A new framework for active involvement
A new framework from Health Service Executive supports hospitals in aim to improve care quality and safety.
As hospitals try to drive rapid improvement, boards have an opportunity and a responsibility to make better quality of care the organisation’s top priority. This critical partnership between broadly-focused executive leadership teams and highly-engaged boards is something which the quality improvement division of Health Service Executive (HSE) have shone the spotlight on; thus they have formulated a new and awakening framework that boards can utilise as a resource for being active in improving the quality and safety of care that exists across the healthcare sector.
“A Board’s Role in Improving Quality and Safety: Guidance and Resources” provides many illustrative
real-world examples of process and outcomes of successful boards in action, considering a range of challenges facing boards, and providing a practical insight for boards to develop and better discharge their responsibilities towards consistent quality and safety in healthcare.
The “Oireachtas Committee on the Future of Healthcare: Sláintecare Report” (2017) recognises the key role of boards and advocates the establishment of healthcare boards. As such, this guidance will assist new and existing boards in using practices which support positive decision-making, governance and accountability; where service users’ needs come first in a culture of person centredness.
HSE’s review of the literature has identified many key findings, ranging from principles for effective boards to the importance of creating a culture of trust by working together. The guidance has been developed with reference to international leading practices which have included a review of relevant publications and material from the UK, USA, Australia, Canada and New Zealand.
A Shifting Role
opinions of many board members were taking into account when developing
the framework, with a Canadian board chair reflecting: “There has been a
real shift in emphasis [over the last decade or so] from processes to
outcomes. It is a board’s responsibility to ensure the right
“processes” are in place; however, the real value a board brings, or
that a highly functioning quality committee adds, is on understanding outcomes and variation in care and or improvement over
time. Patient stories are very helpful but are most helpful if tied to
an indicator or initiative that is in front of the board.”
Key to the proposed environment is a trusting partnership, which is something that any organisation can benefit from, to provide motivation and an impetus to actively progress. the board is key to this overall positive relationship, and its responsibility for ensuring and improving care cannot be delegated to the medical staff and executive leadership, but needs to be tackled face-on, with a shared agenda and understanding. this leadership can set system level expectations, improve accountability for high performance and elimination of harm, and if properly conducted, can dramatically and continually improve the quality and safety of care.
the guidance resource emphasises the appointment of board members with the right skills and values as highly important. a Canadian board chair commented: “While you can grow your own experts in the area of quality and patient safety, it helps if you are very clear identifying the types of skills and experience required when recruiting and appointing board members. I would strongly recommend recruiting at least a couple of people onto boards, where possible, who have manufacturing or transportation backgrounds with proven continuous improvement orientation. Also, adding people with strong customer service backgrounds, not just in delivery but in fundamentally understanding how to imbed a service ethos into staff.
With a superior selection of board members and the increased quality of data being shared with the board, the momentum via this new framework is positive. an Irish board chair highlighted: “The board now get a balanced view of information and a more comprehensive picture of finance, access and quality of clinical care delivered to patients. the information is presented via a board of directors’ quality dash- board. All of the information is represented on one page, grouped by quality domains and aligned to the National Standards for Safer Better Healthcare (HIQA, 2012) and the board quality and safety priorities. the dashboard and accompanying report are circulated prior to the board meeting and provide us with context to the information and enables us to be prepared for a focused discussion at the board meeting.
This resource is designed for use across all types of healthcare providers, including Hospital Groups as well as voluntary HSE funded Section 38 and Section 39 organisations. It may also be useful to providers without boards since the information can be utilised by executive management teams and clinical leaders.
Seven Leading PracticesEach of the seven leading practice sections of the framework describes the rationale and action for board consideration, including prompts for practical application. Here, we have laid out a summary of the key guidance areas:
1. Leadership for Improving Quality and Safety: This involves actively demonstrating a commitment to seeking assurance and driving improvement.
2. Practices for Improving Quality and Safety: Key here is making quality and safety of care a priority of the boards business.
3. Partnerships for Improving Quality and Safety: This concerns developing strong collaborative partnerships with staff and service users and the wider community.
4. Methods for Improving Quality and Safety: The crucial focus here is to support the provider in applying a quality improvement methodology.
5. Measurement for Improving Quality and Safety: This involves selecting board measures to monitor and demonstrate an improvement in the delivery of care.
6. Risk Management and Assurance: Here, it is important to ensure that all risks to service user quality and safety are addressed in a robust and structured way.
7. Planning for Improving Quality and Safety: The focus here is on championing and overseeing the development, implementation and monitoring of a plan for improving quality and safety.
This resource will assist board members to:
• Reflect on their performance and approach to improving quality and safety
• Understand leading quality improvement practices
• Make improving quality and safety a central tenet of a board’s agenda
• Develop partnerships with staff and service users for improving quality and safety
• Drive improvements in care in a measurable way
• Be aware of the importance of using proven quality improvement methodologies
• Seek assurance and approve a plan for improving quality and safety.
• Services must subscribe to a set of clear quality standards that are based on international best practice
The importance of quality and safety
In Ireland, quality in healthcare is defined by the four domains set out in the national standards for safer better healthcare (health information and Quality authority, 2012). these are person-centred effective and safe care and support, better health and wellbeing, leadership, governance and management, workforce and use of resources and information. the overall goal of the HSE quality and patient safety enablement programme is underpinned by four key objectives:
• Services must be safe and there must be a robust level of both quality improvement and quality assurance
• Services must be relevant to the needs of the population
• Patients must be appropriately empowered to interact with the service delivery system.
The first Irish national study of adverse events in hospitals (Rafter et al. 2016) highlights the importance of shifting the focus towards quality and safety of care. A total of 1,574 randomly selected adult inpatient records from a sample of eight hospitals stratified by region and size across the republic of Ireland in 2009 were retrospectively reviewed. the prevalence of adverse events in admissions was12.2 percent, with an incidence of 10.3 events per 100 admissions. Overall 70 percent of events were considered preventable. Irish adverse event prevalence is at the upper end of the range of other inter- national studies.
By putting a focus on quality and safety in all areas, including at the board level, healthcare organisations can make an institutional change, leading to nationwide international changes.
The guidance is hosted on the HSE website and it will be updated to take account of changes in national policies and guidelines, and international best practice. the resources and recommended reading for each section are available electronically on the website.
- Boards have a responsibility to make improvement of care quality the organisation’s top priority
- The HSE has devised a framework to help achieve this goal
- Views of an international team of board members were taking into account for the framework
- The framework comprises seven leading practices available on HSE website at hse.ie