Joint Commission standards and governance best practices require that hospital and system boards conduct a regular board self-assessment to ensure the highest performance governance system and process. However, many boards conduct this important exercise infrequently if at all or, when they do, fail to take the essential step of developing follow-up action plans for governance enhancement. Consultants at Via Healthcare Consulting have developed some of the country’s most recognized and respected hospital board self-assessment tools and are eager to develop a customized process and tool for helping your board meet its highest potential for governance excellence.
Below is a sample work plan for a hospital’s board self-assessment. It can be expanded, condensed, or revised to your particular needs – just ask us!
- Review various documents to ensure a thorough grounding in Memorial General Hospital’s current situation, especially regarding its governance structures and functioning.
- Customize a board self-assessment questionnaire to Memorial General Hospital’s governance situation and administer the survey via e-mail link to a secure Web site to all Board members.
- Conduct brief 30-minute, confidential telephone interviews with each of the Board members, any identified senior hospital executives, and the current president of the medical staff (if desired) to determine the strengths and weaknesses / areas of concern regarding the Board’s current structure and functioning, and to identify specific areas for enhancement.
- Develop objectives and an agenda for a Board Retreat at which the issues identified in the Board self-assessment and interviews will be discussed and addressed. We will prepare a draft packet of materials to be distributed to the Board members in advance of the retreat, including:
- Draft Cover Memo (from the Board Chair)
- Retreat Objectives
- Retreat Agenda
- Consultant’s Background and Bio
- The Memorial General Hospital Board Self-Assessment Report
- Pre-reading Articles
- Develop PowerPoint slides that include a presentation of educational topics including fundamental fiduciary duties and governance best practices in not-for-profit health care governance. The presentation will also include a brief summary of our conclusions about the Board’s strengths and weaknesses and areas for enhancement. We will pay special attention to including best practices for the areas in which the Board most needs improvement.
- Facilitate a 1 ½-day Board Retreat (e.g., 9:00 am to 5:00 pm on Day 1 and 8:00 am to 12:00 pm on Day 2) in which we will:
a) Conduct an interactive presentation of fundamental fiduciary duties and governance best practices in not-for-profit health care governance
b) Present the results of the Memorial General Hospital Board’s customized Board self-assessment;
c) Share our summary observations regarding the Board’s strengths, weaknesses / areas of concern and possible actions for improvement;
d) Facilitate an open discussion regarding the gap between the Board’s current situation and the advanced practices and reach agreement on a limited number (e.g., 3-5) of actions for enhancing Memorial General Hospital’s governance in the next year.
e) Provide a brief report of the decisions made during the Board Retreat (We will have captured the decisions on a flip chart, and will develop the report from those flip chart pages.) This will identify the 3-5 priority actions the Board can pursue for Board enhancement in the coming year.
An optional service we could provide is to assist with the implementation of the governance recommendations (e.g., writing committee charters; developing or updating a Board policy manual).