Governing Board, C-Suite, and Clinical Management Perceptions of Quality and Safety Structures, Processes, and Priorities in U.S. Hospitals/PRACTITIONER APPLICATION

By Vaughn, Thomas; Koepke, Mark et al. | Journal of Healthcare Management, March/April 2014 | Go to article overview

Governing Board, C-Suite, and Clinical Management Perceptions of Quality and Safety Structures, Processes, and Priorities in U.S. Hospitals/PRACTITIONER APPLICATION


Vaughn, Thomas, Koepke, Mark, Levey, Samuel, Kroch, Eugene, Hatcher, Christopher, Tompkins, Christopher, Baloh, Jure, Franks, Dennis E., Journal of Healthcare Management


EXECUTIVE SUMMARY

To achieve quality improvement in hospitals requires greater attention to systems thinking than is typical at this time, including a shared understanding across different levels of the hospital of the current state of quality improvement efforts. A self-administered survey assessed the perceptions of board members, C-suite executives, and clinical managers regarding quality activities and structures. This instrument, the Hospital Leadership and Quality Assessment Tool (HLQAT), includes 13 domains in six conceptual areas that we believe are major organizational drivers of quality and safety: (1) commitment of senior leaders, (2) a vision of exemplary quality, (3) a supportive culture, (4) accountable leadership, (5) appropriate organizational structures, and (6) adaptive capability.

HLQAT survey results from a convenience sample of more than 300 hospitals were linked to performance on the Centers for Medicare & Medicaid Services (CMS) Core Measures. The results show significantly different perceptions between the groups. Higher HLQAT scores for each respondent group were associated with better hospital performance on the CMS Core Measures. There is no magic bullet-no one domain dominates.

Leaders in higher-performing hospitals appear to be more effective at conveying their vision of quality care and creating a culture that supports an expectation that staff and leadership will work across traditional boundaries to improve quality.

BACKGROUND

While progress in hospital quality and safety has been evident since the release of the Institute of Medicine's (IOM) reports To Err Is Human (1999) and Crossing the Quality Chasm (2001), its advance has "proven slow and arduous," and the extent and rate of advance is difficult to measure (Pronovost, Miller, Wächter, & Meyer, 2009).

Multiple roadblocks have hindered this progress. Studies have shown that quality and safety issues do not rank as a top priority for CEOs and boards of directors (ACHE, 2011; Jha & Epstein, 2010). Furthermore, insufficient resources have been allocated for quality/safety educational programs, especially for boards (Jha & Epstein, 2010), and for programs in quality improvement for physicians and executives (Gautam, 2005). Communication structures that facilitate confrontation and resolution of problems are often less than salutary (Bohmer, 2010).

The knowledge and communication issues stretch from board-medical staff relations to the front line, where medical mistakes usually occur. A number of scholars have argued that failure of systems thinking has been a major obstacle to upgrading quality and safety (Shortell & Singer, 2008). Systems thinking is effective only if the members of the system share a common basis for assessment of the current situation and goals for change. Appropriate governance and accountability and the need to speak a common language across all levels regarding quality and safety are urgently needed (Shortell & Singer, 2008). Yet, while several researchers examined differences between frontline workers' perceptions and those of senior managers and supervisors, comparisons that include the governing board are lacking (Singer, Falwell, Gaba, & Baker, 2008).

From Rhetoric to Action

Levey et al. (2007) interviewed board and C-suite-level leaders of 18 U.S. community hospitals and identified considerable gaps between rhetoric regarding quality improvement and actual performance. They concluded that greater commitment from boards and CEOs to a culture of quality is needed, including collaboration between governing boards, C-suites, and physicians in quality improvement activities. Levey et al. (2007) were not able to include objective performance measures in their study, nor did they interview mid-level managers.

To assess internal and external sources of performance improvement, a short, web-based survey of hospital leaders was subsequently conducted by that research group (Vaughn et al. …

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