Given the nature and challenges of small, elected boards, choosing to look inward and improve governance is no easy decision. Our system, the East Phillips County Hospital District, does business as Melissa Memorial Hospital and the Family Practice of Holyoke in Holyoke, Colo. The District is led by five elected directors who serve four-year terms.

With at least two of our five directors up for re-election every two years, it would be easy to avoid governance improvement efforts. However, we realized that longer-term success and better organizational performance are most effective when everyone from the board to the front line recognizes that improving him or herself or the processes surrounding each position contributes to the betterment of the whole organization.

With this in mind, our board in 2010 participated in the Center for Healthcare Governance's Competency-Based Peer Assessment. We focused on trustee core competencies in two categories: personal capabilities and knowledge and skills. The fifteen competencies in the personal capabilities category are: accountability; achievement orientation; change leadership; collaboration; community orientation; impact and influence; information seeking; innovative thinking; managing complexity; organizational awareness; professionalism; relationship building; strategic orientation; talent development; and team leadership. The knowledge and skills category consists of health care delivery and performance; business and finance; and human resources.

We shared the results from the assessment with individual board members via email, while the board as a whole focused on its results during a meeting. Overall, the majority of the results were as expected. While we celebrated and reinforced behaviors related to competencies where we were performing well, there were four areas in which the board was not performing as highly as it would like. These areas became the starting points for a performance-improvement plan.

The four areas identified for improvement were relationship-building, team leadership, innovative thinking and change leadership. At our next meeting, we discussed which one of these areas, if improved significantly, would provide the biggest gains for the board and the district, and decided to focus on relationship-building.

We directed the board's community linkages committee to create a plan that could be reviewed by the whole board, tweaked and then ratified. The committee decided the best way to create linkages, publicize the good things the district does, and build relationships was to have board members visit various local organizations and stakeholder groups. The committee created a list of groups to visit and talking points for board members. The full board discussed and adopted the plan, along with a timetable for making visits.

Each board member is required to meet with one group every six months. After each meeting, the full board discusses how it went, how information was received, how many people attended and the effectiveness of the talking points. The board also reviews questions that were asked on topics other than those in the talking points. Participants in these meetings are asked to complete a brief evaluation to ensure that they are benefiting from the interaction with our board members and to provide feedback about what could be improved for future meetings.

To support individual board member improvement, we decided that sharing all individual assessments with the entire board was not the best use of the board's time and was not consistent with our commitment to keep individual scores confidential. We decided that the chair of the community linkages committee would be the point person for individual plan development and follow-up. Those plans are being created with individual board members and the committee chair, and progress will be reported in general terms to the full board.

Our board believes competency-based peer assessment is a valuable addition to any board's improvement toolbox. It can verify and validate what a board may think it knows about its performance, strengths and opportunities for improvement, while providing excellent prompts for discussion and self-discovery. It brings to light areas of opportunity for individual members and the board as a whole, and provides concrete guideposts for the self-improvement journey.

John J. Ayoub, FACHE (, is administrator, Melissa Memorial Hospital, Holyoke, Colo.