Ask not what your board can do for you -- what can you do for your board?

Play a role in selection and education of hospital leaders

With managed care on the rise, it's all hands on deck. Often overlooked in the battle to stay afloat in the stormy seas of health care are the resources of the hospital's governing board. Health care quality professionals hold the keys to unlock the board's potential. They also can help the board become more effective in its operation. The first step is to educate board members about performance improvement and what role they can play in it.

"They can't be effective unless they have some sort of education," says Vicki L. Searcy, vice president of Qual Ed, a health care consulting company in Santa Ana, CA. "Even [with] those who come from within the health care organization, their frame of reference is limited. This is to say nothing about those who come from outside of the health care field who know nothing about the operation of a hospital. Nobody comes to the board knowledgeable about everything that is going on there."

Orientation sets the tone

Quality professionals who are not currently involved in board orientation could be, Searcy says. One of the things the Joint Commission on Accreditation of Healthcare Organizations looks for in its surveys is how new board members are oriented. Often, this is all CEOs need to know to give quality professionals free reign to make improvements and unleash the board's potential, she says. She has several suggestions that quality professionals can propose or do themselves to energize the hospital board:

* Set expectations. Upon acceptance to the board, the new member signs a pledge to take specific actions, such as agreeing to attend and be prepared for no less than five out of the six board meetings during the year.

* Empanel doers. Seek out -- or suggest that those responsible seek out -- potential board members with recognized community involvement.

* Find experts. Some institutions invite experts from around the country to be board members to help make informed decisions. Often lawyers or business professionals sit on the board to lend their expertise. It is not uncommon to pay these board members.

* Start things the right way. When a hospital adds new services, the board should insist that the developers have a quality plan, as well as a financial plan. Quality professionals should push the board to ask: "How are we going to evaluate the outcomes of this new service? How are we going to evaluate patient satisfaction?" Searcy says. "That is one of the best ways the board can be more proactive with regard to the performance improvement program."

* Promote education. In addition to performance improvement, board members need to be informed about topics concerning the hospital's operation. Scheduled educational briefings at the beginning of board meetings can be very effective.

Make education top priority

Some hospitals plop an orientation manual in front of new board members, have them sign a confirmation of receipt and declare the board member oriented. "That is how a lot of health care organizations approach educating the board members," Searcy says. An orientation video is a step up, but not much, she says.

"If you believe, as a quality professional in your hospital, that you are responsible for developing an annual plan for education -- who needs it and what they need -- you can certainly include your board in those activities," Searcy says. "I have found that if you offer the education at a convenient time and place, they rarely refuse to take that opportunity. When board members are educated to what they are responsible for and how systems in the hospital work, they really try to make thoughtful and informed decisions. Sometimes they are almost forced to rubber stamp things because they don't have adequate information."

Developing a program that breaks down hospital orientation into related chunks, such as safety, operations, finances, and a tour of the physical plant is a more effective method of orientation. Searcy uses a checklist and schedules staff members in their respective areas to explain and demonstrate different operations (See checklist chart, inserted in this issue.)

"It's not something board members are going to do in a day, but they might have a schedule over a period of a few weeks that would cover all the items," Searcy says.

The education does not stop with orientation. Searcy recommends that board members go to various committee meetings, such as safety, medical staff, and finance committee meetings. Supplying board members with cheat sheets explaining the technical language removes barriers, Searcy says. The sheets can define terms and commonly used acronyms to ensure they get more out of those meetings.

After one medical staff meeting, she remembers a board member without a cheat sheet who sheepishly approached her after the meeting to ask, "What's a cabbage?" He was referring to coronary artery bypass graft surgery, otherwise known as a CABG procedure, and was mystified most of the meeting. He was too embarrassed to expose his medical illiteracy at the meeting.

Board members should attend national conferences, too, such as those sponsored by the Chicago-based American Hospital Association. She also highly recommends Estes Park (CO) Institute, which holds several annual conferences covering a wide variety of health care issues that are of interest to hospital administrators, board members, and physician leaders.

Keep it simple

Boards members want to be more involved in the operation and leadership of the hospital, but that is not their primary occupation. They often have other community duties, not to mention their professional pursuits. When it comes to hospital business, they do not want thick, narrative reports. They want information in brief -- a snapshot of how well the institution is operating.

"Give them data they can understand," says Ruth Sens, BSN, CPHQ, director of quality management at University Hospital in Denver. "Put it in lay language." Quality professionals must ensure that board members get the appropriate information as well, she adds. Every detail is not required to give members enough information to make enlightened decisions.

Searcy recalls one hospital she worked with that sent its board a 43-page report on quality operations. "How can anybody on the board be expected to wade through that type of manual?" she asks.

In an effort to make hospital data more accessible to board members and others, The Queen's Medical Center (TQMC) in Honolulu published an improved annual report in 1994. In a straightforward, more graphical format, the report included information on lengths of stay, outcomes, nursing home waiting lists, patient falls, patient satisfaction, and complaints.

"It was a good first step," says Chris Lima, RN, MN, MBA, director of performance improvement at TQMC. "It had a lot of graphics and less narratives."

Following up on that success, TQMC now uses an even briefer format. With the help of Searcy, the medical center issues a report card for the hospital that covers topics such as service quality, utilization, clinical outcomes, and human resources, among others. (See sample excerpt from the report card, inserted in this issue.) The six-page report card, called a dashboard report, gives a good overview of all operations in the hospital without the detail that is only useful to department heads.

Armed with information they can use, instead of information they get lost in, the board members can discuss the issues and take action, Searcy says. "When the minutes say the report was accepted as submitted, then the Joint Commission comes around and asks, "Is this board involved? How come they are not reacting to the information they are presented?"

The dashboard reports include benchmarks to further stimulate the board into action. The internal or external benchmarking goals give board members a frame of reference of how well or how poorly a department is doing relative to local, regional, or national standards. For the same reason, Sens gives her board a consistent set of indicators going back three years to show trends of improvement.

Before completely revamping how the quality department communicates to the board, Sens lends a word of caution. "Always discuss information to be given to the board with senior administration," Sens says. "You must come into agreement on the limits of information before it is passed to the board."

If the information does not indicate improvements, Sens strongly recommends having solutions to problems in hand, or an explanation of what was learned despite the lack of improvement. Quality professionals who do not do this will entice the board to offer suggestions and to micro-manage.

Of course, a well-informed and proactive board is desirable. If that is not reason enough for a quality department to rethink its educational or informational programs with regard to the board, perhaps the specter of a Joint Commission survey can motivate quality professionals.

At Good Samaritan Health System in San Jose, CA, surveyors were particularly scrupulous regarding governance issues, says Susan Henderson, RN, MS, CPHQ, director of quality resource management. "They looked very heavily at the standards as they relate to the governing body and how they get involved with performance improvement activities," she says. During the June 1995 survey, surveyors looked through the minutes of board meetings, and they interviewed board members at length.

Board members were present at each of Good Samaritan's hospitals during the survey so they could respond to questions as they came up. Henderson oversaw the implementation of an updated reporting process at Good Samaritan, which uses a dashboard report format. She says, due in part to the report's simplicity and how it breaks down quality data into information that is meaningful, board members represented the system "superbly." They appeared knowledgeable about the system's quality improvement efforts and were able to cite how the organization is working to meet the mission and vision. *