How COVID-19 has shaped governance
BEFORE:
Multiple committees vet idea
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Monthly committee meetings
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Steps like “approval to initiate”
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Executives hold ultimate
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decision-making authority A lack of focus
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AFTER:
Consolidated committees
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Committees meet more
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frequently Fewer steps to approval
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Decision-making authority
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delegated to managers/staff Patient care/staff safety are the
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primary concerns
IDEAS THAT USED TO TAKE up to eight months for Mayo Clinic to vet are now ready to execute in less than two weeks. The COVID-19 pandemic has accelerated a push to streamline decision-making at Mayo, a move that will permanently shape its governance model. Healthcare organizations across the country are making similar adjustments as they aim to improve long-standing and potentially obsolete oversight policies.
“Are we going to consistently get to the execution stage in 12 days? Maybe not, but now we have the mechanisms to track how long the process is taking and identify the barriers to moving more quickly,” said Roshanak Didehban, Mayo’s chair of practice administration. “I don’t think we can under-recognize the gravitational pull back to the way we used to be. But now we have a systemic approach to get work done quicker.”
Some hospital systems have restructured to be more responsive and flexible, mirroring other U.S. industries. Yet, that change has been slower or nonexistent in certain healthcare institutions given the concern that the heavily regulated industry requires a more deliberate and methodical approach.
Typically, ideas need to go through a myriad of finance, legal, quality and information technology committees that only meet monthly, dragging out the process. But the pandemic has shown many systems that efficient decision-making doesn’t mean sacrificing quality and safety.
“If you have an organizational structure that likes to vet and evaluate practically every position even when it’s not needed, that’s often what took place. People didn’t have that luxury during the pandemic,” said Greg Eli, shareholder at consultancy LBMC. “There’s been a realization among not-for-profit, for-profit and investor-owned systems that you don’t need the same level of formality or as much involvement to make decisions effectively. I think we’ll see the pendulum swinging back somewhat, but it won’t swing back to where it was pre-pandemic.”
Time is of the essence
Prior to the pandemic, Mayo would have to get the green light from up to 12 separate committees and departments to implement an idea.
While the Rochester, Minn.-based system set out to change that dynamic before disaster struck in March, the pandemic kick-started that effort.
COVID-19 revealed how clarity of focus expedited decisions, said Didehban, who serves alongside Dr. Amy Williams, executive dean of practice, in Mayo’s dyad leadership model. Keeping staff, patients and the community safe was of utmost importance, she said.
Mayo consolidated its separate committees into a single multidisciplinary team that operated on an hourly rather than monthly basis. It also delegated decision-making authority to lower levels of the corporate hierarchy and did away with the approval-to-initiate step, Didehban said, describing it as “approval to think about an idea.”
“We noticed this transformation in April and how powerful it was,” she said.
There are two types of governance, one that involves systemic changes in the bylaws and require the board’s guidance, and smaller, day-to-day operational changes, explained Victor Giovanetti, executive vice president of hospital operations at LifePoint Health.
For the former, the Brentwood, Tenn.-based system learned that they could still act quickly and maintain compliance, he said. “At times we got some relief from state and federal waivers, but overall the big governance decisions were easier to manage,” Giovanetti said. “We learned we could do the day-to-day governance and decision-making faster and with more decentralization, while still operating within the guardrails of our bylaws.”
Giovanetti headed up a COVID-19 task force comprising the various departments of the system. Under normal circumstances, it could take a month to secure more ventilators. In March and April, it only took a matter of hours, he said.
But, Giovanetti cautioned, there are certain matters they would not want to move quickly through after the national emergency subsides.
“Drug utilization and purchasing are things that need to have the level of filtration to meet our national quality program,” he said. “While we moved quicker around remdesivir and other therapies with the support of the government, under normal operations they would go through more of a filtering process.”
Still, not all healthcare organizations have streamlined their deliberation process, said Paul Keckley, an industry consultant.
“The existing committee structures have actually continued. If anything, outside of compensation, they’ve defaulted more to management on key issues around COVID,” he said, adding that is the case for larger health systems but things could be different at stand-alone hospitals.
Outlook
Some healthcare organizations are bound to emerge from the pandemic with a revamped decision-making process. Industry observers are hopeful that the momentum will produce more efficient and effective systems.
Many providers have put together executive committees or task forces that essentially act as a board between regularly scheduled meetings. But those have already lost some luster, said Bill Horton, a partner at Jones Walker. And some organizations are reverting to their traditional structures.
“They have started to fall out of favor to some degree because they are not inclusive of the entire board,” he said. “Still, there is recognition that there are means where boards can assemble quickly to handle discreet matters and still preserve a genuine opportunity to deliberate.”
The makeup of those boards has been questioned due to COVID-19, Horton and other experts said. Smaller not-forprofit hospital boards are typically community leaders who may not have much healthcare experience.
“The composition of these boards doesn’t fit the current needs of healthcare, particularly during a pandemic,” said Lyndean Brick, CEO of the consultancy Advis. “When there is an opening for a new board member, we need to ask ourselves what we need and what is the role of a community board member.”
Those smaller organizations were often slower to react, LBMC’s Eli said.
“In healthcare you have the ‘haves’ and the ‘have-nots’— the pandemic has only widened the gap between the two,” he said.
Some of the waivers implemented during the national emergency will be unwound, and leaders will need an informed and knowledgeable board to guide them, Horton said.
“That could be troublesome from a reimbursement and fraud and abuse standpoint,” he said. “The more enlightened boards will see what has worked and what hasn’t and try to be more proactive. If nothing else, boards will be in a position to think about contingency governance plans.”
As for Mayo, there is always the risk of reverting to the mindset of, “this is how we have always done it,” Didehban said. But it’s promising that Didehban and her peers are constantly asking, “why?”
“As an industry, we have to take a step back and realize how quickly we can pivot and meet the needs of our patients more effectively and efficiently,” she said. “It is incumbent upon all of us as healthcare leaders to stay true to the lessons
● we have learned.”
As an industry, we have to take
a step back and realize how quickly we can pivot and meet the needs of our patients more effectively and efficiently. It is incumbent upon all of us as healthcare leaders to stay true to the lessons we have learned.” Roshanak Didehban, Mayo Clinic’s chair of practice administration