Could a board be more effective if it deeply understood the ins and outs of how a health system delivers care? For four years, the Immersion Day program at Mission Health in Asheville, N.C., has brought board members into operating rooms, intensive care units, behavioral health units and the emergency department. Participants see the complexity, challenges and realities faced by management much more vividly than via the best-crafted spreadsheets and PowerPoint presentations.

Collaboration with senior leadership and participation in strategic governance have flourished for trustees who have gone through the program. “I learned more about how hospitals actually operate during my 10 hours of immersion than I had in six years as a board member,” one board chairman said.

Eager learners

Anne Ponder is a Mission board member who knows complexity. As chancellor of the University of North Carolina at Asheville for nearly a decade, she led the intricate enterprise of a modern university, with its diverse stakeholders, revenues and goals.

Yet she remembers her first meeting on the Mission board of directors with acute clarity. The terminology, benchmarks, trends, strategies and challenges of the $1.6 billion, not-for-profit, six-hospital system were foreign to her. And the gravity of the health system’s mission struck her immediately, Ponder recalls: "I realized I needed to become a student of health care in order to be an effective board member. And there was so much to learn."

Scott Hickman, a Mission board member with long experience leading information technology and manufacturing firms, understands technology and complex systems. He feels a need to fully understand any important task that’s given to him, he says, but the complexities of health care were hard to absorb. “In manufacturing, you can't understand the business without first spending time on the production floor," Hickman explains. "Otherwise, you can't grasp the challenges and opportunities."

Show the board

Mission's CEO, Ronald Paulus, M.D., is widely recognized as a talented leader. But during a spring 2013 board meeting, even Paulus struggled to explain some of Mission’s challenges, such as its difficulty moving ED patients from triage to admitted beds in a time faster than 6.5 hours, its challenges in starting 30-plus operating rooms on time each morning and even its plans for surviving $400 million in new government payer cuts announced that year. After Paulus’ presentation, one board member said, “Why can’t you just leverage your software, optimize your algorithms, use Lean production techniques and maximize your throughput?”

As a longtime board member and vascular surgeon, I tried to help Paulus explain that it just wasn’t that simple. But we struggled to describe why. Then, in an epiphany that seems obvious in retrospect, we realized that we could simply show our board. We could take board members deep into the hospital and let them see for themselves why Peter Drucker (the father of modern management) called it “the most complex human organization ever devised.”

After all, our board members were some of the most insightful and experienced leaders in our region. But they came from other fields: banking, law, manufacturing, education. And their exposure to health care derived from meetings, PowerPoints, spreadsheets and — in the vacuum left by the absence of direct observation — perhaps even Hollywood.

First Immersion Day

Two weeks later, Hickman agreed to become our experimental subject in what we soon named "Immersion Day." We began at 7 a.m. in Mission’s 770-bed flagship hospital, signed documents assuring Health Insurance Portability and Accountability Act compliance and changed into scrubs. We walked together to preop, where Hickman met a patient being prepared for major bypass surgery. He followed into the OR, where he saw our "safety timeout" that he’d been hearing about for years. As the surgery unfolded, he watched nurses, doctors, anesthetists, lab and radiology techs, support staff and managers.

We moved to cardiac surgery, where he stood 2 feet away as surgeons stopped a man’s heart and placed it on bypass. He saw da Vinci robots help urologists preserve nerves while excising cancer, and he saw his finance committee’s spreadsheet entry for “supplies” come alive in the central core as he strolled along aisle after aisle of implants destined to replace aortas, spines, hips, knees, heart valves, corneas, bladders, hernias and skin.

Next, we walked to the ICUs, where Hickman saw how poverty, substance abuse and just bad luck can leave anyone fighting for life. He learned why care can be so expensive and caregiving so draining. He watched a trauma surgeon struggle with the electronic health record as alarm chimes, pages and urgent phone calls peppered him. And he listened with palliative care doctors as the family of an elderly woman made the sad but loving decision to withdraw now-futile care.

We stopped at the Remote Patient Observer Center, Mission’s futuristic and high-tech innovation that prevents falls among patients at risk. Hickman sat and talked with a patient on dialysis and began to understand why kidney-failure patients now make up 10 percent of Medicare’s costs. And he watched interventional neuroradiologists guide wires, catheters and coils into the brain of a woman with a cerebral aneurysm.

As Asheville’s rush hour gave way to Friday night, we entered the ED. From the triage desk to the major trauma room, the team showed Hickman how wildly inaccurate TV dramas can be. Mission’s staff tamed chaos with calm and professionalism as they intubated an overdosing teenager, broke the news of advanced cancer to the elderly man in the next bay, and then soothingly and painlessly set the leg fracture of a child with congenitally brittle bones.

Immersion today

Since that first Immersion Day, Mission's program has expanded, adding Immersion Days for journalists and elected policymakers. All receive additional, deep exposure to Mission's behavioral health program and the societal challenges it bears.

Ponder's immersion came just months ago. On locked units of two campuses, Ponder saw firsthand how mental illness, substance abuse, homelessness and shrinking resources combine to place huge stresses on patients and care.

"My Immersion Day was so informative and moving," she relates. "I saw boardroom concepts come to life: quality-of-care for patients, quality-of-life for physicians, futile care. Our patients were older, sicker and poorer in aggregate than I'd imagined, and Mission's tenuous stream of resources seemed fragile. The experience deepened my understanding and commitment to board service."

Insight and collaboration

Now that almost every board member has completed the program, what changes has it brought? Although it’s naturally difficult to quantify, executives and board members agree that their experience put a face on Mission’s need for facility expansion and was instrumental in the board’s decision to approve construction of the $404 million Mission Hospital for Advanced Medicine, a main campus replacement tower. Recently, the board moved toward adding a separate psychiatric hospital and approved Paulus' investment in an innovative anti-burnout program for caregivers.

One effect that Mission’s executive leaders don’t see is any desire on the part of board members to become more involved in operations rather than governance and strategy. Perhaps counterintuitively, it seems that once board members see firsthand how complicated the delivery of care is today, they come to better appreciate the skill and expertise of management — and to leave operations to the management team.

The benefit of immersion for boards seems to be the focus it brings to strategic planning, the experience and authority it gives board members when they advocate for the system, and the bonding that forms between board and management as both face the stress and rapid change of modern care delivery.

Better governance

Health system boards, often born of charity organizations decades ago, have sometimes lagged in adopting the best practices used by large, publicly traded companies. Firms like Home Depot, General Electric and many others require that board members spend several days each year embedded in operations. Given the fact that even medium-size health systems like Mission are now multibillion-dollar enterprises, it’s become essential that they catch up with modern governance strategies.

The Mission website explains that its board of directors “bears the ultimate authority and accountability for everything Mission Health does.” That’s an awesome responsibility. Now, with the Immersion Day program, board members like Ponder and Hickman more fully appreciate the challenges faced by management, and they feel energized and confident in contributing to their community as members of a high-functioning board.

Richard Bock, M.D. (, is a vascular surgeon and founder of Immersion Advisors in Asheville, N.C. With one foot in the boardroom and one in the operating room, Bock divides his time between practicing vascular surgery and helping CEOs and board chairs create immersion programs.

Addressing immersion concerns

There are a number of concerns commonly raised about health care system board immersion. Here are some of them and some responses:

Finding the time: In three years, we’ve never had a board member be too busy to schedule an Immersion Day. Even lawmakers make room for full days with us. They realize it’s a once-in-a-lifetime opportunity to go so deeply behind the scenes.

Seeing something bad: Our board already hears about the really bad stuff. Board meetings can make a trustee forget about all the good that’s delivered in our hospitals every day, and if something bad happens, our board members invariably take it in stride.

Talking with "problem doctors”: Every hospital has a few, and we worried about this, too. But those physicians are already known to management and the board. And over dozens of immersions, we haven’t had a single problem with inappropriate “grandstanding.”

Wanting to dabble in operations: We have consistently observed the opposite. When our board members see how health care is really delivered, they appreciate its complexity more than they ever could through spreadsheets and PowerPoints. They report far less desire to become involved in operations after their immersion experiences.

Interfering with patient care: In our experience, doctors and staff have been uniformly generous with their time and with explaining what they do as they do it. We’ve even observed an unexpected side benefit for staff morale: Most caregivers have never met a board member. When one shows up in scrubs on a Friday afternoon, it sends a powerful message that our board cares about what they do. Word spreads.

Violating privacy regulations: Board members are an integral part of our health system, and there’s no Health Insurance Portability and Accountability Act barrier to a well-planned and well-executed immersion program. Even journalists and policymakers have been properly incorporated into Immersion Days. — Richard Bock