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- [00:00]
A
Welcome to Advancing Health. Members of hospital boards have a wide portfolio of responsibilities. Still, there are five things every board member should know about quality and patient safety. And we hear what they are in today's podcast.
- [00:17]
B
My name is Rebecca Chickey, and I am the Vice President of Behavioral Health and Trustee Services at the American Hospital Association. And it is my honor today to be joined by Dr. Elizabeth Mortal. She is the Vice President and Chief Medical Officer for the Joint Commission. In this role, Liz serves as a primary voice for patient quality and safety and as a key liaison between the Joint Commission and the healthcare quality and safety community, and works closely with healthcare organizations on accreditation processes. Dr. Mort is also the Editor in Chief of the Joint Commission Journal on Patient Safety and Quality. Prior to joining the Joint Commission, she served as the Senior Vice President of Quality and Safety and the Chief Quality Officer at Massachusetts General Hospital for 10 years. And she's also served on AHA's Committee on Clinical Leadership. Dr. Mort, thank you for being here today.
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C
Rebecca, it's a pleasure. Thank you so much for having me.
- [01:16]
B
Well, I also want to thank you not only for the time you're going to spend with us today on this podcast, but. But you've just recently written an article that's going to be featured in the May edition of AHA's Trustee Insights newsletter. In that article, you really described what a board, an overall board, the full board, needs to know about running a quality committee, and you provided five recommendations to elevate the impact of the quality committee, particularly during times of financial and operational challenges. So the focus of our podcast today is really going to be on those five things that all board members need to know about quality and patient safety, including how that relates to Joint Commission surveys and resulting reports. Are you game?
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C
Game? Game on.
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B
Wonderful. So we'll start with this. If you can simply list the top five things that you think all board members should know about quality and patient safety, give maybe a high level one or two sentences about what that means, and then we'll go back and dig into each of those five.
- [02:25]
C
Absolutely. You know, just to. Just to reinforce what you said, Rebecca, a focus on quality is more important now than ever during these difficult times. There's so many competing demands for boards to focus on. It's a great time to think, how are we focusing on quality? And how can we even do a better job? So the five things that I've outlined for that charge really focus on quality is to really own the charter. And what do I mean by that? Boards have charters. If you have a quality Committee, it likely has a charter. And what we need these individuals to do is realize that they can move from generally understanding quality, thinking about quality as an abstract fiduciary. Going from that stance to being more active really put that quality committee to work. The second one is really the board needs to understand what the organization has as an operating system to ensure that quality assurance and performance improvement is happening. So many of you are probably familiar with the fact that the Centers for Medicare and Medicaid Services refer to this as qapi. Quality Assurance and Performance Improvement for board members listening, you've probably heard that acronym, you've probably seen org charts, but you really know how it works. And it's often a committee that goes parallel to an operational org chart. And it's more than just looking at the org chart and seeing various things in boxes. Now is the time to really understand its function. Is it functioning well, and is it getting the results it should? The third thing I would say is that you really need to know your quality metrics and then ask what's missing. Quality measures over the last 20 years have escalated at a very, very rapid pace. And many board members are accustomed to looking at financial reports and looking to the bottom right and seeing whether things are positive or negative in parentheses or not. Quality measurement, unfortunately, is not as easy to summarize. So orgs make choices about what they put on the reports that they show the board. And you have to understand what those measures are and probe. But you also need to ask, what aren't you measuring? What are you worried about? So it's really being much more involved, I would say, in understanding and helping to support choice of measures and improvement of measures. So the fourth one is this. Make risk decisions explicit and transparent. What do I mean by that? Organizations have lots of things that they might want to implement, they might want to resource. Even if they had all the resources. You can't implement everything all at once. So whether it's because of bandwidth, resources, both organizations are constantly making decisions about go with this one, don't go with that one. I would encourage boards to think, particularly during this time when resources are constrained, to find out what wasn't put on the list, why it wasn't put on the list, and that what risks, patient safety, risk, quality risks are associated with delays or discarding things. That isn't often done. And we call that transparent risk assessment. It's really very important, and I think it's particularly important when clearly resources do not allow organizations to do everything they want. It's just simply not possible in today's world. The last one relates to accreditation. I would say boards really need to lean more into accreditation and they should expect continuous readiness. Accreditation organizations come into your organizations on a periodic basis. They give you some feedback and those organizations expect you to be monitoring that, managing that, improving that continuously. And I have seen boards be disappointed when they weren't really aware of that obligation. And a survey might be every three years. I work at the Joint Commission. Our standard surveys are every three years. But the point is that even though you may be only visited on site on a periodic basis, you are responsible for fixing things that were cited. And if they come back, it bounces back to the board. So you really have to understand your accountability for accreditation. You're not going to get quarterly measures unless you do something yourself. So we'll talk more about that.
- [07:00]
B
Thank you. Liz, I'm going to go back up to number one, which you said is called own the charter, really own it. The question I'd love you to dig into a little bit more. There is governance. There's always a balance between for governance roles to be ensuring organizational health and not getting into the day to day operations. Give an example of something that would be on the ensuring organizational health as it relates to patient safety and quality, but that can be active without getting stepping over that line into operations.
- [07:35]
C
It's a fine line obviously, and one that, you know, governance and management, that fine line needs to be walked carefully. I do think being a more active quality committee or having the board be more active in a quality capacity in these times can be done without getting into management. And it's really about in general surfacing where the issues are. So, you know, find the issues, have management share the issues, don't tell management how to solve the issues, but expect management to come back with progress. So it's more of a, you know, what's going wrong, how can I help? Expect that from your management teams and then have them be accountable for reports and tracking the improvements. So, you know, oftentimes what boards will get in our quality committee are report outs. Here's how we're doing on medairs, here's how we're doing on infections, here's how we're doing on falls. And I think then the more active board stance in times like these is well, you're doing well in these metrics, these are not doing well. What's your plan? What's your time frame? Do you have the resources you need? If the answers are we have a plan, we have a timeline, we have the Resources then say, well, when will you be back to show us the results? It's really being more active and supporting them. Some of that is actually asking why they're not where they want to be on a performance metric. The leaning in of the board is really about activating and encouraging improvement, trying to get take barriers away rather than solve the problems tactically or from a management perspective.
- [09:12]
B
And that leads me into, because I think all of these are interconnected as they are asking these questions. Do you see that as a way for them to better understand the quality operating system or the qapi? Is that really a way of being active? Is a way of, you know, rolling up your sleeves and understanding better how the quality process works at their organization?
- [09:36]
C
Well, it could be certainly depending upon what the report out comes back at and who gives it. I think that's a really interesting question is that could you ask a board member, committee member, could we say, you know, when you come back, I'd really love to know how you collaborate. It could be a quality leader, for example, or a chief nurse or a chief medical officer giving a report out at a board meeting. But it might have something to do with medication errors or it might have something to do with high level disinfection. And to really understand how the leaders of quality who are often in that space, cno, cmo, cqo, regulatory leaders, those are the people that often show up at these meetings, but the people doing the work are the ones who are in operations. And how does that all work? One thing to consider would be a board member could say, when you come back with the report, I'd love you to consider bringing those folks who are actually on the front lines and, and hearing from them as to what the barriers are.
- [10:33]
B
That's excellent. I'm going to ask you for the third measure or the third recommendation that you noted and that is to know the quality metrics, then ask what's missing. I think for all of us not knowing what we don't know, that is one of the biggest concerns because there's always something that we don't know. So what are some questions that they might ask beyond what's missing or are there any things that you've seen over the last many years in quality and patient safety where things get left off?
- [11:06]
C
Yeah, you know, it's an interesting history over the last 20 years. You know, if you think back, we used to just have Medicare mortality rates and now we have so many measures that span inpatient. There are a lot of ambulatory measures now and the whole concept of a dashboard is not to flood it with so many measures that it becomes an eye chart and you lose the forest through the trees. But find measures that are important to the organization's health to monitor the health and make some choices about that. People do it different ways, organizations do it different ways. But no organization would put every measure on a dashboard. What I might do is if I were, you know, designing a sort of an approach is I would have boards get some basic information about what we can measure in health care and who's asking organizations to measure it. Because you know, there's government, right, there's cms. Commercial payers are asking to be measuring a lot of things. There's groups like Leapfrog, there are groups like, well, joint commission. We ask for some measures. We try to align very closely with CMS for reduced burden. US News is out there, we have Newsweek, but there are lots of things out there. And my goodness, how are you going to decide what's important? I think educating boards about what's out there, then putting out for the board's even recommendations, these are the things we think are most important, but also committing to monitor what's not being shown so that you have a behind the scenes detailed list of measures that are being tracked because some of those measures are presented to the organization, some have to be collected by the organization, but somebody should be tracking the other measures that aren't on the dashboard.
- [13:01]
B
It just doesn't have to always be reported out to the board unless a certain threshold is reached where it has risen to a level of concern.
- [13:09]
C
And then the board should say, well listen, you know, if you watch those others, you know, and if one is. One is a trigger, I want to hear about it. So that's one way to do it. There are just so many measures right now and there's a lot of conversation in the industry about do we have enough measures, are we doing the right thing? And I imagine that this will evolve. There is not one good solid bottom line measure, unfortunately, that would be very, very nice. Many people have asked me, you know, inpatient mortality adjusted for risk and all these things. It just doesn't cut it as an overall measure like in a financial report. So boards need that education and I think it's education that's worth taking time to provide. There are things that we worry about in health care that don't have measures despite all these measures. So another question I would suggest boards ask their staff. The management is okay, so we got the measures. We see where you're doing well, we see where you're not. You're going to watch these other measures and escalate problems. We've got that covered. What else keeps you up at night? Because not everything that's important from a patient safety risk perspective actually has a measure. And those risks need to be transmitted and talked about, not on a dashboard, but they need to be talked about. So I just didn't want to leave that out. That's super important, too.
- [14:25]
B
That is also related to your fourth recommendation around making risk decisions explicit and transparent. You're making decisions and not reporting those out may have risks that need to be understood. And that's where I circle back to your point about continuing to educate the board members about this whole process. I'll tell a quick story about my own two children. When I would pick them up from school, I would always, before they wanted to game or start talking about something, they had to say, what was one good thing that happened today and what was one bad thing that happened today? It has brought them into adulthood. And somebody else told me this. This was not an original idea, but it's brought them to adulthood being able to share with us the bad things that happen in their life. And that's not easy. And I think enforcing and strengthening the importance of being transparent with the decisions that are difficult, that are complex, that have to be made to let the board know what the risks are because they may have a perspective that is different.
- [15:35]
C
Yeah, that's a great story. And I think it relates also to the tracking of the metrics. I've seen organizations, they get some scores on something, the scores aren't good. They think, I'm going to fix this before I share it. Not the way to go. I think, you know, you need to be. You need to be monitoring metrics and you need to be on top of them. But oftentimes, if things are not going in the way you want, it can't be fixed by one person. It needs a team. And that, you know, what you had your kids do, which is, you know, what didn't go well, that gave them the muscle memory and the comfort and the reflexes to be able to say, hey, I need help. So, you know, never worry alone is something that I've heard said by lots of people. And I would just say, don't, you know, encourage your management, staff, board members to not sit on things. We're here to help.
- [16:24]
B
As we come to the fifth one, which specifically you said the committee should lean into accreditation and expect continuous readiness. Can you help the listeners know what is Continuous readiness. What do you mean when you say that?
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C
So continuous readiness is a term in this case that is referring to the next patient getting high quality, safe, compassionate, appropriate care, continuously being ready for that. But it also can be referring to being ready for the next time somebody comes to your organization to make sure that you're providing for the next patient, for every patient, safe, high quality, continuous, compassionate care. With respect to accreditation and the Joint Commission, I'll use that as the example. That's my organization. Our traditional surveys are every three years. We go into hospitals every three years. And as I mentioned in my opening comments, there are options for more continuous touch points, but the survey itself is sporadic. And what I would encourage and what I did in my old organization is set up a surveillance program so that you're monitoring all the things that CMS and your accrediting organization, in our case it was the Joint Commission, you're monitoring to make sure those things happen every day for every patient. So continuous readiness for all patients, continuous readiness for the next survey. That's extremely important and I'll just share that. You all remember Covid and when Covid happened at its peak, some things had to get back burnered while we just struggled to make sure that we could get a vent for every single patient and needed one. We all did that. We all remember that. As things quieted down, the very first thing I said we needed to put back in our armamentarium of tactics to provide high quality, safe care. The very first thing I said we needed to do is put back that surveillance of continuous readiness. It's a monitoring system and basically teams go and they use tools. Joint Commission has a great tool, a tracer tool. And they're going through the hospital and they're looking for things. They're looking for evidence of infection control, medication management, clean environment, safe environment. Are your emergency equipment, are your code carts ready? Are timeouts being done? And those things are being done in a continuous way. Surveillance and you get the data. I think boards should expect that their organizations aren't just waiting for the next survey, but they are ready for the next patient.
- [18:56]
B
That helps tremendously. Your recommendations are own the charter. Really own it. Be active, not passive. Understand the quality operating system and your organization's approach to qapi. Know the quality metrics and then ask what's missing. Make risk decisions explicit and transparent. And the board and the quality committee should lean into accreditation and expect continuous readiness as you just described. Liz. Dr. Moore, thank you so much for sharing your time, your expertise, providing guidance. Healthcare is complex, but the mission is health care and that involves being able to deliver high quality care for each and every patient we serve. And the words you've shared here with the listeners today will inspire others to take a more active engagement if they're serving on a board. Thank you so much.
- [19:53]
C
My pleasure. Thank you.
- [19:55]
A
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