Insights March 2015

Closing The Board Leadership Gap

Hugh MacLeod and Tom Van Dawark

Today, Tom Van Dawark, former Board Chair of the Virginia Mason Health System, joins me on the "balcony of personal reflection." I share with Tom a story about learning, growth, change and timing. A few months ago I watched my youngest grandson learn how to ride a surfboard. What my grandson experienced and what I observed was a valuable leadership lesson on change and transformation. There are several ways to ride a wave. If you are too far ahead, the wave will crash down on you as you near the limit of its surge. If you are partially on it, you risk sliding back into the trough and being left behind. If you time it right, the wave will carry you forward. Carry forward grows with courage, discipline, conviction and a can do attitude. Set backs are viewed as educational and learning opportunities.

The Ghost of Healthcare HOPE emerges...

"The myriad of issues facing healthcare swirl around like gathering storms and waves. Healthcare’s funding demands continue to build while chronic disease management overwhelms the system at it focal point, acute care hospitals. Patients, especially baby boomers, gather information online like no previous generation. Armed with knowledge, they become more astute medical consumers who demand patient-centered care. Healthcare workers, meanwhile, want a larger say in solving problems created by a lack of system alignment.

As the pressures build and the storms gather it is time for an open and honest conversation about your current realities. Time to leverage quality and patient safety as an unprecedented opportunity to ride the transformation wave.

I hope Boards continually ask – how can we meaningfully tap into the current storm and waves and through sound policy setting create a culture that encourages the expression of intellect, passion, commitment and experience to make real changes that satisfy healthcare consumer needs and expectations.

Like riding a surfboard transformation of healthcare requires courage and discipline. Courage to abandon old patterns, structures and processes found to be incompatible with a changing healthcare system, and discipline to resist knee jerk reactions to mini-crisis and fleeting fads.

I hope Boards will use this “perfect storm” to have an open and honest conversation about current realities -- and about how to leverage quality and patient safety as an unprecedented leadership opportunity to redesign the delivery of appropriate, timely and safe healthcare services. It all begins with Board leadership."

Tom’s view “from the balcony” is somewhat unique, having been a CEO in high reliability industries, a governance leader in an organization committed to be the quality leader, and a consultant working with boards engaged in reducing harm and improving quality performance. Tom shares the following...

”What I see is crystal clear. Decisions made in the boardroom, and the resultant actions taken by the board and CEO, will determine if we make a major impact on reducing patient harm, or tragically, if we do not.

As a new CEO tasked to sell the company, we prepared the slick brochure, developed a leading-edge agenda, and established the polished “show and tell” presentation. Our discussions had become routine and were taking place as scripted. The next potential new owner politely noted he had studied the pre-meeting materials, appreciated the intended agenda, but that he would like to begin the conversation with two questions.

First, are you satisfied with the company’s quality and safety performance? Second, are you confident enough that you would welcome your family or mine to work aboard any vessel in the fleet?

As I listened to my leadership team’s comments, and reflected on my own, I realized we were not where we needed to be. As I worked with this individual as my new board chair, I gained an appreciation for how quickly an organization can get to where it needs to be when the CEO and board are aligned and focused.”

Back on the balcony, we see healthcare board and CEO conversations. Fortunately, we see that many board members now understand they are ultimately accountable for the quality of care, a huge step forward from just a decade ago. The majority of trustees, boards and board committees want to do what is right, and desire to be appropriately engaged in improving performance. A growing number of boards are leading, guiding and supporting quality improvement, and making a significant difference. The evidence strongly suggests that financial performance follows as well.

Unfortunately, at the same time we see a great many other boards still struggling with trying to determine what to do and how to do it. While there is a growing body of knowledge about what governance practices are working to accelerate quality and safety performance, tragically, at present there is no effective way to share these lessons learned for the benefit of all.

We hope we find a way to provide the opportunity for all boards to easily access the governance practices that work for others to reduce harm, so that all patients, families and caregivers benefit. More in a moment.

We hope that boards would review what we see as the five most powerful bundles of practices for reducing harm, and if applicable, consider using these practices as models for what actions to take in their organizations.

  1. Boards need to make the determination to get more appropriately engaged. The “perfect storm” that is upon us is the opportunity to have or renew that critical board conversation regarding the role of governance, the responsibilities of management, and the appropriate board and CEO partnership. Is the board properly structured for its governance role, or is it still focused primarily on fund raising? Is the governance role for quality and safety clearly articulated in policies and procedures? Is the CEO the recognized 24/7 champion for quality improvement? Is there a written board and CEO partnership compact? Is quality and safety a leading component of board member and CEO 360 evaluations? Is thirty percent or greater of the CEO’s compensation tied to quality performance?
  2. Challenge your outcomes, compliance with best practices and your cultural performance indicators. Who is the best? Why not the best? What harm is attributable to not being the best?. What is the ROI on improvement initiatives? Utilize your findings to set a higher performance bar.
  3. Make the governance commitment to quality improvement known organization wide. Do not expect that the organization already knows the boards’ focus on and support for quality and safety. In reality they probably do not. The board, CEO and senior leadership team need to stand together before the organization and provide specifics with respect to the challenges, the goals, improvement actions, and the unrelenting commitment for support.
  4. Open the boardroom so all voices are heard. Begin each board meeting with a patient and caregiver story; the “good, bad and ugly.’ Add high reliability industry experienced board members to the team. Ensure senior leadership and quality and safety staffs are routinely present. Invite all members of the Quality Committee to attend twice a year. Provide an Executive Session One (with just the CEO) and Session Two (without the CEO).
  5. Ensure board members “see and are seen.” Establish procedures for board member rounds to the patient bedside and caregiver work areas. Ensure each member annually attends a Quality, Credentialing and Patient-Centric Care Committee   meeting. Provide the opportunity for each member to participate in a sentinel event review and a performance improvement task force.

The Ghost of Healthcare HOPE returns and offers...

"I visualize key leverage points:

Front Line Service Providers: Quality is ultimately in the hands of those who actually deliver care. Their quality performance is dependent on their knowledge and skills, their beliefs about current levels of quality, their sense of the roles they play in quality, and their perception of the status quo. It also depends on how they define themselves as professionals – their values, aspirations, organizational ethos, information-seeking behaviours, sense of stewardship over resources, and inter-professional comfort levels. These questions apply to all occupations, but physicians are of course central to the prospects for major improvements. What is the hierarchy of values among professionals? Does quality trump other professional values such as autonomy and group loyalty?

Leadership & Management: The day-to-day work of the health care system is transactional. Whether care is of high quality depends significantly on whether and how front line healthcare delivery is managed. The role of governance is to establish quality as a core organizational value -- and hold executives accountable for performance. CEOs and managers carry out the quality-related mandate by designing for quality and by motivating, prioritizing, measuring, coaching, supporting and celebrating excellence. What is needed is deeply committed leaders who are skilled at mobilizing people to accomplish significant improvements.

Healthcare needs CEOs: who see the next five to ten years as an opportunity to “leave a legacy” – a once-in-a-life-time, opportunity to create something of real value to the community they serve. Five years from now, a critical mass of our existing health system leadership will retire. What qualities and competencies are required for the next generation of healthcare leaders? That’s a question Boards need to be asking right now.

Governance: How organizations behave is also significantly influenced by how they are governed. By their priorities, the information they receive, and the decisions they make, governors signal how seriously they take appropriateness, quality and safety issues -- and what they are prepared to do to ensure that quality and safety is a core value and set of practices in their organizations. I hope boards make it clear that the adoption of quality improvement practices is a core expectation. I hope they drive improvement beyond the requirements of government and external accreditation, regulatory and licensing bodies. Wherever Boards are active and involved in quality, there is measurably higher quality. Where Boards are dysfunctional and not paying attention to their responsibilities, outcomes follow."

In Canada, boards represent the interests of the “owners” – who are the citizens of the local community and are responsible for such things as setting strategic policy and directions, ensuring quality, and acting as financial stewards. In addition, Boards are expected to bring their considerable expertise and experience to the task of asking probing questions on behalf of the owners. Management is accountable for implementing the policies and directions of the board.

A number of resources are available for board education from many organizations such as: Ontario Hospital Association (OHA), HealthcareCAN, and Canadian Patient Safety Institute (CPSI). In addition we are working with partners to build-out the not-for-profit “Governance for Patient Safety” Portal, a resource that is intended to be available for board members, board committees and boards engaged in quality and safety improvement. The prototype site can be found at

My guest next week is Professor Graham Dickson in a conversation about... we have a glimpse of the future, leadership capacity will be crucial.

See essays in this series.

See essays from series 2

See essays from series 1

About the Author(s)

Hugh Macleod, Founder Global Healthcare Knowledge Exchange. Concerned and engaged citizen.

Tom Van Dawark, CEO, Orca Partners LLC. Dedicated to sharing knowledge and leading practices with boards engaged in reducing harm.


MacLeod, H. (2013). The Last Word. The Association of Faculties of Medicine of Canada Newsletter. Winter 2012-13

MacLeod, H. (2011). We Have A Perfect Storm - Let’s Use It. HealthcarePapers 11 (2) 


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