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Introduction
Factors influencing effective corporate governance of healthcare quality have increasingly come under scrutiny as a board’s role in ensuring better patient outcomes is made explicit in legislation and regulations (see, e.g. Belmont et al., 2011; Care Quality Commission, 2014). Research demonstrates that governance engagement in healthcare quality activities varies (Bismark and Studdert, 2014; Baker et al., 2010; Prybil et al., 2010), and a small but significant association between engagement and healthcare outcomes exists (Jha and Epstein, 2010; Jiang et al., 2009; Vaughn et al., 2006). However, little is understood as to why engagement varies.
While evidence, in governance literature, on the influence of structural factors, such as board size and composition, on performance is unconvincing and contradictory (Chambers et al., 2013; Cornforth, 2001; Dalton et al., 1998; Roberts et al., 2005), there is growing evidence of the importance of healthcare governance skills. Significant associations between numbers of clinician board members and hospital performance in processes and outcomes of care (Jiang et al., 2009), ratings of quality (Veronesi et al., 2013) and patient experience ratings (Veronesi et al., 2015) have been identified. Higher ratings of board member quality skills and competencies are positively associated with staff attitudes to quality (Mannion et al., 2017), outcomes of care (Jha and Epstein, 2010) and hospital clinical quality performance (Jha and Epstein, 2013).
While healthcare skills are structural factors that appear relevant in healthcare, increasingly there are calls for a greater focus on complex mediating factors that influence governance effectiveness (Bennington, 2010; Chambers et al., 2013; Cornforth, 2012; Edwards and Clough, 2005; Pettigrew, 1992; Pye and Pettigrew, 2005; Roberts et al., 2005). Limited understanding of board internal processes and dynamics has been described as the ‘black box’ of governance (Pettigrew, 1992, p. 178). This paper contributes to emerging research, exploring the internal workings of corporate governance, through examining how key elements of communication and leadership influence healthcare governance engagement. This is explored through a comparative case study of eight Australian public hospitals undertaken through document review, interviews and observations.
This paper first describes emerging research that is beginning to illuminate the black box of governance. The approach taken in this study to explore and build...