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How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England
  1. Lorelei Jones1,
  2. Linda Pomeroy1,
  3. Glenn Robert2,
  4. Susan Burnett3,
  5. Janet E Anderson2,
  6. Naomi J Fulop1
  1. 1 Department of Applied Health Research, University College London, London, UK
  2. 2 The Florence Nightingale Faculty of Nursing& Midwifery, Kings College London, London
  3. 3 Centre for Patient Safety and Service Quality, Imperial College London, London, UK
  1. Correspondence to Dr Lorelei Jones, Applied Health Research, University College London, Gower St, London WC1E 6BT, UK; lorelei.jones{at}


Background Health systems worldwide are increasingly holding boards of healthcare organisations accountable for the quality of care that they provide. Previous empirical research has found associations between certain board practices and higher quality patient care; however, little is known about how boards govern for quality improvement (QI).

Methods We conducted fieldwork over a 30-month period in 15 healthcare provider organisations in England as part of a wider evaluation of a board-level organisational development intervention. Our data comprised board member interviews (n=65), board meeting observations (60 hours) and documents (30 sets of board meeting papers, 15 board minutes and 15 Quality Accounts). We analysed the data using a framework developed from existing evidence of links between board practices and quality of care. We mapped the variation in how boards enacted governance of QI and constructed a measure of QI governance maturity. We then compared organisations to identify the characteristics of those with mature QI governance.

Results We found that boards with higher levels of maturity in relation to governing for QI had the following characteristics: explicitly prioritising QI; balancing short-term (external) priorities with long-term (internal) investment in QI; using data for QI, not just quality assurance; engaging staff and patients in QI; and encouraging a culture of continuous improvement. These characteristics appeared to be particularly enabled and facilitated by board-level clinical leaders.

Conclusions This study contributes to a deeper understanding of how boards govern for QI. The identified characteristics of organisations with mature QI governance seemed to be enabled by active clinical leadership. Future research should explore the biographies, identities and work practices of board-level clinical leaders and their role in organisation-wide QI.

  • Governance
  • Leadership
  • Quality Improvement

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  • Contributors LJ collected and analysed the data and drafted the paper. LP collected and analysed the data and revised the paper. GR, SB, JEA and NJF contributed to the conception and design of the research, data analysis and revision of the paper.

  • Funding The research was funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care North Thames at Barts Health NHS Trust. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.