1. Bored Room to Board Room:Putting Quality on the Agenda

2. Why Do We Care?

3. Role of the Board of Directors • Core fiduciary responsibility • Duty of Care • Components of quality • Clinical • Operational • Regulatory • Credentialing and privilege granting

4. Why Is This a Critical Need? • 37 key indicators for 5 health care system dimensions of care scored the U.S. @66 out of a possible 100 • Efficiency was the single worst score • U.S. world wide leader in costs • U.S. scored 15th out of 19 in mortality attributable to health care services • Basic health IT tools lacking to track patients throughout their lives • Improving performance could save 100-150,000 lives annually and approx. $50-100 billion annually *Source: U.S. Dept of HHS, Office of the Inspector General

5. Interrelation of Quality • Reimbursement and payment • Efficiency • Cost controls • Collaboration between organization, its providers and independent practitioners

6. How Do We Define Quality • Safety, or freedom from accidental harm • Effectiveness or evidence based care • Patient centeredness • Timeliness of care for appointments, diagnosis and treatment • Efficiency or care delivered with optimal use of resources • Equitable care

7. Steps to a Successful Quality Program • CEO’s performance evaluation includes objective measure for achievement of clinical improvement goals & patient safety goals • Board participates in the approval of criteria for MD appointments, re-appointments & clinical privileges • Board agenda focuses on quality performance at least 25% of the agenda time (not on consent agenda) • New board members receive orientation about quality programs and then attend regular quality educational sessions

8. Steps to a Successful Quality Program • Medical staff in involved in setting the agenda for the board’s discussion surrounding quality • Benchmark but know your targets • Adopt best practices for safety • Transparency in reporting; particularly with risk management • Sentinel events reported to full board with corrective action plan developed • Use oral tradition: storytelling can be a powerful tool

9. Steps To a Successful Quality Program • Make the quality committee a prestigious committee assignment • Include quality in your mission statement • Evaluate results through a “quality lens” • Good internal processes = good quality • Good feedback loop is key • Select board members with certain expertise • Clinical • Financial • Regulatory • Legal • Community based

10. Ask The Right (Hard) Questions • What are the goals of the organizations quality improvement program? Where are we now and what is the best of the best? • How is each goal linked to management accountability? • Who are the key managers and clinical leaders responsible for quality and safety? • What metrics and benchmarks are used to monitor progress?

11. Ask The Right (Hard) Questions • How is the organization’s quality assessment and improvement processes integrated into overall corporate policies? • How does the quality program and corporate compliance intersect? • If a sentinel event occurs what is the process for ensuring corrective actions are effective? • What protections are in place for staff to ensure ease of reporting? • How does each department articulate their role in quality and its impact on patient care outcomes?

12. Board commitment to a culture of quality ensures that everyone in the institution will make quality their priority