Effective Governance and Hospital Boards Revisited: Reflections on 25 Years of Research

Impact of C-level positions on hospital performance: a scoping review protocol

INTRODUCTION

The objective of this scoping review is to identify evidence of the impact of hospital managers in top management (c-suite) on hospital performance. Managers generally have various effects on organisational objectives of their organisations. In recent years, the healthcare sector has experienced alterations in hospital governance structures, together with the emergence of new c-suite positions, aligning more closely with those found in private organisations. Their impact on hospital performance (ie, quality of care) is not well known. This scoping review seeks to identify all the available evidence of their impact on the organisational objectives. This scoping review will include primary studies, reviews and commentaries that describe the impact of top management team members on organisational outcomes in a hospital setting.

METHODS AND ANALYSIS

The search strategy aims to locate both published and unpublished documents (ie, grey literature) using a three-step search strategy. An exploratory search of Medline and Google Scholar identified keywords and Medical Subject Headings terms. A second search of Medline (PubMed), Web of Science Core Collection, ScienceDirect, Business Source Premier (EBScoHost), JSTOR, BASE, Lens.org and the Google Search Engine will be performed. The scope of the search will cover 1990-present time using English search terms. Manual searching by two reviewers will be added to the search strategy. The identified documents will be independently screened, selected by two researchers and extracted by one researcher. The data are then presented in tables and graphics coupled with a descriptive summary.

ETHICS AND DISSEMINATION

As this study neither involves human participants nor unpublished secondary data, an ethics approval is not required. Findings will be disseminated through professional networks, conference presentations and publication in a scientific journal.

TRIAL REGISTRATION NUMBER

The protocol was registered on the Open Science Framework (https://doi.org/10.17605/OSF.IO/EBKUP).

Board talk: How members of executive hospital boards influence the positioning of nursing in crisis through talk

Talk by members of executive hospital boards influences the organizational positioning of nurses. Talk is a relational leadership practice. Using a qualitative-interpretive design we organized focus group meetings wherein members of executive hospital boards (7), nurses (14), physicians (7), and managers (6), from 15 Dutch hospitals, discussed the organizational positioning of nursing during COVID crisis. We found that members of executive hospital boards consider the positioning of nursing in crisis a task of nurses themselves and not as a collective, interdependent, and/or specific board responsibility. Furthermore, members of executive hospital boards talk about the nursing profession as (1) more practical than strategic, (2) ambiguous in positioning, and (3) distinctive from the medical profession. Such talk seemingly contrasts with the notion of interdependence that highlights how actors depend on each other in interaction. Interdependence is central to collaboration in hospital crises. In this paper, therefore, we depart from the members of executive hospital boards as leader and "positioner," and focus on talk-as a discursive leadership practice-to illuminate leadership and governance in hospitals in crisis, as social, interdependent processes.

Board Leaders' Perspectives of the Impact of Nurses on Boards

OBJECTIVE

The purpose of the study was to explore the impact of nurses on boards (NOBs) from the perspectives of board leaders who are not nurses.

BACKGROUND

Research about the impact of NOBs derives from nurses' recall of board experiences. No studies explore the impact of NOBs from perspectives other than nurses.

METHODS

Researchers used an exploratory qualitative design with purposive sampling and interviewed 16 participants.

RESULTS

According to participants, NOBs impact board governance as boundary spanners within the healthcare ecosystem. The overarching pattern is supported by 6 traversing themes.

CONCLUSIONS

Board leaders' perspectives of NOBs as boundary spanners illustrate the far-reaching impact nurses have in the board role and on the direction of healthcare organizations.

What is the mind map of the hospital's future changes in a developing country like Iran? A qualitative study

BACKGROUND

Hospitals have a vital role in the future of health systems with upcoming structure, resources, and process changes. Identifying the potential aspects of change helps managers proactively approach them, use the opportunities, and avoid threats. This study presents a mind map of future changes in Iranian hospitals to develop a base for further related studies or prepare evidence for interventions and future-related decisions.

METHODS

This study is a qualitative-exploratory one, conducted in two phases. In the first phase, in-depth and semi-structured interviews were conducted to identify future hospital changes over 15 years. The interviews were analyzed using the content analysis method and MAXQDA 2018 software and holding two expert panels to develop the mind map using the 2016 Visio software.

RESULTS

In the first phase, 33 interviews led to 144 change patterns. In the second phase, a mind map of changes was drawn according to experts' opinions with ten categories: structure and role, knowledge management and research, service delivery, health forces, political and legal, economic, demographic and disease, technological, and values and philosophy, and environmental.

CONCLUSIONS

Many changes affecting hospitals rooted in the past continue to the future, but the point is the increasing intensity and speed of changes. Healthcare systems need a systematic approach to monitoring the environment to be updated, agile and proactive. These monitoring systems are essential in providing evidence for Macro-level decision-makers.

Big Med's Spread

Policy Points Hospital executives posit a number of rationales for system mergers which lack any basis in academic evidence. Decades of academic research question whether system combinations confer public benefits. Antitrust authorities need to continue to closely scrutinize these transactions. Recently, mergers of hospital systems that span different geographic markets are on the rise. Economists have alerted policymakers about the potential impacts such cross-market mergers may have on hospital prices. We suggest there are other reasons for concern that scholars have not often confonted. Cross-market mergers may be conducted for purely self-serving reasons of organizational growth that increases executive compensation. Combinations of sellers should have clear advantages to consumers. System executives and their boards should bear the burden of proof. Federal regulators and state attorney generals should be cognizant that rationales for cross-market systems advanced by merging parties are unlikely to be operative or dominant in merger decision making. Policymakers should be careful about passing legislation that encourages hospitals to consolidate.

CONTEXT

There is a growing trend of combinations among hospital systems that operate in different geographic markets known as cross-market mergers. Economists have analyzed these broader systems in terms of their anticompetitive behavior and pricing power over insurers. This paper evaluates the benefits advanced by these new hospital systems that speak to a different set of issues not usually studied: increased efficiencies, new capabilities, operating synergies, and addressing health inequities. The paper thus "looks under the hood" of these emerging, cross-market systems to assess what value they might bestow and upon whom.

METHODS

The paper examines recently announced cross-market mergers in terms of their supposed benefits, as expressed by the systems' executives as well as by industry consultants. These presumed benefits are then evaluated against existing evidence regarding hospital system outcomes.

FINDINGS

Advocates of cross-market hospital mergers cite a host of benefits. Research suggests these benefits are nonexistent. Additional evidence suggests other motives may be at play in the formation of cross-market mergers that have nothing to do with efficiencies, synergies, or community benefits. Instead these mergers may be self-serving efforts by system chief executive officers (CEOs) to boost their compensation.

CONCLUSIONS

Cross-market hospital mergers may yield no benefits to the hospitals involved or the communities in which they operate. The boards of hospital systems that engage in these cross-market mergers need to exercise greater diligence over the actions of their CEOs.

Charting a Course: A Research Agenda for Studying the Governance of Health Care Networks

Networked forms of organizing in health care are increasingly viewed as an effective means of addressing "wicked", multifaceted health and societal challenges. This is because networks attempt to address these challenges via collaborative approaches in which diverse stakeholders together define the problem(s) and implement solutions. Consequently, there has been a sharp increase in the number and types of networks used in health care. Despite this growth, our understanding of how these networks are governed has not kept pace. The purpose of this chapter is to chart a research agenda for scholars who are interested in studying health care network governance (i.e., the systems of rules and decision-making within networks), which is of particular importance in deliberate networks between organizations. We do so based on our knowledge of the literature and interviews with subject matter experts, both of which are used to identify core network governance concepts that represent gaps in our current knowledge. Our analysis identified various conceptualizations of networks and of their governance, as well as four primary knowledge gaps: "bread and butter" studies of network governance in health care, the role of single organizations in managing health care networks, governance through the life-cycle stages of health care networks, and governing across the multiple levels of health care networks. We first seek to provide some conceptual clarity around networks and network governance. Subsequently, we describe some of the challenges that researchers may confront while addressing the associated knowledge gaps and potential ways to overcome these challenges.

Executive Involvement in Governing Boards and Hospital and Health System Performance

Governing boards and executive leaders play important roles ensuring that their organizations work toward their missions and maintain their visions, while also meeting compliance and performance goals. The level of executive involvement in hospital governing boards varies across organizations, with little evidence to suggest whether and to what degree executive involvement influences hospital performance. The aim of this study is to determine the influence of executive involvement in governance on health system performance. The sample analyzed in this study were organizations responding to The Governance Institute's (TGI) Biennial Survey of Hospital and Health Systems in 2017. Bivariate and multivariate analyses were used to examine associations between self-reported executive leadership team involvement in governing boards and a composite metric of health system performance calculated by Truven Analytics as part of the "Top 100" program. Results indicate executive involvement is associated with several organizational characteristics, including whether an institution was defined as a hospital or health system, whether or not the board was appointed by the parent/system, and whether the board was accountable to the parent/system board. Although no significant direct relationship was found between executive team involvement in governance and overall health system performance, several promising pathways for future study were identified and are discussed, including examining specific organizational performance outcomes rather than composite measures.

Italian healthcare organizations facing new dimensions: changes in governance structure

Private and public organizations facing merger processes may consider reconfiguring the size, composition, and mechanisms used by the strategic apex. In Italian local health organizations (LHOs), the strategic apex had to face challenges arising from an increase in size and its impacts on different governance areas. The aim of this study is to highlight the role of the top management team in shaping the conditions of governance, and link these conditions to certain internal and external characteristics of the specific LHO and to the behavior and vision of the CEO. The study used qualitative techniques to examine the cases of three of the largest Italian LHOs that had undergone merger processes in recent years. The results show how changes in the organizational size impact the structure and mechanisms of the strategic apex. In particular, this study identifies three main governance strategies.

Board level “Picture-Understanding-Action”: a new way of looking at quality

Purpose

The purpose of this study is to present a quality improvement approach titled “Picture-Understanding-Action” used in Ireland to enhance the role of healthcare boards in the oversight of healthcare quality and its improvement.

Design/methodology/approach

The novel and practical “Picture-Understanding-Action” approach was implemented using the Model for Improvement to iteratively introduce changes across three quality improvement projects. This approach outlines the concepts and activities used at each step to support planning and implementation of processes that allow a board to effectively achieve its role in overseeing and improving quality. This approach matured over three quality improvement projects.

Findings

The “Picture” included quantitative and qualitative aspects. The quantitative “Picture” consisted of a quality dashboard/profile of board selected outcome indicators representative of the health system using statistical process control (SPC) charts to focus discussion on real signals of change. The qualitative picture was based on the experience of people who use and work in health services which “people-ised” the numbers. Probing this “Picture” with collective grounding, curiosity and expert training/facilitation developed a shared “Understanding”. This led to “Action(s)” from board members to improve the “Picture” and “Understanding” (feedback action), to ask better questions and make better decisions and recommendations to the executive (feed-forward action). The Model for Improvement, Plan-Do-Study-Act cycles and a co-design approach in design and implementation were key to success.

Originality/value

To the authors’ knowledge, this is the first time a board has undertaken a quality improvement (QI) project to enhance its own processes. It addresses a gap in research by outlining actions that boards can take to improve their oversight of quality of care.

Countries' experiences in reforming hospital administration structure based on the Parker and Harding model: A systematic review study

In recent years, many reforms have been made on the structure of hospital administration, most of which are proposed by Parker-Harding models. Therefore, the purpose of this study is to systematically review global relevant experiences in reforming the hospital governance structure with emphasis on the Parker-Harding model. Required information was collected using keywords autonomization, corporatization, privatization, decentralization, reform, hospital autonomy, governance model, and structural reform in databases such as EMBASE, PubMed, Scopus, SID, MagIran, and other resources. Information on the subjects under study was collected from 1990 to 2020. The content extraction method was used for data extraction and data analysis. Thirty-nine sources were included in the study. Results of searching for relevant evidence on a variety of hospital governance models (government, board, corporate, and private) based on the Parker-Harding model in four categories including strengths (31), weaknesses (30), outcomes (26), and interventions (21) are outlined. In this study, strengths, weaknesses, outcomes, and corrective interventions were presented for different models of hospital administration that could be used by healthcare policymakers. Also, According to the results of this study, governmental model less recommended.

Fitting in as an outsider: a resource dependence theory approach to outside boards

Purpose

This study draws on resource dependence theory (RDT) to explain a board's governance function in the United States (US) nonprofit healthcare industry. Specifically, while various nonprofit research studies have appealed to agency theory (AT) to explain the monitoring role of an outside board, RDT offers an alternative explanation that emphasizes an outside board's resource gathering role.

Design/methodology/approach

In drawing on the nonprofit GuideStar database, a fixed effect (FE) panel estimation was conducted on a sample of 230 US Non Profit Healthcare Organizations (NPHCOs). This panel estimation examines the relationship between the composition of an outside board and an NPHCO’s revenue and public support performance.

Findings

A key finding of this study is that the composition of an outside board involving its' number, compensation and gender impacts an NPHCO’s revenue and public support.

Research limitations/implications

This study shows that the composition of an outside board impacts an NPHCO’s ability to gain access to external resources. As NPHCOs face increasing pressure to seek external forms of revenue support, this study suggests that boards should favor a larger number, compensation and female representation of outside members.

Practical implications

The composition of an outsider board can offer external sources of revenue support that lower the poor's requirements for financial assistance and thus affirm an NPHCO’s identity as a charitable organization.

Originality/value

As an NPHCO’s identity as a charitable organization is dependent on serving the medical needs of the poor, an outside board not only introduces a resource gathering function that is absent in the monitoring explanations of AT, but that this resource gathering function is important to affirming this identity.

Analysis of the Structure of Public Hospitals Administration in Iran: A Qualitative Study

Background: Public hospitals account for approximately 80% of the health system resources while producing only 20% of the public sector's output. Objectives: This study aimed to analyze the current administration structure (strengths, weaknesses, solutions, and proposed models) of Iranian public hospitals. Methods: This study is qualitative research with a phenomenological approach. The required data were collected using semi-structured interviews with 58 national experts in the field of hospital management who were selected based on the purposive sampling method. Data were analyzed using the conventional content analysis method. Results: Nine main themes and 34 sub-themes were identified in the weaknesses. The strengths contained four main themes and 16 sub-themes. The proposed solutions had five main themes and 22 sub-themes, and the proposed models from the experts' points of view were composed of four main themes and six sub-themes. The important weaknesses were low commitment and motivation, poor financial management and budgeting, and centralized decision-making and management. The strengths included strong infrastructure, extensive service delivery, government support, and positive social functions. The most important proposed solutions were complying with the requirements of structural reform, development of related assessment indicators, public-private partnership, payment system reform, delegation, manpower management, hospital organizational structure, and reform of the tariff system. Finally, the model of the Board of Trustees, while maintaining government ownership but observing the legal requirements of this structure, was the main suggestion of experts on reforming the structure of the administration of public hospitals in Iran. Conclusions: According to the expert’s opinions, the current structure of Iranian public hospitals has many problems. Managers and policymakers can make the necessary corrections based on the solutions and models proposed in this study.

Balancing hospital governance: A systematic review of 15 years of empirical research

It is crucial that we gain a deeper understanding of the features of organizational governance and how they contribute to hospital performance. Health care governance research has traditionally had a strong focus on the size and composition (i.e., the attributes) of the governing bodies, but less attention has been given to the dynamics, processes, and roles. Furthermore, evidence regarding the interconnection between the board and the executive management is lacking. This systematic literature review is thus intended to give a detailed summary of the attributes, the dynamics, and the processes, as well as the roles of governing bodies, by synthesizing the findings of published empirical studies. The framework of Kane et al. (2009) was used to position the results, taking into account external constraints and outputs/performance. Sixty-three studies were included in the systematic review. The majority of these studies deal with attributes (n = 34) and roles (n = 27); the smallest number of studies (n = 11) focus on dynamics and processes. There is a lack of consistency in the research findings on attributes and there is too little research into the dynamics and processes of hospital governance. However, it has been shown that clinical participation on the hospital board and the focus on quality in hospital board roles can have a beneficial effect. The studies do not provide sufficient direction on what best practice for governing hospitals should be. For this reason, we here provide a useful framework for understanding the aspects of governance and their impact on performance in hospitals and compare these with general corporate governance literature. Therefrom we propose avenues for further research.

Roles and behaviours of diligent and dynamic healthcare boards

Variation persists in the quality of board-level leadership of hospitals. The consequences of poor leadership can be catastrophic for patients. The year 2019 marks 50 years of public inquiries into healthcare failures in the UK. The aim of this article is to enhance our understanding of context-specific effectiveness of healthcare board practices, drawing on an empirical study of changes in hospital board leadership in England. The study suggests leadership behaviours that lay the conditions for better organisation performance. We locate our findings within the wider theoretical debates about corporate governance, responding to calls for theoretical pluralism and insights into the effects of discretionary effort on the part of board members. We conclude by proposing a framework for the ‘restless’ board from a multi-theoretic standpoint, and suggest a repertoire specifically for healthcare boards. This comprises a suite of board roles as conscience of the organisation, sensor, shock absorber, diplomat and coach, with accompanying dyadic behaviours to match particular organisation aims and priorities. The repertoire indicates the importance of a cluster of leadership practices to fulfil the purposes of healthcare boards in differing, complex and challenging contexts.