Mission-Based Governance

Abstract

Pointer, Alexander, and Zuckerman have made an important contribution to the nascent field of governance of integrated delivery systems. The main thrust of their article is to create a useful taxonomy of possible forms of integrated delivery system governance. I concur with the authors' assertion that the more integrated a system is, the more likely it will be to thrive. I also strongly agree that governance must lead systems toward full integration while being willing and able to transform itself in the process. Governance should be the engine that drives system integration. Instead, it is frequently the caboose dragging along behind, and often hindering the integration of systems. Why? Because many systems never address the question of what governance should do, and how the functions of governance should change as governance of integrated delivery systems moves away from governance based on institutions and toward governance based on services. Form Follows Function Although the authors do raise key questions of the governance function, they confine themselves largely to issues of governance structure. While system governance structure is essential, it is nevertheless secondary to the system governance function. There is little agreement on the ideal governance structure for an integrated delivery system for a very good reason: system governance tends to, and should, reflect the philosophical, religious, and historical roots of the founding, sponsoring, or owning organizations. The number of boards in a system, for example, is often regarded as a significant structural characteristic that critically affects governance function. More numerous, or decentralized, boards are often viewed as inherently ineffective due to more cumbersome decision-making processes and to diffusion of the focus and commitment of each board. It is important to remember, however, that governance structure (issues such as size, decentralized or centralized boards, and composition) does not in itself determine governance function. Structure can only facilitate or inhibit effective governance function. Thus the proper structure for the governance of each system should be determined primarily by the unique and individually defined needs, culture, and mission of each system. The authors propose structural permutations of governance predicated on the answer to the foundational question of whether governance of the system should be centralized or decentralized. They suggest that once that question is answered, the questions of governance structures, board composition(s), and governance functions then flow in a linear fashion. While I believe the question of centralized or decentralized governance control to be important, I do not believe it to be the foundational question for either the structure or the function of governance of integrated delivery systems. Rather, I believe the foundational questions to be: What is the mission of the system? and What is the function of governance relative to achieving that mission? From these questions will then flow the answers to the questions of centralized or decentralized governance control, structure, and composition. The mission is both the governance and system rudder. A most fundamental governance responsibility and function is to develop a meaningful mission statement and to routinely evaluate the mission to verify that it is still valid, to modify it when appropriate, and to ensure that the plans and practices of the system and its boards are consistent with the mission. A focus on mission and governance function results in more emphasis placed on how and why governance decisions are made, and less on how governance is structured. Unfortunately, the mission statements of most systems are so general as to be useless in that they provide no system definition and outline no direction for it. In such situations, governance has abdicated its responsibility to develop a meaningful mission. …