Case Study Library

Case Study Library August 2005 : 0-0

Infrastructure for Board Accountability: Governance Structures and Processes for a Community Hospital

Sandra Kearns, David Vigar and Katherine Scimmi


Healthcare organizations in Canada have board structures and processes in place to guide and direct decision-making. Responsibilities of governing and managing the affairs of a healthcare organization have been in the forefront of Ontario Hospitals with the introduction of Bill 8, The Commitment to the Future of Medicare Act, 2003.

In light of the rapid and significant change that has been imposed on healthcare, the structures and processes for effective governance from 20 years ago do not meet the needs of the trustee today. This article reflects the structure and processes that Bluewater Health in Sarnia, Ontario has adopted during its restructuring, to ensure public accountability.

Bluewater Health is a multisite community hospital located in southwestern Ontario, serving a population of 110,000. Over the past five+ years, Bluewater Health has undergone significant change. Changes that have impacted the organization include:

  • Downsizing and reduction of duplication of services across the original three sites (Sarnia General Hospital, St. Joseph's Health Centre located in Sarnia and Charlotte Eleanor Englehart Hospital in Petrolia, Ontario);
  • Creation of a three-site alliance of hospitals following Health Services Restructuring Commission directives, which created the new "Lambton Hospitals Group";
  • St. Joseph's Health Centre leaving health care delivery and selling assets to the Sarnia General Hospital in 2003;
  • Amalgamation of the three hospitals into one organization, creating the new Bluewater Health organization in 2003.

The outcome of these changes at the governance level has led to a board originally comprised of 48 in 1999, representing three distinct organizations, to be reduced to 15. The Bluewater Health Board of Trustees has built a framework to ensure that the community voice is heard, and that the membership truly reflects the community it serves.

Being Accountable

Accountability to the residents of Lambton County and the city of Sarnia has been a principle focus of the board of Bluewater Health and the previous boards. As the board emerged from the restructuring processes, it felt it needed to reinforce activities of public accountability such as maintaining a "community represented board," while being congruent with the overall organization's purpose of delivery of quality healthcare. The Bluewater Health Board felt they needed to review the way they governed, if they were to be accountable for guiding the hospital into the future. Hundert and Crawford (2002) reflect this concept of not adapting to the change required to meet the governance needs of hospital leaders today (Hundert and Crawford 2002). The review led to the development of structures and processes to ensure that the community's needs remained a focus. The outcome has been the development of the "External Advisory and Accountability Structure" in place today, which acknowledges the board's continuous support for strong community involvement.

The Structure

The Framework Infrastructure: Having the Right People at the Table

The framework that supports community involvement in governance is depicted in Figure 1.

Figure 1. Concept of accountability structure and sources of community representation at Bluewater Health

The structure is based on the continuous process of reinvention of the board through ongoing membership renewal and restructuring, based on the skill set inventory needs. The accountability to the community is continually reinforced through the ongoing education of our trustees and their role as acting as the voice of the community.

The Community Advisory Panel

External Advisors

The Community Advisory Panel was formed in 2002 to act as an advisory group to the board on community issues. The Community Advisory Panel is noted as having the following responsibilities:

  • Be an advisory group to the Board of Trustees;
  • Be broadly representative of the community served;
  • Provide Bluewater Health with input from the surrounding community on matters of common interest and concern;
  • Provide input on rural stakeholder needs and perspectives.

The process of selection of the Community Advisory Panel membership has been delegated to an external facilitator, to ensure a non-biased approach. Delegates are sorted based on the interest or area of expertise that the applicant possesses (see Figure 2). The Executive Committee of the board selects the Community Advisory Panel membership based on the skill, need and demographic area required to be filled on the panel. Names of individuals are hidden until selection is complete. Appointment terms are three years. In addition to serving in an "advisory" capacity to the board, the panel is also used as an initial base for potential Community Committee Board members. Issues that have been reviewed at the Community Advisory Panel include:

  • Visiting hour restrictions due to SARS - Community Advisory Panel assisted in identifying approaches to advise the community;
  • Modifications to in hospital signage to improve "way finding";
  • Made recommendations on hospital information brochures;
  • Provide insight and comment on the new hospital development and design.
Figure 2. Community interest areas sought for Community Advisory Panel

• Business
• Tourism
• Clergy
• Homemaker
• Medical
• Labour
• Arts
• Environmental professional
• Municipal
• Retired professionals social agency
• Emergency personnel
• Education
• First Nations
• Demographic area

Involving Lambton County in Board Decisions: Membership on Committees of the Board

Having a Voice

The original purpose of the external representation on the Board committees came as an opportunity to allow those board members from the previous boards to remain involved in healthcare governance. A maximum of three seats per board committee were reserved for "community" members, in addition to the committee of the board representatives. Community members are not on the board, but participate in all board committee activities, and are included in all board education and development sessions and strategic planning exercises.

This process has added value and benefit to the board committees. Following the initial placement of "previous" board members, the structure has evolved to incorporating "Community Committee Membership" into the bylaws as a foundation to ensure the community voice remains strong.

Membership as a community member on the board committees has also served to provide the Board's Nominating Committee a useful source for potential board members. Community Committee members receive the same orientation as new board members and are exposed to board processes. The committees of the board perform the important groundwork for the board to make decisions and future direction setting. This exposure allows the Community Committee member to have undergone an important education process relating to the hospital's operation of services and programs from a board member's perspective. Being a Board member is very demanding. The potential member is able to determine if they have an interest in this type of community volunteerism. Participation as Community Committee member allows for gaining an understanding of the complexity of the health system as well as the time commitment required. They come committed and prepared for board work and have a sound knowledge of the underlying committee structure that supports the board, should they wish to move up to the board.

Committee of the Board: Speaking Back to the Community

Monthly reports to the community are made in a variety of formats, including a publication titled "Board Highlights" that is posted on the web site. Quarterly reports are shared with our community through the newspaper publication "The Pulse," which outlines special stories on programs and services, and current issues that may impact healthcare provision in our community.

Figure 3. Performance measures for accountability

• CEO evaluation
• Annual board self-assessment
• Annual attendance review
• Annual review of education attendance and community committee member
• Completion of annual "Open House" for community recruitment
• Attendance of all prospective Advisory Panel of Community Committee members at "Orientation"
• Completion of review of strategic plan on annual basis
• % compliance with monthly communication reports to community by publication of "Board Highlights"
• % of open board meetings
• % of time spent "in-camera" on issues (expressed as a rate in relation to total time for board meetings)

Effective measurements provide the board with information in a clear, timely and meaningful format. Performance measurement does not only involve financial and clinical outcomes but must also measure board performance. Through regular review of performance, the Bluewater Health Board is able to continually reassess its ability to meet its accountability goals. Figure 3 outlines the strategies and measures used for evaluation by the board. These types of measures ensure focus on accountability is evident.

All board committee meetings are open to the public and press. Closed meetings are held at a minimum and must meet specific criteria (Figure 4). The amount of time spent on "closed" or "in-camera" issues is tracked to ensure the board is continuously aware of the time devoted to these types of sessions.

The Process

To maintain the strong structure and community focus, the process of recruitment is open and transparent, with board member involvement annually.

Figure 4. Criteria for in-camera board session

• Intimate, personal or financial information in respect of a patient, an employee, member of the medical/ professional staff, or board/community or Advisory Panel member
• Litigation related issues or legal proceedings
• Acquisition of disposal of real estate
• Human resource related issues
• Instructions from professional advisors such as lawyers, architects, etc.


Recruitment, orientation and evidencebased education are the primary process elements for ongoing board development. Recruitment strategies, succession planning and identification of required skills are an ongoing process, reviewed by the Nominating Committee on a quarterly basis. The current board has found that the past practice of meeting annually for the important function of recruitment and selection of board members has not allowed for continued focus on accountability.

Figure 5. Skill inventory list

• Municipal experience
• Small business owner
• Government
• Rural
• Legal expertise
• Human resources
• Public relations
• Financial background
• Corporate executive
• Non-profit company

To ensure that Bluewater Health reaches out to the community and hard-to-reach areas of the county, a variety of processes are used to recruit potential board members, Community Advisory Panel members and Community Committee members. Advertisements in all local newspapers through the county are placed annually. Board personal interactions are encouraged, to bring forward names of potential candidates. Some organizations have deferred this practice to professional recruiters. A conscious decision was made by the board to maintain a community-focused effort at recruitment, rather than a recruitment agency (Brunelle and Steven 2004). The board maintains an inventory skill profile of the member. This profile is then used to maintain an inventory skill list (Figure 5), enabling easy identification of areas of expertise that may be required. The profile covers areas such as:

  • Areas of expertise;
  • Special interests;
  • Background and experience.

An information evening and social gathering, including all board members and potential candidates, is held following the closure of receipt of applications for Committee or Community Advisory Panel membership. This allows the candidate an opportunity to review their respective roles and responsibilities and to gain an overview of the Bluewater Health organization. As noted previously, the Community Advisory Panel is recruited by an external facilitator, but is included in this information session following selection. The potential candidates need to be impressed with the information session to consider becoming involved in your organization. Make the effort to have all senior administration team members and board members present.

Orientation and Board Development

Orientation is held annually and is mandatory for all board, Community Committee and Advisory Panel members as orientation content changes annually. It is an expectation that all board members (both new and current) attend. Development of the members is progressive, with education an ongoing expectation. Measurement and review of outcomes of accomplishments form the basis for topics for future development and education sessions.

The Outcome

The Bluewater Health Board is focused and listening to the community and the clients served. Accountability to the public is mandatory in a publicly funded system such as healthcare. Throughout this article, we have identified the structures and processes that have shaped our "accountability" structure. There is no magic formula for involving the community in decision-making. Effective board leadership will be the bridge to ensure that accountability to the public and the community served is evident. Bluewater Health stays in close touch with its community through its board.

About the Author(s)

Sandra "Sam" Kearns, RN, BHA, MHA is Vice-President Corporate Development/Medical Affairs for Bluewater Health, Sarnia, Ontario.

David Vigar is President and CEO of Bluewater Health.

Katherine Scimmi is Chair of the Board of Trustees of Bluewater Health.

Correspondence should be directed to: S. Kearns, Bluewater Health, 89 Norman Street, Sarnia Ontario N7T 6S3. Email: Tel: (519) 464-4464, Fax: (519) 336-8780


Brunelle, F. and S. Leo. 2004. "Volunteer Trustees: Professional Recruited?" Law & Governance Legal Focus on Healthcare & Insurance. Longwoods Publishing.

Hundert, M. and R. Crawford. 2002. "Issues in the Governance of Canadian Hospitals, Part 1: Structure and Process." Hospital Quarterly 6(1): 63-66.


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