As boards navigate between today's fragmented, volume-focused health care system and one that is becoming more integrated and value-driven, there are plenty of issues that keep trustees up at night. Earlier this year, leaders from the AHA's Center for Healthcare Governance talked with 37 board members, executives and clinical leaders from four different organizations and convened a national panel of experts to learn about "governance in the gap."

Board members and leaders from Rutland (Vt.) Regional Medical Center, Beatrice (Neb.) Community Hospital and Health Center, Fairview Health Services in Minneapolis and Presbyterian Healthcare Services in Albuquerque, N.M., talked candidly about critical governance and leadership challenges and how boards are evolving to guide their organizations through the transformational changes now under way. Panel members distilled key learnings from the interviews and added perspective. Among the findings:

Organizational Challenges: Financial stress and continued viability were common themes as organizations struggle to understand the "alchemy of doing more with less" while delivering greater value higher quality at lower cost. Panel members encouraged boards to move their hospitals and systems beyond an organizationally focused mission to embrace accountability for the health of their communities. They also discussed the role of community boards in health care systems with multilevel governance structures. New models of governance likely will be needed, they said, because competencies required to govern the system as a whole may differ from those needed on the boards of hospitals and other system entities. Boards, executives and physicians need to ask themselves the fundamental question: What type of organization are we operating and what does this mean for governance?

Goverance in transition: Boards must transform the way they govern to successfully lead their organizations through transformative times. Trustee selection is becoming more sophisticated, as boards expand their diversity and competencies. Boards need members who: can think strategically; are comfortable with uncertainty and ambiguity; have led complex organizations in challenging times; participate in political advocacy; question and challenge; are continuous learners; and support innovation and risk-taking. Board members will spend more meeting time in active discussion vs. listening to reports. Committees will work harder to vet and tee up issues for the full board. Technology will assist boards and leaders to continue the dialogue between meetings. Transformative times also call for frequent self-reflection. Boards should ask themselves: If we didn't exist, what might be different? At the end of the day, have we improved the health of our community?

The complete study report will be distributed to the field in December. Findings will be presented in articles, at CHG symposia and through other channels in 2013. Watch for more information about this study at, in Trustee magazine and in other CHG publications and resources to learn about how health care boards are transforming themselves to guide their organizations through the challenges ahead.

John R. Combes, M.D., president and COO of AHA's Center for Healthcare Governance, can be reached at


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