High levels of preventable harm, poor patient experience, and excess costs permeate our health care industry despite ambitious mission statements to improve patient safety or be the world leader in quality of health care. One reason for these undesirable outcomes is the underdeveloped state of accountability in health care. In most organizations outside health care, the Board of Trustees (or Directors) assumes ultimate accountability for performance. This is rarely the case in health care, where boards have traditionally fixated on financial performance and delegated quality of patient care to the medical staff, often with limited board oversight.
Health care organizations are starting to engage their boards in quality. Many health systems have sought to get “boards on board,” encouraging boards to list safety first on the board agenda and to open the board meeting with a story. Though an important start, these efforts can be superficial and will likely do little to improve accountability and provision of care, or to prevent patient harm. Stories are important to engage the heart and spark a lasting memory; yet results matter and boards need to hold health care managers accountable for quality care. While being first on the agenda may signal relative importance, it is paramount that boards create and exercise disciplined processes to monitor performance and ensure accountability, just as they do for financial performance. If health care is to improve, it will need to ensure the board takes a more systematic and disciplined approach to ensuring quality and patient safety.
At Johns Hopkins Medicine (JHM), we recognized that if we were to address health care’s ills, namely, to end preventable harm and improve value, we needed to evolve from viewing quality as a project to viewing it as a disciplined and integrated management system with robust governance. We sought to ensure that the board quality committee functioned with the same rigor as the board finance committee.
Board finance committees offer a prototype for board quality committees. Board finance committees are disciplined and sticklers for accountability. Despite complex organizational structures in health systems, finance committees oversee every dollar spent and received, and organize this information into a consolidated financial statement. Finance and external auditors routinely review the integrity of their data and ensure systems are in place, such as internal controls and accountability, to deliver accuracy. They have leaders at every level of the organization, from the board to the bedside, who are responsible for financial oversight and transparent reporting. The longer financial targets are missed, the more intense the oversight. Unlike performance on quality goals, months of missing financial goals are not tolerated, and financial misses are addressed with clear improvement plans and frequent monitoring until performance improves.
At JHM we used several strategies to ensure that our board quality committee functioned with the same rigor as the board finance committee. The accompanying table outlines the strategies JHM used to govern quality and offers how to apply these strategies. First, we mapped the entire delivery system into our seven overarching areas of care — inpatient hospitals, ambulatory practices, ambulatory procedures, home care, pediatrics, managed care, and international — and appointed an accountable leader for each area. Also, any organization we purchase or partner with in the future has to be part of this governance system. Then, we meet with the accountable leaders and align all quality-related work along five domains: patient safety, which includes internal risks to patient safety; performance on externally reported quality measures; patient experience; value; and health care equity. A lesson we learned is to not let our focus on the hundreds of measures we must externally report distract us from what clinicians often perceive as the greater risks, which are internal risks, such as a culture that silences rather than supports speaking up about patient safety concerns.
One exercise we conducted started at the bedside in both our hospitals and home care encounters and examined whether all areas and types of care had collected quality measures and reported their data to a higher leadership level. Also, we checked to see whether these data ultimately made it to the board quality committee. Through this exercise, we discovered many islands of quality. In places where quality was either not being measured or was being measured but not reported meant that there was no accountability.
For example, pediatric surgery measures were not reported by the surgery department because they were pediatric patients and were not reported by the pediatrics department because they were surgery patients. This exercise was a valuable approach to identify and eliminate many islands of marooned quality data. We also uncovered that some of the data for our quality measures were of variable quality and implemented internal controls and audits to improve the quality of the data.
We created a consolidated quality statement that mirrored the finance committee’s consolidated statement. Because quality measures vary widely by type of care, we generated separate consolidated statements for the seven areas. Some measures are common across most areas, such as patient experience and preventable health care–acquired infections. A sampling of differences in what some areas measure are emergency department wait times (inpatient hospitals), utilization of health care services (ambulatory practices), use of surgery checklists (ambulatory procedures), process measures for pressure ulcer prevention (home care), and Medicare Advantage star ratings (managed care). Pediatrics and international may measure similar things, such as hand hygiene and infections, but these are very different patient populations. These statements are presented by the president of the entity (e.g., a hospital) at the board quality committee meeting and presented by the JHM Senior Vice President for Patient Safety and Quality at the JHM full board meeting, mirroring the presentation of the consolidated financial statements.
Finally, we explicitly defined an accountability plan in which the longer an area misses its quality goals, the greater the degree of oversight. The figure illustrates that after three reporting periods, the area (in this case an inpatient hospital) is audited by the Armstrong Institute for Patient Safety and Quality (the entity that links to the quality board committee and manages quality for Johns Hopkins Medicine) and findings are presented to the board quality committee to explore why quality performance is low and what could be done to improve it. Embedded in this approach is the concept of shared accountability, which means the higher levels of the organization need to hold themselves accountable for giving the lower-level leaders the tools to help them succeed before they can hold a lower-level leader accountable. The tools that lower-level leaders need are knowledge of the goals and their role, performance feedback, the skills, resources, and time for improvement, and regular meetings with the higher-level leader to review performance.
Good governance matters, yet it is too often inconsistent in health care systems. Health care needs to mature their governance by moving the Board of Trustees beyond storytelling and putting safety first on the agenda. A quality board committee can help govern quality if it functions with the rigor as the governance applied by finance committees.