Over the past few decades, many hospitals and health systems have invested significant time and resources in building and reinforcing quality improvement and patient safety programs. This has led to declines in some medical error rates. For instance, central line-associated blood stream infections dropped by 50 percent between 2008 and 2016, and have continued to fall.
However, much more progress needs to be made. Studies differ on the exact number of people who die in hospitals from medical errors every year. But experts agree: Too often patients are still subject to unnecessary, preventable harm.
One well-recognized approach to improving patient safety is the active engagement of governance in quality oversight. This is one of the core strategies for achieving zero harm endorsed by ACHE and the IHI Lucian Leape Institute in the 2017 report Leading a Culture of Safety: A Blueprint for Success.
“The organizations that we see making the most progress are those with tight alignment among the board, senior leadership and medical staff leadership,” says Gary Yates, MD, partner, strategic consulting, Press Ganey.
For instance, one study found that spending more than 25 percent of board time on quality issues was associated with higher hospital quality scores. “Attention is the currency of leadership,” says James Orlikoff, president, Orlikoff & Associates Inc. “Boards that spend their time and attention on issues of patient safety and quality will have better results than boards that don’t.”
Three Core Engagement Steps
To effectively engage trustees around patient safety, Orlikoff recommends that CEOs have three critical conversations with trustees:
See the problem. “If the board does not think there is a safety or quality problem, they’re not going to do anything about it,” Orlikoff says. Thus, CEOs first need to talk to their boards about the extent of preventable medical errors in the United States and in their own organizations.
“You should say, ‘Listen, we need to talk about something that is very difficult and depressing,’” Orlikoff says. “We, like all hospitals, have preventable patient deaths and injuries. I’m sorry if this makes you uncomfortable, but we need to talk about this, and I need your help. If we don’t talk about this, the problem isn’t going to get any better and is likely to get worse.’”
Charles D. Stokes, FACHE, former president and CEO of Memorial Hermann Health System, Houston, recalls that the system leadership took this step with the board in 2006. “We took the position, ‘If we’re going to prevent harm events, we have to be totally transparent with our board, medical staff leadership and all health system leaders,’” Stokes says.
Memorial Hermann trustees were surprised when they learned how frequently medical errors occurred, recalls Deborah Cannon, board chair. “As lay people, we couldn’t understand how this could happen.”
To help the board—and all leaders and staff—learn how to best improve patient safety, Memorial Hermann invested $18 million in training in 2007, and continues to provide ongoing training in Six Sigma, Lean Six and other performance-improvement approaches.
Orlikoff recommends mandatory continuing education around quality and patient safety for all trustees. “The board must be level-set, or literate, in quality and safety,” he says.
Virginia Mason, Seattle, has embraced this advice. New board members are not eligible for a second term unless they undergo extensive education on the Virginia Mason Production System, which is the system’s quality improvement program that incorporates Toyota’s quality approach and elements of Kaizen and Lean. New board members must also go on a two-week study mission to Japan with Virginia Mason staff and regularly attend quality progress meetings.
Own the problem. CEOs also need to ensure that trustees, the medical staff and the entire organization understand the board’s quality role. “Too many boards think their fiduciary responsibility is just financial,” says Tod Hamachek, chair, Virginia Mason board of directors. “In reality, safety and quality must have equal importance and priority, and you want to thoroughly inculcate new board members to that responsibility.”
This message can be challenging to convey because there’s a lot of misinformation circulating. “I’m amazed how frequently I am told that the medical staff bears the ultimate responsibility for quality and safety,” Orlikoff says. However, that belief is inconsistent with regulatory requirements. Medicare conditions of participation and every state hospital licensing statute across the United States places ultimate accountability for patient safety on the board.
Even after they know they bear responsibility for quality and safety, many trustees may incorrectly believe that this means they are responsible for telling physicians how to care for patients. To address this challenge, CEOs need to distinguish between the board’s and the medical staff’s roles in patient safety.
“It’s not the board’s job to tell medical staff leaders how to practice medicine,” Orlikoff says. Instead, the board is in charge of ensuring leaders and staff do their jobs so that medical care is “done right.” Specifically, trustees need to ensure the medical staff has adopted standards of care (e.g., clinical protocols, credentialing requirements) and that those standards are applied consistently.
Boards are also charged with ensuring patient care standards and practices reflect the goals of the organization. For Virginia Mason that means the patient always comes first. “When you look at our strategic mission, the patient is at the top, and patient safety is paramount,” Hamachek says. “That isn’t just lip service. We board members take it very seriously.”
Solve the problem. Boards can use a number of specific top-down strategies to drive improvements in patient safety. One is to discuss and adopt a few bold organizationwide aims that specify “how good, by when and measured by what,” Orlikoff says. “You don’t just say, ‘We aspire to be the best hospital in the country.’ Instead, an example goal might be: ‘reduce preventable mortalities by 50 percent by the end of 2021, as measured by a very specific metric.’”
Once big-dot goals are set, trustees and medical staff leaders need to discuss key drivers of unsafe outcomes. For instance, physicians might identify that sepsis and CLABSIs are major contributors to high mortality rates. Then targets can be set for these infections (e.g., reduce sepsis mortality by 50 percent by end of 2020).
That leads to another vital strategy: review of key quality metrics at every board meeting. To support this board function, Main Line Health, in the suburbs of Philadelphia, developed a quality and safety dashboard that is as “easy to understand as an income statement and balance sheet,” says Jack Lynch, FACHE, president and CEO. “The purpose was to provide the board with a tool that is equivalent to the tool we use to measure financial performance.”
Main Line Health uses a number of presentation techniques to make quality data meaningful and easy to interpret. Measures are organized by the National Academy of Medicine’s six domains of quality, which is summed up by the STEEEP acronym: safe, timely, effective, efficient, equitable, patient-centered. In addition, for each quality metric, a threshold (i.e., 60th percentile performance) and desired targets (75th and 90th percentile performance) are set. Colors (red, yellow, blue and green) are used to make it simple to identify metrics that are not meeting the threshold or targets.
Quality-focused boards also need to receive reports about serious medical errors that occur, complete with action plans for how the medical staff intends to prevent similar errors in the future. The point of reviewing these reports, as well as the quality dashboards, is to drive improvement. “One of the board’s jobs is to be a grain of sand in the oyster, which irritates the organism to create a pearl,” Orlikoff says. “The board’s job is to challenge and ask difficult questions.”
As an example, the Virginia Mason board does not simply rubber stamp action plans the medical staff presents for addressing serious patient safety alerts. “The board’s quality oversight committee must approve the plan as being mistake proof,” says Gary S. Kaplan, MD, chairman and CEO, and an ACHE Member. “Close to 10 percent of the time, one of the board members asks for more work on the plan, saying ‘You know, I think there’s still some things missing here.’”
Other Key Board Strategies
CEOs and board leaders should also consider the following strategies for engaging the board in safety issues:
Recruit trustees wisely. In addition to ensuring that all trustees are literate in quality and safety issues, hospital boards should seek one or two quality/safety experts as members of the board and to sit on and lead the board’s quality committee, Orlikoff says. These trustees don’t have to be experts in healthcare quality, but need expertise in the science of safety (e.g., high reliability, Six Sigma, systems thinking). Boards might find such experts in the aviation, nuclear power, auto or other industries.
For instance, a past Main Line Health trustee worked at UPS. “She used to say, ‘We measure how many times our drivers blink their eyes when they’re delivering packages,’” Lynch says. “Her point was, ‘We measure quality, too.’ So other industries have very applicable techniques that can be applied to healthcare.”
Share patient stories. Every board meeting at Virginia Mason begins with a patient personally sharing a story. At least 50 percent of the stories are about negative care experiences. “About five years ago, the board told Gary [Kaplan] that we were hearing too many good stories,” Hamachek says. “We wanted to hear negative stories, not because we want to embarrass management, but because these tough stories reveal important issues and lead to intelligent discussions around ‘How do we handle these issues going forward.’”
Finding ways to illustrate the human cost of medical errors can help motivate the board to continue driving toward zero patient harm, Orlikoff says. “It’s very easy for boards to say, ‘We’re at 98 percent reliability. That’s pretty good.’ Well, if you hear a story about a patient who got hurt because she was in the 2 percent, it really steals the board’s resolve to get to zero.”
Compare against the organization’s performance. Another way to fight feelings of complacency among trustees is to limit how often boards see data on how well the hospital compares with other hospitals, Orlikoff says. Though looking at comparative data can be helpful once or twice a year, it can lower the board’s expectations. “The danger is you’re measuring yourself against the average, and then you only focus on becoming the cream of the crap,” Orlikoff says. Comparative data is also typically old and doesn’t reflect current realities.
In contrast, hospital leaders who regularly look at their organizations’ performance over time are less likely to develop a false sense of satisfaction. “This involves comparing ourselves relative to the big-dot goal we’ve chosen,” Orlikoff says. “Is our mortality rate getting worse or better? Are we focusing on the right drivers? That’s how a board can meaningfully engage in making things better.”
Enforce patient safety measures. Memorial Hermann’s board ties clinical privileges to quality metrics as a demonstration of its commitment to zero harm. As an example, obstetricians at Memorial Hermann came to a collective decision to require that all obstetricians and obstetrics nurses complete comprehensive training on how to reduce complications during labor and delivery. The medical staff executive committee and all Memorial Hermann hospitals agreed to mandate this training, and the program was tied to physician credentialing and continued employment for obstetrical nurses.
The board supported this initiative wholeheartedly, and Memorial Hermann experienced fewer harm events as a result of this training requirement.
Stokes credits Memorial Hermann’s “no excuses accountability” culture, which permeates down from the board. “When bad things happen, we don’t make excuses, we make action plans. It’s about showing courage and standing up for the right thing.”
Show support with smart investments. Another key board strategy is the willingness to invest significant dollars into resources and technologies that will help hospitals eliminate harm. For example, Memorial Hermann is spending significant resources after hiring and contracting with hospitalists, intensivists and laborists to ensure that every patient admitted to the intensive care unit is seen by a physician within two hours, and patients admitted to regular hospital units are seen within four hours.
“Achieving zero harm isn’t free, and you just can’t tell people to go do this. You actually have to commit resources to making this happen,” Stokes says.
In another example, Main Line Health and Memorial Hermann have invested significant dollars in RFID systems that help ensure surgical sponges are not left inside patients during procedures.
Cannon has seen these kinds of investments pay off at Memorial Hermann—from a patient safety as well as a business perspective. Recently, a major insurer recognized the health system as one of its lowest cost providers due to low medical errors and low readmissions.
“We’ve determined along the way that delivering the highest quality care is not only the right thing to do,” Cannon says. “Safe care is also the most cost-effective care.”
Maggie Van Dyke is a freelance writer based in Chicago.