Practical Matters

Informed and active participation in quality oversight and leadership should be the foundation of every board meeting agenda.

Attaching a measure to the amount of board meeting time spent on quality is one way to prompt boards to carry out their accountability and improve their quality and patient safety knowledge and effectiveness. But being conscious of the governance time spent on quality is only part of the process. Quality should be at the forefront of board discussions and decisions on virtually any agenda topic.

A Fiduciary Duty

In their 2007 report, Corporate Responsibility and Health Care Quality: A Resource for Health Care Boards of Directors, the Office of the Inspector General and the American Health Lawyers Association aimed to equip boards with the rationale and tools to understand and execute their obligations for quality and patient safety.

The report advises boards to exercise general supervision and oversight of quality and patient safety, including: being aware of quality issues, challenges and opportunities; paying close attention to the development of quality measures and reporting requirements (including periodic education from executive staff); and receiving executive updates regarding quality initiatives and associated legal issues.

In the pursuit of "reasonable inquiry," the OIG and AHLA recommend that boards ask and have solid answers to several questions, including:

  • What are the goals of the organization's quality improvement program? What metrics and benchmarks are used to measure progress toward each of these performance goals? How is each goal specifically linked to management accountability?
  • Does the board have a formal orientation and continuing educational process that helps members appreciate external quality and patient safety requirements? Does the board include members with expertise in patient safety and quality improvement issues?
  • What information is essential to the board's ability to understand and evaluate the organization's quality assessment and performance improvement programs? Once these performance metrics and benchmarks are established, how frequently does the board receive reports about the quality improvement efforts?
  • What processes are in place to promote the reporting of quality concerns and medical errors, and to protect those who ask questions and report problems? What guidelines exist for reporting quality and patient safety concerns to the board?

Leadership Fitness

The common theme in governance best practices is trustees' ability to ask insightful questions, such as those recommended by the OIG and AHLA.

Providence Health & Services, a health care system with facilities in five western states, identified seven governance questions to help define board responsibilities and foster wise strategic thinking about quality and safety. As a board seeks to infuse more focus on quality in its meetings, consider these questions and identify substantiating data for the answers, such as the reports the board receives, how they are reviewed, the metrics included and whether they provide the necessary information.

  1. Are we clear about our quality strategic aims and focused on the most important improvement opportunities to achieve these aims?
  2. Is there a solid strategic rationale for the annual and long-term improvement goals that management is recommending?
  3. Are we improving fast enough to meet our annual and long-term improvement goals?
  4. Do we have any systemic weaknesses that should be addressed to meet our internal improvement aims and to respond to external demands for data and accountability?
  5. Are there any individual facilities or programs that have weak improvement capabilities or insufficient capacity to improve?
  6. What are our experiences with improvement telling us about the changes that are necessary in our quality strategic plan?
  7. Are we sparking innovation, finding and systematically spreading best outcome practices and great ideas?

Quality Literacy

Continuous governance education is a critical tool for advancing quality. The ultimate goal is to build the board's quality literacy.

Quality education should begin with new trustee orientation. It should include assistance in understanding reports and dashboards, information about trends, a summary of legal and regulatory mandates, an explanation of terms and acronyms, and a review of the hospital's quality program, initiatives and challenges. One way to improve new trustees' understanding is to assign them to the quality committee. This will give them a deeper understanding of the hospital's quality commitment and efforts.

In addition, boards can further their quality governance through:

Goal achievement and compensation. Tying executive goals and performance to compensation is critical practice. Achieving certain quality goals should be a part of both the CEO's and every staff member's annual performance evaluation. Ensure that achievement is rewarded by linking a meaningful percentage of compensation to it. The entire organization should be focused on quality progress, and goals should cascade through all levels of the organization.
Budget. Ensure that quality improvement plans and goals are incorporated into the budget. Identify the resources needed to help guarantee success far enough in advance so they can be included in the annual budget process. And if budgets need to be reduced, ask what impact those cuts may have on quality.

Quality diversity. Evaluate the diversity of your board. Do you have members with quality expertise? It might be clinical or from an outside industry.

Board self-assessment. Does the annual board self-assessment include an evaluation of board and individual quality expertise and practice? Have you considered those findings as you develop quality and patient safety education for the board?

If trustees begin thinking this way, quality discussions will pervade meeting agendas. More importantly, trustees' focus will shift from the quantity of time spent on quality leadership to the accomplishments their leadership has sparked.

For the complete OIG and AHLA report, go to

Larry Walker ( is president of The Walker Company Healthcare Consulting LLC, Lake Oswego, Ore. He is also a member of Speakers Express.

Sidebar - Where to Begin