Examining healthcare

1. Healthcare boards must have healthcare representatives

They can be clinicians, researchers, sector savants or others. If the board’s ultimate aim is to ensure an equitable distribution of health services and improvement of health outcomes, how can boards ask the right questions if the clinical information in front of them leaves them overwhelmed?

Ash Revell MInstD, an independent consultant says “after a while you realise what a big machine the healthcare delivery system actually is. You start to realise who is making decisions, about what happens on the whole”.

“You have to put your hand up, first and foremost. You have to be in the game to play the game. Plato said, ‘the chief penalty is to be governed by someone worse if a person will not themselves hold office’. I think some people are keen to just get on there and lead, but I think it’s really important for the reluctant leaders to come forward. The people who actually don’t necessarily think they have anything valuable to offer. You can probably add more than you think.”

Ranjna Patel MInstD, director and founder, Tamaki Health, says “you don’t see many doctors in governance because most doctors do what they do best, which is doctoring. And when it gets to the point of being on a health board, they may think everything’s irrelevant except the fact of health. That’s not what a board does. When management executives come from a health background and are passionate, they may not always put a business lens on top”.

A Harvard Business Review survey concluded that boardroom capital is built on five different types of intelligence: financial, strategic, relational, role and cultural. A share of the accountability for the consumer voice rests firmly within the boardroom. In New Zealand, community involvement in health is a long-standing tradition. With numerous silos in health delivery, it isn’t surprising that consumer engagement is among them.

The Health Quality and Safety Commission has listed consumer engagement as a strategic priority and there is growing evidence in support of the relationship between consumer engagement and improved healthcare outcomes.

2. Embedding the consumer voice within healthcare boardrooms

As the CEO of the country’s largest primary health organisation, ProCare, Bindi Norwell MInstD says she has “always been the voice of the customer in the boardroom, thinking innovatively and doing things a bit differently, being open to change. The board, as well as the ELT, need to walk the talk and be culturally aware and support of an inclusive and diverse environment not only in the board, but also in the organisation”.

Norwell described ProCare’s renewed commitment to take a brave look at how they work, “we went through a very big piece of work on our equity journey, taking a look at our organisation from governance through to people on the front line, providing healthcare directly to patients. We took a brave look at how we work and what we needed to change, to be more open, transparent and inclusive. From that piece of work, we launched our pro-equity journey, and governance is part of it. We’ve got new Māori directors and mana whenua directors. We’ve absolutely turned it inside out. I would hope that other organisations would lean into it.”

Norwell’s observations sit comfortably within the expressed intention of the health and disability system reform. “The future system will be supported by a clear set of expectations and guidelines for how local, regional, and national organisations should listen to and involve communities and consumers. This will ensure everyone understands the importance of the community and whānau voices in the services they use.”

While the elected DHB boards, as we know it, will no longer exist, the voice of the healthcare consumer remains a top priority.

For Patricia Mitchell CMInstD, CEO of Health Connections and Independent Director, her journey into the boardroom stemmed from a growing sense of frustration with not seeing the healthcare outcomes she had expected, as a clinician.

“I firmly believe governance has a massive impact on how clinicians can truly do the great work that they’re trained to do. And I often found and felt more frustrated when representation across the board table didn’t reflect the outcomes that were required for unique and underserved populations”.

Many boards are distracted by the details of compliance and new regulations, not knowing enough about long-term strategies that will add value to the organisation. “Do I think that we do well from a governance perspective? Mitchell asked, then answered: “No, we do not. There is a lack of bravery around healthcare boards. I think that we are compliance focused and not innovation focused. I think that we talk about outputs and outcomes. I think we talk about personalities or personality led and not partnership led.”

3. Personality traits around the board table matter

The manner in which a director communicates, deals with conflict and how they relay their opposition will leave their mark with the rest of the board and the management teams. Boards inherit not just expertise, but also inherent behavioural traits from members.

There has been a lot of focus on visible diversity, but a mix of skin colours, genders and ages will only get you so far.

While these boards might look different, they may end up thinking alike. We are all vulnerable to groupthink. We tend to mirror social patterns. In reality, well-appointed boards acknowledge that unconscious biases exist. Tackling the causes of bias requires leadership and continuous conversation focused on getting the right mix of competencies, culture and diversity of skills and age around the board table.

Ben Kepes CFInstD, a professional board director who sits on the Pegasus Health Primary Health Organisation Board among others, says “that a decent board can actually withstand a reasonable amount of individual vested interest because it is about consensus decision-making. If you’ve got seven people around the table, of which two or three have a particular angle, that’s probably going to be okay because the seven is where the decision-making lies, with all of them”.

The multicultural fabric of New Zealand society lends itself to challenging longstanding norms. Many among us might look at boards as mystical ivory towers of governance. This needs to change. Governance is not an exclusive club of chosen individuals.

Patel says “that without diversity of thought boards are going to miss out on whole segments of the population”. She suggests questioning the intent of the board when you are offered a role as director. “I ask boards why they have chosen me, if I sense that it is a tick box exercise, I will let the opportunity go”.

Being a director is not an easy task. It is highly demanding of your time, expertise and commitment, without a comparable income to match the effort. Between council-controlled organisations, state-owned enterprises, not-for-profits, NZX/ASX-listed companies, cooperative companies, unlisted private companies and statutory boards, there is no shortage of opportunity.

“At a macro level, when you’re changing the status quo and you’ve got systematised or institutionalised bias, somebody has to pay the price to redress that,” says Kepes. “Having said that, there’s lots of organisations that need governors. There’s lots of governance opportunities. So there are plenty to go around, I think.”

4. Look through the windscreen, not the rear-view mirror

Governance is tethered when directors spend too much time and energy pondering the past, and not enough time looking past the horizon. Boards need to look further out than anyone else within the organisation.

Deb Boyd MInstD, CEO, Ormiston Hospital and HiNZ Board member, says “it’s important not to get bogged down with operational matters but to stay future-focused and actively engaged in monitoring international trends. One example of this is cyber security, which is a most significant risk and I don’t think that organisations in New Zealand are still very cognisant of it. In 2016, cybersecurity insurance was hard to find. I had to ask for something specifically to be underwritten. This was very new for New Zealand but something more common internationally. Directors need to maintain their education and currency on a wide range of subjects and ensure they can advocate and support the change that is required for companies to stay relevant and future focused”.

So, is there an evidence-based approach that healthcare directors can follow?

Taimi Allan, board member of the Mental Health and Wellbeing Commission and director of Ember Innovations, says we need more. “I’m leading an innovations company at the moment. The very first thing I did was say, ‘okay, where is a more innovative governance structure that we can work with that operates differently?’ It doesn’t exist. There’s nothing there. I’m sitting there going, how do we do this different, better?

“The normal structure of how board meetings run, and how often, isn’t going to work for us because we’re working in a really lean model. I’ve got the best people in New Zealand in innovation and healthcare on my board. How do I get the best out of them? If they’re just turning up to meetings and going through an agenda, I think there must be different structures. So I’d say yes, more evidence needs to be built about what are different models and in what circumstances they work in health”.

Lloyd McCann, CEO and Head of Digital Health, Mercy Radiology and Healthcare Holdings Ltd, says “if there is good governance, it can potentially be quite invisible because you won’t see failures, you won’t see system failures, you won’t see organisational failures, you won’t see failures in terms of healthcare service delivery. So there is that risk that good governance will actually go unnoticed. We must point to good examples of governance when it does occur. We must raise the profile of people working in governance to highlight their contribution and its impact on system performance”.

In the end, boards and governance structures are about people. Often, the problem boards face is not having too few people with sector expertise. The problem is too many people who know their sectors all too well, and predict the future looking into the past.