The hospital board of directors is an important constituency that physician executives need to bring on the bus to promote consistent quality improvement. In fact, the board should be at the wheel, but that may mean physician leaders will have to give board members a few driving lessons, according to David Nash, M.D., chairman of the Department of Health Policy at Jefferson Medical College of Thomas Jefferson University, Philadelphia.
"The current state of board readiness to engage this issue is all over the map," Nash told a room full of physician leaders Sunday at the American College of Physician Executives meeting in Las Vegas, part of a three-day program on advanced quality management.
Most board members are business and community leaders with a lot of experience in finance and business management but with little background in the tools and metrics of quality management.
"The typical board structure is ill prepared to deal with the complexity of quality we're talking about," he said. "But boards are educable," he added, and they have to learn "because they have the ultimate responsibility for quality."
The easy way, and the wrong way, according to Nash, for boards to address quality is to make it a staff function by fobbing off the duty to a designated quality control officer or committee.
"Where quality is a staff function, you have a problem," Nash said. "It can never achieve the level of intensity that you need. The board has to say how you are structuring the everyday processes of achieving quality."
In addition, mission statements aren't enough, Nash said. Board members need to set the quality priorities of their hospitals, including picking specific metrics to be met, and allocating the resources to both measure and achieve those goals.
Just as virtually every board meeting addresses financial concerns, a hospital should "never have a board meeting without talking about quality improvement," Nash said. Quality and safety should be on the agenda of every meeting, and physicians can help create a dashboard of quality and safety indicators for board members to review.
Expensive chart reviews aren't required to run a quality improvement program, he said; quite a few metrics can be created using nominally priced analytical software that analyzes ICD-9 codes. Nash advised the physician leaders to keep things simple at first and come up with measurements such as readmission rates for the same DRG within 15 days, nosocomial urinary-tract infections per 1,000 catheter days, or inpatient admission after two emergency room visits for the same problems in one week.
The board should link executive compensation in a meaningful way -- say 30% of their annual bonus -- to meeting specific, quantifiable quality and safety targets, Nash said.
"Nothing gets the attention of hospital CEOs as this stuff (does)," he said.
Physicians, too, need to be educated about quality metrics -- "most doctors have never had a chance to learn this" -- and the education program must go beyond the typical, occasional continuing medical education session, Nash said.
They need feedback about how they're doing, preferably coming from a respected clinical leader, and they need financial rewards tied to their performance.
"The literature says you have to have 10% to 18% of compensation to get the physician's attention," Nash said.