The Harvard report released this week that showed that half of 722 sampled hospital boards don't see clinical quality as a top priority wasn't much of a surprise.
Nor was it startling that two-thirds of these nonprofit boards had not received formal training in clinical quality. Or that those hospitals whose boards downplayed quality were more likely to perform worse in Hospital Quality Alliance measures than hospitals where quality was a top priority.
I've heard many complaints from physician leaders over the years that data on outcomes and adverse events just weren't on their trustees' radar. Financial performance and philanthropy? Sure. Reputation in the community? Definitely. Building projects? Let's meet with the architect.
But reviewing last month's stats on the number of avoidable falls or the number of medication mistakes? Those details get delegated to management.
"All our board members care about is the artwork and the atrium," I often heard one physician executive grumble.
Parodied another: "The flowers in the lobby are drooping. Isn't it time for lunch?"
But I wonder: With so much emphasis on quality and pay for performance–and with the threat that Medicare now can withhold reimbursement when avoidable mistakes require additional care—shouldn't this board culture be changing?
Yes it should, says James Conway, the Institute for Healthcare Improvement's senior vice president. And the IHI's "Boards On Board" Campaign is trying to do just that.
He ought to know. The IHI is now promoting "Boards on Board," a campaign to get hospital leadership "deeply engaged, starting with the Board of Trustees." He personally visits boards around the country to see how they are addressing quality improvement.
Evidence shows a more engaged board can power the push for programs or controls that prevent adverse events from happening. IHI has run educational programs for thousands of trustees and executive leaders.
"Traditionally, hospital boards and trustees have focused on topics they were most comfortable with, which have been issues of finance or building a marketing strategy," Conway says.
"But this is no dinner party anymore. Sitting on a board is a tremendous responsibility."
Conway sent me the "Boards On Board" 36-page How To Guide, which begins with a list of routine board activities to improve quality and safety within their hospitals. For example, boards should know their mortality and harm rates and set specific goals to reduce them. They should also establish a monitoring system for adverse events.
"At a minimum," the campaign advises, boards should spend "more than 25% of their meeting time on quality and safety issues and by conducting, as a full board, a conversation with at least one patient, or family member of a patient, who sustained serious harm at their institution within the last year."
That will make trustees understand in a powerful and personal way the consequences of avoiding the issue, Conway says. It may seem like a harsh order. But it really works.
"There's nothing we find more powerful than having the board meet with the patient," he says. Some hospitals now regularly show a video of a person with a hospital-acquired infection, or meet with a patient who sustained an avoidable fall, he says. At one hospital in Vermont, the chairman of the board and the CEO interview some of the patients who were hospitalized in the preceding month.
CEOs should personally conduct investigations of events that caused significant patient injury, according to the How To Guide. And then, the CEO "should personally present that case to the board in a session of no less than one hour in length." And if possible, the patient and family should be there to add their account in person.
"The trustees have to become outraged," he says. That doesn't happen "if they don't know that they killed someone, or that five people got serious infections." Those boards also have to make it clear to their CEOs that they expect to be told about such issues. But for some CEOs, "this just isn't the type of information they usually share with the board."
Conway knows what he's talking about. He was COO of Dana Farber Cancer Institute in Boston in the mid-1990s when two chemotherapy overdoses resulted in the death of one woman, a reporter for the Boston Globe, and serious heart injury to another. The events provoked a major introspection of processes and medical error prevention at the institute, and may have laid much of the groundwork for the safety movement today.
Now, regulatory agencies and payers are pushing for boards that have a better appreciation for quality matters, Conway says.
For example, in some states, insurance companies and the Joint Commission are focusing attention on board involvement in hospital quality benchmarks. Blue Cross Blue Shield of Massachusetts will reimburse hospitals more money if the board undergoes quality training, he says.
States like New Jersey have passed laws requiring hospital boards to go through a formal quality curriculum. And, Conway says, quality training for trustees has even provoked some state attorneys general to weigh in on the issue.
"The Inspector General has issued several reports on the topic, and Leapfrog has embraced this as well."
Is it working? I asked Conway.
"Am I meeting more extraordinary boards today? Yes," he says. Today, if the Harvard researchers conducted the same survey, nearly three-fourths would rank clinical quality a major priority, he said, up from 50%.
"But do I also meet with boards whose journey has yet to begin? No question."
Of course, some of hospital boards' failure to grapple with these topics might be blamed on CEOs, who keep their board in the dark. Boards must insist that they expect to be informed.
A formidable obstacle to change remains, one he calls the "arrogance of excellence."
"Good organizations talk about the wonderful things that go on in their hospitals, and bring you to tears about their beautiful stories. But the problem is that those stories are seductive. The arrogance of excellence is that you don't create a space to talk about the harm, the tragedy, and the waste."
Conway says one board meeting he recently attended "was lovely. Everyone was very nice to each other. But there was no discussion of the degree of harm that had gone on. There was a detailed report, and if you were smart enough, you could go find it, but no one pointed it out to the board that it was there."