We have two ears and one mouth so that we can listen twice as much as we speak. Epictetus.

Almost two thousand years later and the wisdom in these words still provoke thought. In our work with over 100 healthcare governing boards, Dr. Jack Mitstifer and I have observed that boards who excel at listening are far more effective than the boards that talk excessively and hardly listen at all. Boards that listen are better boards.

Of all the governance improvement strategies I have personally recommended over the past 30 years, improved listening is the only one that costs nothing and has a profoundly positive impact on the effectiveness of governance in hospital and health system boardrooms. While improved listening is not without its challenges, the rewards are impressive. Integrity Hospital Company has witnessed firsthand how best practice governance begins with an emphasis on good listening.

The Listening Challenge

Governing a healthcare enterprise is a very complicated challenge these days. Agendas are crowded, time is limited, and problems abound. In some boardrooms, agendas are run with military precision, timelines specified to the minute for every agenda item. In these boardrooms the chairman is often more of a timekeeper than a discussion leader.

In other boardrooms, multiple people speak at great lengths but no one really listens. Presentations drone on for many hours. Clock-watching and sleeping are not uncommon in these boardrooms. In my experience neither “time to the minute” nor “everything goes” board meetings are very effective methods. A better balance of listening is needed.

Boards committed to active and engaged listening are on the path to best practice governance. Boards that are committed to listening make more informed decisions. They achieve a better understanding of their enterprise. The job of being on a board is more fulfilling when engaged listening is a central value of governance. The simple act of listening effectively makes a healthcare enterprise board perform better.

Listening effectively is not easy but well worth the investment in time and energy. Key questions all boards should ask themselves periodically are:

“Who do we listen to?”
“How do we listen effectively?”
“How do we use the insights generated from listening to improve healthcare?”

Boards of healthcare enterprises have five constituencies, all of which deserve effective and engaged listening: management, medical staff, patients, staff, and community. What does effective and engaged listening mean for each of these constituencies? Here are some suggestions based on Integrity’s work with highly effective boards, CEOs, and senior leadership teams in hospitals and health systems throughout the United States.

Listening to Management

First, let’s consider management. The board’s principal contact with management is with the chief executive officer, as it should be. I strongly advocate for the chairman of the board and the CEO to have a very direct and open relationship. The chairman and the CEO should meet informally at least monthly in an open discussion context. The chairman needs to listen carefully to what is on the CEO’s mind. The CEO needs to listen carefully to input and suggestions from the chairman. These two individual leaders set the tone for listening for the entire enterprise. If they listen to each other, the rest of the organization will follow. If they don’t, the rest of the organization will notice and follow that negative path

Members of senior leadership, including the chief medical officer, chief nursing officer, chief financial officer, and chief operating officer, should also have regular contact with board leaders, and they should attend and participate in board and board committee meetings. Board members should listen carefully to these management leaders and offer advice and counsel. Much wisdom can be gained by management leaders from listening carefully to their board members’ words of advice and good counsel. In our experience, CEOs and senior leadership benefit from meeting informally with each member of their board at least once a year. This is an excellent listening opportunity for all parties and allows board members and senior management to develop a closer relationship than possible if their only contact were during regular board and committee meetings.

In addition to senior management, boards also benefit from periodic contact with middle management staff. CEOs routinely hold monthly meetings with middle management. Inviting board members to attend periodically these meetings is a good way for them to be introduced to middle management and hear the kinds of issues discussed at these important meetings. One of Integrity’s more progressive CEOs makes it a point to invite board members to meet informally with middle management in small groups throughout the year to listen to issues and challenges, as well as to develop a collegial relationship with members of their management teams. It should be noted that in some healthcare enterprises, CEOs and senior leadership believe no contact between the board and middle management is appropriate. In our experience, however, listening opportunities build relationships that are very positive for both board members and middle management. Board members must remember to carry issues and concerns that arise in these settings to the CEO for follow-up and action. The board members’ role in this context is to listen, not act as decision makers, which could potentially compromise the CEO or members of senior management.

Listening to the Medical Staff

The medical staff is a vital constituency for all hospitals and healthcare systems. The board will, in all likelihood, have several physician members. The more, the better, in Integrity’s view. Time at each board meeting should be directed to truly discussing clinical quality matters, and physicians are best equipped to lead these discussions. If boards spent half as much time listening to clinical quality discussions in the boardroom as they do to financial discussions, hospitals and health systems would be
safer places. Beyond board meetings, board members should be encouraged to access other listening opportunities with members of the medical staff. They should periodically sit in on medical executive committee meetings, quality committee meetings, credentials committee meetings, etc. Medical department meetings can be informative for board members as well. For example, there is no better way for board members to listen to the concerns of surgeons than to periodically hear the issues discussed at Department of Surgery meetings. Board members should not be strangers to physician meetings in their enterprise. In the best case, board members can listen and occasionally even contribute to the discussions when invited.

Another of Integrity’s clients also provides an opportunity for board members to meet and listen to informal leaders and future leaders of the medical staff. In this hospital system, the CEO and chief medical officer meet for dinner monthly with a rotating group of physicians who are not yet office holders in the medical staff hierarchy. These younger, hard-working clinicians are currently more interested in patient care than a position of leadership, but they are the organization’s future medical staff leaders. The CEO makes a point of inviting a few board members to these monthly dinners so the board members can both become acquainted with these important members of the medical staff and they can listen to the kinds of issues and challenges physicians face in everyday practice. Collectively, everyone benefits from this kind of engaged listening opportunity. Ultimately, patient care is the beneficiary.

As with management, care should be taken by board members not to act as decision makers in the context of listening to physicians. CEOs are justifiably concerned when board members attempt to make decisions or commitments for the enterprise. That is the role of management. On the other hand, the more information that flows to management through effective listening, the better their decisions.

Listening to Patients

Patients are an important listening constituency for board members too. How does a board listen to patients? It is not easy, but the rewards of persevering are plentiful. The first opportunity for patient listening is the “Patient Satisfaction” report periodically delivered to all boards. These should not be perfunctory reports with no real discussion. Effective listening means the Patient Satisfaction reports should be in-depth and thought provoking. These reports should be delivered by someone close to the bedside who truly understands patient concerns. Listening and asking good questions about this important report is a critical board responsibility.

Beyond boardroom reports, I have observed effective boards personally getting out into their hospital care delivery areas and observing first hand how patients are treated and how they respond. One creative way used by one of Integrity’s clients is the “White Coat Day”. Board members spend one day a year with a physician observing and listening while the physician practices. This not only provides insight on patient experiences, it provides direct insights about the challenges faced by the medical staff as well. Spending time observing in the emergency department waiting room, outpatient services clinic, discharge planning office, and other areas, is a great listening opportunity for board members to gain insights about what is happening in their enterprise. Truly effective boards view listening to patients, with the full knowledge and support of the CEO and senior management, as an important role of governance. Board members so engaged can provide invaluable feedback to management for followup.

Listening to Staff

The staff is yet another highly important listening constituency. Board members do not usually have an opportunity to listen to members of the staff. It takes some creative thinking to open this avenue of communication. It also takes a CEO and senior leadership team who welcome rather than resist this listening opportunity for board members. CEOs and senior leaders confident in their own leadership styles welcome such communication. Lesser leaders may feel a little threatened at the thought of board members listening to staff.

Integrity clients have created numerous pathways for board members to listen to their staff. For example, all hospitals and health systems hold regular orientations for new employees. Board members should be encouraged to periodically sit in on these sessions to listen to the hopes and aspirations of new employees as well as their reasons for choosing to work at their enterprise. Nearly all CEOs hold periodic “town hall” meetings for employees. These are great opportunities for board members to attend and listen not only to the staff update, but to note the kinds of questions and concerns voiced by the staff. Numerous CEOs and members of senior leadership also typically hold regular departmental meetings. These, too, are great opportunities for board members to attend as guests and listen to updates and concerns. Board members need to be particularly careful not to appear to preempt management when listening to staff. Acting as a conduit to the CEO for the concerns and positive feedback expressed by staff is the role of board members in this listening context.

In addition, boards usually receive periodic reports from management on employee satisfaction, employee engagement, turnover, and exit interview summaries. These reports should be listened to very carefully, and thoughtful discussions should ensue at board meetings to ensure that both positive and negative aspects of these reports are fully understood. Connectivity between the board and staff is a benefit to both constituencies. It should be more common than it is. Only the most capable CEOs and the most effective boards are able to fully benefit from this particular listening opportunity.

Listening to the Community

Last, but certainly not least, board members should be actively listening to the community they serve. Boards are usually made up of community leaders. However, enlightened boards know that they can never, on their own, hope to understand and know all of the issues and concerns a community has about their hospital or health system. Integrity’s most effective board clients go to great lengths to ensure they listen to the community. They ensure that community, business, government, religious, and social service leaders have the benefit of periodic “leader briefings”. These sessions provide the dual purpose of allowing the board and senior leadership to update community leaders about current and future plans. Just as important, these briefings give board members an opportunity to listen to what community leaders have on their minds. Enlightened boards go one step further and periodically participate in management’s “town hall” style meetings open to the community at large. These meetings provide an excellent opportunity to directly listen to community feedback, both positive and negative. The feedback then becomes positive intelligence about how the community perceives the enterprise.

Formal reports are also typically received by the board regarding the community. Board members should expect to receive periodic community perception survey results and, just as importantly, market research reports that identify positive and negative trends with reference to outmigration and the perception of quality among community residents, both those using the organization and those opting to go elsewhere. Listening to these reports should give rise to probing questions and lively, constructive discussion.

Prerequisite for Governance Listening

All of the opportunities for listening described here have two key prerequisites. First, listening opportunities require an enlightened and confident CEO and senior leadership team. In my experience, enlightened leaders want to engage their boards in listening to all key constituencies. They see value and wisdom in encouraging board members to have contact with these constituencies. They are not threatened by this contact—they welcome it. The second prerequisite is a board that truly wants to hear what key constituencies have to say. Board members must not be listening to create a catalogue of “gotcha” moments at the next board meeting. They should not be listening to make decisions on the spot. They are instead listening to accumulate wisdom about how their healthcare enterprise is functioning and for the purpose of asking more informed questions and making more informed judgments. Listening board members make the best advisors to their CEOs and senior leadership teams.

An enlightened CEO and senior leadership team, coupled with board members eager to listen and learn, is a powerful governance combination. If both groups do their part to create an environment of listening, great things can happen.

Rewards of Effective Listening

Board members who engage in active listening are rewarded with a broad range of what Peter Drucker referred to as “emotional intelligence”. In other words, they have a real understanding of what is going on in their enterprises. While sitting in board and committee meetings is helpful, there is no substitute for listening directly to management, physicians, staff, patients, and the community. The wisdom gained by listening to these key constituencies is put to good use by enabling board members to fully understand key issues, ask better questions in the boardroom, and ultimately make better governance decisions.

Listening creates another intended consequence among these constituencies. They get to know members of the board. If board members are exposed to management, physicians, staff, patients, and the community, these constituencies get to know the board as people and as leaders. When constituencies get to know their boards, they more freely offer opinions and insights, all of which can benefit the enterprise. The board of a hospital or health system should be more than a group of formal portraits on the lobby wall. Its members should be engaged in listening for the betterment of their enterprise. Listening creates relationships, which in turn creates a wealth of knowledge to be used to constantly improve the organization’s performance.

Yet another reward for effective listening is that listening makes for a more engaged and fulfilled board. Sitting in board or committee meetings hearing report after report may be necessary, but not a single one of the 1,500 board members I have met in the past 30 years ever described board meetings as fulfilling or fun. Creating direct listening opportunities is fulfilling and can indeed be fun. Listening to management, staff, patients, physicians, and the community is energizing. It gets to the heart of the enterprise. It exposes the good, the bad, and sometimes even the ugly. All these forms of feedback can be used to better the enterprise, and being part of the listening network is always highly enlightening for board members.

Boardroom Suggestions

Dr. Mitstifer and I have attended over 600 board and committee meetings in the past 30 years. We have seen highly effective boards in action and occasionally miserably poor boards in the throes of paralysis. Positive “best practice” lessons learned from our most effective board clients are worth considering for all boards.

  1. Agendas: Make agendas priority-based, with the most important item first and the least important item last. This eliminates the tendency to put “hot topics” under new business at the end of the meeting agenda when people are anxious to leave or have already left.
  2. Discussion: Make time in every meeting for an actual discussion. Avoid the practice of having management present a report, make a recommendation, and then call for a vote with little or no discussion. Discussion is good. It makes life more interesting in the boardroom, and is infinitely more interesting than rubber-stamping a recommendation, no matter how good it is.
  3. Internal Presenters: The best boards make excellent use of their own “experts” for education purposes. They tap physicians, department directors, and clinicians at least once every board meeting to learn about what is happening in their hospital or healthcare system. The best boards know they don’t have to fly to Hawaii or Naples, Florida to attend a conference put on by “national experts”. They listen to their own experts right there at home.
  4. Questions: Excellent board members ask good questions. Over the years, I have become convinced that board members who listen effectively ask the best questions. Good questions lead to good discussions. Good discussions lead to better decisions, hence better performance of the enterprise. The saddest moments I have personally observed in board meetings are when a difficult challenge is identified or a negative outcome is presented by management, and board members sit mute and ask no questions.
  5. Selection: When selecting board members, look for leaders who know how to listen and who value listening. Avoid the tendency to select high profile leaders who bring nothing but “know it all” verbosity to the boardroom.

There is no better way to improve governance in healthcare enterprises than to improve listening. Try it. Your board will be better for it.

Consequences of Not Listening

The absence of effective and engaged listening in the boardroom can be profound. A board that lacks wisdom and insights gained from direct contact with management, physicians, staff, patients, and community will inevitably make uninformed decisions. They will earn the feared title of “rubber stamps”, the anathema of any board. When a board lacks intelligence gained through listening, they don’t know what to question, or when. They don’t have the basis to evaluate the performance of the enterprise or its management or medical staff. The absence of listening creates a governance vacuum in which poor or mediocre performance can thrive. Unfortunately, Dr. Mitstifer and I have seen our share of the aftermath of failure to listen when hospitals and health systems have been shut down or acquired.

The Case for Listening in the Boardroom

We are born with two ears and one mouth. This fact of nature should guide governance behavior in the boardroom. Listening is a profoundly effective leadership tool. The more and better it is practiced at all levels and by all constituencies, the better the organization’s performance. Listening costs nothing. It has great benefits and no downside risk. The rewards are plentiful. Take a hard look around your boardroom. If the greatest fear among board members is having an unexpressed thought, you have work to do to improve listening. The best board’s greatest fear is that they will miss one of their constituencies’ greatest thoughts by not listening enough. Listen, learn, then act. Words to govern by.

Michael E. Rindler
Partner, Integrity Hospital Company

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