Harris Health System has provided a healthcare safety net to the Houston area’s most vulnerable populations since 1965. That was when Harris County Commissioners appointed the Harris Health System Board of Trustees to be stewards of the health system. For years, the board executed their duties by simply reviewing materials from management, approving the minutes and financials from the past meeting, listening to historical reports from management, and, occasionally, making decisions that were important for the future of the organization. This left the board entrenched in an outdated mode of operation that lacked the strategic thinking needed to address the evolving healthcare environment. CEO George Masi saw that a broader perspective and more efficient decision-making were both necessary to ensure Harris Health’s continued effectiveness and long-term viability.
As part of the efforts to make changes, Nicole Streeter was promoted from director, board affairs to vice president, chief governance officer to advise and support the board chair and the CEO in establishing an intentional governance structure. Her background as a William Randolph Hearst Philanthropic Fellow at the Indiana University Lilly Family School of Philanthropy and experience working with a variety of mission-driven organizations and their boards had helped prepare her to assist in driving this dynamic shift. A major part of her responsibilities was to educate Harris Health’s board members on how to change priorities and why the transformation was so critical.
“The fiduciary mode of governing is about stewardship of the tangible assets and risk mitigation,” Streeter says. “The board was actively engaged in operational oversight, which fulfilled their fiduciary responsibility. But we needed a generative approach that would creatively focus on identifying what questions needed to be asked to clarify the vision for the future of the organization.”
As expected, there was some resistance to making changes. Several of the volunteer board members had served for decades, and it wasn’t surprising that they had become accustomed to a particular process and focus in their work.
To help persuade them of the value and importance of adapting to the new approach, Streeter worked with the CEO and the board chair to develop an authority matrix that detailed the board’s governance responsibilities and laid out a codified process for executing them, including delegating some tasks to internal stakeholders. For example, the board identified routine items related to operational oversight that could be approved as consent agenda items. Grants and contracts under a specific threshold would be handled by the CEO rather than being subject to board review and approval as they had in the past. This made valuable meeting time available for engaging in generative and strategic discussion.
“The authority matrix was an aha moment for the board members,” Streeter says. “Once they had a formal structure with a master calendar and mechanisms in place to help execute their fiduciary roles, they began to embrace the idea of letting go of managing operations and, instead, guiding the organization through generative discussion and strategic planning.”
Completing the transition took about two years and included a number of additional steps: the executive staff began tracking board decisions and presenting that record back to the board, which helped keep subsequent actions consistent and aligned with other strategic plans; a new governance committee was created; the board reduced the frequency of its monthly meetings, which helps provide clearer perspectives to recognize and address broader trends; a governance retreat is held annually; and, in keeping with the new focus, the board’s name has officially changed from Board of Managers to Board of Trustees.
The County Commissioners Court also recognized the need to revitalize the board. It has appointed six new members—out of nine—in the past two years. Streeter works with the Court on an ongoing basis so it can recruit members with the experience and expertise needed to address Harris Health’s current strategic needs and priorities.
And the board’s transition has created tangible results. In addition to reaffirming its mission, Harris Health’s finances have improved. This is due, in part, to an organizational realignment and utilizing county funding more efficiently. The organization has just been given a mandate by the Commissioners Court to provide medical care to the area’s incarcerated population and to improve access to behavioral health care across the county.
This all supports Harris Health’s original mission—to provide care to Harris County residents who are most in need. In this regard, the organization not only acts as a care provider, but also makes extensive referrals to address other associated issues, such as food insecurity and violence. It staffs a case management department of nearly two hundred to handle such wrap-around services.
“We’re in a position to take on larger initiatives,” Streeter points out. “We can engage with key community stakeholders, convene focus groups, and draft plans to implement what they need from us.”
Streeter now works with CEO George Masi to maintain the board’s forward-looking vision and the resulting improvements. She continues to draw on her previous mission-driven and board-related experience, which helped her develop skills in cultivating personal relationships and understanding the expertise and drivers of the people she engages with.
“Getting the right people in the right positions is critical to help move the organization forward and to ensure transparency, accountability, and to enhance public trust,” she says. “But it’s also important to understand board members’ personal motivations and to structure our relationships so they benefit from the experience as much as we do.”