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Governance Excellence through Consumer Voice

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Governance Excellence through Consumer Voice

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Content Running head: GOVERNANCE EXCELLENCE 1
Governance Excellence through Consumer Voice
Katie Strautman
Capstone Project
In Partial Fulfillment for the Degree
Doctor of Social Work
Suzanne Dworak-Peck School of Social Work
University of Southern California
August 2020
© Katie Strautman
GOVERNANCE EXCELLENCE 2

Dedications
To my husband, Tim, and son, Brody, for their unconditional love and support. My
parents, Gary Bess and Cindy Ratekin, for paving the walkway to Governance Excellence and
for encouraging me to pursue my dreams. And, to my grandparents, James and Genevieve
Ratekin, for their example of kindness and volunteerism and for believing in me. This is for you!

GOVERNANCE EXCELLENCE 3

Acknowledgements
This is to acknowledge the many people who supported me along the way. First, thank
you to my family and friends. I love and appreciate you! A special thank you to my mother-in-
law and father-in-law, Tammy and Ken, for watching my son, Brody, during classes and when I
just needed to spend a little more time on homework. A shout out to my brother, Grayson, and
niece, Mira, for their much welcomed support and distraction.
To my hometown, Paradise, California, thank you for my foundational education. While I
was in the program, I am grateful that I was able to safely drive from Paradise as the town
experienced the worst wildfire in California history. I am with you Paradise; you will always be
a part of me.
I wish to acknowledge my Gary Bess Associates (GBA) work family for supporting me
and letting me run my crazy ideas by you. I also acknowledge and thank the many Federally
Qualified Health Center (FQHC) staff, board members, and expert consultants for their
commitment to the communities they serve, as well as sharing their time and expertise on this
important issue.
Thank you to my Cohort 7 family for the ongoing support, endless study sessions, and
inspring me with your commitment to the field of social work and the Grand Challenges. And
finally, I would like to thank the faculty that have guided, inspired, challenged, and mentored me
along the way. A special thanks to Dr. Nadim Karim, Dr. Harry Hunter, Philip Browning,
Stephanie Wander, Dr. Michael Rank, Dr. George Orras, James Wind, Dr. Eugenia Weiss, Dr.
Jane James, Dr. William Feueborn, and Dr. Ronald Manderscheid.

GOVERNANCE EXCELLENCE 4

Governance Excellence through Consumer Voice
“A central tenet is that primary care should be rooted in communities, for communities, and with
communities.” – Jack Geiger
Executive Summary
The United States health care system is failing to serve many medically uninsured and
underinsured individuals, causing low-income persons to go untreated, including those with
chronic health conditions (Jacobson & Parmet, 2019). As such, many low-income, and medically
uninsured and underinsured individuals experience health inequities, including inadequate access
to timely, affordable, and culturally responsive health care services (Baron et al., 2014; Walters
et al., 2016). Along with inadequate access to health care services, especially for marginalized
and disenfranchised populations, there is growing social stigma and racial inequities (Baron et
al., 2014; Bent-Goodley, Williams, Teasley, & Gorin, 2019; Walters et al., 2016). These include
ill-informed assumptions that people who are of lower socioeconomic status, have little
education, have a behavioral health condition, and/or have made poor decisions in their past, has
contributed to their current status. Furthermore, systemic racism, discrimination, and segregation
are barriers to equality and justice, which is often observed in health care settings (Williams,
2012).
The social problem is embedded within the Grand Challenge, Close the Health Gap, one
of the 13 Grand Challenges for Social Work developed by the American Academy of Social
Work and Social Welfare (AASWSW). However, it also aligns with the Grand Challenge,
Achieving Equal Opportunity and Justice. These Grand Challenges call on innovative and best
practices to promote and improve upon social determinants of health, and to foster health equity
and inclusion that will have a meaningful and long-lasting impact on communities across the
GOVERNANCE EXCELLENCE 5

country (Grand Challenges for Social Work [GCSW], 2020a). Close the Health Gap and
Achieving Equal Opportunity and Justice provide a framework for understanding and improving
upon current health, social, and racial inequities in the United States. Within these Grand
Challenges, social determinants of health, such as a stable local economy, educational
attainment, good physical health and health care access, the built environment, and social and
community contexts, play a role in addressing this social problem. They are also the foundation
for building a meaningful and inclusive society whereby everyone has equal access to culturally
responsive health care (Walters et al., 2016).
Investing in the Federally Qualified Health Center (FQHC) program is one solution for
improving the United States health care system. The FQHC program, which has been in place for
more than 50 years, is designed to provide comprehensive primary care services to all
individuals across the lifecycle regardless of their ability to pay for services, with a specific focus
on patients at or below 200% of the annual Federal Poverty Guidelines (FPG) (Health Resources
and Services Administration [HRSA], 2018a). Today, there are 1,457 FQHCs in the United
States representing 13,401 sites, with the majority located in low-income and marginalized
communities (Health Resources and Services Administration [HRSA], 2020).
The lack of diversity, equity, and inclusion on FQHC boards of directors, which by
designation are required to have majority consumer (patient) board members, is an important and
often unrecognized social issue in today’s society. Strategies to promote consumer voice in
organizational decision making and policy development is imperative for improving health care
access for low-income, impoverished communities. Through the development of a first-of-its-
kind program, referred to as Governance Excellence through Consumer Voice (Governance
Excellence), technical assistance and training are now available to address the lack of meaningful
GOVERNANCE EXCELLENCE 6

participation and inclusion of consumers on FQHC boards of directors, ensuring that services are
responsive to the needs of the patients and community served by the health center. The
innovative program is designed to question social norms and adds a deviant that addresses
diversity, equity, and inclusion among board members within a variety of organizational
contexts, as the service recipient population is often not treated equally or considered valued
members of society.
The FQHC program, administered by the Bureau of Primary Care within the Health
Resources and Services Administration (HRSA), a department of the United States Health and
Human Services (HHS), requires that these nonprofit, community-based health centers be
governed by a board of directors whose membership consists of a majority of consumer board
members. The Health Center Program Compliance Manual, which follows guidance from
Section 330 of the Public Health Services Act, states the following:
“The majority [at least 51%] of the health center board members must be patients served
by the health center. These health center patient board members must, as a group,
represent the individuals who are served by the health center in terms of demographic
factors, such as race, ethnicity, and gender” (Health Resources and Services
Administration [HRSA], 2018b, p. 78).
Although on its surface this is an admirable attribute, consumers often lack the experience and
support to effectively participate in processes that contribute to collective organizational decision
making and policy development (Law & Saunders, 2015). Furthermore, FQHC boards of
directors are often not diverse or representative of the patients served by the health center, as
required by the program (Wright, 2013a).
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Working within a federal healthcare system that has policies and practices outlined in the
Public Health Services Act and the Health Center Program Compliance Manual, Governance
Excellence complements federal policy and practice by providing the necessary resources for
FQHC boards of directors to effectively and ethically implement consumer-majority governance,
as well as fosters a culture that puts communities first and empowers consumers to participate in
a leadership role. "Centers give patients a real voice – a rarity in today's health care market"
(Lefkowitz, 2007, p. 141).
Governance Excellence’s methodology addresses the social problem as it provides
training and technical assistance to all board members and health center senior managers on
identifying and addressing biases associated with the participation of consumer board members.
It also improves current strategies that promote diversity, equity, and inclusion within the
organization among staff and board members, and outside the organization among funders,
partners, community residents.
The Governance Excellence program is designed to ensure that primary care services in
underserved communities in the United States are culturally responsive, affordable, accessible,
and of high quality. The program aims to a) increase in consumer board members’ feelings of
inclusion on the FQHC boards of directors; b) increase the number of consumer board members
on the FQHC boards of directors; c) increase socio-demographic parity between FQHC
consumer board members and patients served by the health center; d) increase the number of
consumer board members who contribute to, and motion for approval of, a decision on the
FQHC board of directors; and e) increase patients’ sense of culturally responsive, timely, and
quality health care services offered by the health center.
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The five overarching components that comprise this intervention include 1) an
assessment of meaningful participation and inclusion by board members using the Governance
Excellence Inclusion/Exclusion Assessment tool; 2) the development of board-approved
strategies that support and promote diversity, equity, and inclusion; 3) the development of board-
approved strategies to improve parity in board member socio-demographic composition to reflect
consumer representation; 4) the development of board-approved consumer recruitment and
retention plan whereby consumers are educated on their roles and responsibilities; and 5)
education and training on HRSA Health Center Program requirements. Exposure to this
intervention will provide board members with the education, training, and resources to be
confident that they are contributing to a shared vision, while fostering a culture of diversity,
equity, and inclusion that will, in turn, ensure services are culturally responsive and meeting the
needs of the community served by the health center.
The goal for the first year of implementation is to pilot the program with four FQHCs in
southern California, followed by a rollout in 12 FQHCs. A marketing and communications
strategy will be concurrently implemented during the pilot stage, including submission of project
abstracts to present at state and national conferences. Presentations will bring awareness and
knowledge to current practices, and opportunities to create positive change. Furthermore, the
continued engagement and development of formal and informal partnerships is a priority and
will open up additional opportunities for presentations, including webinars and speaking and
consultation engagements.
The innovative program has potential beyond its current scope. Each FQHC is unique,
serving diverse races/ethnicities, and geographic areas where there is justification for unmet
needs. As such, all FQHCs, by designation, are required to have consumer-majority boards of
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directors, and many experience challenges with meeting the consumer-majority board member
composition requirement (HRSA, 2018b). Furthermore, beyond the scope of the FQHC program,
studies suggest that there is a lack of diversity on nonprofit boards of directors in the United
States regardless of the sector (BoardSource, 2017; Buse, Bernstein, & Bilimoria, 2016; Cherry,
2020), opening up opportunities to expand the program beyond the FQHC program.
Conceptual Framework
Statement of Problem
Today, the United States health care system struggles to meet the needs of Americans,
and we continue to experience poor health outcomes especially for our most vulnerable
populations, including people experiencing economic hardship and/or chronic health conditions
(Bent-Goodley et al., 2019; Walters, 2016). Furthermore, our society continues to experience
systemic racism, racial inequities, and segregation (Grand Challenges for Social Work [GCSW],
2020b), which have implications on the current health care system; compromising accessing to
culturally responsive, affordable, and accessible health care services for medically uninsured and
underinsured individuals (Browne et al, 2017; Walters, 2016). The concept of consumers as
decision-makers comes with negative, and sometimes implicit connotations. This includes the ill-
informed idea that people who are not educated, such as not having a high school or college
degree, or are of lower economic status, are not competent to make well-informed decisions or to
have expertise and insight on a specific issue.
To improve access to culturally responsive services, quality of care, and to increase
organizational accountability, systems need to be in place to engage patients in their health care,
including involving patients in health care agencies’ decision-making practices, and policy
development (Mende & Roseman, 2013; County Health Rankings & Roadmaps, 2020).
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Consumer's voice provides insight and justification for the quality of health care services
delivered; ensuring that services are responsive to community needs. Over the years, policies and
practices have been in place to capture consumers’ voices; however, these systems are not
regulated and do not provide guidance on a process or offer resources on how to include
consumers in health care governance. When consumer input is included in health care decision
making, it allows for insight and justification on current and future health care operations, which
in turn, can improve quality care, patient engagement, and overall organizational accountability
(County Health Rankings & Roadmaps, 2020).
The following relevant concepts are important to understand when addressing meaningful
participation and full inclusion of consumer board members on FQHC boards of directors. First,
decision-making is the process by which quality, satisfactory, and timely decisions are made
(Guillemette, Laroche & Cardieux, 2014). Engaging patients in health care decision-making can
ensure that their needs, values, and preferences are being considered (DeCamp, 2015). For the
proposed innovation, decision-making is when all board member input is considered when
making decisions. Second, equity of treatment/leadership addresses the inequalities in leadership
whereby there are different underlying levels of social advantage and privilege (Zere et al.,
2007). A shared governance model requires values of partnership, equity, and accountability
(Bamford-Wade & Moss, 2010). Furthermore, equity is essential to achieving equal opportunity
and justice (Cherry, 2020), and as it pertains to the intervention, equity of treatment/leadership is
when all board members are equally treated.
Third, inclusion refers to having all board members are at the table – figuratively and
literally. They are included in all activities of the board of directors; achieving social integration
(Scorgie & Forlin, 2019). Inclusive leadership at the governance level is a step toward
GOVERNANCE EXCELLENCE 11

organizational inclusion; however, it is interrelated with diversity (Mor Barak, 2017). It is thus
challenging to reach inclusion without having diversity on the board of directors. Fourth,
participation. Board members’ participation is key factors in the board’s effectiveness (Pugliese,
Nicholson & Pieter-Jan, 2015). Studies have found that consumers are more involved in their
health care, including mental health care, when it is consumer-driven (Schauer, Everett, del
Vecchio, & Anderson, 2007). The intervention looks at the level of participation among board
members, including their contribution at board meetings.
Literature and Practice Review of Problem and Innovation
Based on an in-depth literature review, which included understanding the initial intent of
the model, and from interviews with key informants (Appendix A), it is clear that consumer-
majority governance is not an easy task and is not always equitably and inclusively implemented.
While consumer-led governance is essential to the FQHC program, the time and attention needed
to ensure an inclusive board of directors whereby all voices are heard are not always understood
or acknowledged (Lefkowitz, 2007).
The lack of consumer voice and participation has been a problem since its conception.
The FQHC program was initially referred to as the Community-Oriented Primary Care (COPC)
model, which came to the United States in1964 as part of President Lyndon Johnson's call to
action, famously known as the War on Poverty. COPC was initially administered under the
Office of Economic Opportunity (OEO), which no longer exists, whereby the department was
charged with developing new concepts and creating new community action projects (Lefkowitz,
2007). The COPC model, which came out of the OEO, encouraged consumer participation and
involvement in community primary health care. However, many funded institutions, such as
hospitals and medical schools, were concerned with the level of consumer participation in which
GOVERNANCE EXCELLENCE 12

the OEO envisioned, and therefore would disengage from community health centers to mitigate
partnerships and collaborations, which defeated the purpose of the program, which was to be
community-oriented (Lefkowitz, 2007).
The Affordable Care Act (ACA) was a health care reform initiative in 2010, under
President Barack Obama, to increase access to affordable health care coverage for Americans
(Daguerre, 2017). The FQHC program was a component of the ACA, and part of the solution to
improving access to affordable health care services for medically uninsured and underinsured
individuals across the life cycle, including children and adolescents (Kelleher & Gardner, 2016).
While the principal focus of the FQHC program is primary health care, within the last few years,
there has been a push toward an integrated health care approach, which includes primary health
care in coordination with behavioral health services (mental health and substance use disorder),
to address the multiple health care needs of residents in one location (Chaple, Sacks, Randell, &
Kang, 2015). The ACA, building on the Mental Health Parity and Addiction Equity Act,
prioritized affordable health care options that included coverage for behavioral health care
services (Chaple et al., 2015).
Over time, the FQHC program has expanded its scope to include mental health and
substance use disorder services; ensuring individuals had access to quality and affordable
behavioral health care services. In 2018, FQHCs provided mental health care services to more
than two million individuals (Health Resources and Services Administration [HRSA], 2018c).
Additionally, many FQHCs have started using an integrated services model that also includes
other specialty care services, such as dental, vision, and enabling services.
Research studies conducted by Brad Wright, an Associate Professor at the University of
Northern California School of Medicine, have found that consumer board members are often not
GOVERNANCE EXCELLENCE 13

representative of their community, and/or valued for their role or their perspectives as an FQHC
consumer (Wright, 2012; Wright, 2013a; Wright, 2013b; Wright & Ricketts, 2013; Wright &
Martin, 2014). His studies have identified barriers to consumer participation on FQHC boards of
directors.
A study conducted by Wright (2013a), for example, found that a majority of FQHC
boards of directors are lacking consumer board members who reflect patient and community
characteristics. His research suggested that FQHCs who serve urban communities were less
likely to have board members, as a group, that was representative of the community served,
compared with FQHC boards of directors that serve rural communities. Moreover, it was also
found that a majority of the FQHCs that were studied had board members of a higher
socioeconomic status compared with the target population for the FQHC program, which are
individuals at or below 200% of the FPG. These discrepancies between consumer leadership and
patient population could adversely impact board members‘ and health center staff’s awareness
and responsiveness to community needs. Equally as important, it is a violation of the FQHC
Health Center Program requirements of having a consumer majority that resembles the patients
being served.
Wright (2012) also conducted a study to understand whether consumer board members
had an impact on the provision of enabling services that were offered by FQHCs. Enabling
services, which are typically not reimbursed by third parties, include transportation, case
management, insurance eligibility, and enrollment, and are known to reduce barriers to accessing
health care services. His study found that consumers had limited impact on boards of directors in
making these types of decisions; however, consumers who were on the executive committee of
the board had significantly more influence on these types of services. In addition, it was found
GOVERNANCE EXCELLENCE 14

that the executive committee is less likely to be comprised of consumers. And, among all board
members, only 26.5 percent of board members are considered representative consumers,
meaning that about one-quarter of consumer board members’ socioeconomic status resembles
that of the patients served (Wright, 2012). A separate study conducted by Wright & Martin
(2014), found that one-quarter (25%) of board members were elected to the board of directors
before becoming patients, defeating the spirit of consumer participation and voice.
Different perceptions exist when board members are in an advisory role compared with a
decision-making role. Sharma et al. (2018) found that non-consumers and health center staff are
increasingly concerned with consumers on boards of directors where they have decision-making
power, compared with consumers on advisory councils where their perceptions and perspectives
are only offered as insights and suggestions for the full board of directors. These types of
committees often called Patient Advisory Councils (PACs), are recommended for health centers
pursuing the Patient-Centered Medical Home (PCMH) accreditation, which demonstrates an
entity's ability to provide quality and patient-focused care. While HRSA encourages FQHCs to
apply for PCMH accreditation; a PAC cannot replace the consumer-majority requirement on the
board of directors. Sharma et al. (2018) recommended; however, recruiting board members who
are consumers from PAC advisory members, should the board of directors have one in place, as
it serves as a training venue to gain experience in an advisory/leadership role.
The lack of diversity, equity, and inclusion on boards of directors expand beyond the
FQHC program. A 2017 national study of nonprofits conducted by BoardSource found that
nonprofit boards of directors were no more diverse in 2017 than they were in 2015; and their
recruitment priorities indicated that it was not going to change any time soon, which
demonstrates the lack of leadership opportunities for people of color (BoardSource, 2017;
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Cherry, 2020). A study by Buse, Bernstein, and Bilimoria (2016) found an association between
diverse and inclusive non-profit boards of directors and board performance. Diverse and
inclusive board members positively impacted the board's performance, including governance
roles and responsibilities. Policies and practices that promoted inclusion and diversity were also
associated with positive outcomes, including fostering an inclusive culture of health that goes
beyond the board room, impacting health center staff, patients served, and the greater
community.
An inclusive and diverse team sparks innovation and validates that decisions made are
intentional and sustainable (Butler, 2018). As the leadership body for the health center, inclusion
and diversity have long-term benefits for the board of directors, as well as the health center and
community, and they are critical in looking to the future of the health center and the community
served. To foster development and promote inclusion and diversity, board training and
customized technical assistance need to take place (Buse et al., 2016; The Center for Effective
Philanthropy, 2018). The Center for Effective Philanthropy (2018) conducted a survey seeking
input from non-profit organizations on challenges with diversity and inclusion, and ways in
which foundation funders can support their efforts. Survey findings suggested that nonprofit
organizations, like FQHCs, often have a difficult time finding resources for training and
technical assistance on diversity and inclusion.
Social Significance
In 2018, the FQHC program served more than 28 million Americans, which was two and
one-half million more patients than those served in 2016; articulating the social significance for
addressing the social problem (HRSA, 2018c). At present, 1,457 FQHCs are representing 13,401
sites in the United States (HRSA, 2020). Together, these locations provide essential health care
GOVERNANCE EXCELLENCE 16

services to populations that otherwise would not have access to affordable, quality health care
(HRSA, 2018a). Today, there is an FQHC site is in nearly every urban community, and more
popping up in rural communities, whereby there are a high number of low-income and medically
uninsured and underinsured individuals.
The FQHC program is held to a formal and explicit limit or requirement; including that
they have a consumer-majority board of directors, meaning more than one-half (51%) of board
members are patients of the health center and thus have had a primary care visit within the last
two years (HRSA, 2018b). To determine the need for enhanced consumer voice on a national
scale, if all FQHC agencies (1,457) had nine board members, which is the minimum
requirement, and five board members are patients and comprise a consumer majority, there are
approximately 7,285 consumer board members at any given time. While this is a modest
projection as some FQHCs are not meeting the consumer-majority requirement, and some have
more than the minimum requirement, it demonstrates the social significance of this initiative.
As the FQHC program continues to expand to new geographic locations, the number of
agencies, patients served, and board members (consumer and non-consumer) will continue to
grow. Currently, the Trump Administration has continued support for the FQHC program
viewing it as a safety net for many low-income and medically uninsured and underinsured
individuals (Hasstedt, 2017). However, should the ACA be dismantled, which is on the agenda
for many Republicans, there may be increased reliance on the FQHC program to provide
affordable health care services (Paradise et al., 2017). With so much still unknown about the
future of the ACA, and in response to the current health inequities, including the impact of the
Covid-19 pandemic on our health care system, the need for the FQHC program continues to
increase (Wright et al., 2020), leveraging consumer perspectives and perceptions in
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organizational decision making and policy development to ensure that services are responsive to
the community needs.
Conceptual Framework with Logic Model Showing Theory of Change
Governance Excellence is guided by a solidified conceptual framework that clearly
illustrates the theory of change, and is as follows: If 1) FQHC board members (consumers and
non-consumers) are oriented to the values of diversity, equity, and inclusion; and 2) health center
managers similarly embrace these values; and 3) board members are encouraged to value the
contribution that each member makes, including consumers, then 4) the delivery of health care
services will be elevated and quality health care of care will be available to all who require it.
The logic model (Appendix B) illustrates the theory of change, which incorporates a social
inclusion perspective as the theoretical framework to understand and improve upon current
processes that promote diversity, equity, and inclusion, including civic participation and the
proactive protection of human rights (Bulger, 2018). Furthermore, the social inclusion theory
aligns with the National Association of Social Workers (NASW) Code of Ethics through the
following ethical principle of Cultural Awareness and Social Diversity, “Social workers should
obtain education about and seek to understand the nature of social diversity and oppression with
respect to race, ethnicity, national origin, color, sex, sexual orientation, gender identity or
expression, age, marital status, political belief, religion, immigration status, and mental or
physical ability” (National Association of Social Works [NASW], n.d.).
Implicit bias and social norms stigmatize our communities, which in the context of the
FQHC program, contribute to power inequities between board members (consumers and non-
consumers) and health center leadership. It is thus difficult to address the social problem by not
only focusing on educating the consumer board member on their role and responsibility, but
GOVERNANCE EXCELLENCE 18

rather it takes participation from all board members (consumer and non-consumer), as well as
health center leadership to develop strategies that address diversity, equity, and inclusion. As
evidenced in the logic model; however, which aligns with the social inclusion theory of change
perspective, Governance Excellence challenges social norms and introduces new strategies that
promote and encourage new and socially inclusive norms.
Problems of Practice and Innovative Solutions
Governance Excellence builds on the Grand Challenge, Closing the Health Gap and
Achieving Equal Opportunity and Justice, by responding with an innovative solution to address
current health, social, and racial inequities in the health care industry. Investing resources in
FQHC boards of directors to promote meaningful participation and inclusion of consumers on
the boards of directors will allow FQHCs to benefit from a) an improvement in the quality of
health care; b) an increase in consumer engagement in health care, including decision-making;
and c) an increase in organizational accountability (County Health Rankings & Roadmaps,
2020). Furthermore, and importantly, it can ensure that the FQHC is following Health Center
Program requirements, which otherwise would put them at risk of losing their designation.
Proposed Innovation and its Effect on the Grand Challenge
Acknowledging the critical need for timely health care access in the United States,
Governance Excellence will address health, social, and racial inequities in our society through
training and technical assistance for FQHC boards of directors and health center senior managers
(e.g., Chief Executive Officer (CEO), Chief Financial Officer (CFO), Chief Medical Officer
(CMO)). The program’s goal is to improve the meaningful participation and inclusion of
consumer board members on FQHC boards of directors. To achieve its goal, the innovative
program has the following objectives: a) increase in consumer board members’ feelings of
GOVERNANCE EXCELLENCE 19

inclusion on FQHC boards of directors; b) increase in the number of consumers on FQHC boards
of directors; c) increase in parity between consumer board members and health center patients on
FQHC boards of directors; d) increase in the number of consumer board members who
contribute to, and motion for approval of, decisions at board meetings; and e) increase culturally
responsive, timely, and quality health care services for service area patients.
A central component to the program is the Governance Excellence Inclusion/Exclusion
Assessment (Appendix C), which will be completed by FQHC board members (consumer and
non-consumer) to determine their sense of meaningful participation and inclusion on the board of
directors. The assessment tool, which will be given to board members as a pre- and post-test, will
provide a baseline on the extent to which policies and practices encourage and reward diverse
stakeholders, such as consumers and non-consumers, by recognizing their attributes and their
contribution to the board of directors. The assessment will measure a board member's sense of
meaningful participation and inclusion across the following four domains: 1) Decision-making
process, meaning that all board members’ input is considered when making decisions; 2) Equity
of treatment/leadership, meaning that all board members are treated equally; 3) Level of
inclusion/support, meaning all board members are at the table; and 4) Level of participation,
meaning all board members are actively participating.
Operating plan. Governance Excellence, which targets FQHC board members
(consumer and non-consumer) and health center senior managers, is organized into six sessions -
1) Understanding Health Center Governance; 2) Meaningful Participation and Inclusion; 3)
Consumer Recruitment and Retention; 4) Diversity, Equity, and Inclusion; 5) Highly Effective
Board Meetings, and 6) Quality Assurance and Sustainability. Through virtual and onsite
meetings, and consultation and support, the program addresses essential components toward
GOVERNANCE EXCELLENCE 20

achieving meaningful participation and inclusion. While the program is designed to go at a pace
that works for board members, which considers time to implement and adopt new
policies/procedures, the program can be completed in as little as six months.
Beginning with Session 1, Understanding Health Center Governance, the program
provides participants with an overview and operational expectations of the Governance
Excellence program. The session is designed to educate board members and health center senior
managers on board authority, a core requirement of the HRSA Health Center Program. This
session consists of two planned virtual meetings – Program Overview and Expectations and
Understanding Health Center Governance Compliance. Session 2, Meaningful Participation and
Inclusion, identifies current board member's perceptions of inclusion using the Governance
Excellence Inclusion/Exclusion Assessment. Participants will develop strategies to improve upon
existing practices to promote meaningful participation and inclusion. This session consists of two
planned meetings – Addressing Meaningful Participation and Inclusion (in-person) and
Developing Strategies to Improve Meaningful Participation and Inclusion (virtual).
Session 3, Consumer Recruitment and Retention, focuses on strategies to recruit and
retain consumers as board members on FQHC boards of directors. In this session, program
participants will compare the current board of directors' socio-demographic composition with
patients served by the health center. Strategies will be developed to recruit consumer board
members that match current patient demographics, including educating board members on
roles/responsibilities, and strategies for retaining them. The session consists of two planned
meetings – Recruiting for Diversity (in-person) and Consumer Recruitment and Retention
Planning (virtual). Session 4, Diversity, Equity, and Inclusion, will focus on the values of
diversity, equity, and inclusion, including an examination of current practices and opportunities
GOVERNANCE EXCELLENCE 21

to invest in best-practices within and outside the organization. The session is designed to foster a
culture of diversity, equity, and inclusion that ensures services are culturally responsive to the
needs of communities served by the health center. The fourth session consists of one planned
virtual meeting – Addressing Diversity, Equity, and Inclusion.
Session 5, Highly Effective Board Meetings, focuses on best practices for effective board
meetings. This includes learning skills and strategies to improve decision-making processes that
incorporate input from all board members. Furthermore, the session will provide best-practices,
and strategies to improve informed decision-making practices through agenda setting, complete
board packets, and quality board meeting minutes to move forward with ideas and create change
that positively impacts those served by the health center. The fifth session consists of one
planned virtual meeting – Highly Effective Board Meetings. And finally, Session 6, Quality
Assurance and Sustainability, addresses the long-term vision for incorporating and sustaining
practices that support diversity, equity, and inclusion within the health center and on the board of
directors. This session allows time for reflection and affords opportunities to promote and sustain
positive changes within the organization, but also externally concerning how the organization
portrays itself in the community. This sixth session includes one planned in-person meeting –
Quality Assurance and Sustainability.
Views of Key Stakeholders
The problems of current practices have been examined from multiple stakeholder
perspectives. At a high level, efforts to involve consumers in health care governance has these
challenges: a) identifying appropriate consumer participants; b) defining consumer roles and
responsibilities, and c) resistance from some of the key stakeholders can become challenges to
successfully engaging and integrating consumers into a governance role (County Health
GOVERNANCE EXCELLENCE 22

Rankings & Roadmaps, 2015). HRSA, a national stakeholder by administering the FQHC
program, developed a Health Center Program Compliance Manual in 2017 that codified Policy
Information Notices (PINs) and Program Assistance Letters (PALs); each describing a
requirement of the FQHC program. These policy issuances were well-organized, and while still
used at non-regulatory issuances, a majority of these documents were superseded by the Health
Center Program Compliance Manual, which offers a consolidated resource for summarizing and
demonstrating compliance with the FQHC requirements (HRSA, 2018b).
HRSA has increasingly enforced program requirements. An FQHCs project period
length, which is generally three years, can be shortened or even revoked due to non-compliance.
In 2018, HRSA began requiring health centers that are not compliant with program requirements,
such as meeting the consumer majority or consumer representation requirement, to receive a
shorter project period.
The National Center for Farmworker Health (n.d.) and Migrant Clinicians Network (n.d.)
offer resources on compliance for FQHCs that focus specifically on farmworker health. This
author has identified more resources on consumer participation within migrant health initiatives
compared with a community health center or other community-based organizations. While a
literature review focused on migrant health and social norms would need to be conducted to
confirm the hypothesis that less stigmatization is present within the migrant health community
compared with non-migrant programs, and thus board members and managers are receptive to
inclusion and participation among migrant farmworkers as decision-makers on governing boards
(Weinman, 2009). Moreover, as indicated in qualitative interviews with stakeholders, which
included interviews with technical assistance experts, health centers need to improve their
GOVERNANCE EXCELLENCE 23

governance practices with an emphasis on consumer involvement; however, the resources and
framework for providing this level of consultation and support are currently unavailable.
Evidence of Current Context for Proposed Innovation
A review of existing evidence regarding the broader landscape, history, policy, practice,
and public knowledge and discussion found that health center program guidance back to the
1960s was about incorporating input from the community and local stakeholders into community
health center operations and governance. While keeping the spirit of consumer voices, which has
been vocal for more than one-half century, Governance Excellence brings national attention to
the social problem and identifies opportunities to expand the model into new markets. Promotion
of the model includes presentations and workshops at state and national conferences (virtual or
in-person) with conversations bringing the innovation to the forefront as a sustainable resource
and model for FQHCs across the country.
Comparative Assessment of Other Opportunities for Innovation
The deviant to subvert the social norm is new and innovative in that it has not previously
occurred in this type of organizational setting, and offers customized support in six common
FQHC board development areas 1) understanding health center governance; 2) meaningful
participation and inclusion; 3) consumer recruitment and retention; 4) diversity equity, and
inclusion; 5) highly effective board meetings; and 6) quality assurance and sustainability. At
present, there is not a resource like this available that offers the level of support proposed herein.
It will allow board members to engage with one another in a spirit of mutual respect and
collaboration whereby all members’ views are heard and acknowledged and contribute to
strategic direction and policy development for the health center. To address the definition of
innovation as a social change, the proposed intervention is designed to subvert current norms
GOVERNANCE EXCELLENCE 24

associated with the social problem, and promote new, and socially inclusive norms, to create
social change across a population. Without this intervention, many FQHCs are at risk of not
meeting the needs of their patients, and possibly losing their designation due to lack of federal
compliance, adversely impacting the more than 28 million low-income, marginalized Americans
who currently receive their health care at FQHCs.
In summary, the innovation will meet desired results for the following reasons: a)
consumer majority boards of directors, among other governance requirements, is a federal
requirement for FQHCs, and lack of compliance can put the health center’s designation at risk,
potentially leaving low-income Americans without access to adequate health care services; b)
there is not a resource currently available that provides this level of training and technical
assistance for FQHCs; c) there is not currently a resource that addresses meaningful participation
and inclusion of consumers on FQHC boards of directors; and d) inclusion, diversity, and equity
are timely topics, opening opportunities for dedicated boards of directors to address racial
inequities and become recognized for their commitment to these values.
Innovation Linkage to the Logic Model and Theory of Change
The logic for Governance Excellence recognizes and builds on the values of the FQHC
program, stays within federal limits, and considers the future of the FQHC program in the
current climate. An FQHC investing in this initiative can positively impact the way it is viewed
in the community and within a larger environmental framework. Furthermore, by investing in
diversity, equity, and inclusion as a board of directors, other entities, such as funders, can be
assured that the organization is implementing inclusive strategies and that ensure that all
individuals have access to quality of health care services regardless of their race, ethnicity, and
other socio-demographic characteristics.
GOVERNANCE EXCELLENCE 25

Likelihood of success. Governance Excellence has significant potential to be
implemented on a national scale across FQHCs. The innovative program brings awareness to an
unrecognized social issue, and for FQHCs where it is recognized, an opportunity is presented to
address the problem through a well-developed program. Furthermore, the program brings
forward opportunities to present findings from model implementation in a multitude of ways,
including a webinar series, a pre-conference one-day training, and through a train the trainer
model. Finally, the program is timely in that it addresses racial inequities, a high-profile topic in
today’s society. The certificate of completion can be co-branded with another entity such as
HRSA or an accreditation body, like the National Committee for Quality Assurance (NCQA);
demonstrating to funders and the community the FQHCs commitment to diversity, equity, and
inclusion.
Project Structure, Methodology, and Action Components
Description of Capstone Deliverable
A Technical Assistance (TA) Manual (Appendix D), which includes methodological
tools, has been prepared to demonstrate how the program is operationalized. The target audience
for the TA Manual is program facilitators with the TA Manual linking the user to an online
shared platform, Google Drive, where they can review and download supporting documents for
customization. The TA Manual was validated using focus groups to gather expert feedback, and
tabletop exercises, to obtain insight and to make adjustments to ensure that the program meets its
intended objectives.
Comparative Market Analysis
Governance Excellence has many competitors, who also can be partners, such as the
HRSA, National Association of Community Health Centers (NACHC), state primary care
GOVERNANCE EXCELLENCE 26

associations, such as the California Primary Care Association (CPCA), local consortiums, such
as California Community Clinic Association of Los Angeles County (CCALAC) and the
Coalition of Orange County Community Health Centers (COCCHC), and consulting firms that
provide direct support to FQHCs. These competitors are similar in that they provide formal
governance training and/or technical assistance and support to FQHCs on governance best-
practices. They currently do not focus, however, on improving governance decision making and
policy development through consumer input. Furthermore, they lack resources and support
systems for improving racial inequities on boards of directors.
Marketing and communication, which are built into the innovative program, support
program expansion, and open opportunities to present at conferences, and scale the program to
other populations and geographic regions. Findings from Governance Excellence will initially be
shared with the board of directors and health center senior managers; however, there are
opportunities to disseminate results to garner new board member participation and stakeholder
partnerships. Unless permission is received via formal agreements from each participating board
member, the findings will be de-identified so as not to disclose the name of the health center or
board members.
Abstracts describing the model and results will be submitted for presentation in national
and state conferences This will provide an opportunity to promote the program and develop new
partnerships. Stakeholders, who are essential to the program, will be engaged in the distribution
of findings, and webinars will be offered to share findings with interested parties. Following
initial implementation, additional partnerships may come to fruition, including opportunities to
provide technical assistance and training to FQHC boards of directors and other groups outside
of the FQHC program.
GOVERNANCE EXCELLENCE 27

Project Implementation Methods
The Governance Excellence program can be best described using the Exploration,
Preparation, Implementation, and Sustainment (EPIS) implementation framework (Appendix E)
(Moullin, Dickson, Stadnick, Rabin, & Aarons, 2019). The stages – Exploration, Planning,
Implementation, and Sustainment – are used to assess processes and manage barriers and
facilitators that impact implementation. Each phase considers the inner and outer contexts of the
solution, using a mixed-method approach to measure program readiness and success, and
incorporates implementation strategies. The program implementation timeline is clearly
illustrated in the Gantt chart (Appendix F), which is organized by the EPIS phases. Program
facilitators include a Director of Governance Excellence, who will oversee the program, and
serve as the liaison to health center clients. The program will also include two program
specialists to facilitate program activities and work directly with organizational-clients on
implementation. The EPIS Framework will also be used as an implementation framework for
FQHC boards of directors to implement program components (Appendix G).
Analysis of obstacles and alternative pathways. An obstacle to implementation is
obtaining buy-in from board members and health center senior managers to participate in the
program. Some health center managers use different approaches, not always ethical, to
maintaining consumer-majority boards of directors. For example, an individual may be a non-
consumer board member and be reassigned to a consumer board member slot to meet federal
guidelines by having an appointment at the health center. Other times, for example, consumers
are invited to be on the board of directors solely to meet the requirement and are considered
having less of a role (or encouraged not to participate), which defeats the spirit of consumer
voices. To address these practices, and to introduce new pathways, Governance Excellence
GOVERNANCE EXCELLENCE 28

meets a strategic planning requirement of the FQHC program with the financial cost for
consultation and training the same, if not less, than it would cost to contract with a different firm
to develop the strategic plan for the health center (Crawford, 2011).
Leadership strategies. Leadership strategies consider technical and impact
competencies, including strategic management and community collaboration (The Network for
Social Work Management, 2018). Strategic planning looks at the organization and program and
its relationships to inner and outer contexts, as illustrated in the EPIS implementation model.
Strategic planning and a leadership strategy for implementation also expand the health center's
ability to support a meaningful and inclusive process for addressing diversity, equity, and
inclusion as a board of directors. Furthermore, collaboration strategies include developing new
and building on existing relationships to create a bigger impact as a board of directors on the
patients served and in the community.
Other implementation and leadership strategies, as suggested with the Expert
Recommendation for Implementing Change (ERIC) model, including developing a formal
implementation blueprint (i.e., TA Manual) (Appendix D) that includes distinct goals and
objectives, including defining purpose, content, scope, timeframe, milestones, and performance
measures (Powell et al., 2015). The blueprint, which will be updated based on preliminary
findings, provides a foundation for the program, and allows for scalability in that replicability of
the program will be guided by a blueprint that could potentially be implemented with different
populations of focus and across geographic locations.
Other strategies include the active participation of consumer board members. This
requires ongoing efforts by management staff, as well as clients and stakeholders, to mitigate
barriers to participation and create a level field for training. Facilitation strategies have shown
GOVERNANCE EXCELLENCE 29

improvement in the implementation of programs and practices (Kircher et al., 2014).
Furthermore, facilitated leadership during program implementation supports evidence-based
program outcomes (Hauck, Winsett, & Kuric, 2013).
The final strategy includes obtaining and incorporating consumer feedback during
implementation to ensure the program is meeting its goal and outcome objectives. Consumer
board members will have the opportunity to provide feedback on the implementation process,
which will trigger adjustments, as needed, to ensure program fidelity. A consumer participatory
research model in a community mental health setting, for example, found that by engaging
consumers, they were able to build a successful and sustainable intervention (Iyer, Pancake,
Dandino, & Wells, 2015). Similarly, the program ensures that the intervention addresses baseline
knowledge and stakeholder readiness to aid implementation processes.
Financial Plans and Staging
The financial plans (Appendix H) are organized into a six-month start-up budget and a
12-month operating budget. The balanced start-up budget anticipates $50,473.50 revenue and
expenses, and the 12-month operating budget is estimated at $120,000 in revenue and $116,536
in expenses, with a surplus of $3,466 to be carried over for continued expansion and
unanticipated program support. The primary source of revenue for both budgets are client fees at
$10,000 per FQHC to participate in the program. The start-up budget will use $10,473.50 in
reserve funds from Gary Bess Associates (GBA) that are earmarked for this program. The
innovative program, which is under the auspices of GBA (Appendix I), a for-profit consulting
firm specializing in FQHC program compliance, has the potential to create a positive bottom
line, and capability to grow, reaching new target audiences and regions throughout the country.
GOVERNANCE EXCELLENCE 30

The six-month start-up budget includes operational costs to pilot the program in four
FQHCs, including one-time costs that are necessary to implement the program, such as projector
and laptop. Additional costs are associated with marketing and outreach activities, including
attending professional conferences to bring awareness to the social issue. The 12-month
operating budget, which includes operational costs to implement the program in 12 FQHCs, also
includes costs for marketing and participation in professional conferences. Financial plans
include the process for monitoring efficiency and effectiveness of the program, and also
considers program risks. Furthermore, program outcomes are supported by the financial plan.
These outcome measures, which are based on inputs, activities, and outputs, align with the
program’s goal, which is to attain meaningful participation and inclusion of consumers on FQHC
boards of directors.
Project Impact Assessment Methods
Measurement approach. During the initial phase in which the program will be
implemented in four FQHCs, Governance Excellence will utilize a pre-experimental research
design that will include a pre-assessment and post-assessment. There will not be a comparison
group, but rather all FQHCs will receive the intervention. While this approach can create
challenges to internal validity (e.g., lack of a control or comparison group) and external validity
(e.g., difficulty concluding with a small number of FQHCs observed), a future assessment may
include quasi-experimental or randomized control trials.
A formative evaluation approach will be utilized so that corrections in design can be
made as they become apparent. Modifications to the model will be documented, and will not
impact the summative presentation of findings concerning goals and objectives. The evaluation
will be conducted to determine whether the innovative program, Governance Excellence, is
GOVERNANCE EXCELLENCE 31

meeting its intended goals and objectives. Progressively richer evaluation findings will be used
to refine current program content and processes to improve outcomes.
Outcome measures. Five outcome objectives have been developed to measure change
with regard to important components of the Governance Excellence program model. These
outcome measures align with the program’s goal to improve meaningful participation and
inclusion of consumer board members on FQHC boards of directors. Outcome objectives include
a) increased consumer board members’ feelings of inclusion on FQHC boards of directors by a
minimum of 50%; b) increased numbers of consumers on FQHC boards of directors by a
minimum of 25%; c) increased parity (e.g., race, ethnicity, age) between patient and consumer
board members as a measure of patient representation on board of directors by a minimum of
85%; d) increased numbers of consumer board members that contribute to, and motion for
approval of, decisions at board members by 50%; and e) increased culturally responsiveness,
timeliness, and quality of health care services provided by a minimum of 50%.
Evaluation plan. The program will use a mixed-methods approach to evaluation, which
includes quantitative and qualitative primary data. The Governance Excellence
Inclusion/Exclusion Assessment (Appendix C) will be given to board members as a pre-test and
post-test, as well as 12-months and 18 months post-intervention. The assessment, which was
created for this program, will measure each board member's sense of inclusion on the board of
directors. Furthermore, the Strategic Board Member Matrix (Appendix J) will be completed by
the board of directors as a pre- and post-assessment, as well as at 12-months and 18 months post-
intervention to provide insight into the changes to the board of directors, such as composition,
including the number of consumer board members and the socio-demographic representation of
board members. A patient satisfaction survey (Appendix K), which will be administered at the
GOVERNANCE EXCELLENCE 32

same intervals to provide insight on patients' sense of culturally responsive services provided by
the FQHC, as well as their access to timely, affordable, and quality health care services.
Monthly board meeting minutes also will be analyzed throughout the program to evaluate
changes in board member exchanges and contributions to the deliberation. Finally, the federal
Uniform Data System (UDS) report, which provides data on the previous year's patients, will be
required before the start of the intervention, and the Strategic Board Member Matrix will be
completed and compared before and after the program has been implemented. A final evaluation
survey (Appendix L) will be distributed during the last session to gather information from
participants pertaining to the effectiveness of the consult so as to inform future programming.
Stakeholder Engagement Plan
Internal stakeholders. FQHC boards of directors (consumers and non-consumers) and
health center senior managers (e.g., CEO, CMO, CFO) are the primary internal stakeholders. The
intervention is designed to address and change social norms regarding meaningful participation
and full inclusion of members on the board of directors, which can, in turn, improve the quality
of health care and patient engagement in their health care (County Health Rankings &
Roadmaps, 2020). Other internal stakeholders that are involved in the problem include
organizational staff in that directives approved by the board of directors would impact their
role/responsibilities, and may also create changes in policy and protocols. Finally, patients are an
essential internal stakeholder in that changes to policy and practices can improve current
operations, thus ensuring that services are responsive to their needs.
External stakeholders. HRSA, NACHC, state associations, such as CPCA, and local
consortia, such as CCALAC and COCCHC are important external stakeholders. To expand the
program to new geographic locations, these partners are essential to the process, and by
GOVERNANCE EXCELLENCE 33

leveraging their networks, there is an opportunity to bring more awareness to the social problem.
There also are opportunities to co-brand the program so that when FQHC boards of directors’
members complete the program, they will be recognized, demonstrating their commitment to a)
meeting FQHC program requirements; b) prioritizing diversity, equity, and inclusion practices
that address racial inequities; and c) demonstrating meaningful participation and inclusion of all
board members in the decision making and policy development process. Finally, there are
opportunities to engage other community advocacy groups whereby the program can be
customized to meet the needs of boards of directors outside the FQHC system.
Communications Strategies and Products
The marketing and communications strategy (Appendix M) has a strong positive impact
on internal and external stakeholders. To reach internal stakeholders, the proposed
communications plan, includes three phases 1) communication and outreach through social
media outlets, including Facebook, and YouTube; 2) communication and outreach through
FQHC Distribution List, where the primary contact for each FQHC is public information; and 3)
event sponsorships with state and national stakeholders through advertising.
Each phase will focus on a different aspect of the social problem to raise awareness of the
issue. The first phase will raise awareness of the social problem through the current use of data
and opportunities to improve consumer voice which in turn will improve current practices. The
second phase will focus on increasing the number of organizations and individuals that have
expressed interest in the program, Governance Excellence. The third phase will increase the
number of FQHC boards of directors participating in the program.
It is also anticipated that interest and participation will come through referrals from
health centers and internal and external stakeholders affiliated with them. Studies suggest that the
GOVERNANCE EXCELLENCE 34

liking rule (e.g., people or organizations that are trustworthy and overall likable) and authority
principle (e.g., people or organizations who are known for their expertise) are effective strategies
to gather long-term support and "buy-in" (Cialdini, 2009).
To reach external stakeholders, the marketing and communication strategy will include
two phases: 1) outreach to HRSA, NACHC, CPCA, CCALAC, and COCCHC to bring
awareness to the social issue, and to discuss opportunities to i) share this information through
their networks; and ii) partner with them on governance training activities; and 2) submit
conference abstracts to present at state and national conferences that include NACHC, CPCA,
the National Network for Social Work Management (NNSWM), Community Catalyst, Center for
Care Innovations, the National Association of County Behavioral Health and Developmental
Disability Directors (NACBHDD), and the National Association for Rural Mental Health
(NARMH). These activities will begin during the start-up phase of this program, as it is
anticipated that additional opportunities and partnerships will support program expansion within
and outside the FQHC system.
The capstone components, as a collection, are a solution to mitigating social norms. The
TA Manual is organized into eight sections titled Executive Summary, Company Overview,
Program Description, Inclusion/Exclusion Assessment, Operating Plan, Evaluation Plan,
Marketing and Communication Plan, and Implications. These are followed by the Appendices
that include templates and forms necessary to effectively implement the program. Templates, and
other supporting documents, can also be downloaded from an online file sharing system, Google
Drive, for the program facilitator to customize documents for each client and each session.
Following the pilot, additional adjustments will be made to the TA Manual, including the
addition of supporting documents, before the program's first full year of implementation.
GOVERNANCE EXCELLENCE 35

Ethical Considerations
The primary ethical concern is confidentiality. The boards of directors and health center
senior managers will partake in activities that will request feedback and input from all board
members on their perception of inclusion in board activities. Some feedback may be surprising to
participants. While the Governance Excellence Inclusion/Exclusion Assessment is anonymous,
due to the small size of some boards of directors, board members may be concerned that other
participants will recognize their responses.
To address these concerns, anonymous responses will only be shared with GBA for
analysis. The data will be summarized by the board of directors, as a group, as well as comparing
consumer and non-consumer responses. If by chance the board of directors only has one or two
consumer board members (which is not a compliant board), program facilitators have the
discretion to not share specific findings or to not organize the information in a way that
participants would be able to discern who completed the responses.
Other ethical challenges include FQHC boards of directors that are aware of the social
issue, and decide not to change their exclusionary practices, and are using this program as a
vehicle to meet program requirements or to receive a certificate of completion. One strategy to
address the ethical issue is to have the program outputs, which include the development of
policies, procedures, and strategies to improve the meaningful participation and inclusion of
consumer board members, be a requirement to completing the program, which in turn, would
include a certificate of completion. Furthermore, future expansion of the program will consider
renewal courses, or report every few years, on meeting goals outlined in the board-approved
documents.
Conclusions, Actions, and Implications
GOVERNANCE EXCELLENCE 36

Summary of Project Plans
The next step for Governance Excellence is to identify four FQHCs for the start-up
phase. The four FQHCs will be located in Los Angeles County in southern California, and the
recruitment phase is anticipated to take 30 days. Once the four FQHCs are identified, the pilot
program, which is implementation ready, will begin, which is estimated to be in the latter part of
2020. At the same time, additional meetings and networking opportunities will take place to
promote the program and gather support from organizations, including elected and appointed
officials and consumer and health care advocates. Abstracts will be submitted for conferences in
fall 2020, and throughout the calendar year 2021, to promote the initiative and garner additional
support to increase awareness about the issue and the first-of-its-kind program.
The long-term plan for the program is to continue to expand to other geographic regions.
Partnerships will be explored with internal and external stakeholders to take the program to new
FQHC markets, as well as partnerships with HRSA and NACHC to provide customized technical
assistance that establishes GBA as an expert in FQHC governance. Furthermore, the long-term
vision is to expand the program outside the FQHC system. Following the development of
additional partnerships, the TA Manual will be modified for other boards of directors, including
advisory councils.
Current Practice Context for Project Conclusions
There continues to be a significant health care gap, and racial inequities, in the United
States, which impact access to culturally responsive, affordable, and timely health care services.
The low-income, uneducated, and uninsured populations in the United States are not valued
members of society, which may result in access to fewer resources for this population. Without
consumer voices, this aspect of a Grand Challenge will go unaddressed. The mechanism is in
GOVERNANCE EXCELLENCE 37

place for consumer’s voices through their required involvement on FQHC boards of directors. A
consumer's ability to fully contribute; however, is often blocked by the prejudicial social norm
that consumers have less to give to the health center and that they lack ability to make well-
informed and educated decisions.
Many FQHCs thus do not have a compliant board of directors where consumer members,
as a group, truly represent patients served by sharing descriptive factors, such as age, race, and
ethnicity. Governance Excellence addresses this social problem by offering a governance model
that embraces diversity, equity, and inclusion, and is implemented through consultation and
training on the recruitment, onboarding, continuing engagement, and retention of consumer
board members. While the next steps are to pilot the program in four FQHCs, the program has a
detailed plan that is operational, as well as financially sustainable, ethical, and politically timely.
The implications of Governance Excellence are considered at the micro, mezzo, and
macro levels (Appendix N). The program puts consumers at the forefront, ensuring that their
voice is heard and that they are experiencing meaningful participation and inclusion.
Furthermore, ensuring that FQHC boards of directors are effectively responsive to patients and
their needs, means that consumer leadership is an indispensable component. When it comes to
addressing social problems, social workers have analytical and interactional skills, in-depth
knowledge, and training that support individuals, families, and communities, and are able to
address bio-psychosocial issues that impact health and well-being (NASW, n.d.). In a macro
setting, social workers help board members and managers understand the culture of the
organization and the board of directors, and offer orientations and training to new and current
board members (Law & Saunders, 2015). Law and Saunders (2015) note that "social workers can
also focus on the group process within a board and educate members about group dynamics,
GOVERNANCE EXCELLENCE 38

diversity, bias, and related topics" (p. 16). These are critical topics where inclusion, equity, and
diversity within boards of directors can be added and will demonstrate the alignment between the
Grand Challenges and the social problem. Using social workers to address the social problem
from a micro, mezzo, and macro systems approach, the program has the resources and mindset to
improve health care by ensuring that services are offered to the people, for the people, and by the
people, and that meets the health care needs of residents served by FQHCs.
Project Limitations
There are limitations to the program's evaluation design. The Governance Excellence
Inclusion/Exclusion Assessment that was created for this program has face validity but lacks
other measures of reliability and validity. Once the program is implemented; however, research
can be conducted to determine the reliability and validity of the assessment tool with FQHC
boards of directors, as well as with other participating bodies. Furthermore, the data collection
tools are self-reported by the participant, which can compromise the reliability of the information
provided.
There is also limited research on FQHC governance, including the effectiveness of
consumers on boards of directors. A majority of the available research regarding FQHC
governance is nearly 10 years old. Implementation will open up opportunities to conduct
research studies in partnership with academic researchers to understand the current FQHC
governance environment. Furthermore, it opens up opportunities to learn best-practices from
FQHCs that have efficient and effective boards of directors that have a consumer majority, and
are diverse, representing patients served by the health center. These best practice findings can be
incorporated into the program model.
Concrete Plan
GOVERNANCE EXCELLENCE 39

The sequential components of Governance Excellence create a concrete, actionable plan
that is ready to be shared with internal and external constituencies responsible for program
implementation. The plan includes steps for advancing the program beyond the pilot through the
first 12-month period in which 12 FQHCs will be enrolled. Finally, the program has strategies
for promotion and implementation beyond its first full year of operation as it becomes a
sustainable initiative that will benefit FQHCs and other consumer-responsive systems for years
to come.

GOVERNANCE EXCELLENCE 40

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47

Appendix A
Key Informant Interview Takeaways and Interview Questions
Table 1: Interviews with Key Takeaways
Title Expertise Key Takeaways
Chief Executive Officer
Key manager of FQHC (special emphasis
on homeless population).
• Consumer board members are not always well
educated on their roles/responsibilities.
• Wish board members (specifically consumer
members) were more engaged in decision
making.
• A consumer board member has never been an
officer of board of directors (BOD).
• Tremendous benefit in having consumers
participate; provided an example when patient
experience influenced a decision to hire child
psychologist.
• Some health centers have patient advisory
boards that reports to full BOD. Still have a
consumer-majority BOD (required by HRSA).
• Provides quarterly trainings to BOD on
understanding financials, etc.
• Current BOD guide offered by HRSA is
outdated. Needs to be revised. Not compliant.
• HRSA documents are at a high level, incl.
attorney language. Health center required to re-
write in an easier to read/understand format.
• HRSA documents only available in English.
Health center required to translate.
• Building relationships/rapport with each board
member individually is an important piece of
having a successful BOD.
Chief Executive Officer Key manager of FQHC.
• Is aware of FQHCs that find the board members
they want, and then make them patients (not
always providing patient
experience/perspective, as required by HRSA).
• The Executive Committee does not have any
consumer board members. There currently isn’t
an officer of the board that is also a consumer.
• Lack of consumer engagement on board.
• Barriers don’t just exist for consumers, but also
non-consumers who have experience outside
the health industry.
• Trying to find consumers to participate on BOD
is a challenge.
• Building a relationship with each board member
individually is important.
Chief Executive Officer
Key manager of FQHC since it became an
FQHC.
• It’s important to build relationships with your
board members.
• Trust and respect are also key. They trust me to
make decisions on behalf of the health center.
• Important to get different perspectives.
• HRSA needs to provide materials for new board
members that health center can adopt.
• Allow board members to participate in
NACHC, or other organizations that can boost
their knowledge on governance.
48

Chief Executive Officer
Key manager of FQHC since the inception
of the health center.
• As a CEO or new CEO to a health center, it is
important to reach out to other community
agencies who have existing many years to learn
about the community, and need for services,
etc.
• Challenge with some board members not
having an e-mail or access to a computer. In
response, will print documents and mail to
BOD. Or, will call them directly to let them
know about BOD meeting, and/or documents to
review ahead of time.
• HRSA documents are at a high-level. CEO
takes the documents, and revises them to be at a
“third-grade” reading level to accommodate all
BOD.
Professor
Researcher on FQHC consumer
governance.
• Academic perspective looking at the broader
field of consumer and public involvement in
health care is that it is not valued in the United
States.
• There is concern that consumers are required to
steer and make decision on multi-million-dollar
organizations (at times).
• Does it need to be consumer-majority or
“tokenism” – including just one or two
consumers instead of majority ownership.
• More research needs to be done to confirm is
consumer majority BOD effective. And if so,
why? And, why is it effective with some health
centers, and not others? What are the best
practices in implementing/sustaining consumer-
governance?
FQHC Consultant
Expert in HRSA Health Center
Governance.
• The concept of FQHCs came from a model
called Community-Oriented Primary Health
Care (COPC) in South African in the
1950s/60s.
• Initially came out of the Office of Economic
Opportunity (OEO), which has since dissolved,
to promote workforce development.
• Materials, toolkits, trainings are key for
effective consumer-majority governance.
• Procedures need to be in place on how to recruit
board members, and support board members
who do not speak English as their first
language.
• Succession planning is an important piece of
FQHC boards of directors. It’s a big role to fill
to figure out what would happen, and being
able to sustain the health center should the CEO
no longer be in his/her role.
FQHC Consultant
Expert in Health Center Governance.
Currently an interim-CEO at a health
center, and travels around the country
providing governance training.
HRSA consultant doing FQHC
governance audits.
• Three common challenges with BODs: 1) don’t
understand roles/responsibilities; 2) do know
their roles/responsibilities; 3) board that knows
what they’re supposed to do, but chooses not to
do it.
• Often times BODs do not have board packet,
manual, or clear expectation on file.
• Best practices for engagement: have the request
for consumer feedback on monthly agenda;
49

raise your fingers, response on 3.5 cards, and
other activities that require all to participate.
• Understanding cultures and diversity is
important to be affective.
• Don’t assume non-consumer board members
understand their roles/responsibilities, process.
• Make good use of Committees.
• Have mentor relationship between BOD. Hard
to manage, but has been effective.
• Switch the discussion to not think about what
they are not bringing to the table, but say, “what
are they bringing to the table?”
• Having good running board meetings (monthly)
and finding ways to involve all members is key.
FQHC Consultant
Interim Director for the Bureau of Primary
Care, FQHC CEO experience
• The Migrant Health Act required consumer-
majority governance prior to Public Health
Services Act.
• BODs have a lot of business to conduct
monthly, but they won’t be successful without
training.
• You have to have local education to the health
care delivery system in your community. For
example, Medi-Cal can play out differently in
different communities.
• Offer child care, dinner, provide entertaining
training/seminars is important.
• If you don’t invest in your board of directors, it
will struggle, and your health center will
struggle.
• HRSA should require that health centers have
an education plan outlined for all members.
Patient Board Member
Experience/perspective from being on a
FQHC board of directors
• As a board member for more than 9 years, I
know a lot of the staff. However, I make it a
priority to sit in the waiting room when waiting
for an appointment and don’t always talk with
the staff because I want to make sure I
understand what all patients experience.
• Based on experience, I advocated for ways to
improve wait times.
• More trainings are needed. Technology is
changing, and it is hard to keep up. Training on
technology.
• Some board members don’t have access to e-
mail.
• Documents need to be translated into multiple
languages.
• Being on the BOD can be intimidating.
• It is important to have a mentor, someone on
the board that you can lean on if you have
questions, and don’t want to bring it up to the
entire board.
FQHC Consultant/Non-
Consumer Board Member
Contributed to Public Health Services Act
legislation, including FQHC governance
requirements; Current Non-Consumer
Board Member
• Consumer-governance provided power to the
people. Important during the War on Poverty
and Watts Riots in 1960s.
• There were major advances in health care when
Republicans were in charge. Democrats went
after new appropriations, and when Republicans
50

were in charge, people looked at new ways of
doing things with current resources.
• Culturally responsive materials, including
material in multiple languages is needed. It used
to be available by HRSA, but it is outdated.
Board Member (NACHC) and
Health Center Board Liaison
Participated on consumer advisory board
to full NACHC Board of Directors, and
acted as BOD liaison of a health center.
• Consumers have provided insight into the
process of transitioning from Medi-Cal to
Medicare, the need for more assistance on
eligibility
• Health center did not specialize in geriatrics,
and consumer BOD discussed important health
needs.
• NACHC used to have a Board Boot Camp – 3-
day event in conjunction with large conference.
Open to BOD and health center staff.

51

Table 2: Interview Questions
1. How long have you been on the FQHC board of directors?
2. What kind of training, education, and/or orientation did you receive during your introduction
to the board of directors?
3. How were you recruited to be a board member?
4. Can you tell me about a time where your voice was heard? Can you tell me about a time
when your voice was not heard?
5. Do you feel encouraged to contribute your perspective at board meetings?
6. How long have you been a patient of the health center?
7. Please tell me a time when your experience as a health center patient informed your Board
decision-making process.
8. What types of guidance and/or technical assistance do you provide to health centers on
consumer-majority board of directors’ best practices?
9. What kinds of questions do are asked about how best to implement a consumer-majority
board of directors?
10. What are the reasons that legislation was adopted on consumer-majority boards of directors
for the FQHC Health Center Program?
11. Do you think this mandate is making a difference for FQHCs in how they operate, make
decisions, etc.? What are ways (e.g., policy development, training, education) where more
resources could be provided to improve implementation?
12. How long have you reported to a consumer-majority board of directors?
13. What is your experience reporting to a consumer-majority board of directors?
14. Are you currently conducting research related to consumer-majority board of directors?
15. What do you see are the most common challenges/barriers for health centers when addressing
the consumer majority requirement?
16. In your experience, what is the best advice that you can provide to health centers that has a
consumer majority board of directors?
17. Are there others with whom you think I should speak to better understand consumer-majority
boards of director?
18. Is there anything else you would like to share with me regarding consumer-majority board of
directors?
19. Does a patient board member currently, or have in the past, held an office position on the
board (e.g., chair, co-chair, secretary, treasurer)?
20. What types of decisions do the board of directors make?
21. What is the process that the board of directors go through to make a decision?
22. How are board members selected?
23. In what ways do you think patient board members are treated the same and/or differently?
24. Do patient and non-patient board members have the same roles and responsibilities?
25. Do you think in general there is a lack of patient representation and inclusion on board of
directors? If so, why?
52

Appendix B
Logic Model
INPUTS ACTIVITIES OUTCOMES
What we invest What we do Who we reach Short-term results Intermediate results Long-term results
• For-profit FQHC
consulting firm
• Expertise in
FQHC Health
Center Program
requirements
• Strong network
of FQHCs as
existing clients
• Relationship
with system
partners
• Existing staff
capacity
• Interested
parties
• Six sessions (focus areas)
• Three onsite trainings
• Six virtual meetings
• Ongoing technical assistance
• HRSA Governance
Compliance Training
• Templates and resources
(e.g., Board member
composition matrix;
recruitment worksheets;
recruitment plan template;
facilitation questions) to
support meaningful
participation and inclusion.
• Develop board-approved
policies and procedures that
support and promote
diversity, equity, and
inclusion among board
members.
• Develop board-approved
strategies to increase parity
in representation between
patients and consumer board
members.
• Develop board-approved
consumer recruitment and
retention plan
• FQHC Boards
of Directors
(BOD)
• Health Center
Patients
(Consumers)
• FQHC
Management
Staff
FQHC will:
• identify ways to
promote consumer
board member
participation &
inclusion
• be motivated to
promote diversity,
inclusion, and equity
among BODs
• increase awareness
of current parity --
patient socio-
demographic
characteristics and
that of the BODs
FQHC will:
• development of board-
approved recruitment and
retention plan whereby
consumers are educated on
their role/responsibilities
• development of board-
approved policy/procedures
on diversity, equity, and
inclusion
• development of board-
approved strategies to
ensure parity among BOD
and patient descriptive
characteristics
• Understanding of health
center program
requirements
FQHC will:
• increase consumer
board members
feelings of inclusion
by 50%
• increase number of
consumers on BODs
by 25%
• increase parity
between health
center patients and
consumer board
members by 85%
• Increase in the
number of consumer
board members who
contribute to, and
motion for approval
of, decisions at board
meetings by 50%
• increase in culturally
responsive, timely,
and quality health
care services for
service area patients
by 50%
Assumptions
• Common challenges/concerns across FQHCs with regard to consumer
board member participation and inclusion
• FQHC BODs and executive staff will be motivated to improve
participation and inclusion of board members to support meaningful
leadership.
External Factors
• (+) Health Resources & Services Administration (HRSA) requires FQHCs to have a
consumer-majority BOD in order for them to become and sustain their
designation.
• (-) HRSA, state associations, and other stakeholders may be interested in
developing a similar resource to support consumer participation/inclusion.
53

Appendix C
Governance Excellence Inclusion/Exclusion Assessment

To request a copy of the Governance Excellence Inclusion/Exclusion Assessment, please contact
Katie Strautman at katie@garybess.com

54

Appendix D
Technical Assistance Manual

To request a copy of the Technical Assistance Manual, or to arrange for a board consultation,
please contact Katie Strautman at katie@garybess.com

55

Appendix E
EPIS Implementation Framework
Exploration Phase
• Key Informant Interviews
• Literature Review
Preparation Phase
• Development of Program Material
• Tabletop Exercises
• Development of Inclusion/Exclusion Assessment
• Technical Assistance Manual
Implementation
• Conference Presentations/Poster Sessions
• Marketing/Communication Campaign – Brining Awareness and Knowledge to Social
Issue and Solution
• Identify FQHC Boards of Directors to Participate in Pilot (4 FQHCs)
• Pilot in 4 FQHCs
• Identify FQHC Boards of Directors to Participate in First Full Year (12 Months)
• Pilot in 12 FQHCs
Sustainment
• Copyright Program Material
• Identify and Pursue Sustainable Funding Sources
• Increase Internal Capacity
• Submit Abstracts to Journals
• Marketing/Communication Campaign – Bring Awareness and Knowledge to Social Issue
and Solution

56

Table 3: Barriers and Facilities to Inner/Outer Context

•Outer Context
•Barrier: Lack of Policies/Resources Related to
Consumer Governance; Understanding Existing
Social Norms
•Facilitator: Relationships with National, State,
and Local Stakeholders
•Inner Context
•Barrier: Organizational Structure
•Facilitator: Perceived Need for Change
Exploration
•Outer Context
•Barrier: Continued HRSA Program Funding
•Facilitator: Continued FQHC Program Growth
•Inner Context
•Barrier: Organizational Capacity
•Facilitator: Leadership; Culture Embedding
Preparation
•Outer Context
•Barrier: Changes on Boards of Directors and
Key Management
•Facilitator: Stakeholders; Referral Source
•Inner Context
•Barrier: Organizational Characteristics-Model
•Facilitator: Experienced Staff - Rapport with
FQHCs
Implementation
•Outer Context
•Barrier: Funding; FQHC Program Changes
•Facilitator: National Priorities/Initiatives in
Health Care
•Inner Context
•Barrier: Staffing- Capacity/Training
•Facilitator: Existing Staff Expertise/Partnerships
Sustainment
57

Appendix F
Gantt Chart Timeline for Program Implementation

58

59

Appendix G
EPIS Framework for Health Center (FQHC) Implementation

60

61

Appendix H
Financial Plans

To request a copy of the start-up and 12-month operating budget, please contact Katie Strautman at
katie@garybess.com

62

Appendix I
Organizational Chart
Principal
Co-Principal
Grant Writing
Director of
Grant Writing
Grant Writers
Program
Evaluation
Director of
Program
Evaluation
Program
Evaluators
Governance
Excellence through
Consumer Voice
Director of
Governance
Excellence
Program
Specialists
63

Appendix J
Strategic Board Member Matrix

To request a copy of the Strategic Board Member Matrix, please contact Katie Strautman at
katie@garybess.com

64

Appendix K
Patient Satisfaction Survey

65

66

67

68

69

Appendix L
Final Evaluation Survey
70

71

72

Appendix M
Marketing and Communication Strategy
Strategy Primary Audience Timeline
Communication and outreach through social media
outlets, including Facebook, and YouTube
• Federally Qualified Health Center (FQHC)
Senior Managers (e.g., CEO, CFO, CMO)
• FQHC Board Members (consumer and non-
consumer)
July and August 2020

National Health Center Week is August 9 – 15, 2020
Communication and outreach through FQHC
Distribution List, where the primary contact for
each FQHC is public information
• Federally Qualified Health Center (FQHC)
Senior Managers (e.g., CEO, CFO, CMO)

CY 2021

National Health Center Week is August 9 – 15, 2020
Annual and event sponsorships with state and
national stakeholders through advertising.
• Federally Qualified Health Center (FQHC) Senior
Managers (e.g., CEO, CFO, CMO)
• FQHC Board Members (consumer and non-
consumer)
CY 2021
Outreach to federal, national, and state primary care
and local consortium partners to:
1. Share information through their networks.
2. Partner on governance training activities.
• Health Resources and Services Administration
(HRSA)
• National Association of Community Health
Center (NACHC)
• California Primary Care Association (CPCA)
• California Community Clinic Association of Los
Angeles County (CCALAC)
• Coalition of Orange County Community Health
Centers (COCCHC)
• Federally Qualified Health Center (FQHC) Senior
Managers (e.g., CEO, CFO, CMO)
September 2020 – December 2021

National Health Center Week is August 9 – 15, 2020
Submit conference abstracts to present at national
conferences.
• NACHC
• CPCA
• National Network for Social Work Management
(NNSWM)
• Community Catalyst
• Center for Care Innovations
• National Association of County Behavioral
Health and Developmental Disability Directors
(NACBHDD)
• National Association for Rural Mental Health
(NARMH).
CY 2021

73

Appendix N
Micro, Mezzo, and Macro Framework
(Theory of Change)

Abstract (if available)

Abstract The lack of diversity, equity, and inclusion on Federally Qualified Health Center (FQHC) boards of directors, which by designation are required to have majority consumer (patient) board members, is an important and often unrecognized social issue in today’s society. Strategies to promote consumer voice in organizational decision making and policy development is imperative for improving health care access for low-income, impoverished communities. Through the development of a first-of-its-kind program, referred to as Governance Excellence through Consumer Voice, technical assistance and training are now available to address the lack of meaningful participation and inclusion of consumers on FQHC boards of directors, ensuring that services are responsive to the needs of the patients and community served by the health center. The innovative program is designed to question social norms and adds a deviant that addresses diversity, equity, and inclusion among board members within a variety of organizational contexts, as the service recipient population is often not treated equally or considered valued members of society.

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University of Southern California Dissertations and Theses

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Asset Metadata

Creator Strautman, Katie (author)

Core Title Governance Excellence through Consumer Voice

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Publication Date 10/28/2020

Defense Date 08/11/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag access to care,Board of Directors,community health centers,consumer majority,Consumers,diversity,equity,governance,health,health care,health care consumers,inclusion,OAI-PMH Harvest

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Manderscheid, Ron (committee chair), James, Jane (committee member), Orras, George (committee member)

Creator Email katie@garybess.com,kstrautm@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-387241

Unique identifier UC11666566

Identifier etd-StrautmanK-9074.pdf (filename),usctheses-c89-387241 (legacy record id)

Legacy Identifier etd-StrautmanK-9074.pdf

Dmrecord 387241

Document Type Capstone project

Rights Strautman, Katie

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA