Reporting performance results to the board
Use narrative and statistical summaries
By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR
Your organization’s governing board has ultimate responsibility and accountability to the community for ensuring the quality of patient care and services and, therefore, must be kept well informed on all issues related to quality.
Boards need to know what activities are being done to monitor and evaluate medical care and services, they need to know what is being done to improve and/or correct problems and deficiencies, and they need to be assured that those to whom they have delegated the day-to-day responsibilities of performance management are performing their duties. These needs influence the format and content of the board’s performance report.
The information included in the periodic reports to the governing board should help them answer questions such as:
- Is every department and medical staff service adequately monitoring its performance?
- Are the professional staff competent? Are their licenses current?
- Are we measuring what’s important to our patients?
- Is this organization constantly improving performance, or are departments measuring the same thing each month without any documented improvements?
- How does our performance compare to similar organizations?
- Are both clinical and business processes being improved? Are patient and staff recommendations considered when making improvements?
Selecting the right information to pass along to the board starts with an orientation meeting in which the board is acquainted with the many different performance measurement and improvement going on throughout the facility.
Board members must be educated about the medical staff and facility performance measurement endeavors as well as the improvement mechanisms. The orientation also is a good time to discuss the facility’s involvement in comparative measurement projects such as the Joint Commission on Accreditation of Healthcare Organizations’ core measures.
The quality director can take this opportunity to explain thresholds and benchmarks and how these are used in the performance assessment and improvement process.
In addition, board members should be introduced to the performance measurement priorities of local health plans and/or business coalitions, peer review organizations, state regulators, and other external groups.
Following the briefing, board members will be better prepared to select the information they want to receive on a regular basis and what should be given to them only periodically.
In some instances, facility policies may influence how often performance reports go to the board. For instance, the leaders are expected to ensure the competence of all staff members.
If the hospital’s human resource policy states that staff competencies are assessed at least annually, then the board should receive a summary report of findings at least annually. The findings from other activities, such as medical staff peer-review activities, may be summarized and reported quarterly or as often as determined by the board.
To minimize the amount of paperwork received by the board, use a combination of narrative and statistical summaries.
Reporting performance results
Performance results that are reported regularly to the board should be displayed graphically or in a matrix such as the one illustrated in the chart below.
In this report, the results of all performance measures used by the medical staff and departments are categorized into patient-focused and organization functions (as defined by Joint Commission standards).
Measures relevant to the Joint Commission’s National Patient Safety Goals are grouped together in the last category.
Detailed results only are reported for those measures that failed to meet pre-established goals. In addition, actions taken in response to failed expectations are detailed.
At least annually, each department can prepare for the board a one-page abstract of performance improvement activities.
This report, a combination of narrative and measurement data, should include information such as:
- The important patient care and/or organizational functions that were evaluated.
- How performance was measured for those functions.
- The results of measurement activities.
- Significant improvements that were made.
- Improvement priorities for the upcoming year.
The flexible Joint Commission standards give organizations considerable latitude in selecting measures and improvement projects.
This flexibility extends to the reporting process. The higher up the organizational ladder, the less detailed the reports need to be.
However, it’s important that the governing board be provided sufficient information to support their role as overseers of the performance improvement process. In today’s competitive health care environment, it is more important than ever that governing board members receive the data they need to adequately judge the quality of patient care in the institution.