Quality improvement leaders should strive for a working relationship with hospital boards of directors and help the members gain the knowledge necessary to be meaningful champions of quality initiatives. However, that does not mean that board members should be expected to participate in the day-to-day efforts to improve quality and patient safety.
While there is no standard for what board members should know about quality, those who understand quality improvement issues make a more meaningful contribution to the hospital, says Patricia McGaffigan, RN, MS, CPPS, vice president of safety programs with the Institute for Healthcare Improvement in Boston.
“More engaged boards and boards that are involved in ensuring that patients are free from harm probably do a lot more conscientious work in their board meetings on safety and quality,” McGaffigan says.
In a recent report, McGaffigan and her colleagues surveyed a sample of board members and CEOs about their knowledge, understanding, and board activities related to safety and quality, and also asked unpaired safety and quality leaders (SQLs) what they thought of their own boards’ knowledge, understanding, and activities related to safety and quality. They found that the board members and CEOs had similar patterns of self-reported knowledge, understanding, and activities related to safety and quality, but SQLs reported lower evaluations of their own boards and CEOs.
The results suggest room for improvement in governance and leadership practices at board meetings, the authors concluded. (An abstract of the report is available online at http://bit.ly/2sUKVXh.)
“Quality improvement and safety professionals can ask themselves if their board activities are consistent with what we think might be best or better in practice. Do we always have quality and safety meetings on the board agenda, for instance?” McGaffigan says. “Sometimes, quality professionals don’t have great presence with their boards, and our research suggests that the board usually will benefit from more exposure to quality concerns, and by extension so will the hospital and patients.”
Don’t Have to Be Experts
However, McGaffigan points out that it is neither realistic nor necessary for board members to become experts on quality improvement, conversant in all the lingo and statistics. A working familiarity, coupled with an understanding of the impact quality issues can have on patient care and related hospital concerns, is a better goal, she says.
“Sometimes, we might think as clinical and safety professionals that the board has to know everything about quality in order to be a great board, and that might not be the case,” McGaffigan says. “We’re looking for including quality in board activities, and board members having a level of understanding that helps them do their jobs better. They are the ultimate ambassadors for safety and quality in the organization.”
Most hospital boards exert little influence on quality and patient safety, says Geoffrey W. McCarthy, MD, MBA, DipAvMed, in Portland, OR, who serves on the board of a large tertiary care hospital after a career as an Air Force pilot. He draws on the Air Force culture of safety for his work on the board.
“I am skeptical that most hospital boards have a great influence on the conduct of operations within the hospital. If the hospital board did not exist, what would change in the hospital?” McCarthy says. “I think very little.”
However, that’s not how it should be. McCarthy says the better idea is for boards to be knowledgeable and engaged in quality.
“Getting to that point partly depends on getting the right people on the board. You can approach it from looking at the duties and responsibilities of the board as they pertain to quality, and then walk that back to the recruitment of board members,” he says. “You can set up the construct of the ideal, highly engaged board that focuses more on safety than on finances, and work to achieve that.”
No Best Practices for Boards
Lacking any national standards for board education or involvement in quality, healthcare organizations must work with their own boards to determine best practices says, says Beth Daley Ullem, patient advocate and governance expert and a board member with Solutions for Patient Safety and The Center for Healthcare Value. She is a former board member with Children’s Hospital of Wisconsin and Catalysis (formerly ThedaCare Center for Healthcare Value). She also is a co-author of the report with McGaffigan.
“We have national standards and best practices for so many things in healthcare, but the boardroom has often been overlooked, yet ultimately that is where the expectations, the compensation, and the performance metrics for the senior leadership team are set,” Ullem says. “When I go into boardrooms, too often I see senior leadership compensation still based on just financial performance, philanthropic activities, and a few have trickled in quality performance.”
Quality leaders can think in terms of what they want the board to understand, what they should be capable and motivated to engage on, and how to best integrate those issues in all interactions with board members, Ullem says. Ideally, quality leaders can be involved with onboarding and continuing education for board members, she says.
“A lot of hospitals are getting better at least putting quality on the agenda. If any hospital does not have quality as a part of every board agenda, and preferably as a top priority item, I don’t want to be a patient at that hospital,” Ullem says. “Boards are making progress in having quality on the agenda, but a lot still have it on the agenda infrequently or only on the board of the quality committee and not the board as a whole.”
Ullem recalls a hospital that requires any new board members to serve on the board’s quality committee for the first year, sending the signal that protecting patients and ensuring quality is a top priority.
Present Staff Engagement Data
Boards have traditionally focused almost exclusively on financial performance, notes Thomas Lee, MD, chief medical officer at Press Ganey, the quality consulting company in Wakefield, MA. (See the story in this issue for advice on taking advantage of that connection.)
“One of the reasons was that people on boards assumed that quality was pretty good and they constantly heard that it wasn’t really measurable. They made the assumption that they had good people doing good things, and the more they did, the better,” Lee says. “But that era began to end with the Institute of Medicine reports in 1999 and 2001, which made clear that we do have quality problems in healthcare and we can measure and improve them. Since then, there has been a steady improvement in boards getting tuned in to the importance of safety and other dimensions of quality.”
Quality professionals should report engagement data to the board that shows how staff and physicians feel about the culture of quality and safety at the hospital, Lee says. These data should show the board whether the organization is committed to safety and quality, and values teamwork.
“That data is usually going to be painful to present. There is going to be five to 10% of employees who will say they wouldn’t recommend the hospital to a family member and they wouldn’t feel safe being treated there,” Lee says. “The idea of just one employee feeling that way is really painful, but I think getting that feedback and being accountable for trying to improve, no matter how good you currently are, is an important part of leadership and a governance.”
Press Ganey recently released a report that stresses the difference between the role of boards and of management, and offers a quality report card for boards. (See the story in this issue for more on that report.)
Make Quality Dashboard Routine
Boards should review a quality and safety dashboard as a routine part of board meetings, McGaffigan suggests. Presenting quality and safety information in an effective way is key to encouraging board involvement, she says, and board members cringe when someone presents way too much information. They tune out quickly, McGaffigan says, and they dread “death by PowerPoint.”
“This is a two-way opportunity for leaders and governance bodies to come together, to learn how they can work together to best lead and protect our patients and our workforce from harm,” McGaffigan says. “I’ve asked quality leaders, ‘How many of you have ever received education on how to communicate with governance organizations?’ and not a single hand in the room went up. Quality leaders, boards, and CEOs could come together and define the most meaningful approaches to take in board meetings so that the valuable time is used wisely and prioritized.”
When presenting quality and safety information, Lee follows the adage of “no data without stories, and no stories without data.”
“You should be presenting the board with not just numbers but with the stories that bring the numbers to life and show what they really mean. Avoid what we call ‘numbers that numb,’ in which you have board members thumbing through page after page of numbers and zoning out because they don’t know what they’re supposed to be looking for or what the numbers mean,” Lee says. “The data has to be brought to life.”
Quality leaders can ask for feedback on how they communicate with the board, McGaffigan says. This doesn’t have to be at the end of a board presentation, as that may not be the best use of board members’ time, but the quality leader might ask the CEO, a friendly board member, or someone else present at the meeting for an assessment of how the information was presented and received.
McGaffigan also recommends a report from the American College of Healthcare Executives and the National Patient Safety Foundation Lucian Leape Institute. “Leading a Culture of Safety: A Blueprint for Success” is available online at: http://bit.ly/2rWpgJH. One of the report’s suggested measures for determining a culture of safety is “the amount of time spent reviewing and discussing a transparent dashboard on quality and safety culture is equal to or greater than time spent on reviewing financial performance.”
Boards are becoming more receptive to an emphasis on quality and safety, but workforce safety still is neglected in many cases, McGaffigan says.
“Boards just don’t tend to look at workforce safety dashboards, yet that is our most important asset in the organization. Workforce safety is preconditional to making our patients safe,” she says. “If the board is not focusing on the safety of the workforce and seeing what that means in relationship ensuring the safety of our patients, we have a real opportunity to raise awareness levels of the connection between those two elements.”
Fed Measures Aren’t Enough
Hospital boards can sometimes be misled by federal quality measures tied to reimbursement, says Donald E. Fry, MD, executive vice president for clinical outcomes at MPA Healthcare Solutions, a healthcare analytics company in Chicago that has pioneered quality assessment and predictive models. Prior to joining MPA, Fry was for 16 years a professor and chairman of surgery at the University of New Mexico in Albuquerque.
“Some of their perception of quality is driven by the need to comply with process measures and so forth that Medicare puts out. They feel that if they’re complying with Medicare process measures with patient safety indicators put out by Medicare, that they’re doing well,” Fry says. “Hospitals are too content in accepting the meaningless process measures that the government imposes on them and they don’t really know what the true results of care are for their patients.”
Fry advises quality professionals to emphasize quality outcomes when presenting to the board, results that are based on a risk-adjusted methodology and benchmarked to the region or municipal area. These data should be presented at least quarterly, and preferably monthly.
“This should go beyond what I consider the insignificant process measures that the federal government wants you to report to them. My concern is that too many qualify officers feel that if they have fulfilled federal reporting criteria that their job is complete,” Fry says. “You have to go beyond that and put together a comprehensive compendium of what you need to be doing. The quality officer is responsible for that, but the board and the administrative leadership need to understand that there is far more than what government is saying you need to report to them. Good quality officers know that, but their presentations to the board highlight that we are in compliance with what the feds want us to do, and I would argue that quality and safety mean more than that.”
Draw on Board Experience
Even when boards are more focused on quality, they still tend to take passive roles, says John Redding, MD, senior manager with ECG Management Consultants in Chicago. They may be receptive to quality dashboards, but they often do not offer advice or get actively involved, he says, and quality leaders often do not solicit that input.
That could be a waste of potential resources, Redding says.
“Board members may be drawn from a wide variety of backgrounds — banking, legal, industries other than healthcare, but any industry has its own discussion about quality and many of them took a serious approach to measuring and improving quality well before the healthcare industry,” he says. “When it is a passive discussion, it is easy for the issue to be trivialized or just accepted as an unfortunate problem with no real effort to improve. Engaging them in the discussion and encouraging them to draw on their own industry experience creates a more productive scenario in which they can see their value to improving quality.”
- Donald E. Fry, MD, Executive Vice President for Clinical Outcomes, MPA Healthcare Solutions, Chicago. Email: firstname.lastname@example.org. Telephone: (312) 467-1700.
- Thomas Lee, MD, Chief Medical Officer, Press Ganey, Wakefield, MA. Telephone: (800) 232-8032.
- Patricia McGaffigan, RN, MS, CPPS, Vice President of Safety Programs, Institute for Healthcare Improvement, Boston. Telephone: (617) 391-9909. Email: email@example.com.
- John Redding, MD, Senior Manager, ECG Management Consultants, Chicago. Telephone: (571) 814-3846. Email: firstname.lastname@example.org.
- Beth Ullem, Patient Advocate and Governance Expert; Board member, Solutions for Patient Safety and The Center for Healthcare Value; Former Board Member, Children’s Hospital of Wisconsin and Catalysis. Website: www.qualityandsafetyfirst.org.
Board Should Focus on Long-term Quality, Press Ganey Says
Hospital boards should have solid foundation in quality and patient safety, but that does not necessarily mean an intense focus on the day-to-day activities of quality improvement, according to recommendations from Press Ganey, the quality consulting company in Wakefield, MA.
Press Ganey recently released “A Proposed Quality Report Card for Boards,” which establishes the top 10 quality metrics for boards. (The report is available online at: http://bit.ly/2sremiw.) Measures included in the Quality Board Report Card were derived from primary research capturing the insights of CEOs and senior leaders, and combined with Press Ganey data. More than 26 measures across safety, communication, teamwork, loyalty, engagement, value-based purchasing, and outcomes were narrowed to a list of 10 key metrics that help leaders manage and advance performance in safety, safety culture, clinical outcomes, patient experience, and high reliability.
“Boards have the responsibility of overseeing management, but not managing the operation. As one senior executive put it, ‘The board needs to have its eyes on the horizon, because the senior team often has to focus on the icebergs in the water nearby,’” the report says. “Accordingly, boards should not be given the full range of data that CEOs and senior team members use.”
The report suggests boards should focus on a small number of metrics that address the following questions:
- Does the organization lag behind its competitors in important dimensions of quality?
- Is the organization improving relative to the needs of patients?
The Press Ganey report also cautions that boards should be wary of rhetoric that suggests their organization is “the best,” thinking more in terms of, “No matter how good we may be, our duty and our strategy is to try to get better.”
Hospital boards’ proficiency and dedication to quality can be assessed, Press Ganey says, using a report card with the following key elements:
- Serious Safety Event Rate (SEER);
- Employee survey rating: I would feel safe being treated as a patient here.
- Inpatient survey rating: Nurse Communication;
- Inpatient survey rating: Doctor Communication.
- Press Ganey Inpatient survey rating: Staff worked together to care for you.
- HCAHPS/Inpatient survey rating: Likelihood to recommend;
- Employee survey rating: I would recommend this organization to family and friends who need care;
- CGCAHPS/Medical Practice survey rating: Likelihood to recommend.
- Hospitalwide All-Cause 30-Day Readmission (Observed/Expected);
- Hospitalwide All-Cause 30-Day Mortality (Observed/Expected).
Financial Focus of Board Can Be Used for QI
A hospital or health system board’s focus on its fiduciary responsibility should not be seen as a competing interest with quality concerns, says John Redding, MD, senior manager with ECG Management Consultants in Chicago. To criticize a board as concerned only with money and not quality misses the connection between the two, he says.
“In the past, the board has generally focused more on the financial health of the organization and looking at opportunities to advance the organization through revenue optimization or cost reduction. The link between the financial performance of the health system or hospital and quality has not been fully understood by the executives,” Redding says. “In the new value-based structures, the boards are starting to get more knowledgeable and more involved in quality, but it’s far from a complete understanding. It’s something that needs increasing focus and emphasis.”
The financial interests of the hospital or health system always have been intertwined with quality issues, such as maintaining accreditation and avoiding lawsuits or harm to reputation from patient harm, he says. That connection can be used to the quality leader’s advantage, Redding says, by making sure board members can see how quality improvement affects the financial picture.
“There has always been a link to the financial health of the organization through quality and safety. Quality provides a marketable brand for the organization,” he says. “That becomes even more important now because in the past, consumers were not as educated about quality issues and quality was assumed. As networks are narrowed and people decide what outlets are going to be used, consumers and employers are having more informed discussions about the quality of services being offered.”