Say you wake up one morning and notice the hospital system you run isn’t keeping pace with the breakneck changes in health care. You look upon the new day blessing the community you serve and conclude the system could soon fail unless you fix it. Over breakfast (something sensible – half a grapefruit, cereal with 2 percent milk, coffee) you suddenly see all: Medicine over the last century has been revolutionized. Paying for that care, ditto. But the oversight of the hospital – its governance – has hardly changed at all. Aha!

So what would make for better governance? “Lots of openness and accountability, with people the community knows and trusts making the decisions,” says Rick Wade, a senior vice president of the American Hospital Association. “You must make certain the voice of the community is maintained, and you need new and unique ways to keep the community involved.”

This accountability is especially important where the hospital network is also both the major employer and the economic generator of the region, as Eastern Maine Healthcare assuredly is here.

Mr. Wade says the current model of community boards – the one at EMH has 500 corporators – was fine when everyone would get involved in supporting the hospital and the community being served was smaller. Now the model is unwieldy in part because of the many complicated changes in medicine and health-care financing. Corporator boards may need reform, but when you finish reforming, advises Mr. Wade, the public should say, “It’s still our community hospital.”

Health care consultant James Orlikoff has been working with the administration of Eastern Maine Healthcare since, fatefully, Sept. 11, 2001, to streamline the governance of the organization. Where he sees corporator boards, he sees surgery. He has tried to cut them from 50 hospital systems, he estimates, and has been successful 20 times. He doesn’t like these boards; in fact, fewer boards of any sort is usually better, he says. Advisory councils aren’t too bad. But corporator boards? Yank ’em like a ruptured appendix.

Primarily, that would mean persuading corporators to demote themselves, from overseeing board appointments for Eastern Maine Healthcare to watching only the local Eastern Maine Medical Center and Acadia Hospital as EMH becomes Eastern Maine Healthcare Systems to reflect the fact that its network covers two-thirds of the state. Corporators are not eager to do this.

Trust seems to be the key to this reform, so I asked Mr. Orlikoff the other day to characterize the level of public trust for Eastern Maine’s management. “The low end of normal,” he said.

That can’t be good. How about the amount of community tension over the reform? “The 90th percentile,” he said. “This tension is everywhere, but it’s particularly high in Bangor.” He mentioned it could be worse. One board he worked with had received death threats. So that’s something, anyway.

Mr. Orlikoff said the low level of trust “could have a significant potential to damage the [health care] system.” Nevertheless, corporators shouldn’t have appointment control over the parent board, he said, because they no longer represent the regional coverage area for the system, don’t sufficiently understand the challenges pounding hospitals from the government, patients, insurers, the uninsured, doctors, standards organizations, etc., and are too susceptible to public pressures, appointing trustees who will promise what is not in the community’s interest to have its hospitals deliver. They create inefficiency when hospitals are being forced to become ever more efficient to survive and they do not add accountability because public regulators watch hospitals closely and lots of information about private nonprofit hospitals is available electronically to the public.

I don’t doubt that Mr. Orlikoff has a point in his list of charges against the corporator model. Nor do I dismiss his assertion that some of the tension and lack of trust is produced by some physicians trying to protect turf. Nor do I doubt that the press can get overexcited at the smell of a story or that the government shortsightedly overtaxes hospital resources. All likely true and all not the primary problem.

The problem, I think, is this: Eastern Maine Healthcare System officers must run their hospitals with a corporate model befitting the 6,000 people they employ in the most complex of industries. Yet they must respond at the most local level, the level that allows the public to trust that this corporation will be intimately ours when we are most vulnerable; ours when our children are sick and in pain, when our parents are dying.

To an important degree (I’m not good with percentiles) Eastern Maine has failed to convey that idea in recent years. It should be of intense interest to its board to figure out why. Because if Mr. Orlikoff is correct, and these governance changes are crucial but are being resisted by corporators – perhaps because of this low level of trust – then a reform of a different sort is required for the system’s survival. One, for instance, that highlights greater openness and accountability. For board members not to pursue such a change to avoid the harm envisioned by Mr. Orlikoff would be against the best interests of the community and antithetical to their being on the board.

The idea behind a good system, Mr. Orlikoff reminds his clients, is that “no piece of the system is as important as the whole system.” That means hospital officials have some pieces to reconsider and perhaps an “Aha!” of their own.

Todd Benoit is the editorial page editor of the Bangor Daily News.