Boardroom Brief: The Board’s Role in Quality and Patient Safety
Quality and Patient Safety
Background
Hospital and health system governing boards have a critical leadership and oversight role in quality and patient safety. Trustees are responsible for oversight of their organizations to achieve quality outcomes and care that is safe, effective, patient-centered, timely, efficient and equitable.
The AHA recently launched the Patient Safety Initiative, with reinforced commitments from hospital and health system leadership to quality and patient safety, focused on fostering a culture of safety from the board room to the bedside; identifying and addressing inequities in safety; enhancing workforce safety; and integrating innovation into best practices. The board’s role is to shape the hospital or health system’s vision and purpose, support management in the required operations and provide oversight to support the culture.
In 2023, the Centers for Medicare & Medicaid Services (CMS) issued the quality assessment performance improvement (QAPI) guidelines for boards. Boards must understand these guidelines and ensure hospital and health system compliance. This revised guidance explains CMS’ expectations for board leadership and engagement in hospitals’ work on quality and patient safety. In the updated guidance, CMS specifies that hospitals’ governing bodies are responsible for oversight of the QAPI program and should conduct periodic reviews of the hospital’s plan for achieving QAPI goals.
Quality and patient safety should be a routine topic in the boardroom. But often, board members, especially new board members without a health care background, do not know what questions to ask their C-suite leaders about quality and patient safety.
This document includes sample questions trustees can ask to better understand the quality and patient safety climate, structure and initiatives within their hospitals and health systems. The document also includes an overview of key organizations with quality and patient safety oversight, and a list of AHA resources to learn more about the board’s role in this area.
Understanding the Big Picture of Quality and Patient Safety
It is important for hospitals and health systems to orient and engage new board members about many issues, including quality and patient safety. Building a robust orientation program can help new trustees understand the big picture for quality and patient safety and the board’s role. Seasoned board members also should be updated and reminded of quality and patient safety initiatives within the organization and federal and state regulations.
Orienting the Board to Quality and Patient Safety
- What is the organizational governance and operational quality and patient safety structure?
- How does our organization define quality?
- Who is the key contact for quality and patient safety questions and/or concerns?
- What are our organization’s top quality and patient safety priorities and how often are they updated?
- What quality strategy is our organization implementing?
- What is meant by quality, patient safety and patient experience? How are these tied to hospital and physician payment?
Safety Culture
- What is the current safety culture? Does the board establish and monitor safety standards?
- What key measures does our organization use to understand safety culture? How does the board receive measure updates?
- Are new employees, both clinical and administrative, oriented to the safety mission and culture of the hospital?
- What opportunities exist for board members to interact with frontline staff and understand the safety culture of the organization (i.e., board rounding, shadowing, etc.)?
Board Meetings and Quality and Patient Safety Committees
- Does the board have a Quality and Patient Safety committee? If so, what are the committee’s responsibilities?
- Do board members have representation on the Quality and Patient Safety Committees?
- Are quality and patient safety represented on board meeting agendas as priority items?
- If our hospital is part of a system, and both the system and the hospital have boards, which is the fiduciary board with regard to quality and patient safety? What responsibilities does each board have with regard to quality and patient safety? How do they share information and insights about quality or safety issues of concern, opportunities for improvement and excellence in performance?
Quality Improvement
- What quality improvement projects are being conducted?
- How are quality improvement projects selected?
- What measures are used to track improvement and effectiveness?
Examining the Key Elements of Quality and Patient Safety
It is important for board members to understand a variety of aspects that impact the overall quality and patient safety at their hospital and/or health system, a small sample of which are listed below. For each component of quality and patient safety, governing boards need to have a high level overview to fully understand their organization’s. quality and patient safety strategies including current initiatives, goals, measures, outcomes and expectations from federal and state regulators.
Patient and Family Engagement
- What is meant by patient and family engagement?
- How does my organization engage patients and families?
- What key measures does the organization track for patient and family engagement and how often will these come to the board?
- What projects are currently underway to improve patient and family engagement?
Health Equity and Identifying Community Needs
- Is health equity part of the board and organization strategy? If so, how?
- How does our board assess the evaluation and implementation of a Community Health Needs Assessment?
- What data do we collect to understand the different groups of people in our community and inform our decisions about how this organization can best work to improve the health of our patients and other members of the community?
- What are the most important differences in health and in care outcomes in our community and for our patients?
- What are the key projects my organization is working on right now to address these health disparities?
Workforce Safety and Well-being
- What do we mean when we talk about the safety and well-being of our workforce?
- What measures does our organization have of workforce safety and well-being, and how often are these data shared with the board?
- What efforts are currently underway in our organization to improve workforce safety and well-being?
Patient Satisfaction/Experience
- What measures do we use to track patients’ satisfaction and care experience? How do these compare to the scores of other hospitals? Have we broken those scores down by various segments of our community to identify opportunities for improvement with different parts of the community we serve?
- What efforts are currently underway to improve patients’ experiences?
Quality Initiatives and Measures — Using Data for Action
Boards should expect metrics to be presented to them consistently and concisely.
- What quality dashboards exist and what measures are included?
- How are measures chosen to be included in the dashboard?
- How is data shared with with staff, the board and the community?
- Is your organization transparent with the board and/or its quality committee about the institution’s performance?
Organizational Quality and Patient Safety Improvement Goals
CMS Quality Assessment Performance Improvement (QAPI) Guidelines are part of the Medicare hospital conditions of participation. The hospital board is responsible for oversight of the QAPI program through:
- Periodic review of the plan.
- Review of progress on the QAPI project.
- Determination of annual projects.
- Evaluation of the effectiveness of the projects.
- Ensuring that clear expectations for safety are established and communicated throughout the hospital and with those providing services in the hospital (e.g., contractors, medical staff, students, volunteers).
AHA Resources on Boards and Quality and Patient Safety
Articles and Blogs
- The Importance of Quality and Patient Safety (https://trustees.aha.org/importance-quality-and-patient-safety)
- The Board’s Role in Quality and Patient Safety (https://www.aha.org/news/blog/2023-11-08-boards-role-qualityoversight-and-patient-safety)
- Leadership Matters: A Roadmap Towards Effective Governance of Quality and Safety (https://trustees.aha.org/leadership-matters-roadmap-toward-effective-governance-quality-and-safety)
- Boardroom Brief: How Boards Can Prioritize Health Equity (https://trustees.aha.org/system/files?file=media/file/2024/01/Boardroom-Brief-How-Boards-Can-Prioritize-Health-Equity.pdf)
- Boardroom Brief: How Boards Can Support Workforce Behavioral Health (https://trustees.aha.org/system/files?file=media/file/2023/03/Boardroom-Brief-How-Boards-Can-Support-Workforce-Behavioral-Health.pdf)
- The Board’s Role in Health Care Experience (https://trustees.aha.org/boards-role-health-care-experience)
- Wonder, Wander and Round Intentionally (https://trustees.aha.org/wonder-wander-and-round-intentionally)
- From Board to Bedside: Experiencing Patient Safety Culture Firsthand (https://trustees.aha.org/board-bedsideexperiencing-patient-safety-culture-firsthand)
Podcasts
- Unifying Hospital Boards on Quality and Safety (https://www.aha.org/advancing-health-podcast/2024-07-03-unifying-hospital-boards-quality-and-safety)
- Hospital Boards Lay the Foundation for Quality and Safety (https://www.aha.org/advancing-health-podcast/2024-07-31-hospital-boards-lay-foundation-quality-and-safety)
Webinars
- • Leadership Matters: Role of Governance in Quality and Safety (https://trustees.aha.org/leadership-matters-role-governance- quality-and-safety)
- What Boards Need to Know About the New CMS QAPI Requirement (https://trustees.aha.org/what-boards-need-know-about-new-cms-qapi-requirement)
- Quality, Safety and Regulatory Requirements: Practical Recommendations for the Hospital Board (https://trustees.aha.org/quality-safety-and-regulatory-requirements-practical-recommendations-hospital-board)
Websites
- AHA Trustee Services (https://trustees.aha.org/)
- AHA Trustee Services – Quality (https://trustees.aha.org/quality-and-patient-safety)
- AHA Patient Safety Initiative (https://www.aha.org/aha-patient-safety-initiative)
Organizations Responsible for Monitoring and Reporting on Hospital Quality and Patient Safety
Below is a list of several organizations that monitor and report on hospital quality and safety. This list is certainly not exhaustive but can be used as a resource to better understand quality and patient safety data, requirements and priorities.
Centers for Medicare & Medicaid Services (https://www.cms.gov/)
The Centers for Medicare & Medicaid Services (CMS) is the federal agency that provides health coverage to more than 160 million people through Medicare, Medicaid, the Children’s Health Insurance Program and the Health Insurance Marketplace.
Centers for Disease Control and Prevention (https://www.cdc.gov/)
The Centers for Disease Control and Prevention (CDC) is the nation’s leading science-based, data-driven service organization that protects the public’s health.
The Food and Drug Administration (https://www.fda.gov/)
The Food and Drug Administration is responsible for protecting public health by ensuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, as well as the nation’s food supply, cosmetics, and products that emit radiation.
The Agency for Healthcare Research and Quality (https://www.ahrq.gov/)
The Agency for Healthcare Research and Quality’s mission is to produce evidence to make health care safer, higher quality, more accessible and equitable and affordable.
The Joint Commission (https://www.jointcommission.org/)
The Joint Commission is an accreditation and certification organization that sets standards and provides organizations with feedback to drive quality improvement and patient safety in health care.
