Maulik S. Joshi, Dr.P.H. President and CEO Network for Regional Healthcare Improvement

1. Excellence in the Boardroom Leapfrog Conference on The Future of Hospital Governance Maulik S. Joshi, Dr.P.H. President and CEO Network for Regional Healthcare Improvement Email: mjoshi@nrhi.org Phone: 410-829-6252

2. The Full Monty

3. What is Excellence in the Boardroom? • How great is our hospital? • Are we achieving what we need to achieve? • How do we know? • Do we have the right strategies, policies and systems in place to achieve measurable health outcomes in our community?

4. What is Excellence in the Boardroom? Justice Potter Stewart style: "I shall not today attempt further to define the kinds of material I understand to be embraced within that shorthand description; and perhaps I could never succeed in intelligibly doing so. But I know it when I see it,…” --- Jacobellis v. Ohio, 378 U.S. 184 (1964) - United States Supreme Court

5. Governance Context • Enron, etc. • Sarbanes/Oxley • Specific to Healthcare: • Greater “Calls for Responsibility” for Oversight of Quality and Safety • Increased Research on Governance Best Practices • One of the planks for the IHI 5 Million Lives Campaign (“Getting the Board on Board”) • It’s the new new thing

6. What does the “evidence” tell us about what Boards can do to accelerate improvement? From Emerging Research and Case Studies of High Performing Organizations • Alexander JA, Lee SD. Does governance matter? Board configuration and performance in not-for-profit hospitals. The Milbank Quarterly. 2006;84(4):733. • Bisognano M, McCannon J, Botwinick L. A campaign for 100,000 lives: The time is now for boards to lead quality and safety efforts. Trustee. 2005;58(8):12-14,19,1. • Hospital Governing Boards and Quality of Care. A Call to Responsibility. National Quality Forum; 2004. • Joshi MS, Hines SC. Getting the board on board: Engaging hospital boards in quality and patient safety. Joint Commission Journal on Quality and Patient Safety. 2006;32(4):179-187. • Kroch E, Vaughn T, Koepke M, Roman S, Foster D, Sinha S, Levey S. Hospital boards and quality dashboards. Journal of Patient Safety. 2006;2(1):10-19. • Lockee C, Kroom K, Zablocki E, Bader B. Quality. The Governance Institute; 2006. Vaughn T, Koepke M, Kroch et. al. 2006

7. Premise: Transformation is Wanted

8. Board Engagement in Quality (BEQ) • Merriam-Webster Dictionary DefinitionEngagement: emotional involvement or commitment; being in gear • Major research aims: • Hospital CEO and BC perception of the engagement of the hospital board in quality • The relationship between the board’s engagement in quality and the organization’s overall performance • Potential best practices for board engagement in quality • References:* Joshi and Hines, “Getting the Board on Board”, Journal on Quality and Patient Safety, April 2006, Volume 32, Number 4 • * Mastal, Joshi and Schulke, “Nursing Leadership: Championing Quality and Patient Safety in the Boardroom”, Nursing Economics, November/December 2007, Volume 25, Number 6.

9. Quality Literacy • Quality literacy is low regarding landmark reports • Public reporting is strong driver of awareness – “pay attention to what the Internet is saying about your hospital” • Strong awareness of “buzz initiatives” (e.g., IHI 100 Lives Campaign, state-based patient safety centers) • Mixed definition of quality “experts” • Difference in perception of CEO’s quality expertise

10. Set Bold Aims Example: • Aim high • “Our aim is to achieve zero central line infections…” • Aim broad • “…for the entire institution, across all services…” • Take dead aim • “…by August 31, 2008.”

11. Frame an Agenda for Quality • “Building Better Boards”, Harvard Business Review, May 2004 • Engaged Boards reflect the social and work dynamics of a high performance team • Agendas • Maximize discussion time and informal interaction • Norms • Ready to ask questions • Spend appropriate time on important issues • Beliefs • Come prepared • Actively participate • Values • Maintaining the company’s stature in the industry

12. Agenda time for quality increasing • About 30% of the time is spent on quality • Placement: Moved to the front of the agenda • Flavor of the agenda has changed • From credentialing discussion to indicator focused

13. Align with Organizational Priorities

14. Align with Organizational Priorities

15. Hospital Mission Statements • We will, in the spirit of the Sisters of Charity, reveal God’s healing love by improving the health of the individuals and the communities we serve, especially those who are poor or vulnerable. • …to deliver innovative, quality health care to our patients and their families in an environment of compassion, respect, patient safety, education, and fiscal responsibility. • …committed to: Leadership and excellence in delivering quality healthcare services; Expanding the horizons of medical knowledge through biomedical research; Educating and training physicians and other healthcare professionals; Striving to improve the health status of our community. • …to provide the highest quality of care in a comprehensive, innovative and cost effective manner, emphasizing respect, dignity, compassion patient safety and customer service. • …functions as a catalytic force in upgrading the health of the community through an emphasis on wellness and education.

16. What is Excellence in the Boardroom? • How great is our hospital? • Are we achieving what we need to achieve? • How do we know? • Do we have the right strategies, policies and systems in place to achieve measurable health outcomes in our community?

17. Review System Level Performance • Track achievement of measured system-level aims with rigor and discipline • Owned by the governing board • Collectively, the measures answer the question: How good are we? • Transparent—everyone in the organization should know the Key Measures • Think “all or none” measures • Mortality • Readmission Rates • Patient Experience • % of Patients Receiving Care According to the Evidence • Employee Satisfaction, Loyalty or Engagement • Cost per Discharge • Days Cash on Hand • Patient Safety • Access

18. IHI Proposed System Level Measures

19. Creating Alignment Between Desired Results and Quality Projects Source: Pugh Ettinger McCarthy Associates, LLC

20. Aligned Operating Strategies and Quality Projects Drive Desired Results Source: Pugh Ettinger McCarthy Associates, LLC

21. Aligned Operating Strategies and Quality Projects Drive Desired Results Organization: _______________________ • Identify your top organizational aims/indicators • E.g., appointment missed opportunities, tobacco use, infection measures • Identify your top strategies to impact those aims • E.g., improve flow, reduce duplication, improve teamwork, improve communication • Identify the QI projects to support those strategies • E.g., implement teamwork training, SBAR, multi-disciplinary rounds

22. Aligned Operating Strategies and Quality Projects Drive Desired Results Organization: ________________________

23. Pace of Progress and Improvement Robustness • Satisfied with how well the hospital is progressing in improving quality? • CEO Average:7.2 (out of 10) • Board Average: 8.4 • “The Board members would say great job in quality – I say 6.” • Difficulty in describing “best improvement” • Many were educational, policy changes • Few were “breakthrough” with results

24. Patient Centeredness • Having the courage to listen to patient stories • Engaging and involving patients in improvement • Advisory Councils • Improvement Projects

25. Board Engagement Drivers Expertise Pace EmergingIssues Training Education Open Dialogue Awareness Hard-wire Incentives ReviewProcess Strategy Map Strategic/OperatingPlan Bold Aims Set RealPatientInvolvement ValidPatientInput

27. BEQ Checklist • Increase the Board’s Quality Literacy • Educate the board on salient quality issues beyond public reporting. • Initiate discussion with the board on what defines a quality expert and consider adding quality experts to the board. • Use retreats for having in-depth dialogue on quality and quality improvement projects. Think systems. • Have board members attend quality conferences.

28. BEQ Checklist • Frame an Agenda for Quality • Initiate discussion between the board chair and CEO on the status of quality improvement in the hospital. How is the hospital progressing? What are the barriers? What are the strengths? How can the board support improvement? • Ensure discussion of quality on the board agenda gets equal billing with other important agenda items.

29. BEQ Checklist Integrate and Align • Create a vision for quality for the hospital with long-term outcome measures and goals. • Review the hospital’s quality plan and ensure it is aligned with the overall hospital strategic plan. • Ensure the quality measures the board reviews are assessed annually and are well understood by board members. • Integrate the quality measures into the overall board performance metrics and board strategic milestones. • Develop and use a Quality Strategy Map linking and aligning projects with measures and aims. • Link incentive compensation of leadership to quality metrics.

30. BEQ Checklist Patient-Centeredness • Share patient stories at Board meetings to further increase focus on patient-centeredness. • Ensure that patients are involved in improvement, such as by having patients participate on improvement teams.

31. Board Engagement Checklist – The How • 1. Increase quality literacy. • Education, quality expertise • 2. Set bold aims. • High, broad • 3. Frame an agenda for quality. • Time, flavor, ask mode • 4. Review system level performance. • Discipline, all or none, monitored • 5. Align with organizational priorities. • Integrated with strategic planning, leadership accountability • 6. Transparency with the patient/family. • Stories and involvement