The focus on culture in health care is everywhere: a culture of quality, a just culture, cultural transformation, a transparent culture, a punitive culture, a high-reliability culture and so on.

As health care approaches the mother of all inflection points, leaders are struggling to make their organizations relevant to an uncertain and demanding future with the unnerving realization that they will not be able to meet this daunting new challenge with old and often dysfunctional organizational cultures. Boards are being challenged to engage in or even lead these cultural transformations.

Yet before a board can effectively oversee a meaningful and lasting cultural transformation of the organization it governs, it must first assess and transform its own culture. If the governance culture is static and inadequate to meet emerging challenges and new realities, attempts to create meaningful and sustainable transformation of the organizational culture will be doomed.

Culture is the most amorphous and therefore the most often neglected dimension of governance. In academic circles, culture tends to be defined as "shared patterns of meaning" where the same event, phrase, situation or process has the same implicit meaning to all the members of a board. Practically, culture is often defined as "the way we do things around here."

Studies consistently show that boards rate the quality of care provided by their organizations higher than their executive or clinical staffs do. Consulting experience similarly demonstrates that boards also tend to have a higher opinion of their governance culture than is accurate.

Great boards have great governance cultures that drive robust and effective governance systems and that facilitate effective and transformational leadership of their organizations and ultimately and most importantly, drive organizational success. But because cultures are so amorphous, how can a board assess its own culture and identify areas for improvement?

Edgar Schein, an expert and writer on culture, identifies the "primary mechanisms" of culture as:

  • What your board pays attention to, measures and controls on a regular basis. Is finance more important than quality and safety? Is the board "in the weeds" or does it focus on the big picture? Does attendance at board and committee meetings matter? Is continuing governance education required?
  • How your board reacts to critical incidents and organizational crises. Does it revert to blame and punishment? Accept excuses and rationalize failure? Or does the board rely on defined processes and standards of accountability?
  • Observed criteria by which your board allocates scarce resources, including how the board spends its own time during meetings and how it constructs its agendas.
  • Deliberate role modeling, teaching and coaching, including how new board members and board leaders are developed and how board member performance is evaluated.
  • Observed criteria by which the board allocates rewards and status. For example, which board members get recognized and rewarded and why.
  • Observed criteria by which the board recruits, selects, promotes, retires and excommunicates organizational members. How does someone become the board chair, a committee chair or a member of the "inner circle"? When and why is someone removed from or not reappointed to the board?
  • Stories, legends and myths about people and events. What are the "remember when" seminal stories told by and about board members?

Schein says that other things, such as the governance structure, the bylaws, board policies and procedures, and mission, vision and values statements are, at best, secondary drivers of culture.

To improve governance culture, a board must first honestly assess its current culture. This can be a very difficult conversation. But, as the old saying goes, "where there is mystery, there is no mastery." So, for a board to be the master of its culture, it must identify the implicit aspects of governance and make them explicit. Then the culture can be assessed to determine its strengths and weaknesses, and how it should be improved.

To get this crucial leadership conversation started, consider the following questions:

  • Is the "way your board does things" different today than it was several years ago?
  • Does mystery or ambiguity surround any board processes? For example: how decisions are made; how board leaders are chosen; how executive compensation is determined; how the board helps develop and oversee strategy; or how board meeting agendas are determined?

Just because a governance culture is not dysfunctional does not mean it is optimal. Is the culture of your board merely adequate, acceptable or "good enough"? Are suggestions for change usually deflected with the excuse "We've always done it that way and it has always worked"?

What is the real culture of your board and how can it be improved? These days, "good enough" governance cultures won't cut it. An effective and robust governance culture places your organization well along on the path to survival and success, while inadequate governance culture careens the organization toward decline and failure. Your governance culture will largely determine which path your organization takes.

James E. Orlikoff ( is president of Orlikoff and Associates and senior consultant to the Center for Healthcare Governance, Chicago.