The strategic challenges for hospital systems have never been steeper, yet boards have not made any significant headway in boosting the amount of meeting time they devote to crucial discussion and debate, according to findings from the 2014 National Health Care Governance Survey.

In 2014, 41 percent of boards reported dedicating at least half their meetings to discussion and debate — up just slightly from 39 percent three years previously. Meanwhile, nearly one in five boards — 19 percent — reported spending less than 25 percent of their meetings so engaged, a figure that’s unchanged since the 2011 survey.

It’s not enough to recruit and build a diverse board, with a mix of competencies and perspectives, said John Combes, M.D., president of the American Hospital Association’s Center for Governance. “You can’t tap into that [skill set] unless you give boards time to have those kinds of discussions and interchange with one another the ideas, strategies to generate thinking,” he says. “You have to build into your board agenda the time to do that.”

To maximize those scarce hours that trustees spend together, Combes and other governance experts prescribe a combination of strategies, both logistical and psychological, to keep everyone’s attention from straying into minutiae. Among the practical steps they outlined: limiting PowerPoint presentations, relying heavily on the consent agenda for routine items and encouraging committees to shoulder more work prior to the board meetings. Human psychology also can play a role, as it can feel easier to discuss what seems more easily manageable, particular in light of the U.S. health system’s daunting challenges moving forward, says Katherine Keene, a board member at Salem Health, a non-profit system in Salem, Oregon.

“I think there is always a tendency to deal with what you know, and to try to dive down into the weeds,” Keene says. “So if you have a friend or a neighbor who had to wait too long in the emergency department, which is a chronic challenge, you want to talk about why that happened and what can we do about it.”

Protecting Time

To hone their focus on high-level strategy, Salem Health’s board has implemented a number of practices in recent years, including a commitment to arrive prepared with questions about the details in the board packet, and limiting or even eliminating PowerPoint presentation by health system staff, Keene says.

“If it’s been in our packet, and we’ve had a chance to read it, three slides instead of 30 please,” she says. “Give us the high points and the things you think we particularly want to discuss, but let us ask questions.”

To stay on the same page, trustees and senior administrators can work out some ground rules in advance that both sides must follow, says Lawrence Prybil, Ph.D., the Norton Professor in Healthcare Leadership at the University of Kentucky College of Public Health in Lexington.

For example, senior leaders can be asked to send the financial report at least a week before the meeting. Then it’s the board’s duty to read it, Prybil says. If all that occurs, trustees don’t need a 45-minute staff presentation, he points out. “We need a 5-minute overview and then we’ll ask questions. There’s 40 minutes that you didn’t spend on operations.”

Boards also should watch for ways to transfer more of the “heavy lifting” to the various committees, Combes says. For example, the quality committee might tackle the problem of a worrisome rate of vancomycin-resistant enterococci infections across the hospital system, conduct related analyses and determine that an antimicrobial stewardship program is needed.

Once the committee has reached that decision, they can bring to the board meeting action-related questions involving how best to implement that program system wide, Combes says. “Where are some of the obstacles in terms of either the medical staff or cost or authority?”

Finessing Psychology

Joe Wilkins, board chair at Irvine, Calif.-based St. Joseph Hoag Health, says that his system benefits strategically from a two-tiered governance structure, which includes a regional system board along with local boards to oversee the system’s seven hospitals.

The regional board, of which Wilkins is a member, strives to spend 80 percent of its time focused on population health goals, reimbursement changes and other strategic issues, he says. They don’t have many of the presentations that typically occur in board meetings, such as of the quality or compliance reports. Instead, they can review that data online and ask questions, he says.

The regional board is relatively new, formed when St. Joseph Health and Hoag created an affiliated network in 2013. “It took about three or four meetings to remind everyone that we have local boards that are delegated to handle the safety concerns and the regulatory concerns, and that they do a good job,” Wilkins says. To keep the system board aligned with the five local hospital boards, they meet with them once every six weeks either in person or via conference call.

The timing of meeting can be influential in keeping everyone on track, Keene says, describing how Salem Health trustees realized that their board meetings were starting too late. They were scheduled for 5:30 p.m. and sometimes did not really get going until closer to 6 p.m, she says. “We found ourselves exhausted at 9 o’clock when some of the most important decisions would finally come up.”

Beginning this year, the meetings begin promptly at 4:30 p.m. and are wrapped up by 7:30 p.m. or 8 p.m. at the latest, she says. They’ve also moved more of the routine items to the consent agenda to free up discussion time.

For a more in-depth look at the national governance survey data, read “Raising the Bar for Board Performance.”

Charlotte Huff is a contributing writer to Trustee.