Executive Summary
A hospital’s performance on clinical quality metrics is affected significantly by the board of directors and the facility’s management. Quality leaders should remind them of their influence and guide them to improving metrics.
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A recent study quantified the effect on overall quality.
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The board, management, and clinicians should be measured on the same metrics.
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Researchers are establishing a standard way to measure management quality.
Common wisdom has long held that quality healthcare begins at the top, with CEOs and hospital boards setting the right tone and expectations. Now that effect has been proven and quantified.
Quality leaders at hospitals should take the empirical evidence to the boardroom and the C-suite to impress on leadership how much they can influence the overall quality of care, suggests Thomas Tsai, MD, MPH, a surgeon and health policy researcher in the Department of Surgery at Brigham and Women’s Hospital and in the Department of Health Policy and Management at Harvard School of Public Health in Boston. He also is currently serving as an adviser to the Office of the Assistant Secretary for Planning and Evaluation in the Department of Health and Human Services (HHS).
Tsai is the lead author on a study in Health Affairs concluding that more effective management practices are associated with higher-quality hospitals, and that the effect can be measured. (The study is available online at http://tinyurl.com/pk4ocg4.)
In addition, the researchers identified two signatures of high-performing hospitals. First, hospitals with boards that had a high attention to quality had more effective management practices in monitoring. Second, hospitals with boards that effectively used clinical quality metrics were more likely to have effective target setting and operations management practices.
“Hospitals performing above the median overall in the board performance index had a higher overall management score than those performing below the median (2.98 versus 2.70),” the report says. A one-standard-deviation increase in the board score was associated with a 0.297 standard deviation increase in the management score.
The research supports the trend to getting the hospital board more involved with improving quality metrics, Tsai says. Hospital boards, managers, and hospitals have been measured on quality metrics separately in past research, but this study combined them to determine how one affects the others.
“We found that all three were related to each other, such that high-quality hospitals with higher processes of care also had higher-quality board and management practices,” Tsai explains. “This suggests that it is important to maintain the quality of the board and management because the two of those are related to overall better care provided to patients.”
The researchers measured quality in four domains of management practice: operations, monitoring, targets, and human resources. Within each domain, specific criteria were measured. For instance, in the operations domain, a hospital would receive a low score if patient flow was not well thought out so that personnel and resources were utilized most efficiently and effectively. (For examples of how the quality measures were scored, see the story later in this issue.)
Tsai suggests that hospital boards and top management will welcome the data in his report.
“There is a realization that a hospital’s overall strategy needs to be aligned, that you can’t have physicians being measured on bloodstream infections while the managers are incentivized to focus a different set of metrics, and the board focuses on another different set,” he says. “This research suggests that it is important to start aligning the way we think about quality along the entire spectrum of care — from the boardroom, to the C-suite, to management, to the nurses at the bedside.”
Tsai notes that one goal of the research was to create a taxonomy for measuring quality in management, similar to the specific quality metrics in clinical care.
The study’s confirmation of the board and management’s effect on quality could be a valuable tool for quality leaders trying to get more support and involvement from top leaders, says Peggy Crabtree, RN, vice president with The Camden Group in Los Angeles, who has more than 25 years of hospital leadership experience and held executive leadership roles in numerous hospitals.
Quality metrics should be embedded throughout the organization, Crabtree suggests, rather than limiting them to clinicians. Bonus structures should always include performance on quality metrics, she says, and job applicants should be asked how they influenced quality in previous positions.
Crabtree recalls working with a hospital to educate its board about quality and the board members’ role in improving quality. A year later, the chief nursing officer called to say the hospital had received several quality awards and had significantly improved its performance on quality metrics.
“She thought it was because the board got behind them and really got engaged with what was going on,” Crabtree says. “I think we’re seeing that more and more now with bundling, value-based purchasing, and all the other changes. Boards are getting more educated and involved because the financial pressure is making them realize their responsibility for oversight in quality.”
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Peggy Crabtree, RN, Vice President, The Camden Group, Los Angeles. Telephone: (310) 320-3990. Email: [email protected].
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Thomas Tsai, MD, MPH, Surgeon and Health Policy Researcher, Department of Surgery at Brigham and Women’s Hospital, Boston, MA. Email: [email protected].
