2 Governing the Change – Becoming the Change: Leadership Behavior Strategies for Continuous Improvement in Healthcare

Governing the Change

The board of trustees is an underused and overlooked resource in just about every hospital and health system we know. Treated like distant, wealthy relatives holding the purse strings while far removed from daily realities, board members are fed a steady diet of carefully formatted reports at quarterly or monthly meetings and otherwise ignored. How often does a board of trustees know what is most vitally important to an organization?

Put this another way. If your CEO left tomorrow, would the board know the importance of having a humble leader? Or what a humble leader sounded like?


There is so much to be done in a systemwide transformation—from mapping value streams and redesigning care processes to establishing a fully integrated daily management system—that perhaps it is understandable that those distant relations are forgotten. But we ignore them at our peril.

We know this because we are alumni of a cautionary tale. As the CEO (John) and president of hospitals (Kim) at ThedaCare, a large nonprofit cradle-to-grave health system in Wisconsin, we were proud of our national reputation. For 36more than a decade, ThedaCare was known as one of the best, most forward-thinking health systems in the United States.

John’s first book, On the Mend, detailed the redesign of patient care and organizational culture we were undertaking at ThedaCare during the first decade of this century. After the book’s release, we were bombarded with requests for tours and talks, which we gave to hundreds of visiting executive teams. And then Kim created a daily management system and wrote a book about it, Beyond Heroes. A lot more people came to see that. Alongside truly excellent organizations like Seattle Children’s and the Cleveland Clinics, ThedaCare was known as a place to go see what good looked like.

As John was preparing to step down as CEO in 2008, he thought he understood succession planning in the context of ThedaCare’s continuous improvement work. Or, at least, he was trying to.

John had polled his senior executive team for interest in the top job, selected the two best candidates, and created a two-year mentoring plan that aimed to emphasize or instill the qualities of a lean leader as he understood them: patience, curiosity, problem-solving skills, good communication, and a desire to be out in the middle of the action. He gave his top two candidates high-profile work assignments that reported results directly to the board and coached them on their presentations.

Focused as he was on presenting the board with the two very best candidates he could, John did not pay enough attention to the other side of the equation.

The board members were nearly unanimously fans of ThedaCare’s results under John’s leadership. But few understood exactly what was required to keep continuous improvement moving forward. Board members had been told about the concepts and strategy that we were using. But they had not been encouraged to adopt the thinking. So, how could they really know the most important characteristics of a lean leader?

The board selected one of the candidates John had mentored, and during the new CEO’s tenure, ThedaCare was still an organization that was mostly running on the tenets of continuous improvement. Mostly. Erosion was visible in the organization’s focus. There was less team-based problem solving. “Making the numbers” was sometimes more important than how the work got done.

The new CEO told people that a vision would emerge from the senior leadership team. The old vision—creating higher-quality, lower-cost care through lean thinking—was no longer his plan.

But the real deterioration was taking place far from the front line of care: new board members were selected without regard to their knowledge or appreciation of continuous improvement. And once elected to the board, they received no training in the ways of continuous improvement. They were told that ThedaCare had a stellar national reputation, but not how it got there.

So, when it was time to select a new CEO just a few years later, the ThedaCare board thought that continuous improvement was a concept from the organization’s past, not its future. The new CEO brought his own initiatives, and most of the executives left for organizations that were following the principles of lean or organizational excellence.


Nearly every nonprofit hospital has the same board structure: populated by community leaders who volunteer their time and expertise in exchange for the honor of being chosen. (Some small percentage of health systems offer stipends for board members, but it rarely compensates for the time given.) Board members are chosen for their interest in serving and their abilities in areas such as finance, law, education, and medicine. The board usually has a single direct report—the CEO—and meets somewhere between four and a dozen times a year. One might think that the board manages the CEO, but it is often the other way around.

In the years since ThedaCare’s initiative was dismantled, we have learned a lot about the board’s role in creating a lasting culture of transformation. We have seen health systems in Canada, Oregon, and Massachusetts train their incoming board members, agree upon standard work for the board, and essentially create new partners in organizational excellence. Board engagement in continuous improvement is, it turns out, entirely possible as well as necessary.

And considering the fact that the average tenure for CEOs in US hospitals is about five years while board members serve about nine years,1 we can make the argument that there can be no continuity of purpose without instilling the principles and disciplines of continuous improvement in the board of

It is not just for CEO selection that we need trustees who understand the thinking of continuous improvement, of course. Boards create committees that have oversight responsibilities in finance, quality, and HR—all areas critical to organizational excellence. If the trustees who populate the finance, quality, and HR committees are going to understand the organization’s true goals, they need to have at least some background in these concepts.

Trustees do not need to be lean practitioners. But they do need to understand what the organization is doing and why so that they can help keep strategy on track.

So, let’s take a look at how a few forward-thinking organizations have addressed selection, orientation, and training of new board members.


“I think we were like most boards. When we needed new board members, we would look around the room and say, OK, we need another lawyer or someone with experience in mergers. Who can we get? Our selection process was all networking,” says Daniel F. Schuette, board chair of St. Charles Health System in Oregon.

A four-hospital system and the largest employer in central Oregon, St. Charles’s board structure was fairly typical, with 11 to 15 members at any one time, each of whom served three-year terms with no term limit. Some people were naturally more outspoken; others were reluctant to share their opinions. If there was a doctor on the board—and there was usually just one—that member could have outsized influence.

In short, the St. Charles board was similar to most governing bodies in healthcare. And then they hired a new CEO in 2014 who said he needed a mechanism to solve problems and wanted to introduce lean thinking to St. Charles. Right away, Dan Schuette was worried.

The new CEO was impressive and obviously capable, but Dan thought, “Uh-oh. Here we go chasing some shiny ball.”

A longtime financial advisor, Dan said he had seen organizations go down such roads before, adopting new management or quality systems and all the jargon that went with them, and it always seemed like more noise than revolution. There had been a lean initiative at St. Charles years earlier that never quite got traction. After that it was Triple Aim2, then Quadruple Aim,3 and then initiative exhaustion set in. A caregiver survey showed that distrust and change fatigue were higher in the practitioner ranks than anyone wanted.

On another board Dan served on, he found a guy whose résumé said he had a black belt in lean, so Dan asked him about it. What did he think about this lean stuff? The guy said, “Oh, we don’t do that anymore,” and Dan grew more worried still.

Along with another board member, Dan approached the new lean consultant St. Charles was using and asked him what the board—or the board chair—could do to help out with this lean stuff. The consultant said he didn’t know; nobody had ever asked him that before.

Incoming CEO Joe Sluka, on the other hand, had very clear ideas. He wanted the board not just to adopt lean thinking but to help drive the change. He talked to them about the importance of the Shingo principles and suggested they consider having a rapid improvement event of their own.

“Of course, we weren’t going to try and improve a process in the hospitals because the board has no business getting involved in operations. Our job is to help set vision and strategy for the future. We consider things like how the organization needs to respond to changes in payment systems, for instance,” Dan says. “I’m not sure how we might use lean thinking to address those issues in the future, but we thought it could help us with some immediate needs.”

For instance, board members agreed, they really needed to improve the way they found and appointed new board members. And it would be nice if the bimonthly agenda were a little more focused. Did they all really need to read 400 pages of material before every meeting?

So, with an eye toward addressing problems at the board level, the group agreed to a three-day board retreat led by the new CEO—with help from a consultant and an HR executive—to learn the concepts and tools and put them to use.

“We talked a lot about the board’s role in a lean journey and then about how to apply the thinking to some of our own processes,” says Megan Haase, a board member, family nurse practitioner, and the CEO of Mosaic Medical, which operates federally qualified health centers throughout central Oregon, providing healthcare to underserved populations and the general community. “We learned how to use standard work to create agendas that would get us talking about what is really important. We were able to eliminate what was non-value-added and that helped to cut down our 400-page premeeting packets to something like 50 pages.”

Those smaller, more focused premeeting packets were a minor revelation. Even more revelatory were their talks on how leaders should behave in this environment.

Thinking about the Shingo principles and the leadership traits that flow from those—willingness to change, leading with humility, curiosity, perseverance, and self-discipline—the board members realized that they needed to recruit new trustees for traits and behaviors, not just for skills.

Joe Sluka had already been working with HR at St. Charles to adopt behavior-based interviewing at the executive level to ensure he could populate his leadership team with people who were inclined toward continuous improvement, even if they did not know it yet. Joe shared with the board some of the interview questions they had developed. With some editing and rethinking, the board adopted behavior-based questions for their next interviews.

“The interview process has become more intense, more emotional, both for the person being interviewed and for us,” Megan says. “Our questions now are along the lines of, ‘Tell me about a time that you lost trust with a team and then worked to regain it.’

“But now, it becomes very clear quite quickly which candidates will lead in a way that aligns with the lean model. I’ve been so impressed with it that we’ve begun using it at Mosaic,” Megan added.

Now, if the board needs another lawyer or a clinician or a business specialist, they know they need to widen their pool of potential candidates. Just knowing a guy personally is no longer enough. They need enough candidates to be selective.

In-depth questions with new trustees have had real benefits for the board meetings, too. Potential board members have a much better idea of the kind of work being done on St. Charles’s board and the seriousness with which the other trustees regard the position. In short, they are better prepared.

And in the four years since St. Charles’s board began using behavior-based interviewing techniques, the atmosphere in the board meetings has been tangibly improved. Where there used to be cliques, silent resentment, and the occasional bomb thrower, there are now people with a common idea of what a productive board meeting looks like.

“There’s more listening now, and we really work at humble inquiry,” Dan says. “We recognize bullying behavior and call it out.”

Trustees also have mentoring relationships, in which each new board member is paired with an existing one to assist in understanding the work and how it is done.

Existing board members—those who began serving before anyone thought of hiring for behaviors—have used radar charts and personal A3s to help them enhance or adopt desirable leadership behaviors.

At this point, there will be plenty of board members and CEOs reading this who will be asking, Is this really necessary? Do people really need to look deep within their personal beliefs and alter their leadership styles in order to serve on a community hospital board?

The answer is yes, if they want to be useful and engaged in the future.

For most of the twentieth century, there was one standard business model for healthcare in the United States and many other countries: get people into the hospital and get paid. Heads in beds. Now the model is turning away from 44fee-for-service and toward population health, in which health systems make money by offering integrated care and keeping people out of expensive hospitals. That means every hospital CEO needs strong strategic partners to help create a workable plan to be ready for that future.

Should your health system be creating extensive care-at-home initiatives for the elderly and chronically ill? Do you need different facilities, a different mix of skill sets? What should a hospital look like when you are trying to keep people out of it? These are the questions a board must consider. And that means trustees are going to need excellent processes that help them decide strategic direction, including a standard problem-solving process.

As representatives of the community, board members are also responsible for making sure that the executive team’s True North and strategic vision aligns with community needs. This is a critical function as health systems begin redefining their roles. Does the community need a world-class research facility, smaller surgical and urgent care centers, or is it an aging, shrinking population that requires new ideas in affordable long-term care?

The board needs to be able to work together effectively to help explore and answer these questions. And, in many ways, that is a whole new role.


“Boards have changed a lot in the last decade, especially as changes in healthcare have multiplied,” says Christine Henhoeffer, RN and a past board chair of St. Mary’s General Hospital, a 150-bed acute care hospital and regional cardiac center in Kitchener, Ontario. “It used to be that you received a package, read it, and listened to the presentation. We didn’t ask challenging questions. It wasn’t expected. Meetings were pleasant. You did your duty and hoped to get out of there early.”

But somewhere around 2010, St. Mary’s started having financial trouble and meetings became longer and filled with more pressing questions. People thought the hard patch would be over soon, but it was really just the first signal that bigger changes would be coming.

CEO Don Shilton, a champion of lean, was trying to bring transformation to the ED first and having some typical islands-of-excellence issues. St. Mary’s was usually rated in the middle of the pack, quality-wise, among Canadian hospitals, and he was sure it could do better. So he came to the board with a plan to spread lean thinking throughout the organization by having 1,000 frontline improvements implemented in the next year. It was a big goal for a stressed organization, Christine thought.

But she read the book that Don gave them all—On the Mend—and was intrigued. With three other board members, Christine made the trek to Wisconsin to visit ThedaCare and attend an introductory course in lean thinking.

The response she got when she was introduced to other healthcare leaders attending the sessions was curious. “What are you doing here?” they asked. Christine laughs at the memory.

“They could not understand why board members would be interested in this lean stuff,” Christine says. “Still, we went to gemba and huddles on the units and we could see this really was a way to make things better for our patients. We went there not knowing our key performance indicators or what St. Mary’s targets were. But we left knowing that we needed to find out.”

Over the next two years, Don continued to champion lean thinking and Christine, in 2013, became board chair. With help from Don, Christine began a focused education initiative at board meetings. She convinced the other trustees to commit to attending a huddle in a hospital unit, and to visit ThedaCare sometime in the next two years. Together, board members read articles on lean thinking in healthcare and held generative discussions, with a different board member leading the discussion each month.

“Sure, there was some pushback. People started saying we had drunk the Wisconsin Kool-Aid,” Christine says. “There would be knots of people talking in the parking lot later. I got emails concerned about the longer meeting times. But when people went to a huddle or went to ThedaCare, they got it. They came back enthused.”

“They saw engaged staff who were solving problems,” recalls Don Shilton, who retired as CEO in 2018. “That was exciting. So, we started bringing staff into the meetings to present a problem they had solved. It became more real.”

In the hospital, however, the early energy of transformation had begun to fade. Only 10 out of 40 original huddles were still active. Don asked the board for help with a reset. He believed they needed to create a full daily management system, and his aspirations came with a big price tag—somewhere close to $1 million.

Board members were cautious. Were huddles all that important? What would this daily management system do?

Don suggested the board try a huddle of their own. Just 15 minutes, standing up, at the start of each meeting, he said. Half of the huddle was a performance review, looking over the hospital’s most important metrics. Each metric was aligned under its related True North category and labeled with a red dot if the work was not meeting goals, or a green dot if it was. They only talked about the metrics that were in the red, to ask what was being done to correct course.

The second half of the huddle—which was added to their routine several months later—was problem solving to improve board governance. For instance, the meetings often went too long. They looked at the sheer number of agenda items they had every month that were pro forma. Each required a reading and a vote, even though there was never any discussion. Someone had the idea of creating a consent category: all agenda items that needed approval but not discussion were presented as a single item. That shaved about 15 valuable minutes off the general meeting, leaving more time and less grumbling for the huddle or those article reviews.

After about a year of huddles, though, some board members were running out of improvement ideas. Maybe they did not need to have huddles anymore, they told Don. Maybe they were as improved as they could be.

“I’ll admit, I was alarmed when some of them said they did not see the value in huddles anymore,” Don says. “The fact that the board had a regular huddle carried a lot of weight in the organization. They were a positive example for everyone.”

Don asked the trustees to reconsider. They agreed to talk about it, at least, and to use an A3 to guide them as they discussed the relative merits of each element of the huddle. It turned out parts of the huddle were unanimously valued, so they came up with a structure that everyone could agree upon.

It was a valuable lesson in the importance of revisiting standard work on a regular basis to consider how it could be improved. More important still, the board was reminded of its importance to the rest of the organization. Trustees have a part in setting the tone of an organization. They signal to others what is important every time they set foot in the hospital. Attending huddles, visiting units, and asking respectful questions is a far different message than making a beeline to the boardroom and only staying for their private meetings.

“And when trustees go to the ED and see a busy place dealing with a lot of mental health issues, or the consequences of working in an old building with narrow doorways and equipment in the hallways, that’s a lot different than hearing about it in the boardroom,” Don says.

By 2016, the results of organizational excellence at St. Mary’s were helping Don to make his case. In the three years since the organization had recommitted to lean, frontline improvements had helped cut the number of patient falls in half. Hospital-acquired infections were reduced by 60 percent, and the cost per inpatient hospital stay was reduced to 20 percent less than the Canadian average. The people of St. Mary’s were most proud of having the lowest Hospital Standardized Mortality Ratio (HSMR)4 in Canada twice in five years.

Christine and Don are united in their advice to other boards that need to begin learning about continuous improvement. First, they say, go see: have everyone attend a huddle and take groups to see excellent hospitals. Then, encourage board members to get involved by using the tools to solve some of their own problems. Meetings too long? Need new trustees that can think systemically and show constancy of purpose? Create an A3 and agree upon the problem and the current condition before considering countermeasures.


Of course, the most important issue a board considers is selecting a new CEO. Continuity of the leadership required in this environment—humble, curious, disciplined, and committed to improvement—is the reason we actively encourage boards to learn about and use continuous improvement. The question is, does it work?

As of this writing, there has been just one CEO turnover in an organization using continuous improvement at the board level. When Don Shilton announced that he was leaving St. Mary’s in 2018, we watched closely to see what the board would do.

We were encouraged by the board’s selection of a physician leader from Ottawa who was an enthusiastic advocate of continuous improvement. Nobody could foresee, however, that within a week of Dr. Andrew Falconer’s arrival at St. Mary’s as president, the CEO at his former hospital would die. Five months later, Dr. Falconer accepted the invitation to return to his former organization as CEO, regretfully leaving St. Mary’s board with a new decision and a realization.

“We really need to do more work on succession planning, on being prepared for any eventuality,” says Scott Smith, current St. Mary’s board chair and president of High Performance Solutions and Consortiums in Ontario, which operates several co-learning networks focused on organizational excellence. “This situation proved our gap.

“Now we’re looking for someone with experience in a lean organization and, if we can’t find that, for someone with the leadership competencies and characteristics that will help us grow our current system. Someone who understands A3 thinking, is people focused, and leads with humility.”

That is the list of characteristics that should guide any board of trustees looking for a new CEO. But will the trustees know that?


About 560 miles south and east of St. Mary’s, at UMass Memorial Health Care in Worcester, MA, CEO Eric Dickson, MD, talks about succession planning in every board meeting. They talk about what would happen if he—or anyone else in a critical role—were to get hit by a beer truck. Eric asks every senior leader to put a possible successor in place whenever they take vacation or have even a few days leave. The next step, he says, is to write a succession plan into the board’s standardized

That’s right. The board of trustees at UMass is guided by standard work, and it is the first instance we have seen of the discipline at the board level.

For their four formal meetings per year, plus monthly strategy sessions, the 17-member board follows a standard work template as they talk through strategy and metrics. (Leadership each year chooses the 10 most important metrics, including key performance and key behavioral indicators, on which to focus.) There is standard work to guide them as they develop new strategic plans and standard work to execute those plans.

In fact, Eric does not really use the term organizational excellence or lean to describe what they do at UMass. “It’s really just standardized work processes and a standardized management system,” he says. “It’s got to be standardized before it can be improved.”

Eric hired an executive coach with experience and expertise in the Toyota Production System and, from his work with her, created four simple principles to guide their work:

   Have a standardized process that can be continuously improved.

   Make waste visual for all to see.

   Respect everyone.

   Engage everyone in improvement every day.

Eric strongly believes that a system like this requires that everyone is engaged—including the board—and that means everyone at UMass needs to believe in the future of it.

“If I get hit by that beer truck, I want them to be ready,” Eric says. “Look across the country at these great programs in health systems that ended because they were dependent on one strong leader. That’s why I have board members attend a continuous improvement training session, management training, and at least one huddle.”

The training in continuous improvement for board members at UMass includes learning the expected behaviors, which are the same for everyone and are displayed on walls throughout the hospitals and the boardroom as the standards of respect. They are: listen, be kind, acknowledge, be a team player, communicate, and be responsive.

Every leader and manager receives an annual review that includes what Eric describes as a mini-360, in which the reviewer checks in with the person’s peers, direct reports, and bosses on the question of respectful behavior. Board members undergo the review, too.

All of this was especially necessary because when Eric returned to UMass in 2013 as CEO, there was a good bit of shouting and disrespect at the board meetings. To be fair, everyone was under stress. There had been four years of declining operating performance. Nurses voted in favor of going out on a 24-hour strike two months after Eric arrived. Hospitals were shut down and replacement nurses brought in at a cost of $10 million.

Three months after that, the controller realized his office had been miscalculating debt service coverage and default was likely. UMass Memorial Health Care bonds were downgraded to “junk” status. Eric had to oversee the layoffs of 600 people while seven buildings were sold. A psychiatric patient murdered another patient on the ward. And 50 percent of the organization’s executives turned over in the first 16 months of his tenure.

The board of trustees, meanwhile, did not have experience with creating an environment of respect. And it showed. Five board members are appointed by the state; the rest had been selected by the former CEO, whose departure had not been planned or pleasant.

Fortunately, there was one board member who, shortly after Eric’s arrival as CEO, stuck up her hand with a proposal. She had received leadership training from the organizational guru W. Edwards Deming, she said, and she thought what they really needed to decide first was the behaviors they wanted to exhibit.

The idea resonated with a number of trustees who were tired of the acrimony, so they made a short list of behaviors and read them out at the beginning of every meeting. Because they had all agreed to the behaviors, it was not considered confrontational to offer gentle reminders to people who slipped.

After a few months, they did not need to read out the expected behaviors at the beginning of every meeting anymore, so they had the behaviors printed on a sign and displayed. Within a couple of years, the sign was moved to 54some back closet because nobody needed to refer to it anymore. Their expectations about how meetings should proceed had become governed by standardized work instead of egos. Respect was part of the culture.

Some of the change in the boardroom environment has surely been more organic than planned and voted upon. A lot of it has to do with Eric’s style, his belief systems. Under prior leadership, there was a heavy top-down management style. The CEO had been firmly in charge and ran the meetings—like so many CEOs do—like a zero-sum game.

This is not an unusual attitude in US companies. Boards are often seen as necessary evils, a monthly exercise in herding cats that the CEO does artfully or not. Rarely does the top executive really use the board’s various talents to full effect.

But Eric’s favorite sentence is, “I don’t know.” He will say that he does not know enough about marketing or digital therapeutics or finance structures and ask board members if they have expertise or they can find someone who does who can coach him through the finer points. When he gets help like this, he says, he can be more fully engaged in conversations with his on-staff experts. With multiple points of view, he gets a richer dialogue. And board members are reminded of their value.

“Board members are here volunteering because they actually want to serve. They don’t want to just be managed by a CEO,” Eric says. “I serve on seven other boards, and I can tell you when there is tension in board meetings it is because the CEO doesn’t really want to hear from the board. People know when they are not valued.”

Things at UMass Memorial improved over the first six years of Eric’s tenure. Some 70,000 frontline staff improvement ideas had been implemented as of spring 2019, and every year now, there is a Champions of Excellence celebration that includes $10,000 in innovation awards.

Improvements have helped drop inpatient mortality at Marlborough Hospital by 43 percent and at UMass Memorial Medical Center by 21 percent between 2016 and 2019.

There are still problems. One year, the health system had tens of millions in surplus funds. The following year, when managed care health plans stepped up to care for a lot of Medicaid patients, patient demand fell, and UMass was back in the red. While 72 percent of people would “definitely” recommend the UMass Medical Center, the goal for that metric is 83 percent. It is improved, but the gap remains clear.

So, Eric would be the first one to tell you he still needs the expertise and problem solving of an active board. We all do.

In this emerging work we have been doing with boards, we have seen some practices—such as those stand-up huddles that start out every meeting at St. Mary’s—have great impact. We do not recommend, however, that an organization jumps into huddles and rules of behavior with trustees until everyone agrees upon the direction they are heading.

For health systems beginning the work of engaging the board, the first step must be some introduction to lean ideas. This includes having trustees go to see continuous improvement at work in the hospital and inviting the people responsible for frontline improvement to present their work to the board.

Any introduction will also naturally include a discussion of the organization’s principles and the leadership behaviors that must spring from those. Shingo principles such as create value for the patient, create constancy of purpose, and think systemically are particularly relevant for a board of trustees. This is, after all, what we value in board members—the ability to consider the health of the entire organization, to think in the long term, and to remember that they advocate for and serve the

Along with principles and behaviors, the board should also become familiar with True North. In fact, a good board should become keepers of the True North—ensuring that these core goals reflect the community’s needs, that the organization is always aimed toward meeting those needs, and that only the critical few initiatives are given time. A good board should be able to assist the CEO in deselection or, at the very least, track the number of initiatives and weigh them against the organization’s strategy and resources.

As a learning exercise, each of these boards used A3 thinking and other tools to solve some of their own problems, such as overly long meetings and premeeting reports.

We also recommend that boards begin to measure what matters—for example:

   The length of board meetings, in minutes

   The number of pages in the premeeting packet

    The number of minutes spent on strategy discussions, per meeting

   Is succession planning discussed?

   How deep in the organization is succession planning practiced?

Figure 2.1 (see next page) shows a sample board assessment, which is valuable for any organization that wants to determine what good looks like at the board level.

FIGURE 2.1 Board Assessment Questionnaire

When the board begins looking for new members, what does that process look like? At St. Charles and UMass Memorial, there is standardized work in place for both recruitment and interviews. St. Charles’s focus is on behaviors, UMass emphasizes skills and experience when looking for new members. (Eric was determined to bring a millennial on board, for instance, to gain the youth perspective.)

All three of the health systems introduced here have placed careful attention on introducing new board members into their ecosystem. They all offer some kind of organizational excellence training, and then the CEO and board veterans talk to new members one-on-one about behavioral expectations and the principles that guide the organization.

This is all-important work because the board can be thought of as the constancy of a health system. A majority of the trustees will very likely outlast a CEO and choose the next. Without them on the side of continuous improvement, the memory of it will be lost. And the CEOs you will meet in the next chapter will likely be aberrations instead of what we all really need, which is the coming wave.

1. “Hospital CEO Turnover Rate Remains Steady,” American College of Healthcare Executives, June 14, 2018, press release.

2. An approach to healthcare improvement, defined by the Institute for Healthcare Improvement, that has organizations give equal weight to improving the patient experience, improving the health of populations, and reducing per-capita costs.

3. Essentially the same as IHI’s Triple Aim but includes an element of employee/provider satisfaction.

4. The HSMR is the observed number of deaths divided by the expected number of deaths in a given hospital for a given year; it is expressed as a percentage.