View from the Top

“View from the Top” is a new series that looks at quality improvement from the perspective of healthcare executives and governing board members.

By Tom Van Dawark
CEO, Orca Partners, LLC

My first experience with respect to the power of the board to establish the priority and set the expectations for safety and quality in an organization was very early on in my business career. I had just become CEO of a marine transportation company operating tugs and barges in Pacific Northwest and Alaskan waters, when the company was sold, and I led our management team to our first meeting with the new board of directors. Carrying market, operating and financial spreadsheets with us, we were prepared.  The meeting began with the board chair thanking us for the materials and indicating he had just one question: “Would you recommend that I promote our organization  as a safe place to work for my family and friends that want to sail on our vessels?”  As board members and senior leaders in health care, do we ask that question about our organization’s safety and quality as often as we should?

I had the good fortune to be a trustee on the Virginia Mason Health System Board for 12 years, serving as board chair and participating on a number of committees. I developed respect for the challenges in providing patients with safe care and an appreciation for the many opportunities we have to significantly improve the patient experience, when the board makes safety a priority. I witnessed the power and the influence the board has to lead the improvement effort and to make a real difference. 

You cannot be involved in health care without developing a passion for the need for significant improvements in patient safety. I certainly got “hooked” and enjoy contributing as much as I can to promote the role of the board and senior leadership in directing the enhancements needed.

Overcoming Barriers to the Board’s Involvement in Safety and Quality Improvement

In many healthcare organizations there is reluctance on behalf of the board to become involved in safety and quality. Why? Here are three key barriers and the means for overcoming them: 

1. Lack of understanding that the board is ultimately responsible for safety and quality

• We are responsible.  Discuss your fiduciary, core governance and business responsibilities at your next board meeting.
• Have an open, honest conversation regarding board members’ and senior executives’ roles and responsibilities in safety and quality.
• Ask your governance committee for best practices in defining these roles and responsibilities and implementing them in your patient care environment.

2. Assumption that “everything is fine” with your patient safety and quality performance

• Discuss a current assessment of your safety and quality position as compared with best performers; include your trends and how soon you are scheduled to meet your current goals.
• Put a face on your data; if you have reduced the number of falls by five percent, how many patients are still being harmed?
• Solicit the views of those most affected by your safety performance: your patients and their families.
• Engage your physicians, nurses and patient safety personnel; how do they assess your safety performance, and what ideas do they have for improvement? 

3. Lack of clarity about how the board and individual board members can contribute to safety and quality improvement

• Establish patient safety orientation and ongoing education programs for all trustees so they feel comfortable with their involvement in safety work. 
• Discuss the success stories of boards who have made a difference.
• Review the best practices of these boards and determine which practices would be useful in your patient safety environment at this point in time.
• Just do it.  Get your board members involved with the safety and quality committee, the patient service committee, your safety performance improvement teams, etc.  Board members without a clinical background often see issues through a different lens, which can provide great insight.

Working in Partnership with Senior Leaders to Improve Safety and Quality

The board has ultimate responsibility for patient safety and quality.  The leadership team has 24/7 patient safety responsibility and accountability. How should this partnership operate to substantially improve safety and quality?

1. Involve your board and senior leadership in a review of your strategic plan mission, vision, values and key strategies.  Ensure patient safety and quality is properly prioritized.

2. Use the exercise, even if it involves only “tweaking” an already safety focused strategic plan, to build upon the strength of the working partnership of board and senior leadership.
3. The most important issues for the partnership to work on to make significant gains in safety and quality include:

• Initiating a board safety and quality committee if one does not already exist.  Ask your board members who may have safety and quality experience outside health care to play a role on the committee.
• Establishing patient safety goals and objectives that will stretch the imagination but be achievable with the appropriate support.
• Developing a patient safety improvement plan that will achieve your goals with the urgency required.
• The board chair and CEO standing side by side communicating to the organization the importance of patient safety, the plan for improving performance and the commitment of the board and senior leadership to the long-term journey.
• Demonstrating your very important cultural value of transparency by openly tracking, monitoring and sharing the results of your safety performance.
• Establishing evaluation and recognition practices that support your patient safety commitments.
• Start with the board; the board and its members should be annually evaluated for their contributions to improving patient safety.  The CEO should have clear safety responsibilities, performance expectations, evaluation criteria and safety performance tied to compensation.

Bringing the Patient to the Boardroom and the Boardroom to the Bedside

Perhaps the most critical link for successfully connecting the boardroom with healthcare quality and safety is to “put a face” to our mission and to the statistics we see and can get inundated with on a routine basis. How do we gain the perspective of how we are doing with respect to patient safety and quality unless we involve the patient?  Here are some thoughts:

1. Simple as it may seem, put some patient pictures on your safety and quality reports. 

2. We should all ask the question when we are setting our safety goals or reviewing our performance: how many patients are still being harmed after we are pleased with improving hospital-acquired conditions (HAC) performance by five percent?
3. Bring a patient or caregiver to your boardroom to serve as a reminder for why we are in the boardroom in the first place and to put a face on the rest of your agenda items.  Begin the practice with “feel good” stories if you must; there are many great stories to share. Don’t wait too long to engage with the patient who has had a difficult safety experience.  At Virginia Mason, when this practice was initiated a number of years ago, our visit with a patient with a challenging safety experience did more to benefit the patient safety cause than we ever imagined.
4. Bring the boardroom to the bedside.  Establish a routine schedule for board members to be a part of the team that makes rounds to the bedside, the nurses' break room and the clinical areas of the organization.  Ask questions about patient safety and patient care.  Explain the interest and commitment the board has to a safe environment.  Make the urgent issues known to management and share your experiences at the next board meeting.  Board members may be reluctant at first; however, most will agree after participating that the experiences are one of the most important and gratifying parts of their responsibilities.

I hope these thoughts are helpful to you as board members and senior leaders as you continue your efforts to improve patient safety and quality in your organizations.  Our patients expect and deserve a safe healthcare environment. While the tasks are without a doubt very challenging, there are many low-cost and high-benefit opportunities to consider. 

I applaud your establishment of a “View from the Top” to QIO News. I am honored to be your first contributor and look forward to reading your future articles.