Quality
You Have the Quality and Safety Report. Now What?
Quality and Safety expert Dr. Elizabeth Mort shares how trustees can positively affect quality care from the boardroom
By Nikhil Baviskar
Interview
In February 2023, Elizabeth Mort, M.D., MPH, former senior vice president of quality and safety, chief quality officer and practicing primary care doctor at Massachusetts General Hospital (MGH), presented “Reducing Preventable Patient Harm, Results of Safe Care Study and the Improvement Landscape” to the AHA Committees. Nikhil Baviskar, program manager, trustee engagement and strategy at the AHA, sat down with Dr. Mort to discuss how boards can positively impact their organizations’ quality and safety.
Nikhil Baviskar: Quality and patient safety should be an important discussion topic in the boardroom. Can you help us clarify the board’s role in their organization’s patient safety performance?
Dr. Elizabeth Mort: I agree that quality and safety should be a routine topic in the boardroom of health care institutions, but I fear that not all boards have that practice. If the mission of a health care organization is to provide high quality and safe care, then the board’s role is to ensure that happens. From discussions with colleagues across the country and from my reading of the literature, we have room for improvement in performance and in board engagement. The good news is we have some best practice organizations to learn from and this is a great time in the history of health care to review our progress. I believe that some board members feel that clinical performance is the responsibility of senior management, physicians and nurses and need education about their role. Many board members are accountable for clinical performance, and they can play an active role within their governance scope of responsibility. There are actions boards can and should consider taking to ensure that everyone in the institution sees and feels that they expect high quality safe patient care. Their role can be to shape the vision, purpose and support management in the required operations and in setting the culture, a culture of safety, a just culture and a culture that supports inclusion and psychological safety. That’s the big picture.
Obviously, we all appreciate that board roles vary by the type of institution and that boards are not only responsible for overseeing quality and safety performance. Boards have important duties such as finance, compliance, human resources and compensation, diversity and inclusion, community benefit for non-profits and more. While the details of boards’ responsibilities are beyond scope for today’s discussion and vary depending on the type of organization, I would like to emphasize that each of these domains can consider the impact of their policies, procedures and investments in the context of their impact on quality and safety. With today’s financial and workforce challenges, it’s easy to see how boards might focus on the most urgent issues, but quality and safety issues are always important.
There is no time like the present to adjust priorities. We have the data from recent studies to make the case that institutions need their boards to step up, now. Two studies published in the last year using data from 2018 show patient harm and preventable patient harm is still common in our hospitals. The Office of the Inspector General (OIG) published a study in May 2022 looking at Medicare patients that found a quarter experienced harm during their hospital stays. Physician reviewers judged that 43% of the adverse events were preventable. The results from our study, published in January 2023 and known as Safe Care looked at all payor patients hospitalized in 11 Harvard affiliated Massachusetts hospitals in the same year, 2018. Similar to the OIG study, we found that adverse events occurred in a quarter of hospital admissions. Our reviewers found that 23% of events were preventable, a slightly lower proportion than in the OIG study. In February 2022, CMS leaders reported slippage of some key patient safety indicators during the first year of the pandemic. While we are disappointed to learn that we are not performing where we want to be, it’s time for all of us in health care to reflect on what we’ve done well and learn from what hasn’t worked and accelerate improvement. Said another way, the boards in 2023 have a burning platform on which to clarify their commitment to the mission and purpose of their organization, providing high quality and safe care and supporting management and staff to ensure that purpose is aligned from the board to bedside. It starts at the top.
Baviskar: You have clearly made the case that boards have a key role in ensuring patients receive safe and high-quality care. Can you share some approaches for boards to set themselves up for success?
Mort: There is some material in the quality improvement literature that can be helpful, and many boards have adopted strong practices, but for those boards that are looking for advice, here are some ideas. Just in March 2023, CMS issued new guidance on the importance of board engagement in quality and safety. Looking back to 2008, patient safety leader James Conway popularized the phrase “getting boards on board” in his piece on board engagement. It talks about five core leadership activities. While there have been many articles on developing board commitment in quality and safety since, this is a great primer. Those two publications bookend fifteen years of effort. I would argue that we can push ourselves to be bolder and clearer about the board’s priority of reducing patient harm and improving quality, equity, value is imperative! It’s hiding in plain sight, as they say.
Here are a few ideas for boards to consider. Does the institution’s mission statement clearly include quality and safety? Does the board membership include expertise in quality and safety in health care and other industries? Is there an orientation to quality and safety? Are members encouraged to participate in management committees as appropriate? Do board agendas include updates on quality and safety progress? Boards can consider framing all other aspects of hospital management in the context of how each is contributing to the overall organization’s goal. Updates can highlight both successes and opportunities, and boards should consider having a quality committee that oversees the work with the senior team. We know that boards are important in choosing effective leaders. They choose the CEO, and in turn, the CEO chooses the C-Suite. Are these individuals champions of the mission?
In addition to being extremely focused on quality and safety as a key domain, boards should consider whether each of their key committees is making investment and management decisions with the impact on quality and safety in mind. Boards can consider external reviews by experts in addition to the important and foundational compliance surveys. Peer to peer reviews can be very powerful. MGH and Johns Hopkins piloted this idea in 2014. We adapted a method established by the nuclear industry, which involved an open book look at the board to bedside quality improvement structure and a few key areas of practice known to reduce patient harm. This was endorsed by our boards and well-received by leaders and staff alike.
In my opinion, boards should be sure that quality and safety goals are set each year, in the same way institutions have financial and operational plans.
Baviskar: Different organizations use different tools and dashboards. Some board members do not know how to read those dashboards or how to interpret the data. What do you suggest we do when we want to educate the boards on quality and safety?
Mort: Metrics are incredibly important. Dashboard usually implies a limited number of metrics. You might have a limited number of metrics for top quality and safety priorities or goals and these should be described clearly enough so that all board members understand them. In health care today we are being judged on 60 or 70 metrics or indicators which go into important ranking and rating calculations, like Leapfrog, CMS programs, pay for performance programs and others.
Although the entire board does not need to be expert in all of them, the quality leader, typically the CQO or CMO, should be expert in all of them and ensure that they are transparent with the board or its quality committee about the institution’s performance. Some organizations will keep a more detailed version of the report and share it with key stakeholders across the organization, periodically sharing it with the board quality committee so that there is line of sight from the board to the performance reports. When board members get a look at these detailed aggregate measures, I would recommend that they ask for more information about the clinical content. I would expect to see how the institution’s performance measures up against a comparison group or benchmark and board members can ask about that comparison. We all should be shooting for excellence and if the performance is lagging, boards can ask why and whether there are known solutions and whether the board can help.
In addition to standard quality and safety metrics, there are other important quality and safety signals that can be reviewed and shared with the board in the appropriate setting. Aggregate metrics tell part of the story, but there are others such as signals, safety reports, serious reportable events, key claims and suits, results from safety culture surveys and employee engagement surveys and patient experience results.
Unlike a financial report, there is no one gold standard metric that is a complete roll-up of quality and safety performance, but many organizations will select a few aggregate or composite measures as their performance goal. Many of these measures are familiar to boards and are the leading national ranking and rating programs. Each uses different methods and metrics and focusing on only one will not give a board the full picture. These might include a Leapfrog safety grade, CMS stars, performance on CMS P4P, US News Honor Roll and service line rankings, Vizient Quality and Accountability score, professional society’s awards and scores, etc. These scores are often easier to grasp, but I would caution any board from being comfortable with high marks on one or two, as there may be important performance gaps that are not visible. Even the top-rated institutions have opportunities to improve quality and reduce patient harm. Said another way, many of these programs grade on a curve. Boards should celebrate impressive results and ask; how can we raise the bar? What opportunity exists for us to further reduce preventable harm and improve quality?
Baviskar: Workforce challenges can create vulnerability when it comes to quality. You lose staff and you have trouble filling that position. What can board members do to make sure that their organization’s inexperienced staff maintain the level of excellence that they’ve already established?
Mort: We all know that workforce shortages are a major problem. Boards should consider asking management to share their plan to ensure that the current workforce, which may include new graduates and travelers, is trained and that they are performing as expected.
The challenge of training new members of the workforce today is compounded by the loss of more senior staff and the rise of hybrid work, which has reduced the amount of at the elbow informal learning that was once common. This is a fantastic opportunity for innovation of educational support, training, remote support on demand and other innovative programs that may possibly yield better results. This is a fitting example of how workforce and human resources decisions can be viewed through the lens of quality and safety.
Some other common-sense options might be to ramp up your on-boarding and test competencies in simulation centers, assign mentors and provide feedback. Another idea is to start recruiting trainees from local or national schools to bring in new professionals. Organizations might consider standardized touch points, or huddles, during the day which can promote learning, wellness, operational awareness and improvement in quality and safety. These huddles are often recommended by safety experts and can be a place for on the job learning and feedback as well. It is also helpful to have clear escalation pathways, a clear plan and the expectation to ask for help.
Baviskar: Can you provide insight for a board member that is reading this interview as to how to begin a discussion with their peers?
Mort: Trustees can begin by asking questions so they can assess their current state. I would encourage board members to ask for an orientation to quality and safety if that is not part of their routine work. They can also do some education on their own. The paper I mentioned earlier by Jim Conway is helpful. They might also review the new CMS guidance document. Another interesting paper that I would recommend to board members: “Closing the Gap and Raising the Bar” with Tejal Gandhi as senior author. This paper assesses boards’ competency and quality and safety. She and her colleagues did a survey to understand boards in 2014. The survey showed that ten years after the “Get the Board on Board” article, there still is a lot of variability, but there was progress.
The board can ask the management team to help them understand where they are to chart a course forward. Outside consultation may be helpful. Many organizations have terrific board engagement, active engagement and great results. What you do depends on where your organization is in its quality and safety journey.
Another important thing is to have empathy for the senior management teams and the issues they are dealing with: finance, workforce and burnout. It is all foundational to the organization’s health. For many leaders, this is the hardest set of challenges they have ever faced in their career. Despite that reality, boards can show their support by making the case that nothing is more foundational than quality and safety. We need to infuse that into the management plans and have line of sight into the goals, programs, tactics and results. Delivering safe and high-quality care is not the responsibility of one group or one senior executive, it is the responsibility of the entire organization. Each and every individual should understand his or her contribution to the top line goal of high quality and safe care and be held accountable to performing in a highly reliable manner. It starts at the top and now is a great time for boards to reflect on where they are on their quality and safety journey and identify opportunities to accelerate progress. I hope my thoughts are helpful.
Nikhil Baviskar (nbaviskar@aha.org) is program manager, trustee engagement and strategy, at the American Hospital Association.
Please note that the views of the interviewees do not reflect the views of Massachusetts General Hospital or the AHA.