Governance Board Manual Quality

8/9/2019 Governance Board Manual Quality

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QUALITY AND PATIENT SAFETY

Board Responsibilities....................................................................2Board Self-Assessment

Importance of a Quality and Safety Program.............................4

Quality and Safety Improvement .................................................5100K Lives CampaignWashington State Licensing StandardsMedicare Conditions of ParticipationJoint Commission on Accreditation of HealthcareOrganizations

Quality Indicators .........................................................................12

Performance Improvement Processes........................................13

Hospital Compare.........................................................................16

Performance Improvement Activities........................................16

Hospital-Wide ActivitiesMedical Staff ActivitiesPatient-Focused Functions Department ReviewCompliance with External Accreditation

and Regulatory Agencies

Seven Leadership Leverage Points.20

Summary........................................................................................21

References ......................................................................................22


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The two most important issues for trustees to attend toare quality of care and finance. Measurements andbenchmarks are needed to tell how the organization is

doing. It is our responsibility to establish a mission andassure that the organization has the resources to getthere.

Ned Turner, Trustee, Swedish Health Services

The Governing Board of a hospital has the moral, legal and fiduciaryresponsibility to monitor, evaluate, and continuously improve the quality andsafety of care provided. The Board must carry out its oversight role effectively.The Governing Board of a hospital has the ultimate responsibility for quality and patient

safety. This ultimate accountability can not be delegated away.

The Boards oversight is done by setting goals, time lines, and monitoring thequality and patient safety work done in the hospital. The Governing Boardaccomplishes this by supporting and monitoring the CEO as they lead this effortin conjunction with the Medical Staff. Medical Staff has special accountabilitiestogether with the Board as outlined in the JCHAO Accreditation Standards. Thisaccountability is to work together reflecting clearly recognized roles,responsibilities, and accountabilities, to enhance the quality and safety of care,treatment, and services provided to patients. The work of improving quality

although lead by the Governing Board, CEO, and Medical Staff is frequentlyaccomplished through multidisciplinary teams.

BOARD RESPONSIBILITIES

With the ultimate responsibility for the quality and safety, some of the Boardskey responsibilities include: Overseeing a coordinated, systematic, hospital-wide approach to improving

patient care and health outcomes; Understanding the Boards and trustees roles in the performance

improvement program; Setting goals, timeline, and approval of the written performance

improvement or quality assessment plan; Regularly reviewing and monitoring progress towards achieving this plan; Provide a safe environment in which the CEO can implement the strategies

needed for safety and quality care; Create alignment between rewards, compensation, and quality and safety

plan;


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Familiarity with WA State Licensing Standards and Medicare Conditions ofParticipation; and

Familiarity with Joint Commission on Accreditation of HealthcareOrganizations (JCAHO) accreditation standards if accredited.

A meaningful quality and safety program:

Has specific, measurable goals and timelines; Is planned, systematic and ongoing; Incorporates national measures such as the 100K Lives Campaign and

Hospital Compare; Is comprehensive (applies to all of the functions of the hospital clinical,

support, managerial, and governance); Uses objective measures of quality with predetermined indicators or

performance expectations;

Uses comparison data displaying average and top national performance; Ensures that improvements are implemented and sustained through ongoing

monitoring; Incorporates, multidisciplinary and cross departmental teams to improve

quality; and Results in improvement of processes and outcomes.

BOARD SELF ASSESSMENTGoverning boards should assess the effectiveness of their oversight on qualityand safety on an annual basis. The following questions can be used to evaluate

their work in quality and patient safety:

How has our hospital defined quality? What are our specific, measurablegoals and timelines?

Do our hospitals vision, mission statement, and strategic plan incorporate acommitment to quality?

Has the leadership team developed a measurement and reporting system thatprovides monthly feedback to the Governing Board?

Besides using patient demographics, how does our institution determine whoits customers are and what aspects of quality are important?

Does our hospital use the following mechanisms to determine the aspects of

quality that are important to patients and other customers? Community surveys or other feedback Patient satisfaction instrument Review of patient and staff complaints Review of clinical services outcomes Interviews, surveys or focus groups with staff and physicians Reports from business coalitions or other purchasers of services


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Analysis of legal, regulatory and accreditation requirements Media reports

Is accountability for achieving the quality and safety goals embedded into theBoards executive performance feedback system?

Does the Board agenda give a prominent place to the oversight of quality and

safety? Is it first on the agenda? Is it adequately discussed? Does our hospitals medical staff participate in quality and patient safety

improvement activities? Does the entire leadership team take an active role in quality and patient

safety? Quality measurement improvement:

What has the hospital done to reduce preventable deaths? Are rapidresponse teams in place and functioning well?

How has the hospital reduced hospital acquired infections? Is the hospital above average in the Hospital Compare results for heart

attack, pneumonia, heart failure, surgical site infection, and patientperception?

What is the hospitals progress in implementing all of the national patientsafety goals?

How has the hospital reduced medication errors? How are our patients involved in helping with quality and patient safety? Are minutes kept of each review activity? Are summary reports provided to

hospital administration and, as appropriate, to the Board? Does the Board review the effectiveness of performance improvement on an

annual basis including their role?

IMPORTANCE OF A QUALITY AND SAFETY PROGRAM

Patients expect safe, quality care as they receive services from a hospital. Theyexpect that we will not no harm and will help them.

In 1999, the IOM report entitled, To Err is Human: Building a Safer Health System,estimated that as many as 98,000 patients die each year as a result of medicalerrors in hospitals, many of which are preventable. The report garneredattention as the lawmakers and the public found these numbers to be

astonishing.

The IOM released several follow-up reports including, Crossing the QualityChasm: A New Health System for the 21stCentury. This report identifies currentpractices that impede quality care and explores how systems approaches can beused to implement change; but also notes that there are many lives that continueto be lost unnecessarily. Some of the IOM findings in these reports include:


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Only 55 percent of patients received recommended care. (McGlynn et al., 2003)

Medication-related errors for hospitalized patients cost roughly $2 billionannually. (Institute of Medicine, 2000; Bates et al., 1997)

The lag between the discovery of more effective forms of treatment and theirincorporation into routine patient care averages 17 years. (Balas, 2001; Instituteof Medicine, 2003b)

18,000 Americans die each year from heart attacks because they did not receivepreventive medications, although they were eligible for them. (Chassin, 1997;Institute of Medicine, 2003a)

Medical errors kill more people per year than breast cancer, AIDS, or motorvehicle accidents. (Institute of Medicine, 2000; Centers for Disease Control andPrevention; National Center for Health Statistics: Preliminary Data for 1998,1999)

More than 50 percent of patients with diabetes, hypertension, tobacco addiction,hyperlipidemia, congestive heart failure, asthma, depression and chronic atrialfibrillation are currently managed inadequately. (Institute of Medicine, 2003c;Clark et al., 2000; Joint National Committee on Prevention, 1997; Legorreta etal., 2000; McBride et al., 1998; Ni et al., 1998; Perez-Stable and Fuentes-Afflick,1998; Samsa et al., 2000; Young et al., 2001)

In a major report released on July 20, 2006, the Institute for Medicine (IOM)

stated that at least 1.5 million Americans are sickened, injured or killed each yearby avoidable errors in prescribing, dispensing, and taking medications. Onaverage, mistakes in dispensing drugs are so prevalent in hospitals that a patientwill be subjected to a medication error each inpatient day.

These findings have sparked a demand from legislatures, media, and public forhospitals to improve care while at the same time demonstrating significantprogress. Continued study has been requested by Congress as part of theMedicare Modernization Act in 2003. Congress, state legislatures, state hospitalassociations, and hospitals are working together to improve these findings with,

in some cases, very significant results.


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QUALITY AND PATIENT SAFETY IMPROVEMENT

100K LIVES CAMPAIGNMany organizations have supported hospitals to improve efforts. One of themost successful of these is the 100K Lives Campaign. This Campaign over an

eighteen month period has saved 122,300 additional lives in hospitals nationallyand 1,500 lives in the state of Washington as of June 14th2006.

The Campaign is a nationwide initiative of the Institute for HealthcareImprovement (IHI), and was launched in December 2004 by Dr. Donald Berwick,President and CEO of IHI. The goal of the Campaign was to save 100,000 livesby June 2006, by introducing six evidence-based quality improvement changes inabout 2,000 U.S. hospitals. The Campaign has been endorsed by a wide varietyof national health care organizations, including Centers for Medicare andMedicaid Services, American Medical Association, JCAHO, and many others.

At the encouragement of the Washington State Hospital Association Board,Washington State was the first large state to have 100 percent of all communityhospitals committed to join the campaign as of June 1, 2005. Over 3,000 hospitalsnationwide have enrolled in the 100K Lives Campaign.

The six evidence-based quality improvement interventions are as follows:

1) Prevent deaths in patients whose condition is deteriorating byimplementing Rapid Response Teams. These teams are quick response

swat teams which come to the patients bedside to assist prior to thepatients heart or respiration stopping.2) Prevent deaths among patients hospitalized for Acute Myocardial

Infarction (heart attack) by delivering a set of interventions commonlycalled a bundle.

3) Prevent Adverse Drug Events (ADEs) or medication errors byimplementing medication reconciliation at admission, transfer, anddischarge.

4) Prevent central venous catheter-related bloodstream infection byconsistently adhering to infection control practices in the central linebundle.

5) Prevent surgical site infection (SSI) by consistently administeringantibiotics appropriately and implementing a set of interventions knownas the SSI bundle.

6) Prevent ventilator-associated pneumonia and other complications inpatients on ventilators by consistently adhering to infection controlpractices in the ventilator bundle.


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Discrepancies or a pattern of such between preoperative andpostoperative diagnosis

Significant adverse drug reactions (as defined by the hospital) Confirmed transfusion reactions Adverse events or patterns of adverse events during anesthesia use Other hospital specific measurements

b. The needs, expectations, and satisfaction of patientsc. Quality control and risk management activities

The Washington Administrative Code (WAC) has specific standards for hospitalgovernance.

WAC 246-320-125

Governance.

The purpose of the governance section is to provide organizational guidance and oversight and to ensure resources

and staff to support safe and adequate patient care.

The governing authority will:

(1) Adopt and periodically review bylaws which address legal accountabilities and responsibilities. Bylaws willprovide for medical staff communication and conflict resolution with the governing authority;

(2) Establish and review governing authority policies, promote performance improvement, and provide fororganizational management and planning;

(3) Establish a process for selecting and periodically evaluating a chief executive officer;

(4) Establish and appoint a medical staff; and

(5) Approve bylaws, rules, and regulations as adopted by the medical staff before they can become effective.

Additional information on these codes can be found athttp://apps.leg.wa.gov/WAC/default.aspx?cite=246-320.

MEDICARE CONDITIONS OF PARTICIPATIONMost hospitals must meet the conditions to be Medicare certified in order toreceive payment from the Centers for Medicare and Medicaid Services (CMS).Medicare-certified hospitals must meet the Medicare Conditions of Participation.These conditions require that the Governing Board ensure that there is an

effective hospital-wide quality assurance program to evaluate the provision ofpatient care. No specific quality management strategy or approach is mandated.

These requirements state that The hospital must develop, implement, andmaintain an effective, ongoing, hospital-wide, data-driven quality assessmentand performance improvement program. The hospitals governing body mustensure that the program reflects the complexity of the hospitals organizationand services; involves all hospital departments and services (including those
http://apps.leg.wa.gov/WAC/default.aspx?cite=246-320http://apps.leg.wa.gov/WAC/default.aspx?cite=246-320


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services furnished under contract or arrangement); and focuses on indicatorsrelated to improved health outcomes and the prevention and reduction ofmedical errors. The hospital must maintain and demonstrate evidence of itsquality assurance and performance improvement (QAPI) program for review byCMS.

(a) Standard: Program scope(1) The program must include, but not be limited to, an ongoing program thatshows measurable improvement in indicators for which there is evidence that itwill improve health outcomes and identify and reduce medical errors.(2) The hospital must measure, analyze, and track quality indicators, includingadverse patient events, and other aspects of performance that assess processes ofcare, hospital service and operations.

(b) Standard: Program data(1) The program must incorporate quality indicator data including patient caredata, and other relevant data, for example, information submitted to, or receivedfrom, the hospitals Quality Improvement Organization.(2) The hospital must use the data collected to

(i) Monitor the effectiveness and safety of services and quality of care; and(ii) Identify opportunities for improvement and changes that will lead toimprovement.

(3) The frequency and detail of data collection must be specified by the hospitalsgoverning body.

(c) Standard: Program activities

(1) The hospital must set priorities for its performance improvement activitiesthat:

(i) Focus on high-risk, high-volume, or problem-prone areas;(ii) Consider the incidence, prevalence, and severity of problems in thoseareas; and(iii) Affect health outcomes, patient safety, and quality of care.

(2) Performance improvement activities must track medical errors and adversepatient events, analyze their causes, and implement preventive actions andmechanisms that include feedback and learning throughout the hospital.(3) The hospital must take actions aimed at performance improvement and, after

implementing those actions, the hospital must measure its success, and trackperformance to ensure that improvements are sustained.

(d) Standard: Performance improvement projects As part of its quality assessmentand performance improvement program, the hospital must conduct performanceimprovement projects.


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(1) The number and scope of distinct improvement projects conducted annuallymust be proportional to the scope and complexity of the hospitals services andoperations.(2) A hospital may, as one of its projects, develop and implement an informationtechnology system explicitly designed to improve patient safety and quality of

care. This project, in its initial stage of development, does not need todemonstrate measurable improvement in indicators related to health outcomes.(3) The hospital must document what quality improvement projects are beingconducted, the reasons for conducting these projects, and the measurableprogress achieved on these projects.(4) A hospital is not required to participate in a QIO cooperative project, but itsown projects are required to be of comparable effort.

(e) Standard: Executive responsibilitiesThe hospitals governing body (or organized group or individual who assumes

full legal authority and responsibility for operations of the hospital), medicalstaff, and administrative officials are responsible and accountable for ensuringthe following:(1) That an ongoing program for quality improvement and patient safety,including the reduction of medical errors, is defined, implemented, andmaintained.(2) That the hospital-wide quality assessment and performance improvementefforts address priorities for improved quality of care and patient safety; and thatall improvement actions are evaluated.(3) That clear expectations for safety are established.

(4) That adequate resources are allocated for measuring, assessing, improving,and sustaining the hospitals performance and reducing risk to patients.(5) That the determination of the number of distinct improvement projects isconducted annually.[68 FR 3454, Jan. 24, 2003]

When these standards are not met, the hospital can lose its Medicare certificationand reimbursement for services to Medicare patients. Additional information onthese regulations can be found athttp://www.cms.hhs.gov/CFCsAndCoPs/06_Hospitals.asp#TopOfPage.THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCAREORGANIZATIONSAs noted in the previous regulatory section, the Joint Commission onAccreditation of Healthcare Organizations has established standards for eachcomponent of the health care organization. Historically, the standards were veryprescriptive. Today, the standards are broadly stated; emphasis is placed onachieving the outcomes, more generally allowing the hospital to define the


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process that results in continuous performance improvement. However, each ofthe 20,000 organizations that are accredited by JCAHO is evaluated againstprofessionally based standards. The standards address the organizations actualperformance of both hospital/medical staff and the health care organizationscapabilities. The standards set forth by the Joint Commission are categorized

according to the functional areas of the organization. The functional areas are asfollows:

Patient-focused functions Organization-focused functions Structures with functions

The Joint Commission requires each accredited hospital to provide evidence ofplanning for performance improvement. Evidence may take the form of awritten performance improvement plan or other planning documents.Regardless of the format of the planning document(s), the purposes of planning

are to describe the hospital leaders approach to improving performance, ensurethat the efforts are systematic and involve all applicable departments anddisciplines.

The Improving Organization Performance standards emphasize process designand monitoring, analyzing, improving and sustaining performance.Acknowledging the fact that most organizations identify more improvementopportunities than they can address, criteria are set to establish priorities.

Under the JCAHOs new leadership standards:

The Governing Board, senior management and medical staff mustactively support and become involved in the hospitals quality efforts.

While trustees do not necessarily have to know each area in detail, theyshould make sure that the CEO has pertinent review activities takingplace on a scheduled basis and that significant results are reported andthat needed follow-up is occurring.

Trustees should note trends and patterns in performance of services andpatient outcomes and compare the hospitals performance withstandards or data from other hospitals.

The Joint Commissions new accreditation process, Shared Visions-NewPathways, became effective January 2004. The new process focused theaccreditation process on systems that are critical to the safety and quality of care,treatment and services. The process encouraged hospitals to incorporate thestandards as a guide for routine operations. Each year, the Joint Commissionapproves a set of national patient safety goals with related specific requirementsfor improving the safety of patient care in health care organizations. All JointCommission-accredited health care organizations are surveyed for


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implementation of the goals and requirements-or acceptable alternatives-asappropriate to the organization.

In 2006, the Joint Commission completed the transition from a focus on surveypreparation to a focus on continuous operational improvement by moving to

unannounced surveys. Only a hospitals initial survey is scheduled in advance;subsequent surveys are conducted on an unannounced basis approximatelyevery three years.

The Joint Commission publishes hospital performance reports to showaccountability for quality of performance and patient care outcomes. Hard copiesof these reports may be requested from JCAHO by the public, the media orhealth care organizations, or they may be accessed on the JCAHO web site athttp://www.jcaho.org.

QUALITY INDICATORSA quality indicator is a measure of an important aspect of the care or services.The words indicator and measures are often used interchangeably in hospitals.The focus for most indicators is on process or reporting if a needed service orpart of care was completed. An outcome indicator reports what the final resultwas. An example of a process measure is a patient had a heart attack and wasgiven an aspirin. An example of an outcome measure is that the patient made ithome alive. There can also be efficiency or structural.

In general, indicators should represent those procedures, conditions or servicesthat are nationally recognized or are important to your hospital. Measuresdeveloped by your hospital are typically:

Frequently occurring Easy to monitor through the collection of readily accessible data High-risk, high-volume, high cost or problem-prone Amenable to intervention Highly variable in the way they are managed

TYPES OF QUALITY INDICATORSEFFENCY/STRUCTURAL PROCESS OUTCOMEAssesses whether theorganization has thecapability and resourcesto provide high-qualitypatient care appropriate staffing

Process indicatorsmeasure whether theright actions were takento achieve optimal care(outcomes) doing theright things

Outcome indicatorsanswer the question,Did the patient getbetter? deaths within 24

hours of admission
http://www.jcaho.org/http://www.jcaho.org/


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levels equipment standards safety codes being

met Wait time in the

emergencydepartment

antibiotic give prior tosurgery to preventinfection

heart attack patientreceiving medications

on admission withinestablishedtimeframes

staff washes hands toprevent infection

surgical site infectionrate

Indicators also range in scope. Examples include: Hospital-wide,for example, re-admissions within 30 days of discharge Departmental,for example, vaginal births following previous cesarean

delivery

Individual occurrence, particularly for adverse and unusual events, such asan anesthesia-related death (an event unexpected in the normal course of apatients illness). An adverse event indicates the need for furtherinvestigation each time it occurs because of the severity of the occurrence. Thepurpose of the investigation is to analyze the root cause of the event andprevent future occurrences.

Indicator data should be aggregated over time to show trends and patterns.Trustees should not receive reports on all indicators monitored throughout thehospital. They should receive the most significant, ones that represent most the

level of quality and safety of care in the hospital. These are sometimes referredto as the big dot indicators. Reviewing these indicators prompt the setting ofgoals and time lines. Sample reports are available on the Washington StateHospital Association web site at http://www.wsha.org/page.cfm?ID=0124.

PERFORMANCE IMPROVEMENT PROCESSES

An evaluation should begin when an event occurs, performance falls below theestablished goals, or when expected patterns or trends are noted.

ADVERSE EVENTSAny time an adverse event as defined by the Washington State Department ofHealth or sentinel event as defined by JCAHO occurs, hospitals are expected tocomplete a root cause analysis. These are unexpected events that are that involvedeath or serious physical or psychological injury. The root cause analysis helpsto identify improvements to reduce risk, and monitor the effectiveness of thoseimprovements. The root cause analysis is expected to drill down to underlyingorganization systems and processes that can be altered to reduce the likelihood


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of failure in the future and to protect patients from harm when a failure doesoccur. In addition, when unexplained or unacceptable variations in the careprovided by professionals are identified, peer review may be necessary.

At the current time, there are twenty-seven events that must be reported to the

Washington State Department of Health should they occur. These events areavailable to the public.

When improving or prevent adverse events, focus should be on improvingsystems. A common myth is that most quality problems can be blamed onindividuals. In reality, it is estimated that at least 85 percent of these are relatedto system problems bottlenecks in work flow, information breakdowns,poorly designed or inefficient work processes and inadequate resources.

Various approaches have been developed to improve performance and patient

outcomes. Here we highlight JCAHOs 10-step model for quality assessment andimprovement. These are the basic steps to developing a quality assessment andimprovement plan that will result in improved organizational performance. Ahospital may use a customized approach or may select one developed by JCAHOor other experts in quality improvement.

It is not the responsibility of the board to complete the following steps but tolisten during quality reports to ensure that they were completed. The steps are: Assign responsibility Delineate the scope of care and service

Identify important aspects of care and service Establish thresholds for evaluation Collect and organize data Initiate evaluation Take actions to improve care and service Assess effectiveness of the actions and ensure that improvement is

maintained Communicate results to relevant individuals and groups

Assign Responsibility

Hospitals trustees are responsible to overseeperformance improvement while thechief executive officer (CEO) and medical staff are charged with setting priorities(consistent with the boards goals and vision), establishing responsibilities, anddesigning approaches for assessing and improving patient care

Delineate the Scope of Care and ServiceThe key functions (patient-focused, organizational and structural), procedures,treatments and activities to be monitored and evaluated are identified.


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Identify Important Aspects of Care and ServiceHospitals should focus their efforts on those activities that will make a difference(improve care and service) and on key functions, procedures and treatments.Priorities should be established on hospital-wide basis.

Establish Thresholds for EvaluationFor each indicator, an expected, achievable level of performance or a thresholdshould be set. A more in-depth review should occur if for example, thethreshold for the c-section rate is exceeded.

Hospital patterns or trends in performance should be monitored and comparedwith other hospitals or national standards.

Trustees should monitor hospital performance relative to its goals verifying the

source and the appropriateness of selected indicators.

Collect and Organize DataFor each indicator, there should be evidence of ongoing data collection. Datashould be aggregated to identify trends in care, services or outcome. Trusteesshould ensure that physicians, management staff and other staff receive trainingin methods of quality improvement.

Initiate EvaluationAn evaluation should begin when an unexpected pattern or trend is noted or

when performance falls below the established goal. Problems identified arereferred for an intensive review, particularly when the cause and scope of theproblem or trend is unknown.

When unexplained or unacceptable variations in care are identified, peer review(i.e., more detailed examination of records by qualified peer professionals)may be necessary. In addition, other causes and effects, such as how the care isdelivered, may also help explain variations in care. All peer and process reviewfindings should be documented and summarized to help determine theireffectiveness in identifying potential quality problems or situations.

Take Actions to Improve Care and ServiceThis step can pose the greatest difficulty for hospitals. When there is adiscrepancy between actual practice and the hospitals performance expectations,there must be evidence that an improvement plan has been implemented.

Assess the Effectiveness of the Actions and Ensure that Improvement isMaintained


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Critical to the improvement of care or services is determining if the action takenactually improved the care or service and if that change is maintained. If not,staff should determine whether the:

Nature and scope of the problem or trend were correctly identified Corrective actions were appropriate to the identified issue Corrective actions were reasonable and achievable Authority and responsibility for implementing corrective actions were clearly

specified and understood Corrective actions or improvement plans were implemented

Communicate Results to Relevant Individuals and GroupsData should be summarized concisely and reviewed in a timely manner byquality improvement teams, committees or councils, medical staff committees,senior management and the governing board. A schedule for the compilation

and distribution of data should be identified. Special attention should be paid toidentifying mechanisms for monitoring resolution of identified problems orsituations and ongoing improvement of care and patient outcomes.

HOSPITAL COMPARE

Hospital data is published on many web-sites including Hospital Compare. Thisweb-site published quality and patient safety data that is collected by CMS andJCAHO. The reports focus on recommended guidelines for patients withpneumonia, heart attack, heart failure, surgical site infection, and patient

perception (starting in 2007).

Access to this web site can be found at http://www.hospitalcompare.hhs.gov/.You can also view your results against Washington State hospitals using a reportfrom the Washington State Hospital Association. You can get a copy of thisreport from Carol Wagner, Executive Director Patient Safety, by calling (206)577-1831 or emailing [email protected].

PERFORMANCE IMPROVEMENT ACTIVITIES

Trustees should discuss the activities to be included in every performanceimprovement effort. Trustees do not need to know the specific activitiesundertaken but need to ensure that all functions occur regularly, that significantfindings are documented and reported to the appropriate parties, and thatneeded follow-up action is taken. Trends or patterns of performance over timeshould be noted and compared with national or local standards with data fromsimilar hospitals.
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HOSPITAL-WIDE ACTIVITIES Quality performance indicators

Annually or more frequently, the Board should receive a summary of selectedindicators that reflect important dimensions of the quality of patient care andservices at the hospital. Indicators serve the purpose of raising important

questions and promoting meaningful discussion among Board members,medical staff and hospital management. A profile of hospital performanceover time is provided both in relation to the hospital itself and to othercomparable hospitals. Indicators promote the examination and improvementof care across hospital departments, as well.

Infection controlThe Board should review hospital-acquired infection rates as a part of the setof quality indicators. Common measures used are hand hygiene compliance(research has shown to reduce hospital acquired infection by 25%), ventilator

pneumonia, central line infections, surgical site infection, multi-drug resistantorganism, and any outbreaks.

Safety and securityThe activities of hospital-wide safety and security committees should besummarized and reported on a routine basis, including physical plantrequirements and conditions. Board members may also request evidence thatpolicies and procedures are in place to ensure privacy, confidentiality andappropriate resolution of ethical issues.

Utilization management and volume statisticsOn a regular basis, trustees should receive an overview of the volume andutilization of hospital services, not only to assess financial performance butalso to have a framework for identifying trends and issues in quality. Datacould include inpatient and outpatient volume, ancillary service use, averagelengths of stay (e.g., by top DRGs), payer mix and PRO/insurance denials orquality problems.

Patient, employee and physician satisfactionPositive staff morale is an important factor in the quality of patient care

services. A procedure for monitoring patient, employee and medical staffperceptions, attitudes and opinions on an ongoing basis may be included aspart of an institutions overall quality improvement process.


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MEDICAL STAFF ACTIVITIES Departmental review

The quality of patient care offered by each department or the medical staff asa whole must be evaluated. The results of this evaluation, and anyconclusions, recommendations, action and follow-up, should be documented.

Surgical case reviewHigh-risk, high-volume, high cost and problem-prone procedures should bereviewed according to a predetermined sample. A review of all surgical andother invasive procedures is not required. Reviews should also focus on theprocesses related to surgical and invasive procedures, including patientpreparation and procedure selection. The rationale and methodology forselecting, reviewing and reporting surgical case review should bedocumented. Reporting should also occur on antibiotic usage prior tosurgery. Reporting should take place no less than quarterly.

Blood usage reviewThe appropriateness of the ordering, distribution, handling, administrationand monitoring of blood and blood products should be reviewed quarterlyand can be drawn from a sample of cases, as with surgical review. Eachblood use category (e.g., packed red blood cells, platelets, fresh frozenplasma, transfusions) should be sampled, and reporting should occur no lessthan quarterly.

Medication use review

Review of a sample of medication use is permitted as long as frequently used,high-risk, high cost or problem-prone medications are included in the review.The review should focus on whether medications were appropriatelyprescribed, prepared, dispensed, administered and monitored. Reportingshould occur no less than quarterly.

Medical record reviewA representative sample of medical records must be reviewed for clinicalpertinence, adequate and appropriate documentation and timely completion.Reporting should occur quarterly.

Credentialing and privileging (also see medical staff chapter)The appointment and retention of a qualified medical staff are among themost important quality responsibilities of the Board. The composition of itsmedical staff largely determines a hospitals quality of care. The Board mustavoid a rubber stamp approach to granting medical staff appointments,reappointment and clinical privileges. Information to be reported to theBoard on an ongoing basis should include, but is not limited to, the following:


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Evidence of valid license(s) Evidence of educational background and training and continuing

education Evidence that no disciplinary actions have been taken by current or

previous hospitals or Boards Evidence of current and adequate malpractice insurance Valid board certification Evidence of professional competence and ethics Statement of health Malpractice claims history Current privileges

Clinical risk managementA summary of incidents, claims, lawsuits, amounts paid to date and reports

to the National Practitioner Data Bank should be provided on an ongoingbasis to help trustees determine if patterns of loss or liability exist andwhether they are being adequately addressed. Other clinical riskmanagement issues, such as unexpected deaths or operations on incorrectlimbs, and number of malpractice claims should also be addressed.

PATIENT-FOCUSED FUNCTIONS DEPARTMENT REVIEWThe review of nursing and ancillary departments in the carrying out of patient-focused functions should occur in at least the following areas: All nursing units

Alcoholism and other drug dependence services Diagnostic radiology services Dietetic services Emergency services Hospital-sponsored ambulatory care services Nuclear medicine services Nursing services Pathology and medical laboratory services Pharmaceutical services Physical rehabilitation services

Radiation oncology services Respiratory care services Social work services Special care units Surgical and anesthesia services

Currently, in Medicare-certified hospitals, two important aspects of care shouldbe monitored for each service area. Two indicators per aspect of care should be


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reported at a minimum. The Board should receive reports from the variousdepartments on a rotating basis throughout the year.

COMPLIANCE WITH EXTERNAL ACCREDITATION AND REGULATORYAGENCIES

The Board should be updated on the hospitals performance relative toaccreditation, regulatory and licensure requirements. This report should occurfollowing receipt of survey results. It should summarize the findings fromsurveys conducted by agencies such as the following:

Joint Commission on Accreditation of Healthcare Organizations Washington State Department of Health Occupational Safety and Health Administration Medicare

The report should also summarize major recommendations and areas ofnoncompliance, as well as a schedule for corrective action and the results ofthose actions, developed by the hospital and medical staff.

To review, there are important questions for the board to consider in evaluatingtheir effectiveness in assuring quality health care within their organization.The questions below should be added to the board self assessment noted at thebeginning of the section.

Are summary reports provided to hospital administration and, asappropriate, to the Board? Does this information provide a comprehensiveoverview of the hospitals performance, highlighting prioritized indicators,reflecting patterns and trends, needed actions and offering comparison tolocal and national standards?

Are the reports the Board receives manageable in number, clear and concise,routine and ongoing and explained in the appropriate level of detail?

Is additional education or training needed by Board members to understandmore completely the information being presented to them?

SEVEN LEADERSHIP LEVERAGE POINTS

The Institute for Healthcare Improvement has developed seven leadershipleverage points for organization-level improvement in health care. Thisdocument can be downloaded at the following website:http://www.ihi.org/NR/rdonlyres/C84E1503-C05E-4D1B-B8D5-C74CEFE68F7F/0/LeadershipWhitePaper2005.pdf
http://www.ihi.org/NR/rdonlyres/C84E1503-C05E-4D1B-B8D5-C74CEFE68F7F/0/LeadershipWhitePaper2005.pdfhttp://www.ihi.org/NR/rdonlyres/C84E1503-C05E-4D1B-B8D5-C74CEFE68F7F/0/LeadershipWhitePaper2005.pdfhttp://www.ihi.org/NR/rdonlyres/C84E1503-C05E-4D1B-B8D5-C74CEFE68F7F/0/LeadershipWhitePaper2005.pdfhttp://www.ihi.org/NR/rdonlyres/C84E1503-C05E-4D1B-B8D5-C74CEFE68F7F/0/LeadershipWhitePaper2005.pdf


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SUMMARYThe Board is responsible for its hospitals quality of care, including that of themedical staff. This responsibility can not be delegated. An effective hospitalperformance improvement program is necessary for a hospital to receiveaccreditation, licensure and certification from voluntary and governmental

entities, to obtain third-party reimbursement, and as part of our accountability toour community.


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REFERENCESCarey, Raymond G. and Robert C. Lloyd,Measuring Quality Improvement in Healthcare, New York,NY: Quality Resources, 1995.

Grose, Louise, Owner, Shiloh & Associates, Thrall, TX, January, 1998.

Health and Safety Code, Vol. 1, Chapter 108, Vernons Texas Codes Annotated,St. Paul, MN: WestPublishing Co., 1992 and 1998 Supplement.

JCAHO Tip-of-the-Month: First, QA Then, QA&I Now, PI. Is It All the Same?Medical StaffBriefing, December, 1993, pp.6-7.

Joint Commission on Accreditation of Healthcare Organizations, Sentinel Events:Evaluating Cause and Planning Improvement,Oakbrook Terrace, IL, 1998.

Joint Commission on Accreditation of Healthcare Organizations, 1998 HospitalAccreditation Standards,Oakbrook Terrace, IL, 1998.

Joint Commission on Accreditation of Healthcare Organizations, Hospital Accreditation Standardsand Survey Process: Small or Rural Hospitals,Oakbrook Terrace, IL, 1996.

Joint Commission on Accreditation of Healthcare Organizations, The Complete Guide to the 1998Hospital Survey Process, Oakbrook Terrace, IL, 1998.

Medicare Conditions of Participation, 42CFR Subpart C 482.21.

Orlikoff, James and Mary K. Totter, The Boards Role in Quality Care, Chicago, IL:American Hospital Publishing, Inc., 1991.

Orlikoff, James, Trustee Orientation, Fort Worth, TX, 1997.

ORourke, Lisa and Barry Bader, The Quality Letter for Healthcare Leaders, Vol. 5, No. 2, March,1993.

Pointer, Dennis D., Jamie E. Orlikoff, Board Work: Governing Health Care Organizations, Jossey-Bass, San Francisco, 1999

PISL Consulting Group, Developing Critical Pathways in Behavioral Health, Englewood CO: 1994.

Sullivan, Raymond and et.al., Does Your Board of Trustees Really Know Your Hospital?JHQ,Vol. 15, No. 4, July/August, 1993.

Totten, Mary et.al., The Guide to Governance for Hospital Trustees. Chicago, IL: American Hospital

Association, 1990.

Washington Administrative Code 1999

Wayenknecht, Teresa,A Resource Manual for the Healthcare Quality Professional of the 90s, Austin,TX: The Texas Society for Healthcare Quality, 1993.

Documents

Governance Board Manual Quality