Why It Matters
“In health care, boards are essential to the achievement of better care.”
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4 Reasons Your Health System Needs a QI-Savvy Board

By Donald Berwick | Tuesday, March 12, 2019

IHI President Emeritus and Senior Fellow Don Berwick believes that board engagement is essential for health care system transformation. In the following interview, he explains why board education about quality improvement is a worthy investment.

Why is it important to educate health systems boards on quality improvement?

In health care, boards are essential to the achievement of better care. The reasons are a little complex.

First, although I can probably get better at tennis or baking a cake [on my own], for most of what we try to get done in health care — better care, better health, and lower costs — it’s not like that. We must do this together. In fact, we’ve got to work with others. Quality improvement in health care inevitably involves interdependency.

Working together is not automatic in organizations. It must be supported, nurtured, built upon. People need to have time to get together to work on something. There must be clarity about shared aims. I can decide to make a chocolate cake, you can decide to make a strawberry cake, but if we’re going to work together, we need to decide on the cake together. That involves leadership. You need consolidated energy to make progress.

We’re going to have to learn our way to this progress, and quality improvement is all about learning. I always use a child learning to ride a bike as an example of the underlying processes. A child cannot possibly learn to ride a bike without falling. You can’t improve in a complex environment without some failures. The failures help teach you what to try next. So ask: What happens when you fail in your organization? Is it a safe place to fail or not?

Improvement involves recognition of existing defects. We have to acknowledge, for example, that health care has major patient safety problems; that we’re hurting people. So ask: Is it okay to say that? Can we speak up? Can we label the defects? And what about resources? If we’re going to test changes, and, for example, we need a tweak on a webpage or time to gather some data, is there going to be some money to do that? Will we have what my British colleagues call “headroom” for testing changes?

Those are the systemic support issues that allow improvement to occur in a complex world. Who arranges for those supports? Leaders. They’re not commanders, they’re not dictators, they’re arrangers. They make it possible for us to work together so that we can learn, so we can fail and get up and then try again. That’s what leaders do.

The Chief Executive and the Chairman of Medicine and the Director of Nursing, they matter. They’re deciding whether it’s okay to learn. But where do they get their support, their direction? After all, they work for someone, too.

They work for the board. The board hires them, fires them, pays them, counsels them. Without the board right from the start saying, “We understand these are things that need to be made better; we understand it’s a systems matter; we understand that learning is the way to do it, not beating up on people or offering incentives,” then leaders may hesitate to invest in the processes and cultures of learning. Boards go wrong when they hire the wrong leader, when they overreact to evidence of defect, when they conserve resources when they need to be more generous with resources for improvement. Boards set the terms.

How does understanding quality improvement influence a board’s effectiveness?

Boards that master a range of technical quality ideas are better boards. And I don’t just mean a committee on a board; I mean mastery for the entire board. If they understand how to improve a process, how to interpret variation, how we understand human motivation, how we solve conflicts, and how we support tests of change, I think four good things will happen for your organization: 

  1. Boards will manage their own processes. Boards have processes that consume organizational resources. If those processes aren’t continually improved — the way they meet, the reports they get, how they make decisions, how they interact — [these processes] waste everybody’s time.
  2. Boards will better understand their role in resource allocation and rule setting, permission granting, cultural development, and setting a tone in the organization that allows learning and improvement. They ask, “How can we help?” and they listen to and act on the answers.
  3. Boards will address leadership succession. I can tell you very sad stories of health care organizations in which the regime — the CEO and his or her immediate staff — have been totally dedicated to improvement, making great progress, and then the CEO leaves and the board hires a new CEO who doesn’t get it and [improvement work] stops. They stall. Improvement work goes away. And sometimes improvement work crashes. The boards have a job of continuity. W. Edwards Deming emphasized “constancy of purpose for improvement” as his first piece of counsel for leaders who want to foster progress, and that means constancy of purpose across changes of leadership. If boards understand improvement, they’ll be more attentive to proper leadership succession.
  4. Boards will give up on the illusion of incentives as the magic ingredient for improvement. Boards often treat variable compensation, rewards, withholds, and bonuses as if they held the keys to success. Maybe incentives have some effect, but that’s not where authentic quality improvement comes from. If boards study improvement, they will give up relying too heavily on incentive-based board work.

What would you say to someone who expresses doubt that boards have enough time to learn about quality improvement?

They don’t have time, but they need to do it anyway. I’ve become persuaded that investments by boards in seeing quality methods — some of them for the first time — and studying them is an investment worth making.

My colleague, Gary Kaplan, the CEO of Virginia Mason Medical Center, years ago became enamored with the Toyota Production System and Lean production. You can’t be on his board if you haven’t spent two weeks in Japan with him visiting Japanese masters and organizations that use Lean thinking and Lean production as their way.

If I were chief executive of a health care delivery system and wanted to put improvement at the forefront, I would say to my board, “We have to go to school and learn together.”

Editor’s note: This interview has been edited for length and clarity.

(Having difficulty watching this video? Watch on YouTube.)

You may also be interested in:

IHI’s Framework for Effective Board Governance of Health System Quality white paper

The Board's Role in Governing Quality seminar (June 20–21, 2019 in Denver, CO, USA)

WIHI: New Guidance for Governance of Health System Quality – What Trustees Should Know and Do

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