How Much Should Hospital Trustees Know About Patient Safety?

They think they know a lot, research shows. But patient safety professionals are not as confident in trustee knowledge.

Hospital trustees are not usually chosen for their expertise in patient safety and quality of care. They are traditionally bankers, venture capitalists, drug company executives, real estate developers and manufacturers—what used to be called "captains of industry."

How much they know about patient safety and quality of care is not central to their joining a hospital board and has not been well quantified.

Now comes a study entitled "Closing the Gap and Raising the Bar: Assessing Board Competency in Quality and Safety." Published by The Joint Commission Journal on Quality and Patient Safety, it builds on previous research by asking hospital trustees how much they know about quality of care.

"Safety and quality leaders" (SQLs) were then asked for their impressions of trustees' knowledge and involvement with quality issues.

Researchers found hospital quality staff and trustees differ in their perceptions of how much board members understand and act on quality issues:

• About 45 % of the SQLs said board members have a good understanding of teamwork, which is an important element of quality efforts. 
• About 77% or board members report that they understand the role of teamwork.

And

• 85% of board members checked off "All the time" to a question on how often patient safety events that caused harm are reviewed at the board's quality committee meeting.
• 40% of SQLs believe those cases are reviewed "All the time" at the meetings. 

The gaps were smaller on other questions and the study does not suggest that executives and board members are not doing their jobs, says Patricia McGaffigan, RN, the study's lead author. She cautions that the study's size and methods make it difficult to generalize about the results.

McGaffigan, who is the Institute for Healthcare Improvement's (IHI) vice president of safety programs, suggests that hospital boards use the results to do a baseline assessment.

"This is a guidepost…"Here are some important areas that are provocative and help guide us to the priorities"  that organizations may need to address, she says.

McGaffigan was with the National Patient Safety Foundation when she led the research. That group merged with IHI on May 1.  

Training and Certification
The Minnesota Hospital Association helps its member hospitals address these issues by running a "Training Camp for Rookie Trustees" and a trustee certification program. Quality is a major part of those programs.

The knowledge gaps in the survey rang true to Lawrence Massa, the association's president. They have held trustee conferences for years, but the trustees wanted more education, he says. "The trustees felt like they wanted to be more of a partner with the senior leadership team."

That led to a broader effort with major safety and quality components. The handout for the trustee training camp includes a detailed description of every phase of the quality assessment process.

Involved, But Not Too Involved
"Too often boards of trustees assume that quality and safety problems are not an issue in their hospital unless they hear otherwise. Instead, boards should ask specific questions to identify the hospital's current performance and pinpoint areas with the greatest need for improvement," according to the document.

But hospitals don't want the trustees to get too involved.

"We try to be very clear about where the boundaries are between management and governance," Massa said.

The American Hospital Association recently "refocused" its trustee education effort, offering webinar and instructional video hospitals for "boardroom education." 

Debra Stock, AHA's vice president of member relations, wrote in an email that most boards have quality review committees with deeper knowledge of the issues. All members don't all need the same level of proficiency in every area, she wrote.

Instead, boards need members with "a range of competencies including quality, finance, strategic planning, and information technology."

McGaffigan agrees. She says this study and others should motivate trustees and hospital administrator to work together to make sure quality is a priority in and out of the boardroom.   

Holding SQLs Accountable
"It's a great time to have a conversation, to sit down as a team of executives and board member and SQLs [and] to say, 'what are our practices right now? What are the things we are doing that we think affirm that safety of patient?' [That] is a core value of ours," she says.

In an editorial accompanying the paper, consultant James Reinertsen, MD, agrees there is a gap between what boards know and what they should know.  

He says that SQLs have to take some responsibility because they consume "vast quantities of precious meeting time with PowerPoint presentations." Board members listen passively and are not always encouraged to ask questions, Reinertsen writes.

If there is no opportunity to question, "a confusing aspect of the safety dashboards, or [to] challenge a management plan to correct poor performance or [to] dig into a particularly troubling matter concerning the medical staff, what would it matter how knowledgeable they are?"