QUALITY AND PATIENT SAFETY

Board Responsibilities ....................................................................2

Board Self-Assessment
Importance of a Quality and Safety Program .............................4
Quality and Safety Improvement .................................................5
100K Lives Campaign
Washington State Licensing Standards
Medicare Conditions of Participation
Joint Commission on Accreditation of Healthcare
Organizations
Quality Indicators .........................................................................12
Performance Improvement Processes........................................13
Hospital Compare.........................................................................16
Performance Improvement Activities........................................16
Hospital-Wide Activities
Medical Staff Activities
Patient-Focused Functions Department Review
Compliance with External Accreditation
and Regulatory Agencies
Seven Leadership Leverage Points.20
Summary ........................................................................................21
References ......................................................................................22

The two most important issues for trustees to attend to

are quality of care and finance. Measurements and
benchmarks are needed to tell how the organization is
doing. It is our responsibility to establish a mission and
assure that the organization has the resources to get
there.
Ned Turner, Trustee, Swedish Health Services
The Governing Board of a hospital has the moral, legal and fiduciary
responsibility to monitor, evaluate, and continuously improve the quality and
safety of care provided. The Board must carry out its oversight role effectively.
The Governing Board of a hospital has the ultimate responsibility for quality and patient
safety. This ultimate accountability can not be delegated away.
The Boards oversight is done by setting goals, time lines, and monitoring the
quality and patient safety work done in the hospital. The Governing Board
accomplishes this by supporting and monitoring the CEO as they lead this effort
in conjunction with the Medical Staff. Medical Staff has special accountabilities
together with the Board as outlined in the JCHAO Accreditation Standards. This
accountability is to work together reflecting clearly recognized roles,
responsibilities, and accountabilities, to enhance the quality and safety of care,
treatment, and services provided to patients. The work of improving quality
although lead by the Governing Board, CEO, and Medical Staff is frequently
accomplished through multidisciplinary teams.

BOARD RESPONSIBILITIES
With the ultimate responsibility for the quality and safety, some of the Boards
key responsibilities include:
Q
Overseeing a coordinated, systematic, hospital-wide approach to improving
patient care and health outcomes;
Q
Understanding the Boards and trustees roles in the performance
improvement program;
Q
Setting goals, timeline, and approval of the written performance
improvement or quality assessment plan;
Q
Regularly reviewing and monitoring progress towards achieving this plan;
Q
Provide a safe environment in which the CEO can implement the strategies
needed for safety and quality care;
Q
Create alignment between rewards, compensation, and quality and safety
plan;

3
Q

Familiarity with WA State Licensing Standards and Medicare Conditions of

Participation; and
Familiarity with Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) accreditation standards if accredited.

A meaningful quality and safety program:

Q
Q
Q

Q
Q

Has specific, measurable goals and timelines;

Is planned, systematic and ongoing;
Incorporates national measures such as the 100K Lives Campaign and
Hospital Compare;
Is comprehensive (applies to all of the functions of the hospital clinical,
support, managerial, and governance);
Uses objective measures of quality with predetermined indicators or
performance expectations;
Uses comparison data displaying average and top national performance;
Ensures that improvements are implemented and sustained through ongoing
monitoring;
Incorporates, multidisciplinary and cross departmental teams to improve
quality; and
Results in improvement of processes and outcomes.

BOARD SELF ASSESSMENT

Governing boards should assess the effectiveness of their oversight on quality
and safety on an annual basis. The following questions can be used to evaluate
their work in quality and patient safety:
Q

How has our hospital defined quality? What are our specific, measurable
goals and timelines?
Do our hospitals vision, mission statement, and strategic plan incorporate a
commitment to quality?
Has the leadership team developed a measurement and reporting system that
provides monthly feedback to the Governing Board?
Besides using patient demographics, how does our institution determine who
its customers are and what aspects of quality are important?
Does our hospital use the following mechanisms to determine the aspects of
quality that are important to patients and other customers?
Q
Community surveys or other feedback
Q
Patient satisfaction instrument
Q
Review of patient and staff complaints
Q
Review of clinical services outcomes
Q
Interviews, surveys or focus groups with staff and physicians
Q
Reports from business coalitions or other purchasers of services

4
Analysis of legal, regulatory and accreditation requirements
Q
Media reports
Is accountability for achieving the quality and safety goals embedded into the
Boards executive performance feedback system?
Does the Board agenda give a prominent place to the oversight of quality and
safety? Is it first on the agenda? Is it adequately discussed?
Does our hospitals medical staff participate in quality and patient safety
improvement activities?
Does the entire leadership team take an active role in quality and patient
safety?
Quality measurement improvement:
Q
What has the hospital done to reduce preventable deaths? Are rapid
response teams in place and functioning well?
Q
How has the hospital reduced hospital acquired infections?
Q
Is the hospital above average in the Hospital Compare results for heart
attack, pneumonia, heart failure, surgical site infection, and patient
perception?
Q
What is the hospitals progress in implementing all of the national patient
safety goals?
Q
How has the hospital reduced medication errors?
How are our patients involved in helping with quality and patient safety?
Are minutes kept of each review activity? Are summary reports provided to
hospital administration and, as appropriate, to the Board?
Does the Board review the effectiveness of performance improvement on an
annual basis including their role?
Q

Q
Q

IMPORTANCE OF A QUALITY AND SAFETY PROGRAM

Patients expect safe, quality care as they receive services from a hospital. They
expect that we will not no harm and will help them.
In 1999, the IOM report entitled, To Err is Human: Building a Safer Health System,
estimated that as many as 98,000 patients die each year as a result of medical
errors in hospitals, many of which are preventable. The report garnered
attention as the lawmakers and the public found these numbers to be
astonishing.
The IOM released several follow-up reports including, Crossing the Quality
Chasm: A New Health System for the 21st Century. This report identifies current
practices that impede quality care and explores how systems approaches can be
used to implement change; but also notes that there are many lives that continue
to be lost unnecessarily. Some of the IOM findings in these reports include:

5
Only 55 percent of patients received recommended care. (McGlynn et al., 2003)
Medication-related errors for hospitalized patients cost roughly $2 billion
annually. (Institute of Medicine, 2000; Bates et al., 1997)
The lag between the discovery of more effective forms of treatment and their
incorporation into routine patient care averages 17 years. (Balas, 2001; Institute
of Medicine, 2003b)
18,000 Americans die each year from heart attacks because they did not receive
preventive medications, although they were eligible for them. (Chassin, 1997;
Institute of Medicine, 2003a)
Medical errors kill more people per year than breast cancer, AIDS, or motor
vehicle accidents. (Institute of Medicine, 2000; Centers for Disease Control and
Prevention; National Center for Health Statistics: Preliminary Data for 1998,
1999)
More than 50 percent of patients with diabetes, hypertension, tobacco addiction,
hyperlipidemia, congestive heart failure, asthma, depression and chronic atrial
fibrillation are currently managed inadequately. (Institute of Medicine, 2003c;
Clark et al., 2000; Joint National Committee on Prevention, 1997; Legorreta et
al., 2000; McBride et al., 1998; Ni et al., 1998; Perez-Stable and Fuentes-Afflick,
1998; Samsa et al., 2000; Young et al., 2001)
In a major report released on July 20, 2006, the Institute for Medicine (IOM)
stated that at least 1.5 million Americans are sickened, injured or killed each year
by avoidable errors in prescribing, dispensing, and taking medications. On
average, mistakes in dispensing drugs are so prevalent in hospitals that a patient
will be subjected to a medication error each inpatient day.
These findings have sparked a demand from legislatures, media, and public for
hospitals to improve care while at the same time demonstrating significant
progress. Continued study has been requested by Congress as part of the
Medicare Modernization Act in 2003. Congress, state legislatures, state hospital
associations, and hospitals are working together to improve these findings with,
in some cases, very significant results.

6
QUALITY AND PATIENT SAFETY IMPROVEMENT
100K LIVES CAMPAIGN
Many organizations have supported hospitals to improve efforts. One of the
most successful of these is the 100K Lives Campaign. This Campaign over an
eighteen month period has saved 122,300 additional lives in hospitals nationally
and 1,500 lives in the state of Washington as of June 14th 2006.
The Campaign is a nationwide initiative of the Institute for Healthcare
Improvement (IHI), and was launched in December 2004 by Dr. Donald Berwick,
President and CEO of IHI. The goal of the Campaign was to save 100,000 lives
by June 2006, by introducing six evidence-based quality improvement changes in
about 2,000 U.S. hospitals. The Campaign has been endorsed by a wide variety
of national health care organizations, including Centers for Medicare and
Medicaid Services, American Medical Association, JCAHO, and many others.
At the encouragement of the Washington State Hospital Association Board,
Washington State was the first large state to have 100 percent of all community
hospitals committed to join the campaign as of June 1, 2005. Over 3,000 hospitals
nationwide have enrolled in the 100K Lives Campaign.
The six evidence-based quality improvement interventions are as follows:
1) Prevent deaths in patients whose condition is deteriorating by
implementing Rapid Response Teams. These teams are quick response
swat teams which come to the patients bedside to assist prior to the
patients heart or respiration stopping.
2) Prevent deaths among patients hospitalized for Acute Myocardial
Infarction (heart attack) by delivering a set of interventions commonly
called a bundle.
3) Prevent Adverse Drug Events (ADEs) or medication errors by
implementing medication reconciliation at admission, transfer, and
discharge.
4) Prevent central venous catheter-related bloodstream infection by
consistently adhering to infection control practices in the central line
bundle.
5) Prevent surgical site infection (SSI) by consistently administering
antibiotics appropriately and implementing a set of interventions known
as the SSI bundle.
6) Prevent ventilator-associated pneumonia and other complications in
patients on ventilators by consistently adhering to infection control
practices in the ventilator bundle.

7
Simple interventions such as raising the head of the bed up to 45 degrees in
patients with ventilators have been shown as significant in preventing adverse
events to patients. Berwick challenges all Washington hospitals to ensure that
there are:
All Changes All Places
Examples of what these interventions have meant to Washington hospitals are
found at the end of this section.
WASHINGTON STATE LICENSING STANDARDS
The Washington State Licensing Standards also address performance
improvement. The purpose is to ensure continuous improvement of patient
health outcomes through performance improvement activities of staff, medical
staff and outside contractors. These standards reflect minimal standards every
hospital should meet.
Improving organizational performance standards include requirements for:
Q

A hospital-wide approach to process design and performance measurement,

assessment, and improvement of patient care services to include:
A written performance improvement plan that is periodically evaluated
and approved by the governing authority;
Performance improvement activities which are collaborative and
interdisciplinary and include at least one member of the governing
authority; and
Review of serious or undesirable patient outcomes (adverse events) in a
timely manner.
Systematic collection and assessment of the data on important processes or
outcomes related to patient care and organizational functions; followed by
appropriate action to improve and/or continue measurement in response to
data assessment. The minimum data set includes:
a. Processes or outcomes related to:
Q
Operative, other invasive, and noninvasive procedures that place
patients at risk
Q
Infection rates
Q
Mortality
Q
Medication use
Q
Hospital incurred injuries, such as falls
Q
Adverse events, such as an infant abduction or patient suicide

8
Discrepancies or a pattern of such between preoperative and
postoperative diagnosis
Q
Significant adverse drug reactions (as defined by the hospital)
Q
Confirmed transfusion reactions
Q
Adverse events or patterns of adverse events during anesthesia use
Q
Other hospital specific measurements
b. The needs, expectations, and satisfaction of patients
c. Quality control and risk management activities
Q

The Washington Administrative Code (WAC) has specific standards for hospital
governance.
WAC 246-320-125

Governance.
The purpose of the governance section is to provide organizational guidance and oversight and to ensure resources
and staff to support safe and adequate patient care.
The governing authority will:
(1) Adopt and periodically review bylaws which address legal accountabilities and responsibilities. Bylaws will
provide for medical staff communication and conflict resolution with the governing authority;
(2) Establish and review governing authority policies, promote performance improvement, and provide for
organizational management and planning;
(3) Establish a process for selecting and periodically evaluating a chief executive officer;
(4) Establish and appoint a medical staff; and
(5) Approve bylaws, rules, and regulations as adopted by the medical staff before they can become effective.

Additional information on these codes can be found at

http://apps.leg.wa.gov/WAC/default.aspx?cite=246-320.
MEDICARE CONDITIONS OF PARTICIPATION
Most hospitals must meet the conditions to be Medicare certified in order to
receive payment from the Centers for Medicare and Medicaid Services (CMS).
Medicare-certified hospitals must meet the Medicare Conditions of Participation.
These conditions require that the Governing Board ensure that there is an
effective hospital-wide quality assurance program to evaluate the provision of
patient care. No specific quality management strategy or approach is mandated.
These requirements state that The hospital must develop, implement, and
maintain an effective, ongoing, hospital-wide, data-driven quality assessment
and performance improvement program. The hospitals governing body must
ensure that the program reflects the complexity of the hospitals organization
and services; involves all hospital departments and services (including those

9
services furnished under contract or arrangement); and focuses on indicators
related to improved health outcomes and the prevention and reduction of
medical errors. The hospital must maintain and demonstrate evidence of its
quality assurance and performance improvement (QAPI) program for review by
CMS.
(a) Standard: Program scope
(1) The program must include, but not be limited to, an ongoing program that
shows measurable improvement in indicators for which there is evidence that it
will improve health outcomes and identify and reduce medical errors.
(2) The hospital must measure, analyze, and track quality indicators, including
adverse patient events, and other aspects of performance that assess processes of
care, hospital service and operations.
(b) Standard: Program data
(1) The program must incorporate quality indicator data including patient care
data, and other relevant data, for example, information submitted to, or received
from, the hospitals Quality Improvement Organization.
(2) The hospital must use the data collected to
(i) Monitor the effectiveness and safety of services and quality of care; and
(ii) Identify opportunities for improvement and changes that will lead to
improvement.
(3) The frequency and detail of data collection must be specified by the hospitals
governing body.
(c) Standard: Program activities
(1) The hospital must set priorities for its performance improvement activities
that:
(i) Focus on high-risk, high-volume, or problem-prone areas;
(ii) Consider the incidence, prevalence, and severity of problems in those
areas; and
(iii) Affect health outcomes, patient safety, and quality of care.
(2) Performance improvement activities must track medical errors and adverse
patient events, analyze their causes, and implement preventive actions and
mechanisms that include feedback and learning throughout the hospital.
(3) The hospital must take actions aimed at performance improvement and, after
implementing those actions, the hospital must measure its success, and track
performance to ensure that improvements are sustained.
(d) Standard: Performance improvement projects As part of its quality assessment
and performance improvement program, the hospital must conduct performance
improvement projects.

10
(1) The number and scope of distinct improvement projects conducted annually
must be proportional to the scope and complexity of the hospitals services and
operations.
(2) A hospital may, as one of its projects, develop and implement an information
technology system explicitly designed to improve patient safety and quality of
care. This project, in its initial stage of development, does not need to
demonstrate measurable improvement in indicators related to health outcomes.
(3) The hospital must document what quality improvement projects are being
conducted, the reasons for conducting these projects, and the measurable
progress achieved on these projects.
(4) A hospital is not required to participate in a QIO cooperative project, but its
own projects are required to be of comparable effort.
(e) Standard: Executive responsibilities
The hospitals governing body (or organized group or individual who assumes
full legal authority and responsibility for operations of the hospital), medical
staff, and administrative officials are responsible and accountable for ensuring
the following:
(1) That an ongoing program for quality improvement and patient safety,
including the reduction of medical errors, is defined, implemented, and
maintained.
(2) That the hospital-wide quality assessment and performance improvement
efforts address priorities for improved quality of care and patient safety; and that
all improvement actions are evaluated.
(3) That clear expectations for safety are established.
(4) That adequate resources are allocated for measuring, assessing, improving,
and sustaining the hospitals performance and reducing risk to patients.
(5) That the determination of the number of distinct improvement projects is
conducted annually.
[68 FR 3454, Jan. 24, 2003]
When these standards are not met, the hospital can lose its Medicare certification
and reimbursement for services to Medicare patients. Additional information on
these regulations can be found at
http://www.cms.hhs.gov/CFCsAndCoPs/06_Hospitals.asp#TopOfPage.
THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE
ORGANIZATIONS
As noted in the previous regulatory section, the Joint Commission on
Accreditation of Healthcare Organizations has established standards for each
component of the health care organization. Historically, the standards were very
prescriptive. Today, the standards are broadly stated; emphasis is placed on
achieving the outcomes, more generally allowing the hospital to define the

11
process that results in continuous performance improvement. However, each of
the 20,000 organizations that are accredited by JCAHO is evaluated against
professionally based standards. The standards address the organizations actual
performance of both hospital/medical staff and the health care organizations
capabilities. The standards set forth by the Joint Commission are categorized
according to the functional areas of the organization. The functional areas are as
follows:
Q
Patient-focused functions
Q
Organization-focused functions
Q
Structures with functions
The Joint Commission requires each accredited hospital to provide evidence of
planning for performance improvement. Evidence may take the form of a
written performance improvement plan or other planning documents.
Regardless of the format of the planning document(s), the purposes of planning
are to describe the hospital leaders approach to improving performance, ensure
that the efforts are systematic and involve all applicable departments and
disciplines.
The Improving Organization Performance standards emphasize process design
and monitoring, analyzing, improving and sustaining performance.
Acknowledging the fact that most organizations identify more improvement
opportunities than they can address, criteria are set to establish priorities.
Under the JCAHOs new leadership standards:
The Governing Board, senior management and medical staff must
actively support and become involved in the hospitals quality efforts.
While trustees do not necessarily have to know each area in detail, they
should make sure that the CEO has pertinent review activities taking
place on a scheduled basis and that significant results are reported and
that needed follow-up is occurring.
Trustees should note trends and patterns in performance of services and
patient outcomes and compare the hospitals performance with
standards or data from other hospitals.
The Joint Commissions new accreditation process, Shared Visions-New
Pathways, became effective January 2004. The new process focused the
accreditation process on systems that are critical to the safety and quality of care,
treatment and services. The process encouraged hospitals to incorporate the
standards as a guide for routine operations. Each year, the Joint Commission
approves a set of national patient safety goals with related specific requirements
for improving the safety of patient care in health care organizations. All Joint
Commission-accredited health care organizations are surveyed for

12
implementation of the goals and requirements-or acceptable alternatives-as
appropriate to the organization.
In 2006, the Joint Commission completed the transition from a focus on survey
preparation to a focus on continuous operational improvement by moving to
unannounced surveys. Only a hospitals initial survey is scheduled in advance;
subsequent surveys are conducted on an unannounced basis approximately
every three years.
The Joint Commission publishes hospital performance reports to show
accountability for quality of performance and patient care outcomes. Hard copies
of these reports may be requested from JCAHO by the public, the media or
health care organizations, or they may be accessed on the JCAHO web site at
http://www.jcaho.org.

QUALITY INDICATORS
A quality indicator is a measure of an important aspect of the care or services.
The words indicator and measures are often used interchangeably in hospitals.
The focus for most indicators is on process or reporting if a needed service or
part of care was completed. An outcome indicator reports what the final result
was. An example of a process measure is a patient had a heart attack and was
given an aspirin. An example of an outcome measure is that the patient made it
home alive. There can also be efficiency or structural.
In general, indicators should represent those procedures, conditions or services
that are nationally recognized or are important to your hospital. Measures
developed by your hospital are typically:
Q
Q
Q
Q
Q

Frequently occurring
Easy to monitor through the collection of readily accessible data
High-risk, high-volume, high cost or problem-prone
Amenable to intervention
Highly variable in the way they are managed

TYPES OF QUALITY INDICATORS

EFFENCY/STRUCTURAL

Assesses whether the

organization has the
capability and resources
to provide high-quality
patient care
Q
appropriate staffing

PROCESS

Process indicators
measure whether the
right actions were taken
to achieve optimal care
(outcomes) doing the
right things

OUTCOME

Outcome indicators
answer the question,
Did the patient get
better?
Q
deaths within 24
hours of admission

13

Q
Q

levels
equipment standards
safety codes being
met
Wait time in the
emergency
department

antibiotic give prior to

surgery to prevent
infection
heart attack patient
receiving medications
on admission within
established
timeframes
staff washes hands to
prevent infection

surgical site infection

rate

Indicators also range in scope. Examples include:

Q
Hospital-wide, for example, re-admissions within 30 days of discharge
Q
Departmental, for example, vaginal births following previous cesarean
delivery
Q
Individual occurrence, particularly for adverse and unusual events, such as
an anesthesia-related death (an event unexpected in the normal course of a
patients illness). An adverse event indicates the need for further
investigation each time it occurs because of the severity of the occurrence. The
purpose of the investigation is to analyze the root cause of the event and
prevent future occurrences.
Indicator data should be aggregated over time to show trends and patterns.
Trustees should not receive reports on all indicators monitored throughout the
hospital. They should receive the most significant, ones that represent most the
level of quality and safety of care in the hospital. These are sometimes referred
to as the big dot indicators. Reviewing these indicators prompt the setting of
goals and time lines. Sample reports are available on the Washington State
Hospital Association web site at http://www.wsha.org/page.cfm?ID=0124.

PERFORMANCE IMPROVEMENT PROCESSES

An evaluation should begin when an event occurs, performance falls below the
established goals, or when expected patterns or trends are noted.
ADVERSE EVENTS
Any time an adverse event as defined by the Washington State Department of
Health or sentinel event as defined by JCAHO occurs, hospitals are expected to
complete a root cause analysis. These are unexpected events that are that involve
death or serious physical or psychological injury. The root cause analysis helps
to identify improvements to reduce risk, and monitor the effectiveness of those
improvements. The root cause analysis is expected to drill down to underlying
organization systems and processes that can be altered to reduce the likelihood

14
of failure in the future and to protect patients from harm when a failure does
occur. In addition, when unexplained or unacceptable variations in the care
provided by professionals are identified, peer review may be necessary.
At the current time, there are twenty-seven events that must be reported to the
Washington State Department of Health should they occur. These events are
available to the public.
When improving or prevent adverse events, focus should be on improving
systems. A common myth is that most quality problems can be blamed on
individuals. In reality, it is estimated that at least 85 percent of these are related
to system problems bottlenecks in work flow, information breakdowns,
poorly designed or inefficient work processes and inadequate resources.
Various approaches have been developed to improve performance and patient
outcomes. Here we highlight JCAHOs 10-step model for quality assessment and
improvement. These are the basic steps to developing a quality assessment and
improvement plan that will result in improved organizational performance. A
hospital may use a customized approach or may select one developed by JCAHO
or other experts in quality improvement.
It is not the responsibility of the board to complete the following steps but to
listen during quality reports to ensure that they were completed. The steps are:
Q
Assign responsibility
Q
Delineate the scope of care and service
Q
Identify important aspects of care and service
Q
Establish thresholds for evaluation
Q
Collect and organize data
Q
Initiate evaluation
Q
Take actions to improve care and service
Q
Assess effectiveness of the actions and ensure that improvement is
maintained
Q
Communicate results to relevant individuals and groups
Assign Responsibility
Hospitals trustees are responsible to oversee performance improvement while the
chief executive officer (CEO) and medical staff are charged with setting priorities
(consistent with the boards goals and vision), establishing responsibilities, and
designing approaches for assessing and improving patient care
Delineate the Scope of Care and Service
The key functions (patient-focused, organizational and structural), procedures,
treatments and activities to be monitored and evaluated are identified.

15

Identify Important Aspects of Care and Service

Hospitals should focus their efforts on those activities that will make a difference
(improve care and service) and on key functions, procedures and treatments.
Priorities should be established on hospital-wide basis.
Establish Thresholds for Evaluation
For each indicator, an expected, achievable level of performance or a threshold
should be set. A more in-depth review should occur if for example, the
threshold for the c-section rate is exceeded.
Hospital patterns or trends in performance should be monitored and compared
with other hospitals or national standards.
Trustees should monitor hospital performance relative to its goals verifying the
source and the appropriateness of selected indicators.
Collect and Organize Data
For each indicator, there should be evidence of ongoing data collection. Data
should be aggregated to identify trends in care, services or outcome. Trustees
should ensure that physicians, management staff and other staff receive training
in methods of quality improvement.
Initiate Evaluation
An evaluation should begin when an unexpected pattern or trend is noted or
when performance falls below the established goal. Problems identified are
referred for an intensive review, particularly when the cause and scope of the
problem or trend is unknown.
When unexplained or unacceptable variations in care are identified, peer review
(i.e., more detailed examination of records by qualified peer professionals)
may be necessary. In addition, other causes and effects, such as how the care is
delivered, may also help explain variations in care. All peer and process review
findings should be documented and summarized to help determine their
effectiveness in identifying potential quality problems or situations.
Take Actions to Improve Care and Service
This step can pose the greatest difficulty for hospitals. When there is a
discrepancy between actual practice and the hospitals performance expectations,
there must be evidence that an improvement plan has been implemented.
Assess the Effectiveness of the Actions and Ensure that Improvement is
Maintained

16
Critical to the improvement of care or services is determining if the action taken
actually improved the care or service and if that change is maintained. If not,
staff should determine whether the:
Q
Q
Q
Q

Nature and scope of the problem or trend were correctly identified

Corrective actions were appropriate to the identified issue
Corrective actions were reasonable and achievable
Authority and responsibility for implementing corrective actions were clearly
specified and understood
Corrective actions or improvement plans were implemented

Communicate Results to Relevant Individuals and Groups

Data should be summarized concisely and reviewed in a timely manner by
quality improvement teams, committees or councils, medical staff committees,
senior management and the governing board. A schedule for the compilation
and distribution of data should be identified. Special attention should be paid to
identifying mechanisms for monitoring resolution of identified problems or
situations and ongoing improvement of care and patient outcomes.

HOSPITAL COMPARE
Hospital data is published on many web-sites including Hospital Compare. This
web-site published quality and patient safety data that is collected by CMS and
JCAHO. The reports focus on recommended guidelines for patients with
pneumonia, heart attack, heart failure, surgical site infection, and patient
perception (starting in 2007).
Access to this web site can be found at http://www.hospitalcompare.hhs.gov/.
You can also view your results against Washington State hospitals using a report
from the Washington State Hospital Association. You can get a copy of this
report from Carol Wagner, Executive Director Patient Safety, by calling (206)5771831 or emailing CarolW@wsha.org.

PERFORMANCE IMPROVEMENT ACTIVITIES

Trustees should discuss the activities to be included in every performance
improvement effort. Trustees do not need to know the specific activities
undertaken but need to ensure that all functions occur regularly, that significant
findings are documented and reported to the appropriate parties, and that
needed follow-up action is taken. Trends or patterns of performance over time
should be noted and compared with national or local standards with data from
similar hospitals.

17
HOSPITAL-WIDE ACTIVITIES
Q
Quality performance indicators
Annually or more frequently, the Board should receive a summary of selected
indicators that reflect important dimensions of the quality of patient care and
services at the hospital. Indicators serve the purpose of raising important
questions and promoting meaningful discussion among Board members,
medical staff and hospital management. A profile of hospital performance
over time is provided both in relation to the hospital itself and to other
comparable hospitals. Indicators promote the examination and improvement
of care across hospital departments, as well.
Q

Infection control
The Board should review hospital-acquired infection rates as a part of the set
of quality indicators. Common measures used are hand hygiene compliance
(research has shown to reduce hospital acquired infection by 25%), ventilator
pneumonia, central line infections, surgical site infection, multi-drug resistant
organism, and any outbreaks.
Safety and security
The activities of hospital-wide safety and security committees should be
summarized and reported on a routine basis, including physical plant
requirements and conditions. Board members may also request evidence that
policies and procedures are in place to ensure privacy, confidentiality and
appropriate resolution of ethical issues.
Utilization management and volume statistics
On a regular basis, trustees should receive an overview of the volume and
utilization of hospital services, not only to assess financial performance but
also to have a framework for identifying trends and issues in quality. Data
could include inpatient and outpatient volume, ancillary service use, average
lengths of stay (e.g., by top DRGs), payer mix and PRO/insurance denials or
quality problems.
Patient, employee and physician satisfaction
Positive staff morale is an important factor in the quality of patient care
services. A procedure for monitoring patient, employee and medical staff
perceptions, attitudes and opinions on an ongoing basis may be included as
part of an institutions overall quality improvement process.

18
MEDICAL STAFF ACTIVITIES
Q
Departmental review
The quality of patient care offered by each department or the medical staff as
a whole must be evaluated. The results of this evaluation, and any
conclusions, recommendations, action and follow-up, should be documented.
Q

Surgical case review

High-risk, high-volume, high cost and problem-prone procedures should be
reviewed according to a predetermined sample. A review of all surgical and
other invasive procedures is not required. Reviews should also focus on the
processes related to surgical and invasive procedures, including patient
preparation and procedure selection. The rationale and methodology for
selecting, reviewing and reporting surgical case review should be
documented. Reporting should also occur on antibiotic usage prior to
surgery. Reporting should take place no less than quarterly.
Blood usage review
The appropriateness of the ordering, distribution, handling, administration
and monitoring of blood and blood products should be reviewed quarterly
and can be drawn from a sample of cases, as with surgical review. Each
blood use category (e.g., packed red blood cells, platelets, fresh frozen
plasma, transfusions) should be sampled, and reporting should occur no less
than quarterly.
Medication use review
Review of a sample of medication use is permitted as long as frequently used,
high-risk, high cost or problem-prone medications are included in the review.
The review should focus on whether medications were appropriately
prescribed, prepared, dispensed, administered and monitored. Reporting
should occur no less than quarterly.
Medical record review
A representative sample of medical records must be reviewed for clinical
pertinence, adequate and appropriate documentation and timely completion.
Reporting should occur quarterly.
Credentialing and privileging (also see medical staff chapter)
The appointment and retention of a qualified medical staff are among the
most important quality responsibilities of the Board. The composition of its
medical staff largely determines a hospitals quality of care. The Board must
avoid a rubber stamp approach to granting medical staff appointments,
reappointment and clinical privileges. Information to be reported to the
Board on an ongoing basis should include, but is not limited to, the following:

19

Q
Q

Q
Q
Q
Q
Q
Q

Evidence of valid license(s)

Evidence of educational background and training and continuing
education
Evidence that no disciplinary actions have been taken by current or
previous hospitals or Boards
Evidence of current and adequate malpractice insurance
Valid board certification
Evidence of professional competence and ethics
Statement of health
Malpractice claims history
Current privileges

Clinical risk management

A summary of incidents, claims, lawsuits, amounts paid to date and reports
to the National Practitioner Data Bank should be provided on an ongoing
basis to help trustees determine if patterns of loss or liability exist and
whether they are being adequately addressed. Other clinical risk
management issues, such as unexpected deaths or operations on incorrect
limbs, and number of malpractice claims should also be addressed.

PATIENT-FOCUSED FUNCTIONS DEPARTMENT REVIEW

The review of nursing and ancillary departments in the carrying out of patientfocused functions should occur in at least the following areas:
Q
All nursing units
Q
Alcoholism and other drug dependence services
Q
Diagnostic radiology services
Q
Dietetic services
Q
Emergency services
Q
Hospital-sponsored ambulatory care services
Q
Nuclear medicine services
Q
Nursing services
Q
Pathology and medical laboratory services
Q
Pharmaceutical services
Q
Physical rehabilitation services
Q
Radiation oncology services
Q
Respiratory care services
Q
Social work services
Q
Special care units
Q
Surgical and anesthesia services
Currently, in Medicare-certified hospitals, two important aspects of care should
be monitored for each service area. Two indicators per aspect of care should be

20
reported at a minimum. The Board should receive reports from the various
departments on a rotating basis throughout the year.
COMPLIANCE WITH EXTERNAL ACCREDITATION AND REGULATORY
AGENCIES
The Board should be updated on the hospitals performance relative to
accreditation, regulatory and licensure requirements. This report should occur
following receipt of survey results. It should summarize the findings from
surveys conducted by agencies such as the following:
Q
Q
Q
Q

Joint Commission on Accreditation of Healthcare Organizations

Washington State Department of Health
Occupational Safety and Health Administration
Medicare

The report should also summarize major recommendations and areas of

noncompliance, as well as a schedule for corrective action and the results of
those actions, developed by the hospital and medical staff.
To review, there are important questions for the board to consider in evaluating
their effectiveness in assuring quality health care within their organization.
The questions below should be added to the board self assessment noted at the
beginning of the section.
Q

Are summary reports provided to hospital administration and, as

appropriate, to the Board? Does this information provide a comprehensive
overview of the hospitals performance, highlighting prioritized indicators,
reflecting patterns and trends, needed actions and offering comparison to
local and national standards?
Are the reports the Board receives manageable in number, clear and concise,
routine and ongoing and explained in the appropriate level of detail?
Is additional education or training needed by Board members to understand
more completely the information being presented to them?

SEVEN LEADERSHIP LEVERAGE POINTS

The Institute for Healthcare Improvement has developed seven leadership
leverage points for organization-level improvement in health care. This
document can be downloaded at the following website:
http://www.ihi.org/NR/rdonlyres/C84E1503-C05E-4D1B-B8D5C74CEFE68F7F/0/LeadershipWhitePaper2005.pdf

21
SUMMARY
The Board is responsible for its hospitals quality of care, including that of the
medical staff. This responsibility can not be delegated. An effective hospital
performance improvement program is necessary for a hospital to receive
accreditation, licensure and certification from voluntary and governmental
entities, to obtain third-party reimbursement, and as part of our accountability to
our community.

22
REFERENCES
Carey, Raymond G. and Robert C. Lloyd, Measuring Quality Improvement in Healthcare, New York,
NY: Quality Resources, 1995.
Grose, Louise, Owner, Shiloh & Associates, Thrall, TX, January, 1998.
Health and Safety Code, Vol. 1, Chapter 108, Vernons Texas Codes Annotated, St. Paul, MN: West
Publishing Co., 1992 and 1998 Supplement.
JCAHO Tip-of-the-Month: First, QA Then, QA&I Now, PI. Is It All the Same? Medical Staff
Briefing, December, 1993, pp.6-7.
Joint Commission on Accreditation of Healthcare Organizations, Sentinel Events:
Evaluating Cause and Planning Improvement, Oakbrook Terrace, IL, 1998.
Joint Commission on Accreditation of Healthcare Organizations, 1998 Hospital
Accreditation Standards, Oakbrook Terrace, IL, 1998.
Joint Commission on Accreditation of Healthcare Organizations, Hospital Accreditation Standards
and Survey Process: Small or Rural Hospitals, Oakbrook Terrace, IL, 1996.
Joint Commission on Accreditation of Healthcare Organizations, The Complete Guide to the 1998
Hospital Survey Process, Oakbrook Terrace, IL, 1998.
Medicare Conditions of Participation, 42CFR Subpart C 482.21.
Orlikoff, James and Mary K. Totter, The Boards Role in Quality Care, Chicago, IL:
American Hospital Publishing, Inc., 1991.
Orlikoff, James, Trustee Orientation, Fort Worth, TX, 1997.
ORourke, Lisa and Barry Bader, The Quality Letter for Healthcare Leaders, Vol. 5, No. 2, March,
1993.
Pointer, Dennis D., Jamie E. Orlikoff, Board Work: Governing Health Care Organizations, JosseyBass, San Francisco, 1999
PISL Consulting Group, Developing Critical Pathways in Behavioral Health, Englewood CO: 1994.
Sullivan, Raymond and et.al., Does Your Board of Trustees Really Know Your Hospital? JHQ,
Vol. 15, No. 4, July/August, 1993.
Totten, Mary et.al., The Guide to Governance for Hospital Trustees. Chicago, IL: American Hospital
Association, 1990.
Washington Administrative Code 1999
Wayenknecht, Teresa, A Resource Manual for the Healthcare Quality Professional of the 90s, Austin,
TX: The Texas Society for Healthcare Quality, 1993.