Asking the right questions

Hospitals are making greater investments in community health. More and more, they are engaging in “upstream” efforts to address the social determinants of health in the communities they serve. These efforts include assistance with locating affordable housing, elder care, child care, nutritious foods and a variety of other daily needs. Ensuring the support of the board of trustees and engaging it in these initiatives is key to their success.

In a conversation with Todd Linden, CEO of Grinnell Regional Medical Center in Iowa and a Health Forum board member, he laid out what he sees as the key roles a trustee should play in ensuring the delivery of the best “whole person” care and the services needed and demanded by the communities a hospital serves.

In an era of value-based payments and higher patient deductibles, the hospital of today will be less relevant, says Linden. We need to focus on whole-person health and understand the needs and desires of our patients beyond acute medical care. Patients are shopping for the best value and the best care. In fact, a 2007 McKinsey & Co. survey showed that only 20 percent of patients’ choices were based on clinical quality, while a remarkable 41 percent were based on patients' nonclinical experience.

At the board level, discussion needs to move beyond trustees' fiduciary and strategic role to “generative governance,” says Linden. Too often, the board is utilized to provide a seal of approval or rubber stamp for administrators' predetermined or already-laid-out decisions, leaving little room for creativity or tapping into the collective wisdom of the group.

For example, a major decision was needed regarding the future of the fitness center at Grinnell. Founded almost 20 years ago with a goal of serving the wellness needs of the community, the center was not performing up to expectations and was losing money and memberships. It seemed to some that the initiative had run its course. Was it time for Grinnell to revert to being a provider only of acute care services?

Rather than merely looking at the financial pros and cons of operating the center and taking a problem-solving approach, Linden and the board took a generative approach to rethink the issue with these questions:

• What does the community need?
• What is the role of the hospital in responding to that need?
• What is the role of the hospital in improving the health of the community?

Facing these questions, the board's answer was a resounding affirmation of the goal of wellness — that Linden and his board would do what it takes to keep the fitness center open.

Once that commitment was made, Linden said, the philanthropic community stepped forward and ensured the center was fully funded. In his view, full funding by donors was a ratification of the generative process. In one year, membership at the fitness center has doubled.

Generative thinking

Board members have a bird's-eye view of the community. Generative governance allows trustees to bring that wisdom to the boardroom. Based on a model promulgated by William Ryan, Richard P. Chait and others, generative governance is a state of being — asking the right questions and being OK with not having the answers.

Ted Ball, a leadership coach who has written on the topic, says these questions are the only ways in which a board can help its hospital learn how to collaborate with its partners more successfully. Better collaboration enables the hospital to create better and more patient-centered services across the continuum of care, not just within the silos of particular hospital services.

That said, what do you need to know as a board member to engage in generative thinking? Here are a few suggestions:

• Ascertain your community’s interests beyond acute care and ask what services it would like to see your hospital offer.
• Survey your employees to find out what “hidden” skills and interests they already have related to wellness, prevention, integrative health and alternative therapies.
• Learn more about what nonacute services, if any, are offered in your hospital. Are these initiatives supported by your CEO, or is it a bottom-up effort?

As a board member, what else can you do to support whole-person health? Here are some suggestions:

• Get out into the community and learn as much as you can about the needs your constituents are expressing, says Debby Pohlson, a community activist and former board member of Grinnell Regional Medical Center. In the case of integrative health, for example, try massage and acupressure so you can understand how and why they work.
• Bring this information, knowledge and insight back to your hospital administration. How can your hospital serve as a bridge between the community and the health care system?
• Study best practices around the country or the world to see what might work for you, says Pohlson.

Every CEO wants his or her board to be successful and vice versa, says Linden. Generative governance — while it might be uncomfortable at first — is a way for organizations to reinvent themselves. What better way to address the often complex challenges faced by our evolving health care system?

Sita Ananth, M.H.A. (sananth@pacbell.net), is a Napa, Calif.–based consultant and writer specializing in wellness, community health and complementary medicine.