In health care, do the people in power reflect the people they serve?
It was the early 1990s when Toronto’s Wellesley Hospital turned power over to the people. The new strategic plan called for partnerships with local communities and citizen participation in decision making, and Tony DiPede, a local activist who was HIV-positive, became chair of the hospital’s citizen advisory panel on HIV/AIDS. It was a diverse group of patients and staff whose role was to make recommendations about quality and access, and whose meetings could sometimes be heated. “A lot of people were dying,” DiPede said in an interview for the 2006 book, Survival Strategies: The Life, Death and Renaissance of a Canadian Teaching Hospital. “We were probably more aggressive and volatile than might normally be the case.”
When DiPede was asked to sit on the board, he was surprised. “I was very young at that time,” he says today, “and I’m the product of working-class parents. The Wellesley board had bank presidents, people from important Canadian families, heads of some of the major law firms. The chair of the board was the head of Manulife. It’s not my league. But the Wellesley made room for me.”
You might read this and think: Sure, the inclusion of a young, gay man who had a chronic illness and no professional affiliation (DiPede was an entrepreneur) on the board of a hospital might have been a departure 25 years ago, but today it is surely the norm. Given the current emphasis on patient-centred care and patient involvement in decision-making, one would expect hospital boards in Ontario—and those of the province’s Local Health Integration Networks, or LHINs, the regional authorities for health care—to strongly reflect the communities they serve.
But a 2013 survey of leadership in health care in the Greater Toronto Area by Maytree and Mount Sinai Hospital found that although visible minorities made up 47 percent of the population, they comprised only 22 percent of LHIN boards and only 14 percent of hospital boards. Nearly one-fifth of all boards in the survey (which included Community Care Access Centres) had no visible minority representation. The numbers for people with disabilities were even poorer: 16 percent of Ontarians are living with a disability but they made up only about one percent of boards and senior management across the sector.
What accounts for these gaps? And how can hospitals and LHINs ensure that they hear and act on the voices of the people they serve?
Why is there a lack of diversity among decision makers?
In Ontario, hospital boards are responsible for hiring and evaluating the CEO, providing financial oversight, and developing a mission, vision, and strategic plan. LHIN boards, whose members are appointed by the Lieutenant Governor of Ontario, also fill a governance role, overseeing strategic direction and priorities, and they are accountable to the ministry for the LHINs’ use of public funds and performance results.
Most hospital and LHIN boards work with “competency matrices” when recruiting members. These are lists of skills or attributes that are either required or desirable, and include expertise in areas such as finance, law, communications, human resources, fundraising, and risk management. Scroll through the bios of board members at hospitals and LHINs in Ontario, and you almost invariably find several people with established careers in banking, law, consulting firms and government. Some matrices also make a note of a person’s gender, age and ethnicity.
There is a notion “that if you prioritize inclusion and health equity and diversity, somehow you could be risking the overall skills and capability of your board,” says Matt Anderson, president and CEO of Lakeridge Health, a five-site hospital in Durham. “My lived experience is you couldn’t be more wrong.” Camille Orridge, senior fellow at the Wellesley Institute in Toronto and former CEO of the Toronto Central LHIN, says that when people say “‘We’re not sure we can get diversity and a skilled board…’ it’s racist. That’s what they used to say about women. They didn’t think [women] were competent, and yet here you are, as a competent woman on the board. Now you’re saying, ‘We can’t get an Indigenous person on the board because we want competence.’”
Another barrier to inclusion is the time commitment that many boards require—evening meetings, committee work, workshops and retreats—with minimal compensation (hospital board work is completely voluntary). This can be prohibitive for people with small children or family care issues.
And then there’s the matter of fundraising. Hospital boards, says Orridge, serve two functions—they’re governors, but they also attract money. Foundations depend on board members to know potential donors, and hospitals rely on donations for important initiatives like renovations, new buildings and equipment. “It’d be naïve to think that St. Mike’s could suddenly just say, ‘We want a diverse board,’ and bring a whole bunch of poor people on their board,” says Orridge. “That’s why for me, it’s not only about who sits on the board.”
How to build a culture of diversity, equity and inclusion
In fact, says Orridge, focusing on board composition as a way of bringing diversity to an organization is actually a way of perpetuating the status quo. “It’s the easy one to point a finger at, to be critical of, to fill out a box. But what’s the goal?” she says. “If they just do the tick-box and bring people on without having a real plan, then they’re also doing a disservice and tokenizing people.”
The goal, says Orridge, should always be “to make decisions that ensure excellent care for all the people [the organization] provides service to.” In order to do that, an organization must ensure that it’s hearing from all the communities it serves. “You can never get the voices of the population on a board of 15,” says Orridge. “The board composition is but one tool.”
Diversity has to be in an organization’s DNA, says Anderson. It’s about the whole team—volunteers, staff, management and the board—reflecting the community. One simple way of checking how well the organization does this, he says, is to look at postal codes. Do the people serving your patients live in the same places that your patients do? “That basic level of geography,” he says, can help you understand whether your team reflects your community.
If you’re concerned that it doesn’t, one quick way to gather information is through an advisory group, says Anderson. At a previous hospital where he worked, Anderson met with the community advisory group to tell them about the corporation’s strategic planning, which included a commitment to improve service to aging patients. Someone in the group asked why—if the hospital was sensitive to the needs of seniors—the bus stop was several blocks away from the entrance. This led to a year-and-a-half-long project to reroute the bus, which was much more complicated than Anderson anticipated. “But it was important to do because it was a clear issue for the community we were serving,” says Anderson. “They saw we were committed to it and that got us a lot of street cred. And it got them coming back to more discussions with us.”
Another way for boards to hear patient voices is committee participation. At the Children’s Hospital of Eastern Ontario, members of the hospital’s Youth Forum attend a meeting of the Quality and Safety committee every year to deliver their annual report. Meena Roberts, who chairs the committee, thinks it would be great if the president of the forum became a standing member. “So I would have their input all the time,” says Roberts. “I don’t mind if it’s an 18-year old; I think that’s fantastic.” CHEO also invites patients to board retreats and conducts focus groups—this past fall, they went to Ottawa Inuit Children’s Centre to learn about the needs of that community. “You really need the organization to have a variety of tools,” says Orridge. “You need to look and see where you are consistently missing voices. And then do outreach to those communities.”
But Ron Rosenes, a long-time community health activist in Toronto’s HIV community who has sat on multiple boards and advisory groups, is skeptical of how much patient voices can impact decision-making from outside the board. “I’m not sure for a moment that advice from advisory committees makes it to the board very often,” he says. “It seems to me that by not having patients on the board itself, you’re lacking some aspects of strategic vision which you may not necessarily get from board members who have come to you from other industries, other fields.”
Even if diversifying board composition isn’t the answer in and of itself, it nevertheless needs to happen, as the Maytree survey shows. Maytree’s DiverseCity On Board program offers some support to this end, connecting people from under-represented groups with not-for-profit and public boards. “From a recruitment perspective, you always start with skills and experience,” says Anderson. “And then you move to, we would prefer to look for skills and experience to be fulfilled through an inclusion lens, so we’re not just getting three people with an accounting designation, we’re getting three people with an accounting designation who also come from different backgrounds.”
Less tangible than an accounting designation or being a visible minority is a person’s desire to serve an organization’s patients. “You have to bring in people who have that passion for the issues they think are important and the tenacity to keep pushing them forward,” says Dennis Magill, professor emeritus of sociology at U of T who was on the Wellesley Hospital’s board in the early ’90s. “The people we brought on the board did not necessarily have university degrees, but they had a passion for social justice. They had concern for the community.”
Tony DiPede had that kind of passion. “At first, I saw myself as a kind of outsider who really had to stay firm in representing community perspectives,” he says. “But I found the board members were very responsive. And actually quite amazing people. Really committed. Not just sitting there for the prestige or because they worked for a bank and needed to sit on a hospital board for their community quotient.”