How do you get your board on board?
IHI leaders shares secrets
How do you engage the top leadership of your facility in the pursuit of quality improvement? This has been one of the greatest challenges for quality professionals and is now a key objective of the Institute for Healthcare Improvement's (IHI) "5 Million Lives" campaign.
In a recent article in The Joint Commission Journal on Quality and Patient Safety1 the IHI's James Conway, MS, who honchos the 5 Million Lives initiative, shared some of the key learnings from the campaign.
HBQI posed the following question to Conway: If your hospital is currently not participating in 5 Million Lives and your board is not "on board," what can the quality manager do to help get them on board?
"I think the first thing is to show them the evidence," says Conway. "[Recently] the Journal of Healthcare Management, which is read by a lot of health care executives, hit my desk. There is an article 'Board engagement and quality,' which reports on the findings of a survey of hospital and health system leaders. It found that 60% of hospitals have a board quality committee, and in those facilities that do, the outcomes are better."
There is research going back to the 90s, he continues, that shows hospitals where there is engagement of governance and executive leadership have better outcomes, he adds.
Another key issue, he says, is what the IHI calls "will-building." "A lot of times boards don't understand about the harms, the tragedies, and the waste that occur in their facilities, and in the absence of them knowing that it's hard for them to be engaged," he points out. "If we want people to take the time to address critical issues they need to understand there are critical issues in quality and safety."
When working with boards, Conway says he regularly asks them how often patients are seriously harmed or die uneccessarily in their organization. "And it's a rare board that knows the answer to my question," he says. "If they do not know the current reality, how can they be engaged?"
The board, he emphasizes, has the ability to set the hospital's vision. "In 'The Fifth Disclipline,' probably one of the best books on how to lead change, author Peter Senge said that you have to have a great goal or vision, but you also have to confront the realities of practice. If you put vision and reality together it will create tension — and you can use that tension to drive change."
In the past, he notes, health care professionals were trained that a good presentation was one that did not make anyone axious. "What we need to do is be much more balanced in the reports that managers give to boards," he emphasizes. "You have to talk about failures in care in ways that boards can understand. — and often we haven't done that."
Board members, he notes, are people who long ago realized the power of quality and safety in their own businesses, but have not thought of the valuable role they can play in health care. "We must tell stories about our work in a way they can understand and apply their learning to our particular challenges," Conway says.
What boards should do
In order for board engagement to have optimal results, there are six things boards should do, Conway writes in his article:
- Set aims: Conway notes, for example, that Israel Beth Deaconness in Boston set a goal of eliminating preventable harm by 2012. "You've got to engage the board in setting strategic goals, as oposed to bogging them down in details," he advises. "For example, eliminating bloodstream infections is not a strategic goal, but eliminating preventable infections is because it is at a whole system level rather than a specific intervention."
- Get data and hear stories: Reiterating his previous point, Conway notes that data must be presented in a way that the board understands what is going on. "Often when we present data to people we talk about things with a bit of spin, as opposed to presenting the realites of what works and what does not," he says. "Certainly we want to tell about the good things and celebrate exceptional care, but we also want to make sure the board understands the operations fully." Another valuable strategy, he says, is telling stories. "One thing a quality manager can be very helpful in is identifying the stories that would be very helpful for the board to hear — having a particular patient or staff member tell of a tragedy," he notes. "Nothing captures the attention of a board member like hearing a story around harm. Also, give them good data that allow them to understand harm."
- Establish and monitor system-level measures: One of the things a quality manager should be doing is sharing how the hospital is doing in the area of mortality and overall harm, compared to what is expected, Conway notes. "You shouldn't get lost in the weeds, but let the board understand how well you are doing as an organization," Conway advises. "Boards can tell me, for example, how well their facility is doing in medical errors in oncology, but not in overall medical errors."
- Change the environment, policies, and culture: "Other industries have learned that when someone tells of an error they don't always assume it was the fault of a bad person, and that attitude is determined largely based on what you think is important," says Conway. "With respect to boards, I have done research that shows an extraordinary gap between how the board thinks things are going and how the frontline thinks things are going. You have to establish a culture that allows what middle management loses sleep over to become understood by the board."
- Learn: "Middle managers can play an extraordinary role as teachers of curriculum — they can bring a much richer and more reality-based view," says Conway. "Also, the frontline people are proud of their staff and have so many wonderful stories to tell, which allows the board to connect with the passion of the organization."
- Establish executive accountability: Increasingly, the compensation of boards is heavily incented by quality and safety outcomes, and that is moving to a greater degree into middle management, notes Conway. In other words, there is a growing relationship between compensation and bonuses and results compared to overarching goals. "At a very practical level, if I set my annual goals and do not engage middle management there is no way we will ever achieve those goals," He asserts.
Additional advice and tools for quality managers can be found on the IHI web site (www.ihi.org), says Conway. "Specfically, there is a how-to guide for the 5 Million Lives 'board onboard' intervention, which includes a campaign and materials," he notes. "There is a lot of important information there for quality managers."
More specifically, he adds, "The top question we get from quality and risk managers across the country is, 'How do I do dashboards?' and they will find some very nice examples there from our organization."
[For more information, contact:
James Conway, MS, The Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138. Phone: Phone: (617) 301-4800. Toll-Free: (866) 787-0831. Fax: (617) 301-4848.]
Reference
- Conway J. Getting boards on board: engaging governing boards in quality and safety Jt Comm J Qual Patient Saf 2008;34:214-220.
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