- BIOETHICS FORUM ESSAY
Getting on Board with QI
The quality of Mercy Hospital is not strained, say hospital trustees. According to a recent survey published online in Health Affairs only 44 percent of hospital board chairs “chose clinical quality as one of the top two priorities” for assessing how well their CEO was doing, and trustees at low-performing hospitals were far less likely than their counterparts at high-performing hospitals to evaluate their CEOs based on the quality of care provided to patients.
It gets worse. Fifty-eight percent of trustees at these low-performing institutions believed their hospital’s performance to be “better or much better” than the typical American hospital. In fact, the data reported by these same hospitals to the Hospital Quality Alliance and used by the Centers for Medicare and Medicaid Services and the Joint Commission reveal poorer outcomes associated with common conditions, such as pneumonia.
Are these findings yet another manifestation of the Lake Wobegon Effect – the untested belief that one’s leader or group is above average – and its role in CEO evaluation and compensation? Does the association between board training in clinical quality, and the quality of care provided by an institution (investigators found that board training is “far more common” in high-performing hospitals) mean that well-educated boards influence quality of care? Or do high-performing CEOs recruit board members who care about quality and are receptive to education?
The Harvard School of Public Health researchers who directed this study cautioned that their findings did not prove correlation, much less causation, concerning the role of trustees in improving health care quality. However, one finding – that the trustees of low-performing hospitals spent more time dealing with financial issues than did trustees of high-performing hospitals – may shed some light on another recent study, which, like the survey of hospital trustees, was directed by Ashish K. Jha, of the Harvard School of Public Health.
In a survey of all members of the American Hospital Association, Jha and colleagues found that just 1.5 percent of hospitals had an electronic records system in use throughout the institution, under 10 percent of hospitals had even a limited electronic system, and under 20 percent of hospitals had attained the patient safety goal of computerized entry for medications to reduce errors resulting from handwritten or oral orders.
What’s the number-one reason that hospitals cited to explain why they had not yet adopted electronic systems? “Inadequate capital for purchase.” Of the top five reasons cited, four of the five had to do with inadequate resources: not enough upfront money; worries about maintenance costs; worries about return on investment; not enough staff with IT skills. The remaining reason: physician resistance to change. ]
However, the hospitals that had taken the plunge “were less likely to cite” these resource-related reasons as barriers to adoption. They, too, were dealing with physician resistance – and, we can assume, with resource constraints, this being the real world of health care delivery – but had begun to reap financial benefits from going electronic. As they say in the patient-safety world, these early adopters had “QI’ed” the challenge – converted it into a solvable problem with clear benefits to patients and the institution – rather than framing it solely as a financial risk.
Might hospital boards find that investing in quality creates a virtuous circle, one that allows them to spend less time on finances, thereby freeing up more time on the board agenda for learning about and improving quality?