Eliminating Harm, Improving Patient Care: A Trustee Guide Self Assessment. The Board s Role in Quality Improvement & Eliminating Patient Harm

Transcription

1 Elimiatig Harm, Improvig Patiet Care: A Trustee Guide 2018 Self Assessmet This tool offers a basic framework that leaders ca use to evaluate how successfully their board is egaged i the quality improvemet work of the orgaizatio. It is ot iteded to be a bechmark agaist the performace of others. Rather, it should be used to geerate discussio ad help promote the effective implemetatio of policies ad practices that support improvemet work. The Board s Role i Quality Improvemet & Elimiatig Patiet Harm Does your orgaizatio have a board-level quality committee ad/or cliical quality committee? To Be Doe Does the quality committee report to the board? Does your orgaizatio have a strategic quality improvemet pla with clear goals for improvemet that use data ad bechmarks? Does your hospital/health system have a method for moitorig quality ad patiet safety evets?» Ad are quality measures ad patiet safety evets reported to the board? Does your board have writte, well-defied leadership ad oversight resposibilities for quality improvemet? Are improvig quality ad patiet safety embedded ito the strategic pla ad plaig process? Does your board sped a sigificat amout of meaigful time ad eergy discussig quality improvemet? How Boards Ca Be Effective i Improvig Quality & Elimiatig Patiet Harm What type of goverace educatio is offered to esure that board members thoroughly uderstad the importace of quality? To Be Doe Do you recruit board members with quality expertise i mid? Have you assessed your committee s effectiveess i the past two years? Have you idetified a quality improvemet priority? Does your orgaizatio actively look to lear from patiet safety evets ad implemet chages based o such evets? Jauary 2018 Page 1

2 Does your orgaizatio have specific, measureable targets for improvig quality ad elimiatig patiet harm? To Be Doe Are these target goals structured to hold leadership ad staff accoutable for quality performace? Does your board assess ad cotiuously improve quality ad safety literacy through educatio ad traiig? Does your board employ strategies that iclude hearig directly from patiets, helpig to put a huma face o data? Aligig Safety ad Quality with Fiacial Performace Do quality improvemet ad efficiecy measures play a role i your fiacial plaig? To Be Doe Does quality play a role equal to that of fiace withi board meetigs? Does your orgaizatio s quality improvemet strategies impact your fiacial performace? Has your board received educatio o value-based paymet, readmissios pealties ad hospital-acquired coditio pealties? Does your board allocate resources for data collectio ad to support ad implemet quality improvemet iitiatives? Does your board have a clear, uderstood approach to moitor quality that icludes a dashboard for moitorig overall performace? Boards Must Collect & Review Meaigful Data to Keep Pace i A Chagig Ladscape To Be Doe Does your orgaizatio curretly collect ad report quality measures?» Does the board review these measures? Has your orgaizatio begu movig from the first curve to the secod curve? Has your orgaizatio implemeted strategies that move the orgaizatio toward a value-based reimbursemet structure? Does your board routiely track quality performace ad patiet harm i order to improve quality ad patiet safety? Jauary 2018 Page 2

3 To Be Doe Is your board egaged i askig strategic questios of your orgaizatio to assess readiess i movig from the first curve to the secod curve?» Have the aswers bee used to help direct your actios? Does your board oversee ad esure that strategies are put ito place to help the trasitio from first to secod curve, while still improvig quality for patiets? The Importace of Measurig Harm Across the Board To Be Doe Does your board kow the total patiet harm rate withi your orgaizatio?» For the past year, past quarter? Ca you state your orgaizatio's key strategic priorities i terms of reducig patiet harm? Does your leadership ad cliical team track, collect ad share reliable quality ad patiet safety iformatio mothly? Does your board esure that the various quality metrics used are aggregated ito a overall composite rate to track patiet safety evets? Does your board play a active role i idetifyig major orgaizatio-wide strategies to elimiate patiet harm? Boards Must Have a Clear Orgaizatioal Approach & Process for Improvig Quality To Be Doe Does your orgaizatio have a otificatio process i place to both track ad react to patiet safety evets? Does your board take steps to lear about ad uderstad all patiet safety evets, uderstadig the evet ad the factors ivolved i why it may have happeed? How does your board reiforce accoutability while cotiuig to moitor outcomes of care? Does your orgaizatio have effective quality ad safety measures ad trackig processes i place to idetify whe patiet safety evets occur? Does your board ad hospital/health system leadership have a established process for respodig to ad learig from evets? Alog with your leadership, is your board trasparet about performace?» Is your board ope to hearig the bad, as well as the good, examples ad patiet stories? Jauary 2018 Page 3

4 Esurig Cliicia Egagemet is Crucial i Elimiatig Patiet Harm To Be Doe Does your board hear from cliical leaders frequetly? Does your board have at least oe physicia or quality champio servig o it? Do your cliicias commuicate ad iteract with your board with regard to quality improvemet policies?» Does your board esure that cliicias achieve set quality goals? Does your board have reliable, o-goig mechaisms to commuicate with ad egage with cliicias about quality? Is your board make-up such that it has cliical competecies that allow the board to track performace improvemet? Has your board idetified cliical champios withi the orgaizatio to help improve quality ad ehace cliicia support ad egagemet? The Importace of a Strog Quality Culture To Be Doe Has your orgaizatio adopted a culture of safety? Has the board take steps to promote a eviromet of excellece? Does your board egage maagemet i performace improvemet? Does your board tie fiacial icetives to meetig orgaizatioal goals? Does your board recogize successes ad share lessos leared amog all parts of the orgaizatio? Does your orgaizatio have a clearly defied culture that ceters o the patiet, emphasizig trasparecy, reward ad recogitio? Does your board oversee the process of assessig the orgaizatio s values, policies ad leadership actios agaist your desired culture? Does your board support a strog safety culture that ivolves traiig, educatio, resources, trust, respect ad a clear set of expected values ad behaviors? The Importace of Patiet, Family & Commuity Egagemet i Improvig Quality To Be Doe Does your orgaizatio have methods to egage patiets, families ad the commuity i settig quality goals? Jauary 2018 Page 4

5 To Be Doe Does your orgaizatio have a active patiet ad family advisory coucil that participates i your orgaizatio s improvemet efforts? Does your orgaizatio work to educate patiets ad families about their health ad their role i quality improvemet? Does your board ivite patiets ito board meetigs to share both positive ad egative stories? Do your leaders egage patiets ad families to lear about the care process ad idetify opportuities for quality ad safety improvemets? Does your board support ad ecourage egagemet strategies that help educate patiets ad egage them as active parters i their health? How Diversity i the Board Room Ca Improve Quality & Elimiate Disparities To Be Doe Does your board reflect the diversity of your hospital/health system i terms of staff, patiets ad the commuity you serve? Does your board measure ad uderstad potetial disparities amog your patiet populatios? Does your board esure that patiet diversity ad disparities i care are accouted for ad cosidered whe quality improvemet goals are set? Does your board reflect the patiet populatio ad commuity your orgaizatio serves? Does your board set ad moitor efforts to reduce disparities i care? Does your board eforce that strategies are clearly set ad followed through o by staff? Is patiet diversity ad disparities i care a key factor moitored whe collectig data ad settig overall quality improvemet goals? Jauary 2018 Page 5