Quality often an afterthought for system, hospital boards

As CEO of Virginia Mason Health System, Dr. Gary Kaplan sees it as his responsibility to ensure the organization’s board of directors is in-the-know on matters of safety and quality.

Members on the board’s quality committee are notified every time the most serious safety events occur, with what are called red alerts.

Additionally, each board meeting starts with a patient sharing their experiences at the organization, positive or negative. Kaplan, who attends all seven board meetings held annually, said quality concerns are discussed just as much as financial issues at the sessions.

This is a well-established culture of the board since Seattle-based Virginia Mason implemented its management system nearly 20 years ago. Kaplan said he’s perplexed why more institutions haven’t adopted something similar.

“I think it’s interesting that many boards don’t fully appreciate that they are ultimately responsible for the safety and quality of care within the institution they govern,” he said. “Traditionally the thinking has been we delegate quality to the medical staff. That is sort of true, but ultimately the board is accountable.”

While there are some indications governing boards are changing their ways, hurdles remain in getting members more involved in quality issues at health systems and hospitals. For starters, because board members at not-for-profit hospitals and health systems typically aren’t paid, they have less motivation to become deeply engaged, some experts claim.

Another obstacle could be found in the knowledge gap board members have regarding clinical problems. Board members are often part of the business or finance community, so they’re more comfortable discussing revenue, investments and the bottom line.

But perhaps the biggest influence on the board’s investment in quality is the CEO, who sets the culture and expectations. Some CEOs don’t fully appreciate the oversight responsibility that boards have on quality, don’t present information well or aren’t fully honest about quality challenges facing the organization.

“Sometimes the CEO and the C-suite aren’t really transparent and don’t make (quality) a priority for the board agenda or the board’s work,” Kaplan said.

“It’s up to the CEO’s discretion what to present to board,” added Beth Daley Ullem, faculty lead at the Institute for Healthcare Improvement. “There are certain boards that aren’t as motivated (to focus on quality) and it’s up to the CEO and the rest of the C-suite to engage them to select board members who will prioritize quality.”

The risks associated with a board that is uninformed or unconcerned about quality issues played out at Johns Hopkins All Children’s Hospital in Florida. It became public in 2018 that patient deaths in its heart program were disregarded by leadership despite vocal concerns from clinical staff.

“Everything about this case raises the question: Where was the board when all of this was going on?” said Jamie Orlikoff, president of consulting firm Orlikoff & Associates. “This was a failure of governance.”

No board members at Johns Hopkins All Children’s were removed after the issues were exposed. Changes were recommended for both the hospital board and the board of Johns Hopkins Health System in an external review released in June of last year.

Similar to most hospitals that are part of larger systems, Johns Hopkins All Children’s has its own trustees responsible for overseeing quality issues in addition to the system board.

Gibson, Dunn & Crutcher, the firm that conducted the review, recommended both boards better engage members of the patient safety subcommittees and “better orient hospital board members to their role as monitors of patient safety issues at the hospital, rather than mere fiduciaries.”

The firm also recommended that the hospital patient-safety director work with the board chair to set the agenda at subcommittee meetings and facilitate discussion rather than the hospital president.

Both boards have agreed to follow the recommendations, said Danielle Caci, spokeswoman for Johns Hopkins All Children’s Hospital, in an email.

Since serious safety issues at Johns Hopkins All Children’s and other institutions have come to light recently, boards across the country are likely rethinking their quality oversight structure, said Michael Peregrine, a partner at law firm McDermott Will & Emery. “There is tremendous pressure on boards, (more so) than in the past, given the patient-safety crises over the last year,” he said. “It’s fair to say that it’s a good time for boards to reevaluate how they get information on quality and how robust that is.”

One of the most basic practices hospitals and systems can add to their governance structure to ensure boards are appropriately overseeing quality is having a standing quality committee. About 91% of health systems boards have a quality committee, which is a slight dip from 2014 when 94% of systems had such committees, according to the American Hospital Association’s 2019 National Health Care Governance Survey Report.

Rather than having a quality committee, some system boards have created care delivery boards to oversee quality at all their hospitals, clinics and other facilities, basically functioning like a quality committee, said Pamela Knecht, CEO of consultancy Accord Limited who was also involved in the AHA survey.

But the existence of a quality-focused committee doesn’t necessarily mean they are run well, according to Heather Kopecky, senior partner at Korn Ferry. “Some boards have members who don’t even know how to be board members, let alone know something about healthcare,” she said. “For the safety and quality subcommittee, the people on the committee need to know what they’re doing.”

In fact, the AHA survey found that none of the system boards participating considered quality expertise among the top five competencies they seek from trustees, compared with 61% of boards of hospitals that are part of systems and 88% of boards at free-standing hospitals.

This could mean that system boards are delegating more of the quality oversight to their hospital boards, which is a common practice, Knecht said. Boards at hospitals that are part of systems usually don’t have financial authority over the enterprise and can’t fire the hospital CEO, but they are charged with overseeing quality at the facility.

Another possibility is that patient-safety experts on quality committees of the system board aren’t members of the overall system’s board so they aren’t considered as such in the survey, she added.

Still, some health system CEOs don’t think clinical expertise on the board is necessary to appropriately oversee quality. During her time as CEO of Henry Ford Health System in Detroit, Nancy Schlichting said clinicians weren’t leading the board’s quality subcommittee. “I think it’s a mistake to put a clinician in that role,” she said. “It’s helpful when you have people who aren’t in the mix. They don’t make excuses for things.”

Under this structure, clinical members of Henry Ford presented quality information to the committee. Clinicians also took the time to explain quality concepts and educate the board about why certain metrics are important.

“It’s the job of the leadership team to bring in the clinicians and talk about the metrics, the national rankings, the standards and the pay-for-performance programs they are participating in,” she said. Schlichting added, it’s “ridiculous” if C-suites aren’t educating their boards about quality and its importance.

But even for C-suites motivated to involve board members in quality matters, it’s a challenge to find the right balance of what quality information to share with the board so as not to overwhelm them and ensure they don’t begin micromanaging.

“When I talk with boards, a lot say they get hit with too much data,” Ullem at the IHI said.

She recommends boards ask leadership to dive into one or two areas in which the organization is facing challenges and then explain some approaches to address them. “That tends to help facilitate a confidence about management’s approach to identifying, understanding and coming up with a plan to tackle a problem,” she said.

It’s also important that the board sets goals for the organization on quality and make sure they are getting the appropriate data and information to oversee progress.

“The boards have to be active, not passive,” said Andrew Chastain, CEO of executive search firm WittKieffer. “This is their responsibility—that they set goals, that they measure the performance of the goals and they engage with the CEO to do that.”

Transparency between the C-suite and the board when serious safety events happen is key. Schlichting said that during her time at Henry Ford the sharing of quality problems helped improve accountability. “We brought up issues (to the board) that were really bad at times, but we weren’t afraid to bring forward bad news,” she said. “We felt it was our duty to do that when things went wrong because it made us more accountable for fixing it and to make sure the results were improving.”

Part of avoiding a culture of fear of disclosure is not making termination a primary response to a quality incident.

“Bad things can happen to good organizations, but the solution is not just, let’s fire the CEO, problem solved, or fire the nurse,” said Joanne Disch, professor ad honorem at the University of Minnesota who has experience participating on health system boards.

Boards should instead assess if the issue represents a larger problem at the institution by asking management if this has happened before; if it could happen again; what’s being done to prevent it; and how the affected patient and family members are being informed about the error. “You have to do a deeper dive of what can be learned,” she said.

But the act of board members asking tough questions can be awkward for the C-suite, Virginia Mason’s Kaplan said. “Sometimes my team is made a little uncomfortable by the probing questions of our board members, and that is a good thing.”