New Accountabilities:The Boards Emerging Role in Clinical Excellence

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New AccountabilitiesThe Boards Emerging Role in
Clinical Excellence

• National Conference of State Flex Programs
• August 14-16
• John R. Combes M.D.

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Overview

• Organizational Accountability
• Quality, Patient Safety and Clinical Excellence
• Call to Responsibility
• Quality Accountability
• Leadership and Outcomes
• The Future

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Organizational Accountability
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Fiduciary

• A person who has the legal duty, creating by
  his or her undertaking, to act primarily for the
  benefit of another or others in matters connected
  with the undertaking.
• Slees Healthcare Terms

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Fiduciary Duty

• Loyalty
• Care
• Obedience

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Stakeholders

• Individuals and groups for the benefit of whom
  nonprofit organizations are created
  Pointer and Orlikoff
• Community
• Patients and Families
• Medical Staff
• Employees
• Sponsors and Donors

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Accountability

• To hold the organization accountable to what it
  says it is and to what it says it will become
• Mission
• Vision
• Goals

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Quality, Patient Safety and Clinical Excellence
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Current Quality Environment

• Hospital field is attempting to respond to a
  variety of internal/external forces
• Many credible and worthwhile organizations and
  initiatives focused on health care safety and
  quality
• Uneven progress across the field
• Public trust is at stake

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IOM Aims for Quality

• Safe
• Effective
• Patient-Centered
• Timely
• Efficient
• Equitable

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Call to Responsibility
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Boards Quality Role

• Awareness
• Literacy
• Application to Responsibility
• Value-added Work

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NQFs Call to Responsibility

• Vital Role in Monitoring and Improving Hospital
  Care
• Effective Evaluation of Their Role in Enhancing
  Quality
• Develop Quality Literacy
• Oversee and Accountable for their Hospitals
  Participation and Performance in National Quality
  Efforts

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Monitoring and Improving

• Quality is Highest Priority
• Patient Safety and Quality Prominently on Board
  Agenda
• Oversee and Evaluate Outcomes
• System of Improvement and Results
• Recognize Clinicians Roles

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Monitoring and Improving

• Hospital and Medical Staff Policies Clearly
  Define Expectations
• Management Focused on Improvement
• Align Budget with Quality and Safety Goals
• Support Negotiations for reimbursements for
  Quality Investments

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Evaluation of Board's Role

• Diverse Board Composition with Expertise in
  Quality, Safety and Clinical Outcomes
• Not Just Clinicians but Other Disciplines from
  Industry
• Include Effectiveness of Leadership on
  Influencing Hospital Improvement

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Quality Literacy

• Education Both at Orientation and Advanced Level
• Representing Consumers and Community
• Financial Literacy Comparison
• Use Outside Resources

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Participate in National Quality Efforts

• Ensure Participation
• Review of Generated Performance Data
• Cost of Poor Quality
• Context of IOM Aims
• Accountability for Failure to Reach Benchmarks
• Incentive Programs

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Quality Accountability
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DELMARVA Survey Background

• Research conducted over the last 15 months
• Funding by the Robert Wood Johnson Foundation
• Interviewed Hospital CEOs and Board Chairpersons
  (over 75 interviews representing over 50
  hospitals)
• 30 to 45 minute interviews
• Major research aims
• Hospital CEO and BC perception of the engagement
  of the hospital board in quality,
• The relationship between the boards engagement
  in quality and the organizations overall
  performance
• Potential best practices in engaging the board in
  quality

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What do we know today

• Board quality literacy is low to moderate
• Mixed definitions of what is considered quality
  expertise on the Board
• Public reporting is strong driver of awareness
• Strong awareness of current initiatives
• Perceptions between CEOs and Board Chair not
  always aligned

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What do we know today

• Agenda time for quality increasing
• Need better integration of measurement, planning
  and incentives
• High use of Dashboards/Scorecards for performance
  monitoring
• The big aims/big dots/quality goals are not well
  defined
• There is some suggestive link between governance
  practice and organizational performance

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• Quality Expertise on the Board

• Number of Quality Experts on Board?
• CEO says 5.7 people
• Board says 9.8 people

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Measurement, Planning, Incentives
CEO and board chair responses significantly
differ at plt0.05
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• Perceptions between CEOs and Board Chair

CEOs generally give lower scores than BCs
regarding satisfaction with progress in
improvement, CEO improvement expertise, and the
boards engagement in quality.
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Quality Dashboards
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Dashboard Characteristics

• Include Hospital Compare Measures
• Shared Widely Through the Organization
• Content from Multiple Constituents
• Used for General Awareness and Focus rather than
  Operational or Performance Management

Kroch, E Vaughn, TE Koepke,M et. al. (2006)
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Boards, Quality Performance Dashboards

• Higher Quality Performance Associated with
• Shorter Focused Dashboards, Frequently Reviewed
• Active Use of Dashboards by the Board for QI
  Projects, Operational Oversight and Public
  Reporting
• Board Quality Committees that Strongly Influence
  Dashboard Content and Implementation

Kroch, E Vaughn, TE Koepke,M et. al. (2006)
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Bronson 2004 Scorecard
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System-level Performance Measures Big
Dot
IHI, 2004
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Board Leadership and Quality Performance
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Quality Outcomes

• Board Spends More than 25 of their Time on
  Quality Issues
• Receives a Formal Quality Performance Measurement
  Report
• Ties Part of Senior Executive Compensation to
  Quality Performance
• Engages the Medical Staff in High Level
  Interaction on Quality Strategy

Vaughn, TE Koepke,M et. al. (2006)
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The Future
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Pay for Performance

• Hospital Quality Incentive Demonstration Project
• Insurers
• Aetna
• Anthem BC/BS
• Industry Consortium
• Healthcare Purchasing Group
• Consumer Based Coalition

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Quality Literacy

• Educate the board on the range quality issues
• Define quality expertise and add that competency
  to the board.
• Begin in-depth dialogue on quality and quality
  improvement projects.
• Have board members attend quality conferences.

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Quality Agenda

• Initiate discussion between the board and CEO on
  the status of quality improvement in the
  hospital. How is the hospital progressing? What
  are the barriers? What are the strengths? How can
  the board support improvement?
• Ensure discussion of quality on the board agenda
  gets equal billing with other important agenda
  items.

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Quality Planning Performance

• Create a vision for quality for the hospital with
  long- term outcome measures and goals. These
  outcome measures may include aggregate quality
  measures such as mortality rates (100k Lives).
• Review the hospitals quality plan and ensure it
  is aligned with the overall hospital strategic
  plan.
• Ensure the quality measures for the board are
  assessed annually and are well understood by
  board members.
• Integrate the quality measures into the overall
  board performance metrics and board strategic
  milestones.
• Link incentive compensation to quality metrics.

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Patient-Centeredness

• Share patient stories at Board meetings to
  further increase focus on patient-centeredness.
• Ensure that patients are involved in improvement,
  such as by having patients and/or their families
  participate on improvement teams or Board
  Committees.

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Governance as Leadership

• Mode I Fiduciary
• Mode II Strategic
• Mode III Generative

Chait, Ryan Taylor, 2005
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Generative Mode

• Making sense of circumstances.
• Inviting prior questions and alternative
  hypotheses.
• Placing perceived problems/opportunities in new
  light.
• Finding and frames new problems and
  opportunities.
• Concerning values, beliefs, and assumptions.
• Spawning policy, strategy, and decisions.

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Philosophy

• We must all hang together, or, most assuredly,
  we shall all hang separately
• Ben Franklin, 1776
• There are only two forces that unite men- fear
  and interest
• Napoleon, 1804-15