Rural hospitals are closing at a record pace, and many of the reasons why could have been avoided.


By Robert Thorn, MBA, FACHE

Director, Pinnacle Healthcare Consulting

Last week, in Part Five of this six-part series on “we examined Topic #5, Telepharmacy.  This week, in Part Six, we examine Board Education, and how being accountable for care in a community requires the ability to make informed decisions.

Part Six: Board Education

I once had the opportunity to hear a legendary, now since-retired hospital CEO-turned-university professor give a presentation to a group of Critical Access Hospital boards with whom I was working.  Once each year, at the least, I would bring rural hospital boards together for an educational summit where they could put community differences aside (who won the most recent football game could be cause for some very hard feelings), to learn about their roles and responsibilities as board members.  This guest lecturer started his presentation with a simple question: “Who is responsible for the care provided in your community?”  He went around the room to hear the different answers.  Most people said it was the doctors, thinking that was the obvious answer.  Some said it was the nurses, who “really do the work” prescribed by the doctors.  And, others gave answers ranging from the CEO, who brings all the “moving parts” together, to the EVS staff, who keep the environment clean and warm-looking, thus reassuring patients they came to the right place for their care.  While the guest lecturer agreed with all these answers, that each was responsible for their pieces of the puzzle, he asked again which one position, out of all the people in the organization, was responsible for the care provided in the community.  The consensus went to the doctors.

The gentleman chuckled and smiled, and slowly walked to a front row table, slamming his hand down, jolting even those in the back row.  “WRONG!,” he exclaimed.  “Look around.  Who do you see?  A Board member.  The answer lies in this room.  Board members are ultimately responsible for the care.  After all, do they not sign-off on every member of the medical staff, attesting to the skills and education of each?  Do they not set strategy, instruct the CEO on identifying the most existential matters, and approve budgets from which to operate, provide services and ensure new equipment can be purchased?  Yes, each one of you has the ultimate responsibility for the care provided in your community; and, the accountability and legal responsibility that goes with it.”

The room went silent.  I was starting to wonder what I had done, inviting the board members into their own private episode of “Scared Straight.”  However, it was a very effective reminder, almost a re-booting of these boards, to understand what their individual and collective purposes were.  He now had their attention, and they spent the day learning about topics before which many had no knowledge, and to whet their appetite for learning more.

This one education session hit me like a ton of bricks.  For most people in the room, this one day was their only real education as board members.  Compare that one day to the education efforts of the organizations these board members govern, where licensed professionals are required to maintain skills and demonstrate competencies.  However, board members, who are often lay people, serve on their boards for a variety of reasons.  Some are elected, others appointed, but rarely are they required to demonstrate industry knowledge or preparedness.  Rather, by design, they represent all walks of life, and often join and start serving without much more than a brief orientation.  According to a survey by the American Hospital Association (2019), only 29% of hospitals and health systems said they required continuing education for board members in the last year.  Some states, such as Georgia, now require board members, CEOs and CFOs to receive continuing education in Healthcare Finance.  While one could argue that the subject of Finance is only one aspect of healthcare, an often complex and confusing one at that, it is a start.  Compliance, Quality and other important subjects will hopefully follow; but starting with Finance is certainly understandable, as it has been the one area where rural hospitals have been struggling, and a leading cause of rural hospital closures.  Researchers at the University of Washington (2019) examined rural hospitals and found that while the closings of urban hospitals had no impact on their surrounding communities, rural hospital closings caused their populations to see mortality rates rise 5.9 percent. In the case of the State of Georgia, it has recognized that in order to hold a fiduciary responsibility to an organization, and an accountability for the care provided in their communities, board members must have an understanding of how its system works.  Board education is the way that State plans to address it.

To those serving rural and Critical Access Hospitals outside of Georgia, we can raise the bar from the 29% of organizations that require board education.  It does not take a lot of money to bring in an expert such as the guest lecturer used in this example.  State hospital associations and other groups offer sessions for boards regularly.  Yet, before COVID, when I attended these conferences, most of the participants I saw were hospital executives and possibly a small delegation of board members, usually those whose turn it was to attend that year.  Now, with the pandemic upon us, more and more of these educational conferences are being offered virtually.  Even if the registration cost is the same as it had been for in-person conferences, there is no travel, lodging or meals out with a virtual conference.  It does not get much simpler, or cheaper, than this.  As board members often serve as unpaid volunteers, virtual conferences can help keep them from missing work, which may have been a reason why just over a quarter of hospitals have not required continuing board education.

I am not suggesting a board become more educated to manage the hospital and possibly assume responsibilities of the CEO; rather, just the opposite, to support the CEO in collectively making informed, well-educated decisions.  A strong and well-educated board will know the difference between governance and management.  As challenges continue to face rural and Critical Access Hospitals, which are closing at a record pace, now more than ever is the time to invest in board education.  By educating boards, the people at the tip of the accountability spear, the stage is set that the right decisions are being made for the right reasons by the right people at the right time.

If you would like to consider board education options for your rural or Critical Access Hospital, please let me know and I will be glad to speak with you.  I may be reached at or (720) 598-1443.