Hospital Board’s Responsibility for Quality/Patient Safety

Dwight Evans, M.D., FACPThe speaker does not have any relevant financial relationships with any commercial interests

Healthcare System Case Study -Quality/Pt. Safety Failure

•A NHS Hospital from 2005 to 2008 allowed “appalling care” conditions to persist▫Catastrophic failings in Quality/Pt. Safety went

undetected and uncorrected – long incubation time

•Result: Major Breach of Quality and Patient Safety ▫Resulting bad press and ongoing high-level

oversight

Areas of Concern• Elevated mortality (medical and surgical)• Harrowing personal stories of appalling care:

▫ Failure to respond to patient/family concerns▫ Inpatient wards – lacked basic care:

Privacy Cleanliness Assistance with feeding Callous indifference to patients by staff

▫ Triage in Emergency done by non-licensed staff▫ Surgical Dept. “dysfunctional”

• Lack of Basic Nursing care• Hospital Culture: long incubation time before problems addressed

▫ Culture of denial of uncomfortable information▫ Atmosphere of fear of adverse repercussions▫ Lack of openness (secrecy and protectionism)▫ High priority in meeting targets (fiscal)▫ Low employee morale▫ Disengaged medical staff

• Result: passive acceptance of poor standards

Initial Findings: •Poor or Absent Governance / Poor

Management System [Culture of denial of uncomfortable information]▫Senior management “priorities” wrong

No effort to remedy staff deficiencies Absence of effective clinical role in governance Failure to respond to Patient concerns

▫Board inept: Discounted warning signs of deterioration

No urgency to remedy governance issues Focus on finance system not patient outcomes Result: no one responsible

What Happened Next?

•When disaster strikes, the tendency is to seek someone who can be blamed

•Significant press attention to the harrowing stories

•Numerous major external reviews

Basic Problem:•Lack of Oversight by the Hospital’s Board

▫Institutional Culture wrong: Lack of Accountability▫Failure to appreciate the enormity of what was

happening Discounted warning signs –developed “Blindsight”

▫Slow reaction while downplaying the significance

▫Board had seen its role as self promotion instead of critical analysis

▫No Culture for the Board to listen to patient experience

▫Not address shortage of nurses

Culture

• Definition: The Shared basic assumptions, norms, and values and repeated behaviors of a group into which new members are “socialized” to the extent that▫“Culture” is the way things are done

around here”

• “Every System is perfectly designed to get the results it gets”

• “Culture eats strategy for Breakfast”

Lessons Learned

•Hospital’s negative culture should have been addressed▫Failure to put the patient first in everything

that is done!▫Acceptance of poor standards ▫Lack of openness to criticism▫Defensiveness and secrecy▫Looking inward, not outward▫Misplaced assumptions about the

judgments and actions of staff

Lessons Learned II•Problem at multiple levels:

▫“Blunt End” of the system (Board/SN Management): where decisions [resource allocated, policies, rules, regulations] made By shaping the environment where care is

delivered the Board/Sn. Management may create latent conditions that increase the risk of failure – poor quality/patient safety

▫“Sharp End” – the frontline staff Where Care is provided

Lessons Learned - III•To improve Patient safety requires a

“supportive system” [Blunt and Sharp ends]▫System environment may create latent

conditions that increase risk of failure▫Boards must drive the agenda of

building capability to deliver continuous quality improvement

•Lack of a Culture of Safety is toxic

Questions For Your HC Board:

• Does your Board understand its role for quality, patient safety and oversight of the medical staff?

• How will your Board handle a sentinel event? How will your board handle a tragic event that results in the death of a patient?

• Can we link quality, safety, satisfaction and cost issues into a common strategic and operating plan?

• How can your Board have the largest impact on improving both financial and quality performance?

When Leadership [Board and Senior Management] Fails Is the failure due to distractions taking attention away

from patient safety and quality (e.g., financial health paramount, acquisition pending?)

Are there conflicting messages from Board and Senior Managers?

Is the culture aligned with quality and safety goals? Are physicians on board with the quality and safety

agenda? Was there adequate infrastructure in quality and safety

to support the leaders? Were there missing or underdeveloped leadership

competencies? What were the incentives to succeed? What were the

consequences of failure?

Benchmarks of Effective Board Governance1. Function in accordance with policies and structures that

facilitate the performance of their designated responsibilities2. Have members with the competencies, skills, and diversity

that result in constructive, well-informed deliberation and decision-making

3. Careful establishment and closely monitor hospital performance measures and goals through regular review of data, reports, and dashboards.

4. Continuously improve CEO Performance by setting clear expectations, conducting objective evaluation, and taking foll0w-up actions

5. Continuously improve board performance by setting clear expectations, conducting objective evaluation, and taking follow-up actions

6. Intentionally creat a culture that nurtures engagement, mutual trust, willingness to act, and high standards of performance

Evaluation of Board Quality/Pt. Safety Performance• Boards should ask three types of questions:

▫Is our Patient Experience getting Better? Are we on an acceptable track to achieve this, or

do we need to change direction?▫How good is our care [Better Population

Health]? Objectively measured by: “Are our Outcomes

better” compared to others like us?▫Are we aligning our resources to increase Value?

By improving Outcomes while lowering per-capita

cost▫“Triple Aim” not “Triple Fail”

Evaluation of Board Quality/Pt. Safety Performance1. Do high-quality hospital have better

management practices than low-quality hospitals?

2. Is there a relationship between hospital board performance and management performance?

3. Do certain types of board practices correlate with comparable management practices?

Board Myths

•Boards think their organization’s quality is a lot better than the administrators, doctors and nurses do:

▫“But you never told us in a way we could understand”

▫“We’re above average”

▫“Mind the Gap”

Outdated Board Quality/Patient Safety Concepts

1. The primary job of the Board is to hire/fire

the CEO

2. The primary obligation of Board members is

to come to meetings

3. Board members are not accountable for

decisions

4. Board membership is “honorary”

5. Quality is the job of the physicians not the

Board

Board’s Role in Quality What Does The Evidence Tell Us?• Hospitals with high management scores above median, are

more likely to: {Operations, Monitoring, Target Setting, HR}

▫ Be High-quality hospitals (p < 0.01) [43% vs. 14%] One Std Dev increase in management score was associated with a 20% increase in being a high-

quality hospital

▫ Have Higher Board performance ( p < 0.001) How:

a) Attention to Quality [ Board Time spent on Quality in Board Meetings]

b) Effective use of Metrics [Board Monitoring Quality- Management establish targets]]

Result: effective hospital governance by Board is related to a hospital’s performance on Quality! Hospitals with Boards that had high attention to quality had

more effective management practices (monitoring) while hospitals with boards that effectively used clinical quality metrics were more likely to have effective target stetting and operations management practice.

Tsai, Jha, Gawande, Huckman, Bloom and Sadun. “Hospital Board and Management Practices Are Strongly Related to Hospital Performance on Clinical Quality Metrics.” Health Affairs, 34 (8) (2015): 1304-1311.

Board’s Role in Quality What Does The Evidence Tell Us?

• 67% of hospital boards have quality as an agenda item at every Board Meeting

59% have a quality subcommittee

• Most Boards are primarily focused on financial issues (~93%), and assume quality is “adequate”

• Does your Board review quality data?: high quality performers had more Board engagement (and lower Mortality rates)

1. Less Hospital acquired infections2. Less Medication Errors3. Better Core Quality Measures (HEDIS)4. Better Patient Satisfaction Vaughn T, Koepke M, Kroch et. al. J of Patient Safety

2:2-9, 2006

(Jha, Epstein “Hospital Governance and the Quality of Care” Health Affairs 29: 182-187 (Jan 2010)

Jiang JK., Lockee C. Bass L. Fraser O/ 2—0/ “Board Oversight of Quality: Any Differences in Process

of Care and Mortality?” J Healthcare Management 54(1): 15-30.

Board’s Role in Quality What Does The Evidence Tell Us?Outcomes are better in hospitals where:

• Board spends >25% of its time on quality and safety (p = 0.0009)

• Board receives a formal quality measurement report (p= 0.005)

• High level of interaction between the Board and medical staff on quality strategy (p = 0.02)

• Senior executive compensation based in part on quality and safety performance (P – 0.008)

• CEO identified as person with greatest impact on QI, especially when so identified by the QI program director (p = 0.01)

Vaughn T, Koepke M, Kroch et. al. J of Patient Safety 2:2-9, 2006

Board’s Role in Quality/Pt. Safety

• Prioritize Leadership attention to Quality / Patient Safety Improvement• The Currency of Leadership is

Attention! What leaders pay attention to tends to

get the attention of the entire organization

Prioritize your resources to achieve the aim: your calendar, meeting agendas, team reviews, executive performance feedback and compensation systems, hiring and promotion policies…

Board’s Role in Quality/Patient Safety

• Each Board should define roles, responsibilities, expectation/accountability for Quality/Patient Safety:

• Formal education (4 – 8 hours) introducing new board members “Science of Improvement” principles, methods, and communication Tools

• Board Retreat and continuing Board education on quality and patient safety (for example: outside speakers on quality)

• Use stories (adverse patient experiences) to assist in seeing failing or broken systems

• Do your Board members have the skills to recognize the quality and patient experience as well as financial state of your hospital?

Board – Transforming Q / Pt safety• Will:

▫Boards have a powerful role in establishing will for institutional change (improvement)

• Ideas:▫Board members can assist in finding ideas of how

to reduce mishaps• Execution:

▫Select a Change model (Method of improvement)▫Focus on results▫Make improvement part of Management’s

responsibility• Board’s currency is also “Attention”

▫Review both financial status and Quality status

Experts

OperationalLeaders (Executives)

ChangeAgents

(Middle Managers, Project leads)

Everyone

(All Staff)

Unit Based Teams

SharedKnowledge Continuum of PI Knowledge and

Skills

Deep Knowledge

Con

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t: W

hat

Skil

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ach

Em

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Need

?Many People

Few People

Important to make sure that each group receives the knowledge and skill sets they need when they need them and in the appropriate amounts.

A key operating assumption of building capacity is that different groups of people will have different levels of need for PI knowledge and skill.

Board’s Role in Quality/Patient Safety• Be “Problem-Sensing”

▫Actively seeking out weaknesses from multiple sources

▫Be cautious about self-congratulation; when problems are found, sanction doesn’t stop at the “Sharp End” but fall on the “Blunt End” as well

• Don’t be “Comfort-Seeking”▫Focusing on external impression- seeking assurance

that all is well Serious blind spots-limited data reviewed Preoccupied with demonstrating compliance with

external expectations Failure to listen to negative signals from staff Lack of knowledge of the real issues at the front line

Ideal Board Structure

Constituenc

y

HC Board

Executive Committee

Finance Committe

e

Audit Committe

e

MissionCommittee

Quality/Pt. Safety

Committee

Board Quality Committee

•Every Hospital Board should:▫Have a Quality/Pt. Safety Committee

▫Devote at least 25% of Board time (Agenda) to Quality and Patient Safety This symbolically signals the Board’s quality and Pt.

Safety commitment to all hospital staff

▫Set Quality and Patient Safety Goals (Dashboard) that exceed local benchmarks

▫ Include Quality and Pt. Safety outcomes in CEO’s evaluation

Business Case for Quality•Quality (optimum patient outcomes, safety

and service) is a moral imperative•The principal source of financial return

(Re: Quality) comes from removing “waste” from your ‘system’▫Process inefficiency▫Overuse ▫Preventable harm

•Who benefits: Patients, clinical staff, staff, your hospital’s reputation and “He who pays”

Quality/Patient Safety Constraints

•If resources are infinite, most risks can be eliminated

•But resources are not infinite – a constant need to balance risks and resources

•The fight for patient safety is a never-ending struggle against entropy (an enemy that continually emerges and re-emerges)

Quality/Pt Safety Committee

•The Healthcare System’s Quality/Pt Safety Committee must have the same discipline as the Finance and Audit committees:

▫Just as finance committee is accountable for every $ received and spent

▫The Quality and PT Safety Committee should be accountable for the quality and safety of the care delivered to every patient

Quality vs. Finance

• Board needs to link quality and patient safety to the financial status of the hospital

• “If hospitals had a Board Quality committee that function like a finance committee,

• We would transform healthcare.”Peter Pronovost,

M.D.

37

38

39

40

Business Case for Quality• Reducing defects and overuse results in financial

benefit• Improved patient safety will lower professional liability

costs ▫ Lower malpractice costs: many patients don’t even know the

name of their MD, if the patient has a trusting relationship with the provider, a malpractice suit is less likely; and if a settlement, the $ amount is less)

• If patients experience better Q and Safety: ▫ Better reputation: better pt sat = more ‘value’ (the key driver of

reputation = pt satisfaction▫ Better employee satisfaction (esprit de corps) –a measure of staff

engagement

• No tradeoff between productivity and quality: if ‘waste’ is removed▫ If a HC facility fire workers of increase workload to reduce costs,

quality will suffer▫ If a HC facility removes “non-value” work (“waste”) form the

system, quality goes up, costs go down and value is improved

Suggested Board Quality/Pt. Safety Committee Membership

•Chair: Member, Board of Trustees•2+ Board Members with background in

Quality•Hospital CEO/CMO/CNO/CFO•Hospital Quality/Patient Safety Coordinator•2-3 staff (medical, nursing, quality

facilitators, etc.)•Consider 1-2 patient/family members

Quality/Pt. Safety Committee Agenda

• Every meeting begins with the presentation of a clinical case involving a patient who was harmed▫~10 minutes with questions▫Presented by the Medical Director/PI Director▫Use layman’s terminology▫Focus on lessons learned and action plan to

ensure the event never occurs again• Is the control plan “hardwired” so that the

improvement is sustained?• Follow – up report for each metric in 3-6 months

Quality/Pt. Safety Sub-Committee Report to the Board

• Each Board meeting review of your hospital’s quality and safety status ▫ First item on the Agenda▫ Allow for > 25% of Board Agenda time

• Chair of the Quality/ Pt Safety Committee presents report▫ Synopsis of cases reviewed, findings and action plans▫ Overview of performance scorecard:

▫ Clinical Outcomes▫ Patient Safety concerns▫ Patient Experience (satisfaction)

▫ Highlight key issues the Q/Pt Safety Committee is focusing on

▫ Solicit feedback/answer questions▫ Make recommendations for policy changes

Boards/Senior Leadership Challenges

•Critical Leadership factors to create a “Safe” environment:▫Acts of Humility

Such as learning from criticism and admitting mistakes

▫Empowering staff to learn and develop▫Acts of Courage

Such as taking personal risks for the greater good

▫Holding employees responsible for resultsCatalyst, 2014

Board/Senior Leadership Challenge

• It takes Courage to implement any change

Courage comes from doing something “uncomfortable” (different)

• Key: form a Quality/Pt Safety Board committee▫ clearly define its purpose and core behaviors, ▫ have it function like your organization’s finance and

audit committees

Ground Rules For Good Board Function•“Be in the moment” – not on mobile phone,

not reading email, etc. •Be open and honest•Plan to accomplish something (“X” goal at

that board meeting)•Don’t kill the messenger•Ensure that all Board members have the

same opportunity to speak/participate•Listen to the view of others•Focus on what is possible•No “sidebar” conversations

Board Quality/Pt Safety Best Practices

•At least 25% of Board Time (first on Agenda)

spent on Quality and Patient Safety issues

•Board Quality/ Pt. Safety subcommittee

•Review quality performance (dashboard or

“scorecard”)

• Include quality and patient safety goals in

CEO’s Performance Evaluation

Board – Quality/ Pt. Safety Communication Guidelines

• Speak the truth; but do it in love Eph: 4:15

• Speak to those directly involved in the issues Col. 4:5

• Speak respectfully

Ok to be passionate, but with respect Eph. 4:25

• Remember you are addressing a problem, not the person you are talking to Eph. 4:2,25

Not testing motives, evaluating behavior, but addressing a problem