Lawrence D. Prybil

Size, Composition, and Culture of High-Performing Hospital Boards

At the national, state, and community levels of American society, there is a growing cry for more accountability and better performance by the governing boards of business firms, institutions of higher learning, and health care organizations. A recently completed study has examined selected aspects of governance in a set of high-performing nonprofit hospitals versus hospitals that are similar in several respects but whose performance is midrange. This article discusses the findings with respect to the boards’ size, composition, and culture.

Engaging nurses in governing hospitals and health systems.

DRAMATIC DEVELOPMENTS are taking place in the healthcare field. There is alarm at the national, state, and local levels about the persistent increase in healthcare costs and a growing consensus that this pattern is unsustainable. At the same time, a series of landmark reports by the Institute of Medicine and other organizations have demonstrated clearly that the overall quality of patient care provided by our nation’s hospitals and health systems is uneven and needs to be improved.1,2 The public’s awareness of nationwide problems with respect to access, cost, and quality of healthcare services is growing. With that awareness is coming the dissatisfaction with healthcare providers and a growing public demand for change. These developments—in concert with highly visible governance breakdowns in both investor-owned and nonprofit organizations and closer governmental scrutiny—have led to a spotlight being placed on the boards that govern our nation’s hospitals and health systems. Across the country, there is a growing call for more accountability, greater

Nursing involvement in hospital governance.

NURSES comprise a large proportion of the hospital workforce, and the centrality of nursing in determining the overall quality of patient care is unarguable. Hospitals and their patients depend on nurses around the clock every day. Landmark reports by the Institute of Medicine in 19991 and 20012, by the Commonwealth Fund in 20043, and by other groups have identified serious quality issues in our nation’s hospitals. The National Quality Forum, the Institute for Healthcare Improvement, and other prominent healthcare organizations have urged hospital boards to reach out and engage clinical leaders in developing goals and strategies for improving the quality of patient care. Improving communications with clinicians—physicians and nurses—and strengthening their level of engagement in quality improvement initiatives can take many forms. One approach is to engage clinicians by involving them on governing boards and board committees. Hospital boards establish institutional goals, set institutional policies,

Board Oversight of Patient Care Quality in Community Health Systems

In hospitals and health systems, ensuring that standards for the quality of patient care are established and continuous improvement processes are in place are among the board’s most fundamental responsibilities. A recent survey has examined governance oversight of patient care quality at 123 nonprofit community health systems and compared their practices with current benchmarks of good governance. The findings show that 88% of the boards have established standing committees on patient quality and safety, nearly all chief executive officers’ performance expectations now include targets related to patient quality and safety, and 96% of the boards regularly receive formal written reports regarding their organizations’ performance in relation to quality measures and standards. However, there continue to be gaps between present reality and current benchmarks of good governance in several areas. These gaps are somewhat greater for independent systems than for those affiliated with a larger parent organization.

Board Oversight of Community Benefit: An Ethical Imperative

Board oversight of community benefit responsibility in tax-exempt organizations in the nonprofit health care sector is attracting considerable attention. Scrutiny by the IRS and other official bodies has led to stricter measures of compliance with the community benefit standard. But stricter compliance does not sufficiently engage the underlying ethical imperative for boards to provide effective oversight—an imperative that recent research suggests has not been sufficiently honored. This analysis considers why there is a distinctively ethical imperative for board oversight, the organizational nature of the imperative involved, and practical ways to fulfill its obligations. We adopt an organizational ethics paradigm to illuminate the constituent components of the ethical imperative and to clarify emerging benchmarks as flexible guidelines. As these emerging benchmarks enhance board oversight of community benefit they also can shed light on what it means to be a virtuous organization.