High-quality, patient-centered care has always been imperative for health care providers and their boards. But as reimbursement hinges more and more on fee for quality rather than fee for service, quality care has also become a financial imperative. Savvy boards recognize that delivering quality care is now part of their fiduciary responsibilities, and they build a quality review into their board meetings.
To meet quality goals, however, the ways in which hospitals and systems deliver care have to change. Putting patients’ needs first means providing efficient, coordinated care. But this reorganization is disruptive to physicians and staff, and senior leaders may encounter resistance. As a result, it calls for boards that understand and can lead the transformation to patient-centered care.
In our 20 or so years serving on boards for six different providers, we have come to appreciate how boards incorporate a review of quality metrics into their meetings. We have witnessed how the following practices can improve the patient experience and the quality of care.
Board Best Practices
Just as health care delivery is changing, hospital and system boards are changing how they operate to adjust to the challenges of the new era. Some examples:
1. Start every board meeting with a presentation of a patient case, often one in which the outcome was poor. Discussion focuses on what went wrong and why, and what is being done to reduce the chances that the patient’s adverse outcome ever happens again.
2. Devote part of every meeting’s agenda to reviewing quality data, often deliberately placing it before financial reports, to ensure that it receives enough engaged discussion while time is available and energy is high.
3. Create quality committees that meet with senior management to review performance so that data can be explored in greater depth than is possible at a meeting of the full board. They are considered the counterparts to board finance committees.
4. Make explicit efforts to get trustees out of the boardroom and into patient care settings. University of Utah Health Care’s board members each “adopt” a patient care unit and spend an hour there per month, meeting staff and interviewing patients. The Salt Lake City-based academic health care system also has had board members go through an exercise in which they were told they had a disease, such as heart failure, and had to go through the search for information and exploration of decisions that a typical patient would have to make.
Holding management accountable is impossible without good data and plenty of it. That requires an analytic strategy that goes beyond small samples of patients. Organizations need enough data so that they cannot be dismissed as meaningless, and so that individual patient care units and clinicians themselves can understand how they compare with their colleagues. The data will never be perfect, but boards should not allow senior leaders to be paralyzed by this reality.
We believe that boards should be looking at an array of quality data at every meeting, including the following:
1. Mortality metrics. Expected vs. observed mortality is readily calculated for the overall patient population and for specific conditions that are the focus of government value-based purchasing programs, including acute myocardial infarction, pneumonia and heart failure. It is not realistic to push management to be statistically better than expected for mortality because the biggest determinant of mortality is the individual patient’s disease burden. But, if mortality is worse than expected, it should be considered an organizational crisis.
2. Clinical metrics. The clinical metrics that are the focus of value-based purchasing initiatives should include readmission rates for acute myocardial infarction, heart failure, pneumonia, chronic obstructive lung disease and major total joint replacement. Providers should expect to be within the razor-slim performance ranges. If performance is worse than the market, these areas need attention.
3. Market share metrics. These drivers, such as patient experience data, are the most direct measure of the organization’s overall effectiveness in meeting patients’ needs and giving them peace of mind that their clinicians are working well together on their behalf. Our analyses show that what patients value most are the competency, empathy and communication skills of clinicians and the coordination of care — not amenities such as gourmet food and valet parking.
4. Effectiveness of care. These data are especially needed for condition-specific subsets, such as patient-reported outcome measures. Boards should recognize that data at the hospital and physician group-level are important but limited units of analysis and improvement. Major gains in effectiveness and efficiency can be achieved when subsets of patients with similar needs can be identified and teams can be organized to meet those needs.
These teams need data to guide their improvement efforts, and only patients can provide information on the outcomes that matter to them. For example, surgical mortality is low for most procedures for most institutions, but rates are highly variable for incontinence and sexual dysfunction after prostate cancer surgery. Boards should not allow management to assert that their organizations are delivering world-class care without measuring actual outcomes.
5. Engagement of clinicians and other employees. Hospitals and systems need a workforce that takes pride in delivering excellent care, and does so as efficiently as possible. Organizations with better engagement data have lower turnover rates, and better financial and quality performance.
Finally, organizations that make their scores readily and easily accessible on their own websites can indirectly encourage better performance among their clinicians. University of Utah pioneered the way with the first online posting of patient experience data, and it credits significant improvement to transparency initiatives.
Today, nearly 50 percent of its physicians are in the top 10 percent nationally, up from only 4 percent prior to the adoption of transparency initiatives. Other innovators like Piedmont Healthcare, Atlanta, and Wake Forest Baptist Health, Winston-Salem, N.C., also are reporting early success. Trustees can champion transparency strategies and encourage rapid adoption.
The First Item on the Agenda
Just as health care providers need data to do their jobs well, so do the boards of their organizations. Fortunately, we are entering an era in which the data needed to guide the reorganization of care around the needs of patients can be collected quickly and efficiently with technology.
Every patient can be given the chance to contribute information on the quality of his or her care. Enough data can be collected so that units of real potential improvement — for example, patient units and individual clinicians — can learn how they are performing. Boards and management then can create financial and other incentives for improvement.
We expect that great organizations always will be the ones with great boards. The best of those boards will focus on high-quality data first because quality has a direct correlation to financial success and because the relief of patients’ suffering is what draws everyone, including trustees, to health care.