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Accurate evaluation of a health system board is important to understand how to improve quality oversight. The following excerpt from the Framework for Effective Board Governance of Health System Quality IHI white paper describes a tool that health system trustees and senior leaders can use to assess how well their board supports the Institute of Medicine STEEEP dimensions (care that is safe, timely, effective, efficient, equitable, and patient centered) and the IHI Triple Aim.
The Governance of Quality Assessment (GQA) serves as both a roadmap of the key processes the board should undertake to oversee all dimensions of quality, and an assessment of how well the board is doing with respect to those processes. The GQA employs a set of concrete recommendations for 30 core processes of quality oversight organized into six categories, and provides a high-level assessment of board culture, structure, and commitment. The resulting GQA scores (for each core process, each category, and overall total) provide a roadmap for health care leaders and trustees to identify what to do in their work plan — and to assess their progress over time.
Most current board assessments primarily cover elements of safety, patient satisfaction, and/or board culture related to quality oversight. Most assessments do not identify the specific processes for quality oversight beyond safety and do not equally address all the dimensions of quality, including population health and care provided outside of the hospital. Variation across assessments may create confusion among trustees about what really is optimal in the oversight of quality.
The GQA aims to ensure that health system board quality oversight extends beyond the hospital to include the entire continuum of care. While many trustees understand concepts and frameworks like STEEEP, [safe, timely, effective, efficient, equitable, and patient centered], and the IHI Triple Aim, they often have difficulty translating those concepts into specific activities they must perform. The GQA is specific, actionable, and tracks the processes that enable excellent quality governance. The GQA is designed for trustees and those who support them; it is written in straightforward, actionable, and trustee-centered language.
GQA Core Processes and Scoring
The Governance of Quality Assessment provides a snapshot of a total of 30 core processes organized into six categories that a board with fiduciary oversight needs to perform to properly oversee quality. The 30 core processes were developed by the expert group based on their expert opinions combined with insights gathered from more than 50 additional interviews of governance experts and health executives in the research and assessment phase of this work.
As referenced in the companion research summary to the Board Governance white paper, there are limited evidence-based recommendations on core processes for governance of quality beyond a few structural recommendations such as time spent, use of a dashboard, and having a dedicated quality committee. The GQA puts forth a set of core processes for governance of quality that were collaboratively developed, evaluated, and ranked at the expert meeting.
The GQA should be utilized by health systems and results tracked over time to validate the assessment’s effectiveness. Certainly, there are additional quality oversight actions a board could undertake (and many already do) beyond those identified in the GQA. However, the expert group and interviewees identified the core processes in the GQA as a starting point for calibration and improvement. With a commitment to learning and improvement, and in recognition of the dynamic nature of health care, the GQA should also be revised as appropriate to incorporate the insights from new research in the boardroom.
The GQA includes a scoring system (0, 1, or 2) for trustees and health system leaders to assess the current level of performance for the 30 core processes, the six categories, and overall. Scores are totaled so that trustees and health care leaders can establish baseline scores (for each process, category, and overall) and then track their progress over time.
Bringing the GQA to the Boardroom
Health system CEOs should complete the GQA annually with their board chair and quality committee chair(s) and/or quality committee to establish a baseline for assessing their current state of oversight of quality; to identify opportunities for improvement; and to track their GQA scores over time as a measure of improving board quality oversight. It is also useful to have the senior leaders who interface with the board complete the GQA to understand and assess their role with respect to trustee oversight of quality.
Once the respondents have completed the GQA, senior leaders and trustees may choose to focus on the lowest-scoring areas to identify improvement strategies. Within larger health systems, the GQA is a useful tool to evaluate the work of multiple quality committees and create a system-wide work plan and strategies for board oversight of quality. We recommend that boards complete the GQA annually to monitor their performance and progress.
The GQA can also be used to guide discussions about which activities should be conducted at which level of governance in the case of complex systems (e.g., which processes are or should be covered in local boards, the system quality committee, and/or the overall health system board). In addition, the assessment can be used as a tool for discussion in setting agenda items for the board or quality committees.
Finally, governance educators might also use the assessment to help design their educational sessions for board members, targeting educational content to the areas where the clients need more support or education.
The expert group also recommended that the assessment tool be utilized for future research to compare how systems are performing relative to each other, collecting data longitudinally to identify which elements of the GQA are most correlated with various components of quality performance and other metrics of culture and management known to be associated with excellence.
To learn more about the other essential elements of improvement, download the free Framework for Effective Board Governance of Health System Quality white paper.
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