Engaging Health System Boards of Trustees in Quality and Safety: Six Must-Know Guidelines

Around the turn of the 21^stcentury, the National Academy of Medicine (NAM), formerly the Institute of Medicine (IOM), called for profound transformation to improve the culture of patient safety in two landmark reports: To Err Is Human (1999) and Crossing the Quality Chasm (2001). These reports accelerated the pace at which health systems began to understand and implement changes to improve the quality and safety of care.

在不结盟运动的报告之后，几次有影响力的运动和研究都在继续呼吁更好、更安全的护理，并将这一变化的责任推给医疗领导者。Dr. Donald Berwick, former president and CEO of the IHI, added urgency to the need for transformation when he called 2007 the “Year of Governance,” inThe Joint Commission Journal on Patient Quality and Safety，将适当管理医疗保健的责任交由卫生系统董事会负责。贝里克解释说，领导者需要拥有自己的治理能力，这样才能使改善得以落实。

Healthcare governing bodies responded to the NAM and Berwick appeals, as well as appeals and arguments from other governing bodies, with regulations to incentivize good health system governance and crack down on inadequate leadership. This article looks at the repercussions for health systems of falling short on governance measures as well as how organizations can engage their boards around quality and safety measures to better meet their communities’ needs.

Regulators Take a Hard Line on Governance

After Berwick’s call to healthcare boards, regulators soon proved they would take a hard line on governance. For example, in 2008,Modern Healthcare据报道，一家中等规模的地区性医疗中心面临严格的监管审查。The organization’s leadership and board had failed to transparently present and review clinical information anddatathat would have exposed serious safety issues, resulting in harm to multiple patients. By not understanding their fiduciary responsibilities and requirement to hold leadership responsible for unsafe conditions, the board failed the community it served.

在患者投诉后，国家监管机构和CMS指出，该医疗中心在患者护理和管理方面存在合规问题。2008年5月，州卫生部门发现，这家医院有七名开胸病人发生腿部伤口感染;随后，该州关闭了“敞开心扉”项目。

In addition, regulators cited the organization for deficiencies in five areas required for participation in Medicare:

1. 治理。
2. 感染控制。
3. Medical staff.
4. Surgical services.
5. Quality assurance.

The Significant Risks and Repercussions of Bad Governance

With the regulatory crackdown on governance, risks and repercussions of bad governance have significant, costly, and long-term impacts. For example, after the state released the findings of its report on the medical center above, the hospital CEO abruptly resigned, one nearby hospital suspended referrals of cardiac patients, and the hospital’s owner sent staff over 2,000 miles from the corporate office to provide administrative oversight. Such serious consequences placed greater pressure on health system boards to ensure good governance.

Part of the medical center’s correction plan was to ensure that “the [hospital] board is fulfilling its corporate oversight.” The organization clearly hadn’t taken heed of the growing calls within healthcare to improve quality andpatient safety. It failed to establish sound governance practices, despite a growing body of evidence that embracing a culture of patient safety was fundamental for healthcare organizations.

Addressing Urgent Demands for Quality and Patient Safety

While To Err Is Human demonstrated how much needless harm and death occurred in healthcare settings, Crossing the Quality Chasm provided a framework for conceptualizing and defining healthcare quality. This framework, often referred to as the STEEEP framework, laid out six aims for improvement: to provide safe, timely, effective, efficient, equitable, and patient-centered care. Both reports have continued to inform what effective healthcare governance looks like for health system boards.

Although the healthcare industry has improved since these reports’ publication, a 2018IHIanalysis demonstrated that many health systems still lack sound governance practices and that work to improve hospital governance has moved slowly. Governing bodies continue to rest transformation of care delivery firmly on health system boards.

Notable campaigns since the NAM reports, such as the following, outline board responsibility and continue to serve as guidelines towards better governance:

A Call to Responsibility

When the National Quality Forum (NQF) issuedHospital Governing Boards and Quality of Care: A Call to Responsibilityin 2004,the NQF strongly encouraged “hospital governing boards to become actively engaged in quality improvement” to place emphasis on the relationship between governance and quality of care.

Getting Boards on Board

In 2006, the IHI launched the5 Million Lives Campaign, which included a call to health systems to join in “getting boards on board.” The campaign recommended that hospital boards get data and hear stories about safety. The IHI also set the expectation that boards “select and review progress toward safer care as the first agenda item at every board meeting, grounded in transparency, and putting a ‘human face’ on harm data.”

The IHI campaign developed six key steps for improving governance:

1. 设定目标。
2. 收集数据和听故事。
3. Establishing and monitoring system-level measures.
4. 改变环境、政策和文化。
5. Learning (starting with the board).
6. Establishing executive accountability.

Monitoring Performance and Setting Improvement Aims

At its core, the IHI “boards on board” campaign emphasized key elements in creating a culture of patient safety:

• 有效地部署测量系统来监控绩效并设定绩效改进目标。
• Leveraging meaningful data that a non-clinical board could understand.

The campaign clarified that hospital boards, including non-clinical volunteer trustees, have afiduciary responsibilityto ensure high-quality clinical outcomes in their hospitals. Simultaneously, however, the increasing pace of value-based purchasing and data transparency—largely driven by CMS, TJC, and National Committee for Quality Assurance (NCQA)—have made it difficult for boards to overlook poor quality and safety performance.

Four Steps for Appropriate Goal Setting

董事会越来越依赖主题专家小组委员会，包括受托人以及额外的独立外部专家，以支持各个治理领域(例如，财务、质量和患者安全、合规性和战略)，并确定改进目标。来自这些职能领域的医院或卫生系统员工领导负责支持各自的董事会委员会。

Goal setting for an organization’s quality and patient safety performance follows four steps:

1. Appropriate measures and targets: Quality and safety leadership (e.g., the chief clinical officer, chief nursing officer, or patient safety officer) and their teams working closely to recommend appropriate measures and targets to the executive team as well as the board quality and patient safety committee.
2. Recommendations to the full board: The safety and quality committee refers its recommendations to the full board of trustees.
3. Recommendations to the quality and safety committee:工作人员根据患者的需求向董事会质量和患者安全委员会提出建议，从微观系统转向宏观系统。
4. Big dot measures:Ultimately, the board looks for “big dot” macrosystem measures (e.g., overall rate of serious adverse events, system-wide mortality versus heart-failure mortality, or overall patient satisfaction rather than satisfaction with hospital food).

董事会不会希望看到大点衡量的潜在驱动力，除非组织没有改善。然而，董事会委员会想要更深入地了解这些驱动因素。Figure 1 provides a schematic for health systems to view the measurement selectionprocess.

Six Guidelines for Quality and Safety Measures for Engaging Healthcare Boards

Health system boards can follow six guidelines to select quality and safety measures most likely to support good governance and drive improvement for their organizations:

1. Emphasize Quality and Patient Safety Goals

质量和患者安全目标应该很容易地代表委员会审查的所有措施的至少一半。通常，一个组织会跟踪10到20个目标。As Table 1 shows, boards can use the STEEEP framework and big dot approach to guide measure selection:

STEEEP Framework	Measure Examples
Safe	Serious safety events (hospital acquired infections [HAIs], serious reportable events [SREs]) Mortality
Timely	Median time from ED arrival to ED departure of admitted ED patients
Effective	Readmissions Evidence-based measures and protocols (e.g., sepsis protocol adherence) Preventable hospitalization
Efficient	Length of stay Cost per case Per-capita cost Time to next available appointments Patient flow measures
Equitable	Timely ambulatory carePerformance stratified by race and ethnicity
Patient Centered	Patient experience

2. Leverage NQF-Endorsed Measures

The NQF itself does not develop its own measures; other organizations (e.g., the CMS, TJC, and the NCQA) develop measures of accountability for accreditation purposes. Many organizations select measures endorsed by the NQF consensus development process and link these measures to the six aims of the NAM’s Quality Chasm report or the IHI’s Triple or Quadruple Aim. Some boards of trustees have actually made it policy to only use NQF-endorsed measures for quality and patient safety objectives, when available.

Specialty societies, such as the Society of Thoracic Surgeons and the American College of Cardiology, often submit their measures to the NQF for endorsement. The NQF established committees of nationally recognized experts to review specific measure sets. Thus,NQF-endorsed这些措施不仅经过了开发商的内部审查和开发过程，而且还得到了NQF的独立专家的第二次审查。选择nqf认可的措施减少了卫生系统内部对措施有效性的内部争论。

3. Use Benchmarking and Risk Adjustment to Select Targets

Meaningful targets are critical. Most boards and CEOs aspire to achieve top performance, but not all measures have a meaningful benchmark. A true benchmark looks at top performers and understands how their process led them to outstanding outcomes. Healthcare providers often simply look at top decile or top quartile performance and strive for that goal without breaking down the process changes required to achieve a better outcome.

There are a few rules to keep in mind:

• 流程措施不需要进行风险调整:没有办法针对卫生系统无法根据当前指南提供循证实践的情况进行调整。表现的变化不能归因于患者群体的潜在风险。例如，对心脏病发作的病人进行及时的再灌注(恢复血液流动的治疗)或适当地开出出院药物。广泛提供的国家绩效水平几乎涵盖了所有CMS公开报告的措施，以供比较。这些可以帮助供应商了解性能差距并确定改进工作的优先级。
• There is no benchmark for patient harm: Setting a target for an acceptable level of harm is like an airline setting a target for the minimum number of plane crashes per year or a manufacturer setting a target for an acceptable number of employee deaths. Again, CMS and the CDC provide national performance for all measures of harm used for public reporting that are helpful for prioritizing improvement work, but the goal has to be zero harm.
• In contrast, not all mortality, readmissions, or admissions are avoidable: Here, benchmarking against the best in the industry can help drive process improvement. It is important to use appropriate risk adjustment among the multiple models for adjustment available. Ideally, a health system benchmarks against best in class and develops a deep understanding of how a top performer’s processes set it apart from the rest of the industry. Realistically, however, top-performing providers do not share enough detail for organizations to benchmark against. Instead, healthcare ranks providers based on risk-adjusted outcomes data against normative performance of the larger population of providers. The industry assumes that those with the best outcomes are high performers. Yet, 20 years of research on care delivery have demonstrated that better may not be best; when healthcare settles on comparing a single provider/hospital/health system against national performance or database performance at the top levels, it’s creating proxies for best practices. However, given those limitations, some benchmarks and risk adjustment models are better than others. A disproportionate number of benchmarking systems depend only on administrative or claims data. Benchmarking can, and will, improve as the industry increasingly uses more clinical information and artificial intelligence (AI) to proactively identify where an organization is performing well and where it’s underperforming.

4. Access Data Beyond the EHR

一份提交给董事会质量和患者安全委员会以及董事会的报告需要来自多个来源系统的数据。尽管电子病历使用的急剧增长已经产生了大量丰富的临床数据，但电子病历不能提供董事会需要看到的所有信息。例如，患者安全数据通常是在单独的事件或发生率报告系统中收集的;感染数据可能存在于一个独特的监测系统中，作为收入周期过程一部分的数据以及从索赔中收集的数据也很重要。

Boards also expect patient experience of care (satisfaction) from multiple settings:

• Hospital.
• Surgical centers.
• 应急部门。
• 专业护理设施。
• Home care agencies.
• 医生诊所。

The analytics team needs a robust enterprise data warehouse (EDW) or an even more sophisticated data platform, such as the Health Catalyst® Data Operating System (DOS™) to meet the needs of the board. Otherwise, the analytics team will spend much of its time hunting for data and producing reports out of different systems. An integrated data platform will increase the timeliness and consistency of data to provide accurate reporting from across the enterprise.

5. Provide Data and Information for Multiple Organizational Levels

Health system analysts and leadership need to present information to multiple levels in the organization. To determine if its objectives are trending in the correct direction, the full board will typically focus on a single report that includes each of the system’s year-to-date performance for the system’s or hospital’s annual objectives, along with a trend line, spark line, or control chart. Staff will also need to provide an interpretive narrative of the findings for each aim they analyze.

While the board will focus on big dot measures, board committees may also want to understand the organization’s outcomes improvement strategy, especially if the organization is falling short of goals. In a multifacility organization, the subcommittee will also want to determine if certain hospitals, clinics, or other entities are not performing at the same level of the system. Reports that summarize information across multiple facilities run the risk of masking a single facility’s poor performance, so reports must drill down from the system level.

Figure 2 shows a dashboard suitable for board-level reporting, as well as for the executives who will need to speak to performance:

6. Develop a Board-Specific Measurement and Presentation Strategy

Providing information to a board of trustees or a board committee requires a different measurement and presentation strategy than what a service line or department needs to support its operations and performance improvement projects. The most valuable board resource is their time. The trustees consist of a mix of volunteer community members, often with no clinical experience, as well as clinicians from the community. The trustees typically conduct their deliberations with the CEO in attendance as well as other health system leadership. Leadership must present healthcare information clearly so that the board understands performance against meaningful targets but also in a way that empowers the board to raise tough questions about opportunities for improvement. Beyond the staff providing honest and meaningful information, while continuously disclosing failures, a strong board most have sufficient subject matter expertise and independence to hold providers accountable. Presented data must demonstrate that the hospital or health system is placing the safety of the patient first and is looking at the right measures of care. Targets and benchmarks must be clear enough to trustees to encourage them challenge each hospital or health system to improve care and eliminate all patient harm.

The Ongoing, Central Role of the Healthcare Board in Quality and Safety Improvement

Despite the launch of a quality and patient safety movement in the early 21^stcentury, too many hospitals and health systems still lack the resources to give their boards the information required to meet their fiduciary responsibilities. To support safety and quality progress, the industry must accelerate its ability to collect data from an ever-increasing quantity of sources, as well as transform that data into meaningful information for the board of trustees to digest.

Additional Reading

你想了解更多关于这个话题吗?Here are some articles we suggest:

1. A Guide to Applying Quality Improvement to Healthcare: Five Principles
2. Introducing the Health Catalyst Monitor™ Patient Safety Suite: Surveillance Module
3. The Top Five 2019 Healthcare Trends