Hospital board members are engaging as never before on patient quality and safety with new training and tools to help them gain insight into the clinical care happening at the facilities they govern.

"I've seen a sea change in how boards are governing on patient safety in recent years," says John Combes, M.D., president and chief operating officer of the American Hospital Association's Center for Healthcare Governance. "I think boards today spend most of their time creating a safe environment for patients and staff. There is a realization that, as a board member, my primary fiduciary responsibility is around the care of the patient."

Because many board members are non-clinicians they may feel ill-equipped to ask the right questions about patient safety, especially details about core measures and inpatient hospital best practices for specific medical conditions.

But Combes says trustees should remember that they have a high-level role; they don't need to know the specifics of when and which patients receive warfarin therapy or have a central-line inserted. Rather, they can focus on leading indicators to stay at a strategic level.

Boards have six areas of responsibility in which they can have a direct impact on patient safety, Combes says. Boards are responsible for:

1. The mission of the organization. A mission statement can reflect core values on patient safety and quality. Additionally, trustees can resolve to base all their decisions on quality and patient safety.

2. The organization's values. Boards can make sure that the culture of their organization values safety, teamwork and reliability.

3. Performance oversight. Boards set organizational goals, they don't just track performance over time. Boards can think big and aim high. Goals of zero harm or 100 percent compliance are such examples.

4. Leadership decisions. Boards credential all medical staff members, and they select, monitor and incentivize the CEO. Trustees can ensure they have the right competencies and skillsets at the table to achieve harm reduction goals.

5. Strategy and strategy oversight. Trustees can ground themselves in making sure strategies are meeting the needs of the patients, their families and the community. Quality and performance can be used to drive strategy.

6. Resource allocation. Boards can influence quality outcomes by making sure that quality goals match resources. For instance, when determining whether to acquire a new technology, boards should calculate not only financial return on investment but also patient quality return on investment.

Look Outside
Hospital boards should also make sure they aren't missing the boat on patient safety initiatives. While not endorsing any one approach, Combes says that any national patient safety program that can give them comparative data and tools to improve quality are important to be involved in.

"This is part of the overall agenda-setting," Combes says. "Is this a learning organization? Is this a collaborative organization?"

The field of patient safety and quality is still relatively new, and everyone is still learning how to do it effectively, says Maulik Joshi, president of the Health Research & Educational Trust, which operates a Hospital Engagement Network of 1,500 hospitals in partnership with the AHA.

"Measuring quality in hospitals is still in its infancy," Joshi says. "Just 10 years ago we had the first 10 measures for Hospital Compare."

To help hospital trustees become better versed on hospital quality, the Center for Healthcare Governance created curriculum around these topics. The five-hour trainings started in Massachusetts several years ago, after Blue Cross Blue Shield of Massachusetts rolled out its Alternative Quality Contract, which tied hospital quality targets to reimbursement. More than 60 hospital boards in the state have completed the training.

The Center also devised a 10-part video series and workbook in partnership with the AHA/HRET HEN aimed to educate board members on eliminating harm.

Combes says the feedback on the training from board members has been positive.
"One of the best responses I got was that a board member said she now feels empowered to do the work she needs to do," he says. "A lot of board members see quality as being very clinical and they defer to physicians as the experts. But they can challenge assumptions and use their experience and perspective to ask questions patients and families want the answers to as well."

A buzzword in hospital stewardship these days is "transformational governance," as hospitals and health systems adjust to the changing payment landscape and take on more oversight of outpatient and ancillary and supportive services outside of the inpatient walls, Combes says.
Inpatient harm reduction is important so institutions can get to a starting point in this new care environment. "When you look at the triple aim, it is not about reducing patient harm," he says. "It's how are we making and keeping patients healthy? How are we supporting a healthy community? That's the next horizon in governance."

For more on reducing patient harm, read the October cover story, "The Bottom Line on Quality."

Rebecca Vesely is a freelance writer in San Francisco.