Sunday, February 11, 2007

Governing Safety and Quality

Here in Massachusetts -- and probably elsewhere -- a hospital's board of trustees has the statutory responsibility for ensuring the quality and safety of patient care. Think about it: A lay group of volunteer citizens has the final authority for how well you are treated in the hospital. Of course, doctors and nurses and other licensed professionals have their own responsibilities under the law, too, and can be held accountable by various regulatory agencies. But what can and should we expect from the lawyers, real estate investors, bankers, corporate executives, community activists and others who happen to find themselves on the board of a hospital?

The full board's involvement is often entrusted in the first instance to its patient care assessment committee (PCAC). This is a combined trustee/medical staff committee that reviews adverse events, the procedures used by the medical staff to investigate errors and omissions, and the range of programs in the hospital that are designed to reduce medical errors and otherwise enhance quality. The PCAC reports on a regular basis to the full board.

In our place, we supplemented the PCAC reports with a monthly report on the quality indicators that are collected and posted by our accreditation body, by Medicare, and by other insurers (e.g., the percentage of heart attack patients who receive aspirin upon arrival). This "dashboard" covers a variety of such measures and provides a quick visual scan of how the hospital is doing relative to national benchmarks on each one. On the dashboard, measures that are in compliance are shown in green, those with slight trouble are in yellow, and those that are substandard are shown in red. In addition, we would have a presentation by doctors and nurses about particularly interesting quality or safety initiatives.

Our board was not satisfied with this. To them, it did not answer the underlying questions: How well are we doing on quality and safety? Where could we do better? Is the place safe? They asked us to bring in an outside visiting committee of national safety and quality experts to offer an assessment of our programs and advice on how they, as board members, could make sure they were doing their job as well as possible. We did this, and here is what we learned.

We learned that our policies, procedures, and actual quality and safety programs were quite good, with a supportive corporate culture and sound underlying systems and knowledgeable and enthusiastic people who wanted to move things up a notch and get even better. But we were advised that a change in focus was needed to reach our potential. And, interestingly, the key to our success would be to change the relationship with our governing body. While there were several detailed suggestions, here were the two main ideas:

First, said our advisers, the board of trustees is seeing too much green. Don't bother showing them a quality dashboard that mainly displays your success in complying with detailed national quality metrics. That is distracting and boring and an ineffective governance and management tool. Instead, focus the board's attention on where you are doing harm to patients, and tell them how you are going to stop injuring and killing people.

Second, do more to tap the intelligence, skills, and experience of the board members to prompt them to offer advice from their own personal and professional lives that could be useful in designing, implementing, and monitoring progress. During discussions of quality and safety, board members are often intimidated by their lack of medical expertise. Give them the means to participate in thoughtful discussions on these topics. They are bound to have many good ideas. If the board is not spending as much, or more, time on quality and safety as on hospital financial and other business matters during their meetings, something is wrong.

As is often the case, these two simple themes have changed our perspective. At all levels in the organization, we focus less on detailed compliance with regulatory standards and more on how to eliminate harm. This rises up from the units in the hospital, to the divisions and departments, to the medical executive committee, to PCAC, and to the full board. You have seen some examples on this blog: My postings on central line infection and ventilator-associated pneumonia are drawn directly from the work and presentations in the hospital and include many of the same details seen by our board.

The second point is also being implemented. More meeting time is devoted to these topics. Even better, the presentations we have made during the last several months have, indeed, prompted more board discussion and insights from the board members themselves. They have become confident that they can be as "expert" on quality and safety issues as on business issues. They have found this to be engaging and useful, as have the staff.

In summary, we are all learning how to do this better. There is no monopoly on good ideas. I welcome comments from those of you out there who want to share your own experiences.


Ileana said...

Paul, I have no clue what you can do better, but I know who does: your patients, nurses, doctors and other staff. If someone digs into this collective knowledge and interprets it intelligently, you can find out what you need to do.

I wrote a long post about this:

Thanks for the post, Paul! I loved the intellectual exercise... and I am sure that you guys are already doing this anyway...

Anonymous said...

Your board's refusal to be dazzled by all the green on your quality and safety dashboards is wise. Similarly, turning to the peeps themselves for quantum improvements has legs.

I explain:

1. A company in a dangerous industry seemed to have it all right--good corporate ethic around safety, a leader for whom it was a key tenant of his agenda, a large organization teaching, monitoring, and promoting safety. Then several deaths. A deep inquiry of the best minds discovered that what shows may not be enough. Safety is an every-minute, all-hands-on-deck concern and one misstep, one tiny little wrong decision, can be fatal. Everyone needs to live this in environments like AMCs (am I getting the lingo yet?).

2. The practice of turning to the natives for culture change has a long history of radically improving performance. Weatherhead School of Business Prof David Cooperrider's two simple words capture the idea: Appreciative Inquiry. Ask positive questions of the culture--drawing out the stories where people's ingenuity and creativity shine most brightly--and board a very fast route to organizational improvement. Seems to me your head of neuro (see below) was doing precisely this.

Emily DeVoto, Ph.D., said...

Regarding what Jessica Lipnack said: true, hospitals are dangerous environments. It seems to me that if one little misstep can result in a devastating consequence, the systems meant to prevent errors and near misses may not be robust enough. I have written in my blog about how the airline industry learned and implemented safety lessons from a particularly salient plane crash in the 1980s (; the health care industry has some catching up to do.

I agree with both of the previous comments about inviting input from patients and staff. If your corporate culture can truly accommodate such a dialogue, and then implement the changes that arise from it, then you're really on the right track.

Anonymous said...

Emily, please see my posting below on how our OB department used team-training experience from the defense department on this vaery topic.

I recently heard that Cincinnati Children’s Hospital has done intersting things in this area of governance and corporate change. Is anyone familiar with that?