In recent years, the case for improving the quality and safety of care has become irrefutable. Over the next few years, failure to act will likely have far-reaching consequences for hospitals and health systems including loss of market share, increased liability, a demoralized workforce, and a sharp rise in fear and distrust among patients who lack confidence in the ability of their provider to deliver safe care. Most importantly, it would be morally reprehensible for any care provider to not strive to address the urgent need to deliver high quality, safe care.
Because of the complexity of modern health care delivery, realizing sustainable improvements in clinical quality and patient safety will require fundamental and widespread organizational change. The change will be transformational because clinicians will need to change the way they think, act, and work. This will be particularly challenging in health care, because its workforce is dominated by well-educated, proud individuals who do not always willingly embrace change.
Organizations that successfully manage transformational change always demonstrate strong leadership from the top. In these organizations, leadership is able to successfully communicate a clear case for change, create a compelling vision of the way things ought to be, and guide the organization through the inevitable resistance and complexities. The greater the change, the greater is the need for unambiguous, strong, unwavering leadership from the top levels of the organization, including both the governing board and senior executives.
One could reasonably argue that the governing board of a hospital or health system has ultimate accountability for the organization's quality and safety of care. Consistent with this view, the Joint Commission has openly stated that "A hospital's governing body is ultimately responsible for the quality of care that hospital provides." In short, it is the board's responsibility to ensure that the organization does the right thing for every patient every time.
Historically, health care governing boards have generally been passive with respect to quality and safety. That is, they have not owned accountability for the organization's clinical outcomes, nor have they tracked those outcomes over time. In addition, they often do not hold management accountable for clinical outcomes.
This is in sharp contrast to the way the typical hospital or health system board assumes accountability for the financial results of the organization. Boards routinely follow financial parameters very closely and insist on acceptable levels of financial performance on the part of management. If targets are not met, they expect corrective action and carefully follow progress until the situation is back on track.
I believe that, if clinical quality and patient safety are to be improved, hospital and health system boards need to effectively exert their leadership and drive the required organizational changes. However, playing a meaningful role in improving quality and safety is not a trivial task for boards. It requires knowledge and skills that have not historically existed on most health care boards.
PeaceHealth is a health care delivery organization that operates six hospitals, as well as a large multi-specialty medical group and regional lab, serving communities in Oregon, Washington, and Alaska. The System Governing Board has ultimate authority, but it has historically ceded various responsibilities to regional governing boards that oversee the hospitals, clinics, and other entities.
Over the past 2 years, PeaceHealth system and regional governing boards have become increasingly focused on quality and safety, making it clear that improving clinical outcomes is their top priority. This has resulted in an interesting journey as the boards have sought to define their leadership roles and operational strategies with respect to quality and safety. The remainder of this article will provide a brief overview of the issues we have encountered and the key lessons we have learned.
The first step in the journey is to ensure that the board focuses enough time and attention on quality and safety. At PeaceHealth, a System Board Quality Committee was created, and a respected physician board member was selected as committee chair. The three largest regional boards had previously established regional board quality committees. Board quality committees are analogous to the board finance committees, only they focus on quality rather than economic matters. This was a valuable step as it allowed more time for at least a subset of the board to focus on the organization's clinical outcomes, something that was not happening previously.
Typically, each System Board Quality Committee is comprised of only about a third of the board, and the quality committee report at the full board generally occupies only about 15 minutes of the full board's 8-hour agenda. The System Board Quality Committee views this as insufficient, and it has called for at least 25% of the full board's agenda to be focused on quality and safety issues. Recently, the System Board Chairperson has agreed that this will become the practice going forward.
Obtaining the knowledge necessary to effectively lead quality on behalf of the organization has been a challenge, particularly for board members who lack a clinical background. Clinical care is complex, and the internal and external demands being placed on the organization to improve outcomes are extreme. To address this problem, education is a key part of every quality committee agenda. The education includes information about external quality and safety demands, an overview of the organization's quality and safety initiatives, discussions about the appropriate role for leadership over quality and safety, and consideration of the cultural and organizational impediments to improvement. Education about quality and safety has also been made a prominent part of the orientation session for new board members. While the board's awareness and literacy with respect to quality and safety have improved, we expect that it will require 1 to 2 years for the typical board member to fully get up to speed on these complex issues.
To help the board track outcomes, we have created a dashboard of quality and safety metrics that are aligned with board-approved goals. Wherever possible, the dashboard includes benchmark information that reflects best practice. Our goal is to have one dashboard of standard metrics that will be used by all boards, both system and regional. We have found that it is a challenge to find the right balance between a set of metrics that are comprehensive enough to provide the information necessary to understand the organization's quality and safety performance, while not being overwhelming. Everyone wants metrics that conveniently "roll up" to a few simple, easily understandable measures similar to financial measures. However, clinical care is complex, and meaningful single measures do not exist. Hospital mortality has been considered (and is used), but mortality is driven by myriad factors, some of which are beyond the control of management. Moreover, any "drill down" on rising mortality rates quickly leads to a level of complexity that is hard for many board members to understand, especially the non-clinicians. Creating the ideal dashboard of metrics for the board is an iterative process for all governing boards, and we feel like we are partway through our journey to find the right mix.
If quality and safety performance is to be improved at a satisfactory pace, boards must hold executive and clinical leadership accountable. Historically, PeaceHealth governing board members have been comfortable expecting accountability in terms of financial performance, but much less so when it comes to quality and safety performance. As one highly experienced board member commented a few months ago, high quality, safe care was always "assumed" to be present. However, this view is changing, and the System Board recently adopted a set of guiding principles that state the board will:
- Challenge the organization to raise the bar and set stretch goals for quality and safety that are reasonable and appropriate.
- Challenge clinical quality leadership recommendations that fall short of the board's expectations for an appropriate rate of improvement.
- Set the expectation that the executive and clinical leaders will make substantive progress in advancing quality and safety, and hold them accountable for that progress.
Consistent with this new direction, the System Board recently revised executive compensation, putting a heavy emphasis on quality and safety performance. For example, senior System executives are eligible for a bonus equal to 35% of their base pay, and a minimum of 45% of this bonus is based on achieving exceptional care outcomes. This contrasts with financial targets, which represent only 15% of each executive bonus. The bonus system for regional executives is very similar.
Another important challenge is calibrating the relative roles of a central governing board and regional (or in some systems, individual facility) boards. Recently in our system, some regional board members have expressed concern that the System Board may "overshadow" regional boards with respect to quality and safety. These roles have been clear for many years with respect to financial performance: the System Board has ceded a well-defined level of authority to the regional boards. However, this is not yet true with respect to quality and safety performance. We are currently in the process of defining the relative quality and safety roles of system and regional boards and expect to have a system in place within a few months.
In addition to the above, a potpourri of additional measures has been found to be helpful in terms of increasing board engagement in and understanding of quality and safety, including:
- Board members are routinely given good articles and books to read. In our case, every system and regional board member has been given a copy of Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes.
- We have just started the practice of opening every board quality committee meeting with a real story of a patient who has been harmed in our health system. These stories can be both informative and motivating.
- Board members are invited to organizational meetings and events that focus on quality and safety.
- Cases that demonstrate how poor quality, unsafe care worsens financial performance are presented to board stewardship meetings.
- Board members who demonstrate clear passion for improving quality and safety are encouraged to join board quality committees.
- Any quality or safety issues that are being championed by clinical leadership (such as a hospital's chief of staff) are highlighted at board meetings. For example, when the chief of staff at one of our largest hospitals championed improved stroke care to the governing board, it resulted in a highly successful year-long task force and ultimately the decision to become a "center of excellence" in stroke care at our largest regional medical center in Eugene, Oregon.
PeaceHealth is fortunate to have system and regional governing boards that are passionate about improving the quality and safety of care delivered in our institutions. At times, board impatience with our pace of change has butted up against organizational and environmental realities, but we see this as a good problem to have, certainly far better than dealing with an apathetic board. Because of the high level of board engagement that PeaceHealth enjoys, the organization is far better positioned to substantially improve our quality and safety performance in the coming years.
John L. Haughom, MDSenior Vice President, Clinical Quality and Patient Safety, PeaceHealth