Quality improvement professionals know their efforts will be more successful when they gain the support of the hospital board of directors and top executive leaders. However, it can be difficult to obtain this backing. Organizing data and intentions properly, as well as transparency regarding current operations, are key.

The C-suite is critical to achieving quality and patient safety objectives at any hospital, according to Richard Becker, MD, senior managing director with ToneyKorf Partners, a management and advisory firm in New York City specializing in the healthcare industry.

Becker says leadership engagement tracks directly with accomplishing outstanding results. Hospital boards and top executives should help make the hospital or health system a high reliability organization (HRO), in which the organization achieves and continuously maintains excellence in quality and safety across all services.

Becker explains HRO performance is built around these three major areas:

  • Leadership committed to the goal of zero harm;
  • A culture of safety throughout the organization that allows and encourages all staff to report anything that would negatively affect the organization, its patients, and staff;
  • An empowered workforce that employs specific tools to address improvement opportunities they find to drive significant and lasting change.

“Every member of the C-suite must be tirelessly and continuously engaged in developing this approach and culture,” Becker says. “Without leadership that both communicates and demonstrates these principles and behaviors, the hospital will never achieve the level of excellence it seeks.”

Quality improvement professionals should build on the desire of board members and top executives to be associated with a top-quality organization, Becker says.

“Every board wants to be proud of its hospital. Such pride can only be as great as the quality of its services,” he says. “A good quality leader makes sure that leadership is informed and communicates with them the existing state and the desired goals of quality at the hospital. Once the board understands the organization’s current performance and the pathway to improve, getting buy-in and support for specific initiatives is relatively simple — as long as the board reviews the plan and sees the C-suite’s leadership commitment to and accountability for accomplishing the objectives.”

Follow Same Principles on Projects

For any new quality improvement projects, the principle is the same, Becker says. An effective quality leader should engage the board about the issue, help them understand the pathway to improvement, and clearly identify realistic timelines and resource requirements. This allows the board to see a fully informed view of the request for support, he says.

“Ultimately, the board must understand that achieving excellence in quality is the cornerstone of the organization,” Becker stresses. “Great quality builds value and attracts patients, physicians, nurses, and staff, which all supports the hospital remaining in good financial health to sustain its mission.”

Working closely with top leadership will assist hospital quality and patient safety professionals with the complex task of developing organizational quality and patient safety objectives, Becker says. That support will improve the ability to design and implement tactics to achieve those targets, and then continuously monitoring and communicating the results.

“The ultimate performance of a hospital ... depends on not only the approach to quality but also the results and outcomes,” Becker says. “Gaining support and buy-in for quality goals from all stakeholders is, therefore, critical to the organization’s long-term sustainability.”

It is important for every person in the organization to understand their roles in supporting and contributing to the overall quality and patient safety in the hospital, Becker says. Quality comes down to team performance, and it is the individuals on the team who determine the effectiveness of every quality project and program.

“Buy-in begins with stakeholder participation in developing quality objectives. Hospital quality managers should work with unit-based teams and clinical medical services that include all stakeholders from relevant disciplines to identify gaps in the process and performance of various quality, safety, and efficiency metrics,” Becker says. “These goals are prioritized with the strategies and tactics to achieve them. While not always obvious, it is important to include clinical and nonclinical support departments that are integral to implementation, analysis, and even funding of various quality initiatives.”

Once these alignments are “baked-in,” accomplishing the goals becomes a mantra and part of the organization’s top priorities, Becker adds.

Include Frontline Employees

Essential to gaining buy-in is a process that solicits information and solutions from the front-line providers and staff rather than one that dictates or mandates the best answer to an ongoing issue. Often, the care delivery team will have the right answers and, if asked and empowered, will own the solution and execute it to achieve the desired outcome, Becker observes.

It is important to identify quality champions in every clinical service area of the hospital.

“Quality departments are generally small and nimble in most hospitals, which does not allow the quality manager to monitor and advance every project, every day when, in fact, this level of attention is required to achieve the targeted results,” Becker says. “A frontline project champion or leader who can motivate and monitor colleagues to execute on specific initiatives will ensure success and create a grassroots pride throughout the hospital as performance and reputation improve.”

All this should be part of a board-approved, comprehensive, organizational quality and patient safety plan that clearly defines and identifies objectives, timelines, resources, responsibilities, and methodology of performance improvement.

“This plan, which should be shared with stakeholders, becomes the living document that serves as both the framework and roadmap for accomplishing and maintaining excellence in quality and safety,” Becker says.

Transparency Vital to Success

Transparency and communication about current performance are important to establish a baseline and focus relevant groups around the existing vs. the desired results, Becker says. Monitor, report, and communicate widely the ongoing performance. Without this, it becomes too easy for stakeholders to lose their focus and sense of urgency. “Data-driven processes help healthcare organizations make the right decisions. When decisions are not supported by data, organizations are less likely to move in directions that help achieve their goals,” Becker explains. “Develop structures that clearly identify a common purpose, lay out goals and expectations, establish effective communication, provide coaching and feedback, and set up consequences for both positive and negative outcomes. Lack of a clear accountability structure often results in failure to effectively execute a plan and achieve the intended goal.” Becker says it also is important to prioritize. Identify the most significant challenges and focus resources around them to ensure successful outcomes.

“While every organization wants a five-star performance in every measurable area of quality, most organizations do not have the resources to tackle every objective at once,” he notes. “It is much better to focus on a finite number of areas with positive results than to overwhelm the organization with aggressive goals and timelines that are unrealistic and may also lack adequate resources.”

It is critical to gain the support of the C-suite at the level of sponsorship, says Leslie Solomon, PhD, director of healthcare at human capital advisory firm FMG Leading in San Diego. Many healthcare leaders do not understand what the role of sponsor is and need to be given guidance on how to sponsor without micromanaging.

“Clarifying the role of sponsorship as a co-planning and review role, while leaving the deployment and problem-solving to the improvement teams, will be critical,” she says. “It is also helpful for sponsors to understand how to review the improvement project using skillful inquiry to determine whether the process is robust without inserting bias.”

When approaching board members and senior executives, Solomon advises beginning with a vision of the desired state rather than the “problem.” Engage people with what is possible, and that will open their thinking and neural pathways to new thinking rather than beginning with the problem, which will tend to evoke negative emotions and less creativity. Follow leading indicators and metrics for process health so everyone knows which processes are performing and which are failing, Solomon says. Keep leaders and the board updated with dashboards of process performance.

Also, be willing to use nonlinear approaches to problem-solving, such as cognitive interviews and double-loop modeling. Police use cognitive interviews to help witnesses effectively recall details about a crime, using multiple retrieval techniques that acknowledge how memories are made up of a network of associations. Double-loop modeling involves teaching people to think more deeply about their own assumptions and beliefs.

These methods are more conducive to learning from improvements and are more suited to the complexity of healthcare systems, Solomon says. When presenting to board members and top executives, quality leaders should avoid framing process improvement as a fix of failure. That approach does not support a culture of learning.

“Many organizations lack the trust and safety required to report accurately on issues. All quality improvement needs to rest on a Just Culture framework,” she says. “This will provide the safety for employees to report accurately and will also help leaders separate environmental and work design issues from personnel issues.”

Even with all this in mind, it still can be intimidating to go before the hospital board seeking support for quality improvement initiatives. When that time comes, Solomon advises keeping some key points in mind.

“Begin with the desired state, explain why it’s important, clarify the desired impact in risk management, and cost savings. Delineate both hard costs, like investment dollars and savings, and soft costs, like work climate and safety,” Solomon says. “Clarify what you are looking for from them, such as their role as sponsors and how you will keep them engaged in progress. Provide best practice examples at the outset so they have a basis of comparison and a vision of success.”


  • Richard Becker, MD, Senior Managing Director, ToneyKorf Partners, New York City. Phone: (855) 857-1212, ex. 120. Email: rbecker@toneykorf.com.
  • Leslie Solomon, PhD, Director, Healthcare, FMG Leading, San Diego. Phone: (714) 628-2900. Email: lsolomon@fmgleading.com.