Hadassah or Esther? Hospital Governance Needs Transparency

by Mayer Brezis and Sara Singer

Hadassah’s Board of Directors will not renew the contract of hospital CEO, professor Mor-Yosef. No one knows why. As owner, Hadassah Women’s Zionist Organization of America (HWZOA) can do what it sees as right, and confidentiality in sensitive discussions can be necessary. Meanwhile, however, a sense of unfairness and bewilderment raise mistrust among hospital staff.

Hadassah is not a private company with trade secrets like Coca Cola: as a public hospital serving over a half-million patients every year, largely through taxpayer funds, it bears greater accountability for transparency. Transparent governance is especially important in healthcare organizations from which the public demands accountability for quality and safety. People expect openness from nurses and physicians about performance and mistakes. Creating a culture of transparency requires leading by example. By keeping silent, what message does the hospital’s governing body send to staff?

Leading a shift in strategy requires transparency, so that frontline workers understand (even if they don’t agree with) their leaders’ decisions. In Hadassah’s case, this might be particularly important because of the geographic and cultural gulf between the hospital and US-based HWZOA. Leaders who have successfully managed difficult change, such as Paul Levy at Harvard-affiliated Beth Israel Deaconess Medical Center, have employed high levels of communication about their rationale for decisions.

Transparency has characterized Hadassah under Mor-Yosef’s leadership. One of his first moves as CEO was to assign two professors to a new field of clinical quality and safety: Yoel Donchin, an anesthesiologist expert on human errors, and one of us. Mor-Yosef said: “it is time we put a mirror in front of ourselves. If we are good, let’s show it. If not, let’s improve”. This courageous motto enabled various initiatives that have contributed to patient welfare, such as using checklists before surgery to reduce mistakes and before insertion of a central line to reduce infections.

The challenge of balancing high quality care with financial pressure demands more transparency and accountability about decision-making. A substantial limitation to improving safety and outcomes is, as in other industries, production pressure. Managers perceive that they are being measured by their ability to balance budgets. Messages to increase bed occupancy rate or reduce workforce are heard more frequently than discussions on how to prevent medication error or misdiagnosis. The current remunerative system pays for quantity, not quality. In the face of competing incentives and difficult decisions, transparency helps to maintain shared understanding and trust.

HWZOA has a prestigious tradition of promoting public health, education and social action with remarkable generosity towards Israel. Disagreement about funding priorities, for instance if benefactors value social over medical targets, presents an opportunity for discussing social determinants of health – increasingly recognized as the best predictors of disease. If benefactors prefer American over Israeli goals, that is also a legitimate dispute that will profit from public discourse. Israel always benefits from financial help. Israel can benefit no less from exchange of culture, values and knowledge.

HWZOA was founded 98 years ago on Purim. It was named for Hadassah, the original name of Esther, the central heroine of Purim. Esther means in Hebrew secrecy, as hiding Esther’s nationality was pivotal in her winning stratagem to save her people. The Talmud says: “blessing is found only in what is hidden from the eye”. Yet, at the right time, Esther revealed her secret. Similarly in public policy, secrecy can be key to transient success but, it will eventually undermine stakeholders’ own interests. In healthcare, making difficult decisions with limited resources requires transparent governance.

Hadassah is Esther but it should stay Hadassah.

Mayer Brezis, MD MPH, is Professor of Medicine and Director of the Center for Clinical Quality and Safety at Hadassah Hebrew University Medical Center in Jerusalem, Israel.

Sara Singer, MBA PhD, is Assistant Professor of Health Care Management and Policy at the Harvard School of Public Health and Assistant Professor of Medicine at Harvard Medical School/Mongan Institute for Health Policy, Massachusetts General Hospital in Boston, MA, USA.

[eJP note: The JTA’s Fundermentalist blog is reporting that Mor-Yosef has been summoned to New York to meet today with Hadassah’s president, Nancy Falchuk: “It is not clear what will happen when Mor Yosef meets with Falchuk… and there seems to be real suspense on both sides.

According to one Hadassah Women insider there are three options: “He gets fired effective immediately. He gets layered and stays till early 2012. Hadassah caves and he stays forever.”

“This ends very badly, no matter what,” the insider said.]