Accountable care aside, hospitals and systems have never faced as many challenges as they do today to innovate, integrate, out-think and out-market the competition, improve the quality of care, engage staff, reduce costs and increase profitability.

But it takes more than Lean, Six Sigma and executive dashboards to accomplish any objectives of this magnitude. None of these traditional improvement tools brings about sustained change or provides the structure that ensures that change is driven throughout the organization.

Instead, these tools must be used within an organizationwide culture of ownership, and that ownership has to start with the board. It's no longer enough for boards to just get periodic updates on the status of such initiatives. To maintain the transformative processes and cultural evolution that sustains long-term improvement, trustees have to be committed and require accountability.

Otherwise, these efforts become just another flavor of the month.

Why Transformations Fail

Health care isn't unique. Studies show that a high percentage of organizationwide change efforts fail in every industry. The reason is lack of continuous support from organizational leaders, including the board. It's the smoking gun that — from an employee perspective — can turn even the best of intentions into "just another time-wasting idea cooked up by someone in the C-suite."

Trustees may not understand their role in the change process. Even in the largest, most progressive health systems, many board members don't think they have a role in transformation and that it's the responsibility of hospital administration to manage, measure and sustain it. They don't ask about change processes, there isn't a board committee devoted to participating in change management, and they don't demand more than cursory updates on the process and results.

Even before leaders help to determine and guide future organizational direction, there are important issues to address and questions about culture change and transformational improvements that they may neglect to ask: "Are we really any good?" "Are we getting any better?" and "How are we measuring progress?"

Trustees should be able to answer all of these questions because someone in the organization is measuring — and delivering — this information to the board on a regular basis.

Roles and Rules Lacking

Without a doubt, hospital leaders control all the touchpoints in any transformation process — from timing and budgets to assignments of people and departments. But in most cases, trustees aren't kept in the loop if the CEO only sees the process as purely operational and believes trustees don't want to be involved at that level. And admittedly, some administrations don't want their boards involved in operations.

Another reason transformations fail is the quality of departmental meetings. It's hard to believe, but in my experience, easily 60 percent of hospital departments don't meet regularly. This includes post-transformation planning or strategy meetings, as well as those to monitor and improve processes. Executives may believe their managers have regular departmental meetings but front-line staff tend to disagree.

This disparity often can be attributed to lack of basic communication skills. Many times, when departmental meetings occur, managers either lack the skills or understanding of the tools necessary to conduct good meetings: a standardized day and time, an agenda and, most important, a two-way flow of information vs. a one-way monologue from management to staff.

Additionally, managers can be inconsistent in how they pass information to their staffs. Depending on how thorough or remiss they are about sharing details of the transformation process and reporting results as they occur, employees are either well-informed and engaged — or less so — based on their supervisor's communication skills.

Successful communication throughout change initiatives can depend on both human nature and personality. That's why it's important that managers learn to communicate more effectively through training, are given common guidelines that all departments follow, and are provided with the tools and space for meetings that keep teams engaged and enthused about the process and their role in achieving results.

People Drive Change

People are the true pivot point for success or failure in any change initiative. From the boardroom and C-suite to front-line staff, they must be onboard, or sustained change won't happen. But the truth is, it's not always easy being employed by an organization seeking significant cultural change to improve the patient experience and profitability. Initially, employees are asked for improvement ideas, then tasked with implementing day-to-day behavioral changes that require them to put in extra hours. Often, their efforts go unrecognized.

One of the first things employees say when asked if they support change
is, "Will leadership really see it through this time?" When communication to and recognition of employee teams is inconsistent, enthusiasm will wane. Employees will stop supporting the initiative because they don't believe leadership at the very top — including the board — has a serious commitment to the effort.

Without that commitment, progress wanes around the two-year mark when all the easy wins have been achieved. This curve occurs in any change process — the easiest objectives and goals tend to be addressed first. After that, if the C-suite doesn't continue to listen to staff, enthusiasm peters out across the organization.

But commitment at the top goes beyond the C-suite, especially when a leadership change occurs. When trustees aren't involved and haven't embraced the role of overseeing accountability, it's all too easy for a new CEO to come in and change the game or terminate the effort entirely. It's only natural for new leaders to take on a new role with their own visions of success and thoughts about how to accomplish it. But when trustees allow a new CEO to change direction and derail the current process, goals will be missed and months of prior planning, effort and expense often are wasted.

When Transformations Succeed

Trustees may be more important than any other group in the hospital —
including the C-suite — when organizational transformations succeed. As a governing body, there often is more continuity and longer tenure on the board than in the C-suites of many facilities. This makes the board an
unrecognized but key factor in sustaining transformation and determining success.

How can board members contribute to sustainable transformations? Once they commit to taking a role in the process, the steps are clear:

Set expectations. Trustees must have a solid understanding of the transformation process and their role in helping to drive change. That role, says John Davis, board chair at Carteret General Hospital, Morehead City, N.C., is "to keep the change process focused on the things that truly influence operational processes at the hospital, and work with hospital staff to develop sustaining processes to ensure that change continues to be implemented in a responsible fashion."

Track progress. Trustees should expect and receive regular updates on the transformation process and results. This needs to continue beyond achieving initial goals. "Each of our board quality committee meetings typically has a presentation from a staff team reporting on a completed improvement project," says Deborah Weidner, M.D., medical director for Natchaug Hospital, an inpatient and outpatient behavioral health provider in Mansfield Center, Conn., and a member of the Hartford HealthCare system. "And, at [trustees'] request, we have recently provided board members with hospital email addresses so they can review the hospital's [transformation] idea-tracking system and look at improvement projects and results connected to those ideas."

Participate. The steering committee for the ongoing transformation effort should include a board member. He or she will see the complex issues and processes that hospital teams are navigating and bring back unfiltered information to the board.
• Recognize. The board should become part of the transformation-related recognition plan. Employee improvement teams should present outstanding results directly to the board. Trustee recognition and support of even the smallest teams is invaluable. For those involved, achieving the desired results can be exhilarating, and the recognition factor inherent in presenting to the board can be more powerful than any other rewards. While some teams involved in smaller initiatives may more appropriately make their presentations to the steering committee, the most significant efforts always should be presented to the board on a regular basis.

"When Carteret was planning our transformation process, board members sat in on two different report-out sessions," says Ginger Parker, a Carteret trustee. "We wanted staff to understand that this wasn't something imposed on them; rather it was something that empowered and engaged them. Board member attendance at these sessions signaled the importance of this process."

"The notion of recognizing staff is prevalent throughout the entire Hartford HealthCare system and at Natchaug Hospital," says Carol Wiggins, a Natchaug board member and past chair. "As a trustee, I am on a systemwide committee that recognizes staff in organizations across our system. Having multiple locations, spread over a wide geographic area, made it even more important that the staff at those locations not only understood the change plan but more importantly, the board's support of it."

Protect leadership continuity. Continuity is key to successful transformations. If a chief executive change occurs, a new leader should be hired with the understanding that one of his or her key responsibilities is to manage and sustain the change process already underway, not introduce a different model or approach. New board member orientations should include education on the transformation initiative and the board's role in helping to drive and sustain change.

Identify process facilitators. Any change process requires guidelines, rules and tools, and someone to assist in leading it. From standardizing meetings to facilitating measurement of key metrics, one or more staff members are needed to guide the various processes. Hiring or tapping staff to ensure that processes run smoothly so all staff can access the tools they need to accomplish objectives is critical. Most hospitals undergoing transformative change will need at least two staff facilitators in this role. In addition to showing leadership commitment to the effort, these staff members demonstrate that this initiative has dedicated resources and C-suite support.

As liaisons among senior management, middle management and front-line employees, facilitators improve communication up, down and laterally in the organization. By providing feedback and information on the process, they can help everyone to work toward the organization's larger, mission-orientated goals, carry out the direction set by senior management and stay on track. Facilitators must be subtle backseat drivers to provide the constant, gentle pressure to change and improve.

Why do hospitals and systems and their boards find that a robust structure and process are critical to the success of their transformation efforts? Trustees at Carteret General saw the writing on the wall. "We had plateaued as an organization and needed to reinvent ourselves to keep up with the constant changes in health care." says Vernon Small, a board member. "If we didn't change, we'd become obsolete."

That led Carteret to implement five processes to ensure a successful transformation: top-down and bottom-up communications, involvement of all employees, facilitator-guided processes, data-driven measurements, and a customercentric focus.

"Many boards don't understand their role in the transformation process. And because in most cases, the board wasn't involved in bringing change to the hospital, they leave everything entirely up to the CEO," says Richard Brvenik, Carteret president and CEO. "But the board has to set the tone to make sure that transformation takes place at all levels of the organization."

Kenneth G. Bast ( is founder and CEO of Hospital Focus 5 LLC, Burnsville, Minn.