Boards can be safety champions

Trustee talking points

Patient safety is essential for hospitals and health systems, and it should be a strategic priority.
Boards need to be informed about and engaged in their organization's safety efforts.
There are any number of ways for trustees to improve their oversight of safety; a combination of them is usually best.
Board education and collaboration with management are key to improved patient and workforce safety.

This past year brought some good news about patient safety. We continued to see evidence of progress in the wake of federal efforts to reduce health care–associated conditions and readmissions. But progress should not become an excuse for resting in the quest for reliably safe health care.

As hospitals and health systems continue to work to prevent patients and the health care workforce from experiencing adverse safety events, it is vital for board members to understand and champion patient safety. They may not know all the answers, but they must ask critical questions.

Making patient safety a priority is not only the right thing to do, it can also affect an organization’s financial health. As medicine shifts to value-based payment models, health care organizations that invest in patient safety reap benefits in reducing the costs of treating adverse events and reducing the impact of reimbursement penalties. Moreover, a reputation for safety can help boost an organization’s value to the populations it serves.

In addition, there is a growing body of evidence suggesting that when employees feel safe and believe their organization is focused on safety, scores for employee engagement, quality and patient experience are higher. For example, recent data from the National Database of Nursing Quality Indicators show that higher perceptions of workplace safety correspond to lower rates of perceived missed care and health care–associated pressure ulcers, along with higher rates of "recommend" scores on the Centers for Medicare & Medicaid Services Hospital Compare system.

Although health care providers and their boards are asking many questions about the direction of health care delivery and reimbursement policies, safety and quality considerations are timeless. Organizational leadership plays a critical role in charting the course to safety. Therefore, strengthening board awareness of safety performance and board engagement in safety efforts should be a strategic priority.

Progress and gaps

Results of a recent survey conducted by the National Patient Safety Foundation add to a growing body of knowledge about board members’ roles and practices in regard to patient and health care workforce safety and reveal both progress and gaps. According to the survey, 80 percent of board members report that “patient safety and/or quality is ranked No. 1 on our list of strategic priorities.” That compares favorably with an earlier study from 2010 that found that fewer than half of board chairs rated quality as one of their top two priorities.

Yet the NPSF survey also shows room for improvement. Safety concepts self-reported as most familiar to board members include their obligations when it comes to credentialing and accreditation, their oversight of adverse events, and their understanding of the importance of teamwork to a safety culture. Respondents, however, also reported being least familiar with workers' compensation rates, the transparency and communication of adverse events to the public, and the concept of high reliability.

In terms of quality and safety discussions at the board level, 88 percent of board members reported that patient safety or quality executives participate in or provide related education at board meetings. The trustees, though, said that far too few adverse patient safety events are discussed at full board meetings.

What can be done

Governance plays a critical role in setting goals and priorities for health care organizations. Chief executives and board members must work together with senior management to enable, foster and sustain a culture of safety in their organizations. Hospitals and health systems can ensure this kind of leadership through careful selection of board members, provision of board education as needed and other practices. Key areas to address include the following:

Establishing a clear vision: A clear vision with high-level aims and a goal of zero preventable adverse events positions patient safety as a core value in the organization. Organizational priorities can change. Core values should not. This message must come from the CEO and the board and funnel through the organization by their actions and those of other leaders.

Creating a culture of safety: According to the NPSF, a culture of safety is one in which individuals are held accountable for their choices and actions, but human error is not punished; where reporting is encouraged, and feedback is provided to reporters about actions taken to prevent or reduce risk; and where the organization’s focus is on preventing adverse events before they happen, not just investigating them after the fact.

In order to be sustained, this culture must be constantly nurtured by strong leadership at the board and executive levels. Leaders can practice a number of actions to embed their cultural beliefs. Chief among them, according to organizational development expert Edgar Schein, is to systematically pay attention to safety — by commenting, questioning, measuring, controlling and rewarding the safety-related elements of the organization.

Recruiting a diverse board and providing board education: Hospital boards of the past were largely composed of business leaders or major donors. More recently, there is a growing appreciation of the value of appointing board members with competencies and experience that can support the strategic direction of the organization.

Today, the most effective boards include clinicians, safety experts and patient representatives, as well as members from the financial, business, human services and other sectors. A diverse board with broad experience allows for more robust oversight of clinical quality and safety, as well as the finances of an organization. Hospital boards should work with leadership to assess gaps in board competency and close them with either recruitment efforts or education.

Health care organizations also need to ensure that board members receive education about safety science, "just culture," human factors and other relevant subjects to best inform their oversight. This goal can be achieved through the use of foundational educational programs, as well as through training by quality, safety and clinical leaders in the organization.

Holding effective board meetings: The results of the NPSF survey clearly show an opportunity for improvement in bringing patient safety into the boardroom. While 70 percent of respondents reported that adverse patient safety events are discussed at board subcommittees on quality and safety, only 40 percent reported them being discussed at full board meetings. If safety is to be a priority, it must be a central and standard item on the board’s agenda for all of its meetings.

This improvement in board work can be achieved in a number of ways. In fact, multiple tactics should be employed. Many organizations already include a story of an adverse patient safety event in every board meeting, and nothing is more effective at generating action than the patient’s or family’s voice. Board members should also be seeing the most important metrics and dashboards to monitor performance, and they should be informed about root cause analyses and other actions being taken to prevent adverse events or risk from recurring.

In terms of workforce safety, only about half of survey respondents had knowledge of risks to workforce safety and awareness of dashboards that measure injuries to staff. This finding corresponds to the results of a recent Press Ganey survey of CEOs, presidents and other senior leaders to determine metrics to support safe, high-quality care. None of their proposed metrics addressed workforce safety. A growing number of experts and organizations such as the NPSF recognize workforce safety as being essential (or even a precondition) to patient safety, so this is clearly an area where boards need to improve their oversight.

Seeing things firsthand: To truly understand their organization’s challenges and efforts in patient safety, board members need to spend time on the ground with frontline health care providers. This can be achieved through their participation in leadership walk-arounds, daily huddles and safety briefings. These actions have a dual benefit: They help educate the board members and demonstrate to staff the board’s commitment to safety.

Holding the C-suite accountable: One of the most important jobs of any hospital board is to oversee the executive team. Creating and articulating a compelling vision will be meaningless if the hard work to advance that vision goes undone. One way to improve accountability is to incorporate patient safety into performance expectations and to set incentives for reaching goals chosen by the board.

A constant

Health care has undergone tremendous change in the past decade, and the only thing certain today is that more change is on the horizon. Board members play a critical role in setting goals and overseeing quality and safety for their organization. Regardless of what the future brings in terms of payment and regulatory reform, boards would do well to make — and keep — patient and workforce safety as a core value for their organization.

Tejal K. Gandhi, M.D., M.P.H., CPPS (tgandhi@npsf.org), is the president and CEO of the National Patient Safety Foundation in Boston. Gary Yates, M.D. (Gary.Yates@pressganey.com), is a partner in the strategic consulting practice of Press Ganey Associates Inc. He is based in Virginia Beach, Va.

Trustee takeaways

One way boards can positively influence an organization is by asking good questions to stimulate dialogue and identify potential gaps in their patient safety oversight. Here are eight questions board members might ask:

Have we clearly positioned safety as an uncompromising core value? (How would we know? What indicators would we look for to verify this?)
Have we adopted a comprehensive, multiyear plan for improving patient and workforce safety and for monitoring progress regularly?
Have we embraced transparency for sharing adverse patient safety events and lessons learned across our system?
Have we established a healthy reporting environment and a “fair and just culture”?
Have we clearly established respect for patients, co-workers and physicians as an expectation within the organization?
Do we put a face on adverse events and hear patient stories regularly, ideally directly from patients?
Do we consider the safety and quality implications of all major organizational decisions?
Do we devote sufficient board time and attention to safety, quality and the patient experience of care?