“The more I measure, the less I sleep,” notes Dr. David Rosser, Executive Medical Director of University Hospitals, Birmingham, UK. “Even if you would know what to measure, you lie awake thinking about what to do with this data. You can’t just throw it back at your doctors; you have to make it live for them and be actionable.” Hospitals need to clarify responsibility for outcomes, and reporting structures, so that the board can identify who is accountable and measure his or her performance. As Mary Jo Haddad of SickKids Hospital emphasizes: “Jobs and roles have to be crystal clear, and that’s often not the case.”
As a starting point, patient pathways through the organization should have identifiable owners and teams, in the same way that units such as wards, intensive care and emergency have clear lines of responsibility. When these owners – professionals and managers – are accountable for their performance, the organization has a basis for continuous quality and cost improvement.
"We don’t operate with a standard, top-down recipe book. Top clinicians are the crucial element, and they have to become owners, to ensure that the standard is a joint endeavor rather than a management initiative.” - Dr. Panigrahi, Head of Medical Operations, Fortis Healthcare, India
By making outcomes the most important objective, the board sets the tone and oversees the quality strategy and implementation, underpinned by the proper metrics, with the Chief Executive Officer (CEO) and other executives fully accountable. An internal audit function augments such an approach, to monitor and improve governance processes, risk management and quality control. In this way, clinical governance should mirror financial governance, as David Dalton of Salford Royal Foundation Trust, UK explains: “The system for quality governance is built into our Trust’s annual plan. Each of the risks are rated, and responsibility for monitoring and management is allocated on the basis of the level of risk involved, with the most critical sitting with the entire board, then the Chief Exec and so on. Quality and safety are a key part of all board meetings, and we’ve trained all board members. These topics constitute about a third of the agenda and time, and they are usually the first part of the meeting.”
A streamlined upward flow of the most important measures can keep everyone informed and avoid information overload, with appropriate levels of detail for each audience.
King’s College Hospital NHS Foundation Trust, UK, has a well-developed approach, says Tim Smart, CEO: “We now have a Quality and Governance Board committee, on which I sit, in addition to Finance, Workforce and so forth. That committee has several feeder committees – which I don’t attend – which cover all the subtopics, and are in turn fed by the ward and unit management.”
Successful healthcare organizations no longer develop measures from the top down and recognize that those at the front line know what is most important to track. ”In the old days, quality governance staff were on the sidelines and not respected nor attended to,” says David Rosser of University Hospitals Birmingham, UK, “We’ve changed that, making the quality of the work the central responsibility of our core lines. You have to make them accountable, and measure and monitor their work in a very timely way. That creates the drive.”
In the German Helios hospital chain, data is reported from each clinic’s medical director to the regional level, and then up to headquarters. “We go through reporting cycles like that every two months,” explains Ralf Kuhlen, Chief Medical Officer. “We found ourselves scoring ‘average’ on stroke outcomes, for example, and that was simply not good enough. So we picked that up, went into the best- and least-performing clinics, learned what worked and what didn’t, and improved our overall performance.
“Everybody has to participate, and we follow-up on problematic scores and enforce agreed quality measures, such as the usage of general surgery checklists. We have made it very clear, at all levels, who is responsible for such measures. Those are ‘must dos’; when you don’t, you’re not working with us.”