to me that a CEO in a leadership mindset needs first to realize the importance of organizational culture and its many subcultures that contribute to the success of an entity. Organizational culture reflects the beliefs and behaviors in which, overtime, a body develops, learns and acts out each day. Its objective is the status quo [survival], and today in many healthcare organizations, survival is the only mindset.
Very few CEOs perceive the importance of their role and that of senior leaders plays in leading and championing desired culture change to ensure its survival and competitiveness. Mr. Mitchell does.
The vast majority of CEOs do not understand how the power of their organizational culture correlates to their legacy or tenure success. Most CEOs focus on pleasing their board chair and feel partially accountable for the behaviors and beliefs demonstrated every day in their organization, about which they cannot change as they focus on the bottom line. I say “partial” accountability for their organization’s culture because full accountability is with the board of directors. I can safely say many board members do not understand this responsibility as one of their primary duties as many have revealed, “I was never told.”
In reality, physician clinical integration and alignment in most cases requires an organization to transform their culture to the new behavior
In my experience conducting organizational key stakeholders’ relationship assessments, most physicians I have interviewed have the perception they are not the hospital’s #1 customer. They do know they have less influence and control over the hospital environment they work in – whether employed by the hospital or an as Independent Practitioner.
When I asked a family practice physician why he had this perception, he, in turn, asked me if I had seen their physicians’ lounge. He recommended I take the time to see it to understand what he meant.
When I toured the lounge, I saw a poorly lit room with worn furniture – a small cluttered desk with one phone, an outdated desktop computer, and a thermos of coffee with a short stack of Styrofoam cups on an end table.
Another physician related his frustration with the intensive care unit being sporadically opened and closed, noting the situation had been ongoing for a year. If physicians were the medical center’s #1 customer, he would not have lost the needed patient revenue for his practice nor had to inconvenience his patients and their families when he had to transfer them to an ICU at a competing hospital 90 miles away.
When I further inquired about the intensive care unit not being consistently open, I was told a staffing issue had been plaguing the unit. The medical center could not attract or retain critical care nurses and the situation was further exacerbated by staff absenteeism.
Physicians know they are their healthcare organization’s #1 rainmakers, yet many are not made to feel as if they are the most important contributor to the organization revenue stream. Most physicians realize the board and hospital administration have little clue to their needs or expectations nor for the organizational bureaucracy they encounter every day when implementing their clinical patient orders.
The attitude among the top-board members and management teams is very transparent and drives the organization’s attitude toward the physicians, which manifests itself in many ways by well-intentioned persons.
Most organizations rely on implicit expectations when dealing with physicians; these are unwritten and unspoken rules, requirements or understandings among people.
Board policies shape the way management and medical staff undertake their work. Boards are accountable for setting policy with directions and behavioral expectations. They must be clear in what they want the organization to do or refrain from doing.
When was the last time your board of directors discussed and approved an explicit policy with expectations on how they wanted the organization to conduct and transact business with their physicians? If the answer is never, why not?
When people have a clear understanding of what is expected of them in providing customer service to physicians and meeting those expectations, trust grows and relationships develop. The opposite occurs when customer service expectations are not clear and not being met; trust diminishes and key stakeholder relationships become strained.
The board may have a policy consensus but that does not guarantee that hospital management and their staff agree.
Going back to the story shared by the physician about the conditions of the physician’s’ lounge – in the corrective action, the board and hospital management established an ad hoc committee of management and doctors to determine and recommend remodeling options.
Within 90 days, the lounge had a complete makeover which included new furniture, a kitchen area with food, coffee machine, etc. The dietary department became accountable for daily replenishment and environmental services was responsible for daily cleanliness.
The efforts by the board, hospital management and the ad hoc committee were well received by the physicians. Within a couple days of the lounge’s reopening, a nursing supervisor and a small band of nurses expressed a subtle resentment at the upgrade done for the doctors and not for the nurses.
Regarding the physician’s story concerning the inconsistency of the intensive care unit’s hours, the board and hospital management approved a physician-led ad hoc committee to determine action plans and recommendations to enhance the credibility of the ICU.
Within 90 days, a well-respected internal medicine physician assessed the ICU to determine both its strengths and areas needing change. He made the following recommendations: (1) become the unit’s medical director for one year, (2) schedule physician education for the unit’s nursing staff and (3) collaborate with nursing management to transfer the unit manager and find her replacement. Interestingly enough, nursing salaries were not a major issue. Hospital management collaborated to make the long-needed changes in the unit’s leadership. A formidable minority of employees perceived the physicians were now running the hospital.
Commitment begins with the board of directors being accountable for setting policy and expectations. People Employees look to their hospital management to take the time to share and clarify such expectations and consequences. Shared accountabilities create ownership and build relationships of trust and support.
Development of a “physician customer service policy” is the responsibility of the board. Its successful implementation is with the hospital management and their staff who must fully understand performance expectations and consequences when interacting daily with physicians.
The culture of healthcare organizations continuous to be in a vicious cycle of self-perpetuation in an organizational climate of mistrust, miscommunications, finger pointing, discrediting and hoarding of control.
Dysfunctional behaviors are condoned and rewarded every day by performance reviews not given, salary increases, budget appropriations and contract approvals. Healthcare culture appear to be in a survival state of defensiveness, physical slowness and mental dullness.
Why is it so hard to see and feel the confidence and courage in the board of trustees, hospital management and medical staff leadership who everyday, whether they realize it or not, by their daily actions, create or reinforce the culture within their organization?
The board of trustees must step up and become accountable for setting in motion a process for renewing their organizational current culture by re-aligning key stakeholders’ roles, expectations and behaviors for themselves, hospital management and medical staff leadership.
Most boards do not know they are accountable for their organization’s culture, they rely on their CEO for recommendations and continue operating in a traditional hospital governance model – which in most cases is the status quo.
Board members, CEO, Senior Leaders and Medical Staff Providers need to examine together real experiences that constitutes their current attitudes and behaviors when they interact with each other. Determining functional relationships is about being in sync and aligned with clear roles and agreed on expectations.
The board of trustees are responsible for discussing the following:
First and foremost the board of trustees must require accountability of itself, hospital senior management and medical staff leadership. In doing so, working together as business partners modeling direct, honest and open communications, establishes the beginning of new rules of engagement, which starts with individual accountability, which shifts the organization to the desired culture.
Reality check – If health care organizations are going to succeed in their current environment it will require board members and their CEOs to reassess their understanding of the board’s accountability to its community; its governance model; its strategic plan; its responsibilities for clinical quality; patient safety, finances, patient, physician and employee satisfaction and its ability to assess the recommendations and performance of executive management.
Never before has there been more of an emphasis placed on Trustees leadership skills, business acumen, risk management, collaboration, diplomacy and the ability to think and act proactively.
Health care organizations are staggering from regulations to reimbursement, medical treatment advances to an aging population.
How should boards approach their responsibilities today with the relentless fast moving stream of changes?
How do you find out if their board and its members are being held accountable for their role responsibilities?
Best practice strongly suggests annually conducting an Individual Board Member Performance Self-Assessment.
It is essential for the board to take a timeout each year to think about and rate their own performance. This self assessment is not about the performance of the CEO or the management team. The purpose is to evaluate the board’s satisfaction with aspects of its performance and to be candid on the areas needing improvement.
The objectives are twofold:
Self Assessment questions range from 15 – 20 questions with a rating scale #1 Disagree, #5 agree #10 strongly agree. Each question includes, “How can we improve?”
Each trustee independently and anonymously rates the board’s performance on the set of questions, i.e., “Our board has developed trustee performance expectations that are shared with new candidates and used annually as part of the ongoing performance assessment and reappointment.”
Effective boards take the time and expend the effort to ensure each trustee has a clear understanding of their role and responsibilities and understands the performance expectation the board has of them. Having informed, engaged trustees committed to continuous learning and performance improvement is essential to the board’s effectiveness.
Board members must be responsible for making a contribution and for their own behavior – being on time, coming prepared, asking good questions and engaging in constructive discussions and decision making. It only takes a single director’s dysfunctional behavior to undermine the entire board’s ability to work together and do good work.