Quality
Quality Committees Matter More During Times Like These
Five ways to harness the committee’s potential and safeguard the mission in challenging times
By Elizabeth Mort, M.D., M.P.H.
Hospital and health system board committees have distinct functions that support the same goal — to deliver high quality of care to the patients the organization serves. Finance committees track margins, Strategy committees debate future direction and Quality committees oversee the core mission of these organizations.
When finances are strained and the future is uncertain, a board’s focus is often on finance and strategy. How do we adjust course to meet margin targets? How do we recruit more providers? How do we increase access? How do we fund strategic priorities and invest in needed facility upgrades?
When facing challenges like these — financial uncertainty, workforce shortages, capacity and access challenges — focusing more on improving quality can help the margin by avoiding waste, errors and mistakes that are expensive to address. During these times, consider how you can ask your Quality Committee to ensure care quality is protected during operational strain. Support the Quality Committee as they ask questions of management and help leadership build a culture where quality and safety are primary priorities, and where patient safety and performance risks are raised and acknowledged in a transparent manner, making risk mitigation more visible.
Whether you are a board committee member, CEO, CMO, CNO, CQO, compliance officer or operational leader, here are five things to consider to support your Quality Committee during hard times.
1. Own the charter.
While Quality Committees on different boards may vary in their responsibilities, each one takes that responsibility seriously and owns the role. Owning the Committee’s charter means members move from thinking about their role as an abstract fiduciary of quality performance to taking an active oversight approach to ensure quality performance is being delivered. Members don’t cross the line into management affairs, but they can adopt a more active and engaged approach to the work, and they can tailor that work to the challenges the organization is experiencing. For example, tight margins limit investments, workforce shortages create operational gaps and rural hospitals struggle with specialty access. In circumstances like these, the Quality Committee can review its charter and keep these challenges in mind as they support their management teams. Are there quality improvement targets that can both improve care and costs? This could be a routine question, but it is even more important to emphasize in challenging times.
Typical Quality Committee core responsibilities include ensuring that quality plans are set, regulations are understood and adhered to, adverse events are reviewed, follow-up is done correctly and improvements are implemented. Some boards may also oversee credentialling and privileging.
To take this a step further, the committee might reconsider their meeting mechanics. How often should they be meeting? Does the membership make sense? Should other board members rotate through the meetings? Consider that some senior staff may be dealing with these operational challenges for the first time and will value your wisdom and advice.
The Quality Committee serves as the board’s delegated body for oversight of quality and patient safety. It ensures that management has credible systems, that important quality issues are escalated and that the full board is informed when necessary. Quality Committee meetings are more than informational; they should be substantial.
Suggested action: Review the committee charter annually. Clarify scope, responsibilities, escalation triggers and expectations for management reporting. Ensure all committee members are trained and understand and own their accountability to the hospital. Participate in cross committee discussions and board agenda planning.
2. 2.Understand the quality operating system and the organization’s approach to quality assurance and performance improvement.
An organization’s quality operating system is foundational to the success of delivering high quality care. The Centers for Medicare & Medicaid Services (CMS) refers to this as Quality Assurance Performance Improvement, or QAPI. Think of QAPI as the organization’s structured way to make sure it is doing the right things, doing them well and constantly getting better. A successful QAPI structure is required by CMS and is the foundation on which high-quality care is delivered. It typically involves many if not most of the organization’s departments to perform well, such as hiring and onboarding surgeons, training infection preventionists, using methodologies for improvement and purchasing diagnostics, as well as excellence in specialized functions like risk management, patient safety, patient experience and regulatory readiness, among others. There is often an organizational chart or roadmap that shows how these parts work together.
Board members may be able to relate this to other industries. A car manufacturer ensures every vehicle is safe and dependable. But health care is more complex. Pregnant women present for the first time at term, trauma patients come in at 2 a.m., emergency departments are crowded with patients waiting for ICU beds and care needs to be delivered even when conditions are not ideal.
The Quality Committee should deepen its understanding of how quality is managed through the organization’s QAPI. Where are the resources, accountabilities, reporting lines and escalation pathways? How are risks elevated to management and the board? How are the financial impacts of quality improvement work assessed, discussed and considered as priorities are set and implementation is tracked?
Suggested action: Schedule an annual presentation describing QAPI and how quality is organized, led, funded, measured and improved across the organization. Ensure accountability for QAPI not only includes the quality, safety, regulatory and risk management departments but also the core operational leaders in finance, nursing, medical staff and service lines. Get to know them and let them know you want to support them during these challenging times. Encourage them to strengthen their approach to QAPI, if needed
3. Know the quality metrics, then ask if anything is missing.
Quality and safety metrics have proliferated over the past two decades at a brisk pace. Organizations summarize performance through different lenses and offer their view of their performance compared with others. Become as familiar with these metrics as you are with those on your financial balance sheet. Review them just as you look for large financial gains or losses and probe for explanations of variances.
There isn’t, however, a bottom-line metric for quality that is analogous to the financial margin. Hospital mortality is often thought of as a good summary indicator, but it has limitations. Management teams often consult common rating systems such as Leapfrog hospital safety rankings, CMS Stars, Joint Commission accreditation and certifications, Vizient Top Performers and US News Honor roll and other scores and then choose what other factors they will monitor above required metrics. Larger, well-resourced organizations may also participate in registries or certification programs and have insight into more areas of performance such as service lines. There is no one-size-fits-all metric that works across all hospitals and health systems.
Because of this variability, Quality Committee members should understand how blind spots in quality dashboards’ monitoring may have important consequences.
Suggested action: When the annual plan is set, spend time on metrics and ask management what they are tracking, what are they not tracking and why. Ask for a report on the measures that are available, which ones are required, which are optional and what is important, and consider whether some metrics can be sunset so that others can be included. In each meeting, explore what important risk is not fully captured on the dashboard or in the quality report.
4. Make risk decisions explicit and transparent.
During times of fiscal stress, organizations need to make tough calls. Deferred investments incur risks, sometimes in patient safety. For example, when a hospital defers replacing aging equipment, delays implementation of a software program that would strengthen handoffs between shifts, decides not to add pharmacists to assist with medication reconciliation, leaves positions open due to strained budget or lack of available staff, there are risks for patients. Quality Committee members should be made aware of and understand these risks.
Strong budget processes include reviews of financial decisions’ clinical and quality implications. When resources are not available, acknowledge the risk, inform leadership and determine how to mitigate it. The Quality Committee will get a report when this happens.
Too often financial choices that impact quality are not discussed. The Quality Committee should not expect every proposal to be approved, but quality-related tradeoffs need to be visible and managed. The phrase often used to describe this process is Transparent Risk Acceptance. In challenging times like ours, Quality Committees are in the position to support management in the ownership and management of these risks.
Suggested action: Ask whether quality and safety implications are explored during budgeting processes. Maintain a summary of deferred quality or safety investments, associated risks and mitigation plans, and ask for updates from accountable owners.
5. Lean into accreditation and expect continuous readiness.
Accrediting organizations survey health care organizations to ensure they follow what CMS refers to as the Conditions of Participation. These are requirements which need to be met to receive payment for patients with Medicare as their health care insurance. Quality Committees and boards can be surprised when deficiencies resurface during an accreditation survey. Consider taking a “no surprise” approach to ensure the organization’s foundational processes are in place, every day for every patient and just when a survey is due.
The board is accountable for ensuring that any condition-level deficiencies identified during a Joint Commission survey are corrected and sustained. Quality Committees should expect to see continuous readiness. Joint Commission offers excellent monitoring software that organizations can use to track key patient safety and environmental risks and allow flexibility to tailor the program based on need.
In CMS’ view, the board cannot delegate this accountability; it must demonstrate active oversight and due diligence. If condition-level findings are not corrected between surveys, patient care can suffer, and adverse events can trigger escalating regulatory actions, including focused follow-up surveys, denial of payment, or, rarely, termination of Medicare certification. In short, unresolved condition-level findings put both patient safety and the organization’s reputation and viability at risk.
Suggested action: Review accreditation results in detail and monitor progress in areas where repeated findings were cited. Monitor improvement plans and important readiness risks. Consider adopting a way to strongly support continuous readiness through monitoring patient care processes via tracer programs.
Summary:
The Quality Committee’s high-level oversight ensures the hospital or health system delivers high-quality care consistently. It takes active ownership of its responsibility and strengthens its role and impact on organizational performance.
These five recommendations provide options for elevating the impact of the Quality Committee and are particularly important during times of financial and operational challenges. Producing high-quality care is the business of health care. Avoiding errors that harm patients align with both our clinical goals and financial goals. Those organizations that maintain high performance now will be well positioned to soar as the industry works through current headwinds. They can embrace new digital tools and explore new models of health care delivery without faltering on the core mission of providing high-quality, safe care to the patients who trust them to do so, and who deserve nothing less.
Elizabeth Mort, M.D., M.P.H., (emort@jointcommission.org), is vice president and chief medical officer at The Joint Commission in Oakbrook Terrace, Ill.
Please note that the views of authors do not always reflect the views of the AHA.