How nurses are making inroads in hospital boardrooms
BY ALEX KACIK
At Palo Pinto General Hospital, two of the seven board members are nurses—making the government-owned facility in a rural community west of Fort Worth, Texas, an anomaly.
About 5% of board members at health systems and hospitals are nurses, according to 2022 data from the American Hospital Association. The ratio has stayed constant for the last two decades, while finance experts with backgrounds in banking, wealth management and corporate investment have dominated boardroom seats.
Lori Boyd, a registered nurse, has been on the Palo Pinto board for about 10 years. Her role enables her to survey best practices from other area hospitals concerning infection control protocols, discharge planning, quality improvement measures and staffing strategies.
Boards without nurses are likely missing a crucial perspective on care quality and the day-to-day patient experience, she said.
“We have an extremely deep understanding of what [board] decisions mean in terms of a positive or negative outcome for the patient,” said Boyd, who is also the vocational nursing director at nearby Weatherford College.
Nurses’ participation in the boardroom has been historically limited. Some providers are trying to achieve balance in governance.
Amid the nursing labor shortage, providers’ financial pressures, the increasing prominence of quality measures and the tension between nurse unions and systems, it’s imperative that nurses have a seat at the table, industry observers said.
“As unions are coming after hospitals to revisit their nurse staffing levels and considering how much of the cost of running a hospital is dedicated to nursing, [board representation] has become a big issue,” said industry consultant Paul Keckley, who specializes in hospital governance.
“Activists and unions are elevating the discussion about what role nurses should play in governance, but we generally haven’t seen any uptake in terms of boards adding nurses,” Keckley said.
Nurses make up more than a third of the 16.7 million jobs in healthcare. But despite their outsized role in care delivery, a range of systemic and logistical barriers have limited their influence in how hospitals and health systems are run.
Nearly 80% of the 933 hospital and health system CEOs polled by the AHA from November 2021 to March 2022 said their organizations had at least one physician board member. Only 43% had a nurse board member.
Those findings were supported by another study of the 15 U.S. News and World Report top-ranked hospitals’ board members published in February in the Journal of General Internal Medicine. Nearly half of the 529 board members studied had backgrounds in finance, while less than 15% had clinical experience, researchers found. Only 0.9% were nurses.
Biased board selection processes have played a role in the lack of nurse representation. Succession planning—when it exists—frequently relies on referrals, so replacements often resemble current board members.
“It is a function of the perceived hierarchy within medicine and also gender issues,” said Stephen Shortell, a health policy and management professor emeritus at University of California, Berkeley who founded the school’s Center for Healthcare Organizational and Innovation Research.
“The process for recruiting board members has historically relied on board members reaching out to their own networks, so it is self-perpetuating,” said Shortell, who was not affiliated with the Journal of General Internal Medicine study.
Systemic biases and narrow selection processes aren’t always to blame. Health systems tend to struggle to keep doctors and nurses on the board because of conflict-of-interest issues, pressure from their peers who expect them to lobby for better pay, equipment and other interests, and the time commitment, said Jamie Orlikoff, president of Orlikoff & Associates, a consulting firm that specializes in healthcare governance.
Physicians and nurses who are directly employed by a given hospital or health system are forced to sit out of some discussions involving compensation, medical licensure and other issues, he said.
“We would lose two or three clinicians every year because of conflicts,” said Orlikoff, who served on the board of what is now Virginia Mason Franciscan Health in Seattle for 12 years. “You could have a great person, but then you can’t use their input in the most important governance functions.”
The push for nurse board members has taken on more importance amid rising labor costs, staffing constraints and care quality measures.
Labor is hospitals’ biggest expense, and nurses account for most of it. The costs have increased as health systems have boosted hourly pay and benefits for workers and hiring staffing agencies.
Putting more nurses on the board could boost nurse recruitment and retention, said Linda Aiken, a health policy professor at the University of Pennsylvania. Their input could also improve hospitals’ bottom lines, such as by improving discharge planning to reduce readmissions, she said.
There is a direct link between adequate representation on health system boards and workplace morale, research shows. Aiken was the lead author of a study published in Nursing Outlook that found more than 70% of hospital bedside care nurses lack confidence that top management will resolve problems they identify in patient care, according to the analysis of survey data from more than 40,000 nurses across Illinois and New York gathered between late 2019 and mid-2021.
“That is a glaring chasm that explains why nurses have no loyalty to their employers,” Aiken said. “There is a reluctance to see nurses as a resource, not just a cost.”
Putting more nurses in the boardroom would shift the dynamic, she said.
The disconnect contributed to the dozens of strikes unions organized last year over inadequate staffing and other labor practices they deemed unfair. Nurses and physicians are also increasingly protesting the widening gap between executive and staff pay and are looking to their peers to shape the conversation in the boardroom, Keckley said.
Care quality is another factor.
Nurse and physician board input has helped to limit catheter-related infections, reduce mortality rates and shorten length of stay at Sparrow Health System, a six-hospital system based in Lansing, Michigan. Sparrow has two nurses and two physicians on its 15-member system board, one of whom is Dr. Candace Metcalf, a retired anesthesiologist who started her career as a registered nurse. She said she explains quality-related acronyms and how they impact patient care.
“I see my role as being an interpreter,” said Metcalf, who chairs the board’s quality committee. “Much of our reimbursement is dependent on quality metrics. But more importantly, these aren’t just numbers, these are my neighbors. I was born in a Sparrow hospital and my parents received end-of-life care here—it’s critical we identify these numbers as people.”
Nursing care is the main driver of quality, so it isn’t prudent to exclude nurse leaders from the boardroom, said Lawrence Prybil, a retired University of Kentucky healthcare leadership professor who studies board composition.
“I have been disappointed that the representation of nurses on hospital and system boards is still lower than it should be,” Prybil said.
Researchers say hospital and system boards that include more nurses and physicians tend to produce better outcomes. Still, most of the data are correlational, given that it is hard to directly link quality performance to board composition, or any singular factor.
“It’s important for us to maintain a focus on care quality and safety, which is why we are intentional about the need to have clinical expertise on the board,” said Dale Maxwell, president and CEO of the nonprofit health system Presbyterian Healthcare Services, based in Albuquerque, New Mexico.
“Physicians and nurses bring real-life examples about the implications of our decisions as a board on patients or fellow caregivers,” Maxwell said.
Presbyterian has one nurse and four physicians on its 13-member board. The system tends to lean more on physicians in the boardroom for their perspectives on quality, but that does not discount nurses’ knowledge or experience, Maxwell said.
“As clinician board members turn over, we will look at the best candidate in terms of clinical expertise,” he said. “There is less emphasis on selecting a physician versus a nurse—if the best candidate is a nurse, we will pick a nurse.”
Barbara Balik, a registered nurse and former hospital CEO, chairs the quality committee on Presbyterian’s system board.
“You are deficient as a governing committee if you lack clinical perspective,” Balik said. “I am confident that advocacy will continue to call attention to this issue and that representation will improve.”
Hospital and health system leaders have placed the highest value on strategic planning/vision and financial acumen when selecting board members, according to a 2021 survey from the Governance Institute, which provides research about nonprofit hospital boards. Expertise in quality and safety ranked third, the survey found.
Meanwhile, only 17.6% of boards without nurses have plans to add one to the board, according to the survey.
“Many hospitals came close to failing during the pandemic and haven’t been able to recover, so how successful has it been to put a focus on the financial side?” UPenn’s Aiken said. “It’s amazing that hospitals don’t say we should have some nurses on the board instead of businesspeople from Pepsi.”
Providers aiming to strike a better balance of expertise among their boards will need to improve their succession planning, experts said. Only 44% of nonprofit hospitals said their organization maintains a written, current succession plan for senior executive leadership, including board members, according to the Governance Institute survey.
“Succession planning in a large proportion of hospitals and systems is not good,” Prybil said. “In today’s world, hospitals need to constantly assess what talent we need around the table and what is lacking.”
A comprehensive succession plan can mitigate any potential selection biases, Prybil said: Board members can use it to broaden the search instead of solely relying on current board members for referrals. Some best practices regarding succession planning include creating a committee, drafting and updating a list of qualified candidates, establishing term limits and regularly assessing holes in expertise, Prybil said.
Presbyterian, for instance, regularly updates the so-called competency matrix used in its succession planning to reflect changes in the industry, Maxwell said. It looks at clinical expertise, innovation, community involvement, patient experience, growth, population health and financial expertise, among other competencies, he said.
“We try to populate our board on an even basis across those competencies,” Maxwell said. “We strive to have a healthy balance from clinicians to non-clinician finance-types.”
Morristown, New Jersey-based Atlantic Health System recently turned to the executive search firm Korn Ferry to improve its overall board recruitment efforts.
“We have moved from working with ‘family and friends’ to working with a recruiter to recruit board members who have a particular set of competencies,” said President and CEO Brian Gragnolati.
He pointed to the desire for expertise in alternative payment models, patient safety, consumerism, marketing, cybersecurity, innovation, mergers and acquisitions, law and human resources.
“Not a lot of organizations are taking this kind of approach to recruit for a position that doesn’t pay anything,” Gragnolati said.
Four members of Atlantic Health System’s 16-person board are physicians. It had a nurse, but their term recently ended, Gragnolati said.
“We have a number of nurses [on boards] at the hospital level. We will have nurses again on [the system] board—it’s in our recruitment strategy,” he said.
Meanwhile, initiatives such as the Nursing on Boards Coalition aim to increase the number of nurses on boards through advocacy and training. The AARP and Robert Wood Johnson Foundation helped start the coalition in 2014. As of 2021, the group, which is financially supported by more than two dozen health systems, had assisted 10,000 nurses in becoming board members.
Still, hospitals and health systems may choose to lean even more on finance-savvy experts as they face lower investment income, rising interest rates and declining reimbursement levels. Metcalf said she relies on financial experts on the Sparrow board to help her understand earnings statements. But the board also needs clinicians to explain quality measures and patient care trends, she said.
“When a board has inadequate clinician representation, there might be a tendency to focus more on the dollar as opposed to the patient experience,” Metcalf said.
Hospitals are a business, Aiken said.
“But within that business, that product is patient care,” she said. “It seems obvious you would want to have experts of your product on the board.”
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