Enhancing board oversight on quality of hospital care: an agency theory perspective.

BACKGROUND: Community hospitals in the United States are almost all governed by a governing board that is legally accountable for the quality of care provided. Increasing pressures for better quality and safety are prompting boards to strengthen their oversight function on quality. PURPOSE: In this study, we aimed to provide an update to prior research by exploring the role and practices of governing boards in quality oversight through the lens of agency theory and comparing hospital quality performance in relation to the adoption of those practices. METHODOLOGY: Data on board practices from a survey conducted by The Governance Institute in 2007 were merged with data on hospital quality drawn from two federal sources that measured processes of care and mortality. The study sample includes 445 public and private not-for-profit hospitals. We used factor analysis to explore the underlying dimensions of board practices. We further compared hospital quality performance by the adoption of each individual board practice. FINDINGS: Consistent with the agency theory, the 13 board practices included in the survey appear to center around enhancing accountability of the board, management, and the medical staff. Reviewing the hospital's quality performance on a regular basis was the most common practice. A number of board practices, not examined in prior research, showed significant association with better performance on process of care and/or risk-adjusted mortality: requiring major new clinical programs to meet quality-related criteria, setting some quality goals at the "theoretical ideal" level, requiring both the board and the medical staff to be as involved as management in setting the agenda for discussion on quality, and requiring the hospital to report its quality/safety performance to the general public. PRACTICE IMPLICATIONS: Hospital governing boards should examine their current practices and consider adopting those that would enhance the accountability of the board itself, management, and the medical staff.

Board oversight of quality: any differences in process of care and mortality?

In response to legal and accreditation mandates as well as pressures from purchasers and consumers for quality improvement, hospital governing boards seek to improve their oversight of quality of care by adopting various practices. Based on a previous survey of hospital presidents/chief executive officers, this study examines differences in hospital quality performance associated with the adoption of particular practices in board oversight of quality. Quality was measured by performance in process of care and risk-adjusted mortality, using the Hospital Compare data from the Centers for Medicare & Medicaid Services and the Healthcare Cost and Utilization Project inpatient databases of the Agency for Healthcare Research and Quality. Board practices found to be associated with better performance in both process of care and mortality include (1) having a board quality committee; (2) establishing strategic goals for quality improvement; (3) being involved in setting the quality agenda for the hospital; (4) including a specific item on quality in board meetings; (5) using a dashboard with national benchmarks that includes indicators for clinical quality, patient safety, and patient satisfaction; and (6) linking senior executives' performance evaluation to quality and patient safety indicators. Involvement of physician leadership in the board quality committee further enhanced the hospital's quality performance. Taken together, these findings seem to support the will-execution-constancy of purpose framework on improving the effectiveness of hospital boards in overseeing quality. Future study should examine how specific board practices influence the culture and operations of the hospital that lead to better quality of care.

Review: how do hospital organizational structure and processes affect quality of care?: a critical review of research methods.

Interest in organizational contributions to the delivery of care has risen significantly in recent years. A challenge facing researchers, practitioners, and policy makers is identifying ways to improve care by improving the organizations that provide this care, given the complexity of health care organizations and the role organizations play in influencing systems of care. This article reviews the literature on the relationship between the structural characteristics and organizational processes of hospitals and quality of care. The review uses Donabedian's structure-process-outcome and level of analysis frameworks to organize the literature. The results of this review indicate that a preponderance of studies are conducted at the hospital level of analysis and are predominantly focused on the organizational structure-quality outcome relationship. The article concludes with recommendations of how health services researchers can expand their research to enhance one's understanding of the relationship between organizational characteristics and quality of care.

Board engagement in quality: findings of a survey of hospital and system leaders.

Hospital governing boards assume an important role in improving delivery of quality care in the hospital. More knowledge about the prevalence and impact of particular board activities can help them perform this role more effectively. This study draws from a survey of hospital and system leaders (presidents/chief executive officers [CEOs]) that was conducted in the first six months of 2006 with a total of 562 respondents. The survey contained 27 questions on various aspects of board engagement in quality. More than 80 percent of the responding CEOs indicated that their governing boards establish strategic goals for quality improvement, use quality dashboards to track performance, and follow up on corrective actions related to adverse events. The adoption of other practices was reported less frequently. Only 61 percent of the respondents indicated that their governing boards have a quality committee. The existence of a board quality committee was associated with higher likelihoods of adopting various oversight practices and lower mortality rates for six common medical conditions measured by the Agency for Healthcare Research and Quality's Inpatient Quality Indicators and the State Inpatient Databases. Hospital governing boards appear to be actively engaged in quality oversight, particularly through use of internal data and national benchmarks to monitor the quality performance of their organizations. Having a board quality committee can significantly enhance the board's oversight function. Other potentially useful activities-such as board involvement in setting the agenda for the discussion on quality, inclusion of the quality measures in the CEO's performance evaluation, and improvement of quality literacy of board members-are currently performed infrequently.

Redesigning health systems for quality: Lessons from emerging practices.

BACKGROUND: It has been five years since the Institute of Medicine (IOM) report, Crossing the Quality Chasm, proposed systemwide changes to transform our health care system. What progress has been made? What lessons have been learned? How should we move forward? METHODS: Semistructured telephone interviews were conducted with 16 health care providers and researchers at organizations involved in system redesign. The findings were supplemented with a focused literature review and discussions from a national expert meeting. RESULTS: Many promising and innovative examples of redesign were identified. However, even delivery systems that are redesigning care in pursuit of the six IOM aims face daunting challenges, reflecting the need to align system changes across multiple levels and to integrate redesign efforts with ongoing system features. Four success factors were reported by providers as crucial in overcoming redesign barriers: (1) directly involving top and middle-level leaders, (2) strategically aligning and integrating improvement efforts with organizational priorities, (3) systematically establishing infrastructure, process, and performance appraisal systems for continuous improvement, and (4) actively developing champions, teams, and staff. A framework that integrates these success factors to facilitate a systems approach to redesigning health care organizations and delivery systems for improved performance is provided. CONCLUSIONS: Successful system redesign requires coordinating and managing a complex set of changes across multiple levels rather than isolated projects.

New Evidence on What Works in Effective Public Reporting.

OBJECTIVE: To describe the current state of the public reporting field and provide guidance to public report producers based on the evidence. PRINCIPAL FINDINGS: Public reports should address the questions and priorities that consumers actually have; present information credibly and in a way that is understood by the intended audience; reach the intended audience; and enable consumers to act on the information. CONCLUSIONS: Public reports have advanced greatly in recent years, but there remains much room for improvement. Report producers should continually evaluate their reports and apply the latest evidence to maximize their usefulness and impact.

Crossing the language chasm.

The quality of communication between patients and clinicians can have a major impact on health outcomes, and limited English proficiency can interfere with effective communication. More than ten million U.S. residents speak English poorly or not at all, constituting a language chasm in the health care system. This paper reviews the evidence on the link between linguistic competence and health care quality and the impact of particular language-assistance strategies. Drawing on the experiences of fourteen health plans that have been at the forefront of linguistic competence efforts, we identify lessons for plans, purchasers, policymakers, and researchers on ways to improve the availability and quality of interpreter services.

Volume thresholds and hospital characteristics in the United States.

Procedure volume has been used as a proxy for quality and recommended as a basis for hospital referrals. We studied the volume, mortality, and associated hospital and staffing characteristics of ten complex procedures in U.S. hospitals using the 2000 HCUP Nationwide Inpatient Sample. Although the majority of patients had their procedures performed in high-volume hospitals, for seven procedures, more than three-fourths of hospitals would be considered low-volume. Unadjusted mortality rates were significantly higher at low-volume hospitals for five procedures. Low-volume hospitals also tended to have lower mean numbers of residents and RNs. However, for two procedures, low-volume hospitals had RN and resident staffing equal to or higher than those of high-volume hospitals, and the unadjusted mortality rates were no different.

Reducing disparities through culturally competent health care: an analysis of the business case.

Finding ways to deliver high-quality health care to an increasingly diverse population is a major challenge for the American health care system. The persistence of racial and ethnic disparities in health care access, quality, and outcomes has prompted considerable interest in increasing the cultural competence of health care, both as an end in its own right and as a potential means to reduce disparities. This article reviews the potential role of cultural competence in reducing racial and ethnic health disparities, the strength of health care organizations' current incentives to adopt cultural competence techniques, and the limitations inherent in these incentives that will need to be overcome if cultural competence techniques are to become widely adopted.

Increasing the relevance of research to health care managers: hospital CEO imperatives for improving quality and lowering costs.

BACKGROUND: Evidence-based management assumes that available research evidence is consistent with the problems and decision-making conditions faced by those who will utilize this evidence in practice. PURPOSE: This article attempts to identify how hospital leaders view key determinants of hospital quality and costs, as well as the fundamental ways these leaders "think" about solutions to quality and cost issues in their organizations. The objective of this analysis is to better inform the research agenda and approaches pursued by health services research so that this research reflects the "realities" of practice in hospitals. METHODS: We conducted a series of semistructured interviews with a convenience sample of eight hospital and three health system leaders. Questions focused on current and future challenges facing hospitals as they relate to hospital quality, costs, and efficiency, and potential solutions to those challenges. FINDINGS: Nine major organizational and managerial factors emerged from the interviews, including staffing, evidence-based practice, information technology, data availability and benchmarking, and leadership. Hospital leaders tend to think about these factors systemically and consider process-related factors as the important drivers of cost and quality. PRACTICE IMPLICATIONS: The results suggest a need to expand the methods utilized by health services researchers to make their research more relevant to health care managers. Expanding research methods to reflect the systemic way that managers view the challenges and solutions facing their organizations may enhance the application of research findings into management practice. Finally, better communication is needed between the research and practice communities. Researchers must learn to think more like managers if their research is to be relevant, and managers must learn to more effectively communicate their issues with the research community and frame their problems in researchable terms.

Organizational research with impact: working backwards.

BACKGROUND OR RATIONALE: To improve health care, we need to improve the organization of care, along with the payment systems that shape organizational priorities and behavior. The opportunity and challenge for research are to find a way to work with health care leadership so that future management decisions can make use of strong evidence. AIMS AND METHODS: This article uses findings from research on nursing to illustrate the potential for organizational research and management research to improve health care. It then distills recommendations from six focused stakeholder meetings to identify five ways in which we might improve organizational, management, and policy research to maximize its use. RESULTS AND DISCUSSION: Hospital, health plan, and other system leaders have five recommendations for research: (1) Design studies that answer user questions, with a focus on the "why" and "what if" rather than just the "what." (2) Present findings in leaders' time and space, defining evidence as they do and identifying generalizability of findings. (3) Change the incentive system for researchers so that they are rewarded for the activities that maximize impact on decision making. (4) Build user-researcher collaborations and dialogue. (5) Change the way we disseminate evidence, with dissemination through "early adopters," trade association meetings, consultants, etc. IMPLICATIONS FOR RESEARCH, PRACTICE, AND POLICY: System and policy leaders control important levers for improving health care, since they shape organizational structure, processes and culture, payment strategies, program design, and regulation. Just as evidence-based medicine can improve clinical practice, evidence-based management and policymaking can change how these powerful levers are used. But for evidence to inform the decisions of system and policy leaders, we will need to rethink and restructure the research enterprise itself, bringing the potential users of evidence into the production process.

Translation research: where do we go from here?

AIM: Where do we go from here? This article draws on other articles in this supplement, the dialogue from the meeting that generated it, and other sources to identify steps to advance translation research, and in particular to achieve broader translation and use of evidence. IMPLICATIONS: To move from the growing accumulation of individual successes in translation to broader scale translation and implementation of evidence, those who use research and those who do research will need to do four things: (1) increase synergy and synchronization across studies, through cross-disease studies, adoption of a common and precise language to describe interventions, addressing issues of customization of interventions, and finding commonality in quality and outcomes measures; (2) take account of organizational factors that can shape the impact of interventions, and also move to the implementation of organizational evidence; (3) address environmental factors such as reimbursement and market competition; and (4) take findings to a larger scale through national demonstrations, efforts of national agents of change, challenge or partnership grants, or use of provider-based networks.