By Karma H. Bass, MPH, FACHE, Managing Principal, Via Healthcare Consulting
Good governance feeds on diverse perspectives. Boardroom discussions that include differing opinions can generate thoughtful questions and lead to more well-rounded decision-making and a higher-level of governance effectiveness.
Several years ago, after working for a while with a particular hospital’s governing board, I noticed that although the board members did not hold dramatically different perspectives, their perspectives did vary.
The members would make oblique comments about what they thought on the issues facing the board, but when it came time to discuss specifics, they were excessively polite and deferential with each other and the CEO.
It appeared to me, an outside observer, that members were worried about stepping on each others’ toes, metaphorically speaking. When a board member offered an opinion about an issue, it was as if the issue were closed and all other comments were made to express alignment with what had already been said. Board members never verbalized any differences in opinions, however slight.
When I was asked to offer suggestions for how the members could enhance their board effectiveness, I told them, “I think you’re too nice. I’ve never heard you disagree with each other, and I worry that this is stifling conversation that may be helpful to the CEO and the board.”
Speaking Up with Intent
In this day and age in health care, with so much disruption, board members need to be sure they are practicing the art of “disagreeing without being disagreeable.” Each member needs to muster the “intestinal fortitude” to ask tough questions and give the leadership team a chance to respond. Board members who do not voice their disagreement are shirking their responsibility to build governance effectiveness.
As a member of a governing board, when your organization’s performance isn’t meeting the identified goals – in any area of oversight, but especially with quality – a primary function of your role is to serve as an accountability partner to the executive leaders by holding them accountable for creating improvement plans and demonstrating progress.
Not that you need to be unreasonable in doing this.
Conflict comes in different forms, and some people may find conflict very uncomfortable and avoid it. Some conflict can be destructive—raised voices, accusations, ill-intent. That is not the form of conflict I’m talking about. Destructive conflict can negatively impact everyone in the room, not just those who actively engage in it.
Board and council members should be self-aware enough to ensure their comments and behavior are not construed as overly confrontational, attacking, or unyielding. With the board I referenced above, no one even really wanted to ask a question that could be perceived as challenging or disrespectful – to fellow board members or the CEO. But there’s a fine line between being constructive and being confrontational in your questioning.
Boardroom Dynamics | The Importance of Naming It
Too often in governance meetings where discussion is moving quickly from one agenda item to another, there can be a tendency to default to non-action – or not make a decision. There is a need to get better at surfacing differing opinions, so they can be worked through and not covered up. It is okay to agree to disagree, so go ahead and disagree – that will lead to the next step.
A good way to start the process of actively disagreeing is by talking about the need to do it.
Speaking to the dynamics of what is going on in the room is incredibly powerful. If you are observing a culture in general or a specific circumstance in which members are verbally tiptoeing around an issue, finding a way to name the issue that is not being addressed can be freeing and constructive, if it is done in a way that is respectful.
For instance, instead of making a statement, try asking a question: “Sometimes I’ve noticed this board has meetings where something is not being said. I wonder if it’s possible that there’s an issue that we’re all thinking about, but no one is speaking to? We’ve seen some issues with a workforce shortage, which if there isn’t improvement in the next three months can impact quality scores. I feel like no one’s talking about this. Am I the only one who is picking up on this?”
In other words, frame perceptions as questions, instead of as the absolute truth. This openness to disagreement should be the norm for any board.
Disagreeing Without Being Disagreeable
All board members should be allowed to express a divergent perspective with complete freedom and safety. In my governance work, I have coached governance teams on approaches to disagreement that enrich discussion and result in more rounded and thoughtful decision-making. The key to managing such disagreement is knowing how to disagree without being disagreeable.
Although it is expected that you and your colleagues on the board will disagree, no one should be shaming, blaming, or attacking anyone. Instead, seek to help others find their own clarity through deep listening and asking questions based on curiosity. It is important for all members to stay engaged and act in ways that will help others stay engaged. This means no one person should be dominating the meeting; at the same time no one should be “hiding” from or indifferent to boardroom discussions.
Questioning during discussion should be appropriately probing, but respectful and in a way that reinforces you are all on the same team. An example: “I know there’s been a workforce shortage and the financial headwinds are still strong, but our hospital has had several safety incidents this quarter and I’m concerned there’s going to be an uptick. Would it be possible to hear from leadership on how they are going to address the safety issue, in spite of the workforce shortage?”
This ‘team” spirit should be extended to discussions with the CEO, as well.
This is why we recommend having as few people in the boardroom as possible during discussions. Good governance is not a spectator sport. You should not have an audience when you are practicing it. If 10 of the CEO’s direct reports are sitting around the room, which I’ve seen happen, a board member may not feel comfortable asking a pointed question of the CEO, because the member does not want to appear unsupportive of the CEO in front on his or her direct reports. However, with fewer people in the room, questions can be more probing without the fear of undermining the CEO.
The Art of Active Listening
The other part of constructive disagreement is listening with the intent of understanding, not to win: Consider reflecting back to someone what you are hearing and infer, “Jane, what I hear you saying is you’re really concerned about our quality and safety situation. Is this correct?”
Disagreeing without being disagreeable also means being aware of the impact and intent of your words. Remember, it is possible to have the best of intentions, but still have a negative impact when you do not fully realize how someone might react to your words. Be open to learning and seeing. Use compassionate inquiry, not reactive judgment.
When providing opinions that diverge from another’s, governance members should strive to be honest and kind. Use language that focuses on the differing ideas, not the person who is stating that difference of opinion. State the areas of agreement that exist and reinforce where you believe there is alignment and a shared vision, while also stating where you disagree.
Positive communication builds trust and goodwill across the governance team, which strengthens the team’s ability to be productive and do good work.
Slow, But Constructive, Change
These issues, at their core, are about the board’s culture. Culture can be difficult to change and takes time, so patience is needed. Yet, it can happen. I had the privilege of working with the board I mentioned earlier over a number of years and was gratified to see a gradual shift to more constructively challenging dialogue in the boardroom.
It might help to look at it this way: If there were easy answers, then the issue would never have made it to the board’s agenda in the first place; it would have been resolved at a lower level in the organization.
It is sometimes far too easy to retreat to the corners when a situation gets disruptive. Governance members need to lean in to discomfort. As one CEO I worked with once said, “We need to get comfortable with being uncomfortable.”
It is okay and even expected that reasonable, well intentioned, moral, ethical people have an obligation to disagree. Patients and community members deserve no less.
Questions to Consider
- How can we encourage more engaged discussion at our meetings?
- How comfortable do our members feel in voicing their perspectives, especially if it is an opposing perspective?
- How well do we encourage positive disruption during our discussions?
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