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Chris Dadlez wanted to tackle some of the health problems that disproportionately impact minority residents in Hartford, Conn., but the Saint Francis Hospital and Medical Center's chief executive officer acknowledges that he had some governance goals as well. By forming a men's health institute, he hoped to expand his network of talented minority leaders, with an eye toward better diversifying his own board. "It was really premeditated," he says.

Several years ago, Saint Francis leaders opened the Curtis D. Robinson Men's Health Institute to focus on health disparities, with a particular focus on prostate cancer among African-American men. And that institute, along with other efforts, is starting to pay off.

Since 2011, when the 34-member board passed a resolution to address health disparities, the number of minority trustees has increased from two to five. Dadlez's eventual goal: at least 10 minority members to help lead the 617-bed nonprofit hospital, which has a minority patient population of at least 30 percent.

"The point is that where there's a will, there is a way," he says. "The folks who say it's too hard to find [minority] leaders, I think it's more of an excuse than anything else. Because if you really worked at developing the relationships, there are definitely very talented people out in the community who would be willing to step up and work with you."

Diversifying the board table, a long-discussed goal, still is more of an agenda item than reality, according to the findings of a 2011 survey of 924 hospitals released last year by the Institute for Diversity in Health Management, an American Hospital Association affiliate. Nationally, 29 percent of patients are from a minority group; comparatively, 14 percent of trustees are, the study found.

But hospital leaders like Dadlez argue that the strategic business case, already a pressing one, has only become more acute amid changes in demographics and hospital reimbursement trends. By 2043, minorities will outnumber Caucasians nationally, according to the latest Census Bureau projections issued in late 2012. Meanwhile, as Medicare and other insurance models begin to pay hospitals based on keeping patients healthier and away from the hospital, the case for addressing the long-documented health disparities that impact some minority populations becomes even more compelling.

In tackling these complex health and business issues, community perception also matters, says John Bluford, CEO of Truman Medical Centers in Kansas City, Mo. One-third of that facility's 34-member board is African-American or Hispanic, according to a 2012 analysis.

The board's multicultural face, and the connections that it's built with the surrounding community, played a role in the successful vote this spring to extend the health levy for indigent care, Bluford says. Three-fourths of voters approved the levy, which raises $15 million, two-thirds of which will cover treatment at Truman. "In an anti-tax environment, that's pretty impressive," he says. "I think that our diverse board and their [community] engagement contributed significantly to that."

Still, long-time proponents for better governance diversity sometimes verge on the exasperated, as they reflect upon the limited progress to date. Fred Hobby, CEO at the Institute for Diversity in Health Management, pointed out that the 14 percent rate of minority trustees might be the "best-case scenario." Another survey, published in 2011 by the AHA Center for Healthcare Governance, found that minorities comprised just 10 percent of boards nationally.

Locating talented candidates has never been easier, says Hobby, pointing to the Minority Trustee Candidate Registry. The online database, created in 2008 by the Institute and other AHA partners, is approaching nearly 600 candidates. Hobby knows of only three dozen or so individuals who have been tapped to join boards.

"The AHA has actually invested a lot of time, money and human resources to go out to these communities and identify qualified professional minorities who have the skill sets to be on boards," Hobby says. "And yet they are not getting recruited."

'Inappropriate and Untenable'

Hobby and others say the problem is not malevolence, but neglecting to work harder to recast the recruiting net. It takes time and occasionally moving beyond those ingrained networking circles. "People like to be around their peers," Hobby says. Even a Caucasian professional, he notes, might feel less comfortable with someone with a more working-class job.

Mixing up the board table is not without its risks, says James E. Orlikoff, a Chicago-based health care governance expert and senior consultant to the Center for Healthcare Governance. A lot of advanced planning is critical to make sure that the trustees who are recruited not only have the expertise the board needs, but also address other gaps in the board's composition.

During recruitment and orientation, new members may need to be reminded that their primary role is to represent the board to avoid falling into the trap of representational governance and focusing disproportionately on the interests of their demographic group, he says.

"There is something inappropriate and untenable about having a group of white males lead organizations which serve increasingly diverse communities," Orlikoff says. "So the question becomes: 'How do we change in a way to get more diverse leaders of health care organizations without falling into the traps?' And the key is to recognize the traps."

The AHA and four other groups continue to push hospitals to demonstrate some momentum through the Equity of Care initiative. This spring, Equity of Care's National Call to Action set targets, urging hospitals to increase minority board representation to at least 20 percent by 2020.

For some hospital systems, that target might be higher or lower, depending upon the demographic mix of the communities they serve, says Matt Fenwick, who directs program and partnership development for AHA's Health Research & Educational Trust. Picking a performance goal is designed to "move the dial a little bit," he says. "These seemed reasonable. These seemed doable."

Race is not the only underrepresented group in board discussions. Just 28 percent of trustees are female, according to the Center for Healthcare Governance survey. This oversight doesn't make strategic sense, notes Hobby, given that hospital staffers are overwhelmingly female and studies show that women make the bulk of the family's health spending decisions.

Some hospital leaders described how paying closer attention to the backgrounds of their patients helped them to think in new ways about diversity. Several years ago, Cleveland-based University Hospitals made an effort to identify and recruit an Amish board member to serve at one of its community hospitals, Geauga Medical Center in northeastern Ohio, a region with a sizable Amish population. Saint Francis' Dadlez says that he's keeping an eye on health issues related to an emerging Burmese population there and would be open to adding a board member from that community at some point.

Janet Miller, chief legal officer at University Hospitals, closely tracks the composition of that hospital system's board, sending a memo each year with an update. As of early 2013, the 37-member board, which includes ex-officios, was 73 percent white and 16 percent African-American; the remaining members were Asian or Hispanic.

A systematic analysis incorporating many variables is a good place to start, Orlikoff says. Besides race and gender, break down the age of the members, where they live, their professional backgrounds and how long they've been on the board, he suggests.

"That in and of itself is incredibly revealing," he says. "Amazingly, many boards think they already know, just because they are sitting around these people."

In Kansas City, Bluford described a concerted effort in the last several years to boost Hispanic representation on his board after watching the Midwestern city's rapidly changing demographics. These days, 20 to 25 percent of babies born at Truman have a Hispanic surname compared with 8 percent a decade ago, he says.

Today's board includes three Hispanic members, recruited through community leaders. At the same time, the board filled specific skills gaps, locating experts in architecture and public relations, Bluford says.

Juan M. Rangel Jr., now in his fifth year on the board, says that he was recruited in part because of his experience in diversity, along with his educational expertise. "But I'm not the Latino expert," says Rangel, who also is director of community engagement at Metropolitan Community College in Kansas City.

Still, Rangel says he occasionally helps to link hospital leaders more closely with the Hispanic community. A few years ago, he suggested a reception with Hispanic leaders at Truman, a meeting that resulted in some new staff hires and other connections.

Rangel also says that he's sometimes pushed and asked questions about ways to improve minority hiring at all levels of the nonprofit hospital system, which includes two facilities with a total of 422 licensed beds. "Are we thinking not just about Hispanic/Latino groups, but all groups?" he says. "I think it comes from a different face when they hear it from me."

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Options for Elected Boards

Orlikoff advises boards to court potential candidates strategically, thinking several years ahead. Perhaps the board knows it will lose the head of the audit committee. At the same time, members want to increase Hispanic representation on the board. Now they have time to identify and recruit someone who is a great fit on both counts.

Flummoxed about where to start? Look within relevant professional networks, suggests Mary Medina, executive director of the Center for Trustee Initiatives and Summer Enrichment Program at the Greater New York Hospital Association. If the board needs an architect or a lawyer, try associated groups. Consider intriguing leaders within your church or synagogue, she says.

Working through connections might not only identify future trustees, but also can help tremendously in recruiting them, she says. "You have to have a comfort level for the outreach," she say, ticking off some ice breakers. "We talk sports. We talk universities. We talk profession. Those are all natural things we can do and it's comfortable."

At Saint Francis, Dadlez is striving these days to improve Hispanic representation on his board. He's reaching out through community leaders to broaden his pool of candidates, including asking for recommendations from Hispanic physicians on the hospital's staff. He also would like to increase the number of Asian board members — ideally, from countries in East Asia, which are not currently represented.

Not all hospital boards enjoy the luxury of such targeted recruitment and instead rely on voters to fill the board seats. Still, don't assume that elected boards can't be changed, said Richard de Filippi, who chairs AHA's Equity of Care Committee and is a trustee at Cambridge (Mass.) Health Alliance Foundation.

Talented candidates can be encouraged to add their names to the ballot, de Filippi says. Plus, he adds, "You could discourage somebody from running for re-election if he's been doing it for the last 35 years and he's sitting in the back of the board room waiting for the reception and dinner."

Richard Akin, now board chair of Lee Memorial Health System in Fort Myers, Fla., recalls being encouraged to run in 2006 for a seat on the public health system's board. But recruiting is only part of the equation, he says.

Voters tend to focus on higher-profile state and national elections and, thus, can make some seemingly random hospital board decisions in the polling booth, he says. "We have not elected in a few cases some terrific people."

In general, hospital candidates have a better chance of being elected if their name is toward the top of the alphabet, Akin says. In the most recent election, voters demonstrated a preference for female candidates, he says. (The 10-member board is now evenly split, but lacks minority representation.) Unusual sounding names don't fare well, which works against minority candidates, he says.

Caucasian board members can be responsive to the differing treatment needs and hurdles that other populations face, Hobby says. "We do have culturally competent Caucasians. And there is no arguing that."

But a more varied mix of trustees will boost the chances that the medical care and health challenges of minority groups will be more frequently discussed, says Hobby, echoing a point made by Donnie Perkins, vice president of diversity and inclusion at University Hospitals.

Both Perkins and Miller say they weren't aiming for a specific minority percentage on the system's board per se. "I'm comfortable with where we are, but [diversity] is a constant focus, Miller says. The ongoing goal, they say: to obtain a mix of perspectives and expertise and, in the process, send a signal to potential patients in Cleveland and beyond.

"Research has shown that patients want to be and are comfortable with people who walk like, talk like, sound like, look like them," Perkins says. "And that would be true in leadership as well.

"The more we are engaging in this area, and reflect our patient base as it is changing, the stronger we will be as a hospital system and in our commitment to our community."

Charlotte Huff is a health and business writer based in Fort Worth, Texas.

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