Viewpoint
What is the Board’s Role in Quality?
By Peter McGinn and Rajesh Davé, M.D.
According to both legal precedent (Darling vs. Charleston Memorial Hospital, 1965) and Joint Commission accreditation standards, the board has the ultimate responsibility for quality in the hospital. But do board members truly accept this level of accountability? Can they, as mostly lay volunteers, exercise meaningful oversight over the activities of health care professionals? The short answer is yes.
You can picture the stakeholders of hospital quality as a five-pointed star with board members at the top. Patients, of course, are in the center. Physicians form one base leg, while hospital staff form the other. The arms include families on one side and regulators on the other. The legs of the star are the implementers of quality, while the top half of the star are the overseers.
Donald Berwick, M.D., and his colleagues at the Institute for Healthcare Improvement (IHI), Cambridge, Mass., have attacked the status quo in hospital care, first with the 100,000 Lives Campaign and now with the 5 Million Lives Campaign. The genius of the first campaign was to pick a target and a method—saving 100,000 lives in 18 months by employing a small number of documented and repeatable best practices in hospitals nationwide. The signal feature of the second campaign is the central role that boards will play. The IHI is asking boards to set a pre-emptive agenda for quality and safety and to hold the CEO accountable for it.
Most hospital boards have had trouble with this responsibility for quality for the same reasons almost everyone else has. First, medical knowledge is complex and acquired through long and arduous training, and physicians fill the role of respected authorities and healers. Therefore, lay trustees and executives ordinarily defer to physicians whenever medical facts or judgments are under consideration. As a consequence, boards may not exercise their fiduciary responsibility for quality with the same confidence as they do in other areas, despite their personal commitment or concerns about this important charge.
Second, boards and CEOs develop relationships of trust and support that are essential for smooth governance operations, so boards tend not to hold CEOs to strict accountability standards under ordinary circumstances.
However, board members can make a large impact on quality even under these circumstances. For example, board and committee chairs set a tone in each meeting for how problems or issues will be handled. They signal whether they will engage in or shy away from important issues. In addition, the questions that trustees raise can lead to new insights or actions by the board and management. In some cases, for example, a good question can cause others to recognize assumptions that they were making unconsciously. Nonmedical people can also bring their experiences in other settings to bear helpfully on issues in the hospital setting.
For example, in one hospital, a visitor from Federal Express spoke about a change in quality analysis that took place in his organization. As he described it, Fed-Ex had once used the percentage of packages delivered on time as a measure of quality. However, since its marketing pitch was that consumers should use Fed-Ex whenever they “absolutely, positively” had to get something delivered overnight, Fed-Ex changed its measure of quality to the actual number of packages that did not arrive as promised. Changing the criterion from a percentage of success to the number of failures significantly increased the company’s attention to every package. The applicability to hospital quality was obvious, but the reference was completely nonmedical. Similarly, through their unique point of view, trustees can help ensure that the right things are being measured.
New York State has a mandatory reporting process for certain types of medical or surgical cases called NYPORTS—the New York Patient Occurrence Reporting and Tracking System for adverse events. Observing the system over time, it can be seen that serious negative outcomes are seldom the result of a single disastrous mistake. Rather, they are usually the product of a series of small mistakes that, lined up together, lead to a negative outcome far out of proportion to any one of the individual errors.
Board members have the skill and responsibility to hold medical staff and management accountable for building systems and processes that minimize such errors. There is an old saying that board members should keep in mind whenever they consider their role in quality: “You get what you inspect, not what you expect.” Board members expect good quality. They should inspect for it as well.
The acronym, PROBE, summarizes key recommendations for board members who want to help their hospitals improve quality:
P = Personal accountability of the CEO is a key first step. Berwick and the IHI got this right.
R = Recruitment and retention of good clinical staff is a critical success factor for institutional quality, and it may become the single most important factor going forward.
O = Outliers, whether considered particularly bad patient outcomes or poorly performing physicians, are symptoms of quality problems and are good places to begin quality assessments.
B = Budgets represent how the board wants to invest the organization’s resources. Quality and safety should be two of the key targets for allocations of time, effort and money.
E = Expectations for quality should be proactively stated by the board in terms of both indicators of performance and the level of performance desired.
Finally, the word “probe” itself is a reminder that board members need to ask the “Why?” and “Why not?” questions. Trustees need to ask how changes are being made so that improvements will last. Board members’ concern for patients and families should lead them to dig deeper than would be appropriate in an ordinary social setting.
A final thought for board members: exercising your responsibility for quality may make you and others uncomfortable at first, but there is no change without discomfort.
Peter McGinn, Ph.D., is president of Leadership Impact LLC in Vestal, N.Y., and former president and CEO of United Health Services, Binghamton, N.Y. He may be reached at (607) 206-5187, or at mcginn@leadershipimpact.com. Rajesh Davé, M.D., is chief medical officer of United Health Services and dean of the Upstate Medical University’s Clinical Campus in Binghamton. He may be reached at rajesh_dave@uhs.org.
This article 1st appeared in the September 2007 issue of Trustee Magazine.
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