Thursday, August 09, 2007

Meeting a statutory responsibility

While we have spent a lot of time here and in the media in the last few days and weeks discussing the merits of public disclosure of hospital infection rates and other quality metrics, we have neglected discussion of the role of a hospital's governing body in holding the medical and administrative staff accountable for patient safety.

Back in February, I talked about the role of the hospital's board of trustees in governing safety and quality. The board does have final authority for these matters under state law. How it should do the job is not specifically set forth in the law. A lot of what I presented in my February posting was suggested by an external review committee we had retained for BIDMC to evaluate our safety and quality programs.

One member of that review committee was Jim Conway, former COO of Dana Farber Cancer Institute, and now working at the Institute for Healthcare Improvement and teaching part-time at the Harvard School of Public Health. Jim recently had an interview with an organization called Great Boards. It is well worth reading, and I link to it here.

As I read through his recommendations, I see that we have implemented some of them, but some items are left to be done. For example, over 25% of our board meetings are devoted to these topics, and we present specific cases of where we have done harm to patients and what we have learned and changed as a result. In October, we are holding a two-day board retreat focused solely on this topic. Our board members will participate in on-site visits of patient care areas -- talking with doctors, nurses, transporters, and others -- will review Jim's recommendations and others, and then they will decide how they want to govern quality and safety at BIDMC going forward. I know that similar discussions are taking place at several other hospitals in the region.

But here's a question for the public debate: Should the state DPH, which has authority over public health matters, or the Attorney General, who has supervisory authority over public charities, require some certification of board of trustee training in safety and quality matters? We could not imagine a doctor or nurse being permitted to serve the public without training. Should board members who have the statutory responsibility for patient welfare also be required to meet some minimum level of competence in this regard? I am not suggesting they would need to have the technical depth of MDs or RNs, but perhaps they should be required to have a working knowledge of the governance issue surrounding quality and safety.

What do you think?


Anonymous said...

Yes, absolutely. The board, much less the administration, at my mid sized hospital are mostly ignorant of the nursing and support staff issues that affect patient care quality and safety. So when they do come to the floor they have no idea what's going on. Even requiring them to take and pass a basic Certified Nursing Assistant course lasting a couple of months would constitute a vast increase in their knowledge.

Anonymous said...

Good idea, but I don't think you can ask them to do quite that, i.e, a CNA course. These are people with full time jobs elsewhere, who are volunteering to be on a non-profit board in their spare time. So whatever training takes place has to be highly targeted to their function as hospital overseers, and it has to be done within a time frame that fits into their schedules.

So the training has to be in how you GOVERN a hospital, and how you hold highly technically trained providers accountable for quality and safety. I know this sounds contradictory, but you don't actually have to know how to deliver medical care to hold the management and medical staff accountable on these matters. People serve on the boards of other types of highly technical corporations without knowing the details of those industrial process -- yet they can be adept at holding management accountable. Same idea here.

Anonymous said...

Response to "the sak": I am not going to publish your repeated comments and complaints about other hospitals and institutions in Boston. This is not the place for that. Please take up those matters directly with the people who run those places.

Anonymous said...

Perhaps another idea would be to dismiss old boardmembers and begin anew, removing the old ways of thinking. It's a new time. A time for the board to be a true mixture of the community; men and women, young and old, teachers, counselors, farmers, etc., etc. They should also be empowered with the authority over all hospital workers-including physicians and CEO.

As I visit hospitals and take a glance at the board photo, I see older men with an occasional older women thrown in. One board in particular in NY that I've reviewed consisted of the mayor, six lawyers, a nun, a physician, the hospital CEO, another physician that was arrested for drug use and sale and a priest who was involved in withholding evidence of pastoral abuse of children. There is something wrong with this picture but I think it may exist more than we realize.

The board "team" should be trained but will learn as they go as long as the focus is kept on the patient and integrity. If the personal values aren't there, they should be dismissed.

Anonymous said...

While the board tends to be a team in itself, is there anything wrong with making a sub-team or a sub-leader focused on taking classes or seminars regarding hospital safety and quality? Perhaps a portion of each board meeting could cover what that designated person learned in his/her most recent seminar? This could easily lead into the hospital's recent results or new protocols. Most board members are voluntary, but they are working with the hospital because, in some respects, they must care. Right?

Anonymous said...

I think that it's important for the board to hold administration responsible. However, there is the danger that involving the board invites micromanaging the staff. How as CEO do you work with the board to stay strategically focused?

Anonymous said...

Right! There is actually a special committee of the board, the patient care assessment committee, that is charged with detailed review of safety and quality matters, that reports back to the full body. The PCAC members get totally immersed in this stuff.

Anonymous said...

Hi Paul;

This is a very interesting and timely topic. Forgive the length of this comment, but I feel strongly about this issue.
My opinionated answer to your specific question is, no. Training mandated by a limited (state) bureaucracy will not accomplish what you want. Who would provide the training, and would it unnecessarily circumscribe the trainee's thinking to just what the trainer thinks? (e.g. discourage out of the box thinking by someone from another industry, or just be the politically correct approach of the moment) Would it discourage people from wanting to serve on your board? On and on. Also, physicians and nurses are often the least knowledgeable and accepting of SYSTEMS approaches to reducing medical errors, not recognizing that individual human error is inevitable.

I know there are abundant resources out there for board members to educate themselves adequately about patient safety, and I believe it's incumbent on the hospital's administration to provide these materials to all board members and automatically to new ones. For instance, I was appointed to our hospital's Performance Improvement Council. Sure, I was a physician, but I knew squat about any of the literature on PI, quality, patient safety, whatever you want to call it. It fell to our very active and educated quality assurance dept. to educate me and provide literature and references that made me a knowledgeable and contributing member. It looks like you are doing similar things with your retreat and with implementing the outside recommendations.

But here's the rub - what if the administration itself doesn't care about patient safety; how is the board to rise above that and force the issue? I think the answer is that JCAHO and other standards pretty much tell boards what they are supposed to be doing, and a smart board will ask these questions, just as your board did of you with the outside review.
But it all resides with the composition of the board. Hopefully, the members who show the most interest and aptitude for these issues will comprise your patient safety committee.

I'd be interested in your thoughts.

Anonymous said...

Kevin is right on target. The board needs to do enough to hold people accountable, but not micromanage. In fact, if they micromanage, they are, in essence running the place, and REMOVE accountability from the professional staff. So the balance has to be carefully set and maintained.

Anonymous said...

Dear Anon 8:50,

I posed the question because I was curious to see what people had to say -- so many thanks for your thoughtfdul reply. I am not sure that the Joint Commission surveys get to this level of oversight, but they might. Maybe someone from there can comment.

Something is amiss, though, because I know that lots of boards are not sufficiently trained or actively involved in this. This happens even in places where management does care a lot about the issue. I am sure it happens, too, in places where management has insufficient interest.

Thoughts from others out there?

Rob said...

Wow. Interesting topic. I tend to simplify and go holistic with these things because I am a technologist by trade and a writer by avocation.

So when I say that a hospital is a technology system that processes sick people to make them well, I know it's a grave simplification (for example, some of the work is in letting people die in some comfort, and managing disease that will never be cured), but I believe the model is sound.

Just as precious few ordinary people actually know or care how an automobile works yet can drive, I'm not sure that a board really must understand many of the complexities in order to steer.

However. They do have to understand the controls and the dashboard instruments to do the job right. They need to know the machine's expected behavior, limitations, and road conditions. It's part of driving.

To that extent, I think it's imperative that any organization do what it can to explain its own operation to its board. In that process, the organization may find that there are areas that need definition and perhaps it's a good thing someone asked.

In other words, this needn't be adversarial or a micro-managing. A car, a computer, a space ship - these are all incomplete technologies without someone's will to guide it. A hospital, big as it is, is the same way. It is incomplete without wise guidance.

That wisdom comes from not over-complicating our purpose and forgetting what a hospital is for. It does come from a commitment to precisely that purpose, and a basic understanding of it's implications.

Can someone be trained to do that? I dunno. I think they can be educated, and I think they should be expected to observe and ask questions. Curiosity is the cornerstone to knowledge and wisdom.

If someone doesn't care to know? Get rid of them. They're a bad driver.

Anonymous said...


theszak said...

There are better ways to blog, to use the format of blogging and involve all who respond to your excellent writing.

Editorial priviledge should be supported as well as there should be critique of the editing.

Anonymous said...

Great Blog! As a trustee of community hospital for 12 years I notice that things really start happening in quality when the CEO starts pushing the envelop. The best things a board can do for itself, once you have such a CEO, are to 1) get really thoughtful and curious members to support and challenge the physicians and CEO, 2) set ambitious goals, and 3) hold people accountable. As for board training, the new education program designed by Blue Cross and MHA is a good start in that it focuses on the tools boards already have to make progress in quality, such as mission, quality oversight, and how board meeting time is used. Best.