As we in health care become accustomed to pointing to leadership as the key factor influencing an organization’s culture, the governing board’s role is also getting more attention. That’s because while the CEO is the person who sets expectations and models the organization’s core values on a daily basis, the board members are the ones who hire the CEO. Through that selection, they ultimately have a voice in the kind of organization they want to create.
Research into organizational development shows that it takes many years of focused work to solidify changes in culture. With a number of hospitals having CEOs serving for less than four years, the board, in essence, becomes the constant variable.
The National Steering Committee for Patient Safety — a public-private partnership working to develop a national action plan to prevent harm in health care — put leadership, culture, and governance together as a single area of focus because these three elements are so intimately linked. Governance influences leadership, which influences culture. And culture is the underlying state that either allows change to happen or not.
Leaders Learning to Focus
When it comes to learning about culture, leaders have a lot of tools and research at their disposal. In the real world, many CEOs must juggle demands on their time and energy. From the day-to-day distractions of keeping the organization running on a tight margin to navigating mergers and acquisitions, there is much to pull attention away from culture.
It requires intentional leadership, but simple practices like daily safety huddles can make a strong statement about what’s most important in an organization. Having the CEO be the person leading the huddles goes a long way in the effort to mold the culture. Being visible, being present, and living the organization’s values every day can bring about long-term change.
During my early days in health care I worked at an organization with a strong positive culture. It was not unusual for Mr. Ed McCree, the CEO, to casually sit down at a table in the cafeteria and engage in a chat with staff. He created an environment where people knew that, if they had an issue, they could knock on his door and say, “this is what I’m seeing.”
I’ve seen this kind of success at big and small organizations alike. I rounded with a CEO of one of Michigan’s largest hospitals before leadership rounding was a thing, and everyone we met knew him and had something to say. It takes an incredible amount of effort on the part of a leader to get to that, but it can be done.
While the CEO and other senior leaders are working to build trust and transparency, where does the board come in? Historically, there has been a tendency for nonclinical board members to defer to clinical leaders on the board when it comes to issues related to clinical care. Yet one need not be schooled in pharmacology to understand that processes are critical to medication safety, for example. Recent work from the IHI Lucian Leape Institute provides a foundation to help board members fully grasp their role. My hope is that through this work, there can be a reframing of the board’s responsibilities and what their contributions represent.
As I see it, there are three things that board members can do to evolve in their role:
- Ask the right questions. By that I don’t mean operational questions, but those large, strategic questions. How are we learning as an organization? How are we sharing information? How can we make sure we have the resources to support the work we want to achieve? That is a careful dance in quality, because it’s easy to fall back into operational discussions.
- Set expectations. The board has to set the expectation for excellence and a culture of safety. They can do this, for example, by conducting rounds at the point of care, reviewing Serious Safety Events and workforce injury events in a timely manner, and reviewing patient-reported complaints. They are the ones who hear from their community if things are not right — or if they are. And they need to recognize that they are ultimately accountable for what they’re hearing, good or bad.
- Recognize that this work is hard. There are times when the board needs to provide “air cover” by showing support for the CEO. Not everyone in an organization will be happy with changes that are made in the effort to improve quality and safety. There are those — sometimes influential clinicians — who may be upset about change and turn to an ally on the board for help. If this should happen, it’s vitally important for the board member to understand and embrace their role in the governance of the organization and not their role as a friend, and support the changes that the leaders are implementing.
When leaders and board members commit to culture change, the benefits spill into other areas that contribute to safe, high-quality care. For example, a culture that encourages transparency can help improve workforce safety by providing mechanisms for the reporting of incidents and learning from them. Likewise, greater transparency with patients and families can increase their engagement and contributions to co-designing care. Our hope is that the national action plan will offer guidance on these and other issues to rapidly advance safe systems of care.
Sam Watson is Senior Vice President, Field Engagement, at the Michigan Health & Hospital Association, the MHA Keystone Center and a member of the IHI Board of Directors. He is also a member of the National Steering Committee for Patient Safety, an initiative of IHI, a public-private partnership working to develop a national action plan to prevent harm in health care. He co-chairs the subcommittee on culture, leadership, and governance.
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