Few opportunities exist for potential board members to learn the expectations and skills required and to learn the differences between governance and management.
A respected physician leader is asked to serve on a board. Despite chairing several medical committees at the county and state medical associations, his transition to the board has been rocky. He knows that his approach, which seemed to work well in the medical associations, has fallen flat in the board, but he does not know why. He is afraid that he is losing credibility with the physician and nonphysician leaders.
Because of their medical training, previous medical leadership positions and respect among colleagues, physician leaders are commonly tapped to serve on boards that include physician and nonphysician leaders. It is painful to observe physician leaders struggle at this level, where physician leadership and insights are particularly needed.
It is difficult, if not impossible, for board members to entirely separate strategy from operations. Management is more tangible and seemingly more objective. The messy work of mission and vision that drives strategic decisions may be uncomfortable for physicians.
The dynamics on a local or state medical association board versus a hospital, foundation or national medical association board can be quite different. On a local or state medical association board, the physician is likely a dues-paying member, and the association staff serves at the behest of the medical leaders.
In contrast, physician and nonphysician board members who serve on a hospital, foundation or national medical association board are likely to have considerably more experience and distinct perspectives. The hierarchies may be flatter.
Unless a new physician board member can quickly gain credibility by demonstrating strategic thinking, broad and deep insights and financial acumen, the new board member risks becoming marginalized. This may occur despite the board’s deliberate attempts to orient the new physician board member.
In my experience, new physician board members become less effective and fail to make their boards fully effective when they have the following three misunderstandings:
- Lack of understanding of the specific roles of a governing board member.
- Insistence on managing rather than governing when they are on the board.
- Failure to trust other board members or to gain trust by the board.
Roles of a Governing Board Member
The Center for Creative Leadership pioneered a model 30 years ago that states “70 percent of [leadership] development … consist[s] of on-the-job learning, supported by 20 percent coaching and mentoring, and 10 percent classroom training.”1
This is upside down from the way previous medical school training was provided, which traditionally relied on heavy classroom training and didactic lectures. Leadership training is experiential.
Becoming an effective governing board member is similar to learning new skills like cooking, golf or dancing. More experienced board members can “point out common pitfalls, offer practical advice, and help steer the learner away from bad habits.”1
Formal learning and reading are still important “when it supplies technical skills, theories, and explanations that apply directly to what is learned through experience — and when it is both valued and quickly integrated within the work environment.”1
The “Ten Basic Responsibilities of Nonprofit Boards” arose from a National Center for Nonprofit Boards (now known as BoardSource) paper on the roles and responsibilities of the board.2,3 From this work, they recommended that the board’s responsibilities were to:
- Determine the mission and purpose.
- Select the chief executive.
- Support and evaluate the chief executive.
- Ensure effective planning.
- Monitor and strengthen programs and services.
- Ensure adequate financial resources.
- Protect assets and provide financial oversight.
- Build a competent board.
- Ensure legal and ethical integrity.
- Enhance the organization’s public standing.
Some board members may not appreciate the collective nature of the board and that the board does not even exist unless it is formally meeting in session. “Why do we exist as an organization?” is a question that the board answers for internal and external constituencies.
Working through a chief executive officer is likely to be novel for most physicians, especially if staff bypasses the CEO to go directly to a new board member with a concern. This is a pitfall. The new board member may be tempted to intervene. However, the wise board member works through the CEO, who is responsible for the management of the organization, including the staff.
Governance: Leadership, Not Management
It is difficult, if not impossible, for board members to entirely separate strategy from operations. Management is more tangible and seemingly more objective. The messy work of mission and vision that drives strategic decisions may be uncomfortable for physicians, even for a few physician leaders.
It may be challenging to make the transition from a physician who is more comfortable giving directives to a board member who provides direction. Asking the right questions instead of giving the best answers is a learned skill.
Over the past 20 years there have been several recommendations from consulting groups, research and literature on how to make nonprofit boards more effective. BoardSource has collaborated with the Hauser Center for Nonprofit Organizations at Harvard University to re-examine governance.3
Several issues can impede optimal governance of the board, including poor communication, dominance by the vocal few and hidden agendas. Board members may be engaged or disengaged. Most commonly, board members may simply be unclear about what is expected of them and how it differs from their previous medical leadership and management roles.
Physicians, accustomed to leading allied health care staff or other physicians, may be unprepared to listen more robustly to other leaders on the board who have different but equally valid perspectives. Aggressive tactics can be counterproductive at the board level. Persuasion, not power, wins the day.
Board member performance can be summarized with the following performance criteria: 4
- Active and thoughtful contributor at board and committee meetings.
- Does not attempt to dominate discussion at meetings.
- Reads agenda materials prior to meetings and comes prepared to address the defined issues.
- Supports board actions and does not attempt to subvert past decisions or policy.
- Is comfortable expressing a dissenting opinion or vote.
- Expresses dissenting opinion constructively, not in a negative or ad hominem manner.
- Integrates continuing education into board deliberation and function.
- Has not violated confidentiality of boardroom.
- Has not violated conflict-of-interest policy.
- Clearly places the best interests of the organization above personal or business interests.
- Understands and abides by policies and procedures governing board member conduct.
- Supports the organization’s vision and mission.
- Is well-versed in the strategy of the organization and uses it as the basis for deliberating and considering issues before the board.
- Has communicated effectively with key constituents regarding board positions when asked to do so.
When a board member falls short of the performance criteria, then the board member risks losing credibility and trust by the rest of the board.
Importance of Trust
Stephen Covey described the Smart Trust Matrix.5 He divided the matrix into four quadrants.
- Blind trust is the zone of gullibility reached by a high propensity to trust without appropriate analysis.
- The quadrant of Indecision involves low propensity to trust, but also low analysis. People who reside in this quadrant are insecure and protective.
- The quadrant of Suspicion comprises low propensity to trust, but high analysis. People in this zone rarely trust beyond themselves. Some may reason that this zone is low risk. Covey points out that it is actually high risk, because “high suspicion leads you to validate and analyze everything to death, decreasing speed and increasing cost.”5
- The quadrant of Judgment, in which people show high propensity to trust, but also high analysis.
Covey concludes that, “managers who don’t become leaders don’t know how to extend Smart Trust. … They delegate tasks without parameters or extend fake trust, but they don’t fully entrust people with stewardship that engages genuine ownership and accountability.”6
Ultimately, governing well requires board members to trust each other. The board is only as strong as the weakest trust exhibited on the board. Glenn Tecker states that a culture of trust “allows associations to abandon politically motivated permissions to proceed that add little or no value to the quality of a decision.”7
On the other hand, a board that exhibits trust shows the following characteristics:7
- Board members have knowledge and expertise and engage in the dialogue necessary to make informed decisions with confidence.
- Staff and volunteers have well-defined roles and interrelationships, within a particular context, so that leaders can make efficient decisions without command and control approvals.
- The board has responsibility for strategy and direction setting; member and staff workgroups have accountability for the detail and implementation of strategy.
- The chief staff executive is considered an integral part of the association’s leadership team, understands the members’ marketplace and maintains an open flow of communication to volunteer leaders.
- The national organization actively solicits the opinions of leaders of state and local component groups in creating the future for the industry, profession or cause they represent.
- Leadership constantly informs members and, where appropriate, asks for their opinions so that they feel part of the decision-making process and that they are adding value to the overall community.
- The association has a reputation as a trusted source for information and engagement in a social media world.
Recalibrated Board Member
Let’s return to the new board member whose approach on the board was falling short of expectations. Based on his previous service on a medical association board, the hospital board likely believed he would be a good fit.
It is critical for potential board members to clearly understand their roles and that they are being asked to govern, not manage, while serving on the board. The board expects a new board member to see matters broadly, deeply and thoughtfully.
Tecker7 lists the behaviors common among governance and staff leaders who have the ability to create and maintain a culture of trust:
- Listen well.
- Have respect for diversity of opinion.
- Are willing to share common and appropriate information.
- Are committed to open communication and facilitated dialogue.
- Have complete confidence in the abilities of others.
- Are committed to honesty and integrity.
- Delegate responsibilities effectively.
- Practice transparency.
- Are committed to “open book” financial accountability.
- Are open to criticism and willing to admit mistakes.
- Are aware of what they do not know.
Sage advice from previous board members and best practices among governing boards can help new board members to effectively serve on the board, for the mutual satisfaction of the new board member and the board.
James S. Hernandez, MD, MS, FCAP, is medical director and laboratory medicine division chair, and associate professor of laboratory medicine and pathology, at Mayo Clinic and its College of Medicine in Arizona. The American Association for Physician Leadership originally published this article in September 2014.
- The 70-20-10 Leadership Development Model, accessed on December 27, 2013, at https://www.bridgespan.org/insights/library/leadership-development/the-70-20-10-leadership-development-model
- Ingram, R.T., Ten Basic Responsibilities of Nonprofit Boards, 2nd edition, BoardSource, Washington, DC, 2009.
- Ten Basic Responsibilities of Nonprofit Boards, accessed on December 27, 2013 from www.nami.org/
- Pointer, D.D. and Orlikoff, J.E., Board Work, Governing Heath Care Organization, Jossey-Bass, San Francisco, 1999
- The Speed of Trust Summary, accessed on December 27, 2013, at http://www.speedoftrust.com/How-The-Speed-of-Trust-works/book
- Covey, S.M.R., The Speed of Trust: The One Thing That Changes Everything, Free Press, a Division of Simon and Schuster, Inc. New York, NY, 2006
- Tecker, GT, et al, The Will to Govern Well, ASAE Press, Washington, DC, 2010.