Finding the Right Size for Your Hospital Board

What’s the ideal size for a board of trustees?

Consider an unlikely model: “Goldilocks and the Three Bears.” Goldilocks tried three bowls of porridge, chairs and beds to find which suited her. Each choice meant rejecting two that were perfect for two bears. So, too, with governance.

The unequivocal answer to “ideal size?” is, “That depends.” Large boards may be necessary for some. Small boards may be right for others. There’s no one-size-fits-all answer (see figure below).

Board size must be tailored to each organization’s needs. Otherwise, dysfunction will reign. Advice about how a board should be structured without knowing its challenges recalls the medical axiom, “Prescription before diagnosis is malpractice.”

Reach a consensus

The word “rightsizing” does not necessarily mean shrinking. Size is an equal partner with “whom.” A board should not aim for a predetermined size whose membership bucket is automatically filled to the brim.

Aligning the puzzle of size has two dynamics: balancing talents with needs (deciding the talents and personal attributes most likely to create high-performing governance) and fostering a healthy boardroom culture.

Consider solving the puzzle by engaging trustees in an exploration of critical qualities needed in the boardroom. “Putting All the Pieces Together,” an article for Trustee by Barry S. Bader and Sharon O’Malley, divides desired attributes into three categories:

1. Must-haves "(universal competencies"): personal characteristics (e.g., values, backgrounds and talents) needed in every trustee. No exceptions.
2. All together (“collective competencies”): talents needed on the board as a whole but not in every trustee.
3. Variables (“desirable competencies”): qualities that might be priorities for the board.

After reaching a consensus, results can be compared with the board’s current composition and terms of office. That exercise should lead to the most effective size for current needs.

Bigger vs. Smaller Boards: The Pros and Cons

Find the ideal size

How big is big? How small is small?

Except for startups, health care boards are more often too large than too small. The most extreme example? A well-known medical center with 150 trustees. More common are boards with 24 to 30 trustees. They fall into the “big” category.

Consider the August 2014 Wall Street Journal article “Smaller Boards Get Bigger Returns.” It summarized research that smaller boards generate bigger earnings and that they “foster deeper debates and more nimble decision-making.”

Another study, the 2015 Survey on Board of Directors of Nonprofit Organizations by Stanford University’s Graduate School of Business, reinforces the importance of board size. The study found the most significant contribution trustees can make is sound governance practice, including board development and succession planning.

Recommendations about board size are usually rooted in how groups work most effectively. The size most often recommended is from 12 to 15 trustees.

What if a board is double or even half again as large? Downsizing need not be traumatic, but practical considerations — pride, personal relationships, internal politics and prevailing attitudes — can sidetrack progress.

Two options may help. First, leave open the vacated board seats. Attrition works best with boards where gentle trimming can reach the goal. The second is to foster deliberations about the best approach for reaching composition and size goals and then implementing the most popular one.

The following steps may lead to rightsizing if the board can’t agree, if there aren’t term limits, if a faster answer is needed or if those remaining after attrition don’t fit needs:

• Orchestrate candid private discussions between each trustee and the board chair.
• Adjust board terms and limits so that every trustee is affected.
• Fashion new outlets for former trustees to stay connected. Options might include honorary or advisory status or committee appointments.

Still unsuccessful? Using surveys might be an answer. If board culture is so weak that rightsizing is urgent, consider a “nuclear option”:

• Process of elimination: Trustees first agree on a goal, say, going from 25 to 13. Then they participate in a survey to rank each other from 1 to 25. Rankings are averaged, and only those whose scores are on the right side of 13 will remain on the board.
• Ranking competencies: Trustees are asked to complete surveys that rate their abilities and those of other trustees. Results show what they think of themselves compared with how others rated them and the board average. Those below average end their service.

Take the quiz

Goldilocks didn’t hesitate to make her decision. The accompanying quiz (“Does Your Board Need to be Rightsized?”) could help your board determine its readiness to rightsize.

Does Your Board Need to Be Rightsized?

Boards are often too busy governing to consider how they are governing. That board size can be a conundrum reflects a tendency to foot-drag about evaluating governance systems, including determining who is governing and why.

Quantity doesn’t mean quality. Finding the right size for your board can make it more effective and high-performing for your organization. 

Paul J. Taylor (pjtaylor7x@gmail.com) is a consultant, board member and author. He is former senior vice president of South Shore Hospital, Weymouth, Mass, and lives in Hingham, Mass.