Most health care organizations have mission and vision statements that broadly express their purpose related to meeting stakeholder needs. Statements like "We will strive to be a high-quality, low-cost provider,” are common, but relatively few organizations publicly link that commitment to specific practices that the organization and its board are undertaking to meet its mission and focus on the needs of the communities they serve.

While the idea of compacts between health care organizations and their internal stakeholders, such as physicians, are becoming more common, a formal, publicly shared compact around performance between the organization, its board and the community is rare. At Inova Loudoun Hospital, Leesburg, Va., a quality compact addresses these practices and demonstrates the board's ongoing commitment to and oversight of specific areas of performance that the hospital and board are monitoring to ensure high-quality care for patients.

"Inova Loudoun Hospital has been a high-level performer for a long time,” says Connie Curran, CEO of Best on Board, an educational, testing and certification services program for health care trustees and executive leaders. After working with Inova Loudoun for several years, Curran conducted training on quality and safety performance oversight for its governing board. When the training was complete, the group asked: "What's next?” Curran suggested translating education into action by creating a compact. "Select those areas where improving performance will make the greatest impact and then make a commitment to all of your stakeholders to address them,” she told them.

Inova Loudoun decided to make a public commitment to its community about where the organization is going to drive quality performance in the years ahead. Then it went further: the organization posted its quality compact and performance data on a public website so community members and other stakeholders can follow the results of its journey to improved quality and patient safety (see the compact at

"That level of performance transparency is what all hospitals should strive for if they are truly committed to high-quality, safe care. I think it's going to give Inova Loudoun Hospital an enormous competitive advantage," says Curran. " … Very few boards have made a public commitment to their stakeholders to be transparent and to drive a plan to improve quality."

The Right Thing to Do

As payment models shift from volume-based care to value-based care, understanding community and patient expectations and formalizing a commitment to meet them are more important than ever. Curran advises focusing on the few areas of performance that are most important to a hospital and its constituents. "In hospitals, there are often so many competing agendas and so many initiatives going on that it's easy for the organization's focus to become diluted," she says. "By putting a public focus on quality performance and then selecting three or four key metrics to monitor, the organization can concentrate its focus and launch a full-court press for improvement.

"Given the enormous financial strain facing many hospitals, it would be very easy for them to focus all of their attention on making ends meet,” she adds. "However, we know that quality and cost are inextricably connected. If you drive your quality up, your costs will, in fact, come down."

Inova Loudoun is rising to the challenge, says Martha Calihan, M.D., a physician in the Integrative Family Medicine Center, Leesburg, Va., and chair of the Inova Loudoun Hospital board. "Our hospital, like many in the last few years, has really been on a journey of focusing more on quality across the board," she says. After she completed the training on quality and safety oversight for trustees, she brought it to her board. That was the tipping point. "We have had ongoing board education within the organization, but this was above and beyond that," she says of the decision to create a compact with the community.

"It's about not only looking internally at our results, but being transparent about them with our community," she says. " … When you put it out there publicly, the commitment becomes associated with a new level of accountability — you know you're going to be serious about what you're doing. Nobody wants to see bad data, so you're not going to ignore it if it's staring you in the face."

Inova Loudoun also began gathering insights from patients and their family members. Hospital leaders were concerned that they were not getting a complete picture of the patient experience through other sources of input, so they convened a patient experience committee that meets every four to six weeks with recently hospitalized patients and their families. Calihan chairs the committee, which includes the CEO, chief medical and nursing officers and a patient advocate.

"We wanted to better understand the experience of care through the eyes of the patient," Calihan says. "I think the hospital provides good care, and our numbers show that we do, but what is care really like for patients? What did we do well? What did we not do well?" She says the experience can be affirming or painful depending on the patient and family feedback.

It Starts with the Board

The first step to quality accountability, says Curran, is making sure that the board has a commitment to quality. Boards that have made this commitment typically have a quality committee that assumes responsibility for overseeing and improving quality outcomes and educating board members about key quality and safety issues and trends. Then, it needs to "look at where the community is in terms of its health status, where they want to be and then define the core metrics.”

Those steps are not uncommon. But the next step — developing a formal and widely shared compact — can lead health care organizations to the next level in quality accountability.

This process includes some challenges, Calihan admits. The hospital's board, executives and clinical leaders must be comfortable going forward, she notes. "Quite frankly, the challenge of what happens if you have bad data is there," she says. But, a focus on the understanding that sharing performance data is the right thing to do can help to build momentum. "The results are the results, and even if we don't have good scores, our commitment is to figure out why and to do what we can to improve them," she says.

Inova Loudoun's board, executives and clinical leaders had an opportunity to give feedback, which helped generate buy-in. "There was no resistance or pushback,” Calihan says. "Once we started talking about it, we stepped back and said, ‘You mean we don't already do this?'”

The hospital introduced the compact to the community with a letter from Calihan discussing the hospital's quality and safety efforts. It highlighted the release of the first quality report and explained the quality indicators it would track: national measures of hospital quality, rates of infection and other health care-associated conditions, unplanned hospital readmission, and patient satisfaction. It also announced the formation of the patient experience committee.

Calihan encourages other hospitals to consider developing a compact and publicly sharing their quality and safety performance. "It provides a focus on the importance of quality metrics,” she says. "We're all doing that work and looking at those numbers internally anyway. But I think it's really important for the community to know what their hospital and its board are working on.”

The process must start with the board, Curran stresses. "As stewards of an essential community asset, board members are accountable for care quality and safety, oversight of the CEO and development of senior leaders, the credentialing and performance of the medical staff, fulfillment of fiduciary and legal duties, and ensuring that the organization operates according to its mission,” she notes. Using a compact to make a formal, visible commitment to constituents is not an option, but a must-do, she says. "I don't think you can be part of a sector that accounts for 18 percent of a country's GDP and not have clear, visible accountability to your stakeholders."

Linda Pophal ( is a communications consultant with Strategic Communications LLC, Chippewa Falls, Wis.