1. Prybil, Lawrence D. PhD, LFACHE

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IN THE UNITED STATES, the health care field is experiencing the most dramatic changes since the Medicare and Medicaid programs were established in 1965. An aging and increasingly diverse population; persistent global and nationwide economic problems; stark evidence of major disparities in access, affordability, and quality1-3; stunning advancements in medical science and technology; and efforts to institute reforms at the federal and state levels are among the powerful forces that are affecting providers, payers, and consumers of services.


In concert with growing awareness that ongoing increases in expenditures and wide variability in the quality of patient care are not sustainable, these forces are creating serious challenges for clinical, governance, and management leaders of America's health care organizations. Stakeholders such as governmental regulators, third-party payers, rating agencies, the media, and the public at-large are demanding more accountability, greater transparency, and better performance by these institutions.


These developments are necessitating major changes in traditional governance patterns and practices.4 Increasing scrutiny by external stakeholders and the advent of value-based payment systems demand greater attention to controlling costs while, at the same time, improving patient care quality and safety. To achieve these dual aims, engaging clinical leaders in developing and implementing effective strategies is essential. Appointing capable, dedicated clinicians to serve on governing boards is one important way to enable such engagement. During the past quarter century, involving physicians as voting members of hospital and health systems has become the norm and now is widely accepted as a standard practice.5 Traditionally, however, the involvement of nurses as voting members of hospital and health system boards has been uncommon. This article presents current information about nurse engagement on governing boards and discusses some factors that are affecting the pace of change.



While comprehensive data are not available, several studies conducted in recent years showed that the involvement of nurses as voting members of hospital and health system boards has been quite limited:


* A 2004-2005 study of 14 nonprofit general hospitals found that, in total, only 2% of the voting board members (4 of 203) were engaged in nursing practice at these or other health care institutions. In contrast, 26% of the board members were practicing physicians.6,7


* A study conducted in 2008-2009 examined board composition and practices in 123 nonprofit community health systems. For the purpose of this study, community health systems were defined as nonprofit health care organizations that (1) operate 2 or more general acute and/or critical access hospitals and other health care programs in a single, contiguous geographic area and (2) have a chief executive officer (CEO) and a system-level board of directors who provide governance oversight over all of these institutions and programs. In these organizations, 2.3% of the voting board members (48 of 2046) were nurses while 22% were physicians.8,9


* Using a different measure of involvement, the Governance Institute's 2011 survey of hospitals and health systems found that 1% of chief nursing officers were voting board members at the organizations where they were employed, while 5% of the organizations' chief medical officers were serving in this capacity. These figures are virtually unchanged from the Institute's 2007 survey.10



On the contrary, 2 recently completed studies suggest some upward shift in the level of involvement of nurses in hospital and health system governance. Information from more than 1000 nonfederal community hospitals compiled by the American Hospital Association (AHA) in the winter of 2010-2011 found that 6% of their board members were nurses. The overall proportion of physicians on these boards was 20%, the same figure found in the AHA's previous (2005) study of hospital governing boards.11 Unfortunately, the 2005 study did not collect information about nurse engagement on hospital boards.


A study of 14 of the country's largest nonprofit health systems completed in 2012 also looked at system-level board composition, along with other aspects of governance structures, processes, and culture. Similar to the 2011 AHA study of hospital boards, this study found that, on an overall basis, nurses comprised 6% (17 of 274) of the boards' voting members.4(pp12-13)


However, as shown in the Table, nurses are not evenly distributed among these boards. Nine of the 14 boards included in this study population are faith-based; 8 are sponsored or controlled by Roman Catholic entities. One system is operated by the Charlotte-Mecklenburg Hospital Authority, and the other 4 systems are independent, nonprofit entities that do not have parent organizations. (For a list of the participating health systems, see, p 3). Collectively, 9% of the voting members of the 9 faith-based system boards are nurses; of the secular system boards, only 2% of the voting members are nurses. Four of these boards included no nurses who were voting members at the time this study was conducted.

Table. Clinical Comp... - Click to enlarge in new windowTable. Clinical Composition of Large System Boards


In the contemporary health care environment, several factors support the idea of engaging nurses in the governance of hospitals and health systems. The pressures on these organizations to contain costs and improve patient care quality and safely are growing. The nursing workforce has great impact on operating expenses, the quality of patient care, and patient satisfaction. It seems clear that nursing expertise and leadership can be highly valuable in formulating organizational policies and strategies for controlling costs and improving quality. Similarly, these skills can be helpful in setting organizational targets and metrics and assessing the organization's performance in relation to them.12 Board members without clinical education or experience constitute a large majority of most hospital and system boards; many need and welcome physician and nurse expertise in deliberations at board and board committee meetings.


For years, several leading health-related organizations such as the National Quality Forum and Robert Wood Johnson Foundation have encouraged hospital and health system leaders to engage highly qualified nurse leaders in the work of boards and board committees. In a recent Institute of Medicine report on the future of the nursing profession, the authors concluded that "private, public, and governmental health care decision makers at every level should include representation from nursing on boards, on executive management teams, and in other key leadership positions."13 This view is shared by Dr Donald Berwick14 and other respected leaders in the health care field.15



Nurses comprise a large proportion of the workforce in hospitals and other health care organizations. The Institute of Medicine13 and many other authorities recognize that nurses have great impact in determining the cost and quality of health care services. Leaders in the nursing profession constitute a deep pool of talent for governance roles in health care organizations that historically has been essentially untapped.


While systematic longitudinal trend data do not exist, the most recent studies of board composition in America's community hospitals and large nonprofit health systems indicate that nurses now constitute 6% of voting board members. These findings suggest a considerable change from previous studies of community hospitals and community-based health systems, which found nurses comprised about 2% of voting board members.


However, data from the recent study of large health systems show a statistically significant disparity between nurse engagement on the boards of faith-based (9%) versus secular health systems (2%). More than 90% of registered nurses in this country are women, and disparity also exists in the overall proportion of women on the boards of faith-based (40%) versus the secular health systems (21%). Eight of the 9 faith-based systems in the study population were founded and sponsored by congregations of religious women. It is clear that their historical commitment to providing leadership opportunities for qualified women is reflected in these findings. Comparable data from the AHA's 2011 survey of community hospitals are not publicly available.


Thus, the present status of nurse involvement on the boards of hospitals and health systems is mixed. As discussed in a previous article in this series on nursing engagement in health care governance,9 the contributing factors may include the following:


* First, disparities continue to exist in the board composition of many large companies in America. For example, in 2011, only 16% of Fortune 500 board members were women.16 Approximately 12% of the Fortune 500 boards still include no women.17 The limited engagement of nurses as voting members on governing boards in the health care field can be viewed as a reflection of gender disparity in other sectors.


* Second, it is evident that some board leaders and CEOs have been slow to fully understand the nursing profession's critical role in providing patient care and the impact of nursing leadership on the quality and cost of those services. It is obvious to everyone that nurses comprise a large proportion of the workforce in hospitals and other health care organizations. However, nurses too often are viewed as mid-level technicians rather than skilled professionals whose impact on patient care and patient satisfaction is enormous. Board leaders and CEOs who do not recognize this fact are unlikely to consider nurses as suitable candidates for board appointments.


* Third, some board leaders are reluctant to appoint any organizational employees other than their CEOs as voting members of governing boards. With respect to nurses, this concern can be addressed in several ways. One avenue is to look outside the organization for highly qualified nursing leaders who are affiliated with other institutions, for example, health care organizations in other communities, consulting firms, universities, etc. When nurses whose primary professional affiliation is with the health care organization where they are being considered for a board appointment, the potential for conflicts of interest can and should be addressed through existing policies and procedures. Such policies and procedures typically are well-established and employed routinely when physicians who are employed by and/or serve on the medical staff of their health care organization are being considered for a board appointment.


* Fourth, some board leaders and CEOs hold the opinion that it is difficult to find nurses who are fully prepared and qualified for board appointments. On the basis of nearly 20 years in senior executive roles in 2 nonprofit health systems, full- or part-time faculty appointments in 4 academic medical centers, and leading 3 national studies of governance in hospitals and health systems, my view is quite different. I believe that, in the contemporary environment, there is an abundance of highly-qualified nurse leaders who, if invited, would be highly interested in governance roles and, if appointed, would make signal contributions to board deliberations and decision making. I have had the privilege of serving on boards that include highly experienced and skilled nurses, and I have witnessed their positive contributions to the work of these boards and board committees.




The evidence from recent studies indicates that some progress is being made in engaging nurse leaders in the governance of America's hospitals and health systems. However, the progress is uneven, and it is apparent that unwarranted barriers still exist to board appointments for nurse leaders. In the health care field, the need for board members with integrity, deep commitment to the organization's mission and values, demonstrated competence in disciplines where the board requires expertise, and willingness to dedicate the time and effort required to perform governance duties properly is greater than ever before. The nursing profession includes many persons who can meet these standards fully; yet, relatively few are being asked to consider appointments as voting members of hospital or health system boards.


I encourage all board leaders and CEOs with responsibility for board succession planning and for nominating candidates for board appointments to deliberately seek, recruit, and nominate highly qualified nurses. In most situations, the talent pool is substantial and largely untapped. Highly qualified nurses are available for governance roles and, if invited to serve, can make strong, enduring contributions to the increasingly complex work of hospital and health system boards.




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