Every board seeks to be healthy, vibrant and ready for each challenge, able to react swiftly and intelligently to achieve the hospital's mission, vision and strategic objectives. All too often, however, boards suffer from a variety of governance diseases that can jeopardize their effectiveness. The most common afflictions are: agenda-sclerosis, dialogue deficit disorder, knowledgedystrophy, successionitis and leadershipresbyopia.

Each of these diseases is characterized by a variety of symptoms and complications. They are preventable when trustees have a clear understanding of their symptoms and conditions, and can be cured when trustees work together to follow defined prescriptions for change that will help to ensure governance vitality, health and wellness.


This common disease is characterized by a clogging of valuable meeting time with unproductive, inefficient discussion. Boards suffering from agendasclerosis often find that they spend an inordinate amount of time focusing on the past rather than on the future and what to do about it. This disease is typically a result of benign neglect and governance inertia, and its effects are compounded when they cause fractured thinking and painful processes throughout the governance body.

Agendasclerosis is an ineffective structuring of the agenda, which in turn results in inefficient use of limited and valuable time, and an uneven focus on the most critical and pressing issues.

Boards suffering from agendasclerosis often rely too heavily on anecdotes rather than evidence and data. Personal stories and opinions take precedence over facts, and decisions are made without appropriate due diligence.

Agendasclerosis also contributes to a serious case of missing dialogue. Meetings that are rote and routine, and that don't inspire spirited discussion and creative energy dampen the dialogue needed to ensure full and complete discussion of the issues that matter most.

A great board meeting always will include targeted governance education and a meeting assessment as the last item on the agenda.

Finally, because the board chair is most responsible for meeting organization and trustee participation, poor performance by the chair is often the main cause of agendasclerosis.

Diagnostic Questions

  • How much of the board's time is focused on talk vs. action?
  • Do the agendas reflect the most important strategic issues facing the organization?
  • Do they empower a pinpoint focus on your most urgent and critical priorities?
  • Do agendas inspire thoughtfulness and creativity, and promote active participation by all trustees?
  • Do they drive meeting outcomes that truly matter to the success of the organization?


  1. Consider using a consent agenda to bundle routine reports that don't require board approval. Consent agendas are an excellent way to eliminate unnecessary, unproductive reviews and reports and are useful in creating additional time for a focus on the board's most urgent and critical matters.
  2. Make your agendas purposeful and energizing and make your meetings can't-miss opportunities for robust dialogue on strategic issues, trends, scenarios and future opportunities.
  3. Build the board's knowledge capital through targeted governance education at every meeting.
  4. Make your board meetings action-oriented instead of report-oriented. Ensure that you spend a few minutes at the end of every meeting to evaluate how well you performed as a governance leadership team in advancing the hospital's opportunities for success.

Dialogue Deficit Disorder

Dialogue deficit disorder exhibits a number of symptoms and complications, including unexpressed ideas and a concern among some trustees that their input will not be welcomed or will be viewed as a waste of time.

When boards experience a dialogue deficit, they miss opportunities to explore alternative ideas and courses of action. Dialogue deficit disorder often results in pro forma decisions made with little insight or understanding.

One of the primary complications of dialogue deficit disorder is the missed opportunities for board learning that occur when trustees engage in robust discussion, challenge each other's assumptions and drive toward consensus that is grounded in mutual knowledge, understanding and commitment.

Severe cases of dialogue deficit disorder may cause cloudy vision and lead to another common ailment, irritable trustee syndrome.

Diagnostic Questions

  • Do your agendas facilitate or inhibit rich governance dialogue?
  • Do your meeting materials stimulate questions and innovative thinking, and prepare the board for meaningful dialogue in advance of meetings?


  1. Create a compelling and fast-paced agenda that makes the meeting lively, engaging and outcomes-oriented.
  2. Never undertake an important decision without engaging the board in a discussion of the pros and cons and ensuring that all sides of issues are fully explored and understood.
  3. Make sure that part of the expectation of the board chair is to be attuned to the personalities and body language of board members throughout the meeting. Chairing a meeting requires understanding and managing board members' expectations, facilitating fluid discussions and ensuring that every trustee is engaged actively in the governance process.
  4. Provide board members with the right information in the right way at the right time to prepare them for meaningful governance engagement.


Knowledgedystrophy is a weakness in the body of knowledge that is required for meaningful and effective decision-making. If left unattended, it contributes to a shriveling of strategic thought, and it worsens over time if not corrected with a vigorous exercise of governance knowledge.

First on the list of symptoms is a painful defect in the board's knowledge capital. All boards require vigorous knowledge exercise and intelligence muscle-building to stay on top of the implications of rapid change.

Sufferers of knowledgedystrophy often find themselves making decisions in a governance vacuum, without adequate research, discussion and debate. These boards are unable to make sense of complexity, which results in uninformed, ill-timed decisions or no decisions at all when they're needed most.

Diagnostic Questions

  • How thoroughly has your board defined the areas in which trustees collectively and individually need information and intelligence?
  • How knowledgeable is your board about the issues that will define your future, and how ready are you to address them?
  • How committed is your board to building trustee knowledge as one of your governing leadership core competencies?


  1. Ensure that all board members have ready access to the background information and intelligence resources they need, when they need them, to enhance their governance knowledge.
  2. At every meeting, make sure to ask: "What do we know today that we didn't know at our last board meeting, and how does this new knowledge in any way change our assumptions or reshape our strategic thinking?"
  3. Expect that every board member will participate in and make a commitment to building his or her governance knowledge with continuous education on current and emerging organizational challenges and issues.
  4. Incorporate a commitment to education and continuous knowledge building as an expectation in the new trustee recruitment process.


This governance disease results in ill-defined trustee recruitment efforts, and an inability to renew and reinvigorate the governance body. Boards suffering from successionitis exhibit leadership anxiety and an inability to lead effectively. Severe cases may result in governance heart palpitations and damage the very soul of the organization.

The leading symptom of successionitis is a lack of a coordinated, long-term governance succession plan. A governance succession plan is more than a trustee recruitment effort. It involves a careful examination of which and when trustees are rotating off the board, the skills and experience that will be lost to the board when these trustees' terms expire, and the new leadership experience and skills that will be needed by the board to successfully meet the governance challenges of the future.

Diagnostic Questions

  • How well does your board understand the hospital's future leadership challenges and needs, and how well-connected is your governance succession planning process with those challenges and needs?
  • Do you periodically assess board strengths and weaknesses?
  • How do you incorporate those into your succession planning process?
  • Have you defined the critical skills, experience and perspectives required for individual trustee success, and do you use those to narrow the field of prospective trustee candidates when planning for the future board?
  • Do you put your strategic plan to work to assist in defining future leadership requirements, identifying future leadership needs that may be different from your needs today?
  • Do you know what your competency gaps are today, and what they likely will be in the future?


  1. Define the unique qualities, skills and characteristics of the highly successful trustee. What do you expect of that individual? How will a changing environment and marketplace influence your future leadership needs? And how can you grow future leaders well in advance of their board service?
  2. Work to strengthen your governance brainpower through a highly focused governance knowledge-building educational curriculum.
  3. Recruit new trustees with an emphasis on acquiring the skills, resources, relationships and experience your board will need to meet tomorrow's challenges. Develop a succession planning process that looks at least five years into the future.


Leadershipresbyopia is a symptom or outgrowth of missionmyopia, a related disease. It creates severely clouded vision, causes organizational disorientation, weakness and pain, and can spread quietly throughout the organization if not aggressively treated. Left untreated, it kills slowly and efficiently.

The symptoms and complications of leadershipresbyopia include a myopic, short-sighted mission, cloudy vision, unproductive and unfocused meetings, and a disorder of direction.

Diagnostic Questions

  • Does the board have a clear, compelling and focused vision of the future?
  • Has the board defined the leadership required of the board as a whole, and of individual trustees, in advancing the hospital's mission and vision?
  • Does the board have an expectation of engaging in strategic thinking at every board and committee meeting?
  • Is the board committed to building its leadership effectiveness through a consistent and understandable analysis of its strategic performance using board-approved measurements, milestones and benchmarks?


  1. Set a leadership course based on a foundation of vision. That means having a clear sense of where the board seeks to guide the hospital over the next several years, and what will occur as a result of the attainment of the vision.
  2. Have a clear sense of problems and opportunities facing the organization, and of what knowledge, information and data mean.
  3. Question assumptions, probe feasibility, identify obstacles and opportunities, and determine alternative ways of framing issues.
  4. Engage in real-time planning where new information, ideas and perspectives are continually incorporated into the strategic planning framework.
  5. Create a leadership atmosphere that stimulates decisive dialogue and demands personal trustee commitment to high performance.

Ensuring Healthy Governance

Preventing or curing governance diseases doesn't happen overnight. It requires trustees to assess their risk of contracting the diseases and defining specific actions they will take to ensure their governance health and wellness.

Any board willing to undertake the challenging, sometimes uncomfortable work of diagnosing the symptoms of leadership ineffectiveness, and applying some practical prescriptions to treat those symptoms can achieve governance health and wellness. Ultimately, a healthy board is every trustee's responsibility.

Larry Walker (lw@walkercompany.com) is president of The Walker Company Healthcare Consulting LLC, Lake Oswego, Ore.