Over the last decade, research into health care governance has identified a correlation between health system board prioritization of quality and higher performance on key quality indicators. During this same period, the knowledge that board members need to fulfill their quality oversight responsibilities has grown exponentially. In response, the IHI Lucian Leape Institute has published the Framework for Effective Board Governance of Health System Quality white paper. In the following interview, one of the white paper co-authors, IHI’s Chief Clinical and Safety Officer Tejal K. Gandhi, MD, MPH, CPPS, explains why it’s necessary to fully engage trustees in quality and safety.
How has the role of health system boards evolved over the last 10-15 years?
More people understand that boards oversee quality and safety as part of their overall fiduciary responsibility. Traditional boards were very much focused on financial stability, but now there’s so much more a board needs to know and address.
It’s worth noting, however, that it’s been hard for boards to make that shift. Often, the people on health system boards are not clinicians and don’t necessarily feel comfortable having oversight over things like quality and safety. Clinical information is complicated. There is so much jargon, and so many acronyms and nuances. It’s hard to provide boards with the information they need to ask the right questions without overwhelming them.
How is the increased focus on population health and the Triple Aim influencing boards?
Because the breadth of what hospitals need to work on is expanding, the breadth of what boards need to understand and oversee is expanding as well. When our team was writing the Framework for Effective Board Governance of Health System Quality white paper, we inventoried the board education that’s available. Most of it focuses on safety. This is great because safety is important, but there is much more than safety under the quality umbrella. This includes topics such as population health, equity, workforce safety, and quality and safety across the entire continuum, not just in hospitals.
Why should health care leaders support better trustee engagement when some may frankly not welcome too much board involvement?
Whether leaders like it or not, a board must also hold their CEO accountable for quality and safety. A colleague of mine has said that boards should be spending as much or more time on quality and safety as they do on finance, and that can be a big cultural shift for all parties. Making that transition requires a CEO and quality leader who are committed to making it happen. An aligned and engaged board can also help leaders accelerate progress by providing support or eliminating barriers.
What is an example that illustrates the potential influence of an engaged board?
Gary Kaplan [Chairman and CEO of Virginia Mason Health System] says that people often ask him, “How do you manage your board?” He’ll say, “The board manages me.”
He says that the board is an asset that needs to be leveraged, not a threat to be managed. He often says Virginia Mason’s work based on the Toyota Lean model took off once he had an engaged board. They supported funding for Lean initiatives and to send people to Japan to study the Toyota Production System.
The other thing Gary talks about is sustainability. CEOs come and go — their average tenure is under 3.5 years — so you need a board who prioritizes quality and safety, not just a CEO. Boards also pick the CEO, so they need to ensure that whoever they select as CEO places the right priority and emphasis on quality and safety.
Why did IHI decide to publish the Framework for Effective Board Governance of Health System Quality white paper?
Last year, IHI and Safe & Reliable Healthcare issued a white paper (A Framework for Safe, Reliable, and Effective Care) stating that, to create a culture of safety, you need to focus on six domains. One of the domains is engaging boards, and we decided we needed to do a deep dive to better understand what board engagement means and how to support it.
We did a landscape analysis to look at the board education that’s available. As we did that, we concluded that board education needs to be not only about safety, but about the full spectrum of quality. This means care that’s safe, effective and affordable, equitable and patient-centered, efficient and timely, and addresses the health of populations and communities. If you’re going to fully engage your board, you can’t pick and choose different components of quality. You must address all these components.
In addition to a landscape analysis, we conducted expert interviews, and convened a meeting of experts on board education, quality and safety operations, and CEOs. We tried to determine how much knowledge a board member needs to be an informed and active governance participant while not overloading them with unnecessary details.
In addition to highlighting knowledge board members need, the white paper recommends actions boards should take to help them understand quality and safety in their organization. The white paper includes a lot about the importance of representing patient voices on the board. It addresses the executive walk rounds board members can do to learn more from the people closest to the point of care. The white paper is the consensus of many of the experts in the field as well as CEOs from organizations that we think are exemplars. We believe that CEOs, chief quality and safety officers, and trustees who want to work on quality will find it very helpful.
Why is an organizational assessment part of the white paper?
We built an assessment so that readers can evaluate how their board is doing with overseeing the various domains of quality. It’s a tool to help organizations prioritize how to advance their board’s knowledge.
Realistically, it may be hard to take on all the quality components at the same time. We hope that completing the assessment will help organizations see where they’re doing well as well as where they need more work.
IHI President Emerita and Senior Fellow Maureen Bisognano talks about how clinicians need to be “bilingual” to communicate effectively with non-clinicians. How would that apply to boards?
We had a lot of discussion about language for the white paper because clinicians tend to use clinical language. We decided that many board members don’t have clinical backgrounds, so we’ve tried to use clear language in the white paper. For example, instead of saying patient safety we say, “Don’t harm me.” That makes it personal, but also more understandable.
Solutions for Patient Safety, which is a network of children’s hospitals, has been doing a lot of work on board education. They have meetings where they’ll have board members from, say, 50 hospitals together. They’ll say, “We’re going to talk about central line infections.” They show what a central line is, where it’s inserted, how it works, and describe why a central line infection can be so devastating.
Without a clinical background, you would have no idea what a central line is and why those infections matter. It can seem very amorphous. Holding a central line in your hand makes it real. Those are the kinds of strategies we need to use with board members.
Editor’s note: This interview has been edited for length and clarity.