Last week I joined a panel of international experts to talk about hospital governance in Belgium. It is a timely albeit unsexy topic in health care today.

How Hywel Dda hardwired flexibility into strategic planning

Several countries around the world are pushing to bring independent organizations like hospitals, physician groups, primary care clinics, and even non-health care organizations into cooperative business models. These cooperatives are currently coalitions of the willing—independent entities with their own statutory and financial obligations that partner with other organizations "voluntarily."

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Our read is that even though progress here was stunted because of the pandemic, we expect the push to accelerate these cooperatives will rocket to the top of agenda when governments start the multi-year work to rein in budgets.

Anyone who is currently navigating this effort will tell you it's complicated, politically fraught work. I'd like to share some of the insights we've gleaned from watching progress in multiple markets across the world.

1. Corporate governance emerged to "prevent bad decisions." Today in health care we need governance to "make good decisions."

Accountability will always be a part of health care governance but increasingly these emerging cooperatives are looking for governance to help set direction and make bets in an increasingly volatile and complex world. That means alongside questions of legality and regulation, the function of governance must capture and respond to questions of visions, mission, values, and strategy. That requires new competencies and new resources to do effectively.

2. Many organizations get tripped up on reporting structures, committee sizes, and voting rules. These are protocols and tools that serve to set direction and make decisions. Use them where they make sense.

If you've ever seen my presentation on governance, you'll probably remember a graphic of a voluntary board from an early iteration of an Integrated Care System (ICS) in England. It's a web of reporting structures designed to make sure everyone has a seat the table.

Board effectiveness assessment

It was no surprise, however, that very few decisions were made because the structure was designed to report not make decisions. Think first about what the decisions are that you'll need to make. Then design structures to ensure that those best positioned to make those decisions are empowered to do so. 

3. Cascading plans from the top of the organization can be fraught with challenges. Consider devolving authority, when possible, to those groups that will execute on decisions.

Here is where global case studies can offer some practical inspiration. We think that the way that planning and action connects at Hywel Dda in Wales is worthy of consideration.

In their model the board sets the direction for the organization as aspirational and principled. It's not necessarily specific or quantifiable—more akin to "smudges on the horizon." They leave the practical elements of design and execution to other teams to deliver. The overall concept here is that those closest to the decisions are best placed to design the plans.

The last insight I'll leave you with is the one that gained the most traction at the symposium: Governance is much more of a human function than a technical one. Health care is very good at exploring answers to the technical set of problems. Where we're out of our comfort zone is when we need to cede authority and build trust with "outsiders." And that's precisely what good governance entails.