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Transforming health care through research and education.

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Leveraging research and education to create a society of healthy communities, where all individuals reach their highest potential for health.

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Enhancing the Board's Role in Quality

Bryan J. Weiner, PhD, University of North Carolina at Chapel Hill

The board's roles as steward of an organization's mission and assets, strategic partner with management, and advisor for management provide opportunities for enhancing the board's oversight, leadership, and service in the quality arena.

As the organizational entity legally accountable for quality of care, governing boards have an important role to play in overseeing quality improvement efforts and patient safety initiatives. Boards also have the potential for providing leadership through:

  • establishing quality and safety as organizational priorities,
  • allocating resources to support quality improvement efforts and patient safety initiatives,
  • revising executive compensation and performance evaluation criteria, and
  • fostering corporate culture that values quality and safety.

With healthcare organizations facing mounting pressure to improve quality and safety performance and increase public accountability, a pressing need exists to identify the organizational structures and practices that enhance the board’s ability to fulfill both its oversight responsibility and its leadership potential.

Certain features of composition, structure, process, and context impede the board's potential role as advocates of quality. First, few board members possess healthcare backgrounds or clinical expertise: they are often selected on the basis of business experience, professional skills, community ties, personal values, and time availability. Although board members from manufacturing and service industries may be well versed in quality issues, they report feeling confused about their responsibility for quality of care, ill prepared to evaluate quality of care, and uncomfortable taking action to rectify a quality issue. Second, the dual-committee structure—in which both hospital committees and medical staff committees are charged with improving quality of care—can complicate the board's ability to perform effective oversight. Third, many boards do not possess information systems that are adequate to support their governance work. Finally, board members spend much of their meeting time focused on financial issues and on reviewing what has happened since the last board meeting rather than engaging in forward-looking discussion and decision-making; quality may not even appear as a regular agenda item in every board meeting.

Through in-depth case studies of five health systems—including interviews with 25 system-level board members and executives and 44 hospital-level board members and executives—this research project developed theoretically informed, empirically grounded knowledge of governance principles and best practices for enhancing the board's role in quality.  As a result of the study, participating systems gained a better understanding of the strengths and limitations of their current governance practices as well as practical recommendations for optimizing their boards’ future involvement in quality.  These case studies can serve as examples of “best practices” for other health systems.

The project addressed a fundamental question confronting hospital- and system-level board members and executives:  What is the role of the board in quality?  According to the researcher, developing practical strategies directed at strengthening the board’s role in quality required defining the purposes of the board’s involvement in quality.  Three specific purposes were identified and defined:

  • oversight emphasizes the board’s role as fiduciary or steward of the organization’s mission and assets,
  • leadership emphasizes the board’s role as strategic partner with management, and
  • service emphasizes the board’s role as advisor and sounding board for management.

The project then developed a series of specific questions to be asked in board meetings to stimulate a higher level of discussion and a greater degree of board engagement in quality.  The questions, detailed in the full report, were based on the three purposes for the board’s involvement in quality.  In the oversight category, questions included:  What have we done to create a culture of safety?  What have we done to balance a culture of accountability with a culture of learning?  In the area of leadership, questions for the board included: How do we position ourselves to be ahead of the pack in terms of quality improvement and performance measurement?  How can we leverage our higher quality to increase customer (patient/physician) loyalty?  Questions to provoke board involvement in service included:  What would happen to our financial health if, starting tomorrow, CMS tied hospital payment to quality performance?  What is the biggest gap between what the organization claims and what it actually is?

The project also sought to determine how healthcare delivery organizations with multi-tiered governance structures could best define and coordinate the role in quality of the system board and the hospital board.  Recommendations included identifying those governance tasks that only the system board could do by virtue of its position within the system.  To increase the time available for quality leadership and service tasks, system boards were asked to delegate quality oversight tasks to hospital affiliate boards.  System boards were also encouraged take on the responsibility of strengthening affiliate-level governance for quality oversight, leadership, and service.  For example, system boards might work with system executives to (a) develop a process for annually or biannually assessing affiliate board capabilities, performance, and needs; (b) develop systems for identifying and transferring best practices in governance within the system; and (c) support affiliate boards by developing high-quality education materials, “internal consultants,” and technical assistance so that these costs can be born collectively rather than by individual affiliates.

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