QM reports to the board -- it's just good business
July 1, 1996 5 minutes read
QM reports to the board -- it's just good business
Inform them with highlights
By Patrice Spath, ART
Consultant in Health Care Quality and
Resource Management
Forest Grove, OR
(Editor's note: In the February issue of Hospital Peer Review, we presented ideas and techniques to improve a hospital governing board's effectiveness. This month, Ms. Spath offers more detailed tools and tips on how to better communicate with the board.)
Communicating performance measurement and improvement information to the governing board is not just a Joint Commission requirement, it is good business. The board has ultimate responsibility and accountability to the community for assuring the quality of patient care and services at their facility, and therefore must be kept well informed on all issues related to quality.
Boards need to know what activities are being done to monitor and evaluate medical care and services, and they need to know what is being done to improve and/or correct problems and deficiencies. They need to be assured that those to whom they have delegated the day-to-day responsibilities of quality management are performing their duties. It is those needs that should influence the format and content of the quality management program report to the board.
The information that must be shared with the hospital governing board is not clearly stated in the Joint Commission standards. The leadership standard states "relevant information is forwarded to leaders and coordinators of hospitalwide performance improvement activities." (1996; The Joint Commission on Accreditation of Healthcare Organization's Accreditation Manual for Hospitals, Sec. II, p. 123, LD.4.3.2) Therefore, hospitals can select the data items that are most important to their board's oversight role. The information included in the periodic reports to the governing board should help them answer questions such as:
* Is every hospital department and medical staff service monitoring their performance?
* Are the professional staff competent? Are their licenses current?
* Are we measuring what's important to our patients?
* Is this organization constantly improving performance, or are departments measuring the same thing each month without any documented improvements?
* How does our performance compare to similar hospitals?
* Are both clinical and business processes being improved? Is patient satisfaction considered when making improvements?
Education of the board
Selecting the right information to pass along to the board should start with an orientation meeting with the board in which the many different quality management activities are introduced to the board members. The board members must be educated about the medical staff and hospital performance measurement endeavors as well as the improvement mechanisms. That orientation also provides the quality management director with an opportunity to explain thresholds and benchmarks, and how those are used in the performance assessment and improvement process.
In addition, the governing board should be introduced to the performance measurement priorities of:
* local health plans;
* business coalitions;
* the state Medicare Peer Review Organization;
* any external review activities impacting your organization.
For example, in February 1996, the New York State Department of Health in Albany called on all hospitals in the state to provide careful attention to fundamental aspects of obstetrical/neonatal patient care. After studying current practices in New York City hospitals, the state Department of Health suggested that hospitals should focus on improved monitoring of high-risk patients, communication among the members of the medical team, attention to laboratory test results in patient management, appropriate use of consultants, patient education, and meaningful discharge planning.
If your state health department is conducting quality studies on a hospital-related topic, or other external groups are gathering performance data relevant to your hospital, it is important for your governing board to be kept apprised of your hospital's performance in those specific clinical services.
Following that briefing, the board members should be better able to determine what information they wish to receive on a regular basis and which they only wish to receive periodically. In some instances, hospital policies may influence how often summary reports go to the board. For example, the leaders are expected to ensure the competence of all staff members. If the hospital's human resources policy states that staff competencies are assessed at least annually, then the board should receive a summary report of findings at least annually. The findings from other activities, such as quarterly medical record review, may be summarized and reported quarterly or as often as requested by the board.
Get to the point
Do not ask board members to sift through mountains of data to find the answers to their questions. To minimize the amount of paperwork received by the board, use a combination of narrative and statistical summaries. (See the February 1996 insert in Hospital Peer Review for an example of a "Dashboard Report.") Routine performance measures should be reported at every board meeting. Those measurements can be displayed graphically or in a matrix such as the one illustrated in Figure 1 (see p. 101). It is important that comparative data or benchmarks be defined for each measure to help the board evaluate the significance of the information.
At least annually, each department can prepare for the board a one-page abstract of their quality management activities.
Another way of reporting the activities of individual departments is to aggregate their measurement findings into division-specific statistical reports. Figure 2 is an example of a report for all performance measures used by department in a particular hospital division (see p. 102). Rather than detailing the results of everyone's performance measures, the results are aggregated for reporting purposes. Only those measures that failed to meet the standard or threshold are described in greater detail.
With the new, flexible Joint Commission standards, hospitals have been given a lot of latitude to measure and improve what is important to them. That flexibility extends to the quality management reports. The higher up the organizational ladder, the less detailed the reports need to be. It is important to remember, however, that the governing board be provided sufficient information to support their role as overseers of the quality management process. In today's competitive health care environment, it is more important than ever that the governing board members receive the data before they need to adequately judge the quality of patient care in the institution.
(Editor's note: NY State Department of Health Evaluates Quality of Maternity/Newborn Services at New York City Hospitals and Their Affiliate Academic Medical Centers was reported by the New York State Health Department, Feb. 13, 1996. The complete report is available on the Internet at gopher://gopher.health.state.ny.us/00/dohpubs/.files/neonatal.txt.) *
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