A Board s Roe in Improving Quaity and Safety Guidance and Resources Buiding a Better Heath Service Seirbhís Sáinte Níos Fearr á Forbairt
This resource forms part of a series of resources deveoped to support services in using the Framework for Improving Quaity in our Heath Service : Quaity and Patient Safety: Cinica Governance Information Leafet (February 2012) Quaity and Patient Safety: Cinica Governance Deveopment: An assurance check for Heath Service Providers (February 2012) Quaity and Safety Prompts for Mutidiscipinary Teams (October 2012) Safety Pause: Information Sheet (May 2013) Quaity and Safety Cinica Governance Deveopment Initiative: Sharing our Learning (March 2014) Nationa Cinica Programmes Mode of Care Deveopment: Checkist Governance for Quaity and Safety (October 2014) Report of the Quaity and Safety Cinica Governance Deveopment Initiative Primary Care: Sharing our Learning (Apri 2015) Board on Board with Quaity of Cinica Care: Quaity Improvement Project: Case Study Report (June 2015) Framework for Improving Quaity in our Heath Service: Part 1 Introducing the Framework (Apri 2016) Quaity and Safety Wak-rounds: A Co-designed Approach Tookit and Case Study (June 2016) Quaity and Safety Committees: Guidance and Resources (October 2016) Copies of the documents above and the resources and recommended reading for each of the board eading practices are avaiabe eectronicay on the website ocated at www.quaityimprovement.ie. Quaity Improvement Division Heath Service Executive Quaity Improvement Division, 11 September 2017 ISBN 978-1-78602-056-7 Quaity Improvement Division Heath Service Executive Dr Steevens Hospita Dubin D08 W2A8 Ireand w +353 1 6352344 nationaqid@hse.ie @hseqi www.hse.ie Acknowedgements: thank you to service users and the many staff and board members in Ireand who participated in the consutation process for the deveopment of this guidance. Particuar thanks to Tom Lynch, Aveen Murray and Ruthe Anne Conyngham for sharing their persona refections and to Dannie Currie, Joan Dawe, and Gisee Guenard, Canadian Patient Safety Institute; Eeanor Rivoire, Canadian Independent Heathcare Advisor; Heather Shearer, Heathcare Improvement Scotand; and Robin Gaud, University of Otago, New Zeaand; for their vauabe feedback and suggestions. The HSE ibrary team provided essentia support undertaking iterature searches and sourcing key references. Project group: Siobhan Reynods, Karen Reynods, Tina Brennan, Anne Marie Heffernan and Maureen Fynn, Quaity Improvement Division, HSE. The terms patient, resident, service user, and consumer are used interchangeaby in heathcare. Some terms may not be appropriate or preferred when referring to individuas who access heathcare services depending on the care setting or sector. For carity and consistency, the term service user is used throughout this guidance. Cite this document as: Heath Service Executive (2017), A Board s Roe in Improving Quaity and Safety: Guidance and Resources, Dubin: Quaity Improvement Division, Heath Service Executive. This work is icensed under a Creative Commons Attribution-NonCommercia-ShareAike 4.0 Internationa License.
Foreword I am very peased to introduce A Board s Roe in Improving Quaity and Safety Guidance and Resources. This pubication provides many iustrative rea-word exampes of process and outcomes of successfu Boards in Action. Considering the chaenges facing boards, this guidance document offers a practica insight to how boards can deveop to discharge their responsibiities for quaity and safety in heathcare more consistenty in the future. The Oireachtas Committee on the Future of Heathcare: Sáintecare Report (2017) recognises the key roe of boards and advocates the estabishment of heathcare boards. This guidance wi assist new and existing boards in using practices which supports positive decision-making, governance and accountabiity; where service users needs come first in driving safety, quaity and cutures of person centeredness. Foreword It is written primariy for non-executive and executive members of boards of heathcare providers to support them to perform their roe in improving services. Though many exampes come from the acute care setting, it is designed for use across a types of heathcare providers, incuding Hospita Groups, and vountary HSE funded Section 38 and Section 39 organisations. It may aso be usefu to providers without boards by making information avaiabe to executive management teams and cinica eaders. This document presents a practica guide to approaches that ensure the quaity and safety of service users, staff and heathcare providers aike. It aso forms part of a series of resources deveoped to support the appication of the Framework for Improving Quaity in our Heath Service pubished by the HSE in 2016. This guidance shares internationa and nationa perspectives on a board s roe in improving quaity and safety by providing exampes of eading practices, resources and recommended reading. Our review of the iterature has identified many key findings ranging from principes for effective boards and the importance of creating a cuture of trust by working together with respectfu and robust chaenge in achieving high quaity care in a sustainabe way. I thank the many staff and board members across the heath system that have shared their experiences and made suggestions for strengthening the board s focus on quaity and safety during the consutation processes. I aso very much appreciate the considerabe commitment and support that the Quaity Improvement Division team have given in preparing this document and wish you every success with your board s journey in improving quaity of care and assuring service user safety. Dr. Phiip Crowey Nationa Director Quaity Improvement Division Heath Services Executive 3
About This Guidance There are a number of key documents and resources appicabe to boards and executives within heathcare in Ireand. This guidance buids on existing documentation and provides a centra repository of internationa and nationa perspectives on the board s roe in improving quaity and safety by providing exampes of eading practices, resources and recommended reading. The resource is hosted on the HSE website and it wi be updated to take account of changes in nationa poicies and guideines and internationa best practice. The resources and recommended reading for each section are avaiabe eectronicay on the website. This guidance wi assist board members to: - Refect on their performance and approach to improving quaity and safety - Understand eading quaity improvement practices - Make improving quaity and safety a centra tenet of a board s agenda - Deveop partnerships with staff and service users for improving quaity and safety - Drive improvements in care in a measurabe way - Be aware of the importance of using proven quaity improvement methodoogies - Seek assurance and approve a pan for improving quaity and safety. How was this guidance and resource deveoped? This document has been deveoped with reference to internationa eading practices which have incuded a review of reevant pubications and materia from the UK, USA, Austraia, Canada and New Zeaand. In addition to the above, the HSE Quaity Improvement Division has engaged with Irish and internationa subject matter speciaists in respect of the proposed content. How to use this guidance? This guidance is written primariy for non-executive and executive members of boards of heathcare providers to support them to perform their roe in improving services. It may aso be usefu to organisations without boards by providing information to executive management teams and cinica eaders. Refective questions are provided in each of the sections, reated reading and resources for use by board members are ocated on the reevant web pages ocated on the Governance for Quaity section of the Quaity Improvement Division website at www.quaityimprovement.ie. The HSE Quaity Improvement Division resources have been prepared in a generic manner and are ready for adaptation in a oca context. With regard to other resources, pease ink with reevant authors regarding adaptation. Highy engaged Executive Leadership Teams working with highy engaged Boards in a trusting partnership can be the source of wi for the entire organisation. As hospitas try to drive rapid improvement, Boards have an opportunity and a responsibiity to make better quaity of care the organisation s top priority. The Board s responsibiity for ensuring and improving care cannot be deegated to the medica staff and executive eadership; ensuring safe and harm free care to patients is the Board s job, at the very core of their fiduciary responsibiity. An activated Board, in partnership with executive eadership, can set system eve expectations and accountabiity for high performance and eimination of harm and propery conducted this eadership work can dramaticay and continuay improve the quaity and safety of care. (Institute for Heath Care Improvement, 2008) 4
Summary of Board Leading Practices in Improving Quaity and Safety 1 Leadership for Improving Quaity & Safety Activey demonstrating a commitment to seek assurance and drive improvement Board ensures there is a cear vision, goa and strategy for quaity and safety. Board provides visibe eadership in deveoping a positive cuture for the organisation. Some board members are recruited with cinica quaity and safety expertise. Board advises and requests action on quaity and safety of care matters. 2 3 Practices for Improving Quaity & Safety Making quaity and safety of care a priority of the boards business Board identifies and authorises board terms of reference with a focus on assuring quaity and safety. Board provides induction and orientation in quaity and safety structures for new board members. Board prioritises and aocates time on the board agenda to discuss quaity and safety. Board pans and receives training and deveopment in quaity and safety. Partnerships for Improving Quaity & Safety Deveoping strong coaborative partnerships with staff and service users and the wider community Board has the mechanism for direct engagement with service users, staff and wider community. 4 Methods for Improving Quaity & Safety Supporting the provider in appying a quaity improvement methodoogy 5 Measurement for Improving Quaity & Safety Seecting board measures to monitor and demonstrate an improvement in the deivery of care Board approves resources and oversees quaity improvement programme seected by the executive. Board reviews quaity and safety information (dashboards, reports). Board advises and requests actions for improvement of quaity and safety of care. 6Risk Management & Assurance Ensuring a risks to service user quaity and safety are addressed in a robust and structured way 7 Panning for Improving Quaity & Safety Championing and overseeing the deveopment, impementation and monitoring of a pan for improving quaity and safety Board seeks assurance of quaity and safety of care. Board monitors and oversees risks to quaity and safety of care. Board guides the Executive in the deveopment of Quaity and Safety Pan. Board approves the Quaity and Safety Pan. Board supports the organisation in ceebrating the key miestones and successes. Each of the seven eading practices sections describes the rationae, board action and prompts for board consideration. 5
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Contents Foreword... 3 Introduction... 9 The Nationa Context... 9 Types of Boards in Ireand... 9 Why is Governance for Quaity and Safety so important?... 10 Getting Boards on board in Ireand... 11 Summary... 11 1. Leadership for Improving Quaity and Safety... 13 Board Roes and Responsibiities... 13 Chief Executive Officer and Executive Responsibiities... 14 Leadership Behaviours for Improving Quaity... 16 2 Practices for Improving Quaity and Safety... 19 Buiding Board Knowedge and Skis for Improving Quaity... 19 Board Quaity and Safety Committee... 20 Board Evauation... 21 3 Partnerships for Improving Quaity and Safety... 25 Communicating a Quaity and Safety Programme and Strategy to Key Partners and Stakehoders... 27 4 Methods for Improving Quaity and Safety... 29 Quaity Improvement Approaches... 29 HSE Framework for Improving Quaity... 29 Methods... 30 5 Measurement for Improving Quaity and Safety... 33 Mutipe Sources of Information Avaiabe to the Board... 34 Prioritisation of Measures... 34 Presentation of Measures... 34 Understanding Measures... 35 Anaysing and Using Measures... 35 6 Risk Management and Assurance... 37 Board Assurance... 37 Risk and Incident Management... 38 7 Panning for Improving Quaity and Safety... 41 Setting Strategic Priorities... 41 Overview of Considerations for Deveoping a Pan for Improving Quaity and Safety... 41 Communication of the Quaity and Safety Pan... 42 Contents Refection from Board Members... 43 References... 47 Gossary... 51 Appendix 1: Poicy Context... 54 Appendix 2: HSE Performance Accountabiity Framework... 55 List of HSE Resources... 56 7
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Introduction The Nationa Context Quaity and safety of care has been a major focus over recent years and internationay significant efforts are being made to incorporate this as an integra part of a heath systems. The HSE paces safety and quaity of care at the heart of service provision and deivery (HSE, 2017a). In Ireand, quaity in heathcare is defined by the four domains set out in the Nationa Standards for Safer Better Heathcare (Heath Information and Quaity Authority, 2012) i.e. person centred, effective, safe and better heath and webeing. The overa goa of the HSE quaity and patient safety enabement programme as outined in the HSE Code of Governance (2015) is underpinned by four key objectives: Services must subscribe to a set of cear quaity standards that are based on internationa best practice Services must be safe and there must be a robust eve of both quaity improvement and quaity assurance Services must be reevant to the needs of the popuation Patients must be appropriatey empowered to interact with the service deivery system. Introduction In 2016, the HSE aunched the Framework for Improving Quaity in our Heath Service (HSE, 2016a) which outines six critica success factors to enabe services in achieving a cuture that paces the person at the centre, reiaby deivers safe, effective, equitabe, personaised care and continuousy seeks improvement. The six drivers in improving quaity are: (i) Leadership for Quaity, (ii) Person and Famiy Engagement, (iii) Staff Engagement, (iv) Use of Improvement Methods, (v) Measurement for Quaity, and (vi) Governance for Quaity. Governance for quaity and safety invoves having the necessary structures, processes, standards, oversight and accountabiity in pace to ensure that person centred, safe and effective services are deivered. Good governance supports strong reationships between frontine staff, service users and eaders within any organisation (HSE, 2016a). Types of Boards in Ireand Currenty in Ireand there are an estimated 500 peope participating on heathcare boards. The governing board eads the organisation using authority to direct and contro provided by the owner and the ega act of formation (where appicabe). They set initia direction and have the authority to act in the service user and services best interest. Governing boards function at arm s ength from the operationa organisation. They focus on the big picture, are futureoriented and act as a singe entity. There are a number of key poicy documents and resources appicabe to boards and executives within heathcare in Ireand (see Appendix 1 for a summary of poicy context). When services do not have boards the CEO / Genera Manager and executive team take on this responsibiity. There are different types of boards within HSE funded heathcare services which operate within the HSE Performance Accountabiity Framework (see Appendix 2). These incude: Hospita Group Boards Pubication of The Estabishment of Hospita Groups as a Transition to Independent Hospita Trusts (Higgins, 2013) ed to the creation of seven hospita groups within Ireand. Whie the governance for Hospita Groups is currenty in deveopment and pending the necessary ega framework for hospita groups to perform their governance and assurance functions, interim arrangements are being progressed to estabish Hospita Group Boards within the existing ega framework. Hospita Groups are ed by a Group CEO who is egay accountabe. These boards are created on a non-statutory basis and have an administrative capacity. During this administrative stage of the reform programme Hospita Group boards have no ega accountabiity in reation to the Hospita. The soe ine of executive accountabiity for the Group CEO is to the Nationa Director for Acute Hospita Services. The boards are comprised of non-executive directors with executive directors in attendance. Given the scae of these organisations, strong governance arrangements are critica to their success and to quaity of care. This guidance document wi take account of future arrangements as they emerge. 9
Vountary Heathcare Provider Board of Directors (Section 38 and 39) Many board members are on the boards of HSE funded Section 38 and Section 39 vountary heathcare providers. These boards comprise of executive and non-executive director members (governance roe integrated corporate and cinica / care governance). Vountary / non-statutory heathcare providers have a ong history of providing heath and persona socia services in Ireand. These organisations vary in scae and compexity, ranging from arge acute hospitas to oca community based organisations providing socia care services. There are a significant number of Section 38 Agencies - 24 vountary acute hospitas and 22 socia care agencies currenty within the HSE Empoyment Contro Framework (HR Circuar 019/2017b). Section 39 Service Arrangements cover a vountary and community agencies, other than the above, in receipt of funding over 0.250m. Traditionay Section 39 agencies have been invoved in the provision of disabiity and socia services in Ireand. Advisory Boards Some acute hospitas have an advisory Medica Board. It usuay comprises of medica doctors who meet monthy / quartery in an advisory capacity. This arrangement precedes the estabishment of cinica directorates and is being changed as structures deveop and evove. Cinica directors ead each directorate and aong with the chief cinica director are members of the executive management team. Why is Governance for Quaity and Safety so important? The first Irish nationa study of adverse events in hospitas (Rafter et a., 2016) highights the importance of shifting the focus towards quaity and safety of care. A tota of 1,574 randomy seected adut inpatient records from a sampe of eight hospitas stratified by region and size across the Repubic of Ireand in 2009 were retrospectivey reviewed. The prevaence of adverse events in admissions was 12.2%, with an incidence of 10.3 events per 100 admissions. Overa 70 % of events were considered preventabe. Irish adverse event prevaence is at the upper end of the range of other internationa studies (3% to 17%). This study quantifies the adverse event burden and provides an incentive to drive quaity improvement. Achieving sustainabe changes to quaity and safety is not easy and requires a strategic, consistent and evidence informed approach at a eves in the organisation. A report pubished by HIQA into the governance of patient safety within Taaght Hospita (HIQA, 2012b) which focused party on the roe of the board, made a number of recommendations. Some of these focus on strengthening the arrangements to hod chief executives and chairpersons to account for the deivery and quaity of the service. It aso incuded a requirement for existing boards and executives of a heath and socia care service providers in receipt of state funds to assess themseves against the reevant recommendations within the report and to modernise the constitutiona basis, composition and competency of such boards (HIQA, 2012b). Irish Boards can aso earn from the experience in the UK, where Monitor (Independent Reguator of NHS Trusts) highighted the foowing areas of consistent faiure (Ha, 2012): 1. Leadership of quaity is weak: Lack of awareness of quaity indicators, ack of discussion and chaenge, quaity is not adequatey prioritised. 2. Faiure to recognise a probem: Information provided to the board is insufficient to enabe chaenge / action (particuary proactive action) issues / risks are not communicated appropriatey. 3. Lack of assurance and chaenge: Check and chaenge of frontine compiance, the board has taken sensibe actions but has no assurance process to check they are being compied with, the board has no mechanism to independenty assure quaity governance. 4. Inadequate risk management: Inabiity to identify risk for itsef and then put it right sustainaby, too much reiance on third parties, ineffective risk management, ack of cinica engagement with some or a staff groups. 5. Inadequate impementation of poicies, procedures, protocos and guideines: Confusing the existence of poicies, procedures, protocos and guideines with their appropriate use. 10
There is a growing iterature showing that hospita board activities matter for better, safer patient care (Botje, et a., 2013; Jones et a., 2017; Mannion et a., 2017). Board composition and board practices are found to be important factors reated to quaity and safety of care (Jiang et a., 2009). Getting Boards on board in Ireand The benefit of board eadership in Ireand was recenty demonstrated in a quaity improvement project Board on Board with Quaity of Cinica Care (Mater Misericordiae University Hospita and HSE Quaity Improvement Division, 2015). This project had an overa aim that the Board woud individuay and coectivey get a picture of the quaity of cinica care. The Board woud have an understanding of same and act to hod the hospita accountabe on the quaity of cinica care deivered. Introduction During the project the board and staff had the opportunity to meet with Sir Stephen Moss, former Chairman of the Mid Staffordshire NHS Trust Board to discuss how boards can ensure that quaity and safety are priority agenda items for a board meetings. Based on his experience of eading heathcare boards responding to critica cinica incidents Sir Stephen Moss posed four questions for boards. Board Considerations If there is one esson to be earnt, I suggest that peope must aways come before numbers. How is your board making this a reaity? As a board, how do you ensure the right baance between strategy / operationa issues in board meetings, and how do you use operationa feedback reating to service user safety and experience to deveop strategic intentions? How do you proactivey seek out the views of the community you serve and how does the board use this inteigence to improve the quaity of care? How do your board members get the evidence to assure them of the safety and quaity of services you provide? Source: Sir Stephen Moss (2014) Summary Boards have a key roe to pay in the governance of an organisation as accountabiity for the quaity and safety of a service utimatey rests with the board and its executive team. Much of the focus and studies has been on the roe of cinicians and management in reation to safety, however the roe and infuence of boards has not received the same attention. The purpose of this guidance is to support boards of heathcare organisations to expore and understand their roe in improving quaity and safety. L 11
1 Leadership for Improving Quaity and Safety Leadership for Improving Quaity and Safety Board eadership is a critica ingredient to achieving better, safer care and governing boards can choose to be either active eaders or passive overseers in the process (Bader et a., 2006) 12
The Board of a heathcare provider has a roe in setting out the vision and goas for improving quaity and safety. Board members, eaders, managers and cinicians can seek out and use a opportunities to visiby dispay their commitment to buiding a cuture of quaity and safety by activey demonstrating the vaues of the service, reguary istening to service users and staff, seeking assurance of safety and evidence of the quaity of services. Board Roes and Responsibiities The Code of Practice for the Governance of State Bodies (Department of Pubic Expenditure and Reform, 2016) provides a framework for the appication of best practice in corporate governance by both commercia and non-commercia state bodies. In Ireand, the Pubic Appointments Service is responsibe for the recruitment of members to state boards. It has outined as part of the recruitment for Hospita Group Boards the chairperson s roe in the deveopment and impementation of effective corporate and cinica governance structures, aong with oversight of the quaity and safety of systems of care in pace for service users (Pubic Appointments Service, 2017a). In order to be an effective contributor on a board it is recommended that members: Bring independent and objective scrutiny to the oversight of the organisation; Be prepared to be chaenging, when necessary, whie being supportive to the deivery of strategy and objectives; Be equipped to offer considered advice on the basis of sound judgement and experience; Be prepared to make a time commitment to their work commensurate with the roe; Constructivey supports and chaenges the Chief Executive as to the demonstrabe effectiveness of the quaity, safety and timeiness of the services deivered; Constructivey supports and chaenges the Chief Executive in the oversight of risk management; Provide advice in reation to strategic direction, effective roe of the board in coectivey eading for quaity. Leadership for Improving Quaity and Safety The board comprises across its membership, the necessary skis, competencies and experience to enabe it to deiver on the strategic and visionary change management agenda and oversee the provision of high quaity safe service user care. The appointment process for members of the Hospita Groups seeks to ensure demonstrabe expertise in cinica, business, socia, ega, medica academic, nursing and patient advocacy (Pubic Appointments Service, 2017b). Competencies in cinica governance, quaity assurance and patient safety are sought to ensure the correct board ski mix and competencies. Recent studies revea a significant and positive association between a higher percentage of cinicians on boards (both as non-executive and executive members) and the quaity ratings of heathcare provided, especiay where doctors are concerned. This positive infuence is aso confirmed in reation to ower morbidity rates (Sidorov, 2016; Veronesi et a., 2013). A further study demonstrates that executive nurse / midwife directors, who are members of boards, can provide invauabe advice and support to the board around matters of quaity and safety (Jones et a., 2016; Masta, et a., 2007; Matche, et a., 2010). Board effectiveness for improving quaity and safety reies on the ways in which board members use their knowedge and the information they receive in overseeing the provider s pans for improving quaity (Ninnger, 2011). In order for quaity and safety of care to be a priority for the board it is schedued in a dedicated section of the board agenda to ensure that appropriate attention is given. In many cases, a dedicated board quaity and safety committee can be estabished to review reports of quaity of care in greater detai. The roes of the board and the chief executive shoud be cear around addressing quaity concerns and questions. Tabe 1 outines the roe of the board chair, the chief executive and non-executive and executive members of the board. 13
Chief Executive Officer and Executive Responsibiities Whie this guidance seeks to increase board members understanding of best practice in improving quaity and safety, it is the responsibiity of the Chief Executive Officer (CEO) to impement the board s poicies in reation to quaity and safety and for ensuring quaity and safety within the organisation. By providing timey accurate and precise information to the board the CEO ensures the board can carry out their function with regard to governance for quaity and safety and to aow it fufi the safety objectives and functions set out in this guidance document. It is the CEO s responsibiity to ensure the board has sufficient information on risk identification, assessment and contro strategies and ensures effective systems, procedures and practices are in pace in order to evauate the effectiveness of its operations. The CEO encourages board competencies and commitment regarding quaity and safety, whie providing a transparent ine of sight between the board and the rest of the organisation. An engaged board pays a key roe in organisationa cuture and safety. Deveoping and engaging the board is one of the key eadership domains that require CEO focus and dedication to deveop and sustain a cuture of safety (American Coege of Heathcare Executives and the Nationa Patient Safety Foundation s Lucian Leape Institute, 2017). 14
Tabe 1: Key Governance Strategic Roes Formuate Strategy Ensure Accountabiity Shape Cuture Chair Chief Executive Non-executive Executive Ensures board deveops vision, strategies and cear objectives Hods CEO to account for operations and strategy. Ensures board committee are propery constituted with terms of reference Reports to the owner / sharehoder Provides visibe eadership in deveoping a positive cuture for the organisation, and ensures that this is refected and modeed in their own and in the board s behaviour and decision making Leads strategy deveopment process Leads the organisation in the deivery of strategy Estabishes effective performance management arrangements and contros Acts as Accountabe Officer Provides visibe eadership in deveoping a positive cuture for the organisation, and ensures that this is refected in their own and the executive s behaviour and decision making Brings independence, externa skis and perspectives, and chaenge to strategy Hods the executive to account for strategy Offers constructive scrutiny and chaenge Participates as member of key committees Activey supports and promotes a positive cuture. Provides a safe point of access to the board for whistebowers (protected discosure) Takes ead roe in deveoping strategic proposas drawing on professiona and cinica expertise (where reevant) Leads impementation of strategy within functiona areas Activey supports and promotes a positive cuture for the organisation and refects this in their own behaviour Leadership for Improving Quaity and Safety Context Ensures a board members are we briefed on externa context Ensures a board members are we briefed on externa context Ensures reevant members of their teams are we briefed Inteigence Ensures requirements for accurate, timey and cear information to board / directors are cear to executive Ensures provision of accurate, timey and cear information to board / directors Satisfies themseves of the integrity of financia and quaity and safety inteigence Takes principa responsibiity for providing accurate, timey and cear information to the board Engagement Pays key roe as an ambassador, and in buiding strong partnerships with: Service users and pubic Cinicians and staff Key institutiona stakehoders Reguators Pays key eadership roe in effective communication and buiding strong partnerships with: Service users and pubic Cinicians and staff Key institutiona stakehoders Reguators Ensures board acts in best interests of the pubic Senior independent director is avaiabe if there are unresoved concerns Leads on engagement with specific interna or externa stakehoder groups Source: adapted from Rice et a., (2015) 15
Leadership Behaviours for Improving Quaity Pace the quaity of patient care, especiay patient safety, above a other aims. Engage, empower, and hear patients and carers at a times. Foster whoe-heartedy the growth and deveopment of a staff, incuding their abiity and support to improve the processes in which they work. Embrace transparency unequivocay and everywhere, in the service of accountabiity, trust, and the growth of knowedge. (Extract from the Nationa Advisory Group on the Safety of Patients in Engand, A Promise to Learn, a Commitment to Act, 2013) Board members as eaders have the opportunity to be more than champions for improving quaity of care; they can be active participants (HSE, 2016a). A board can ceary demonstrate their commitment to quaity and safety by coectivey eading and infuencing the overa cuture of the organisation. Maintaining a cuture that prioritises quaity and service users safety is a reasonabe expectation for highy effective boards. Boards can channe their efforts towards supporting a cuture of earning rather than driving compiance ony. Individua and coective board member behaviours can acceerate the organisation s quaity journey. The Institute for Heathcare Improvement (IHI) High-Impact Leadership Behaviours: Five Things Leaders Can Do to Promote Improvement (2013) outines how eaders can examine their own behaviours (see Figure 1 beow). Figure 1: IHI High Impact Leadership Behaviours 1 Person-Centeredness Be consistenty person-centred in word and deed 2 Front-Line Engagement Be an authentic presence at the frontine and a visibe champion of improvement 3 Reentess Focus Remain focused on the vision and strategy 4 Transparency Require transparency about resuts, progress, aims and defects 5 Boundariessness Encourage and practice systems thinking and coaboration across boundaries Source: adapted from Swensen et a., (2013) 16
Boards have an essentia roe in promoting a cuture of quaity and safety of care through their own behaviours and actions by: Setting one arge goa for quaity and safety for the organisation Making quaity and safety of care a core part of the board s meeting agenda Refecting the core vaues of the organisation in the decisions of the board Supporting the provider in becoming a earning organisation Sharing service user stories at board meetings Fostering a cuture of transparency and honest communication Encouraging and supporting the executive to identify resources for staff education on improving quaity and safety Supporting the executive in deveoping the provider s programme for improving quaity and safety. Board Considerations - Roe of Leadership in improving Quaity and Safety How does our board define quaity and safety? What are our specific targets and outcomes for improving quaity and reducing harm? Who can be part of the process to deveop those aims? Does our board demonstrate our commitment to quaity and safety by the actions we take? Leadership for Improving Quaity and Safety Does our board communicate in a transparent way? How does our board invest in the deveopment of staff as eaders for improving quaity? How does our board ring fence resources for improving quaity and safety? 17
2 Practices for Improving Quaity and Safety Practices for Improving Quaity and Safety The capabiity of boards and board quaity committees to function effectivey and to move appropriatey between fiduciary and strategic modes reies on boards and senior eadership capacity to deveop trust and a strong coaborative reationship, whie not undermining the board s duty to ask chaenging questions. (Canadian Patient Safety Institute, 2011) 18
Heathcare providers continuousy grappe with execution of effective systems for quaity and safety. The deveopment of the right strategies to get the board on board to improve quaity and safety require investment and the impementation of appropriate processes at the board, organisationa and cinica eves (Canadian Patient Safety Institute, 2011). Many countries have a statutory duty for boards on ensuring quaity is a core part of the main board meetings and discussed in more detai by a quaity and safety committee (Nationa Leadership Counci for Board Deveopment, 2010; Exceent Care for A Act, 2010). The Oireachtas Committee on the Future of Heathcare: Sáintecare Report (2017) recommends a statutory quaity and safety committee of the board that may hep to organise information and review a materia pertinent to quaity and safety. Athough a board may deegate some tasks, the entire board is sti responsibe for oversight and decision making around quaity and safety (Canadian Patient Safety Institute, 2011). In Ireand, the HSE (2015) Code of Governance section 7 outines the commitment to service quaity, safety and risk management and the commitment to a quaity and patient safety enabement function in the HSE. The board estabishes the structures to make quaity and safety a centra tenet on the board s agenda by: Buiding the board s capabiity (knowedge and skis) Prioritising board time discussing quaity and safety Estabishing a board quaity and safety committee, and Evauating the board s performance with an emphasis aways on quaity and safety improvement. Practices for Improving Quaity and Safety Recent studies suggest that effective hospita governance by boards is reated to a hospita s performance on quaity (Miar, et a., 2013; Jiang et a., 2009; Jones et a., 2017; Tsai et a., 2015). Hospitas with a higher eve of board attention to quaity are ikey to have stronger management practices centred on monitoring quaity. Understanding the dynamics among heathcare providers governance, management, cinicians and reguators offers new opportunities for improving quaity and safety (Fresko and Rubenstein, 2013). Buiding Board Knowedge and Skis for Improving Quaity Boards bear the utimate responsibiity for everything in a heathcare provider, incuding quaity and safety. To discharge that responsibiity we, board members require a soid knowedge base about quaity and safety and appy that knowedge in action (McGaffigan et a., 2017; Reinertsen, 2017). As board members may not have backgrounds in heathcare, a comprehensive board induction and mentoring programme wi provide support to new board members in their roe. An orientation programme wi provide an overview of the organisation and roes and responsibiities of a board member. Assigning a mentor for each new board member is another method of ensuring that board members transition into their roe. Organising one-to-one meetings prior to and after board meetings wi enabe new board members understand the business of the board and the information on quaity and safety provided to it. Ongoing deveopment of individua board member s knowedge and skis can be achieved through peer support, forma mentoring programmes and more focused training days or master casses. Board deveopment days can provide members with opportunities to earn and work together, and bring the board members, executives and other eaders in the same room (see Tabe 2 outine of board deveopment). Deveopment days can aso foster a shared agenda, as we as enabe acquisition of quaity improvement skis and knowedge. Board members may vaue support in the form of discussion forums, action based interventions, and group coaching (Canadian Patient Safety Institute, 2011). The board can create opportunities to earn from other simiar boards as organisations can share eading practices and initiatives through existing networks and conferences. Critica friend visits using an appreciative enquiry ethos have aso been used effectivey (Heathcare Improvement Scotand, 2015). Using a board evauation process to identify what the board perceives as their education requirements wi support the deveopment of ongoing programmes (See Resources for sampe approaches). 19
Tabe 2: Outine of Board Deveopment Orientation programmes for new directors with specific references to quaity and safety Inviting board members to attend key briefings on nationa poicies / reguatory requirements Distributing artices and reevant reading materia Participating in quaity improvement programmes with academic partners Raising awareness of outside conferences / master casses Partnering with simiar organisations to organise site visits Inviting staff to brief board members on quaity improvement initiatives Participating in quaity and safety wak-rounds across the service Meeting with service user forums / councis or panes. Source: adapted from Bader and O Maey (2006) There is an opportunity to estabish practices - at board eve and committee - that aow board members time to appy their knowedge effectivey (see Tabe 3). This wi avoid fiing up meeting time sharing information that coud easiy be read in advance of the meeting, thereby creating sufficient time for board discussion and questioning with the executive (Reinertsen, 2017). Board Quaity and Safety Committee The board quaity and safety committee oversees quaity and safety on behaf of the board (See Resources for sampe terms of reference, agenda, minutes, and checkist for prioritisation of measures). This group focuses on the organisation s approach to quaity and safety (Joint Commission Internationa, 2007). The board quaity and safety committee has a roe in heping the board to focus its discussions on important opportunities to improve safety and quaity across the system (Joint Commission Internationa, 2007). The HSE service agreement with Section 38 and 39 heathcare providers requires them to estabish a quaity and safety committee of their board (Part one cause 24.6). Part 2 of the agreement describes the committee s function (Schedue 2 quaity and safety). The committee terms of reference can ceary set out the responsibiity of this committee - to carry out work on behaf of and report to the board. The committee can carefuy seect board members with quaity / safety expertise from other professions and members of the committee can aso earn from cinica staff on the committee through schedued one-one meetings or wakrounds in services (HSE, 2016c). The board s quaity and safety committee may ook at more detaied reports than the fu board does. The entire board see the areas that are important to the specific quaity and safety objectives / targets. Dashboards can be hepfu with a narrative summary of key indicators (Joint Commission Internationa, 2007). Staff can be invited to attend board meetings to present quaity improvement initiatives. Service users and famiy members can give a new perspective on how the provider deivers care and can provide a human face to the care represented by the data presented (Joint Commission Internationa, 2007; Thompson, 2013). The board quaity and safety committee is estabished to (HSE, 2016b): Provide a eve of assurance to the board on the appropriate governance; structures, processes, standards, oversight and contros Oversee the deveopment by the executive management team of a quaity improvement pan for the service in ine with an agreed quaity improvement strategy Recommend to the board a quaity and safety programme and an executive management team structure, poicies and processes that ceary articuates responsibiity, authority and accountabiity for safety, risk management and improving quaity across the service Secure assurance from the executive management team on the impementation of the quaity and safety programme and the appication of appropriate governance structure and processes (e.g. communicating risk) incuding 20
monitored outcomes through quaity indicators and outcome measures Secure assurance from the executive management team that the service is conforming with a reguatory and ega requirements to assure quaity safety and risk management Consider in greater depth matters referred to the committee by the board and referra of issues to the board for consideration when necessary. The board quaity and safety committee normay consist of a number of executive and non-executive directors (drawn from the board) and service user representatives / advisors. The committee is normay chaired by a non-executive director (member of the board) who reports on behaf of the committee to the chair of the board. Board Evauation Annua evauation of the board and its operations is a good method to ensure that the board is functioning effectivey as set out in the terms of reference and standing orders. When board committees are effective they enabe more time to be used at board meetings for discussion and deveopment opportunities. Working committees are the engine that powers effective boards and despite the importance of committees, it is noted that few boards engage in a reguar and focused evauation of their working parts (Canadian Patient Safety Institute, 2011). The Code of Practice for the Governance of State Boards (2016) provides a mode Board sef-assessment evauation questionnaire. Board evauations can take many different forms using externa reviewers, surveys of members or faciitated workshops. Practices for Improving Quaity and Safety Boards with higher eves of maturity in reation to governing for quaity improvement (QI) have the foowing characteristics: expicity prioritising QI; baancing short-term (externa) priorities with ong-term (interna) investment in QI; using data for QI, not just quaity assurance; engaging staff and service users in QI; and encouraging a cuture of continuous improvement; enabed and supported by board-eve cinica eaders. (Jones et a., 2017) 21
Tabe 3: Embedding Board Discipines Competent, systematic board discipines form the bedrock of good board functioning. The chair gives thoughtfu attention to board agenda panning and management to maintain a baance between oversight of operations (incuding dedicated time for quaity and safety) and strategy. Chairs face the chaenge of attending to the fu breadth of the board s roe whie ensuring that board meetings do not descend into a grueing test of board member endurance. The foowing board discipines are considered: Board and committee year panners and annua programmes of work: to ensure a coherent programme for forma board meetings, board seminars and away-days and committee meetings. It is good practice for the work of every committee (incuding quaity and safety) of the board to be shaped by an annua pan. Board papers: The effectiveness of the board is dependent on the timey avaiabiity of board papers. Timeiness: the board papers provided ideay a week ahead of meetings (incuding reports and quaity of care indicators). Cover sheets: incuding, for each paper, the name of the author, a brief summary of the issue, the organisationa forums where the paper has been considered (for exampe executive quaity and safety committee), the strategic or reguatory objective. Executive summaries: Succinct executive summaries that direct the readers attention to the most important aspects. Action ogs: Boards and committees can be heped to keep track of actions agreed by maintaining and monitoring a og. The og shoud show a actions agreed by the board and for each action the ownership, due dates and status. Source: adapted from Nationa Leadership Counci for Board Deveopment (2010) 22
Board Considerations - Practices for Improving Quaity and Safety Does our board prioritise quaity and safety on the board s agenda? As a board, do we spend a minimum of 25 % of board meetings discussing quaity and safety of care? How do we support board members to understand the information presented on quaity and safety of care? How do we monitor progress towards quaity and safety goas? What are the ways in which our board evauates performance on quaity and safety? Practices for Improving Quaity and Safety 23
Partnerships for Improving Quaity and Safety 3 Partnerships for Improving Quaity and Safety Effective boards give priority to engagement with stakehoders and Effective boards give priority to engagement with stakehoders and opinion formers within and beyond the organisation; the emphasis here is on buiding a heathy diaogue with, and being accountabe to, service users, the pubic, and staff, governors and members, commissioners and reguators (adapted from Nationa Leadership Counci for Board Deveopment, 2010). 24
The board and management work in partnership to ensure the deivery of safe, high quaity care. The perspectives of staff, services users, professiona bodies, other service providers and reguators provide insights to how the organisation provides this care. Outined in Figure 2 are a number of key stakehoders that the board may wish to directy engage with to gain an understanding of the quaity and safety of care provided by the organisation they have oversight for. Figure 2: Key Stakehoder Partnerships for Boards Other Service Providers/ Groups/Networks Professiona/ Representative Bodies Reguators Service Users and their Famiies Board Staff Community Academic Partners Partnerships for Improving Quaity and Safety Commissioners/ HSE Nationa Divisions Service Users and their Famiies - There are a range of benefits in coecting and using service user and their famiies experiences. It heps to improve communication and shared decision-making between service users and staff and informs panning and service improvement. Boards have a roe in ensuring that the ethos and cuture of the organisation has a focus on person centred care and that that the views and suggestions of service users and their famiies are sought and incorporated in any change to services (NHS Scotand 2016a; Pomey, et a., 2016). Incuding service user representatives within the board membership aong with service user stories as part of the board s agenda supports the board to focus on the service users of the organisation. In Ireand, we describe person centred care as an approach to practice estabished through the formation and fostering of heathfu reationships between a care providers, service users and others significant to them in their ives (McCormack, McCance, 2017). Engaging and invoving service users in the design, panning and deivery of a care demonstrates a commitment to person centred care (HSE, 2016a). Staff - Positive staff engagement is critica to achieving high quaity safe care. Boards, directors, managers and cinica staff can deveop an understanding of each other s roes and create strong coaborative reationships to achieve the quaity and safety objectives set by the provider. Exampes of methods of buiding board understanding and reationships with staff: promoting the visibiity of board members via wak-rounds, photos of board members hoding board meetings in pubic and circuating board minutes meeting staff members who have ed on quaity and safety initiatives seeking assurance from the executive that there are systems in pace to obtain staff feedback, e.g. staff exit interviews and student pacement reviews. 25
Staff are engaged when they fee vaued, are emotionay connected, fuy invoved enthusiastic and committed to providing a good service when each person knows what they do and say matters and makes a difference. (HSE Nationa Staff Engagement Forum, 2016) Academic Partners - Boards can work with academic partners to support the overa provider in improving the quaity and safety of care by resourcing and faciitating research and innovation in ine with overa quaity strategic pans. Academic partners can aso pay a roe in designing and providing education programmes for staff and undergraduates that integrate theory and practice in the care environment. The report to the Minister for Heath on the estabishment of hospita groups recommends the roe of a chief academic officer whose roe is to bring the academic function to top tabe decision making (Higgins, 2013). A Hospita Groups have been aigned to Universities who have medica and heathcare facuties within their catchment area. The report aso emphasises the importance of academic inkages to focus on the research, innovation, education and training agendas that are so fundamenta to improved service user care. Community - Effective boards are informed by the externa context within which they operate. Boards have a roe in engaging with the communities they serve. The board has a roe overseeing the funding, resourcing and reporting on quaity improvement to the community and by submitting the annua statement of compiance to the HSE / funder. Professiona and Reguatory Bodies - Quaity assurance information such as information received from reguators and professiona bodies can be utiised to drive quaity improvement. The board can frequenty review the themes and nature (i.e. positive or negative) of the feedback from independent sources and comparing this to other interna sources of feedback, for exampe, Nationa Cinica Audits and Speciaty Quaity Improvement Programmes. Other Service Providers - Boards can earn from other simiar service providers by participating in networking and conferences. Boards need to be aware of and understand where their organisation stands in reation to the best. Participating in coaborative and benchmarking initiatives enabes boards to connect with wider communities in gaining this insight. remember that non-executive directors are the eyes and ears of the outsider but have privieged access to the inside of the hospita. That is your vaue to patients, to the executives and to the board. Use it we but take your time thoughtfu refection about what can go wrong and why is a too rare, and we need ots more of it at every eve of the system Commit yoursef to a year-ong schedue of informa visits to wards, cinics and departments Be patient and graduay the workings of the hospita wi revea themseves. Be persistent and word wi spread that the board is seriousy interested in the work of caring for patients and the conditions that make it possibe. (extract from Corne, 2013) 26
Communicating a Quaity and Safety Programme and Strategy to Key Partners and Stakehoders To support consistent and effective communication, it is important for heathcare providers to take a transparent and proactive approach to the communication of their quaity and safety strategy and associated programme with key stakehoders. This incudes the foowing activities: Incuding quaity and safety priorities in a board / CEO presentations or speeches Hoding meetings with stakehoders in sma groups or community ha settings Pubishing minutes of meetings and hoding pubic board meetings Dispaying quaity and safety messages in posters, buetin boards and websites associated with the heathcare provider Proactivey communicating cear, consistent messages and exampes of quaity and safety programmes in action in interna and externa newsetters Buiding staff knowedge and skis through training and education forums or seminars, and Buiding conversations and creating connections with stakehoders through socia media sharing. Deveoping an integrated / mutifaceted communication strategy with the executive supports the creation of a positive quaity and safety cuture. The communication strategy shoud aim to: 1. Demonstrate that the provider takes its responsibiity and accountabiity for quaity and safety seriousy 2. Highight impending changes that may impact the quaity and safety cuture 3. Inform the stakehoders of their roe in the quaity and safety initiatives 4. Demonstrate transparency and good stewardship of pubic funding 5. Champion and create a positive attitude around the quaity and safety strategy for the organisation 6. Proactivey communicate content that enabes education and behaviour change, and 7. Manage communications pans and resources to deivery agreed quaity and safety outcomes and vaue for money. Partnerships for Improving Quaity and Safety Board Considerations - Partnerships for Improving Quaity and Safety How does our board incude a reevant stakehoders in the decisions that affect them? What methods does our board use to hear service user and staff stories on quaity improvement and safety at board meetings? How is quaity and safety data presented in a meaningfu way? i.e. from a service user / staff perspective) How does our board meet directy with staff and hear their suggestions for improvement? 27
Methods for Improving Quaity and Safety 4 Methods for Improving Quaity and Safety A quaity improvement methods highight the importance of accessing the unique knowedge that frontine staff possess and invoving them in any change and improvement process. Improving the quaity of care, and sustaining it, requires a programmes to have a theory of change that is based on the appication of improvement science (Heath Service Executive, 2016a) 28
Quaity Improvement Approaches There are many approaches a provider can take when appying quaity improvement methods. Chief executives of the majority of provider trusts rated outstanding by the Care Quaity Commission UK credit estabished quaity improvement (QI) methods for improvement in their operationa performance, staff satisfaction and quaity outcomes (NILDB, 2016). The board pays a roe in supporting the executive management team on the resourcing and promotion of the chosen quaity improvement method. Buiding staff improvement knowedge and skis is an essentia part of the impementation of a programme and wi enabe the prioritisation of key quaity and safety soutions to prevent harm and improve care. Outined beow are some of the approaches heathcare providers can take when starting on a journey of quaity improvement (Bataden, et a., 2007) and providers may wish to foow a number of different methods depending on what is to be achieved. HSE Framework for Improving Quaity The HSE aunched a Framework for Improving Quaity in our Heath Service (HSE, 2016a) which assists services to impement sustainabe quaity of care improvements in order to provide better experience and outcomes (See Figure 3). Six key critica success factors make up this framework and enabe services in achieving a cuture that paces the person at the centre, reiaby deivers safe, effective, equitabe, personaised care and continuousy seeks improvement. The six drivers based on internationa experiences in improving quaity are summarised in Tabe 4. Figure 3: Framework for Improving Quaity in our Heath Service (HSE, 2016a) Methods for Improving Quaity and Safety 29
Tabe 4: Framework for Improving Quaity Drivers Leadership for Quaity Leadership that supports and fosters a cuture of continua earning and improvement. Leaders shape cuture, create the conditions and mode the behaviour necessary for quaity to fourish. Person and Famiy Engagement Engaging and invoving service users in the design, panning and deivery of a care demonstrates a commitment to person centred care. Engagement buids a cuture of istening to and earning from the care experiences of service users and their famiies. Staff Engagement An engaged workforce is one where staff are vaued, istened to and provided with the toos, resources and skis to do meaningfu work. Use of Improvement Methods Measurement for Quaity Using improvement methods highight the importance of accessing the unique knowedge that frontine staff possess and invoving them in any change and improvement process. Information and measurement are centra to improving quaity of care. Buiding measurement into a improvement methods. Governance for Quaity Governance for quaity invoves having the necessary structures, processes, standards, oversight and accountabiity in pace to ensure that safe person centred and effective services are deivered. Methods Mode for Improvement- The Institute for Heathcare Improvement uses the Mode for Improvement as the framework to guide improvement work. The Mode for Improvement deveoped by Associates in Process Improvement (Langey et a., 2009) is a too for acceerating improvement. Testing changes on a sma scae using Pan-Do-Study-Act (PDSA) cyces which are inked with three key questions (see Figure 4): Question 1: What are we trying to accompish? Question 2: How wi we know that a change is an improvement? Question 3: What changes can we make that wi resut in improvement? Figure 4: Mode for Improvement Source: Adapted from Mode for Improvement from Associates in Process Improvement Langey et a., (2009) 30