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Patient safety and ongoing quality improvement are top-of-mind priorities for all hospitals, but the pressure to improve quality and reduce costs has never been greater. As both public and private payers increasingly base payments on outcomes-related performance data, the business case for quality is no longer theoretical — it's a daily, bottom-line metric.

And while hospital boards are always concerned with keeping patients safe and providing excellent care, the challenges of the new era can be daunting. From patient satisfaction surveys to quality measures developed by the Centers for Medicare & Medicaid Services and private insurers, there are scores of metrics to report on and a plethora of quality improvement strategies to use to drive organizational improvement.

But hospitals don't have to go it alone. In recent years, a number of national, public-private partnerships have been launched, with the goal of bringing hospitals and other providers together to share best practices, compare performance data and develop new strategies for tackling age-old patient safety concerns. Notably, these efforts include the two-year-old CMS-led Partnership for Patients, an ambitious national initiative that aims to reduce inpatient harm by 40 percent and readmissions by 20 percent by the end of 2013.

For acute care providers, the Partnership includes opportunities to join 26 Hospital Engagement Networks, known as HENs. The networks are designed to help meet those lofty goals through the regular reporting of performance data, access to technical assistance that helps participants track and monitor their progress, and opportunities for hospital staff to collaborate with their peers.

"You've got to have some benchmarks so we can compare our performance against other hospitals," says James Spann, chairman of the board of trustees, Trinity Medical Center in Birmingham, Ala., one of 1,600 hospitals in 31 states participating in the HEN administered by the American Hospital Association's Health Research & Educational Trust. "The data from the HEN is a tremendous opportunity to make those comparisons and see how we're doing in a very real-world way."

Even with assistance from national efforts like the HENs, though, boards can find it difficult to suddenly oversee and manage complex clinical interventions across a variety of quality metrics, especially for trustees who aren't necessarily familiar with the nuts and bolts of each initiative.

To begin the journey to patient safety excellence, quality improvement experts recommend that boards put patient safety and harm-reduction at the heart of their strategic plans, and carry out that vision by incentivizing their management team and clinical staff around quality improvement and by devoting the resources needed to achieve that vision.

From there, boards can stay informed on progress through performance updates at board meetings and regular contact with executive leadership, complemented by occasional meetings with clinical staff to discuss both safety issues and success stories from the front lines of the hospital.

"Once an organization makes the commitment to go into the HEN and work on these issues, boards should be aware of progress or lack of progress," says John Combes, M.D., president and chief operating officer of the AHA's Center for Healthcare Governance and a senior fellow with HRET.

David Nash, M.D., dean of the Jefferson School of Population Health at Thomas Jefferson University in Philadelphia, agrees, noting that no matter what other health care trends are occupying the board's attention, patient safety is ultimately the top priority.

"What I tell board members almost every week is to keep your eye on the safety-related issues," says Nash, who's also on the board at Philadelphia's Main Line Health. "We're all worried about ACOs and health insurance exchanges, but let's not forget about the knitting, which is to do no harm."

'Connecting the Boardroom to the Bedside'

At Trinity Medical Center, the board begins every meeting with a detailed quality improvement report that includes the HEN data, Spann says. Putting that commitment front and center, he notes, sends a strong message to all hospital stakeholders about the 534-bed hospital's focus on "improving clinical outcomes and making it a safe place for patients and their families."

To reach those goals, many boards begin by directing their administrative and clinical staff to put quality improvement at the center of the organization's outlook. That's the approach McDonough District Hospital in Macomb, Ill., took, recalls Maggie Goettsche, R.N., the 113-bed hospital's administrative leader of quality and innovation. The board also approved the development and recruitment of new positions supporting the HEN and other quality initiatives, including a reliability engineer and a dedicated patient educator.

"The board has made this a priority through the strategic plan process," Goettsche says.

Jefferson Regional Medical Center, a 471-bed hospital in Pine Bluff, Ark., takes a similar approach, setting organizational directives centered around the achievement of quality and patient safety goals. To meet those aims, the board has supported participation in HRET's HEN collaborative through the Arkansas Hospital Association, as well as decisions to invest in IT staffing and nursing education, says Walter Johnson, Jefferson Regional's CEO.

"The board of directors has long recognized the importance of having a strong and vibrant patient safety program in place," he says.

Beyond the data from initiatives like the HEN and the strategic planning commitment, many boards demonstrate their focus on patient safety and harm-reduction by regularly hearing from the front-line clinicians at meetings. Spencer Stevens, a board member at 430-bed Nebraska Methodist Hospital in Omaha, part of HRET's HEN collaborative, says he and his fellow board members occasionally attend clinical team meetings — regular gatherings of physicians, nutritionists, radiologists and other specialists — after receiving permission from the front-line staff. Those settings give the board a chance to learn more about their institutions, but also drive home to staff the message of board involvement in quality, Stevens says.

"That engagement is what promotes good health care at our institution," he notes.

The AHA's Combes agrees, noting that teaching opportunities around harm are ultimately a chance to focus board members on the essence of the institutions they oversee.

"I don't think it hurts to talk about the hospital harm rate and then talk about cases that show harm, or how we avoided harm in a particular case," he says. "It's about connecting the boardroom to the bedside, and getting the board to see that what they sit on — it's not a hotel."

Data Tell the Story

Once hospitals are engaged in the HEN or other quality improvement platforms, the access to comparative data can be a compelling starting point for measuring progress and assessing areas of improvement, says Wayne Griffith, CEO at Princeton (W.V.) Community Hospital. Griffith, who says their first peek at HEN performance data helped executives and the board to realize the 267-bed hospital wasn't performing as well as they had previously believed, says that realization led to an overhaul of the hospital's quality operations. What emerged after the transformation was a new model that integrated HEN metrics, data from a value-based purchasing program and other quality efforts into one quality package for the board to monitor.

"We said we need to do better," he recalls. "We all accepted that responsibility. We said we are going to improve, and we communicated that clearly to our medical staff."

Hospitals that already are engaged in a mix of patient safety initiatives face a different challenge — integrating the HEN initiative into an already-full quality portfolio without overwhelming staff, says Stephen Grossbart, senior vice president and chief quality officer for the Center for Patient Safety and Clinical Transformation at Catholic Health Partners, Cincinnati. When his system joined the Premier HEN, the key challenge was developing a process for integrating the HEN effort and results into the rest of the system's quality efforts.

"We got started well before CMS launched the Partnership for Patients," Grossbart recalls. "We had a fairly robust infrastructure in place. Our challenge was twofold — we had to take advantage of the resources and tools in the HEN to accelerate the work we were already doing or planning to start. We had to balance that with the quality and safety agenda we already had."

Boards Drive Staff Engagement

While board members can drive improvement through strategic planning and executive support, it's critical that they ultimately delegate the nuts and bolts to their executive and clinical leadership, the AHA's Combes says.

"It's management's function to engage on this project," Combes says. "The board needs to be aware of ongoing efforts in the organization to improve quality. At their level, they're setting policy around quality and overseeing and creating the conditions for improvement."

Many boards carry out that vision by creating incentives for both executive and clinical staff for specific harm-reduction goals. At Catholic Health Partners, Grossbart recalls, CEO Michael Conley committed to a 40 percent reduction in harm across the board, which is the same goal the Partnership for Patients set nationally when it was established by CMS in 2011.

At Princeton Community Hospital, for example, CEO Griffith has a series of specific incentives for reductions in readmission rates to baseline rates in key areas including pneumonia, congestive heart failure and acute myocardial infarction. Those goals were developed with Princeton's board, he notes. The board also receives regular updates at every meeting.

"We believe strongly that what gets measured, gets done," Griffith says.

There are also less formal ways of achieving the same goal, says Nebraska Methodist Hospital's Stevens. While the hospital doesn't have specific financial incentives around quality, the board hears from physicians and other clinicians at nearly every board meeting, with quality taking center stage during those discussions.

"Our board members … can see how all of this is working together to streamline our care, but also add quality," Stevens says. "The incentives [staff] see is a board that's very interested."

And in an era where hospitals are increasingly paid for the value of the care they provide in contracts with both Medicare and private payers, linking quality and financial performance — perennial top-of-mind goals for any provider — is increasingly an essential task for boards, the AHA's Combes says.

"HEN activities are related to pay for performance, so it's also a good way for boards to link the financial outcomes with the clinical outcomes," he notes. "It's a simple metric. You have all the dollars at risk in the organization in the quality initiative. You can look at the return on those dollars."

Managing It All

After the goals have been set, staff has been looped in and implementation has begun, hospital leaders have to contend with the trickiest element of these projects — managing 10 distinct, complex clinical initiatives across the institution.

Princeton Community Hospital's Griffith recalls that the hospital once delegated all of its quality improvement efforts to the hospital quality department. When Princeton joined the HEN, however, progress in each of the 10 HEN core areas was delegated to specific champions of each initiative. While the hospital's quality director still reports to the board on progress in all 10 areas, the decision to divide up specific tasks and goals allowed for greater buy-in throughout the organization, Griffith recalls.

"They took more pride in the accomplishment of individual projects within the HEN," Griffith recalls. "That was instrumental."

To that end, the hospital has shared its patient safety goals with medical staff at every step of the HEN journey, ensuring buy-in at every point in the process.

"It's absolutely essential to involve the medical staff and management team early," Griffith says. You have to clearly communicate your expectations to staff."

The initiative also helps hospitals and health systems to identify potential areas for improvement, even if they already boast robust quality improvement performance. At Catholic Health Partners, Grossbart credits the initiative with helping the system tackle patient safety challenges it hadn't spent a lot of time on previously. Grossbart says his organization redoubled its efforts to reduce readmissions, leading to significant changes in patient discharge instructions.

"Prior to launch of the [HEN], there was complacency around readmissions. It helped change the conversation to: 'This is avoidable. Look at the data. Who's getting readmitted?' "

The Power of Culture

Qualitative data aren't the only decision points, however. The Jefferson School of Population Health's Nash stresses that without meaningful culture change, no hospital can sustain best practices that rely on open, transparent communication between clinicians with varying roles.

"Until that operating room nurse feels comfortable telling the chief of surgery he's not taking another step until he takes a [surgical] timeout, that's the litmus test," Nash says.
Achieving that holistic culture change, he says, is dependent on continual efforts by the board to meaningfully engage in the key patient safety challenges facing their institution, even if they delegate the day-to-day operations of their efforts to executive and clinical staff.

"There are lots of very effective boards who still believe this is the doctor business, when, in fact, it's their responsibility," Nash says.

And, ultimately, board members and quality improvement experts alike agree that driving patient safety improvement always has been a central part of what it means to be a trustee.

"Years ago, when I was asked to serve on the board, my first question was, 'What am I supposed to do?' " recalls Trinity Health's Spann. "I was told my job description was to look after the best interests of the people of the state of Alabama. That made it perfectly clear."

Haydn Bush (hbush@gymr.com), former Hospitals & Health Networks senior online editor, is account supervisor, GYMR Public Relations, Washington, D.C.

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