Diversity on the Rural Hospital Board
By Philip Dunn
Challenges for Today and Beyond
Six years ago, the board of directors of Albemarle Hospital was largely white, male and older than 50. The Elizabeth City, N.C., hospital’s 15-member board had just two women, two African-Americans and no one born after the late 1940s—in a community that was, according to 2000 U.S. Census figures, 56 percent African-American and 66 percent younger than 45. Nobody questioned either the dedication or the quality of the board, but to Sharon M. Tanner, the newly hired president and CEO, the disconnect was obvious. “The population looks to see people who look like them in leadership positions,” Tanner says. “They will come to the hospital because they see that kind of commitment.”
Six years later, Albemarle’s board looks quite different. It now includes five women, four African-Americans, and seven members under age 50. In other words, the board now looks like the community it serves.
But this reconfiguration didn’t just happen by accident. Tanner and a series of board chairs made an explicit commitment to diversify their board—to seek potential trustees from quarters that had previously been overlooked. It was a risky proposition, but it paid off: Today, Albemarle boasts a rich, engaged board of directors who bring a variety of perspectives.
With a local population of approximately 17,000, and 140,000 in the hospital’s seven-county service area—27 percent of whom live below the federal poverty line—Elizabeth City might not strike a casual observer as a breeding ground for board talent. Then again, Tanner was no casual observer. “If you cast your net wide enough, you’ll find there are good people who represent whatever your demographic mix is,” she says. “We just made sure we cast our net wide.” Diversity is a sticky subject. Boards that seek to address it often find themselves in a political minefield. If not executed properly, a bid for diversity can backfire and leave a sour taste in a community for years. Even so, experts say it’s an issue that hospital boards must confront.
This is particularly so in places where it’s hardest to achieve—rural America. In small towns and communities, board talent is considered difficult to find at best. “It’s a major problem for rural hospitals just to get board members at all, given the limited population they have to draw from,” says John R. Combes, M.D., president and chief operating officer of the American Hospital Association’s Center for Healthcare Governance.
Consultant Eric D. Lister, M.D., managing director of Ki Associates, Portsmouth, N.H., calls the problem “a lack of perceived bench strength in terms of civic leadership.”
Nevertheless, it is in rural communities that board diversity is most important. Diversity, experts say, brings fresh perspectives and new life to a board. It keeps it from growing stagnant and positions it to better serve the hospital—and, by extension, the community.
It is important to note that diversity does not necessarily mean only diversity of race and ethnicity—although in many communities that is a critical component. Diversity comes in many flavors beyond these considerations, including age, gender, geography and occupation. The point is not to fashion a board that merely appeases segments of the community, but to ensure that the board serves the hospital and the community as well it as it can. “The reason you want diversity on your board is so you can get various perspectives around an issue,” Combes says. “Board decisions become more informed—and consequently better—when you have people of diverse opinions and backgrounds to frame a decision. It allows for better choices.”
The essential challenge inherent in diversification is how to broaden the board’s composition while maintaining or exceeding its current level of performance. It isn’t easy—especially where it’s difficult to recruit board members in the first place. But guidance for doing so does exist. Following are some tips:
Talk to People You Don’t Know
When board seats are about to become available, the automatic reaction is to look around the boardroom and ask, “Does anyone know anybody who might make a good candidate?” That’s the wrong question. Good trustees do have an innate sense of who would make a good candidate to join their ranks, but a board that limits itself to known quantities risks missing valuable input from new blood. “We might be looking too traditionally for the obvious civic leader with a history of community service,” Lister explains. Begin by taking a close look at the community’s social organizations.
“Look to see where leadership exists in populations where you currently don’t have representation,” Combes advises. Chambers of commerce and local governing bodies, such as the city council or county board, are obvious sources of potential board members; other less obvious, but potentially fruitful sources might include church or school boards, or governing bodies of local social or political organizations. Don’t underestimate the difficulty of the task, but don’t make it harder than it needs to be, experts recommend.
“It’s too easy to say, ‘There’s just not anybody qualified out there,’” says consultant Mac McCrary, president of the McCrary Company, Morganton, N.C. “If you don’t go out into the community and find new people, then you’re stuck with the same board you always had.” In doing so, define “community” broadly, and feel free to leave the hospital’s service area.
“There’s no rule that says that all trustees have to live in the area served by the hospital,” McCrary says. This is not an uncontroversial notion, however. In rural communities, local control is highly valued and fiercely protected, and the idea of bringing in “outsiders” strikes some residents as an intrusion.
Lister advises seeking potential trustees who have some legacy or tie to the area even if they don’t live there currently; someone who grew up in the community or has a family connection there; or an alumnus of a nearby college. “It’s possible to find folks who aren’t local who can make a profound contribution—if you look for them,” Lister says.
Look for Balance
Think about the traditional board member—a bank vice president, for example, or the plant manager at the local factory. While it’s important to keep going to that well, there are other local candidates who might make valuable contributions, such as students, academics, part-time residents (especially in a tourist community), and area residents who work in occupations not traditionally identified with health care governance, such as small business owners or public school teachers.
Bringing in nontraditional board members means reaching outside your comfort zone. “We’ve got to get over this mind-set that says, ‘I want to find somebody who is just like me, somebody who makes me comfortable,’” McCrary says. At the same time, however, boards have their own culture and they need to maintain a degree of comity. “There’s a difference between altering the culture of the board and disrupting it,” McCrary says.
Goodall Hospital in Sanford, Maine, has found the balance between long-time residents and newcomers (see sidebar), in part by ensuring that the board does not exist to advance social networking. “I don’t think that anybody goes shopping with anybody else on this board,” says Lorraine Masure, a trustee at Goodall for six years. “There are no cliques here. Everybody’s collegial, but I don’t think there are any two people who are really close friends outside of their service on the board.”
In Albemarle Hospital’s service area, agriculture is a key economic driver, so Tanner has sought to maintain an old hospital tradition of having at least one farmer on the board. “They pick it up pretty quickly,” she says. “If you’re smart enough to run a farm, you’re smart enough to serve on a board.”
Maintain a Permanent Recruitment Campaign
Here’s a newsflash: board terms expire. Even the most stable boards have to face turnover. So, boards should always be looking for candidates, even when there are no current vacancies. “Recruiting for the board should never be an episodic process that starts and stops,” McCrary says. In fact, you will need a constant stream of new people, forever.
So, onward with the permanent campaign. One tactic: formulate advisory committees or other working groups that can contribute to the hospital in some fashion without assuming the responsibility of governance immediately. The goal, ultimately, is to “develop the bench”—to generate a pool of good candidates who are familiar with the hospital and the demands that board membership entails, who are then ready to serve when needed. Often, this means cultivating raw talent—finding someone in the community who may not yet be ready to be a trustee, but shows promise. “If you nurture this kind of talent, you may find people who aren’t prepared yet, but will be—and if you spend three or five years developing them, then by the time you tap them they may turn into fabulous trustees,” Lister says.
Beyond this however, it’s important to spell out the organization’s expectations for new trustees ahead of time. Before trustees join the board of Goodall Hospital, Darlene Stromstad, the hospital’s president and CEO, together with a member of the board’s executive committee, has a frank discussion about what is required of board members. “We talk about hours of commitment, number of meetings we expect them to come to, what they need to understand in terms of finances and quality,” she says. “I tell them this is serious business and they are attracted to that.”
In developing a permanent campaign, trustees should sell the hospital as if they were selling real estate—put together good marketing materials and have the “elevator speech” (i.e., how one would sell the institution if they had only a few seconds to talk in an elevator) ready to go. “This should not be a cold phone call,” McCrary says. Plan out a method for approaching new members, and have a first-rate package—including the mission, financial statements, and plans for growth—in place for those conversations.
This is especially true when seeking board members who live outside the geographic region, who may not know the hospital. McCrary, himself a trustee of Blue Ridge HealthCare in Morganton, N.C., tells the story of recruiting a trustee from Asheville, an hour’s drive away and out of the system’s service area. “The first time we approached her, she had that deer-in-the-headlights look,” he recalls. “But the hospital had identified [her as] a solid candidate and was persistent, following up with multiple subsequent visits. If you’ve got a good prospect, and they say ‘no,’ don’t quit.”
Educate and Integrate
The education process should begin long before a trustee joins the board and should continue long after, experts say. “It’s one thing to reach out to the community and bring a new member onto the board; it’s another thing to get the new member to perform well,” Combes says.
Start with recruitment—a good recruitment process leads to a pool of candidates who are educated about the hospital and about issues facing health care. If trustees develop advisory boards or other nonboard committees, that experience begins to teach potential trustees about how a hospital should be run.
Then, once the candidate is about to be nominated, make sure he or she fully understands what the commitment means—and feels included with fellow trustees in making it. The goal is not just to get bodies on the board, but to make sure that all those bodies are working. This is critical when you’re bringing in a fresh face, Combes says. “If you get [people] on the board for the first time and don’t reach out to them once they’re there, they won’t be very useful,” he says. “They might be socially isolated, their concerns are not the same as what others may have; in the long run, they may lose interest. You’ve got to prepare candidates to make sure that when they’re on the board, they’re integrated into the social fabric as well as the governance fabric.”
Meeting the Challenge
When looking to diversify, boards must take care. There is no room for error, and risks abound. The biggest risk is having a new trustee believe that he or she is on the board to represent an interest group or a constituency rather than the hospital at large. “If I walk into a boardroom thinking my job is to represent my segment of the community, rather than the board as a whole, we as a board have shot ourselves in the foot,” says McCrary. “Under that scenario, I’m not going to be a good board member—and, in fact, I’ll create a lot of problems.”
The importance of avoiding factional interest politics applies whether the board is trying to integrate racially, ethnically or in other ways. One difficult constituency to satisfy in this arena is physicians. “They really believe that board physicians should be representing the medical staff—we always have to remind them [that] the chief of staff sits on the board representing the medical staff [and] the other physicians are there to represent the entire community through the eyes of a trained physician,” Albemarle’s Tanner says. To avoid any potential misunderstanding, Tanner sought a physician for her board who doesn’t admit his patients to the hospital.
A second potential pitfall is the conflict-of-interest trap. Conflict is a big issue in hospitals in general, and all boards must be aware of it, but if all potential board members who do business with the hospital are taken out of consideration because of conflict-of-interest considerations—particularly in rural areas—you may be eliminating too many good potential candidates. “In rural communities, conflicts are inevitable because of the size [of the community],” Lister says. “If everybody knows everybody, conflicts are bound to emerge. Solid board policies and careful attention can ensure, however, that these do not become problematic.” A good, rigorous recusal policy can help prevent a potential problem as long as trustees know when they shouldn’t take part in a conversation.
No one argues that diversifying, however you choose to define it, is easy. But Tanner’s lesson demonstrates that it can be done. “The key is doing it collectively and making a commitment,” she says. “Don’t put a timeframe on it; just go out and do it as quickly as possible.”
Philip Dunn is a writer who lives in Chicago.
This article 1st appeared in the June 2007 issue of Trustee Magazine.
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