I was walking towards the cafeteria one morning when I recognized one of our hospital board members. I recalled seeing him at one the meetings where I had presented hospital board reports addressing quality. We stopped to chat for a minute.
He had been on the board for several years, and had an intimate knowledge of the performance of the hospital. He knew many of the local medical staff. His wife had once worked for the hospital.
At one point in our brief conversation he said, “ You know, John, I really look forward to your quality reports. We all do. The board members like to know that things are going well. We also want to know when there are potential problems, and the steps taken to address them.”
I thanked him and promised that I would continue to keep the board informed, and he went on his way. Over the years, other board members mentioned similar sentiments. They were very interested in how the organization was addressing quality and safety.
Thirty years ago, hospital boards spent most of their time reviewing financial reports, statistics about patient volumes, new programs, and capital investments in equipment or the physical plant.
But over the past few decades, there has been an increasing emphasis in healthcare on measuring and improving quality and safety. Hospital and health system boards are well aware of this evolution. They are interested in assuring that their organization is meeting its mission to provide safe, high quality care to its patients.
Simultaneously, quality, safety, infection control, risk management and decision support departments have grown in size and sophistication. The number of reports describing outcome and process measures has also grown. Many of these are of great interest to your board of directors. And physician executives, like the chief quality officer and the chief medical officer, have stepped up to lead that process.
The 7 Hospital Board Reports
The following is a list of some of the reports I have personally provided to our board. These always generated discussion and good questions.
1. Review of Hospital Compare Data
These reports include an overall star rating, core measure performance, complications, readmissions and mortality. Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) is also posted on the Hospital Compare website.
There is probably too much information to present at one sitting. Note that some of the information is presented annually, while some is available quarterly. Since this information is available to the public, it is very important for the board to be aware of current rankings and trends.
2. Annual HealthGrades Summary
HealthGrades applies its own risk adjustment and analysis to publicly available data and generates an annual comparison of the hospitals and physicians each year. It analyzes the data to generate one- three- and five-star ratings (below average, average and above average, respectively) for several clinical conditions.
My board found it useful to review a grid that I developed to summarize the star rating for each item each year. The grid included a row for each measure. Each column included the star rating for that measure in a given year. I also included a total for each column of the number of five-star and one-star ratings.
3. Annual or Quarterly Quality Review
Using a quality improvement tool that extracts information from the coding and billing information, most hospitals can generate risk adjusted outcomes for its most common discharge diagnoses. We would generally review risk-adjusted length of stay, complication rates and mortality rates for our top 20 (by volume) diagnoses.
I would summarize these data by creating a bar graph that presented the observed over expected ratios, from highest (worse performance) to lowest (best performance) for the measures noted above. I might then compare year the results from the previous year to the current year.
4. Sentinel Event Summary
Every hospital and health system experiences sentinel events. Large systems probably count more than a dozen or so, if they are honest with themselves. In addition to the events that meet the CMS definition, there are also near misses that deserve a root cause analysis (RCA). In a hospital setting, these sentinel events may include the administration of the wrong medication, an unexpected death, wrong site surgery, patient suicide or a fire in the operating room.
During the root cause analysis of an error that threatened the life or limb of a patient, the RCA team will identify the proximate causes, the contributing factors and the root causes of the untoward event. For the board's purposes, it can be useful to summarize each year's RCAs. Place each event into a specific category and review the root causes that were identified and the plans for addressing each.
5. Patient Safety Update
I discussed the patient safety indicators when I discussed how to deliver patient safety. These events consist of uncommon occurrences, especially during or following surgery. Because their rates are so low, be prepared to answer questions about why they occurred and what steps are being taken to prevent them in the future.
These are best shown in tabular format, which includes historical information by year for each PSI and the national averages. The goal for most PSIs is for none to occur, unlike quality indicators in which is generally some baseline rate due to unavoidable patient factors.
6. Annual Review of Behavioral Issues
Due to the widespread recognition that so-called “disruptive behaviors” by physicians threaten good patient care, many hospitals have developed a plan for reducing such incidents. This includes the adoption of a universal code of conduct (or code of behavior) and creating escalating consequences for violating the code. There is usually a committee to oversee the process and investigate the validity of alleged violations of the code by physicians.
Our organization created a physician-led multidisciplinary team that reported to the Medical Executive Committee (MEC). It investigated allegations of inappropriate behaviors. The team was able to interview and provide education to those with minor violations of the code of conduct. When serious violations were confirmed, they were sent to the MEC for action.
Once each year, I presented a summary to the board that listed the nature of the confirmed violations and the actions taken. I also presented a graph depicting the number of annual investigations, which showed the declining rate of occurrences after the program was put in place.
7. Infection Control Updates
You should be producing a monthly report that describes the incidence of serious hospital acquired infections. This is usually reported in the form of a dashboard. This can be rolled up to an annual summary and then trended over several years for review by the board.
Health system and hospital board members want to see more than just financial reports. They genuinely want to know that the care being provided is good, and that it is improving. These seven reports will provide your board with a good sense of the quality and patient safety being delivered at your institution.
I would really like to hear your additions. What reports have you presented, or seen presented? Which of them seemed to produce the greatest discussion and questions? Please share in the COMMENTS.
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