In Good Company: The Gathering Force of Board Engagement with Quality and Safety

Decades have passed since researchers first identified major shortfalls in US health care quality. Still, clinical studies conducted by California’s RAND Corporation and other research centers show that, for many medical conditions with well-defined criteria for the best treatment, only about 50 percent of the recommended care is ever delivered.
Now, as out-of-control costs threaten, again, to overwhelm both public and private financing of health care, the ground may be shifting. Moral imperatives aside, unreliable care and medical errors are just too expensive to be tolerated. Eliminating waste and harm can save money as well as vastly improve health care quality and safety. Keen to achieve both ends, major payers ranging from Medicare, to the Blue Cross and Blue Shield Health Plans of America, to General Motors are setting performance standards that health care providers will increasingly have to meet in order to remain competitive. Even bond-rating agencies have taken notice of quality and safety. Both Moody’s and Standard and Poor’s have declared their intention to consider clinical performance as a component of health care organizations’ investment-worthiness.
With economic pressures converging on clinical issues, hospital governing boards, which traditionally oversee fiscal management most of all, are being asked to engage in matters of quality like never before, says James Conway, MS, Senior Vice President of the Institute for Healthcare Improvement (IHI). “Interest in expanding the role of hospital governance to help raise the bar on clinical performance has accelerated in the past year or so,” says Conway. “Our training sessions on board leadership fill up so quickly now that we’ve had to turn people away.” The two-day course, “From the Top: The Role of the Board in Quality and Safety,” elucidates six board activities that IHI and governance experts have identified as critical to meaningful change. These activities are also at the heart of the “Governance Leadership” — also called “Boards on Board” — intervention in the 5 Million Lives Campaign. 
Charles Denham, MD, chairman of the Texas Medical Institute for Technology in Austin, calls hospital boards “the health system’s biggest untapped resource for change.” So powerful is their influence, says Denham, that when the National Quality Forum — a membership group based in Washington, DC, working on voluntary quality standards — updated its recommendations of 30 safe practices to reduce patient harm, the group embedded board involvement in virtually every aspect.
Admittedly, says Denham, stepping up to the plate on clinical issues may require some attitude adjustment on the part of board members. “Historically, the mindset has been ‘don’t ask, don’t tell’ — let the medical staff worry about it,” says Denham. “Call me an optimist, but I think that view is changing. For one thing, it’s hard to pretend you don’t know that hospitals can be dangerous places when it’s all over the Reader’s Digest.”
In addition to industry — and social — pressure, regulatory and accreditation pressure is also building for greater board oversight of clinical performance. In April 2007, The Joint Commission, the main accrediting body for hospitals, approved a new set of standards detailing an explicit array of responsibilities for hospital boards. “We’ve had a chapter on leadership in our manual since 1995,” says Paul Schyve, MD, Senior Vice President, “but now we’ve spelled out exactly what is expected.” Highlights of the new standards include required collaboration among the governing board, medical staff, and administration, defining and assigning accountability, specifying recourse in case of failures of accountability, managing conflict between or among leadership groups, managing disruptive practitioners, and quality oversight of contracted services. “It’s a lot of responsibility,” acknowledges Schyve, “and hospitals are aware of that so they asked for a little extra time to comply.” The standard will become effective in 2009.
States, too, have begun contemplating the rightful role of hospital boards. In April 2007, New Jersey passed the country’s first law requiring hospital trustees to undergo formal training of “at least one day” as a condition of serving. Sally Roslow, Vice President for Development and Trustee Relations at the New Jersey Hospital Association, which has led voluntary sessions for board members for more than two decades, says it’s not yet clear who will conduct the training or what it will include, “but quality and safety have always been a part of our program and we expect that to continue in the mandated training.” The regulation becomes effective in November 2007.
Tennessee has enacted a voluntary certification program for board members, and Blue Cross Blue Shield of Massachusetts is expected to boost payments for good performance to hospitals whose board members have completed six hours of training.
Another spur to change is likely to be hard data. It may seem intuitive that board involvement helps raise the bar — and therefore the performance — on hospital quality and safety, but it helps that studies have begun to confirm this. In 2005, researchers from CareScience, a health care performance analysis firm, and several partners, including the University of Iowa College of Public Health, the Wharton School, and the Centers for Medicare & Medicaid Services (CMS), conducted a survey to help identify characteristics of hospital leadership. The group compared responses from the 413 participating hospitals to those hospitals’ medical outcomes, as tracked by the CareScience Quality Index, a rating system based on risk-adjusted measures of inpatient morbidity, mortality, and medical complications. Results were clear, says Eugene Kroch, PhD, Director of Research at CareScience. “We found that better quality performance is likely to occur in hospitals where the board spends more than 25 percent of its time on quality issues, receives a formal report on quality measurement scores, is highly engaged with the medical staff on quality issues, and bases executive compensation in part on quality improvement.”   
Researchers from the Governance Institute, an educational and advisory group, and the Solucient Center for Healthcare Improvement have made similar observations. During a September 2006 “Hospital Leadership Summit” convened by the CMS, they unveiled early analysis of an ongoing study begun in January 2006. Responses by the CEOs of 562 not-for-profit acute care general hospitals to a survey of their own board’s practices were compared with each institution’s score on Solucient’s hospital-wide performance measurement as well as each hospital’s quality-specific score. The researchers found a high correlation between proactive boards and high scores on both measures.
IHI’s Jim Conway couldn’t be more encouraged by all this activity. “Governing boards have the power to set aggressive aims, provide the will, and assure execution to achieve a care system we will all be proud of and all deserve. It’s exciting to see so many already embrace the evidence, and announce ‘let’s do it and do it now. Our patients, their families, and our staff deserve nothing less.’”
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