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Diversity and Equity

In Board Governance, Inclusion Starts with Intention

Changing trustee compositions are just the first step

By Kimberly A. Russel

Achieving diversity in the board room has been an intentional goal of many hospital and health system boards for years – with even greater focus throughout the pandemic and its backdrop of social unrest. According to The Governance Institute’s 2021 biennial survey, the field is finally realizing progress. Sixty-two percent of hospitals and health systems report at least one person of color on the board compared to 49% in 2019. The median number of female board members increased (from 3 in 2019 to 4 in 2021) and the average age of board members decreased from 69.8 in 2019 to 58.1 in 2021. Boards that have engineered changes in their trustee composition should consider this early success to be only a first step. Targeted board recruitment efforts must continue – these statistics should not be the end game. Just as important, equal attention should be devoted to the concept of inclusion for all trustees, with special attention to new trustees.

The purpose of diverse board composition is to actively bring a broad variety of personal and professional experiences along with divergent viewpoints into the board room dynamic. A group of people from different social and professional circles is more likely to ask the difficult questions, frame issues in new ways, air all key considerations and therefore avoid the perils of groupthink. The benefits of diverse board composition will occur only when each board member is fully incorporated into the board’s work. Similarly, if full inclusion does not happen, the board will not achieve the purpose of diversification. And without inclusion, trustee retention is at risk.

Board Culture

Inclusion is the result of both a positive board culture and deliberate actions. The culture of the board must be positive and open. As boards embark upon a diversity pathway, an important first step is assessing its culture. An annual board assessment tool, with full and honest participation from all board members, can reveal opportunities for improvement in the board’s culture. Key questions to pose to existing trustees include: Do you believe your fellow board members listen when you speak? Do board discussions generally involve all board members, or just a few? Are you comfortable expressing a different viewpoint? The board may have work to do to improve its culture as it welcomes new members to the board room.

Governance Committee Action Steps

Due to its role in board recruitment, the Governance Committee is well positioned to oversee the first steps of fully integrating each new trustee into the spectrum of governance. The first interaction for new members of the board is usually trustee orientation. The new trustee’s readiness to make significant contributions to board processes and discussions is directly related to the effectiveness of the orientation process.

The Governance Committee should provide oversight into the orientation plan for each new board member. Although it may be tempting to use the same orientation design year after year for all new trustees, an individualized orientation plan – customized to the professional background of the new member – is preferred. For example, an individual with no previous health care background will require different content compared to someone with a medical or nursing degree.

The Governance Committee should consider new trustee orientation to be a process rather than a one-time meeting. For example, are there educational videos, podcasts or publications that will assist a new trustee in getting up to speed quickly? Is there a regional or national conference that would be beneficial? A targeted orientation plan should build background knowledge as efficiently as possible for busy new trustees. A thorough and effective orientation is essential in helping the new trustee develop a knowledge base for active group participation.

Beyond formal board orientation processes, developing personal connections among all trustees is a vital step along the inclusion pathway. When a board is successful in recruiting individuals with a diverse background, standing or preexisting personal relationships with current board members may not exist. Governance Committee members can lead the way with personal outreach to each new trustee. As individual person-to-person relationships are forged, the new trustee will likely contribute to board room discussions and decisions sooner rather than later.

Developing interpersonal relationships is especially difficult if all or most board meetings are conducted remotely. Fostering inclusivity amongst all board members is a strong reason for boards to return to in person board meetings.

Some boards may benefit from deliberate strategies to nudge along personal relationship-building. Perhaps some social events can be planned to facilitate board members getting to know one another. Boards may wish to consider timing their annual retreat soon after new trustees join the board for another pathway to rapid engagement.

The Governance Committee may also wish to assign a ‘board buddy’ to each new trustee. The purpose of the board buddy is to be a peer resource. The peer is generally a trustee with several years of board experience. The peer should also initiate occasional between-meeting contact with the new trustee to answer questions.

The Governance Committee should make thoughtful committee assignments to new trustees, which is most likely to generate robust participation in board activities. The new trustee should be provided with specific orientation to the board committee(s) to which he or she has been assigned. Alternatively, some boards ask new trustees to rotate among all committees for the first year or two of board service to gain an understanding of the full spectrum of the board’s work.

The Role of the Board Chair

The board chair has a critical role to ensure full participation of all trustees around the board table along with due consideration of the points raised by each trustee. Prior to each board meeting, the chair should be thinking about how to facilitate the board room conversation to draw out the best thinking from each trustee in the room. The board chair may need to pose a direct question to draw a new trustee into the dialog. The board chair should be prepared for novel perspectives from new trustees – perhaps thoughts and opinions that have not surfaced in past board room conversations. The group facilitation skills of the board chair are paramount to achieve the goal of a respectful and inclusive board.

The Role of the CEO

Like the board chair, the CEO should be especially attentive to new trustees. The CEO is in a unique position to provide ‘just in time’ education to the new trustee about the complexities of health care and the associated board room discussions. The CEO should initiate a follow-up conversation with the new trustee after his or her first few board meetings to continue the orientation process on an informal level.

Final Considerations

The additional effort to prepare new board members and to fully incorporate new perspectives into the board room will ultimately pay off for the board and the organization. A broader level of perspectives and experiences will add both depth and nuance to board room discussions. A fully inclusive board that encompasses diverse backgrounds and viewpoints will be best prepared to navigate the challenging future ahead.

Kimberly A. Russel ( is CEO of Russel Advisors, a health care governance and CEO consulting firm.

Please note that the views of authors do not always reflect the views of AHA.