Category: Board of Directors

Mission Focused Board Leadership


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:

  • Personality, chemistry and style of the CEO.
  • Having a climate of openness, clear and consistent communications.
  • Adherence to well-defined roles and agreed on performance expectations between the Board Chair and CEO and vice-versa.
  • Collaborating the right issues in the right way at the right time.
  • Ensure that nothing is undiscussable in the boardroom.

Characteristics of an Effective Board Chair

  • Effective communicator, consensus builder, respectable in conflict management and encourages dialogue and participation from all board members.
  • Governance work gets done at meetings. How well the meetings are planned and conducted has a huge impact on a board’s performance and achievement.
  • The most important determinants of board meeting effectiveness and efficiency is the chair’s knowledge/skills in the areas of agenda planning and meeting process facilitation.
  • Ensuring everyone has an opportunity to weigh in and no one dominates or bullies is critical for sound decision making.
  • The most effective chairs are characterized by vigorous discussion, deliberation and debate; encouraged by engaged, active, thoughtful and prepared participation.

Governance Committee

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:

  1. Determine and validate the do-ability of the chair’s roles and responsibilities to the board and to senior management [bylaws are usually vague],
  2. Set 24-month goal and objectives for the next chair,
  3. Determine the desired attributes, personality traits, skills and experience that are essential and
  4. Take to and discuss with the full board and CEO for their approval.

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.

Is Your Board Chair the Right Person?

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.  

Being Accountable Starts With Board Members

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:

  1. Enable the board to reflect on its overall performance during the past 12 months and identify area of strength and areas needing improvement.
  2. Develop action plans to continue the board’s educational development and improvement in its governance style.

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.

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