Board engagement is crucial for healthcare organizations seeking to create cultures of safety and quality. However, many boards are unfamiliar or uncomfortable with quality oversight and instead focus on other aspects of health system performance, like financial metrics.
"Healthcare organizations often tell us they spend a couple hours on other board activities and then have a five- or 10-minute report about quality and safety," said Tejal K. Gandhi, MD, chief clinical and safety officer at the Institute for Healthcare Improvement. "The board's role needs to be broader."
To better understand healthcare boards' experience with quality governance, researchers from IHI's think tank, the Lucian Leape Institute, analyzed all existing programming used to train boards on quality and safety, and interviewed more than 50 governance experts, health system leaders and trustees. They used this information to create the "Framework for Effective Board Governance of Health System Quality" and a Governance of Quality Assessment tool, which health systems can use to evaluate their board's performance on 30 core quality oversight processes to identify areas of improvement.
Dr. Gandhi, who also serves as president of the Lucian Leape Institute, spoke with Becker's Hospital Review about the new framework and how boards can improve their oversight of healthcare quality.
Editor's note: Responses were lightly edited for style and clarity.
Question: How are boards missing the mark when it comes to overseeing health system quality?
Dr. Tejal Gandhi: Board members often don't feel comfortable asking questions about quality and safety because most do not come from a clinical background. It can be a challenge for them to know what questions to ask when talking about quality and safety issues because the language can be very different. Also, I think boards have historically focused much more on the financial measures of an organization's success and delegated the quality and safety functions to clinicians. But it's the board's fiduciary responsibility to ensure quality and safety, among other functions. Not to mention, the board is a critical asset when leaders of organizations are looking for investments in quality and safety. It's important to make sure the board has a good understanding of why we need those investments.
Q: What did you discover when researching and developing IHI's new framework?
TG: We found a lot of variation in terms of what metrics boards are looking at and how they're using the time spent on quality and safety. Some boards may be getting a quick quality report without time for questions. Others might be spending much more time on discussion. Even the level of data can vary.
In addition, if the boards are doing work in quality, most of it is focused on safety. I'm happy boards are looking at that, but quality is much more than safety. We found boards were not looking at the other domains of quality such as timeliness, efficiency or equity.
The third thing we learned was that boards should not only focus on the quality-related content they need to know, but also quality-related board activities or functions. Based on these findings, combined with an expert meeting of about 25 people last June, we developed the assessment tool. The tool helps boards and organizations identify the tactical things they can do to make sure they're accomplishing oversight of all quality domains.
Q: What does a board that is fully engaged in health system quality look like?
TG: A fully engaged board would first have a diverse composition comprising members from industry or banking, members with expertise in quality and safety — not necessarily from healthcare — and a patient advocate who represents the community the board is serving. At those board meetings, they would have robust discussions across all the domains of quality. It wouldn't be a quick PowerPoint presentation before they move on to the next thing. We've said the amount of time spent on quality and safety should at least match the time spent on finance. For robust quality discussions to happen, the board would potentially have gone through training and education to bring them up to speed on core content areas so they can start asking appropriate questions.
The benefit comes from having the board understand the organizational strategy around some key quality issues. The board can help ensure the organization is allocating resources appropriately and hold the CEO accountable to viewing quality and safety as a core value. That commitment to safety and quality comes from the board and C-suite, and then trickles down to the organization.
Q: What processes or activities can boards adopt to boost their knowledge of — and focus on — health system quality?
TG: The Governance of Quality Assessment tool has a long list of processes boards can adopt. Key strategies include educating board members on core quality measures and allocating more time for conversations about quality during board meetings. Boards can also adopt performance incentives for CEOs to make sure they are aligned not just on financial targets, but also on quality and safety. Another activity that makes a huge difference is having boards go on rounds at the health system to hear directly from patients and caregivers. It helps them put faces and names to what they're hearing about.
Boards must also approach serious safety events as more than just statistics. They should look at what exactly happened, ask how the organization is addressing the issue and hold leadership accountable for implementing strong action plans. Another key area is workforce safety. The board needs to review statistics around workforce injuries or harm and understand the plan on how to improve them. We think workplace safety is underrepresented on board agendas. We cannot deliver high-quality care if our workforce is not protected.
Q: How can health system leaders help support a board's effort to improve quality oversight?
TG: The most important thing is to see the board as a real asset to leverage. We often see stories about healthcare leaders sugar-coating things for the board or not letting them see an organization's dirty laundry. I think that is going to require a real shift in how leaders look at their boards. They need to be open and transparent with board members and let them see issues they could potentially help with. Once that mindset is in place, then health system leaders can support the board by providing education and training, opportunities to visit the front lines and by structuring meetings to feature a greater depth of information on quality.