Changes in the structure, composition, and activity of hospital governing boards, 1989-1997: evidence from two national surveys

Governance structures and practices in for-profit and not-for profit hospitals in Egypt

BACKGROUND

Governance is a system that ensures and promotes accountability and responsibility toward stakeholders. The present study aims to compare the governance structures and practices in for-profit and non-for profit hospitals in Alexandria, Egypt.

METHODS

The study is a descriptive cross sectional study in which Chief Executive officers (CEOs) in all hospitals in Alexandria Governorate were interviewed. A predesigned questionnaire was used in the interview that is composed of four section. The first section explored characteristics of study hospitals. The second section assessed the composition and the characteristics of boards. The third section assessed the functions of the board and the fourth section assessed boards' training and evaluation.

RESULTS

A centralized board existed in the Health Insurance, Ministry of Health and Population and University hospitals. As for private hospitals, board existed in only 72 hospitals (82.75 %). Almost all boards have CEO duality. Board members were as few as two members in some boards and up to twenty members in others. Some hospital boards did not have an orientation manual or program.

CONCLUSION

A proportion of study hospitals does not have a governing board. For the hospitals with governing boards, there were wide variation in governance structures and practices.

Effective Governance and Hospital Boards Revisited: Reflections on 25 Years of Research

This study reviews and synthesizes empirical research literature focusing on the relationship between boards of directors and organizational effectiveness of U.S. hospitals. The study examines literature published in scholarly journals during the period of 1991-2017. Fifty-one empirical articles were identified that met the study's inclusion criteria. A framework from the corporate governance and nonprofit governance literature is used to classify the articles according to level of analysis (individual actors, governing bodies, organizations, and networks, alliances and multiorganizational initiatives) and focus of research (formal structure and behavioral dynamics-including informal structures and processes). Results are discussed, emerging trends are identified, and recommendations are made for future research.

Trends in governance structure and activities among not-for-profit U.S. hospitals: 2009-2015

BACKGROUND

In U.S. hospitals, boards of directors (BODs) have numerous governance responsibilities including overseeing hospital activities and guiding strategic decisions. BODs can help hospitals adapt to changes in their markets including those stemming from a shift from fee-for-service to value-based purchasing. The recent increase in market turbulence for hospitals has brought renewed attention to the work of BODs.

PURPOSE

The aim of the study was to examine trends in hospital BOD structure and activities and determine whether these changes are commensurate with approaches designed to respond to market pressures.

METHODOLOGY/APPROACH

We examined hospital level data from The Governance Institute Survey (2009, 2011, 2013, and 2015) and corresponding years of the American Hospital Association Annual Survey in a pooled, cross-sectional design. We conducted individual multivariate models with adjustments for hospital and market characteristics, comparing the changes in BOD structures, demographics, and activities over time.

FINDINGS

The sample included 1,811 hospital-year observations, including 682 unique facilities. We found that BODs in 2015 had less internal management (β = -2.25, p < .001) and fewer employed and nonemployed physicians (β = -8.28, p < .001) involved on the BOD. Moreover, compared to 2009, racial and ethnic minorities (2013 β = 2.88, p < .001) and women (2013 β = 1.60, p = .045; 2015 β = 2.06, p = .049) on BODs increased over time. In addition, BODs were significantly less likely to spend time on the following activities in 2015, as compared to 2009: discussing strategy and setting policy (β = -5.46, p = .002); receiving reports from management, board committees, and subsidiaries (β = -29.04, p < .001); and educating board members (β = -4.21, p < .001). Finally, BODs had no changes in the type of committees reported over time.

PRACTICE IMPLICATIONS

Our results indicate that hospital BODs deploy various strategies to adapt to current market trends. Hospital decision-makers should be aware of the potential effects of board structure on organization's position in the changing health care market.

Hospital ownership, decisions on supervisory board characteristics, and financial performance

BACKGROUND

Dynamic and complex transformations in the hospital market increase the relevance of good corporate governance. However, hospital performance and the characteristics of supervisory boards differ depending on ownership. The question therefore arises whether hospital owners can influence performance by addressing supervisory board characteristics.

PURPOSE

The objective of this study is to explain differences in the financial performance of hospitals with regard to ownership by studying the size and composition of supervisory boards.

METHODOLOGY

The AMADEUS database was used to collect information on hospital financial performance in 2009 and 2010. Business and quality reports, hospital websites, and data from health insurer were used to obtain information on hospital and board characteristics. The resulting sample consisted of 175 German hospital corporations. We utilized ANOVA and regression analysis to test a mediation hypothesis that investigated whether decisions regarding board size and composition were associated with financial performance and could explain performance differences.

FINDINGS

Financial performance and board size and composition depend on ownership. An increase in board size and greater politician participation were negatively associated with all five tested measures of financial performance. Furthermore, an increase in physician participation was positively associated with one dimension of financial performance, whereas one negative relationship was identified for nurse and economist participation. For clerics, no associations were found.

PRACTICE IMPLICATIONS

Decisions concerning board size and composition are important as they relate to hospital financial performance. We contribute to existing research by showing that, in addition to board size and physician participation, the participation of other professionals can also influence financial performance.

Review of the corporate and healthcare governance literature

The governance and effectiveness of the healthcare sector is paramount due to its impact on human well-being and the size of this sector of the economy. Astute governments and healthcare boards need to know how to improve the governance of the sector. Therefore, this review draws together the theoretical and empirical literature from both the corporate and healthcare governance literature to determine the state of knowledge that can confidently guide those who either perform board roles as directors or who create governance structures. It concludes by suggesting that further theoretical work and research are necessary, and that the focus of both needs to be broader to take into account the complexity of the sector.

Review of the corporate and healthcare governance literature

The governance and effectiveness of the healthcare sector is paramount due to its impact on human well-being and the size of this sector of the economy. Astute governments and healthcare boards need to know how to improve the governance of the sector. Therefore, this review draws together the theoretical and empirical literature from both the corporate and healthcare governance literature to determine the state of knowledge that can confidently guide those who either perform board roles as directors or who create governance structures. It concludes by suggesting that further theoretical work and research are necessary, and that the focus of both needs to be broader to take into account the complexity of the sector.

Towards a framework for enhancing the performance of NHS boards: a synthesis of the evidence about board governance, board effectiveness and board development

Background

There is a need to reduce the variation in organisational performance across the NHS for which boards hold ultimate responsibility. By exploring how boards can add value, we hope that this research will benefit patients and improve service efficiency and effectiveness.

Objectives

We know that there are knowledge gaps in relation to the composition and characteristics of effective boards in the NHS, their impact and the range of tools and techniques available for developing effective boards. This realist synthesis study, therefore, aims to add to existing knowledge by (1) providing a theoretical contribution to board governance and relating it to the NHS context, (2) offering fresh insights into effective board composition, structures, processes and behaviours in the NHS, (3) furthering an understanding of how NHS boards can affect organisational performance and (4) summarising and analysing the range of board assessment tools and development interventions available for the NHS.

Method

The study adopted a realist approach to an evidence synthesis of a diffuse literature. In line with realist review principles, we tested, honed and refined the research questions and emerging findings with a joint expert advisory and stakeholder group of 23 people. A search was conducted across relevant library and external sources including ABI/INFORM® (ProQuest, Ann Arbor, MI, USA), SciVerse® ScienceDirect® (Elsevier, Amsterdam, the Netherlands), MEDLINE, EMBASE and the Social Science Research Network, from 1968 to 2011. A total of 618 general articles, 209 health-care-related articles, 252 textbooks and 54 reports were identified.

Results

Frameworks that have developed from theory and from practice were categorised into the three elements of composition (board structure), focus (what the board does) and dynamics (the behavioural dimension), and the potential conjunction between board theories and practices was explored. We found some important distinguishing characteristics in the public, non-profit and health-care sectors. In relation to the impact of boards on organisational performance, the importance of contingency factors was highlighted and there is positive empirical support for the role of physicians on the board. Other than self-reports, we could not find any significant studies on the impact of board development on board effectiveness.

Limitations

The study is dependent on the diverse nature of the sources of evidence and the relative infancy of the realist synthesis method. The literature is fragmented, equivocal and, at times, contradictory. We believe, nevertheless, that the study offers insights in terms of developing middle-range theories for effective health-care boards.

Conclusions

We found no simple theory about how boards should operate. The use of certain models for boards may be more appropriate than others, depending on what the priority is in terms of organisation outcome. We have identified some important distinguishing characteristics in the public and non-profit sectors. On the whole, evidence lends some further support for a theory about the dynamics of an effective board in relation to high challenge, high trust and high engagement, modified in the light of our developing understanding about the linkages between different contexts and desired outcomes. We identified five areas in which board development approaches should be more focused. We suggest three main areas for further research: the composition of NHS boards, the conditions under which health-care boards are able to exert a sustained focus on clinical quality and an evaluation of the impact of board development activities on organisational performance.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Hospital boards and hospital strategic focus: the impact of board involvement in strategic decision making

BACKGROUND

Despite pressures to change the role of hospital boards, hospitals have made few changes in board composition or director selection criteria. Hospital boards have often continued to operate in their traditional roles as either "monitors" or "advisors." More attention to the direct involvement of hospital boards in the strategic decision-making process of the organizations they serve, the timing and circumstances under which board involvement occurs, and the board composition that enhances their abilities to participate fully is needed.

PURPOSES

We investigated the relationship between broader expertise among hospital board members, board involvement in the stages of strategic decision making, and the hospital's strategic focus.

METHODOLOGY/APPROACH

We surveyed top management team members of 72 nonacademic hospitals to explore the participation of critical stakeholder groups such as the board of directors in the strategic decision-making process. We used hierarchical regression analysis to explore our hypotheses that there is a relationship between both the nature and involvement of the board and the hospital's strategic orientation.

FINDINGS

Hospitals with broader expertise on their boards reported an external focus. For some of their externally-oriented goals, hospitals also reported that their boards were involved earlier in the stages of decision making.

PRACTICE IMPLICATIONS

In light of the complex and dynamic environment of hospitals today, those charged with developing hospital boards should match the variety in the external issues that the hospital faces with more variety in board makeup. By developing a board with greater breadth of expertise, the hospital responds to its complex environment by absorbing that complexity, enabling a greater potential for sensemaking and learning. Rather than acting only as monitors and advisors, boards impact their hospitals' strategic focus through their participation in the strategic decision-making process.

Describing local boards of health: insights from the 2008 National Association of Local Boards of Health Survey

OBJECTIVES

We examined findings from the 2008 National Association of Local Boards of Health Survey to provide information about this understudied entity to the public health community.

METHODS

The survey instrument consisted of 196 items covering five parts: (1) demographics; (2) composition and organizational structure; (3) roles, responsibilities, and authorities; (4) telecommunications infrastructure; and (5) concerns and needs. The survey was sent to chairs of local boards of health (LBHs) in 2008 (n = 3,276). After six months of follow-ups and reminders, and a month of data cleaning and screening, the final sample consisted of 870 respondents, for a return rate of 27%.

RESULTS

LBHs tend to represent smaller communities and are primarily appointed. Governing and policy-making boards are more prevalent than advisory boards. Most boards do not have official websites or e-mail addresses of board members available to the public; however, most report the capability to receive training via webcasts. Boards express concerns and needs in a variety of areas, particularly public health law, strategic planning, and accreditation.

CONCLUSIONS

Little is known about the more than 3,000 LBHs across the United States that are often charged with making and enforcing public health law. This article is a first step toward providing the public health community with information about LBHs based on survey data.

Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challenges

Concern about the quality and safety of health care persists, 10 years after the 1999 Institute of Medicine report To Err is Human. Despite growing awareness of quality and safety risks, and significant efforts to improve, progress is difficult to measure. Hospital leaders, including boards and medical staffs, are accountable to improve care, yet they often address this duty independently. Shared responsibility for quality and patient safety improvement presents unique challenges and unprecedented opportunities for boards and medical staffs. To capitalize on the pressure to improve, both groups may benefit from a better understanding of their synergistic potential. Boards should be educated about the quality of care provided in their institutions and about the challenges of valid measurement and accurate reporting. Boards strengthen their quality oversight capacity by recruiting physicians for vacant board seats. Medical staff members strengthen their role as hospital leaders when they understand the unique duties of the governing board. A quality improvement strategy rooted in synergistic efforts by the board and the medical staff may offer the greatest potential for safer care. Such a mutually advantageous approach requires a clear appreciation of roles and responsibilities and respect for differences. In this article, we review these responsibilities, describe opportunities for boards and medical staffs to collaborate as leaders, and offer recommendations for how boards and medical staff members can address the challenges of shared responsibility for quality of care.

An exploration of policy options to assist district health authorities in attending to the health needs of African Canadians: a case study

Purpose

The purpose of this paper is to examine the governing boards responsible for health care in Nova Scotia to determine the extent to which they facilitate and/or impede efforts to attend to the health needs of African Canadians.

Design/methodology/approach

A case study method was employed. Qualitative interview and documentary data were interpreted by means of a hybrid of methods including discourse analysis, thematic analysis, reflexive ethnography and ethnography.

Findings

Key findings from this study suggest that the complex mandate of DHAs, a lack of processes to assess need and limited data (including a lack of research) to support decision‐making contribute to a limited understanding of the health needs of African Canadians among DHA board members and executive management. Policy options include improving access to, and development of, culturally competent health services, conducting research and improving access to data to facilitate decision‐making, and educating board members and executive management about black culture. DHAs need to explore new and innovative ways to engage and include the black community in decision‐making.

Practical implications

Continued public and political emphasis on the maintenance of the acute care system, limited resources devoted to “population health” and internal and external constraints that serve to limit the capacity for health boards to make independent decisions pose significant challenges for DHAs as they seek to fulfill their legislated mandate to improve the health of their catchment population. Policy options are presented to address issues such as research and information management, education and awareness, representation and building meaningful opportunities for inclusion.

Originality/value

There is a dearth of literature examining the roles and responsibilities of governing boards in attending to the health needs of minority populations.

Does governance matter? Board configuration and performance in not-for-profit hospitals

As performance accountabilities, external oversight, and market competition among not-for-profit (NFP) hospitals have grown, governing boards have been given a more central leadership role. This article examines these boards' effectiveness, particularly how their configuration influenced a range of performance outcomes in NFP community hospitals. Results indicate that hospitals governed by boards using a corporate governance model, versus hospitals governed by philanthropic-style boards, were likely to be more efficient and have more admissions and a larger share of the local market. Occupancy and cash flow were generally unrelated to hospitals' governing board configuration. However, effects of governance configuration were more pronounced in freestanding and public NFP hospitals compared with system-affiliated and private NFP hospitals, respectively.

Governance, public participation and accountability: to whom are regional health authorities accountable?

The discourse of health reform has emphasized the need to increase public participation in decision-making as a way to enhance accountability. Despite recent gains in public participation in health care--primarily through citizen governance of regional health authorities--a clearly articulated accountability framework remains elusive in the Canadian context. If citizen participation is to be effective and meaningful, governing boards and politicians need to adopt an accountability framework that clearly delineates roles and responsibilities.

From Corporate Governance To Hospital Governance

As a result of multiple developments in health care and health care policy, hospital administrators, policy makers and researchers are increasingly challenged to reflect on the meaning of good hospital governance and how they can implement it in the hospital organisations. The question arises whether and to what extent governance models that have been developed within the corporate world can be valuable for these reflections. Due to the unique societal position of hospitals--which involves a large diversity of stakeholders--the claim for autonomy of various highly professional groups and the lack of clear business objectives, principles of corporate governance cannot be translated into the hospital sector without specific adjustments. However, irrespective of these contextual differences, corporate governance can provide for a comprehensive 'frame of reference', to which the hospital sector will have to give its own interpretation. A multidisciplinary research unit of the university of Leuven has taken the initiative to develop a governance model for Belgian hospitals. As part of the preliminary research work a survey has been performed among 82 hospitals of the Flemish Community on their governance structure, the composition of the governance entities, the partition of competencies and the relationship between management and medical staff.