Rethinking Hospitals’ Governing Boards’ Role in Quality and Safety
The public expects hospitals and their physicians to maintain the highest safety and quality standards. Unfortunately, that is not always the case.
In not-for-profit health care hospitals, the board of trustees, also known as the governing body, is ultimately accountable for the quality and safety of the hospital. The Centers for Medicare and Medicaid Services (CMS) and private accrediting organizations, such as The Joint Commission make clear the governing bodies’ responsibilities.
They are expected, among other things, to approve the medical staff recommendations regarding medical staff appointments, re-appointments, privileging and disciplinary action. They also ensure hospital call coverage and in-patient care is provided by medical staff members with appropriate privileges, and they approve and monitor the hospital-wide quality assurance and performance improvement programs (QAPI).
As part of the QAPI program, governing boards are expected to monitor quality and safety of all hospital programs including contracted services. They also hold the leadership and medical staff accountable for identification of, prevention of and reduction in medical errors. Governing boards also ensure improvements take place when opportunities are identified.
In this increased area of value, it is essential that the governing body be diligent and rigorous in its duties related to quality and safety just as they likely do around finances. However, not all trustees may have the people or the processes in place to truly be accountable for the quality and safety of their hospital and physicians.
As a result, most boards delegate the true heavy lifting to a board quality committee, and most try to place physicians on this committee and the board to provide their expertise. But these efforts may not meet the public’s standards of accountability.
According to the IHI Framework for Effective Board Governance of Health System Quality, trustee competency around quality and safety depends on:
Their understanding of medical terminology and an appreciation of how care is delivered
Familiarity with the hospital’s QAPI program
A commitment to a culture of safety.
However, from my experience and review of the literature, these competencies are certainly necessary but not sufficient. Governing boards would also benefit from a process for dealing with instances when medical staff or the QAPI program first identify an observed variance to safe and high-quality care, even if the variance is quantitatively small but the risk is great.
I suggest the following recommendations for a process for governing bodies to follow to uphold their accountability for safety and quality:
Once the board is made aware of a quality or safety concern, the trustees should convene a task force that will focus on understanding the concern and developing a plan of action for management.
Management must educate trustees on the context and events under review. This education must be sufficient for these trustees to perceive themselves as being competent. Management should present quantitative data such as mortality and complication rates and trends. It is essential that trustees also review qualitative information collected through direct observation of the concerning process and staff or patient interviews. If concerns exist that there may be bias in the qualitative data, unbiased experts should be brought in to supplement the information.
Trustees should render a verdict to management on whether or not the variance represents a real safety and quality problem and trustees should propose a plan of action, a timeline and a monitoring plan. If the trustees are unable to render a verdict, then full consideration should be given to stopping all clinical activities related to the variance until further information can be gathered and a verdict can be rendered.
Most of all, trustees must be courageous and accept full responsibility for holding management accountable to swiftly and effectively acknowledge and fix the issue. Trustees’ lack of medical expertise and inherent deference to the executive leadership team should not mitigate the trustees’ responsibility to act in their capacity as stewards of a public service. Further, other competing issues confronting the trustees should not preempt the trustees’ focus on even small observed variances in safety and quality.
While these recommendations could be further developed, I am confident they represent a step in the right direction. They reflect the need for physicians and hospitals to better meet the demands of a public increasingly concerned about quality and safety.
The days of physicians and administrators dictating to society what those standards may be coming to an end. Thus, the governing body of a not-for-profit health care hospital must take responsibility for defining what is acceptable care and for holding management accountable to this standard. They must not let their ignorance of medicine or an unreliable process get in the way of their duty.