A New Model of Governance for Improving Community Health

A New Model of Governance for Improving Community Health by Mary K. Totten Embedded in the transformation of health care delivery and payment is a bro...
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A New Model of Governance for Improving Community Health by Mary K. Totten Embedded in the transformation of health care delivery and payment is a broader focus on improving the overall health and quality of life for the communities health care organizations serve. This expanded purpose is being expressed in a number of ways, including: • health care organizations revising their mission statements to drive work that not only focuses on “delivering affordable, safe, high-quality care,” but also on “improving community health;” • clinicians applying what has been learned from caring for individual patients to improving the health of entire populations of patients with similar diseases and conditions; • health care providers and payers sharing risk for delivering the right care in the right setting at the right time to provide greater value to patients and communities; • hospitals and their clinicians taking responsibility for care and treatment delivered outside the hospital walls in a variety of community-based settings (nursing homes, home care, skilled care facilities, etc.); and

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Fall 2016 Managing Editor Mary K. Totten Senior Consultant for Content Development, AHA’s Center for Healthcare Governance Editor Dan Paloski Senior Project Specialist, AHA’s Center for Healthcare Governance

• health care organizations joining with other community partners to understand and address community health needs and factors such as lack of education, crime, poverty and other social issues that can negatively affect health status and quality of life. A recent study of partnerships that improve community health, conducted by the AHA’s Center for Healthcare Governance with generous support from The Baxter International Foundation, provides insights into partnership structure and function; mission, vision and sustainability; and governance. The Center’s study focused on community partnerships involving selected recipients of the Foster G. McGaw Prize for Excellence in Community Service (see sidebar listing study

organizations and partnership attributes on Page 2). Results of 34 interviews with hospital/health system leaders and others affiliated with study partnerships were analyzed by a Blue Ribbon Panel of partnership experts and participants to identify themes and perspectives that can be considered and adopted by others in this emerging field. The study concludes that a collaborative governance model may be a promising approach for governing a next-generation “system for health” comprised of community partners, including health care organizations, focused on achieving the broader aim of community health improvement. As one study participant said: “It seems we have two-level governance thinking. We have to change ourselves as health care organizations, but we also have to figure out how to engage community partners and empower them to carry out the important work of improving community health without us being the controllers and directors of the process. There’s always governance that exists at the health system level, but that’s not the same as governance of a broad range of community health improvement activities. The fundamental question is, should there be a true community governance model, and what would it look like?” Partnership Governance Themes The study report, Learnings on Governance from Partnerships that Improve Community Health (AHA’s Center for Healthcare Governance, 2016), discusses collaborative governance as a model that unites organizations and boards with common interests and common missions in integrated thinking, planning and doing to achieve collective impact and share accountability for outcomes that support the common good. This model, the study says, has the potential to accelerate the transformation of health care from a system of organizations working in silos to a system continued on page 2

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focused on multi-sector collaboration to improve community health and well-being. Study participants shared observations on factors that can influence the effectiveness of collaborative governance. Because partnerships themselves can be complex, sometimes involving hundreds of partner organizations and individuals working on dozens of initiatives, study participants suggested that collaborative governance should focus on achieving success through simplicity. Partnerships can benefit from adhering to a simple set of foundational

principles to guide their work and governance (see sidebar on Sample Principles for Collaborative Partnerships on Page 3). Governance structure and function in well-established organizations with enduring and focused missions, such as hospitals/health systems or other organizations that sponsor community partnerships, are likely to be different from governance of partnerships themselves. Partnership governance may need to be more fluid and flexible to engage a broad range of partners to address evolving community needs.

Study Organizations and Partnership Attributes Allegiance Health (Jackson, Mich.): a 480-bed health system serving south central Michigan since 1918, working with more than 500 partner organizations and community members on 15 collaborative initiatives. Governance Model: “Community-based Governance with Allegiance Health ‘Backbone’ Support” Crozer-Keystone Health System (Springfield, Penn.): a five-hospital system serving the five-county Delaware Valley region, working with more than 75 partner organizations and community leaders on numerous initiatives. Governance Model: “Broad Engagement with Community Boards” Henry Ford Health System (Detroit, Mich.): a system encompassing multiple hospitals and medical centers serving a tri-county area of Southeast Michigan since 1915, working with more than 200 partners on numerous initiatives. Governance Model: “Grassroots Entrepreneurialism Guided by a Strategic Pillar Focused on Community” Memorial Hospital of South Bend/Beacon Health System (South Bend, Ind.): a community-owned system including 526-bed Memorial Hospital, which has served Saint Joseph County, Ind., since 1893, working with more than 40 partners on some 30 initiatives. Governance Model: “Strategic Seeding of Innovative Community Interventions” Mt. Ascutney Hospital and Health Center (Windsor, Vt.): a 35-bed hospital and health center serving a nine-town area in Windsor County, Vt., and Sullivan County, N.H., since 1933, working with 42 community partners on 28 initiatives. Governance Model: “Community Governance with Intentional and Inclusive Representation” Palmetto Health (Columbia, S.C.): a hospital network serving Richland County and surrounding areas in the South Carolina Midlands region, working with more than 200 partners on numerous initiatives. Governance Model: “Strategic Investment and Leadership in Community-driven Health Improvement Initiatives” St. Joseph’s/Candler Health System (Savannah, Ga.): a 714-bed system serving Savannah and the Low Country district of South Carolina, working with 40 partners on more than 50 initiatives. Governance Model: “Governance Support for Mission-driven Grassroots Community Programs” 2 | Great Boards | Fall 2016

Despite the “different cultures” and “very different worlds” that community partners live in, study participants note that better understanding of the need for investment in community health partnerships and in better health outcomes results when representatives from partner organizations serve on the partnership’s policy-setting body or board or on the hospital/ health system board. Study participants said that sustainability, even in partnerships where collaboration is strong, requires determining who’s in charge and what role governance should play in partnership work. One panelist suggests that partnership governance should provide overarching coordination of partnership efforts “to study, prioritize and resource problems and then drive the work to resolve them, educate, assess, measure, improve and advocate.” Identifying competencies for governance and leadership can foster continuity and help sustain partnerships for the long-term. A variety of individual and collective competencies that can support partnership success emerged from the study. Examples of these appear in the sidebar on Page 4. Study participants say that hospital and health system governance must evolve to encompass a focus on the community. They note that “traditional” governance of hospitals and health systems already has broadened beyond a primary focus on financial oversight to include increased emphasis on patient safety, patient engagement, compliance and strategic thinking and planning. As hospital and system boards further expand their primary areas of focus to include community health improvement, study participants encourage them to engage the community and its various voices in their efforts. One study partnership, for example, has a 25-member board. Eleven seats on the board are designated for specific community resources, such as area health departments, that are considered vital to the work of the partnership. continued on page 3

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Advancing the Work The study concludes that the size and scope of hospitals and health systems uniquely positions them to advance the work of community partnerships through collaborative governance. The study report suggests that collaborative governance—defined as a model which unites organizations with common interests and missions in integrated thinking, planning and doing—is “ideal” for hospitals, health systems and their partners because it holds the potential to accelerate change by encouraging organizations with sometimes conflicting priorities to work together for the common good. Study panelists said it will likely be the governance model embraced by health care organizations and their partners as they work together to improve community health and well-being. The study report includes a series of recommendations for both hospitals and health systems and for partnerships to consider as they deepen their commitment and increase their capacity to improve community health.

Sample Principles for Collaborative Partnerships 1. Partnerships must be community-driven. Partnerships and their governance will look different from community to community and must be flexible to meet each community’s needs, resources and characteristics. 2. All stakeholders must be meaningfully engaged. All community stakeholders should be represented in determining, planning and executing on governance priorities. 3. More can be achieved together than alone. Stakeholders working together to leverage each other’s resources and talents can achieve collective outcomes beyond what any individual or organization could achieve alone. 4. Partner equity ensures sustainability. All stakeholders are considered to be equal. Anchor institutions that provide substantial financial and other support to the partnership may need to play the role of convener or facilitator and relinquish control of the agenda in order for the partnership to succeed. 5. Community health and well-being improvement is a shared core purpose. As stewards of community resources, members of the partnership’s governance structure must be committed to working together for the community’s benefit. The community’s health and well-being are the focal point for partnership work. 6. Creative approaches are needed to tackle all-encompassing problems. Partnership must be mindful of maintaining a long-term perspective, making data-driven decisions, seeking out best practices, taking calculated risks and being bold and innovative.

Recommendations for hospitals/ health systems include ensuring a governance commitment to a robust effort to improve community health. Implementing this recommendation might start with convening a board retreat to examine the organization’s current commitment and review lessons learned from the Center’s study. An outcome of such a retreat might be that the board ensures a mission commitment to improving community health and participates in finalizing and prioritizing specific strategies to address it. Health care organizations and their boards should communicate with key stakeholders about the organization’s commitment to improve community health and take action to build a “culture for health” organization-wide.

through their finance, quality or strategy committees, appointing a board community health improvement committee and developing a charter to guide its activities is one way to create a “home” for this work.

As health care organization boards expand their focus on community health improvement they may choose to reflect that focus within the board’s structure. While some boards might address community health issues

Boards also should ensure the organization participates in a community health needs assessment (CHNA) and addresses results with community partners. Hospitals and health systems should work with their community

7. A “systems approach” ensures continuity. This approach helps create a solid foundation for building and aligning integrated delivery systems for improving and maintaining community health. 8. Goals and progress reporting ensure accountability. Change requires a keen focus on results. Clear metrics; use of reporting formats such as balanced scorecards; consistent monitoring of performance; and communication regarding progress to the community all build trust and hope. 9. Governance must be structured to ensure sustainability. Partnerships that last depend on governance based on a clear mission/purpose, shared commitments among partners, adequate funding, a plan of action effectively implemented and demonstrated progress.

partners to identify and address barriers to community health improvement. Partnerships, the study recommends, can begin or strengthen their work by assessing community health-related resources that might be willing to collaborate on initiatives that meet shared goals. Such an evaluation can help determine an initial list of partners to participate in a CHNA. continued on page 4 3 | Great Boards | Fall 2016

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The Center study report and a companion document described on Page 5 are resources partnerships can use to evaluate options for their governance. Consideration should be given to creating a durable structure for the partnership; determining its mission, vision and values; and identifying ways to efficiently coordinate and resource community health improvement efforts. The study report also recommends that partnerships engage their partners in jointly creating a competency-based, multi-disciplinary community partnership board. The work of this board can include developing governance principles; establishing strategic goals for the partnership; working through committees and task forces to oversee work on goals and objectives; and developing and monitoring performance metrics to measure progress toward desired outcomes.

from their own partnership’s development. Key themes include the importance of recognizing that improving community health is a goal that cannot be accomplished by a single organization alone. While partnership and collaboration are critical to success, study participants say that partners need to arrive at a shared understanding

well-intentioned, but used to working alone; change occurs when they come to understand the value of collaboration.

Study participants advise that change also requires more than simply identifying a community need; a focus on results is critical. Other factors for partnership success include establishing an infrastructure; staffing aligned interests; Sample Competencies for Partnership stability; a shared passion for the Governance and Leadership partnership mission; and support for governance.

Individual Competencies Personal characteristics: Well-respected and trusted community leader; demonstrates integrity and humility; driven by passion, not power; inspires and influences others. Collaborative skills and behaviors: Values partnership and teamwork; strives to build consensus and cohesiveness; flexible; cooperates to address common needs; looks beyond self-interest; shares leadership with other partners to serve the best interests of the partnership. Knowledge and expertise: Able to analyze data and perceive trends; asks questions to understand root causes; thinks critically; deals with complexity effectively; seeks creative approaches to address challenges; able to think strategically and see the big picture; comfortable with uncertainty and ambiguity; contributes insight; willing to make difficult decisions based on information and evidence; understands strategic partnerships and networks.

Participants also emphasize the need for partnerships to involve the community in planning for and setting partnership priorities. As one study participant suggested: “Plans cannot be based on what the organization thinks the community needs.” Given that community partnerships and their governance continue to evolve, with many in early stages of development and sustainability, the study report also offers a readiness assessment for community partnership governance. Assessment questions address issues for both hospitals/health systems and partnerships to consider.

Study participants also recommend that partnerships and their boards adopt a commitment to continuous Collective Competencies Among Partners improvement. For boards, this commitment should Behaviors: Mission-focused; committed to respectful reinclude regular evalualationships among partners; inclusive; continually seeking tion of board performance partners who are critical to the success of the partnership. to identify and address Knowledge, skills and expertise: Experience in strategic planIssues for hospitals and opportunities for improvening and implementation; data and trend analysis expertise; health systems include ment. Partnerships also can knowledge of epidemiology and population health; experilevel of organizational benefit from continuously ence with models of community collaboration; fundraising leadership commitment refining their operations. skills; background in financial planning and management; to community health Activities might include participation in advocacy at the policy level. improvement, extent to conducting “real-time” which the organization’s assessments of emerging culture is community-focused, current community health needs; periodically of the hospital or health system’s role board and leadership engagement in reviewing the partnership’s progress; in the partnership. They also suggest the community and current level of reincorporating new partners; and that readiness and sustainability of a reviewing fund allocation to achieve coalition of partners is essential before sources devoted to community benefit and community health improvement. maximum impact. moving ahead and caution against moving forward too quickly. Challenges When a hospital, health system or Those interviewed for the study also sometimes arise, participants observe, other large community organization offer advice for other community when working with partners who are partnerships based on lessons learned

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evaluates whether to take on the role of providing anchor support for a community partnership, considerations include whether the anchor has the ability to cede control of the partnership’s agenda to other partners and “lead from behind.” Anchor organization boards and executives should have in-depth discussions about the best use of anchor resources to improve community health. Anchor organizations also need to determine their ability to provide financial, staff and other expertise to support the partnership’s work and their willingness to be accountable to priorities, not funding. The success of the partnership depends on its members having a common understanding of partnership mission and vision. Partnerships should evaluate the extent to which their partners have a shared understanding of the community’s definition of a “healthy community,” the ability to focus on partnership purpose versus individual partner self-interest and a common understanding of key partnership priorities and initiatives. Collaborative work and governance of that work require conditions that foster effective engagement among stakeholders. Questions for partnerships to consider include: Do partners understand the value of collaboration? Are their missions and purposes wellaligned? Is the level of trust among partners sufficient to put aside competitive interests and collaborate for the good of the partnership and the community? Do partners share an inclusive mindset, continually looking for and engaging new partners to advance the work? Are partner roles clearly defined? Multiple organizations and individuals working and governing together to achieve collective impact can benefit from common goals and structures that enable and empower their efforts. Setting bold targets that exceed what any one partner could accomplish alone and being accountable to goals that focus beyond the needs of a single partner to benefit the entire commu-

nity reinforce the value of working in partnership. Identifying competencies to guide selection of partnership leaders and governing body members can help foster partnership continuity and sustainability. The level of communication about partnership goals, initiatives and performance to sponsoring organizations, among partners and to the community speaks to a partnership’s commitment to transparency. In addition to evaluating factors like these, partnerships also should assess whether the benefits of a more formal governance structure may outweigh less formal approaches to governing as a partnership grows and develops. The readiness assessments also asks partnerships to consider the extent to which they reflect attributes of successful partnerships, including: collaboration; common understanding of impact; disruption of status quo; flexibility; innovation; mission-driven. Conclusion The Center’s research builds on the conclusions of other studies focused

on community health improvement. For example, the findings and recommendations of a study of 12 successful hospital-public health partnerships to improve community health (Improving Community Health through Hospital— Public Health Collaboration, Prybil, et. al, 2014) are similar to and reinforce the conclusions of the Center’s study. Studies by the Robert Wood Johnson Foundation, Institute of Medicine, the Trust for America’s Health and other organizations also are focused on supporting and strengthening work to achieve the goal of improving our nation’s health. Mary K. Totten is Senior Consultant for Content Development for AHA’s Center for Healthcare Governance. She can be reached at [email protected]. Adapted with permission from Trustee magazine from "Collaborative Governance the Key to Improving Community Health," July/August 2016 Trustee Workbook.

Additional Resources This study, Learnings on Governance from Partnerships that Improve Community Health, conducted by AHA’s Center for Healthcare Governance with generous support from the Baxter International Foundation, explores how selected Foster G. McGaw Prize for Excellence in Community Service recipients and their partners are addressing community health needs and ensuring sustainable partnership governance. To download a copy, click here.

BRP Report

A companion document to the study report, Community Partnership Profiles, provides more details on the governance, staffing, resources/funding and other aspects of the partnerships in which study organizations are involved. To download a copy, click here.

Community Partnership Profiles 5 | Great Boards | Fall 2016

Unequal Board Participation: A Threat to Good Governance? by Luanne R. Stout

“…silence is sometimes the most costly of commodities...” ― Allen Bradley, The Sweetness at the Bottom of the Pie Board self-assessment surveys often ask whether participation during meetings is roughly equal across all board members. For governance veterans, it’s no surprise that this question is frequently one of the lowest-scoring. Uneven participation among board members happens in virtually every board room across the country and can signal underlying problems with board culture and member engagement. This article, explores several reasons for unequal participation, the impact it can have on the board and organization, and potential solutions.

for everyone to have a say. Or, some members may be in over their heads and have little to contribute. There are less obvious reasons why unequal participation is becoming an increasingly challenging problem in board rooms today. Generational and cultural differences are emerging as boards begin to transition from the “leap at the chance to talk” Traditionalists and

Reasons for Unequal Board Participation There are people who like to talk and others who do not. However, most board members are selected for their leadership qualities and business success, so it seems counter-intuitive that these community leaders would be quiet individuals who rarely speak up. So, why do some of them have little to say in the board room? Some causes for this problem are obvious. For example, on some boards it’s tough to get a word in. One or two people typically chime in at every opportunity, offering their opinions on virtually every agenda item. Alternatively, the board culture may be so dominated by board or executive leadership that it is uncomfortable for anyone except the most brave to speak up. Maybe the board is large and there is insufficient time at meetings 6 | Great Boards | Fall 2016

Baby Boomers to the “wait to be called on” Generation X and Millennials. As boards strive to increase their diversity, they should become aware of changing cultural norms, especially among younger individuals. Think back on an occasion when the board chair took a moment to ask each member for his or her individual thoughts. Chances are at least one or two individuals who rarely spoke up thanked the chair for the opportunity and then offered insightful

comments. These individuals may have been waiting to be asked to contribute, and were perhaps relieved that they finally got a chance to speak. Silence is Not Golden in the Board Room There are still some governance cultures that welcome a quiet board that approves every proposal without much discussion or questioning. However, most boards work hard to seek members with the right mix of competencies, skills and attributes to create a board that serves as a valuable resource to the senior leadership team. These boards challenge assumptions and ask hard questions before approving strategies and initiatives. They also drive development of quantitative metrics and hold management accountable for performance. The most obvious impact of unequal board participation is that the board and senior leadership do not benefit at all from the competencies possessed by the silent board members. This can lead to undue emphasis on strategies and initiatives supported by those board members who routinely speak up. “Group think” may result when those who hold similar views are the ones who readily share their perspectives, while those who hold different opinions remain silent, waiting to be called on or for someone else to raise them. Lack of engagement often translates into spotty attendance and resignations from those who do not participate. When this happens, it is easy to conclude that while the individual had a promising resume, he or she just continued on page 7

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did not turn out to be a good board member. However, was that really the issue? Perhaps these board members gave up on waiting to be asked to offer their thoughts. Perhaps they got frustrated listening to the frequent flyers talk at every meeting. Perhaps the board failed to support them to become a functioning member. Let’s Get Them Talking Let’s be honest: there will always be misses in board selection—people whose resume indicated the right competencies, but who may have joined the board to enhance their own prestige or resume and who never intended to actively participate. In those situations, it is best for these individuals and the board to part company. Most board members, however, enter into board service with every intention of contributing and having a mutually rewarding experience. Therefore, boards should take steps that increase the likelihood that all members will actively participate so that the board and the organization can benefit from their competencies and expertise. Provide Orientation. Health care is widely acknowledged as one of the most complex, rapidly changing sectors of our nation’s economy. Therefore, an excellent orientation is absolutely critical for the new trustee. Governance experts suggest it takes two years on average for a new trustee to feel comfortable enough to actively participate in board meetings. The goal of a robust orientation program should be to reduce that time significantly. An exceptional orientation should address the critical issues a board member needs to understand on day one of his or her board service. Texas Health Resources utilizes a 40-page manual with a companion DVD to help new board members begin to get up to speed. We tell new board members that we expect they will participate at the first board meeting. Ongoing education for new trustees using flexible options such as resources provided through a 7 | Great Boards | Fall 2016

“Boards that benefit from all the competencies of their members likely will be most successful in today’s dynamic and demanding health care environment.” board portal, especially during the first 18 months of board service, is ideal. Appoint a Trustee Buddy/Liaison. A number of organizations have found that assigning another member of the board to serve as a “buddy” or mentor for the new trustee is invaluable. Others have a Chief Governance Officer or other internal support person serve as a liaison. These mentors or liaisons should be easily accessible to answer questions for new trustees, offer additional insights or background about issues the board is addressing, provide resources, and generally serve as a friendly face that cares about that new member’s success on the board. Set Expectations. It is important that new trustees understand they have been selected for board service based on specific competencies that are needed by the board and that they are expected to apply their competencies to board work from day one. This expectation should be included in the board job description. Setting expectations up front makes it clear that the new trustee is not just one of the crowd and helps he or she know how to succeed as a board member. It also may encourage trustees to step outside their generational or cultural norms to participate in board work and create value for the organization they are serving. Train the Chair. Board chairs can be instrumental in drawing out the quiet individuals in the room. Certainly not for every question, but periodically for the most important issues the board chair can go around the room and ask each board member to comment. There should be at least one oppor-

tunity at every board meeting to do so. For board members who may feel more comfortable being prepared, the chair can select topics for which the trustee has expertise and ask prior to the meeting if he or she would be willing to make comments. Board chairs can then ask board members to raise their hands if they want to provide feedback and first call on those who do not participate often. When a talkative trustee takes the floor, the board chair, after a reasonable time, can politely, yet firmly, move on in order to preserve time for others to speak. Conclusion All boards have members with different personalities that come from different generations and cultures, each with specific competencies needed by the board to govern effectively. Providing a robust orientation and ongoing education, appointing a mentor/ liaison, setting expectations for active participation, and training the board chair to routinely seek opinions from all board members are some strategies that can help new trustees quickly add value to board work. Boards that benefit from all the competencies of their members likely will be most successful in today’s dynamic and demanding health care environment. Luanne R. Stout is vice president/chief governance officer/corporate secretary, Texas Health Resources, Arlington, Texas. She can be reached at [email protected].

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