No systematic research has been undertaken in Canada on the relationship between hospital performance, organizational monitoring capacity and board governance. This three-part dissertation aims to fill that gap. The conceptual framework elaborated in a theoretical paper and tested in two exploratory empirical studies proposes that boards reflect their institutions, with high performers exhibiting greater capacity to harmonize accountability needs and align governance decision-making and monitoring systems with external performance measurement and reporting requirements. Top team (board and management) characteristics, and governance practices, both proposed elements of “governance capacity,” are hypothesized to reflect and reinforce “organizational monitoring and alignment capacity” thereby contributing directly and indirectly to key aspects of hospital performance including quality of care, financial health and patient satisfaction. Using hierarchical regression analyses, six hypotheses were tested on a sample of 101 acute hospital corporations that participated in the 2005, 2006 and 2007 Ontario Hospital Report Research Collaborative. After controlling for hospital size, evidence of a statistically significant relationship was detected between organizational monitoring and alignment capacity and quality performance, and between one element of governance capacity, governance practices, and financial performance. A relationship was also detected between governance practices and top team characteristics, including diversity, education and turnover. These findings suggest that the relationship between hospital governance and performance is tenuous and that some aspects of performance may be more amenable to governance influence than others. In highly-regulated environments governance space is circumscribed and myriad stakeholders have a stronger pulse on singular aspects of organizational performance than the board. This study argues that the role of boards in environments of distributed governance is to mine the ‘accountability web’ for timely, multivariate intelligence on performance and use it to drive alignment, integration and performance improvement. The contribution of this research, its limitations, and implications for researchers, policymakers and hospital leaders are discussed.

No systematic research has been undertaken in Canada on the relationship between hospital performance, organizational monitoring capacity and board governance. This three-part dissertation aims to fill that gap. The conceptual framework elaborated in a theoretical paper and tested in two exploratory empirical studies proposes that boards reflect their institutions, with high performers exhibiting greater capacity to harmonize accountability needs and align governance decision-making and monitoring systems with external performance measurement and reporting requirements. Top team (board and management) characteristics, and governance practices, both proposed elements of “governance capacity,” are hypothesized to reflect and reinforce “organizational monitoring and alignment capacity” thereby contributing directly and indirectly to key aspects of hospital performance including quality of care, financial health and patient satisfaction. Using hierarchical regression analyses, six hypotheses were tested on a sample of 101 acute hospital corporations that participated in the 2005, 2006 and 2007 Ontario Hospital Report Research Collaborative. After controlling for hospital size, evidence of a statistically significant relationship was detected between organizational monitoring and alignment capacity and quality performance, and between one element of governance capacity, governance practices, and financial performance. A relationship was also detected between governance practices and top team characteristics, including diversity, education and turnover. These findings suggest that the relationship between hospital governance and performance is tenuous and that some aspects of performance may be more amenable to governance influence than others. In highly-regulated environments governance space is circumscribed and myriad stakeholders have a stronger pulse on singular aspects of organizational performance than the board. This study argues that the role of boards in environments of distributed governance is to mine the ‘accountability web’ for timely, multivariate intelligence on performance and use it to drive alignment, integration and performance improvement. The contribution of this research, its limitations, and implications for researchers, policymakers and hospital leaders are discussed.