The Profile and Effectiveness of Governing Body: A Study Among Christian Mission Hospitals in India

 Introduction

The healthcare industry is growing at a tremendous pace due to recent advancements in technology and innovative solutions. In India, the healthcare industry is a priority sector for many investors since it is unregulated. Even though India is a developing country, it is gearing up to become the hub of healthcare facilities. The contribution of Christianity, especially the Christian  mission hospitals to the growth of Indian healthcare infrastructure is remarkable. History has proven that they gave their best to deliver healthcare to everyone, especially the socially disadvantaged, economically challenged, and systemically marginalized, and they never forget people in remote areas. The growth of the mission hospital rests on a sound governing body. How the board is organized to do its work, the experience, expertise or competency, and the knowledge that will contribute value to the board’s leadership capacity has an impact on its efficiency and effectiveness. Non profit organizations depend heavily on their governing board of directors to provide leadership, guidance, and f inancial inputs.¹

Considerable analysis so far has been focused on the composition, role, competency of the governing board, and financial viability of the Christian mission hospitals in other countries. Few studies have provided information on the inclusiveness, sustainability, and challenges faced by Christian mission hospitals in India. Further research is needed to examine the profile, role, effectiveness, and competency of governing boards in Christian mission hospitals in India. A hospital's ability to operate effectively, deliver high-quality health care, and maintain a positive reputation in the community it serves is vital. As a result, it is critical to comprehend the characteristics of governing boards, which are tasked with maintaining the hospital's high performance.²

According to a study on the empirical taxonomy of hospital governing board roles conducted in the US in 2004 by Shoou-Yih D. Lee and Jeffrey A. Alexander, while it is acknowledged that all governing boards have the same clear objective of creating and maintaining an effective organization, what they actually do to achieve that objective varies greatly. As a collection of interconnected parts, hospital governing boards work together holistically and mutually reinforcingly.³ Having the optimal mix of skills, expertise, and experience is crucial to ensure that the board is equipped to ensure the organization’s mission.⁴ Board Self Assessment Questionnaire (BSAQ) is one such tool used in this study to assess the board members' profile, competencies, and effectiveness.

Materials and Methods

A descriptive study was conducted among 30 Christian mission hospitals in India. Primary data were collected from governing board members of 30 Christian mission hospitals using a standard BSAQ questionnaire that was freely available through open source. The popu- lation of Christian mission hospitals in India is 900. Purposive sampling was adopted for the study. Purposive sampling was helpful in assuring the representation of hospitals from different Christian denominations and different parts of the country. A total of 167 governing board members from 30 hospitals were included. Small and medium-sized Christian mission hospitals with a bed strength of 25-320 were included. The hospitals that had existed for more than five years and had more than four governing board members were included in the study. Tertiary care hospitals were excluded from the scope of this study.

The BSAQ questionnaire, the profile details form, the subject information sheet, and the consent form for individual governing board members were sent to the administrators of 30 Christian mission hospitals through mail or post. The administrators distributed and then collected the filled questionnaires from each governing board member in their hospital and sent them back to the investigator. IEC approval was taken before commencing the data collection.

The Board Self-Assessment Questionnaire (BSAQ) contains 65 questions, which constitute six variables.¹ Each variable represents the distinguishing competencies of high-performing boards.

Competency # 1: Understands context: 12 questions

Competency # 2: Builds learning: 12 questions

Competency # 3: Nurtures group: 11 questions

Competency # 4: Recognizes complexity: 10 questions

Competency # 5: Respects process: 8 questions

Competency # 6: Shapes direction: 12 questions

All the questions in the BSAQ were measured on a four-point Likert scale. The maximum for any response varied across the six competencies of the scale. The score depends on the number of questions in each competency. Questions were scored by assigning a score of 3 to a response of “strongly agree,” a score of 2 to “agree,” 1 to “disagree,” and a score of 0 to “strongly disagree.” The total score was obtained for each competency. Ratings were given for the total score by the researcher. Higher than 60% of the total score for the variable was rated as ‘good’, and below 60% was rated as ‘poor.’

Results

The following tables show the profile and competency levels of the governing board members. The BSAQ effectiveness score and scores of six subdimensions were also calculated.

Discussion

The governing board's profile is important in effective and forward-thinking hospitals and healthcare systems. Diversity in profile refers to categories like gender, age, and having a governing board with a diversity of knowledge, experience, management training, pers- pectives, and competencies. These are important for the viability and competitive positioning of the hospital.

Four generic strategies are suggested in Miles and Snow's typology of company strategy - prospector, analyst, defender, and reactor. A defender hospital provides a consistent set of services and programs and is not at the forefront of new healthcare initiatives. Instead, it ignores changes that have no immediate bearing on its current business and focuses on providing the best care possible in that sector. The study done by Gary Young found that defenders had a small and relatively homogeneous governing board and the highest proportion of medical staff members on the governing board. His findings suggest that the strong internal orientation of defenders lead them to include medical staff members on the governing board as a structural mechanism for obtaining information on hospital efficiency issues.⁵ The Christian mission hospitals in the current study could be placed under the defender category.

In the study done by Mannion et al., the smallest board had eight members, while the majority (93%) consisted of between ten and fifteen members.⁶ In the current study, the board size ranged between 4-10, the representation of medical professionals was high and the board was more homogeneous in nature (Table 1).

A cross-sectional study done by Ogbonnia Godfrey in Nigeria found that healthcare governing board members receive patchy training in management. A few continually attend training, and those with substantial knowledge and skills are unable to apply such within an unstructured and uncoordinated management system. Their work established the critical need for formal and informal health management training for healthcare managers. The bulk of the governing board members in his research were aged between 35 and 45 years. Males outnum- bered females by a margin of 63.5%. A bachelor's degree was held by 34.6%, a postgraduate degree by 27.9%, and a master's degree by 33.7%. Majority of them had 3-10 years of experience in hospital administration (47.1%). In formal healthcare management training, only a small percentage (27.9%) had no training, while in informal healthcare management training, everyone had some type of training, with in-service training being the most common (84.6%).⁷ In the current study, it was found that 46 (27.5%) were aged above 60 years. Only 9% of the total respondents were holding MHA/MBA degree. Overall, 47.3% had some kind of training in management (Table 1).

Internal governing board members include the CEO and top medical personnel, while external governing board members represent shareholders or members of the community. Internal governing board members are better familiar with the organization's dynamics, whilst external members can bring new expertise and change.Internal governing board members are better positioned than external governing board members to motivate and supervise hospital management, according to Jermias.⁸ In the current study, internal governing board members outnumber external governing board members in all hospitals. Carol Molinari, in his study, found that insider board participation may also enhance the medical staff's support and compliance with board policies, thus enhancing hospital performance.⁹ Karen Ford-Eickhof's study found that hospitals with broader expertise on their boards reported an external focus. The greater range of expertise enables the hospital to fully take advantage of the opportunities and tackle threats in the environment rather than attempting to reduce the complexity of the issues in their field of view.¹⁰ In the current study, the boards lacked broader expertise. The representation of external experts in the board was poor (Table 1).

The study conducted by Hersh demonstrated that companies with a higher representation of women directors on the board perform better than those with a lower representation of women.¹¹ In the present study, 90% of the sample considered were females. National healthcare governance survey report in America (AHA, 2014), observed that although there are four generations represented within the workforce, most of the board members were between the ages of 51-70 years, with only two in ten under the age of 50. While older directors provide a wealth of information, boards with inadequate age diversity could also be missing out on differing perspectives of varying age groups.¹² In the current study, 73% of the board members were in the 51-60 years age category, while only 12 were in the >40 age category. 

Callen et al. demonstrated a powerful association between the composition of the board of administrators and the efficiency of the nonprofit organization. The study also reported a statistically significant positive relationship between education and chair effectiveness (r=.235; P = .009) as measured by the Multifactor Leadership Questionnaire (MLQ) and perceived by board members.¹³ The present study does not show any positive association between the profile variables like age, education qualification, years of experience, etc., and the competencies (Tables 2-4). Table 5 reveals that the effectiveness of the governing board is not related to organizational variables like age, bed strength of the hospital, and the size of the governing board.

Mathew M Hodge also used the BSAQ tool to calculate the perceived overall effectiveness of the board of directors. Table 6 shows that the aggregate average effectiveness score for 30 Christian mission hospitals in India closely aligns with the board effectiveness scores published by Holland and the findings of the study conducted by Mathew M Hodge.¹

Conclusion

The demographic variables like age, educational qualification and the years of experience in their respective hospitals do not have a significant association with their competencies. The study found that the overall effectiveness of the governing boards of 30 hospitals was 0.62, indicating a strong measure of board’s effectiveness.

Conflict of Interest

Nil