Helping Your Board Ensure Patient Safety

Your quality team has studied the new standard changes, updated policies, and conducted tracers to monitor compliance. What else can you do as an executive to help your hospital prepare for more rigorous regulatory surveys? Communicate with your board!Currently, the Centers for Medicare and Medicaid Services (CMS) require hospitals to have a governing body (the board) that is legally responsible for the conduct of the hospital as an institution. The board of a hospital must hire the CEO, establish a competent medical staff, and oversee key aspects of the organization, such as the strategic plan and budget. However, it’s the governing body’s role in oversight of quality care that is most commonly cited during a complaint survey.

Rather than taking an active role in ensuring patient safety, most boards feel forced into a “rubber stamp” approach to quality oversight. This is often due to a combination of factors, including confusion about how the board oversees quality and lack of adequate knowledge about patient safety. But, hospital executives can support the board in fulfilling their responsibilities. Follow these guidelines to ensure that the board is an effective resource for your hospital.

Provide your board with an orientation. While not explicitly mentioned in the standard, board orientation has become an expectation for both CMS and The Joint Commission. Board members should receive an orientation to the hospital’s operations and quality program, as well as opportunities for additional education, if needed. Orientation also provides a chance for you and your hospital’s quality team to learn more about the needs and preferences of the board. What kinds of people serve on the board? What are their professional backgrounds? What kinds of report formats would best convey information to them in a meaningful way?

Make quality information universally understandable. Hospital boards generally consist of people from a wide variety of professional backgrounds. While many members may have some knowledge of basic quality control, it is likely that they do not know very much about the hospital’s quality standards. Therefore, the hospital must inform board members about quality care in a way that makes sense to them. Reports should be written for a lay (non-healthcare) audience and emphasize meaningful information over data.

Outline and document specific expectations for board members. In order for the board to effectively oversee patient safety (or operations in general), members must be engaged, interested, and willing to ask questions. Let your board know that you expect members to challenge old ideas, and encourage inquiry when appropriate.

Hold the board accountable for oversight. Boards receive quality reports for two reasons, to gain information and to direct action. Be clear when you want the board to take action on an identified issue, state your recommendation, then allow the board the opportunity to act. Merely approving a report is not meaningful action when there are problems. Once expectations have been stated, follow up in subsequent meetings.

Maintain transparency. Keeping the board informed is extremely important, particularly if your hospital is facing financial difficulties or adverse survey results like Immediate Jeopardy. A properly informed board can be the hospital’s greatest asset when it comes to communicating with the community and mitigating the impact of financial downturn or negative survey results. On the other hand, leaving the board in the dark about poor survey results can be disastrous, not only for reversing the findings, but in the loss of trust with the board and the community they represent. For more information and the story of one hospital that learned this lesson the hard way, read “Hospital Near-Death Experience: How Medicare Termination Can Push Your Hospital to the Brink of Closing.”

Filed Under: Clinical Improvement • Compliance Recovery

Tags: better hospitals, board development, board of directors, CMS compliance, Featured Articles, hospital accreditation, Joint Commission, Medicare termination, patient safety, performance improvement, Ruth Elzer