As Christmas 2006 approached, the directors of Denver’s Exempla Healthcare began a two-day board meeting and retreat with senior staff. Lillee Gelinas, RN, MSN, FAAN, Vice President and Chief Nursing Officer of VHA Inc. and a long-time director of Exempla’s 1,200-bed, three-hospital network, is still moved by what she found when she entered the meeting room that first morning. A holiday tree, lit but undecorated, stood at the front. Waiting at each seat was a glass ornament.
Marty Helldorfer, the board’s Vice President of Mission, explained that each ornament bore a description of a patient whose life had been saved by Exempla’s adherence to the highest standards of clinical care. “He asked us to read out the inscriptions as we placed our ornaments on the ‘Tree of Life’,” recalls Gelinas. “Privacy rules protected people’s names, but we knew there were four teenagers, 20 grandmothers, five homeless people, two politicians, three Exempla employees, nine undocumented persons, and dozens more.”
The sum of the 269 lives saved — calculated by Exempla during their participation in the recent 100,000 Lives Campaign (now the 5 Million Lives Campaign) sponsored by the Institute for Healthcare Improvement (IHI) — was impressive. Yet Gelinas and her board colleagues were struck more by the parts than the whole. Each distinctively inscribed ornament symbolized the one-on-one connection between directors and the individual patients who rely on the hospitals they govern. “The tree glowed right next to us throughout our board deliberations,” says Gelinas. “I think it helped remind us who we really work for.”
Based on the success of IHI’s 18-month initiative, during which hospitals engaged in the Campaign as well as many other improvement initiatives collectively prevented an estimated 122,000 unnecessary deaths, IHI has now launched an even more ambitious effort, aimed at reducing incidents of medical harm. The 5 Million Lives Campaign
, which includes the six clinical interventions targeted in the earlier 100,000 Lives Campaign, adds six new interventions, including the first non-clinical one: effective leadership and governance by hospital boards
IHI’s former President and CEO, Donald Berwick, MD, MPP, says a board’s interest and investment in better patient care have become essential.
“Historically, boards have assumed that they are responsible for the fiscal integrity, reputation, and lay management of the hospital, but that responsibility for care lies with the clinical staff, not with the board,” says Berwick. “For many boards, medical care, itself, is remarkably foreign terrain. Yet, in a time of increasing corporate accountability, consumer voice, and system complexity, this view will no longer suffice, if it ever did. A large share of the accountability for the safety and quality of care rests firmly in the board room.”
Often, says Berwick, the first step to board stewardship of safety and quality is the simple recognition that it is the board’s duty in the first place. Even with this recognition, he says, boards must learn new skills to monitor and improve care. Improvements can look simple, but they actually require major changes in culture, habits, training, and purpose for a hospital. “Changes at this scale require leadership, not just good will in the workforce, and in the final analysis, defining the organization’s strategic intent and priorities is the responsibility of those who govern the organization,” asserts Berwick.
To help boards assume a major leadership role in improving clinical quality and reducing harm, in the 5 Million Lives Campaign, IHI has identified six crucial activities for boards:
- Set Aims: Make an explicit, public commitment to measurable improvement.
- Seek Data and Personal Stories: Audit at least 20 randomly chosen patient charts for all types and levels of injury, and conduct a “deep dive” investigation of one major incident, including interviewing the affected patient, family, and staff.
- Establish and Monitor System-Level Measures: Track organization-wide progress by installing and overseeing crucial system-level metrics of clinical quality, such as medical harm per 1,000 patient days or risk-adjusted mortality rates over time.
- Change the Environment, Policies, and Culture: Require respect, communication, disclosure, transparency, resolution, and all the elements of an organization fully committed to quality and safety.
- Encourage Learning, Starting with Yourself: Identify the capabilities and achievements of the best hospital boards and apply that standard to yourself and all staff.
- Establish Accountability: Set the agenda for improvement by linking executive performance and compensation.
As a publicly-funded academic health system, Cambridge Health Alliance (CHA), whose three hospitals (and 21 health centers) serve 400,000 people in Boston’s metro-north region, has been reporting performance metrics for years. “Goals to improve our scores on HEDIS, patient satisfaction, heart attack care, adverse drug events — all the common measures — are part of our balanced scorecard and results are both reported widely and are on our website,” says Priscilla Dasse, RN, MPH, CHA’s Senior Vice President for Performance Improvement. “What’s new are requests for explicit, detailed data on specific issues of quality and patient safety from our corporate board. Those have been steadily increasing.”
Dasse attributes the board’s surging interest, in part, to growing public awareness, reinforced by organizations such as IHI and the Institute of Medicine, that hospitals have serious problems with safety and delivering reliable care. “Health care, in general, does not have a good track record on preventing harm to patients,” says Dasse.
CHA’s board has been especially activated due to some of its members, including one of the nation’s leading experts on patient safety, Lucian Leape, MD, and Jane Metzger, RN, DNSc, a widely-recognized authority on electronic record keeping. “While these trustees are on our board to represent the people we serve,” says Dasse, “we knew their leadership in patient quality and safety would help create the necessary dynamics for positive change.”
And it has. The board recently asked Dasse to compile statistics on a dozen topics ranging from patient complaints to readmissions to staff injuries. “They want that information mainly for educational purposes, because those events reveal things about our environment, both the physical one and our culture,” explains Dasse. The board also tasked Dasse and her staff to eliminate all “never events” — inexcusable lapses, such as wrong-site surgery, mismatched blood transfusions, or severe bed sores.
“We already have a plan in place, as part of IHI’s 5 Million Lives Campaign, but now we’re reviewing it with the board’s instructions in mind,” says Dasse, who points out that demanding improvement is only a preliminary step. “Actually achieving it takes a lot of changes down the line.”
To illustrate, Dasse cites avoidable deaths. “We report and analyze mortality rates, including unexpected deaths, as all hospitals do, but the board wants to be sure we’re finding all the avoidable ones. To do that, we need to set criteria for investigation, appoint the investigators, formulate an action plan. It’s going to take a while, but we’re on it.”
While safety and quality are their own best reasons for change, an increasingly competitive health care marketplace can give a board additional incentive for improvement. In 2004, when two major Denver health insurers threatened to “carve us out of their contracts,” Exempla Healthcare CEO Jeff Selberg sat down with board members to discuss the crisis. The problem wasn’t patient care. The company’s two (now three) hospitals got consistently high marks in surveys of safety, clinical outcomes, and patient satisfaction. “We were always on somebody’s ‘top hospitals’ list,” says Selberg, “but, to purchasers, it seemed like a platitude because we didn’t have good ways to measure and report our own performance.” Clear, compelling metrics, Selberg and the board realized, would help impress purchasers, raise the performance bar even higher, and create a solid framework for accountability.
“So we produced our own report card, based on metrics set by experts such as the National Quality Forum and IHI. Then we met with the media and the buyers to pitch our quality advantage.” The information campaign — plus Exempla’s new 172-bed Good Samaritan Medical Center, built in 2004 to increase network capacity — worked. Purchasers have retained their contracts and Exempla has committed to be in the top decile on all its performance metrics by the end of 2007, a goal that is advancing well, according to Selberg.
“Our main challenge is to avoid the feeling that we’re good enough.” To help counteract complacency, Exempla’s board is supporting front-line staff with, among other things, improvements in electronic record keeping and by raising their own awareness of the challenges staffers face. Every board member has either "shadowed a nurse" or accompanied key clinical staff on a mock Joint Commission survey in an Exempla hospital. Some board members have done both. That level of board member engagement with the front line has been invaluable to conversations on clinical quality and patient safety in the board room. It also fuels greater understanding and quicker action when needed.
At southern California’s MemorialCare Medical Centers health system (MHS), quality improvement efforts were historically decentralized until 2004. Each of the 1,500-bed network’s five hospitals and their individual boards set and pursued performance goals their own way. In 2005, the MHS corporate board, which consistently scores above average in all nine areas of governance defined by The Governance Institute, an education and advisory group, realized that their “vision of excellence” could not be achieved with a fragmented effort.
“We realized the previous goals were too narrow and we needed to tie them directly to our overall strategic plan to create the right focus,” says Helen Macfie, PharmD, hired in October 2005 as Vice President of Performance Improvement. Starting with a system-wide Leadership Summit for all board members, physician leaders, and executives, the MHS board issued a new set of Bold Goals, including specific “what-by-when” aims in five key areas. By June 2007, MHS aims to reduce inpatient mortality by 15 percent and avoidable infections by 50 percent system-wide. Other goals include increasing the attainment of Perfect Care — complete adherence to all evidence-based protocols — for acute heart attacks, heart failure, and community-acquired pneumonia to 95 percent, reducing codes outside of intensive care units by 50 percent, and producing a rising level of patient satisfaction. “Big goals create the opportunity for us to focus on executing big aims,” observes Macfie.
Using this framework, MemorialCare is making good progress towards its Bold Goals (see table below).
In-depth study sessions help lay board members further understand quality metrics and how they can help MHS move the bar. “We are now experiencing increased interest, time, and attention to quality at our board meetings, and the boards see what an impact they can have,” adds Macfie.
According to Barry Arbuckle, President and CEO for MHS, “Taking our boards to a higher level of understanding and involvement in improving quality and safety in our hospitals required that all of our executives gave the issue more time on their personal agendas. Now I and my entire senior executive team spend as much time talking about patients and quality as we do talking about finances, an encouraging and reassuring trend given the business we’re in.”
The Bold Goals have really taken off, says Macfie. MHS is already designing its FY08 Strategic Plan. “We don’t want to dilute the focus too much, but we do want to include further stretches to the next level of ‘what-by-when’ in terms of again halving the number of infections and further mortality reduction. We’re also planning more focus on effective hand washing and preventing hospital-acquired pressure ulcers.”
Seattle’s Virginia Mason Medical Center (VMMC) began its “change journey,” as CEO Gary Kaplan, MD, calls it, in 2000, well before most other hospitals. “We knew that, to produce the best patient care, we had to eliminate defects, just like the best manufacturers do.” Accordingly, VMMC board members accompanied Kaplan to Japan, working on the Hitachi assembly line to learn more about waste-free, defect-free production methods.
In 2003, the VMMC board established a Quality Oversight Committee to, among other activities, oversee Patient Safety Alerts (PSAs) — situations with the potential for harm. At VMMC, any member of a health care team who perceives a flaw in care or in a system can verbally stop the process, creating a PSA. Depending on the flaw’s potential for causing harm, PSAs are then deemed yellow for minor, orange for moderate, and red for flaws that produce actual harm or a high likelihood of harm, even if none occurred. At each of its 11 monthly meetings each year, the Committee reviews statistical reports on a dozen or so minor or moderate incidents. They delve more deeply into the one or two red PSAs that may have occurred since the last meeting, receiving detailed verbal and written reports from relevant staffers. “The reports let us really understand what happened, how and why it happened, and what procedures have been put in place to prevent it from happening again,” says VMMC Board Chairman Tom Van Dawark, who sits on the Committee.
The hospital does not deem red PSAs resolved until all Committee members have signed off on the root causes and the remedy. Though neither Van Dawark nor the other two public board members on the Quality Oversight Committee have medical backgrounds — Van Dawark is a shipping executive — CEO Kaplan has no doubts about their ability to adjudicate. “It’s health care professionals who compartmentalize and don’t face up to what’s really going on. Our lay board members haven’t learned to do that, and that’s exactly what makes them the right people for the job.”