Quality professionals often wish for more support from the board of the hospital or health system — the kind of top-tier backing that can drive a quality improvement initiative to success.
Such support requires a good relationship with the board, and that often requires quality professionals to take the first steps.
Many hospitals require the quality improvement department to report directly to the board on a regular basis, and more are now developing quality committees for the board, notes Jessica Turgon, principal with ECG Management Consultants in Arlington, VA.
“We’re starting to see a greater sophistication in quality reporting and key initiatives to focus on. It’s not just the basics anymore when you go to the board,” Turgon says. “There is more interest from the board, and that means there is pressure on the management team to demonstrate that you are providing quality care — more than just providing HEDIS [Healthcare Effectiveness Data and Information Set] scores and basic quality outcomes. They are more interested in hearing about specific performance improvement projects.”
As a result, quality improvement departments may need to bolster their infrastructure in order to track and manage data, she says.
A potential barrier is that hospital quality departments often are seen as primarily responsible for compliance rather than a quality improvement model, says Scott J. Cullen, MD, principal with ECG Management Consultants in Boston. The compliance part of quality is not all that sexy when talking to the board, so it can be harder to encourage participation, he says.
But that could be changing. With their financial interests, hospital boards have traditionally been more focused on donors and other constituencies than on competency and quality, Cullen says. Now, many hospital boards are moving more toward a competency-based governance model.
“As that shifts, I think you’ll see a little less friction and more traction around system-level initiatives regarding quality,” he says.
Get on the Agenda
Quality professionals can cultivate a close and productive relationship with the hospital board by keeping healthcare quality at the forefront of the board agenda, says Tracey Klein, JD, shareholder with the Polsinelli law and consulting firm in Chicago.
Linking education on quality and improvement to the board’s fiduciary duty of oversight is critical, she says. For starters, comprehensive training on the health system’s quality and improvement programs should be part of board member orientation.
“Offering to do semi-annual presentations can highlight achievements, as well as offering board members an opportunity to ask questions and learn about the clinical aspect of the enterprise. If the board does not have a quality committee, consider establishing one and moving quality to the forefront of the board agenda on a regular basis,” she says. “Candor and transparency are essential to the process. Quality should be given priority on the board agenda.”
When the board tracks quality and enhances its level of oversight of quality, it sets the tone from the top, Klein explains. This encourages administration to put enhanced resources behind making improvements.
In the early 2000s, Klein became a frequent lecturer on quality and board governance. She sat on a health system board as legal counsel and found that board members were interested in education and further development on quality issues. (See the related story in this issue for more about Klein’s experience with boards and quality.)
There can be challenges in creating a better relationship with the board. Representatives of administration tend not to like discussing shortcomings in any area with their board, Klein notes.
“Quality issues that have arisen are particularly embarrassing to discuss. This is especially true when there has been an unexpected death or injury,” Klein says. “I can remember working tirelessly to educate a board on quality oversight, and the real tipping point came when someone known to the board chair died as a result of a medical error at the hospital. The president of the hospital noted it was truly an unfortunate situation. The board chair corrected him and said it’s not just unfortunate, it’s actually tragic.”
Klein says that point was the moment the hospital president decided he needed more resources for quality and that he probably needed to affiliate with a bigger system to achieve the transformation required to keep pace.
Transparency Is Key
Ideally, the board should be briefed on publicly available hospital comparison websites, Klein says. Patient stories can and should be shared.
Transparency will be key, Klein says. The best approach is to reveal to the board any serious quality issue that has arisen. The incident must be investigated and assessed quickly, with a corrective plan offered, she says.
“It’s impossible to assure that there will never be a quality issue to be reported to the board. The trick is to have a plan in place immediately that puts the board at ease,” Klein says. “The board must be educated to be comfortable that quality requires continuous transformation and improvement in systems and methods. It should not be static.”
Emphasize to board members that they are caregivers just like physicians and nurses, says Jim Merlino, MD, president and chief medical officer of Press Ganey’s strategic consulting division. He has served on a hospital board. It is important to educate them on what their responsibility is and how it connects to the front lines for patients and caregivers, he says.
“I worry that some board members don’t really know what happens on the front line. They need to understand how the decisions the board makes affect individual patients, which requires quality leaders to bring stories to the board, rather than just metrics, to make it real,” Merlino says. “Make it personal. A preventable death was not just a nameless statistic; it was a real person who was harmed. A family and the caregivers were affected.”
A recent Press Ganey report notes that boards have the ultimate responsibility for the hospital or health system’s culture, which comes in large part from the CEO they choose to run the organization. Press Ganey data demonstrate that organizations with higher employee engagement perform better on quality metrics, Merlino notes.
For that reason, quality professionals should address organizational culture with the board, focusing on issues such as turnover rates and employee engagement, he says. (See the related story in this issue for more on the Press Ganey report.)
Engaged Board Improves Outcomes
It is crucial for the board to be involved with quality and safety activities, says Tejal K. Gandhi, MD, MPH, CPPS, chief clinical and safety officer with the Institute for Healthcare Improvement (IHI) in Boston. IHI recently published a report, “What Boards Must Do to Achieve Better Quality Health Care,” that provides guidance on integrating boards into quality efforts. (See the related story in this issue for more on that report and other resources.)
Some research shows a correlation between a more engaged board and better outcomes on the quality and safety front, Gandhi says, but that can come only when the board has a deep understanding of the relevant issues.
“It is important to get commitment from the CEO and board, but also we have to make sure they understand some of the core concepts around quality and safety. That can be a barrier for some of the lay board members who understand finance and similar issues far better than they understand quality and safety,” Gandhi says. “Boards need to acquire that core content knowledge so that they can ask the right questions and have much deeper understanding of quality and safety efforts at their organization.”
Don’t be surprised if some boards resist more involvement with quality or at least are unenthusiastic about it. Traditionally, boards have found it easier to talk about financial margins or what the next building might look like, says Beth Daley Ullem, faculty lead with IHI and president of Quality and Safety First, a consulting company in Boston. Ullem has served on two boards, sitting on the quality committee for both.
Boards must be shown that quality and safety are the core of what the organization provides, and therefore it should be a fundamental concern for the board, Ullem says.
Ullem notes that some hospitals require board member immersion in quality. Cincinnati Children’s Hospital in Ohio, for instance, expects every board member to serve on the quality committee before any others, she notes.
“Quality is their core operation, so this would be their entryway to understanding the health system,” Ullem says. “Doing things like that and taking board members out to see the quality operations in practice are great ways to help your board understand the quality focus. It also shows your commitment to quality upfront rather than having it be just a report or consent agenda in the board meeting.”
Even when board members are fully supportive, they often are unsure about exactly what they should be doing in their quality committees or in other oversight of quality and safety issues, Ullem says. They will welcome specific suggestions and roadmaps to follow, she says. “They’re looking for something similar to what they would receive if they were in a board or trustee position in the private sector, where each of their committees would receive specific direction on what to oversee.”
Don’t Discourage Accountability
Be careful not to discourage executive involvement with quality efforts, says David Munch, MD, senior principal at Vizient, a healthcare performance improvement company based in Irving, TX.
If executives are held accountable to the board for reporting quality issues, they will be motivated to support and participate in quality improvement efforts, he notes. But if the quality department develops such a direct relationship with the board that those executives are no longer on the firing line, their support and involvement can wane, Munch cautions.
“When the quality department does all the reporting and presentations, it allows the executives to check out, to not think so much about quality in the hospital. Someone else is presenting the data to the board, for better or worse,” he says. “That doesn’t mean the quality professional shouldn’t be at the board meeting to assist or provide resources, but avoid that unintended consequence of taking the executive out of the process and removing their accountability.”
Agenda Time Important
A barrier can arise when quality improvement professionals try to get time on the board agenda to make these inroads, says Gandhi. The CEO often manages the board agenda and keeps a tight grip on allocating time to the many parties who want face time with the board, she notes.
“Some CEOs don’t necessarily want board interference in these issues, so we sometimes have to change the CEO’s mindset to see how this can be an asset before we ever get a chance to start influencing the board,” Gandhi says.
Ullem notes that the notion of quality improvement will not be entirely new to many board members who come from a manufacturing or business background that values quality, culture, workplace safety, and related issues.
The key can be talking to board members in a language they can relate to, which often means minimizing medical jargon. Avoid flooding board members with lots of details and terminology that would be welcomed by a roomful of quality professionals but might be counterproductive with a board.
“While we often pepper the board with terms and issues specific to healthcare, the fundamental concepts are operational things that the board can understand from their own industries. If we take out some of the medical acronyms, we can create a bridge for us being able to speak the same language,” Ullem says. “They may not understand what a pressure ulcer is, but they certainly know how to read a run chart and understand defect rates. They can understand when you talk about managing a process for decreasing what is effectively a defect in our care, because if you manage a manufacturing plant, that is what you deal with all the time.”
Play to Business Experience
Similarly, it is useful to encourage board members to think in terms of patient expectations. This is a concept they can relate to in the business world, Ullem says.
“CEOs in the business world think about delivering on consumer expectations, whether that is good pricing, good customer experience, an airline getting you there on time and not losing your bags. They understand this concept,” she says. “So, we can work to have them think about customer expectations in healthcare and the board members’ role in overseeing that. If you mention STEEEP, their eyes will glaze over, but you can talk instead about how the patient expects us to keep them safe and expects us to help them navigate their care.”
Cullen says the business background of board members may even make them useful allies when quality professionals need more support from hospital management.
“The board can inject a perspective that the medical community and hospital management are now always on board with. They can say the patient experience is a major quality dynamic for us, a competitive dynamic for us, and you need to be looking at patients as customers rather than as a captive audience that we can do things to,” Cullen says.
Boards also will be drawn to the importance of the patient experience in setting the hospital apart from competitors, Turgon notes. Especially in competitive markets, new payment models are forcing hospitals to become more patient-centered, and board members will see the value in quality improvement efforts.
“If they don’t have that proactive approach to communicating where you are in quality, you’re at the mercy of Yelp or Healthgrades, and that does not always tell the story,” Turgon says. “It often does not necessarily tell the story the board wants to be told.”
- Scott J. Cullen, MD, Principal, ECG Management Consultants, Boston. Email: firstname.lastname@example.org.
- Tejal K. Gandhi, MD, MPH, CPPS, Chief Clinical and Safety Officer, Institute for Healthcare Improvement, Boston. Phone: (617-301-4800.
- Tracey Klein, JD, Shareholder, Polsinelli, Chicago. Phone: (312) 873-3613. Email: email@example.com.
- Jim Merlino, President and Chief Medical Officer, Press Ganey, South Bend, IN. Phone: (800) 232-8032.
- David Munch, MD, Senior Principal, Vizient, Irving, TX. Phone: (615) 206-0701.
- Jessica Turgon, Principal, ECG Management Consultants, Arlington, VA. Phone: (571-257-1017. Email: firstname.lastname@example.org.
- Beth Daley Ullem, Faculty Lead, Institute for Healthcare Improvement, Boston. Phone: (617-301-4800.