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From the top down

Boards play key role in clinical improvement: study

By Cinda Becker
Posted: October 9, 2006 - 7:08 pm ET

A hospital's board of directors appears to play far more than a symbolic role in both clinical and financial operations. The hands-on engagement of the board in the oversight of quality practices differentiates top-performing hospitals, according to a groundbreaking and ongoing study just released by the Governance Institute and Solucient. The study, based on a survey of 4,200 not-for-profit hospitals and health systems in the U.S., so far has found five statistically significant relationships between board practices and consistently high-performing hospitals. In the coming weeks, Solucient will further analyze data from the survey for more correlations between board practices and facilities on Solucient's 100 Top Hospitals rankings, the authors say.
"I think what these practices -- that are significantly correlated with high hospitalwide performance -- reflect are early-adopter practices for coping with a transparent world," says Jean Chenoweth, Solucient's senior vice president of performance improvement and 100 Top Hospitals programs. "These are boards that are using their traditional powers to move the whole organization toward performance improvement."
Hospitals where the CEO's performance evaluation included incentives for meeting clinical improvement goals, the board participated in developing physician credentialing criteria and the board quality committee annually reviewed patient-satisfaction scores correlated significantly with Solucient's 100 Top Hospitals rankings. Other high achievers included hospitals where the board set the agenda for its quality discussions and where the medical staff was also involved in setting the agenda for the board's discussion surrounding quality.
One subject of further analysis will be the differences between boards that have quality committees and those that don't, says Carlin Lockee, managing editor at the Governance Institute, which is owned by National Research Corp. Although the Governance Institute is not prepared to say that boards with quality committees oversee quality initiatives more effectively, "There is something going on here," she says. In general, the boards of hospital systems seem to be more involved in quality improvement than those at stand-alone hospitals, Lockee says.
Another area of concern to the Governance Institute is chief financial officer involvement in board quality activities, Lockee says. Of all the respondents who said they have board quality committees, nearly all noted that their chief executive officers sat on that committee, yet only 19% of those same respondents said the CFO was also a member. Considering the strong role CFOs play in the operations of a hospital as well as their crucial link to the purse strings, the Governance Institute would like to see that number increase, she says.
Meanwhile, fewer than half of the boards at the hospitals surveyed have developed a formal statement on quality -- a "somewhat surprising" finding, Chenoweth says. Of those that have issued such policies, the information has been disseminated to only 76% of the hospital's staff.
Now that the study has identified board practices that correlate with hospitalwide performance, Solucient will study relationships between board practices and individual performance measures such as mortality, complications, length of stay and expense per discharge, Chenoweth says.
The correlations between board practices and top hospitals resonated with Robert Kiely, president and CEO of 168-bed Middlesex Hospital in Middletown, Conn., where all of the practices are in place, he says in an e-mail. Middlesex was on Solucient's 100 Top Hospitals roster in 2004.
For example, more than 10 years ago measures for achieving clinical improvement goals were included in the executive-staff incentive-compensation program, he says. Financial incentives are awarded for such goals as patient satisfaction, medication error reduction, compliance with Leapfrog Group measures and use of clinical pathways. The Middlesex board has also worked with the medical staff leadership for more than 10 years to refine the credentialing process. The Middlesex board likewise tracks patient-satisfaction measures for inpatients, outpatients and emergency room patients.
As for the board setting the quality agenda, one example is a board-driven practice in which board members are regularly updated on adverse events that occur in the hospital, including findings from root-cause analyses, Kiely says. Finally, he says, it would be hard to imagine "how the medical staff could not be involved in setting the agenda for the board's discussion around quality." Recognizing that the science of quality improvement was rapidly advancing with "the early stirrings" of public reporting, the Middlesex board and physician leaders about five years ago installed new physician leadership for quality-improvement efforts, he says.
Middlesex's achievements would not have been possible "had the board not set the organization on (its) course ... and were they not vitally interested in moving the quality agenda forward," Kiely says.
Robert Evans, administrator and CEO at 422-bed East Texas Medical Center, Tyler, which has landed on Solucient's 100 Top Hospitals list four out of the past eight years, similarly completed the Governance Institute's survey of board practices. The East Texas board is intimately involved in quality initiatives as the governing body "ultimately responsible for the quality of care in our institution," Evans says. Board members are given monthly reports on quality initiatives and outcomes, and they also help set priorities.

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