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  1. 1. Texas Healthcare Trustees Leading Transformation and Change in the Post Pandemic Era: From Trauma to Transformation Les Wallace, Ph.D. President, Signature Resources Inc. Author: Principles of 21`st Century Governance 1
  2. 2. Texas Healthcare Trustees 18 Months of Total Chaos… followed by resuming traditional chaos. ow many of your boards have members with executive Leadership experience navigating chaos, massive transformation, and uncertain risk? 2
  3. 3. Texas Healthcare Trustees The Pandemic has given hospitals… • an overload of trauma to our personnel • added financial burden in an already burdened industry • an unwelcome pause in much of our strategic Intent • and a high stakes period of recovery where attending to the trauma and to much needed transformation compete for priorities Hospitals could lose between $53B and $122B this year due to pandemic Feb 24, 2021 https://www.fiercehealthcare.com/hospitals-health-systems 3
  4. 4. Texas Healthcare Trustees Tracing Pandemic Trauma to Health Care Team “Prevalence and correlates of stress and burnout a U.S. healthcare workers during the COVID-19 pande A national cross-sectional survey study” EClinicalMedicine, Vol. 35, May 1, 2021 https://doi.org/10.1016/j.eclinm.2021.100879 https://mhanational.org/mental-health-healthcare-workers-covid-19 “Texas Hospitals’ Year-Long Fight” From the first COVID-19 cases in Texas to the arrival of a groundbreaking vaccine, we look back at the significant milestones for Texas hospitals. by Emily A. Cheslock 4
  5. 5. Texas Healthcare Trustees Self—reported Burnout and Stress Levels of Hospital Staff https://doi.org/10.1016/j.eclinm.2021.100879 5
  6. 6. Texas Healthcare Trustees Where’s Your Governance in the Digital A Brian Stafford and Dottie Schindlinger, 2019  Is your board a “foundational board,” reactive and taking direction from management?  A “structural board,” more accustomed to asking questions with a strong oversight focus?  A “catalyst board,” diverse board perspectives, seeks insight from peers to innovate, take risks and experime  A “futuristic board,” driving a strategic agenda with a focus on innovation and an in-depth knowledge of how technology is changing their business? 6
  7. 7. Texas Healthcare Trustees Governance in the Post Pandemic Age Now is a good time to refresh your board culture! Can you continue to lean mostly Toward “caretaking”? Or, might you need to pick up your catalytic pace? 7
  8. 8. Texas Healthcare Trustees Disruptions In Hospital Land Continue Post Covid  In 2018 Deloitte predicted consolidation will result in a 50% reduction in health systems by 2024  21% of all rural hospitals are on the brink of closure in 2020—430 hospitals across 43 states  Payors will be brutal about “value based payment” and quality performance aligned with national standards of care and health outcomes  Private equity firms will continue to circle our hospitals  Partnerships / new businesses with non-hospital partners: insurance companies, medical equipment, pharmaceuticals, and non-traditional partners, e.g. CVS-Aetna.  Entrepreneurial boards who understand “marketplace” dynamics more so than clinical dynamics will outperform in the near term 8
  9. 9. Texas Healthcare Trustees Post-Pandemic Workforce In Flux  25-30% of nursing workforce potentially retiring in 3-5 years. (Brandeis U.)  Pandemic is causing nurses to change careers earlier.  A vaccinated workforce challenges hospital policy: • Require? / Terminate? • Bonus: $500 to get vaccinated + post bonus for those already vaccinated. In Texas…  Physician shortage statewide projected to increase from 6,218 to 10,330 FTEs in 2032  Among 35 Dr. specialties general internal medicine is expected to have the greatest absolute shortage in 2032 of 2,608  Family medicine expected to have the greatest shortage of 2,495 FTEs “Texas Physician Supply and Demand Projections 2018- 2032” Texas Health and Human Services report May 2020. 9
  10. 10. Texas Healthcare Trustees What Transformation Priorities will we face Post-Pandemic?  Assuring we have the right board of directors for a period of chaotic challenge and transformation.  ”Trauma Informed Attention” to the acute stress / PTSD manifestations of sustained covid emergency for our staff.  Rebuilding the board’s “strategic planning” infrastructure based on modern board practices.  Refreshing out governance processes top to bottom from meetings to committee structure. 10
  11. 11. Texas Healthcare Trustees What Transformation Priorities will we face Post-Pandemic?  Accelerating the development / adoption of digital technologies to serve our communities and help our staff be more efficient.  Updating our attention to other organizational risks: e.g., cyber security, staff retention and recruitment, emergency redundancy for power outages, reaffirming our “succession planning” from top to bottom of the organizational chart.  Attending to a “live” barometer of how corporate culture is doing: employee engagement, employee development, turnover, coaching and mentoring. 11
  12. 12. Texas Healthcare Trustees SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach Prepared by SAMHSA’s Trauma and Justice Strategic Initiative July 2014 Trauma Informed, Change, and Transforma Most people don’t resist change…. They resist being changed! 12
  13. 13. Texas Healthcare Trustees Response to Trauma and Leading Transformation Share Common Rubrics  Listening and reassurance  Inclusion—all actors are given a voice  Collaboration and empowerment with actions  Transparency  Celebrating hospital “good news” about quality / patient experience  Safety…what’s in it for me? Give me a voice!  Clarity on vision for the future  Reasonable (evidence based) reassurance of a purposeful direction  Outlets for those who feel helpless or powerless  Mentoring and peer support 13
  14. 14. Texas Healthcare Trustees Gaining Commitment to Change: Four Fundamental Questions to Answer Clearly  Why should we be changing? Better, more competitive, safer, happier, successful. What’s in it for me?  What does the destination look like? Describe in as much detail as possible. Show benchmarks if someone else has already gone there.  How will we get there? Is there a roadmap? Roadmaps and measurable milestones give confidence. How will we handle the disruption / pain of changing?  What’s my role? How will you use my experience and intellectual capital? How will you protect me from the fallout of change? What choices will I have? 14
  15. 15. Texas Healthcare Trustees Use a Proven Model for Generating Transformative Thought and Action John Kotter, Leading Change 15
  16. 16. Texas Healthcare Trustees Use a Proven Model for Generating Transformative Thought and Action John Kotter, Leading Change  Step One: Create a Sense of Urgency....  Step Two: Form a Powerful Coalition....  Step Three: Create a Vision for Change....  Step Four: Communicate the Vision.... Time Ten!  Step Five: Remove Obstacles....  Step Six: Create Short-Term Wins....  Step Seven: Build on the Change....  Step Eight: Anchor the Changes in Corporate Culture. 16
  17. 17. Texas Healthcare Trustees Change and Transformation Helical, Not Linear 17
  18. 18. Texas Healthcare Trustees Board Talent Strategy Performance and Risk Governance Process Transformation was Happening in Every Domain of Board Governance Pre-Covid elf-Assessment: Conduct a post-covid inventory / assessment and refresh of each of these governance domains. Slides 45-48 8
  19. 19. Texas Healthcare Trustees Resources for Tracing Governance Transfor “National Health Care: Governance Survey Report,” AHA Trustee Services, 2020 “Applying Lean Principles to Board Work,” Mary Totten, AHA Trustee Services 2020 U.S. Spencer Stuart Board Index 19
  20. 20. Texas Healthcare Trustees Peer into questions for the future of your governance  Do we have the right people around the Board table?  Are we investing more in the right strategy for this environment?  Do we have a full enterprise risk management approach? Tracking and mitigating risks beyond financial and clinical? E.g. cybersecurity, organizational culture, succession planning, turnover.  Is our workplace culture engaging staff to be the best they can be?  Can the board count on the “institutional chief quality and patient safety officer” to be accurately tracking outcomes in real time.  Have we made the “patient experience” a point of emphasis? 20
  21. 21. Texas Healthcare Trustees We are Already Familiar with Payment, Technological, and Treatment Disruption… The next big disruption in the hospital space is board governance: Board makeup Governance processes A Corporate feel to strategy vs. incremental movement Leaving bureaucratic models of oversight “Hospital boards are ill prepared for the future.” James Orlikoff, AHA 21
  22. 22. Texas Healthcare Trustees Board Makeup: Trending in Hospital Governance  Average board age gets younger as a new generation is sought out  Diversity gets increased scrutiny by the public and by payors [AHA has partnered with the Urban League and Unidos US to increase diversity options for hospitals]  Full Diversity: ethnic, gender, sexual orientation, disabilities, age, professional backgrounds…  Board compensation a certainty [25% of large systems compensate their boards]  $25K annually—only if you’re governance certified  Minimum of 20+ hours a month required of every board member 22
  23. 23. Texas Healthcare Trustees Challenging The Clinician on the Board  A clinician on the board gives a false sense of security that the board is “keeping up.”  The board already hears from the Chief of Staff, CMO and CNO regularly and has national “quality standards” to guide oversight with numerous clinical committees reviewing quality performance!  How much to you hear from the “patient experience” executives?  Key clinical metrics, trends, issues, are all available for guidance on-line and are easily adapted to your community’s experience. 23
  24. 24. Texas Healthcare Trustees Should Your Next Board Member be…  IT executive?  Mergers / Acquisitions expert  Younger professional?  Futurist  Corporate CEO / COO / CFO / CTO  Regional leader?  Systems expert?  “Customer experience” expert?  Risk management expert?  “Lean systems” expert  Organizational transformation expert?  Strategic planning expert? If / when your board is paid… the public scrutiny increases around competency. 24
  25. 25. Texas Healthcare Trustees Transition Governance Process to 2021 Standards… not some future ideal!  Modern Agendas  Oversight dashboards beyond $ and clinical quality  ERM  Committees 25
  26. 26. Texas Healthcare Trustees Future of Governance Process: Flipped Presentations Cuts out Oral Reporting From Presentations... To increased dialogue You’re moving from hand-to-hand combat during the pandemic to a more strategic period and frame of reference. THIS REQUIRES DIALOGUE! 26
  27. 27. Texas Healthcare Trustees The Flipped Presentation To the Board  All background reading including “frequently asked questions” and answers prior to the meeting in executive summary.  No oral presentations to Board without “pre-submitted materials!” This especially includes CONSULTANTS!  An executive summary prior to the meeting scopes ALL recommendations.  The “agenda item” therefore begins in “discussion” mode rather than background mode—thus saving precious face-to-face time for dialogue. signatureresources.com/about-us/flip-meeting-improve-outcomes- engagement-and-satisfaction https://www.linkedin.com/pulse/getting-your-hands-frog-les- wallace-les-signatureresources-com-/ 27
  28. 28. Texas Healthcare Trustees The Modern Board Meeting has Evolved The Modern Board Meeting has Evolved  Convene • Checking conflict of interest • Consent agenda • Past minutes approved  Performance dashboards, updates and reports (finance, clinical quality, culture) Monthly/quarterly?  ERM: Risk/Compliance reports / updates Monthly/Quarterly?  Strategy: updates, adjustments, metrics, business environment reviews o Committee Update reports in Consent Agenda. o Action items in appropriate section of
  29. 29. Texas Healthcare Trustees Confirm Robust Organizational Dashboard Tracking  Financial performance: key indicators  Patient safety and clinical quality  Patient experience  Compliance  Organizational Culture and Engagement*  ERM not simply clinical Risk (med staff committees?)  Innovation  Population health  Community citizenship What external “quality” standards guide your standards? e.g. CMS, Consumer Reports Hospital Safety Ratings, Healthgrades, Press Gainey? *“Culture eats strategy for breakfast!” Peter Drucker 29
  30. 30. Texas Healthcare Trustees Enterprise Risk Management a “corporate” view of risks…a strategic look across the organization rather than a series of silo views.  Cyber security issues reaching “pandemic” level  Power systems / backup redundant  Strategy risks: too fast, too slow  Board makeup for future bus. environment  Population shifts  Succession / Talent risks  Innovation / lack of  Mergers / acquisitions  Compliance  Succession planning  Corporate culture  CEO compensation 30
  31. 31. Texas Healthcare Trustees Transforming Board Committees: Old Models in a New Era of Governance ? ? ? ? ? ? 31
  32. 32. Texas Healthcare Trustees What’s a Quality Committee to Do? Delegating and Enforcing Accountability More oversight—safety, quality, risk management— delegated to “quality directors” [CMO / CNO /CXO] with regular board reports. Review all quality indicators, compare them to typical hospital quality indicators, set “stretch” standards for the ones with the most mortality, associated costs, and reimbursement risk. [Does the board know these?] Regular reporting to the board:  Hi priority / risk performance monthly reporting- dashboard!  Overall quality performance—lower risk—quarterly For unwanted variations from expected goals the Board issues an accountability notice to CEO! 32
  33. 33. Texas Healthcare Trustees Where are the biggest risks in your clinical services? The medical staff organization monitors these regularly. Does your quality committee get a “risk report” from them? • Medical Staff Committees • Bylaws • Care Improvement • Cath Angio Medical Committee (CAMC) • Committee for Professionalism • Credentials and Privileges • Ethics • Health Information Management • ICU CQI • Infection Control • Interdisciplinary Practice • Medical Executive Committee (MEC) • Operating Room Medical Committee • Perioperative Services Medical Committee • Pharmacy & Therapeutics • Quality Patient Safety & Effectiveness • Well Being Committee • Stanford Committee for Professional Satisfaction and Support (SCPSS) • Graduate Medical Education Review • Patient Safety Committee • Tissue Committee 33
  34. 34. Texas Healthcare Trustees Transform Strategy Development “If financial & quality indicators are performing adequately, strategy becomes 70% of a Board’s focus” “The annual strategy review frequently amounts to little more than a stage on which business unit leaders present warmed over updates of last years presentations, take few risks in broaching new ideas, and strive above all to avoid embarrassment.” “Has it become a primitive tribal ritual?” McKinsey Quarterly 2002 34
  35. 35. Texas Healthcare Trustees YIKES! How do Future Boards Sort Through Massive Choices to find the Right Strategy? Answer: they adopt a “strategic rhythm. 35
  36. 36. Texas Healthcare Trustees An annual Strategic Rhythm helps Future Proof Your Organization Future proofing is the process of regularly anticipating and discussing the future and developing methods of minimizing the effects of shocks and stresses and taking advantage of future events. • “Strategic awareness and thinking year around.” • Two strategic retreats a year! • 70% of meeting time focused on future facing strategic issues 36
  37. 37. Texas Healthcare Trustees Create More Space for Strategic Thinking and Dialogue  Strategic thinking is a curious and intellectual exploration of future scenarios and developing trends that result in more innovative approaches to the marketplace.  Strategic planning is a tactical process to outline an execution plan for moving forward. 37
  38. 38. Texas Healthcare Trustees Becoming a “Futurist” Trustee “Pay attention to world signals.”  They follow major trends.  They conjure up possibilities / scenarios.  They are “intellectually promiscuous scanning diverse sources of news, ideas and innovations.  They observe and discuss how the best in class behave.  The look for “possibilities” rather certainties.  They discuss possibilities incessantly.
  39. 39. Texas Healthcare Trustees Transform How Your Board Approaches Strategy  Invest more time in scanning the horizon sensing and detecting the signals of change happening now!  Identify the issues that are priorities for sustaining our ability to survive and thrive.  INVOLVE a broad base of physicians, clinical staff and other staff in learning about the trends, discussing their potential impact on the hospital and discussing priority actions.  How about a “futures panel?”  Execute on a “vital few” key elements…not 10…closer to 5! 39
  40. 40. Texas Healthcare Trustees Hospital Boards of Directors are Now Focusing on These Elements of Strategy  Business and clinical technology infrastructure and improvement  Cybersecurity  Organizational Culture and staff engagement—including Drs.  Shifting demographics and population health strategy  ”Lean” strategy / “rapid process improvement”  Governance best practices  Board makeup  ERM (enterprise risk management)  Mergers, acquisitions, partnerships (MAP strategy) 40
  41. 41. Texas Healthcare Trustees  Strategy progress updates  Business environment discussions / new models  Disruptions  Scenario thinking  Tracking community population health shifts  Developing partnerships / affiliations  Innovation / “Lean” rapid improvement processes  Technology / Digital transformation  Benchmarking peers and competitors  Patient experience advances  Governance succession and development Of Board Agenda is Strategic 41
  42. 42. Texas Healthcare Trustees The Pandemic Gave Us Permission to Consider and Implement New Ideas 42
  43. 43. Texas Healthcare Trustees Board Talent Strategy Performance and Risk Governance Process Significant New Models Existed for Every Domain of Board Governance Pre-Covid Self-Assessment: Conduct a post-covid inventory / assessment and refresh of each of these governance domains 43
  44. 44. Texas Healthcare Trustees Questions 44
  45. 45. Texas Healthcare Trustees Board Makeup The mix of competencies and professional experience your board needs to match the changing business environment and help navigate the future.  Profile of Desired Board competencies / experiences / diversity…for our future  Board refresh/term limits; active recruitment / succession pipeline action plan  Investment in current Board development; industry seminars & board reading  Investment in Officer development  Certifying Governance literacy  Thorough Board orientation  Regular governance self-assessment: macro assessment every four years; micro each year BOARD MAKEUP The mix of competencies and professional experience your board needs to match the changing business environment and help navigate the future. 45
  46. 46. Texas Healthcare Trustees Strategic Intent As a strategic partner, the board is involved in the analysis, consideration and assessment of how the future will unfold for the organization and what is needed to navigate it with the most success.  Enhance Board partnership & dialogue with executive team  Increased board investment in strategic dialogue through meeting agenda refresh  Strategic thinking—be innovative & visionary  More scenario discussions…”what if?”  Strategic conversations +/- 70% every meeting; 2 retreats a year  3-5 year strategic plan with clear accountabilities  Strategic metrics: outcome / impact, calendar progress, investment, accomplishment Strategic Intent As a strategic partner, the board is a catalyst for the analysis, consideration and assessment of how the future will unfold for the organization and what is needed to navigate it with the most success. 46
  47. 47. Texas Healthcare Trustees Organizational Oversight Tracking fiduciary performance: finance, organizational culture, customer/client value and risk. +/- 20% of meeting & committee time.  Basic Performance Dashboards: financial, patience experience, org. culture / employee engagement  Other “performance” dashboard indicators important to the organization (innovation, turnover, employee development, performance of new initiatives)  Enterprise Risk Management tracking separately & quarterly  Annual external financial audit  Benchmarking / comparing with other successful hospitals Organizational Oversight Tracking fiduciary performance: finance, organizational culture, Patient experience. +/- 20% of meeting & committee time. 47
  48. 48. Texas Healthcare Trustees Governance Process Maximizing board meetings and committee work to effectively utilize board talent and time.  Efficient agendas with “limited” presentations and increased dialogue (e.g. flipped meetings)  70% + investment in strategic dialogue  Regular self-assessment and governance development plan  Committee charters and performance: (committee annual reports of accomplishment & recommended future agenda)  Board culture expectations and rules of engagement defined and assessed regularly  Partnership with the CEO; twice a year CEO performance feedback Maximizing 48
  49. 49. Texas Healthcare Trustees Les Wallace, Ph.D. President, Signature Resources Inc. Les@signatureresources.com  Dr. Wallace is recognized for tracking business environment and workplace trends and their impact upon business and government. His latest book, co-authored with Dr. Jim Trinka, A Legacy of 21st Century Leadership, outlines the leadership organizations need in a global, fast moving business environment. His book, Principles of 21st Century Governance is being used by many boards in the profit and not-for-profit sectors to design governance development approaches.  His latest book, Personal Success in a Team Environment is used by individuals and organizations to improve teamwork, career building and success at work.  Les is a frequent consultant and speaker on issues of organizational transformation and leadership, employee engagement, strategic thinking and board of directors development and governance. His clients include Fortune 100 businesses, Government agencies, and not-for-profit organizations world-wide where he has helped with major transformation efforts, building organizational leadership development, and improving corporate culture.  Les is a member of the National Association of Corporate Directors and has served on the Board of Security First Bank and the international Boards of the World Future Society and Counterpart International. He most recently served on the board of the Mental Health Center of Denver. 49