A board that guides the strategic direction of a health care system must have a keen sense of its business environment — the blend of market forces, financial realities and significant influences affecting every move the board makes. In the past, there had to be financial, legal and clinical acumen to guide decisions. That's not enough today, as providers reorient priorities toward population-level health.

From allocating capital funds to improving community health status, the diverse makeup of the service area has to be factored into decisions, and trustees steeped in the unique factors of that diversity are essential, says Kelvin Westbrook, who chairs the board of BJC Healthcare, St. Louis. "The creativity that comes from having a diverse board — and it doesn't necessarily embody itself in one particular race or another — the probing, the asking of questions, particularly when it comes to health care challenges, I think it's that mix of perspectives that can provide some greater insight into how we might approach these challenges in a different way."

Without attention to a diverse board, "what you get is a group-think," says Deanna Banks, principal of Furst Group, a health care executive search and consulting firm. "You've got similar-minded people from a singular exposure making decisions on behalf of things for which they lack insight and understanding — and sometimes empathy."

Health care "is not one-size-fits-all," says Westbrook, appointed last year as the first African-American chair of BJC's board. "Often you'll find even in a place with very outstanding health care institutions and individuals, there are pockets of the community that don't have as much access; they are not as learned or literate when it comes to their health status and their health care." Health status is complicated by "where you live, how you're raised, what you can afford to do, the quality of your education, etc." These socioeconomic determinants have to be well-understood for their variable impact on behavior, he says.

Differences Count

At Minneapolis-based HealthPartners, where the board chair is African-American and the vice chair and immediate past chair are women, "we make diversity on our board a priority," says Mary Brainerd, president and CEO of the health system and health plan. "I think we make better decisions when our ideas and approaches are challenged by people who have had different life experiences and different ways of coming at issues."

From the time Calvin Allen joined HealthPartners in 2004 as senior vice president for strategic planning and human resources, he has made presentations twice a year on either the strategic plan or people priorities, and the board consistently raises the question of diversity. He says the questions and counsel are about progress internally on leadership, recruitment and workforce development, as well as things the organization is doing to engage the community more effectively so that it can serve people "in a very detailed, targeted, personal way."

HealthPartners routinely collects information at point of service on race and ethnicity of all patients and plan members, part of an extensive program to identify disparities of care and close the gaps. The executive team devised the program in response to a challenge the board leveled nearly 15 years ago, and it has become an invaluable capability, Brainerd says. Among other results, it detected disparities in the rate of mammograms between white women and women of color, and a push for same-day mammography has helped to close that gap, says Allen.

In St. Louis, the board was frustrated over disparities between African-Americans and white citizens regarding several health issues, particularly infant mortality, which varies by as much as 300 percent by neighborhood. "You have to ask why," says Westbrook. BJC has created an outreach program to identify pregnant women sooner and get them to follow prenatal protocols. "That's the sort of question that we've been asking, and those are the sorts of challenges we're putting on the table."

Seeing What Others Don't

As health care systems take heed of such population health challenges as the incidence of chronic diseases and their higher prevalence in certain neighborhoods, a heightened understanding at the board level of economic and cultural barriers to better care is essential. "Diversity on the board ensures that there is diversity of thought and a wide variety of considerations given for the varied demographics reflected in the patients and communities that are served," Banks says.

It doesn't mean merely finding a complement of minorities and women to proportionally reflect the service area, says Bob Clarke, CEO of Furst Group. Putting women and people of ethnic origin on the board just to have them "is almost worse than not paying attention to it at all, because it becomes a token appointment." Just as a board specifically seeks out banking and legal experience or clinically astute health professionals, it should seek dynamic individuals who ably represent the needs for cultural and community awareness. "And you fill those slots the same intentional way. It's not just window dressing."

At minimum, diverse representation can reduce the number of seemingly valid assumptions for expensive decisions that fail in ways that no one saw coming. Banks relates the example in which a hospital built a state-of-the-art birthing center in a heavily populated Latino neighborhood. No Latinos were part of the facility planning.

"What it didn't take into consideration was that in the Latino community, a birth is a family event." A mom's parents, grandparents and others wanted to gather, but the rooms were too small to accommodate more than a few visitors at a time, offending people who felt turned away. "It was a beautiful birthing center that people refused to use," she said. Someone from that community on the board might have raised a concern. "You may not even know you have an issue until you're bringing in somebody who's going to give you that perspective."

Achieving Population Health with a Focus on Individual Differences

Anticipating health problems instead of waiting for people to show up sick is difficult enough, but this central objective of health care reform is compounded by a realization that there is no one way to go about it, says Mary Brainerd, president and CEO of Minneapolis-based HealthPartners.

"For a long time, people believed that if we treat everyone the same, that's equal care. What we've learned is … we need to … treat people as individuals and understand differences, understand that we may need to do things differently for people who have different cultural interests, different values, and are of different races."

Diversity goes further. HealthPartners has benefited from having board members at age extremes to understand those with Medicare, or young mothers. That brought home, Brainerd says, the need to expand services for more convenient access. Saturday morning appointments at clinics. More online care. Being more effective on the phone. Putting a clinic at Target Corp.'s world headquarters to reach thousands at work. All these ideas sprang from board members "who are thinking what they would do for their own families, things that might not come to the fore" on a board with the same gender, age or ethnic profile, she says.

Direction from the top has filtered down into priorities for community engagement, "to recognize some of the differences in what our neighborhoods were like 20 years go and what they're like today, and open up the conversation about what people need and expect," says Brainerd.

The conversations start with HealthPartners employees, says Calvin Allen, senior vice president for strategy and human resources. They're told how to not just collect but connect when they ask patients about race, ethnicity, preferred language and the like. All of it goes into the ongoing disparities analysis. "We want all our employees and colleagues to interact with the people we serve from a perspective of cultural humility. We don't know all the answers to everything as we interact with those we serve."

Assessing Diversity with 'The Shoe Test'

Health care is a challenge of cultural competency and changing business models, neither of which can be addressed without listening to different voices, says Kelvin Westbrook, chair of BJC Healthcare, St. Louis. "It's apparent that you need to have a board with a variety of perspectives so that you can share and devise the best approaches, not just for the minority community, but for the entirety of the community."

BJC's reach throughout eastern Missouri takes in rural, suburban, urban and inner-city areas, and the decision-makers need to hear what each community perceives as its challenges, he says. "Those of us who've been around the block once or twice know that not all communities see the world the same. … You do need to get input in terms of what might work somewhere and what might work someplace else."

Part of Rhonda Brandon's job as chief human resources officer is to make sure the workforce is culturally competent to deal with the differences among groups of people. "Diversity is a pillar; it's pivotal to doing the work that we do, and doing it effectively." The board challenges management to engage directly with patients through family councils, to understand them better and, in some cases, to design facilities according to what would be a better use of space and services, she says.

Westbrook, who also chairs BJC's children's hospital and previously was on the board of one of its community hospitals, has kept one idea in mind during 20 years of volunteering in health care. "A young man told me years ago [that] if you're trying to do something for the public, in the community, and you don't meet the shoe test, it's going to be problematic. By that he meant, if you look under the table and you don't have a diversity of shoes, you're probably going to get a much narrower perspective on what can and cannot work than you would if you have a diversity of shoes around the table."