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BY: DOUGAL HEWITT and PAMELA MITCHELL-BOYD

The quality of governance that was sufficient to get your organization where it is today will be insufficient to get it where it needs to be tomorrow.

— Jamie Orlikoff, futurist, author, speaker

At the end of 2011, Resurrection Health Care of Chicago and Provena Health of Mokena, Illinois, merged to ensure the continued flourishing of Catholic health care in the state and of the spirit of healing and hope in the communities served.

From its beginning, there was a commitment to establishing structures that would ensure that the new system, Presence Health, could effectively address the social determinants of health for the patient population in the service delivery areas. There also was a recognition that old models of governance would need to change to meet the demands of the new health care environment and to ensure consistency across the new system.

Presence Health established a governance task force that proposed new models to strengthen oversight, to advance value-based care and population health, to deepen engagement with local communities and to support philanthropy. Particularly notable is the creation of community leadership boards, which have helped to transform local governance and strengthen Presence Health's ties to its communities.

BACKGROUND
The newly formed Presence Health was sponsored by five founding congregations: Franciscan Sisters of the Sacred Heart, Servants of the Holy Heart of Mary, Sisters of the Holy Family of Nazareth, Sisters of Mercy and Sisters of the Resurrection. The ministry's sponsors, board and leadership were well aware that Presence faced significant competitive and financial challenges. They also recognized the need to establish internal structures that would support the mission and overarching vision of Presence Health.

A couple of years after the merger, Presence Health was still in the early stages of system development and overall integration. System services had an integrated operating model, but not clinical operations. Management integration at the operations level did not yet extend across the full continuum of care. The legacy governance structures did not match and were not suited for Presence Health's population health management and new care delivery goals.

As the various parts of the newly formed system came together, it also became apparent that there was considerable confusion in governance. Affiliate hospital boards were not clear on their role and their authorities because, historically, Resurrection and Provena had different philosophies regarding the governance-management relationship.

An inventory of the existing governance structure revealed nearly 120 boards, committees and councils accounting for more than 400 meetings a year. That meant preparing for and participating in the system's governance would require a staggering number of hours.

In response, the Presence Health Board of Directors formed the Governance Improvement Project Committee to develop a governance model that would advance the vision of the newly formed system according to these principles:

• Minimalism – fewer governance entities are better
• Consistency – governance and leadership structures should be consistent throughout Presence
• Authority – centralize authority and decentralize decision-making
• Leadership – the purpose of governance is to lead the system, not to create slots for representation of constituencies and stakeholders
• Intentionality – governance structures and functions are based on conscious choices and explicit principles, not on history or happenstance

Over the summer and autumn of 2014, the Governance Improvement Project Committee developed recommendations for the Presence Health board. The committee members engaged key stakeholders across the system in the process and investigated the governance models that high-performing health care systems used, analyzing features such as size, geographic scope and range of provider types in terms of what was distinguishing and what was comparable.

The committee developed a set of recommendations to enable Presence Health to function effectively and efficiently as an integrated delivery system, further the system's strategic goals and be consistent with the principles underlying the new operating model, namely:

• Support the Catholic identity, mission, vision, values, and strategy
• Improve quality throughout the system
• Increase community input and connections
• Clarify roles, responsibilities, and authority
• Enhance governance effectiveness and efficiency

In spring 2015, the Presence Health board reviewed and approved the revised governance structure. The new plan called for a focused system board that would have several boards reporting to it, including one for quality/transformation, another for the accountable care organization, and philanthropy and boards representing the communities Presence serves.

The Governance Improvement Project Committee aligned committees with each board's authority and tasks, and roles and responsibilities were documented so that the subsidiary boards had delegated tasks to perform and clear lines of authority.

COMMUNITY LEADERSHIP BOARDS
Among the new governance entities at Presence Health are 12 community leadership boards. They are essentially advisory, and there is a heavy emphasis on identifying and engaging community partners for membership, as well as developing ways for board members to provide input to help shape a shared community vision supported by health improvement plans. Among their responsibilities are oversight and approval of annual charity care and community benefit reports, which then go to the Presence Health board to be incorporated into state and federal reports. The community leadership boards also annually select an inspiring organization or individual to be recognized.

An important area of focus for the community leadership boards is to advocate on behalf of the vulnerable and underserved. This is done through deepening the understanding of community health needs assessments and health improvement plans, connecting with established community organizations and creating new initiatives to address health disparities. Additionally, community support has been an area of particular emphasis, fortified strongly by the Presence Advocacy team and a newly created website that greatly eased the ways to educate and inform legislators. The website is open to all patients, associates, legislators and the general public. As the website indicates, Presence Health's commitment to advocacy requires the team to be active at the local, state and national levels, where health care policy decisions are made. Legislators continually make decisions related to health care and associated financing, yet elected officials may not know the impact of their decisions on the people and communities served, unless they are informed. The site is a great wealth of legislative information that provides guidance and understanding of these important initiatives.

COMPOSITION AND SELECTION
It took considerable planning, selection and recruitment to create a new role for local boards to help Presence Health identify its community's health needs across the full continuum of care and to assist in the critically important work of population health management. The Governance Improvement Project Committee provided general guidelines for the community leadership boards' size and composition: there should be approximately 15 voting members, with the majority being external, local community members. Clinicians from within the local area could serve, and there was a special desire to include leaders of community-based organizations such as social service agencies. The board chair should be one of the external members. The Presence Health board also stressed the importance of recruiting a board that was diverse in terms of ethnicity, race, age and experience.

Around the time that Presence was developing the charters for its new community leadership boards, the American Hospital Association's Institute for Diversity and Health Equity published a study of diversity and disparities benchmarks of hospitals across the United States. The study explored areas of health equity regarding cultural competency, race, ethnicity and language, as well as diversity and inclusion in leadership and governance. One key finding indicated that, although minorities represented 32 percent of the patient population of the hospitals surveyed, the percentage of minorities on those hospital boards was 14 percent.

The dangers of such a situation were highlighted in a 2014 Modern Healthcare article that asserted, "Homogeneous boards that fail to reflect the demographics of the communities they serve – by gender, race, ethnicity, age, geography, and socio-economic status — risk excluding knowledge and experience that will better inform policies to improve patient care and provide services communities need."¹

Presence Health's new governance model, established in 2015, includes diversity as a key selection criteria. The geographic area served by each community board has unique characteristics, and board members were identified, selected and invited to serve so that the new boards would be more representative of the communities' diverse compositions.

The commitment to diversity and inclusion continues to be reflected in the 2018 board: gender representation is a perfectly (and somewhat unexpectedly) balanced 50 percent male to 50 percent female ratio, and minority representation on the boards is 24 percent versus 14 percent nationally.

The Presence Health board's desire to recruit board members who bring a wide range of competencies that would support the move towards population health has largely been achieved.

One of the first challenges encountered in establishing the community leadership boards was helping the members become sufficiently oriented and educated to execute their new responsibilities well.

Another challenge, particularly for board members who had understood their role to be more fiduciary in nature, was to adjust their understanding of their role as advisory in supporting Presence Health's ability to manage population health. The diverse mix of expertise and backgrounds has helped the boards to focus on the non-acute services and providers that are essential in addressing the social determinants of health. A governance convocation held in the autumn of 2015 helped provide overall initial education. Subsequent convocations and gatherings have further reinforced the critical roles of those who serve on the community leadership boards.

COMMUNITY TRANSFORMATION
Each of the community leadership boards reflects some dimensions unique to the communities they serve. In general, however, it is clear that selection and appointment of engaged board chairs is of critical importance to how quickly the boards absorb and advance their roles. Also, board members find it important to have a tangible focus.

Here are a few examples of relationships driven by community leadership boards that formed into programs, partners or policies Presence Health supports. These all align with the system's four priority areas: Access to Care, Chronic Disease, Mental Health, and Social Determinants of Health.

Lakeshore: Craig Maki, EdD, the executive director, has been a member of the Presence Lakeshore Community Leadership Board since its January 2016 inception. Homelessness was identified as one of Lakeshore's challenges, and Maki encouraged the community leadership board to find ways to assist individuals before they become homeless.

The result was an emergency financial assistance program to help low-income and underserved residents, many of whom are little more than a crisis away from losing their housing. Presence Health served as a catalyst for gaining program funding.

Evanston: Presence Health partners with the City of Evanston Health Department to expand mental health services to the community. Presence has served as a catalyst for funding a behavioral health Social Worker in the Library initiative at Evanston Public Library, where Presence has a full-time social worker on-site connecting patrons to resources on short-term crisis management. This program was introduced by Evonda Thomas-Smith, Evanston Community Leadership Board member and head of Evanston Health Department.

Des Plaines: Sr. Cathy Ryan, the executive director of Maryville Academy and chairwoman of the Des Plaines Community Leadership Board, partnered with the New Beginnings Clinic at Presence Holy Family Medical Center to create the Unaccompanied Children Program, governed under the auspices of the U.S. Office of Refugee Resettlement.

Through this partnership, Maryville serves as a receiving center for unaccompanied children ages 13-17 who fled their country and have been detained by federal authorities entering the United States and are now awaiting re-unification with parents and family in the U.S. These children have left their homes in countries such as Mexico, Guatemala, Honduras and El Salvador, often fleeing violence and poverty.

In some instances, the children have traveled with other family members and are separated from these adults at the time of their detention. Their journeys often are long and arduous and many have traveled on the roofs of freight trains, walked through deserts, and worked along the way crossing from one country to another until arriving at the U.S. border.

Presence Holy Family Medical Center provides medical consultations within 48 hours of the children's' arrival at Maryville. These consultations include a full physical examination, TB testing, immunizations, and emotional support. The clinic is a welcoming and culturally sensitive environment where the staff speaks their language and understands their needs. In less than a year, more than 200 children have been cared for through the program before being reunited with their families in the U.S. It is through the relationships that were established with the community leadership board that this critically important program came into being.

ADDITIONAL OBSERVATIONS AND CONCLUSIONS
Since the community leadership boards were formed there have been closer relationships between Presence and the communities served. Community leadership board members take the initiative to identify other community organizations that may be of assistance in meeting the needs of patients or the needs of community served by the hospital. Email introductions occur more naturally and there is an ongoing focus on addressing the social determinants of health.

The Presence Health Board recruits community leadership board members who bring a wide range of competencies that support the move towards population health. In summary, those collective competencies are:

• Catholic identity and mission focus
• Community health needs assessment
• Population health management
• Chronic disease management
• Public health
• Behavioral health
• Advocacy/public policy
• Community relations
• Community benefit
• Social service agency connections
• Physician/clinician relations
• Wellness and prevention
• Change management
• Community leadership

Presence Health provides patient care to many racially and culturally diverse communities throughout Chicago and the surrounding metropolitan area. In 2017, Presence served people who spoke in 118 different languages. This fact alone demonstrates the need to ensure inclusive board representation. It is imperative that health care providers are connecting with the health care needs of those who seek care and wellness in a meaningful way, including through community board governance.

DOUGAL HEWITT was chief officer for mission and external affairs for Presence Health and is now executive vice president and chief mission officer for Providence St. Joseph Health, Renton, Washington.

PAMELA MITCHELL-BOYD is system director of diversity and inclusion, Presence/Amita Health, Chicago.

NOTE

1. Melanie Evans, "Hospital Boards Still Playing Catch-Up on Diversity," Modern Healthcare April 12, 2014, website, www.modernhealthcare.com/article/20140412/MAGAZINE/304129986.