Shortly after medical social work was first established nationally at the Massachusetts General Hospital in 1905, a physician identified social workers as “the conscience of the hospital.”

But who acts as the community’s conscience for the hospital? It is and must be the board of trustees.

During both orientation and continued education in governance, trustees always learn about standard fiduciary responsibilities, such as the chief executive officer’s appointment and performance evaluation, strategic planning, financial oversight of the organization, review and approval of medical staff recommendations, and promotion of high-quality care.

Too little time and effort, however, are devoted to how the hospital is addressing three admittedly diverse issues: the needs of its most vulnerable patients; problems associated with marginally performing staff; and conflicts of interest when allocating resources and making strategic decisions. How the institution deals with similarly less acknowledged conundrums constitutes a litmus test of how well its moral compass is functioning.

Individual patients are unlikely to know why handling such challenges is so critical to fulfilling the hospital’s mission. Consequently, the governing body, in collaboration with the CEO and the medical staff leadership, has to act in the community’s best interest, thinking creatively about what specific steps may be needed and how performance will be monitored.

Vulnerable Patients

Hospitalized patients, whether admitted on an emergency or elective basis, are physically and emotionally fragile. They depend on others to meet their most basic needs. The maze of forms and procedures can be intimidating, especially for the uninitiated. Even the unconscious use of hospital jargon can be confusing and disconcerting. Richard Bates, M.D., a popular speaker in the 1960s and 1970s, was fond of telling trustees about the patient who was asked if she were a “pre-admit” and who responded promptly, “No, I’m a Presbyterian.”

Patients who are cognitively impaired, severely disabled, mentally unstable or do not speak English are much more likely to feel vulnerable and compromised when hospitalized. We also know they are less likely to ask questions, including during the informed consent and discharge planning processes.

Marginal Performers

Confronting poor performers in a timely manner is a major challenge for hospitals and one that frequently goes neglected. When the poor performer is the CEO, a physician responsible for admitting a large volume of patients or a counterproductive board member who is a major donor, rationalizing why action cannot be taken is understandably common. Admittedly, these are tough issues.

Board members have a vested interest in maintaining harmonious relationships, avoiding tension and fostering organizational stability. And yet, if timely intervention does not occur, the cost of delay is invariably much higher. The organization’s reputation, integrity and fiscal health are at risk when these issues are not confronted, and hard conversations are deferred because they are predictably uncomfortable, inconvenient and painful for the participants.

Conflicts of Interest

Almost every hospital will receive more capital equipment requests than can be funded. As a result, expensive new medical technology, not always economically justified, occasionally will trump mundane proposals for upgrading computer systems or replacing beds. Similarly, in an attempt to increase market share and generate additional revenue, a proposal to establish a unique service line may be submitted without compelling evidence of community need. Another example is the pursuit of a merger in the absence of reliable data demonstrating short- and long-term benefits for current and future patients.

All of these decisions can be and often are unduly influenced by people with a vested interest. Political power or leverage, whether informal or formal, can be used constructively to benefit the community, but we know this is not always the case.

It is rare to have all the information desired to make an informed decision. However, a board that simply approves recommendations because time constraints do not permit consideration of viable options is doing a grave disservice to all its constituents — especially the community.

What To Do

There are at least eight steps that trustees should take to fulfill their role as the community’s conscience.

1. Insist on receiving material describing how the organization is providing culturally competent care and using evidence-based best practices to improve services for particularly vulnerable patients.

2. Request reports demonstrating the hospital’s role in reducing disparities in health care.

3. Demand annual evidence of improvements in community health status.

4. Recommend that periodic organizational ethics audits be performed to solicit feedback from personnel, physicians and board members. Alternatively, include nontraditional questions focusing on ethical issues in periodic surveys completed by these individuals.

5. Identify existing or potential issues that may adversely affect the decisions and performance of key institutional leaders.

6. Help trustees to refine their problem-solving and communication skills by using case studies at board retreats to provoke challenging conversations.

7. Create a decision-making matrix that includes criteria to prevent improper political influence and increase the probability of objective, defensible outcomes to use when making resource-allocation and strategic decisions.

8. Develop a template for all major decisions that incorporates organizational values to assure they inform the process and the impact of such decisions.

For decades, our health care system has been described as being in crisis. Actually, it’s not. More accurately, it is and will continue to be in a chronic condition, so we should improve our hospital governance by taking steps to move beyond the board’s conventional fiduciary functions.

This will require boards to think imaginatively about what the future role of the hospital ought to be in the community. Trustees take pride in their hospital in the traditional sense of that word. However, the customary hospital services may be less important to the health and well-being of the community than a larger primary care or public health focus. Trustees must ask tough questions about what the community really needs and how their institution can work even more collaboratively with other organizations to best meet these needs.

No one would suggest that a board’s responsibility to serve as the community’s conscience is an easy task. Most boards may implicitly assume such a function, but they have an ethical responsibility to take explicit and transparent steps to demonstrate a greater commitment to this vital role. 

Paul B. Hofmann, Dr.P.H., FACHE (, is president of the Hofmann Healthcare Group in Moraga, Calif., and serves on the American Hospital Association–McKesson Quest for Quality Prize Committee. He is a member of Speakers Express.