Board Governance: Transformational Approaches Under Healthcare Reform

Previous successes of healthcare organizations and effective governance practices in the pre-reform environment are not predictive of future success. Healthcare has been through numerous phases of growth and development using tried-and-true strategies. The challenge is that our toolbox does not contain what is needed to build the future healthcare delivery systems required in the post-reform world. Healthcare has had a parochial focus at the local level, with some broadening of horizons at the state and national levels. But healthcare delivery is now a global issue that requires a totally different perspective, and many countries are confronting similar issues. US healthcare reform initiatives have far-reaching implications. Compounding the reform dynamics are the simultaneously occurring, gamechanging accelerants such as enabling information technologies and mobile health, new providers of healthcare, increased consumer demands, and limited healthcare dollars, to name a few. Operating in this turbulent environment requires transformational board, executive, and physician leadership because traditional ways of planning for incremental change and attempting to time those adjustments can prove disastrous. Creating the legacy healthcare system for tomorrow requires governing boards and executive leadership to act today as they would in the desired future system. Boards need to create a culture that fosters.innovation with a tolerance for risk and some failure. To provide effective governance, boards must essentially develop new skills, expertise, and ways of thinking. The rapid rate of change requires board members to possess certain capabilities, including the ability to deal with ambiguity and uncertainty while demonstrating flexibility and adaptability, all with a driving commitment to metrics and results. This requires development plans for both individual members and the overall board. In short, the board needs to function differently, particularly regarding the types of discussions at and the focus of board meetings.

International aid and natural disasters: a pre- and post-earthquake longitudinal study of the healthcare infrastructure in Leogane, Haiti

The reconstruction of healthcare systems in developing countries after natural disasters is poorly understood. Using data collected before and after the 2010 Haiti earthquake, we detail the response of aid agencies and their interaction with local healthcare providers in Leogane, the city closest to the epicenter. We find that the period after the earthquake was associated with an increase in the total number of healthcare facilities, inpatient beds, and surgical facilities and that international aid has been a driving force behind this recovery. Aid has funded 12 of 13 new healthcare facilities that have opened since the earthquake as well as the reconstruction of 7 of 8 healthcare facilities that have been rebuilt. Despite increases in free, aid-financed healthcare, private Haitian healthcare facilities have remained at a constant number. The planned phase-out of several aid-financed facilities, however, will leave Leogane with fewer inpatient beds and healthcare services compared with the pre-earthquake period.

Lost in translation? 'Evidence' and the articulation of institutional logics in integrated care pathways: from positive to negative boundary object?

This article examines the translation of a clinical governance concept - integrated care pathways (ICPs)--into an infrastructural technology. Building on previous work, the application of boundary object theory is extended in this article to argue that stakeholder enrolment in pathway methodology may be less thoroughgoing than originally assumed. Pathways have effectively aligned management and nursing interests around a quality agenda and nurses have emerged as the leaders in this field, but doctors have rather lower levels of engagement. It is suggested that the contradictory logics inherent in pathway philosophy (primarily as these relate to 'evidence') and the social organisation of ICP development foster a transformation of the concept when this is translated into the technology, creating a negative boundary object from the perspective of doctors. Medicine is a powerful actor in health care, which is consequential for whether pathways, as designated boundary objects, become boundary objects-in-use. It also has implications for the diffusion of the concept as a mechanism of clinical governance and the credibility of nurses as emergent leaders in this field. Qualitative case studies of ICP development processes undertaken in the UK National Health Service and ethnographic research on the ICP community provide the empirical foundations for the analysis.

Banning the hiring of tobacco users: where's the fire?

This commentary addresses the article in this issue by Huddle and colleagues concerning the implementation of policies by the University of Alabama at Birmingham (UAB) School of Medicine and other academic health centers to not hire users of tobacco products. Huddle and colleagues explore the basis for such policies and find that even though institutions may be within their rights to implement such policies, the policies are inconsistent with the societal role of an academic health center as a caregiving institution. They see a potential for discrimination, as contemporary users of tobacco are more likely to have less education and lower incomes than nonusers.The authors of this commentary review the arguments for and against such policies and explore the complexities of the implementation of such a policy by a state institution. They express concern that a state institution has chosen not to hire state residents who use tobacco products, which are legal. The authors also explore the potentially discriminatory aspects of such policies and possible implications of these policies in the context of rights and legal frameworks.The academic medicine community must learn from the experience that will follow from such policies as well as from other state and nonstate institutions that have implemented similar employment policies. Huddle and colleagues have provided a thoughtful contribution to a complex and inevitably continuing discussion.

Blue ocean leadership

Ten years ago, two INSEAD professors broke ground by introducing "blue ocean strategy," a new model for discovering uncontested markets that are ripe for growth. In this article, they apply their concepts and tools to what is perhaps the greatest challenge of leadership: closing the gulf between the potential and the realized talent and energy of employees. Research indicates that this gulf is vast: According to Gallup, 70% of workers are disengaged from their jobs. If companies could find a way to convert them into engaged employees, the results could be transformative. The trouble is, managers lack a clear understanding of what changes they could make to bring out the best in everyone. Here, Kim and Mauborgne offer a solution to that problem: a systematic approach to uncovering, at each level of the organization, which leadership acts and activities will inspire employees to give their all, and a process for getting managers throughout the company to start doing them. Blue ocean leadership works because the managers' "customers"-that is, the people managers oversee and report to-are involved in identifying what's effective and what isn't. Moreover, the approach doesn't require leaders to alter who they are, just to undertake a different set of tasks. And that kind of change is much easier to implement and track than changes to values and mind-sets.