Half of the board chairs of the nation's nonprofit hospitals said their boards don't rank clinical quality as one of their two highest priorities, according to results of a Harvard survey said to be the first of its kind.
However, chairs of boards that did prioritize quality oversaw hospitals that performed better on national Hospital Quality Alliance measurements than hospitals where boards didn't rank quality of highest importance. "Most of them don't even prioritize it for evaluating their chief executive officers. They just don't think it's much of a priority," says Ashish K. Jha, associate professor in the Harvard School of Public Health.
The survey, conducted with co-author Arnold M. Epstein, chair of the Department of Health Policy and Management at the Harvard School of Public Health, is published in this week's journal Health Affairs.
The board chairs were asked to rank priorities from these six issues: quality, financial performance, operations, business strategy, patient satisfaction, and community benefit.
The authors see an association between these boards that are more engaged with the issue of quality at their hospital, and the likelihood that the hospital does well on quality measures. Likewise, they saw a link between hospitals where the boards didn't prioritize quality—and lower HQA scores.
"In high performing hospitals, boards are far more engaged, they know quality data, follow it closely, and think it's a high priority," Jha explains. "The boards ask 'how many patients did we harm last month? How many infections did we cause?' It may be that at high performing institutions, that sets the tone."
The authors concluded "this area represents a tempting target for intervention," however, added "the less than optimal focus on clinical quality . . . points to a difficult road ahead."
The researchers gathered 2007 national Hospital Quality Alliance scores for 3,410 nonprofit acute-care hospitals in three clinical conditions: acute myocardial infarction, congestive heart failure, and pneumonia. They then randomly selected 1,000 hospitals from this group, but oversampled those ranked in the top or bottom 10%, the high performing or low performing HAQ hospitals.
Board chairs of these 1,000 hospitals were asked to rank their top two priorities from those six issues. More than two-thirds, 722, responded.
Looking at the response rate for low-performing HAQ hospitals versus high-performing ones, there were significant differences, Jha says.
For example, among all hospital board chairs responding, only 44% said clinical quality was an issue considered in ranking a CEO's performance. But at low-performing hospitals, only 30% said it was a consideration while at high-performing HQA hospitals, 60% said it was considered.
Carlin Lockee, managing editor of the Governance Institute, which assists hospital boards, says she was surprised at the study's results. She says they differ from the Institute's similar surveys of nonprofit hospital CEOs.
"We have found more encouraging results," Lockee says. "And we believe that hospital boards still have a long way to go, but they have improved significantly over the last five years."
In fact, it's unclear whether the CEO in fact sets the tone, and not the board, and that those hospitals that perform better do so because they have better CEOs. It may not matter what the boards discuss on their agendas.
But Jha and Epstein say that their data "provide evidence of an association, although we cannot affirm a causal link" connecting boards that value quality with better hospital performance.
Among the survey's other findings:
- Nearly three-fourths of board chairs of all hospitals responding reported that their boards have moderate or substantial expertise in quality of care. But high-performing hospitals reported a rate of 87%, compared to low-performing hospitals that had a 66%.
- Only 20% of board chairs responding reported that the board chair, the board or one of the board's committees, was one of the two most influential quality forces at the hospital. Board chairs from high-performing hospitals were nearly four times as likely as those from low-performing hospitals to report that the board was influential.
- More than two-thirds of board chairs reported being somewhat or very familiar with Joint Commission core measures or with HQA measures. But chairs of high-performing hospitals were far more likely than those from low-performing hospitals to say they were informed of those measures.
- Quality performance was on the agenda at every board meeting in 63% of U.S. hospitals, and financial performance was always on the agenda in 93%.