Expert answer:Response to Discussion Post U9R18034TH
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Provide substantive comments to the posts of at least one of your peers,
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Your response must be a minimum of 200 words in length. Include at least two
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Critically Evaluate Information on Governance
After reading the article, I have found that I would be able to make a decision
based on Sara finding. I think that it is great to use the six dimensions of
contextual, educational, interpersonal, analytical, political and strategic to come
up with a great board. Sometimes you may have to incorporate some other
things to see if they are a good fit for the company. As well as have the
companies best interest in mind.
The next step I would say to Sara is set the interviews up and put her process to
plan. Come up with a great board that has all the qualifications and has some
back ground in the organization, whether they went to school or have worked in
the field before.
References
CHAPTER 8: LOOK IT UP
Sara Mody, with an introduction by Anthony R. Kovner
Introduction
Sara Mody, a first-year graduate student at NYU/Wagner, wrote the following piece to help
graduate students in healthcare management follow an evidence-based approach. I asked her to
imagine she was an administrative fellow of a large health system assigned to research “hospital
governance”—a topic with which I was already familiar. My secondary motive was to validate
that I had a good handle on the information surrounding the subject.
What might a CEO do after reading the one-page presentation on hospital governance that Sara
prepared (presented at the end of this chapter)? The CEO might do nothing, or she might ask
Sara to go back and find additional evidence in the literature or from other sources on the issues.
As an example of how a CEO might push an issue further, let’s focus on a topic the memo raises:
the value of setting measurable objectives. Let’s assume the hospital board does not set
measurable objectives, share them with key stakeholders, report quarterly on attainment of
objectives, or regularly change objectives or strategies as circumstances change. This notion is
mine, not Sara’s, although she does provide evidence supporting the value of measureable
objectives, obtained from literature on effective hospital boards:
• •The board monitors the financial health of the organization. It establishes financial objectives,
ensures financial planning, requires strong financial performance, and invests prudently.
• •The board handles executive human resource issues, including recruitment, the establishment of
performance expectations, salary determination, and termination.
• •The board measures performance (including its own performance), evaluating both financial and
quality indicators.
If the CEO were to use this information to begin a consideration of governance practices, Sara’s
concise presentation would be considered successful.
Although not part of the assignment, the memo does not demonstrate how the CEO, and
presumably the board chair, would implement a change in board culture. This process is
discussed extensively in research literature and documented experience. Cultural change is a
difficult and risky undertaking that the CEO and board chair may not wish to pursue. If they do
pursue it, they should do everything they can to execute the task successfully.
Anthony R. Kovner
Look It Up
As an administrative fellow, I am asked to participate in a variety of projects and data collection
activities around the hospital. Most recently, I was asked to evaluate our hospital board’s
performance. Administration knew the board was not operating to its potential and asked me to
find out what we could do to make the board more effective.
Our board is made up of intelligent self-starters who generally pay little attention to hospital
affairs outside of board meetings. Many of its elderly members received board appointment
because they were friends of an effective chair several years ago, while others were invited to
join the board because they were substantial donors to the hospital. Telling them they were doing
a bad job without furnishing evidence would have made them immediately defensive. Moreover,
they were not necessarily doing a bad job; rather, they were doing a job different from the one
administration expected. Specifically, the board and administration disagreed on what the board
was doing and how it was using its role.
Using the evidence-based approach to address this question allows a hospital’s administration to
take opinions and feelings out of the equation. If the administration’s position is that it needs to
ask more of the board, it will need evidence to support it. More important, the administration
must convince the board of the need for change. Evidence that high-performing boards have a
positive effect on their organizations’ overall performance will help the board understand the
benefits of change. Evidence also will enable the hospital and board to establish measurable,
shared objectives, without which there is no accountability. Ultimately, the board should
understand the issue is not someone “thinking” the board is ineffective; instead, both the board
and administration must know the board could be more effective.
Given the number of other projects I was working on, I could not dedicate more than 40 hours to
finding an answer to this situation. I planned to spend about half a day framing the question and
discussing the final research question(s) with the CEO, one day researching, two days evaluating
the research, and one day organizing the applicable research for further use.
Day One: Framing the Question
Before I could begin my research, I needed to figure out what the hospital administration meant
by “effective.” If the board had the wrong people (e.g., they didn’t have the desired expertise,
conflicts of interest existed, they were poor leaders) or the wrong structure (e.g., there were too
many or too few members, the meeting format didn’t work, the hospital leadership and board
didn’t communicate well), it would no doubt be ineffective. Even with the ideal people and
correct structure, the board could still be considered ineffective if members did not have a clear
understanding of their role. Before addressing people or structure, I needed to define board
objectives. People and structure, although important, can be addressed in the implementation
phase of the change initiative.
While meeting to discuss my definition of the research question, the CEO and I added another
element: finding evidence to support measurement of board performance. This addition raised
two questions: Is good board performance a criterion for effective operation? If so, what should
an organization use to measure board performance?
We also decided that, in the interest of time, we should use only the most recent research. We
determined that articles published between 2000 and 2007 would suffice. Useful older articles
would be cited in the more recent articles.
Day Two: Finding Sources of Information
I started my search with Google Scholar. I entered the search criteria “hospital + board +
composition,” which returned 40,800 hits. The search criteria “hospital + board + governance +
best practice” returned 19,200 hits. My final search of “hospital + board + governance” returned
23,500 hits. Unfortunately, while I had thousands of possible articles, none of the search criteria
quickly led me to what I needed.
Search Tips: Google Scholar works well—sometimes. I found that the search engine usually will
give you what you need in the first 20 articles returned. Google Scholar’s “Advanced Scholar
Search” limits the number of relevant hits in many cases, since you can specify publication, date,
and subject area in addition to the normal key word and phrase specifics.
I then searched another large database of journal articles, PubMed.
Search Tips: If you are unsure which academic journals publish articles on the topic you are
interested in, a database of journals can guide you. Again, you can sort the results by date of
publication. When you select an article or abstract, PubMed has a useful “Related Links” feature
that displays a listing of similar articles.
I searched for “hospital board” (1,036 hits) and “board relations” (1,843 hits).
The first search proved to be the most useful. Since I was interested in only the most recent
academic research, I sorted the hits by publication date. A recent article in the Journal of
Healthcare Managementtitled “Hospital Governing Boards: A Study of Their Effectiveness in
Relation to Organizational Performance” was tenth in my list of search results. I could not have
asked for a more relevant article. The Related Links feature offered 103 similar articles, of which
34 were published after 2000. From title alone I determined that some were not relevant, but in
the end, I had 12 articles to review more closely—a much more manageable number than the
original 40,800.
Now that I had found the potentially relevant journal articles, I looked to see what the major
research organizations might offer. I browsed the websites of the Center for Health Management
Research, the Advisory Board Company, the Canadian Health Services Research Foundation
(CHSRF), the Governance Institute, and the Health Research and Educational Trust. CHSRF’s
site returned 287 hits when I searched for “governance”; however, none of the articles appeared
applicable. The Advisory Board’s site had some potentially relevant articles, but membership
was required to access the most promising ones. The Governance Institute and Health Research
and Educational Trust sites were most helpful; both supplied some useful sources.
Days Three and Four: Evaluating the Evidence
Pfeffer and Sutton (2006) could not have put it better—when looking at research, you need to
determine the difference between “hard facts, dangerous half-truths, and total nonsense.” As I
began reviewing the articles, I noticed that I had a mix of empirical studies, qualitative studies,
and anecdotal advice. I had to determine what reliable evidence looked like. The best way to
explain the difference between “good” evidence and “better” evidence is to walk through an
evaluation of two journal articles. Both articles came from trustworthy healthcare journals, which
shows you cannot rely on journal name alone to provide solid, actionable evidence.
The Good Evidence
In spring 2005, a journal published by the American College of Healthcare Executives, Frontiers
of Health Services Management, ran an article by E. George Middleton, Jr. (2005), titled
“Priority Issues for Hospital Boards.” The author is a board member of a successful hospital
system in Virginia. The title of the paper suggested it would contain exactly what I needed to
know. At first glance, the article appeared reliable and relevant.
Middleton explains the most important functions for a hospital board and provides
recommendations for implementation. He identifies issues such as member qualification, board
structure, quality, and compliance as key focus areas, supporting each topic with compelling
arguments. While there is nothing inherently wrong with the priorities he listed, there is also
nothing obviously right about them, either. The author did not perform quantitative or qualitative
research. In fact, Middleton supports his suggestions with only one reference in the entire tenpage article. Instead, he bases his comments on personal experience, insights, and opinions. As
much value as they may have, without supporting evidence, I was reluctant to put much stock in
what might be “dangerous half-truths.”
The Better Evidence
As mentioned earlier, the Journal of Healthcare Management had published an article regarding
a board’s impact on hospital effectiveness. The article begins with a summary of the changes
governing boards have experienced in recent years. After reviewing the current literature, the
author, Kathryn J. McDonagh (2006), concludes that two questions remain unanswered: Do
boards really make a difference? How can boards improve hospital performance?
To pursue these two inquiries, the author framed the following research questions: Are the six
competency factors in the BSAQ (Board Self-Assessment Questionnaire) tool widely used in
nonprofit organizations similar to those used in nonprofit hospitals? Do better-performing boards
result in better-performing hospitals? (The BSAQ has been tested extensively and is widely
considered reliable. It measures board performance along six dimensions: contextual,
educational, interpersonal, analytical, political, and strategic.) McDonagh collected data using
convenience sampling over a four-month period. One hundred fifty-one CEOs and other
organizational leaders from 64 hospitals around the country responded, yielding a 13 percent
response rate. McDonagh based hospital performance on Solucient’s 100 Top Hospitals
program, a ranking system frequently used in other studies.
The author describes in detail the statistical techniques she used to evaluate the data. Factor
analyses supported the common thought that successful boards work as cohesive teams. Singlefactor findings drew attention away from the usual “keys” to board success—size, composition,
and term limits—and brought it toward the idea of boards as social systems.
Most important, the research showed that high-performing boards were more likely to be leading
better-performing hospitals, particularly in terms of profitability and expense management.
Higher-performing boards also showed lower BSAQ scores on the “political” dimension, which
means they focus on relationships with key stakeholders, without letting politics get in the way.
The article concludes with the author’s recommendations for applying the findings. The paper
clearly displays findings and statistical correlations in easy-to-understand tables. A strong
sample, reliable statistical analysis, applicable findings, and clear presentation led me to consider
the results of this study “hard facts.”
The Evidence: Bottom Line
The caution in relying heavily on Middleton’s article lies in the lack of support for his assertions.
While his recommendations may be correct, they may appear less convincing to board members,
who might believe they could just as easily find a paper written by someone with opposing
views. Evidence should support legitimate initiatives, not lead the group into a battle of opinions.
I found McDonagh’s strong evidence noteworthy, but I found the general recommendations for
board objectives lacking. For instance, the evidence supports the need for boards’ building strong
relationships with key stakeholders, but does not clearly define who should be included in the
“key stakeholder” mix. More in-depth research could be performed on each of the general
recommendations to clarify them.
While a continued literature review would have been useful, I decided to try to access additional
information through other sources. For example, the hospital executives could get input from
their contacts on high-performing boards in noncompeting areas or other hospitals within the
system. Or the hospital could establish a partnership with a local university to obtain the advice
of an academic expert on board relations. Literature provides quick access to information, but if
time allows, personal interviews and informal conversations may provide a deeper
understanding.
Day Five: Organizing and Presenting Findings
Ultimately, I used seven articles from my PubMed search, one article from the Governance
Institute, and one from the Health Research and Educational Trust. After picking my final
sources, I needed to find an easy way to present the information to the CEO. Given the value of
her time, I put together a one-page guide to the research. The guide walked the reader through
common board perceptions, two models of governance, board objectives, and key takeaways.
In addition, I created an annotated bibliography that grouped my sources into two categories—
empirical studies and qualitative studies (see the Appendix to this chapter). I intended for the
bibliography to lead the administrators and board members through the research methodology
and key findings for each source cited in the guide.
During my presentation to the CEO, I walked her through the one-page brief and recommended
the following:
• •First, I emphasized the importance of identifying a board champion to help lead the change
initiative. The board champion would give key stakeholders a voice and involve them in the
change process.
• •I recommended contracting an outside consultant to facilitate the process. The consultant could
help guide the board and administration and ensure that the new structure aligned with the
hospital’s mission and vision.
• •The hospital would also need an easy way to monitor the board’s performance once goals were
established. I proposed the services of a nonprofit organization called BoardSource
(www.boardsource.org), which has a multitude of electronic tools for this purpose.
• •Last, I suggested recruiting board members with a history of participation in successful boards.
Conclusion
Upon reflection, a few other important points come to mind. Setting the research question
remains a crucial step to producing an end product that people will use. I have a tendency to get
ahead of myself and jump right into the research process. I didn’t fully understand the value of
discussing the question with the CEO until later, when I started digging through hundreds of
articles. The question kept me focused on the end purpose of my research.
This assignment also helped me realize the importance of setting research standards. When is
research too old to be relevant? Can the research question be sufficiently answered on qualitative
evidence alone? What qualifies as good evidence? Deciding beforehand what I thought the end
users would consider reliable evidence helped me manage the research process, and I quickly
learned to differentiate between good advice and untested recommendations.
Finally, I concluded that it was not important to produce a lengthy document to demonstrate how
much research I had done. Instead, I chose quality over quantity. A handful of reliable sources
will prove more useful than a plethora of opinions and hearsay.
Appendix
Do Effective Boards Lead to Better Performing Hospitals? Yes.
Editor’s Note: This appendix is an example of the research one could put together for an
administrator. This shows research does not have to be an overwhelming amount of information.
Presenting information succinctly makes the research manageable and actionable.
Common Board Views
Surveyed board members did not believe governing board performance strongly correlated to
hospital financial performance. In order from most to least important, they ranked market
conditions, clinical expertise, and CEO performance above board performance (McDonagh
2006).
Types of Governance Models
•Philanthropic Characteristics: emphasis on community participation, due process, and
stewardship
• •Corporate Characteristics: emphasis on strategy development, risk taking, and competitive
positioning
• •Research (Alexander and Lee 2006):
o •Philanthropic-style boards are more likely to close their hospitals under conditions of low
organizational performance
o •Hospitals governed by corporate-style boards are more likely to be more efficient, have
higher admissions, and possess a greater market share
•
Philanthrop …
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