Becoming a visionary board

Hospital trustees sometimes question how they can determine a strategic future when so much in health care is changing and the future is seemingly unknown and unpredictable. But this is precisely the time when boards must be at their best. Forward-thinking, visionary boards anticipate potential futures. They prepare for and embrace the changes ahead.

In their book Governance as Leadership: Reframing the Work of Nonprofit Boards, Richard P. Chait, William P. Ryan and Barbara E. Taylor define three types of governance: fiduciary governance, strategic governance and generative governance. Fiduciary governance is the cornerstone of the board’s responsibilities and involves stewardship of organizational assets, ensuring legal and regulatory compliance, and providing operational oversight. When practicing strategic governance, boards ensure that the organization is working toward fulfilling its vision and mission by setting strategic priorities and goals and monitoring performance against them.

Generative governance also must be a priority for trustees in today’s environment, characterized by fast-paced change and offering only a hazy view of tomorrow. It involves envisioning the organization’s purpose and meaning in an evolving world of shifting stakeholder needs and preferences. Boards that practice generative governance take time to question assumptions, explore nontraditional scenarios and perspectives, and discover new and innovative ways of accomplishing goals, achieving visions and fulfilling missions.

'What if?' and 'So what?'

Visionary trustees consistently ask themselves a series of questions, including, “What do we know today that we didn’t know yesterday?” By staying well-informed with a continuing flow of new information and evidence, visionary boards can anticipate emerging trends. They begin to envision potential futures by asking themselves, “What if … ?” For example: “What if our patient volume continues to decline as preventive and wellness efforts succeed in improving our community’s health, as our initiatives succeed in reducing readmissions and as care continues to shift to outpatient settings?” “What if health care is no longer hospital-centric?” “What if retail pharmacies become a preferred source of diabetic care?” “What if we formed a partnership with … ?” “What if we look at this differently?”

Boards move another step closer to becoming visionary when they also ask: “What could that mean to us? What implications does it have for our hospital?” and “What could or should we do to be prepared?” These are questions that begin to generate deeper understanding of new paradigms and their implications for the hospitals and health systems that boards are responsible for leading. They are the questions that prompt challenges to the assumptions and status quo that may hold organizations back.

By considering a variety of potential scenarios and possible responses, visionary boards are able to consider carefully what possible actions they must take to capitalize on the forces for change. They are better prepared to act quickly, confidently and on their own timetable instead of reacting to situations that may be forced upon them.

Some obstacles   

While there are many potential challenges that prevent trustees from maximizing their visionary potential, here are a few of the most common causes that derail boards.

Failing to stay well-informed: Without credible and current information and data, trustees cannot hope to recognize or anticipate the forces, trends and changes happening in the environment around them. They must develop a high level of understanding in the areas most critical to organizational success and performance. Passing knowledge is not enough. Today’s board members must be continuous learners in and outside of the boardroom. Well-informed boards search out opinions, ideas and perspectives that may be different from their own. They listen to a variety of voices outside the organization, engaging the viewpoints of people with unique experiences and perspectives. In doing so, visionary boards expand their knowledge base and open new lines of thinking.

Poor agenda planning and meeting management: Confronted with multiple challenges and competing priorities, effective boards must focus their time and attention on the issues most critical to achieving the organization’s mission and vision. Board chairs must ensure that meeting agendas allow the board to focus on strategic issues. The board chair also must manage meetings to engage trustees at high levels of thinking and planning, enabling and facilitating the inquiry, dialogue and debate needed to be visionary.

AtlantiCare board chair Michael Charlton meets with the organization’s CEO weekly to discuss strategic priorities and any changes in course that may be emerging to understand where the organization is going and determine issues that need to be discussed at upcoming board meetings. Senior staff draft meeting agendas organized around the Egg Harbor Township, N.J.-based health system’s strategic priorities.

Charlton then meets with the CEO, chief of staff and board liaison to ask questions, reflect on committee issues and staff reports, and finalize the board agenda, which includes a consent agenda to address fiduciary items and open up board meeting time for strategic and generative discussion. Board meeting materials are distributed a week in advance for review. A few days before each meeting, Charlton talks with board members to understand their issues and perspectives so he can draft questions that will tee up issues for board discussion.

“Our board is composed of many CEOs, including myself, but, as board chair, I don’t play that role,” he says. “My job is to pose thought-provoking questions. What I’ve learned through board chair coaching and my own experience is that when I talk less, meetings are more productive.”

Focus on the wrong issues: Boards must continually adjust their attention to deal with the issues of the future, not the issues of the past. Time should be concentrated on understanding trends and priorities and their implications for the organization rather than dealing with operational details. The board’s focus should be on visionary-focused dialogue about the challenges, issues and opportunities ahead.

Disengaged trustees: Board service has never been more challenging. Trustees must know and understand more and take on greater responsibility than they have in the past. Board members must have the time, availability and discipline to act on their commitment to the board and the responsibilities of trusteeship, and those expectations should be part of a job description shared with board candidates and reviewed by the full board annually. Board members also should possess personal attributes and qualities, outlined in more detail below, that ensure the caliber of engagement and contribution required for effective, visionary governance.

Failing to engage in deep, decisive dialogue: Visionary board members ensure that their governance conversations are always vibrant, vital and focused on purpose and outcomes. Dialogue should be the board’s “social operating mechanism.” Through synergistic discussions, boards can generate innovative solutions by grappling with new concepts, ideas and solutions. Without constructive challenges to conventional wisdom and thought, the best solutions may never surface.

Visionary boards regularly confront issues by challenging assumptions and exploring alternatives to traditional thinking. They ask questions such as: “What are other hospitals and health systems doing to address this issue?” “What alternatives did we explore and why did we decide not to pursue them?” “With whom might we partner to make the greatest impact?”

Holding on to the status quo: Holding on to the status quo will not push organizations to excel. Improvement and advancement are the keys to future viability in a complex, evolving health care world. Trustees must lead their organization in a way that lets it capitalize on new opportunities. Innovation and change must be encouraged and rewarded in all areas and levels of the organization. This requires trustees to provide leadership of thought, ideas, creativity, accountability and purpose. It also means letting go to embrace a future that may be markedly different from the past.

Lack of a common purpose: As organizations grow through mergers, joint ventures, partnerships and collaborations across the continuum of care, all stakeholders must share a common purpose or mission. Nothing is more motivating than a clear picture of a bright and successful future. Accomplishing this demands that the board develop an exciting, shared mission that will stimulate enthusiastic followers and ensure development of a common culture that supports and empowers mission fulfillment.

Attributes of visionary trustees

Visionary trustees possess the personal attributes and qualities that ensure the caliber of engagement and contribution required for generative governance. Developing the needed expertise requires motivation, commitment and time. High-caliber trustees voluntarily seek to be well-informed and knowledgeable, and demonstrate intelligence and quick understanding.

Visionary trustees are big-picture thinkers open to new ideas. They think and speak strategically in discussions about complex scenarios and situations. Visionary trustees analyze trends to determine possible implications to the hospital or health system. They display creative and resourceful thinking, considering situations from multiple angles and perspectives.

Visionary trustees use “reasonable inquiry” to pursue new solutions and opportunities, asking thoughtful and insightful questions. Visionary trustees also are willing to challenge the status quo and take calculated risks in the interest of moving their organization forward and fulfilling its mission. These individuals look into the future and imagine what might be achieved.

Visionary boards do not develop by chance. They build on the sound foundation of their organization's mission, a good understanding of their communities’ health care concerns and the bigger perspective of how health care is evolving.

When boards ask penetrating questions and engage in vibrant conversations that explore new possibilities, their visionary focus can stimulate creative thinking, dialogue and debate. Such deliberation helps trustees to identify and evaluate new and different strategies, overcome challenges and barriers, and encourage calculated risk-taking that leads to visionary futures.

Mary K. Totten ( is a senior governance consultant to the American Hospital Association.

Visionary governance starts with strong board leadership

Board leadership focused on mission and community helped chair Michael Charlton and his board guide AtlantiCare to take a significant first step toward improving community health and quality of life by addressing social determinants of health such as poverty, violence, lack of education and unhealthy behaviors. AtlantiCare, based in Egg Harbor Township, N.J., convened 1,800 people in the community through survey and discussion to determine how the health system could make a difference.

“Many participants were wedded to their own personal views about how AtlantiCare should help,” Charlton said. “But it was the involvement of our board and many tough conversations and board-level discussions that helped move the ball forward.”

The board stayed focused on the organization’s mission and embedded itself in the community’s view of key needs that should be addressed. After 14 months, AtlantiCare is poised to launch efforts toward reducing opioid deaths in the community, and it is now aligning health system and community performance metrics to monitor progress.

“A focus on our community is the board’s true north,” Charlton says. “We can’t move away from this. If health systems talk about population health and community but all they do is create greater size and scale to improve reimbursement, then they’ve lost their key focus. Pursuing true north takes courage. Boards need to ask themselves, ‘Are we doing what we need to do to take care of this community and the people we serve?’”

— Mary K. Totten

10 board transformations

Here's what trustees can do to ensure visionary governance.

  1. Develop new levels of expertise in the issues driving health care.
  2. Focus on strategic issues.
  3. Understand the community’s health concerns.
  4. Envision multiple futures.
  5. Focus more on the emergent and less on the urgent.
  6. Ensure high-quality trustee engagement, commitment and contribution.
  7. Engage in deep, decisive dialogue.
  8. Be catalysts for change, challenge assumptions and generate new thinking.
  9. Listen to outside views and perspectives.
  10. Maintain a constant focus on mission and value.

— Mary K. Totten