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“A board with QI knowledge will be more effective in their governance role because they’ll spend time on the right things.”
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The Risks of Keeping Health Care Boards in the Dark

By Derek Feeley | Thursday, November 15, 2018

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It’s an open secret that some health care executives prefer to keep the members of their board of trustees at arm’s length. Rather than working in partnership, leaders around the world have told me, “I much rather my board members stay out of my way.” Some even boast, “I give them enough information to keep them quiet or I bury them in the details.”

Given this, it’s not surprising that board members have also confided to me that they often don’t understand the data executives share with them. “I don’t want to speak up,” some admit, “because I’m afraid I’m going to ask the wrong question and make a fool of myself.”

If we’re serious about transforming health care, we can’t allow this to continue. Executives and boards who do not work together do a disservice to their communities. The core business of a health care board of governance is to get assurance on behalf of the people they serve that the system is delivering the high-quality care they’ve promised. How can boards successfully achieve this mandate if executives keep them in the dark?

The Importance of Board Education

A study published in Health Affairs in 2010 found that fewer than half of the 1,000 not-for-profit hospital boards surveyed viewed quality as one of their top two priorities. Fewer than half! Less than a third had some formal quality training for their board members. There’s no evidence that the situation is much better in 2018.

Educating boards about quality is essential because boards that understand quality help health care leaders prioritize quality. You can’t treat quality with the urgency it deserves if your governance systems and boards think they only need to care about the bottom line.

A board with QI knowledge will be more effective in their governance role because they’ll spend time on the right things. They won’t end up chasing random variation in your system. They won’t overreact to each quality report in isolation without looking at data over time. They won’t settle for the status quo because the numbers appear to compare favorably to arbitrary benchmarks.

As a health care leader, you can have constructive dialogue with board members educated about quality. The alternative is a one-way flood of information from the executive team to the board members in which everyone gets deluged with too much information and not enough intelligence. Quality should be the top priority for any health care executive, but you can’t do it well without the full support of your board.


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The Keys to a Good Partnership

To build a productive health care improvement partnership, the executive team and the non-executive members of the board must come to consensus on three key areas:

  • Priorities
    — What are your quality priorities? Do you have a common understanding about what you mean by “quality”? What are you trying to accomplish? Research suggests that boards, trustees, and boards of governance tend to have a rosier picture of the performance of a system than do the executive team, physicians, or nurses. If you’re not in agreement with your board about the urgency of the need for change, how can you get where you need to go?
  • Methods — How are you going to achieve your priorities? The board should understand your theory and method for securing the improvement you’ve identified as necessary. You need to be open and transparent, not just about what you’re going to do, but also how you’re going to do it. You need to introduce them to the basics of improvement. PDSA cycles, the importance of aim setting, or how to scale-up improvement should not be a mystery to board members. When board members aren’t equipped to think in systems terms, they tend to focus on “shame and blame” if something goes wrong.
  • Motivation — Why are the improvements you’re taking on important to patients? When board members understand their role in improving quality, I find that — more often than executives do — they see quality from the patient’s point of view. They talk about the urgent need for change from the perspective of the people they meet in their place of work or in the grocery store. When your board is not deeply engaged in quality, you may miss opportunities to see care as patients and families do.

Inside a Board Room

An example of how this looks in a board room might be helpful: There’s a board chair I’ve worked with over the years who I’ve found to be especially insightful. She’s helped me develop my sense of the great potential for working effectively with a board.

She is intensely curious. When I suggest an idea, she asks, “Who else is doing this?” She asks if her already high-performing organization can learn from other high-performing organizations.

Through her example, I’ve seen the importance of having a shared understanding about the roles of the board chair and the chief executive. If you have a chief executive and a board chair who are not on the same page, it causes chaos and leads to confusion about the organization’s strategic direction.

This board chair is constantly pushing the boundaries of what’s possible and never wants the organization to rest on its laurels. But she does it in a humble and respectful way. She thanks people and is always among the first to celebrate the successes of the organization. I believe this is why she is well-received even when she asks hard questions or challenges the organization to aim higher.

At a time when health care executives face unprecedented challenges, it makes no sense to waste the talent and energy on your board by leaving them uninformed. Their experience, expertise, and connections to communities can make them invaluable partners. Investing in the quality education of your board will raise your entire organization from where you are to where you aspire to be.

Editor’s note: Look for more from IHI President and CEO Derek Feeley (@DerekFeeleyIHI) on leadership, innovation, and improvement in health and health care in the “Line of Sight” series on the IHI blog.

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

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