- Email: [email protected]
Nurses on Boards: The Time Has Come
Nurses on Boards: The Time Has Come Lawrence D. Prybil, PhD, Melanie C. Dreher, RN, PhD, and Connie R. Curran, RN, EdD
N
early 18% of the United States’ gross
despite our large investment of resources in
national product presently is devoted
healthcare—the United States lags behind other
to healthcare, and for many years, the rate of
industrialized countries on multiple metrics of
growth has exceeded other sectors of our nation’s
population health such as infant mortality and life
economy. However, landmark studies by the
expectancy.1 Moreover, there is strong evidence of
Institute of Medicine, the Commonwealth Fund,
disparities around our country in access, cost, and
and other organizations have demonstrated that—
quality of healthcare services.2
48
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August 2014
S
o, there is abundant documentation of a troublesome paradox: the United States is investing a large and growing proportion of our nation’s resources in healthcare, but the outcomes in terms of access to services, the quality of those services, and the health of our population are unsatisfactory in many ways. It is clear that many factors contribute to this paradox—demographic, economic, environmental, lifestyle, political, and social—and all warrant societal attention. However, given their prominent social role and the magnitude of economic resources they consume, growing scrutiny is being given to America’s hospitals and health systems. Key stakeholders including public and private payers, state and federal government regulators, bond-rating agencies, the media, and the public-at-large are demanding more transparency and better performance by these institutions and their clinical, executive, and governance leaders.3 This scrutiny—and the growing complexity of the healthcare environment and the advent of value-based payment systems—are demanding changes in traditional governance structures and practices.4,5 The governing boards with fiduciary and moral responsibility for hospitals and health systems must address the challenge of controlling operating and capital costs while concurrently improving patient care quality and safety. To achieve these goals, engaging the organization’s clinical leaders in setting priorities and developing sound strategies is imperative. Appointing highly qualified and committed clinicians as voting members of the organization’s board of directors and board committees is one of the basic mechanisms to enable such engagement. Over the past 20 to 25 years, involving physicians as voting members of hospital and health system boards has become the norm and now is widely regarded as standard practice.6 Numerous surveys in recent years have shown that physicians generally constitute around 20% of hospital and system board membership.5 However— despite the advocacy of organizations such as the Robert Wood Johnson Foundation, the Jonas Foundation, Sigma Theta Tau International, and the Institute of Medicine in its 2011 report entitled The Future of Nursing Leadership: Advancing Health—the involvement of nurses as voting members of hospital and health system boards is uncommon. This article summarizes information from several recent studies regarding nurse engagement on governing boards, discusses several factors we believe have influenced the level of their engagement, and presents a case for change.
NURSE INVOLVEMENT IN HOSPITAL AND HEALTH SYSTEM GOVERNANCE Comprehensive, longitudinal data regarding the presence of nurses as voting members of hospital and health system boards do not exist. However, several studies conducted in recent years show clearly that the involvement of nurses as voting members of these boards has been, and continues to be, quite limited: • A 2004 to 2005 study of governance in matched groups of high-performing versus mid-range performing community hospitals found that only 2% of voting www.nurseleader.com
board members in both groups were nurses actively engaged in practice in these or other healthcare institutions. By comparison, 26% of their board members were physicians.7 • A 2008 to 2009 study of governance structures and practices in 123 nonprofit community health systems— all of which were operating 2 or more hospitals and other health programs in a single community—found that 2.4% of voting board members were nurses whereas 22% were physicians.8,9 • Information from a survey of more than 1,000 nonfederal community hospitals conducted by the American Hospital Association in 2010 to 2011 found a somewhat higher level of nursing involvement in governance. In the institutions that participated in this survey, 6% of board members were nurses and 20% were physicians.10 • Similarly, a study of governance in 14 of the nation’s 15 largest nonprofit health systems, completed in 2012, also found that on an overall basis, 6% of the systems’ voting board members were nurses.5 However, as shown in Table 1, the proportion is not uniform among the systems. Nine of the 14 systems are faith-based (8 sponsored or controlled by Roman Catholic entities, 1 Adventist-sponsored). In combination, 9% of the voting members of the faith-based system boards were nurses, whereas among the 5 secular systems, only 2% of voting board members were nurses. Eight of the 9 large faith-based health systems in this study population were founded by congregations of religious women. It is apparent that their strong, historical commitment to promoting leadership development and providing leadership opportunities for qualified women is reflected in these findings. (For a list of the 14 health systems that participated in this study, see www.americangovernance.com/govbooklet, p. 3) • The Governance Institute conducts biennial surveys of hospitals and health systems. The Institute’s 2013 survey generated responses from 63 systems and 478 hospitals. In the aggregate, nurses represented 3% of the voting members of these organizations’ boards; 19% were physicians. Among the governing boards of these hospitals and health systems in 2013, 72% had no nurses as voting board members.11 • A 2013 study of healthcare organizations and agencies in New York City found that 93% of hospitals had 1 or more physicians on their governing boards, whereas only 26% of these boards included nurses.12 • During 2013 to 2014, the University HealthSystem Consortium (UHC)—a coalition whose principal members are 119 university-based academic medical centers—studied the structures, practices, and cultures of boards with principal responsibility for setting the medical centers’ performance standards and overseeing their operations. Among the 62 institutions that participated in this study, 2% of the boards voting members (22 of 1,122) are nurses; 19% (214 of 1,122) are physicians. At this time, 71% of these institutions have no nurses as
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Table 1. Clinical Composition of Large Nonprofit Health System Boards*
Member
Board Composition in Faith-Based Systems (n ⫽ 179)
Board Composition in Secular Systems (n ⫽ 95)
Board Composition in All Systems (N ⫽ 274)
Nurses
9%
2%
6%
Physicians
11%
18%
14%
Other
80%
80%
80%
*Chi-square test demonstrates significantly different proportions of nurses in the board compositions of faith-based versus secular systems, P ⬍ 0.05.
voting members of their boards (M. Szekendi, personal communication, January 6, 2014). In summary, several independent studies conducted during the past decade demonstrate that nurse involvement as voting members of healthcare organization boards—hospitals, health systems, and academic medical centers—is quite limited. Moreover, the evidence does not indicate a trend toward an increasing level of engagement.
FACTORS CONTRIBUTING TO THE LIMITED ENGAGEMENT OF NURSES ON HEALTHCARE ORGANIZATION BOARDS So, although nurses constitute a large proportion of healthcare organizations’ workforce and have enormous impact on the quality of patient care and the level of patient satisfaction, the presence of nurses as voting members of these organizations’ governing boards is limited and, in many cases, nonexistent. What are the factors that have contributed to this situation? Based on the authors’ collective experience in working for, serving on, chairing, and providing advice and assistance to healthcare boards for many years, it is our shared view that the contributing factors include the following: • Board selection process. First, although board appointment processes vary somewhat from organization to organization, the identification and nomination of persons to serve on governing boards typically is handled by a small subset of current board members (e.g., the board’s executive committee, a nominating committee, or an ad hoc group appointed by the board chair), usually with input from the organization’s chief executive officer (CEO). The nursing profession is large and disparate, with significant variation in academic preparation and credentials. It includes licensed practical nurses, many of whom do not have college degrees, registered nurses with associate degrees from community colleges, and others with baccalaureate degrees, and a growing number with graduate degrees at the master’s and doctoral levels. To lay board members who are assigned responsibility to identify and nominate candidates for board appointments, the structure of the nursing profes-
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sion can be unclear and perplexing. Too often they view nurses on the whole as mid-level technicians and do not understand that most are highly educated and skilled professionals who are vitally important in determining organizational performance. Board members who do not recognize and understand these distinctions are unlikely to consider nurses as suitable candidates for board appointments. Clearly, there is a role for board education and advocacy by influential CEOs, physicians, and nurses who understand the contributions nurse leaders can make to board deliberations. • Gender disparities. Second, gender disparities continue to exist in board composition in many sectors of American society. For example, in 2012, only 17% of Fortune 500 board seats were held by women, and only 3% of these boards were chaired by women.13 More than 10% of the Fortune 500 boards include no women at all.14 Although less pronounced, gender imbalance continues to exist within the boards of healthcare organizations, too. For example, the Governance Institute’s 2013 survey of hospital and health system boards found that only 27% of voting board members were women.11 More than 90% of registered nurses in the United States are women. At least to some extent, the limited presence of women on the boards of America’s hospitals, health systems, and academic medical centers can be viewed as a reflection of the gender disparity that continues to exist among governing boards in other sectors of American society. • Board policies and practices. Third, a substantial number of board leaders are hesitant to appoint any organizational employees other than the CEO as voting members of the institution’s governing board. This reluctance is due in part to calls by the Panel on the Nonprofit Sector, the Internal Revenue Service, and other authorities for nonprofit organizations to ensure that a strong majority of their board members are “independent,” that is, not a member of a sponsoring body such as a religious congregation, not a full- or part-time employee of the organization, and not directly affiliated
August 2014
with the organization in any way except serving as a board member.5 More generally, appointing employees other than the CEO to board positions simply has not become common practice among healthcare organizations, at least in the nonprofit sector. With respect to nurses, this particular concern can be addressed and resolved in several ways. One avenue is simply to look outside the organization for highly qualified nursing leaders as candidates for board appointments, e.g., nurses who hold senior leadership positions in other healthcare organizations or are affiliated with universities, foundations, or consulting firms. In instances where there is a desire to extend a board appointment to a nurse who is an employee, the potential for conflict of interest can be addressed through existing policies and procedures that typically are well-established and applied routinely whenever a physician who is employed by and/or serves on the medical staff of an organization where he or she is being considered for a board appointment. • Lack of nurse advocacy efforts. Fourth, although some major organizations such as the Robert Wood Johnson Foundation and some executive leaders15 have advocated strongly for greater involvement of highly qualified nurses in the governance of hospitals and health systems, other organizations that surely recognize the importance of the nursing profession in affecting healthcare quality and cost—such as the American Nurses Credentialing Center, the Joint Commission, and rating agencies—have been surprisingly silent on this topic. And so, for the most part, have been influential hospital associations and nursing associations. Whatever the reasons for their reticence, it certainly has contributed to the strikingly low level of nurse engagement in the governance of America’s hospitals and health systems.
THE CASE FOR CHANGE It is the authors’ shared belief that there is an abundance of nurse leaders who are highly qualified for board roles and who, if invited and appointed, would contribute substantially to board deliberations and decision making.Yet, a series of studies by independent parties clearly suggest this talent remains largely untapped. So, what is the case for change? Why would it be beneficial for hospital and health system boards, the institutions for which they are responsible, and the communities they serve to have the presence of nurse leaders as voting members? • Organizational knowledge and impact. First, with all respect to physicians and other health professionals, the impact of nurses on the quality of patient care is enormous and unarguable. In the inpatient setting, nurses perform many complex clinical procedures and, even more importantly, are charged with the duties of advocacy, care, and vigilance for patients 24 hours a day, 7 days a week. Because of around-the-clock responsibilities, nursing practice demands highly coordinated teamwork with excellent communications, effective handoffs, and shared accountability. In today’s hospitals, where www.nurseleader.com
acuity levels are rising, clinical outcomes and patient satisfaction increasingly are dependent upon nursing care and leadership. It would seem apparent that board deliberations and decision making would be enriched by the perspectives of expert nurse leaders who are uniquely equipped to assess the impact of board decisions on nursing practice and patient care. • Public trust and confidence. Second, we are in an era in which the American public has lost confidence in large institutions, both government and private. It is clear the public wants more transparency, better performance, and more accountability from those who are responsible for these institutions, including hospitals and health systems.16 Meanwhile, a host of surveys by Gallup and other experts demonstrate that nurses are viewed as patient advocates and that nursing is the most trusted profession in the United States.17 In addition to the value of nurse leaders’ expertise and input in board deliberations, it seems apparent that the presence of nurse leaders on boards would enhance the credibility of boards and their decisions in the eyes of the community they serve and other stakeholders. The fact that more than 70% of America’s hospitals, health systems, and academic medical centers include no nurses as voting members on their boards is simply incredulous to the lay public with whom the authors interact. • Relevance to healthcare reform objectives. Third, passage of the Patient Protection and Affordable Care Act in 2010 and growing recognition that improving America’s healthcare system requires concerted attention to the Institute for Healthcare Improvement triple aim of “better patient care, better population health, and lower costs” have heightened the logic for increasing the engagement of nurse leaders on the boards of healthcare organizations. Without nursing involvement and support, little progress can be made in achieving any part of the triple aim. In formulating and implementing organizational policies, priorities, and strategies, the expertise and perspectives of nursing is increasingly essential.The fact that most American hospitals, health systems, and academic medical center boards make major decisions without the intellectual capital and votes of nurse leaders is indefensible. • Large pool of well-qualified candidates. Fourth, in many communities around the country, it is difficult to identify highly capable persons who possess the competencies required to serve effectively in healthcare governance roles and are willing to devote the time these roles demand nowadays. For example, a recent survey of hospitals and health systems found that 50% of respondents report “…it is becoming increasingly difficult to recruit new (qualified) board members.”18 The nursing profession includes large and growing numbers of highly educated professionals with strong skills and experience in areas of great importance to hospital, health system, and academic medical center boards, e.g., quality measurement and control, process improvement, resource allocation, and performance evaluation. Nurses represent a tremendous pool of competence and experience with
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direct relevance to the issues that healthcare boards must address today. Moreover, they bring deep dedication to improving patient care and population health. The multiple reasons why nursing engagement in governance is important does not mean that nurse board members need to be drawn from the organization’s work force or that all nurses are prepared or qualified for governance roles. To the contrary, all candidates for board appointments should have a deep commitment to the organization’s mission and values, strong experience and pertinent competencies, and willingness to devote the growing amount of time and effort required to be a productive board member in the contemporary healthcare environment. The pool of potential nurse candidates can and should include nurse leaders in other healthcare organizations, consulting firms, academic institutions, foundations, and so on. Hospital, health system, and academic medical boards should not be composed of “representatives” of professional or organizational quadrants. Evaluation of potential board candidates should be competency-based; all appointees should meet high standards and be fully committed to the long-term success of the organization they will govern. Board members are not there to serve as the “representative” of a particular stakeholder group. For too many years, very few nursing leaders have been given the opportunity to serve as voting members of hospital, health system, and academic medical center boards. Instead of being at the boardroom table, participating in board deliberations, and helping the CEO and physician colleagues to inform and educate lay board members about patient care and contemporary healthcare issues, nurse leaders largely have been seated as observers in the back of the boardroom or, in too many cases, totally absent from board and board committee settings. The effect has been to deprive most boards of the valuable experience, insights, and perspectives that nurse leaders can bring to board deliberations and decision making. It is our shared conviction that the presence of nurse leaders as voting members of healthcare boards will improve governance effectiveness. We call upon healthcare boards and CEOs who have not already done so to consider the potential benefits of adding highly qualified nurse leaders as voting members. We believe the case for taking that step is powerful, and that the time for action is now. NL
7. Prybil L. Nursing involvement in hospital governance. J Nurs Care Qual. 2007;22(1):1-3. 8. Prybil L, Levey S. Peterson R, et al. Governance in Nonprofit Community Health Systems. Chicago, IL: Grant Thornton; 2008:5-6. 9. Prybil L. Engaging nurses in governing hospitals and health systems. J Nurs Care Qual. 2009;24(1):5-8. 10. Van Dyke K, Combes J, Joshi M. 2011 AHA Health Care Governance Survey Report. Chicago, IL: AHA Center for Healthcare Governance; 2011:13. 11. The Governance Institute. Governing the Value Journey: A Profile of Structure, Culture, and Practices of Boards in Transition: Biennial Survey of Hospitals and Health Systems. San Diego, CA: The Governance Institute; 2013: 5. 12. Mason D, Keepnews D, Holmberg J, Murray E. The representation of health professionals on governing boards of health care organizations in New York City. J Urban Health. 2013;90:888-901. 13. Kristoff N. She’s (rarely) the boss. New York Times. January 27, 2013:SR11. 14. Petrecca L. More women on tap to lead companies. USA Today. October 27, 2011:3B. 15. Lumpkin J. The missing voices. BoardRoom Press. D2013;24(6):4-14. 16. Prybil L, Ackerman K, Hastings D, King, J. The Evolving Accountability of Nonprofit Health System Boards. Chicago, IL: AHA Center for Healthcare Governance; 2013:9-10. 17. Nursing Leadership from Bedside to Boardroom: Opinion Leaders’ Perceptions. Prepared by Gallup for the Robert Wood Johnson Foundation; January 20, 2010. http://www.rwjf.org/en/research-publications/find-rwjfresearch/2010/01/nursing-leadership-from-bedside-to-boardroom.html. Accessed January 2014. 18. Murphy S. Board Recruitment and Retention: Building Better Boards Now…and for Our Future. San Diego, CA: Governance Institute; 2013:1,7-8.
Lawrence D. Prybil, PhD, is Norton professor of Health Care Leadership and associate dean at the College of Public Health, University of Kentucky in Lexington, Kentucky. Dr. Prybil presently serves on the boards of the AHA Center for Healthcare Governance and the Institute of Accountable Healthcare Governance, Inc. He can be reached at [email protected]. Melanie C. Dreher, RN, PhD, is dean emeritus of the College of Nursing, Rush University, Chicago, Illinois. She presently serves on the boards of CHE/Trinity Health (chair) and Wellmark Blue Cross and Blue Shield. Connie R. Curran, RN, EdD, is president of Curran Associates in Chicago, Illinois. She presently serves on the boards of DeVry, Inc. (chair), DePaul University, Hospira, Inc., Lurie Chicago Children’s Hospital, and the University of Wisconsin Foundation. 1541-4612/2014 Copyright 2014 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2014.05.011
References 1. Moses H, Matheson D, Dorsey E, George B, Sadoff D, Yoshimura S. The anatomy of health care in the united states. JAMA. 2013;310:1947-1963. 2. Yong PI, Saunders RS, Olsen LA, eds. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. Washington, DC: National Academies Press; 2010. http://www.iom.edu/Reports/2011/TheHealthcare-Imperative-Lowering-Costs-and-Improving-Outcomes.aspx. Accessed January 2014. 3. Prybil L, Ackerman K, Hastings D, King J. The Evolving Accountability of Nonprofit System Boards. Chicago, IL: AHA Center for Healthcare Governance; 2013:5. 4. Totten M. The Value of Governance. Chicago, IL: AHA Center for Healthcare Governance; 2013:8-11. 5. Prybil L, Levey S, Killian R, et al. Governance in Large, Nonprofit Health Systems: Current Profile and Emerging Patterns. Lexington, KY: Commonwealth Center for Governance Studies; 2012:6-45. 6. Bader B, Kazemek E, Knecht P, et al. Physician participation on the hospital board; a moving target. BoardRoom Press. 2010;21(2):18-20.
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N
early 18% of the United States’ gross
despite our large investment of resources in
national product presently is devoted
healthcare—the United States lags behind other
to healthcare, and for many years, the rate of
industrialized countries on multiple metrics of
growth has exceeded other sectors of our nation’s
population health such as infant mortality and life
economy. However, landmark studies by the
expectancy.1 Moreover, there is strong evidence of
Institute of Medicine, the Commonwealth Fund,
disparities around our country in access, cost, and
and other organizations have demonstrated that—
quality of healthcare services.2
48
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August 2014
S
o, there is abundant documentation of a troublesome paradox: the United States is investing a large and growing proportion of our nation’s resources in healthcare, but the outcomes in terms of access to services, the quality of those services, and the health of our population are unsatisfactory in many ways. It is clear that many factors contribute to this paradox—demographic, economic, environmental, lifestyle, political, and social—and all warrant societal attention. However, given their prominent social role and the magnitude of economic resources they consume, growing scrutiny is being given to America’s hospitals and health systems. Key stakeholders including public and private payers, state and federal government regulators, bond-rating agencies, the media, and the public-at-large are demanding more transparency and better performance by these institutions and their clinical, executive, and governance leaders.3 This scrutiny—and the growing complexity of the healthcare environment and the advent of value-based payment systems—are demanding changes in traditional governance structures and practices.4,5 The governing boards with fiduciary and moral responsibility for hospitals and health systems must address the challenge of controlling operating and capital costs while concurrently improving patient care quality and safety. To achieve these goals, engaging the organization’s clinical leaders in setting priorities and developing sound strategies is imperative. Appointing highly qualified and committed clinicians as voting members of the organization’s board of directors and board committees is one of the basic mechanisms to enable such engagement. Over the past 20 to 25 years, involving physicians as voting members of hospital and health system boards has become the norm and now is widely regarded as standard practice.6 Numerous surveys in recent years have shown that physicians generally constitute around 20% of hospital and system board membership.5 However— despite the advocacy of organizations such as the Robert Wood Johnson Foundation, the Jonas Foundation, Sigma Theta Tau International, and the Institute of Medicine in its 2011 report entitled The Future of Nursing Leadership: Advancing Health—the involvement of nurses as voting members of hospital and health system boards is uncommon. This article summarizes information from several recent studies regarding nurse engagement on governing boards, discusses several factors we believe have influenced the level of their engagement, and presents a case for change.
NURSE INVOLVEMENT IN HOSPITAL AND HEALTH SYSTEM GOVERNANCE Comprehensive, longitudinal data regarding the presence of nurses as voting members of hospital and health system boards do not exist. However, several studies conducted in recent years show clearly that the involvement of nurses as voting members of these boards has been, and continues to be, quite limited: • A 2004 to 2005 study of governance in matched groups of high-performing versus mid-range performing community hospitals found that only 2% of voting www.nurseleader.com
board members in both groups were nurses actively engaged in practice in these or other healthcare institutions. By comparison, 26% of their board members were physicians.7 • A 2008 to 2009 study of governance structures and practices in 123 nonprofit community health systems— all of which were operating 2 or more hospitals and other health programs in a single community—found that 2.4% of voting board members were nurses whereas 22% were physicians.8,9 • Information from a survey of more than 1,000 nonfederal community hospitals conducted by the American Hospital Association in 2010 to 2011 found a somewhat higher level of nursing involvement in governance. In the institutions that participated in this survey, 6% of board members were nurses and 20% were physicians.10 • Similarly, a study of governance in 14 of the nation’s 15 largest nonprofit health systems, completed in 2012, also found that on an overall basis, 6% of the systems’ voting board members were nurses.5 However, as shown in Table 1, the proportion is not uniform among the systems. Nine of the 14 systems are faith-based (8 sponsored or controlled by Roman Catholic entities, 1 Adventist-sponsored). In combination, 9% of the voting members of the faith-based system boards were nurses, whereas among the 5 secular systems, only 2% of voting board members were nurses. Eight of the 9 large faith-based health systems in this study population were founded by congregations of religious women. It is apparent that their strong, historical commitment to promoting leadership development and providing leadership opportunities for qualified women is reflected in these findings. (For a list of the 14 health systems that participated in this study, see www.americangovernance.com/govbooklet, p. 3) • The Governance Institute conducts biennial surveys of hospitals and health systems. The Institute’s 2013 survey generated responses from 63 systems and 478 hospitals. In the aggregate, nurses represented 3% of the voting members of these organizations’ boards; 19% were physicians. Among the governing boards of these hospitals and health systems in 2013, 72% had no nurses as voting board members.11 • A 2013 study of healthcare organizations and agencies in New York City found that 93% of hospitals had 1 or more physicians on their governing boards, whereas only 26% of these boards included nurses.12 • During 2013 to 2014, the University HealthSystem Consortium (UHC)—a coalition whose principal members are 119 university-based academic medical centers—studied the structures, practices, and cultures of boards with principal responsibility for setting the medical centers’ performance standards and overseeing their operations. Among the 62 institutions that participated in this study, 2% of the boards voting members (22 of 1,122) are nurses; 19% (214 of 1,122) are physicians. At this time, 71% of these institutions have no nurses as
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Table 1. Clinical Composition of Large Nonprofit Health System Boards*
Member
Board Composition in Faith-Based Systems (n ⫽ 179)
Board Composition in Secular Systems (n ⫽ 95)
Board Composition in All Systems (N ⫽ 274)
Nurses
9%
2%
6%
Physicians
11%
18%
14%
Other
80%
80%
80%
*Chi-square test demonstrates significantly different proportions of nurses in the board compositions of faith-based versus secular systems, P ⬍ 0.05.
voting members of their boards (M. Szekendi, personal communication, January 6, 2014). In summary, several independent studies conducted during the past decade demonstrate that nurse involvement as voting members of healthcare organization boards—hospitals, health systems, and academic medical centers—is quite limited. Moreover, the evidence does not indicate a trend toward an increasing level of engagement.
FACTORS CONTRIBUTING TO THE LIMITED ENGAGEMENT OF NURSES ON HEALTHCARE ORGANIZATION BOARDS So, although nurses constitute a large proportion of healthcare organizations’ workforce and have enormous impact on the quality of patient care and the level of patient satisfaction, the presence of nurses as voting members of these organizations’ governing boards is limited and, in many cases, nonexistent. What are the factors that have contributed to this situation? Based on the authors’ collective experience in working for, serving on, chairing, and providing advice and assistance to healthcare boards for many years, it is our shared view that the contributing factors include the following: • Board selection process. First, although board appointment processes vary somewhat from organization to organization, the identification and nomination of persons to serve on governing boards typically is handled by a small subset of current board members (e.g., the board’s executive committee, a nominating committee, or an ad hoc group appointed by the board chair), usually with input from the organization’s chief executive officer (CEO). The nursing profession is large and disparate, with significant variation in academic preparation and credentials. It includes licensed practical nurses, many of whom do not have college degrees, registered nurses with associate degrees from community colleges, and others with baccalaureate degrees, and a growing number with graduate degrees at the master’s and doctoral levels. To lay board members who are assigned responsibility to identify and nominate candidates for board appointments, the structure of the nursing profes-
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sion can be unclear and perplexing. Too often they view nurses on the whole as mid-level technicians and do not understand that most are highly educated and skilled professionals who are vitally important in determining organizational performance. Board members who do not recognize and understand these distinctions are unlikely to consider nurses as suitable candidates for board appointments. Clearly, there is a role for board education and advocacy by influential CEOs, physicians, and nurses who understand the contributions nurse leaders can make to board deliberations. • Gender disparities. Second, gender disparities continue to exist in board composition in many sectors of American society. For example, in 2012, only 17% of Fortune 500 board seats were held by women, and only 3% of these boards were chaired by women.13 More than 10% of the Fortune 500 boards include no women at all.14 Although less pronounced, gender imbalance continues to exist within the boards of healthcare organizations, too. For example, the Governance Institute’s 2013 survey of hospital and health system boards found that only 27% of voting board members were women.11 More than 90% of registered nurses in the United States are women. At least to some extent, the limited presence of women on the boards of America’s hospitals, health systems, and academic medical centers can be viewed as a reflection of the gender disparity that continues to exist among governing boards in other sectors of American society. • Board policies and practices. Third, a substantial number of board leaders are hesitant to appoint any organizational employees other than the CEO as voting members of the institution’s governing board. This reluctance is due in part to calls by the Panel on the Nonprofit Sector, the Internal Revenue Service, and other authorities for nonprofit organizations to ensure that a strong majority of their board members are “independent,” that is, not a member of a sponsoring body such as a religious congregation, not a full- or part-time employee of the organization, and not directly affiliated
August 2014
with the organization in any way except serving as a board member.5 More generally, appointing employees other than the CEO to board positions simply has not become common practice among healthcare organizations, at least in the nonprofit sector. With respect to nurses, this particular concern can be addressed and resolved in several ways. One avenue is simply to look outside the organization for highly qualified nursing leaders as candidates for board appointments, e.g., nurses who hold senior leadership positions in other healthcare organizations or are affiliated with universities, foundations, or consulting firms. In instances where there is a desire to extend a board appointment to a nurse who is an employee, the potential for conflict of interest can be addressed through existing policies and procedures that typically are well-established and applied routinely whenever a physician who is employed by and/or serves on the medical staff of an organization where he or she is being considered for a board appointment. • Lack of nurse advocacy efforts. Fourth, although some major organizations such as the Robert Wood Johnson Foundation and some executive leaders15 have advocated strongly for greater involvement of highly qualified nurses in the governance of hospitals and health systems, other organizations that surely recognize the importance of the nursing profession in affecting healthcare quality and cost—such as the American Nurses Credentialing Center, the Joint Commission, and rating agencies—have been surprisingly silent on this topic. And so, for the most part, have been influential hospital associations and nursing associations. Whatever the reasons for their reticence, it certainly has contributed to the strikingly low level of nurse engagement in the governance of America’s hospitals and health systems.
THE CASE FOR CHANGE It is the authors’ shared belief that there is an abundance of nurse leaders who are highly qualified for board roles and who, if invited and appointed, would contribute substantially to board deliberations and decision making.Yet, a series of studies by independent parties clearly suggest this talent remains largely untapped. So, what is the case for change? Why would it be beneficial for hospital and health system boards, the institutions for which they are responsible, and the communities they serve to have the presence of nurse leaders as voting members? • Organizational knowledge and impact. First, with all respect to physicians and other health professionals, the impact of nurses on the quality of patient care is enormous and unarguable. In the inpatient setting, nurses perform many complex clinical procedures and, even more importantly, are charged with the duties of advocacy, care, and vigilance for patients 24 hours a day, 7 days a week. Because of around-the-clock responsibilities, nursing practice demands highly coordinated teamwork with excellent communications, effective handoffs, and shared accountability. In today’s hospitals, where www.nurseleader.com
acuity levels are rising, clinical outcomes and patient satisfaction increasingly are dependent upon nursing care and leadership. It would seem apparent that board deliberations and decision making would be enriched by the perspectives of expert nurse leaders who are uniquely equipped to assess the impact of board decisions on nursing practice and patient care. • Public trust and confidence. Second, we are in an era in which the American public has lost confidence in large institutions, both government and private. It is clear the public wants more transparency, better performance, and more accountability from those who are responsible for these institutions, including hospitals and health systems.16 Meanwhile, a host of surveys by Gallup and other experts demonstrate that nurses are viewed as patient advocates and that nursing is the most trusted profession in the United States.17 In addition to the value of nurse leaders’ expertise and input in board deliberations, it seems apparent that the presence of nurse leaders on boards would enhance the credibility of boards and their decisions in the eyes of the community they serve and other stakeholders. The fact that more than 70% of America’s hospitals, health systems, and academic medical centers include no nurses as voting members on their boards is simply incredulous to the lay public with whom the authors interact. • Relevance to healthcare reform objectives. Third, passage of the Patient Protection and Affordable Care Act in 2010 and growing recognition that improving America’s healthcare system requires concerted attention to the Institute for Healthcare Improvement triple aim of “better patient care, better population health, and lower costs” have heightened the logic for increasing the engagement of nurse leaders on the boards of healthcare organizations. Without nursing involvement and support, little progress can be made in achieving any part of the triple aim. In formulating and implementing organizational policies, priorities, and strategies, the expertise and perspectives of nursing is increasingly essential.The fact that most American hospitals, health systems, and academic medical center boards make major decisions without the intellectual capital and votes of nurse leaders is indefensible. • Large pool of well-qualified candidates. Fourth, in many communities around the country, it is difficult to identify highly capable persons who possess the competencies required to serve effectively in healthcare governance roles and are willing to devote the time these roles demand nowadays. For example, a recent survey of hospitals and health systems found that 50% of respondents report “…it is becoming increasingly difficult to recruit new (qualified) board members.”18 The nursing profession includes large and growing numbers of highly educated professionals with strong skills and experience in areas of great importance to hospital, health system, and academic medical center boards, e.g., quality measurement and control, process improvement, resource allocation, and performance evaluation. Nurses represent a tremendous pool of competence and experience with
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direct relevance to the issues that healthcare boards must address today. Moreover, they bring deep dedication to improving patient care and population health. The multiple reasons why nursing engagement in governance is important does not mean that nurse board members need to be drawn from the organization’s work force or that all nurses are prepared or qualified for governance roles. To the contrary, all candidates for board appointments should have a deep commitment to the organization’s mission and values, strong experience and pertinent competencies, and willingness to devote the growing amount of time and effort required to be a productive board member in the contemporary healthcare environment. The pool of potential nurse candidates can and should include nurse leaders in other healthcare organizations, consulting firms, academic institutions, foundations, and so on. Hospital, health system, and academic medical boards should not be composed of “representatives” of professional or organizational quadrants. Evaluation of potential board candidates should be competency-based; all appointees should meet high standards and be fully committed to the long-term success of the organization they will govern. Board members are not there to serve as the “representative” of a particular stakeholder group. For too many years, very few nursing leaders have been given the opportunity to serve as voting members of hospital, health system, and academic medical center boards. Instead of being at the boardroom table, participating in board deliberations, and helping the CEO and physician colleagues to inform and educate lay board members about patient care and contemporary healthcare issues, nurse leaders largely have been seated as observers in the back of the boardroom or, in too many cases, totally absent from board and board committee settings. The effect has been to deprive most boards of the valuable experience, insights, and perspectives that nurse leaders can bring to board deliberations and decision making. It is our shared conviction that the presence of nurse leaders as voting members of healthcare boards will improve governance effectiveness. We call upon healthcare boards and CEOs who have not already done so to consider the potential benefits of adding highly qualified nurse leaders as voting members. We believe the case for taking that step is powerful, and that the time for action is now. NL
7. Prybil L. Nursing involvement in hospital governance. J Nurs Care Qual. 2007;22(1):1-3. 8. Prybil L, Levey S. Peterson R, et al. Governance in Nonprofit Community Health Systems. Chicago, IL: Grant Thornton; 2008:5-6. 9. Prybil L. Engaging nurses in governing hospitals and health systems. J Nurs Care Qual. 2009;24(1):5-8. 10. Van Dyke K, Combes J, Joshi M. 2011 AHA Health Care Governance Survey Report. Chicago, IL: AHA Center for Healthcare Governance; 2011:13. 11. The Governance Institute. Governing the Value Journey: A Profile of Structure, Culture, and Practices of Boards in Transition: Biennial Survey of Hospitals and Health Systems. San Diego, CA: The Governance Institute; 2013: 5. 12. Mason D, Keepnews D, Holmberg J, Murray E. The representation of health professionals on governing boards of health care organizations in New York City. J Urban Health. 2013;90:888-901. 13. Kristoff N. She’s (rarely) the boss. New York Times. January 27, 2013:SR11. 14. Petrecca L. More women on tap to lead companies. USA Today. October 27, 2011:3B. 15. Lumpkin J. The missing voices. BoardRoom Press. D2013;24(6):4-14. 16. Prybil L, Ackerman K, Hastings D, King, J. The Evolving Accountability of Nonprofit Health System Boards. Chicago, IL: AHA Center for Healthcare Governance; 2013:9-10. 17. Nursing Leadership from Bedside to Boardroom: Opinion Leaders’ Perceptions. Prepared by Gallup for the Robert Wood Johnson Foundation; January 20, 2010. http://www.rwjf.org/en/research-publications/find-rwjfresearch/2010/01/nursing-leadership-from-bedside-to-boardroom.html. Accessed January 2014. 18. Murphy S. Board Recruitment and Retention: Building Better Boards Now…and for Our Future. San Diego, CA: Governance Institute; 2013:1,7-8.
Lawrence D. Prybil, PhD, is Norton professor of Health Care Leadership and associate dean at the College of Public Health, University of Kentucky in Lexington, Kentucky. Dr. Prybil presently serves on the boards of the AHA Center for Healthcare Governance and the Institute of Accountable Healthcare Governance, Inc. He can be reached at [email protected]. Melanie C. Dreher, RN, PhD, is dean emeritus of the College of Nursing, Rush University, Chicago, Illinois. She presently serves on the boards of CHE/Trinity Health (chair) and Wellmark Blue Cross and Blue Shield. Connie R. Curran, RN, EdD, is president of Curran Associates in Chicago, Illinois. She presently serves on the boards of DeVry, Inc. (chair), DePaul University, Hospira, Inc., Lurie Chicago Children’s Hospital, and the University of Wisconsin Foundation. 1541-4612/2014 Copyright 2014 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2014.05.011
References 1. Moses H, Matheson D, Dorsey E, George B, Sadoff D, Yoshimura S. The anatomy of health care in the united states. JAMA. 2013;310:1947-1963. 2. Yong PI, Saunders RS, Olsen LA, eds. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. Washington, DC: National Academies Press; 2010. http://www.iom.edu/Reports/2011/TheHealthcare-Imperative-Lowering-Costs-and-Improving-Outcomes.aspx. Accessed January 2014. 3. Prybil L, Ackerman K, Hastings D, King J. The Evolving Accountability of Nonprofit System Boards. Chicago, IL: AHA Center for Healthcare Governance; 2013:5. 4. Totten M. The Value of Governance. Chicago, IL: AHA Center for Healthcare Governance; 2013:8-11. 5. Prybil L, Levey S, Killian R, et al. Governance in Large, Nonprofit Health Systems: Current Profile and Emerging Patterns. Lexington, KY: Commonwealth Center for Governance Studies; 2012:6-45. 6. Bader B, Kazemek E, Knecht P, et al. Physician participation on the hospital board; a moving target. BoardRoom Press. 2010;21(2):18-20.
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