Healthcare Issues & Trends

Advice & Insights for healthcare's Leaders & HR Professionals

Competency Based Governance

Posted on February 25, 2016 by James A. Rice, Ph.D., FACHE

Community leaders who step up to serve on local health sector governing bodies need an increasingly wide array of competencies to be effective. The competency profile also varies between boards that oversee hospitals compared to Accountable Care Organizations (ACOs), County Health Boards, Federally Qualified Health Centers (FQHCs) or Academic Medical Centers. 

For hospitals, the Center for Healthcare Governance of the American Hospital Association has published a study that defines a comprehensive set of competencies.[1] This study identified two sets of trustee core competencies for board members of hospitals and health systems.

Knowledge and Skills

• Health Care Delivery and Performance

• Business and Finance

• Human Resources


The AHA panel recommended that all boards, regardless of the type of hospital or system they govern, should include some members with these knowledge and skills competencies. The panel further recommended that the competencies included in the list below should be sought in all board members.

Personal Capabilities

• Accountability

• Achievement Orientation

• Change Leadership

• Collaboration

• Community Orientation

• Information Seeking

• Innovative Thinking

• Complexity Management

• Organizational Awareness

• Professionalism

• Relationship Building

• Strategic Orientation

• Talent Development

• Team Leadership

Are the trustees of tomorrow ready to deliver these competencies? As trustees are expected both to oversee the performance of management and play a key role in population health management strategy planning and implementation, what makes them competent to do all of this?

The corporate failures of the last decade also are reshaping traditional perspectives on what it means to govern well. It is now clear that the boards of many failed organizations were composed of very

Knowledgeable, capable individuals who were unable or unwilling to prevent these disasters. This

Realization, and a growing body of research linking effective board and organizational performance, are

Motivating us to look beyond traditional notions of board composition or structure as the keys to good governance to also examine board culture and what makes boards work together as effective teams.[2]

In the past, we could point to lists of university degrees, professional designations and previous employment experiences on the prospective director’s resumé. However, in the uncharted waters of population health management and accountable care, traditional credentials are only part of the answer.

What types of competencies are needed to govern organizations dealing with gains in community health, not just gains in health service volume growth? Perhaps we should look at the profiles of those serving in the population health governing bodies in England, Canada and Europe?

In England, their National Health Service (NHS) has called for a new generation of board leaders with diverse competencies.[3] In overseeing the population health performance, board members need to deliver such competencies as: Quality assurance and clinical governance; Financial Stewardship;  Risk Management; influencing legislative action and regulations;  group decision-making; and also corporate policy making and oversight. 

In Europe there is a call for stronger background in epidemiology and systems thinking.[4] As the US becomes more racially diverse, ethnic and cultural awareness must also be factored into our competency profiles.[5]  In the population health orientation of Canada, we see four key competencies (alignment, efficiency, effectiveness, and ethics) are needed to govern across diverse community health organizations.[6] They ask for:

Alignment: To plan and oversee strategy, boards need to be able to work as a team and to do this they must be aligned both with their mandate as a board and with each other as members of a functioning unit. Equally, there must be team alignment between the board and management – two teams pulling together toward a common set of strategic objectives.

Efficiency: Self-management of the board as a working unit is important. The board’s annual mandate and work-plan need to be managed efficiently so that all duties are discharged, and in a timely fashion. As well, meetings must be run smoothly and professionally allowing all opinions to be heard and decisions made within the time allotted. Further, since senior hospital administrators provide essential information, reports, analyses and judgments, which take considerable time and effort, boards must use the valuable management asset wisely. Extracting value from management should not exhaust them.

Effectiveness: A board may be able to get through its meeting agenda in a timely fashion, but it might make poor strategic and operational decisions in the process. Effective boards achieve their desired outcomes, not just by being efficient, but also by coming to conclusions that lead to decisions of good quality. Among other things, a board is responsible for the oversight of innovations in patient care, optimizing capital expenditures and enhancing the hospital’s reputation in the community. But there is a gradation of quality in performing these mandated functions. Good governance means not just fulfilling the board mandate, but also doing it at a high level.

Ethical management: Hospitals are social enterprises whose purpose has inherent moral worth. Still, as functioning organizations they must not only embody moral principles of promoting good health and curing the sick, but also plan strategies and operationalize them in terms of institutional policies and procedures that ensure ethical conduct, such as codes of ethics, workplace health and safety, anti-harassment, whistleblowing, etc. Equally, the board must visibly exhibit an exemplary tone at the top as individuals.

So how ready are our US health system boards for new competencies? What can our boards do to recruit and develop trustees and directors that have, and can continuously enhance these type competencies?




[1] Center for Healthcare Governance and Health Research & Educational Trust, see:

[2]Sonnenfeld, Jeffrey A. “What Makes Great Boards Great.” Harvard Business Review September 1, 2002: 106-113 and McDonagh, Kathryn J. The Changing Face of Healthcare Boards.” Frontiers of Health Services Management Vol. 21, No. 3: 31-35 (2005)

[3] See:

[4] See:


[6] See Dr. Scott Carson “Governance and Strategy: Four Tests of Competency” in Boards, Centre for Excellence in Governance, Ontario Hospital Association, November 2013, page 6

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5 Virtues for Frontline Leaders

Posted on February 10, 2016 by James A. Rice, Ph.D., FACHE


How can Hospital and Ministry of Health Leaders from SE Asia master new approaches to leadership and management? To address this question, The US Embassy Singapore developed a two week program involving faculty from the Singapore public hospital system, SingHealth, and USAID supported health sector managers from the US. Bob Stevens, CEO of Ridgeview Medical Center and I conducted four workshops in this program. Twenty-three participants from the health sectors of Philippines, Thailand, Vietnam, Myanmar, Laos and Cambodia were encouraged to avoid common vices of ineffective leaders such as the inability to take risks, and the failure to engage and listen to diverse stakeholders. Effective frontline leaders should embrace the flip-side of such vices by striving to accomplish these five virtues:

Virtue 1: Engage Diverse Stakeholders

Stakeholders have a right and need to understand and guide the good work of clinicians and community health workers to deliver health services that are not only of good clinical quality, but that also satisfy patients, are cost effective and contribute to stronger communities and nations. Smart leaders provide sincere invitations for eclectic and diverse groups of people to engage in important decision-making processes.  

Virtue 2: Ask Smart Questions

Experienced leaders know how to ask smart questions that seek to probe the real meaning of the essential characteristics of a situation, challenge, problem or opportunity. These questions are asked not just of close confidants of the leader, but of diverse stakeholders and especially the most vulnerable and disenfranchised of the organization’s service population.

Virtue 3: Listen to Stakeholder Insights and Advice:

Effective leaders must also listen carefully to the answers and insights gained from the question asking process. Many leaders are not good at listening.

Virtue 4: Take Sensible Risks:

Effective leaders are willing to take sensible risks to overcome obstacles, to yield innovation and to create conditions for health workers and managers in which they can explore new methods and processes for accomplishing their goals and plans.

Virtue 5: Provide Recognition & Rewards:

Great leaders create “celebration cultures” in which health workers, staff and stakeholders believe their ideas, insights and initiatives are needed, welcomed and valued. Smart leaders provide recognition and rewards for participants in their organization’s pursuit of service improvements. These leaders also recognize that sustainable rewards are often more than just money.

To expand your effectiveness, we hope you will avoid the vices and embrace the virtues outlined in this blog.

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Governing in the Context of Health: a global perspective

Posted on January 26, 2016 by James A. Rice, Ph.D., FACHE


In the North America and Europe,  tax-exempt hospitals have benefited from boards composed of community leaders who generally volunteer their time and expertise to enhance the performance of one of their community’s largest employers and essential contributors to the health and well being of the community and its employers

That is not the case in many low and middle income countries in Asia, Latin America and Africa. To explore our prior work to develop good governance practices in Africa, we include a series of blogs here that provide insights into the challenges faced by these hospital governing boards. The first resource is a web based educational program being used by health systems managers and board members in Asia, Latin America and Africa

You can Learn “Governing in the Context of Health” in Eight Hours in a new USAID Unveiled Governance and Health eLearning Certificate Program. To register for the program click here.

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Can Health System Boards Learn from University Boards?

Posted on January 13, 2016 by James A. Rice, Ph.D., FACHE

In a recent landmark report from the National Commission of College and University Board Governance,[1]   we find seven important recommendations to enhance the effectiveness of good board work. As we explore these seven imperatives, consider how they can also stimulate health systems’ boards to raise the bar on their own performance in the changing situations for hospitals and health services delivery

  1. Boards must improve value in their institutions and lead a restoration of public trust in higher education (aka hospital care).
  2. Boards must add value to institutional leadership and decision making by focusing on their essential role as institutional fiduciaries.
  3. Boards must act to ensure the long-term sustainability of their institutions by addressing changes finances and the imperative to deliver a high-quality education (aka health care) at lower cost
  4. Boards must improve shared governance within their institutions through attention to board-president relationships and a reinvigoration of faculty (aka medical staff) shared governance.
  5. Boards must improve their own capacity and functionality through increased attention to the qualifications and recruitment of members, board orientation, committee composition, and removal of members for cause.
  6. Boards must focus their time on issues of greatest consequence to the institution by reducing time spent reviewing routine reports and redirecting attention to cross-cutting and strategic issues not addressed elsewhere.
  7. Boards must hold themselves accountable for their own performance by modeling the same behaviors and performance they expect from others in their institutions.

Perhaps our health systems’ board members should meet periodically with their university board colleagues to share ideas about how best to leverage the time and talents of community leaders for stronger board work for stronger organizational performance?


[1] “Consequential Boards: Adding Value Where it Matters Most,” Association of Governing Boards , of Colleges and Universities, Washington DC 2014

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People Strategy: Board Oversight of C-Suite Development

Posted on October 30, 2015 by James A. Rice, Ph.D., FACHE

A new Board Chairperson asked the CEO of a mid-sized health system... "I see we have invested a lot to establish a new IT plan; a master facilities plan; and a record-setting capital plan.  Where is our 'People Plan'?  What are our strategies to invest to enhance the pride and performance of the human assets that represent almost 60% of our operating budget, and impact 100% of our success in quality and operational efficencies... our people?"

A good question.  A question not being asked enough, nor talked about enough in the boardrooms of our nation's leading hospital and health systems.  

Successful health care organizations can only improve and sustain their performance if they raise the bar on their talent management strategies.  Enhancing talent management will not flourish unless it receives more serious attention in the boardroom and C-suite offices.  Such attention is more likely if CEOs and senior HR executives are invited into the boardroom to engage Board leaders in broader and deeper "critical conversations"about these issues:

  • The current shortages of mission-critical health professionals in medicine, nursing, and many other technician jobs;
  • The large portion of our health professionals that will be retiring over the next 5-10 years;
  • The long lead-time needed to attract in new clinical and leadership talent;
  • The lack of clear investments to ensure our people (medical staff, employees, and managers) are able to practice in a culture that is patent centered, performance driven, and values based.
  • We too often lack "The Long View" about sensible and structured ten year strategies for:
  • Nursing and allied health professional recruitment and development;
  • Medical staff recruitment and development;
  • Physician leadership development;
  • Modern web-based employee support systems;
  • Executive and middle manager succession and career planning;
  • The link between HR capital and capital for facilities, medical technologies, and IT; and
  • The business case for more sophisticated talent management.
Boards need to be more effective, enthusiastic, and engaged in setting the strategic framework for the development and deployment of their organization's human capital.  This enhanced sophistication can only happen, and be sustained, if CEOs and senior HR executives step up now to move their "People Strategy" onto the Board's radar screen.

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