Better information for the board

Healthcare managers are making quicker, riskier decisions in an increasingly competitive and regulated environment. Questions have been raised regarding the accountability and performance of boards of these organizations, as board members are not always selected based on their competencies to guide such decisions. Adapting mission and strategy and monitoring organizational performance require information that boards get mostly from management. The purpose of this study was to examine the information that boards regularly get to carry out their functions. I obtained board documents from four not-for-profit hospitals and health systems in different boroughs of New York City. At each institution, I conducted one-hour interviews with at least three board members and three top managers. I also attended at least one board or executive committee meeting and one additional meeting, usually of the finance committee. Principal findings were that the boards get too much data, the same data that management gets, and little comparative data on performance of similar benchmarked organizations. Board members and managers are satisfied with the information that board members get and have no plans to improve their system of shaping, or the quality of, information. Key recommendations to boards and managers are: (1) boards must take greater responsibility for identifying the information that they get and how they wish to get it, (2) managers must ensure that measurable objectives are developed, against which organizational performance can be evaluated, (3) boards must get information that is targeted and shaped to better fit board functions, (4) managers must develop information sets for main service lines, (5) boards must get information on the expectations and satisfaction levels of key stakeholders, (6) boards must get better and more focused information on performance of benchmarked institutions, and (7) boards must get less hospital operating data on a monthly basis.     

Rural‐Urban Differences in Consumer Governance at Community Health Centers

Context: Community health centers (CHCs) are primary care clinics that serve mostly low‐income patients in rural and urban areas. They are required to be governed by a consumer majority. What little is known about the structure and function of these boards in practice suggests that CHC boards in rural areas may look and act differently from CHC boards in urban areas. Purpose: To identify differences in the structure and function of consumer governance at CHCs in rural and urban areas. Methods: Semistructured telephone interviews were conducted with 30 CHC board members from 14 different states. Questions focused on board members’ perceptions of board composition and the role of consumers on the board. Findings: CHCs in rural areas are more likely to have representative boards, are better able to convey confidence in the organization, and are better able to assess community needs than CHCs in urban areas. However, CHCs in rural areas often have problems achieving objective decision‐making, and they may have fewer means for objectively evaluating quality of care due to the lack of patient board member anonymity. Conclusions: Consumer governance is implemented differently in rural and urban communities, and the advantages and disadvantages in each setting are unique.     

Trust, commitment key to board/CEO relations

Hospital chief executive officers who set long-term strategy and business goals, communicate openly and honestly with their boards and work in partnership with their medical staffs are meeting the key expectations of trustees. Within these parameters lies the formula for successful board/CEO relations, hospital board chairmen say.     

Consumer-based boards of health centers: structural problems in achieving effective control

The fact that consumers have problems in utilizing their formal power as board members is usually attributed to individual deficiencies or cultural differences. The position argued here is that such views need to be questioned and amended. Thus, the ties between a health center and the larger health care system, the relations of consumers to their community environments, and the internal organization of health centers are examined as structural factors which limit the effectiveness of consumer board members.Despite the magnitude and durability of such factors, suggestions are made for increasing the effectiveness of consumer-based boards.     

Selecting consumers for neighborhood health center boards

During the winter of 1978, a study of board members of 13 neighborhood health centers was conducted in which consumers were found to have parity of influence with non-consumers. Organized group sponsorship and backing of consumers, rather than their election or appointment, were partially responsible for this parity. Despite literature reports that organized group backing would increase the chances of "vested interest" conflicts on the board, consumers who were affiliated with organized groups were not found to be more competitive than those who were not thus affiliated. In contrast, nonconsumers with organized group backing did have a tendency to feel competitive on their boards.     

Board engagement in quality: findings of a survey of hospital and system leaders

Hospital governing boards assume an important role in improving delivery of quality care in the hospital. More knowledge about the prevalence and impact of particular board activities can help them perform this role more effectively. This study draws from a survey of hospital and system leaders (presidents/chief executive officers [CEOs]) that was conducted in the first six months of 2006 with a total of 562 respondents. The survey contained 27 questions on various aspects of board engagement in quality. More than 80 percent of the responding CEOs indicated that their governing boards establish strategic goals for quality improvement, use quality dashboards to track performance, and follow up on corrective actions related to adverse events. The adoption of other practices was reported less frequently. Only 61 percent of the respondents indicated that their governing boards have a quality committee. The existence of a board quality committee was associated with higher likelihoods of adopting various oversight practices and lower mortality rates for six common medical conditions measured by the Agency for Healthcare Research and Quality's Inpatient Quality Indicators and the State Inpatient Databases. Hospital governing boards appear to be actively engaged in quality oversight, particularly through use of internal data and national benchmarks to monitor the quality performance of their organizations. Having a board quality committee can significantly enhance the board's oversight function. Other potentially useful activities-such as board involvement in setting the agenda for the discussion on quality, inclusion of the quality measures in the CEO's performance evaluation, and improvement of quality literacy of board members-are currently performed infrequently.     

For bondholders, limited access to executives often raises red flag

When a hospital's bondholders hear that their facility is struggling financially, they want information. When a facility's chief executive officer doesn't let them talk to decisionmakers, such as board members and the medical staff chief, they feel like they're being denied information. This can come back to haunt the hospital that has to sell more debt in the future.     

The health planning process: are consumers really in control?

This study of the governing board of a Health Systems Agency tends to support those who argue that a numerical majority of consumers does not guarantee consumer control of the decision-making process. Empirical support stems from the fact that consumers, relative to providers, appeared to be at a decided disadvantage in three areas: 1. Consumers see themselves as experiencing greater communication problems. 2. Consumers are more likely to perceive their knowledge as being inadequate. 3. Consumers are more likely to feel intimidated by other governing board members. The consumers' disadvantages in these three areas likely diminish the amount of influence they hold. Indeed, both provider and consumer board members felt consumers held less than one-fourth of the influence on the governing board. Although consumers wanted more influence they did not desire majority control. Staff was seen as exerting most of the influence within the HSA.     

Healthcare and physician leadership

At a recent social policy conference - Recovering Together? Fiscal Pressures, Federalism and Social Policy, hosted by Queen's International Institute on Social Policy - there was much discussion of "healthcare's crowding out" of others of the determinants of health, education and income security being the predominant examples. I was struck by the loose language, four words/phrases in particular, used to describe reality - healthcare, system, single-payer and publicly funded. Physicians are increasingly moving beyond their already-demanding clinical roles to become chief executive officers (CEOs), chiefs of staff, clinical leaders, board members, deans and directors. Is this a good thing, and should physician leadership be encouraged? Or as Ron Liepert (2009, August), minister of Alberta Health and Wellness, asserts, are physicians better at diagnosing and treating people than running $8 billion organizations?     

Human resources execs making strides

Hospital human resources executives are making more money and more of them are reporting directly to chief executive officers, according to a recent study by an executive search firm. Both trends are seen as an indication that hospitals are placing greater importance on the human resources function and are considering human resources executives to be members of their senior management teams.     

Die Rollen der Vorstandsmitglieder in einem Universitätsklinikum

Demographic changes and medical progress in combination with vastly altered regulatory and economic environments have forced considerable change in the structure of German university hospitals in recent years. These changes have affected medical care as well as research and medical school training. To allow for more flexibility and a higher level of reactivity to the changing environment German university hospitals were transferred from state agencies to independent corporate structures. All but one remains wholly owned by the respective state governments. The governing structure of these independent medical hospitals consists of an executive board, generally made up of a medical director, a financial director, a director for nursing, and the dean of the medical faculty. In most hospitals, the medical director serves as chief executive officer. The regulations governing the composition and responsibility of the members of the executive board differ from state to state. These differences do affect to some degree the interactive effectiveness of the members of the executive boards. Modalities that stress the overall responsibility for all board members seem to work better than those that define clear portfolio limits. Even more than organizational and regulatory differences, the effectiveness of the work of the executive boards is influenced by the personality of the board members themselves. Success appears to be a clear function of the willingness of all members to work together.     

Governance in non-for-profit hospitals: Effects of board members’ remuneration and expertise on CEO compensation

Although hospitals vary in terms of their governance structures, little research has focused on the effectiveness of these governance mechanisms through the study of executive contracting. Using a sample of 80 non-for-profit private hospitals in the Netherlands, I investigate whether differences in governance structures of hospitals are informative for explaining the variations in chief executive pay. After controlling for important economic determinants of CEO compensation in hospitals (i.e., type and size of the hospital, CEO type and job complexity, market conditions and performance attributes), the results suggest that CEOs on average earn more (1) when the hospital's supervisory board members receive more remuneration (a higher absolute as well as an excessive remuneration) and (2) when supervisory board members have a lower level of expertise. The findings suggest that supervisory boards are more effective in controlling agency problems (i.e., aligning CEO pay to economic conditions) when their members have more expertise, but at the same time that the monitoring function is hampered when supervisory board members receive a large (excessive) remuneration.     

Acquisition and allocation of human, financial, and physical resources in the health care system

Based on the current financial status and forthcoming changes in the health care system, governing boards give chief executive officers the responsibility to manage human, financial, and physical resources. The role and degree of involvement of chief executive officers in managing resources--the resource allocation process, retention and recruitment, technology adaptation, reimbursement, and expansion of the outpatient program--are illustrated in this article. A new strategy for diverting resources to tap into the outpatient market is the appropriate direction to choose during days when the economy is down and people are not seeking inpatient treatment as in the past. Reimbursement in the future will depend on customer satisfaction scores; therefore, a dedicated and loyal staff is the most important resource for any service organization.     

Determinants of consumer influence in a health systems agency.

An 18-month study of consumer participation and influence in a Health Systems Agency (HSA) found consumer board members to be less influential than provider board members in agency decision-making. In an effort to investigate causes of the influence deficit experienced by consumer HSA board members three issues were studied: staff attitudes toward consumer participation; board member degree of representative accountability; and board member attitudes concerning commitment to consumer participation, commitment to health planning, health services attitude, and feelings of social powerlessness. Results indicated that staff members were favorable toward the concept of consumer participation. They recognized a lack of low-income minority participation, but they did not provide support or allocate resources to enhance consumers' ability to participate. Providers were less committed to consumer participation, felt more socially powerful, and had greater representative accountability than did consumers. Several strategies for increasing consumer influence in HSA decision-making processes are proposed.     

Hospital executives' pay beginning to raise eyebrows

The average base salary for hospital chief executive officers rose 9.7% this year to $150,800, according to a survey conducted by Hay Management Consultants and Modern Healthcare. That's down from the 10.9% increase last year, but is still considered high. As hospital executives' pay continues to rise, board members, community leaders and the local press are beginning to ask whether hospitals are getting their money's worth.     

Building better boards in the new era of accountability

Healthcare boards are entering a new era of heightened accountability, scrutiny, and reform. Sarbanes-Oxley legislation, Internal Revenue Service scrutiny, pressure from creditors and bond insurers, activist state attorneys general, media attention, and other forces have sharply increased awareness of the importance of governance and have also raised the bar on what is required of boards and what is considered best-practice governance performance. Yet good governance cannot be legislated. The structure, composition, and specific required functions of boards can be legislated or mandated, but the effective function of boards cannot. At the same time that governance faces this new era of accountability, it is also being bombarded with the legions of monumental challenges in the tumultuous healthcare field. Chief executive officers and their boards must be willing to recognize the challenges and risks to the field of governance in general and to their boards in particular. Furthermore, they must be willing to implement new strategies and approaches for successful governance, including becoming compliant with Sarbanes-Oxley requirements; conducting a comprehensive audit of the structure, function, composition, and culture of the board; and seeking board members from outside the community, among many others.     

The challenge of contributing to policy making in primary care: the gendered experiences and strategies of nurses

This paper explores nurses’ experiences as members of primary care organisations set up to develop and commission health services for local communities. Nurses, alongside GPs and other health professionals, were given a place on the governing bodies (boards) of Local Health Groups – a move widely welcomed by the nursing profession as long overdue recognition of the important contribution nurses and nursing could bring to the policy arena. Nurse board members faced a number of challenges in their attempts to contribute to and influence local health policy. This ethnographic study (which involved non‐participant observation of 33 board meetings and interviews with 29 board members including nurses) suggests that medical authority and control, and hierarchical power relations between doctors and nurses on the board, were seen by nurses as significant obstacles to their participation in this new policy arena. In response to their perceived lack of power and subordinate status, nurses employed a number of strategies to negotiate their participation as board members – these included ‘getting it right’, ‘achieving the right balance’, ‘self‐presentation’ and ‘unassertiveness’. These strategies reflected and reproduced gendered identities and relations of power and raise important questions regarding the influence of nurses and nursing within policy making.     

Measuring the quality of chiropractic alternative care in a managed care environment

Today's health care environment is more consumer driven with regard to quality issues, and consumers want open access to alternative care, which includes chiropractic care. Given the growing demand for quality, the majority of the top health care plans are requiring their providers to participate in a credentialing process and an on-site office review. These standards allow managed care organizations to make an informed, objective decision regarding the network selection process of chiropractic providers.     

Consumer participation in health policy decisions: empowerment or puffery?

Many consumers in today's society have increased access to information about health and medical care through books, videotapes, audiotapes, the Internet, and television programming. However, consumers often are excluded from involvement in health policy decision making because it is believed that they do not have the necessary expertise. In this paper, the following will be discussed: (1) the historic role of consumer involvement in health policy decision making, (2) an overview of major barriers that consumers have encountered in health policy decision making, and (3) strategies for overcoming these barriers so that consumer empowerment can be enhanced when they serve on health policy panels.     

The impact of training on consumer participation in the delivery of health services.

A retrospective evaluation of training provided to six hospital consumer advisory groups is described. The training program was designed to provide information and decision-making skills to consumers of services and community representatives serving on voluntary hospital advisory boards. The evaluation, initiated after the end of the training program, demonstrates different effects of training depending on the stage of development of the consumer board. All but one of the six boards studied showed positive changes in the number and type of activities following training.