NYT: Hospital boards have an important role in quality efforts

Although hospital boards can have a profound impact on quality and mortality rates, research shows that only a small number rank quality concerns high among their priorities, Austin Frakt writes for the New York Times' "The Upshot" blog.

Board members: Clinical quality is physicians' jobs

According to Harvard physician Ashish Jha, hospital board members are typically community leaders recruited to boards because of their fundraising skills or knowledge of a certain field, such as finance or regulatory policy. As such, few board members are medical professionals or have experience in the health care sector.

Jha says that board members "don't think it's their job to hold management accountable for performance." Instead, he says, "board members often feel like clinical quality is physicians' jobs, and they don't want to step on doctors toes."

For instance, a study conducted by Jha and his colleagues found that just 20% of hospital board chairs at not-for-profit organizations believed their boards were a driving force for quality improvement at their hospitals. Just 11% of chairs at institutions with low-quality scores on Medicare standards said the same.  Meanwhile, just 50% of boards ranked quality among their top two concerns, while about 75% said financial performance was a top priority.

Moreover, more than half of boards could not adequately assess their organization's quality. About 50% of boards at hospitals with low quality scores ranked their quality as above average.

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How can boards impact quality?

However, Frakt writes that hospital boards are actually well-equipped to promote quality change because they can "influence care in ways physicians cannot."

For instance, boards have the power to hire and fire top-level executives at their hospitals, including CEOs. According to Frakt, the average hospital CEO receives an annual salary slightly below $600,000, but a study conducted by Harvard physician Karen Joynt and colleagues found that those salaries are not often tied to quality performance. Instead, higher compensation is typically given to CEOs at hospitals that use advanced technology, receive high patient satisfaction scores, and are teaching institutions.

But even though their pay isn't tied to quality, several studies have shown that CEO involvement is integral to quality improvement. "I'm a much better doctor in a well-managed hospital where the systems are in place to help me do my best work," Jha says, adding, "Even a great chef can't produce a good omelet with eggs that are stored in the freezer or the stove doesn't work reliably."

Jonathan Kalodimos, an economist with the Securities and Exchange Commission, found that when hospital boards promote stronger oversight of hospital management and compensation, medical treatment at the facility improves, including lower heart attack mortality rates.

In addition, Frakt says boards can:

• Develop standards that ensure important information is conveyed to the right people in a timely manner;
• Establish an infrastructure that allows equipment and supplies to be available when needed;
• Set the standard for a high-performance culture; and
• Require monitoring for quality and promote incentives to work toward those targets.

Oregon Health & Science University health economist K. John McConnell and colleagues also found that hospital management styles borrowed from technology and manufacturing sectors —such as "lean" methodology pioneered by Toyota—can promote quality and reduce mortality rates. Boards can also work to reduce inefficiencies, set goals, and improve collaboration.

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Frakt concludes, "It's natural to think that direct caregivers—doctors, nurses, and other technicians and assistants—bear the entire burden of providing better care," but "If we don't foster a focus on quality at high levels, even the best health care workers may not provide the best care" (Frakt, "The Upshot," New York Times, 2/16).

How to Build a Quality Infrastructure

To build a solid foundation for your organization’s quality improvement efforts, you should follow these three imperatives:

• Dedicate staff to quality;
• Solicit multi-disciplinary feedback; and
• Select and track value-centric metrics.

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