Chest
Volume 138, Issue 1, July 2010, Pages 171-178
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MEDICAL ETHICS
Responsibility for Quality Improvement and Patient Safety: Hospital Board and Medical Staff Leadership Challenges

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Concern about the quality and safety of health care persists, 10 years after the 1999 Institute of Medicine report To Err is Human. Despite growing awareness of quality and safety risks, and significant efforts to improve, progress is difficult to measure. Hospital leaders, including boards and medical staffs, are accountable to improve care, yet they often address this duty independently. Shared responsibility for quality and patient safety improvement presents unique challenges and unprecedented opportunities for boards and medical staffs. To capitalize on the pressure to improve, both groups may benefit from a better understanding of their synergistic potential. Boards should be educated about the quality of care provided in their institutions and about the challenges of valid measurement and accurate reporting. Boards strengthen their quality oversight capacity by recruiting physicians for vacant board seats. Medical staff members strengthen their role as hospital leaders when they understand the unique duties of the governing board. A quality improvement strategy rooted in synergistic efforts by the board and the medical staff may offer the greatest potential for safer care. Such a mutually advantageous approach requires a clear appreciation of roles and responsibilities and respect for differences. In this article, we review these responsibilities, describe opportunities for boards and medical staffs to collaborate as leaders, and offer recommendations for how boards and medical staff members can address the challenges of shared responsibility for quality of care.

Section snippets

The Legal and Regulatory Contexts for Boards' Activities

In not-for-profit (NFP) hospitals, the roles and responsibilities of governing boards are complex, interconnected, and critical to institutional viability and to fulfilling their community obligation.8 NFP hospital governance boards are legally bound to the fiduciary duties of care, loyalty, and obedience.1, 9 Historically, the interpretation of those duties varied widely in accordance with local culture and reflected the flexibility of state statutes.

Wide variation still exists in the level of

Model for a Meaningful Safety Scorecard

Boards face substantial challenges in monitoring quality of care and patient safety. Current measures to evaluate progress in patient safety do not provide an adequate evaluation of services across an institution and many are of dubious validity. Without rigorous and standardized measurement, boards, hospital leaders, and medical staffs do not know whether care is really any safer than it was previously. Boards are often left monitoring what administrative staffs determine is important (or, to

Conclusions

Hospital boards face increased accountability for the quality and safety of care in their organizations. Many boards are responding admirably, and all of them can do so if they and their medical staffs are willing to adapt.

Boards must engage their medical staffs by becoming more involved in and educated about the quality of care provided in their institutions and by inviting physicians to join the governing body. Medical staff members should understand the unique duties of boards, which may

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Wachter reports having an equity interest and/or serving on paid advisory boards for PatientSafe Solutions and Epocrates; receiving fees from QuantiaMD for helping to produce a Web-based series on patient safety; receiving honoraria from the American Board of Internal Medicine for serving on its board of directors and Executive Committee; receiving honoraria for many speeches on

References (40)

  • PJ Pronovost et al.

    A practical tool to learn from defects in patient care

    Jt Comm J Qual Saf

    (2006)
  • AN Callendar et al.

    Corporate Responsibility and Health Care Quality: A Resource for Health Care Boards of Directors

    (2007)
  • AK Jha et al.

    Hospital governance and the quality of care

    Health Aff

    (2010)
  • LR Burns et al.

    The fall of the house of AHERF: the Allegheny bankruptcy

    Health Aff

    (2000)
  • MW Peregrine et al.

    “Independence” and the nonprofit board: a general counsel's guide

    J Health Law

    (2006)
  • Committee on Quality of Health Care in America, Institute of Medicine

    Crossing the Quality Chasm: A New Health System for the 21st Century

    (2001)
  • EA McGlynn et al.

    The quality of health care delivered to adults in the United States

    N Engl J Med

    (2003)
  • JE Orlikoff et al.
  • DD Pointer et al.
  • DR Longo et al.

    Profile of hospital governance: a report from the nation's hospitals

    Trustee

    (1990)
  • JA Alexander et al.

    Changes in the structure, composition, and activity of hospital governing boards, 1989-1997: evidence from two national surveys

    Milbank Q

    (2001)
  • S Tregoning

    Hospital board structure: changing form and changing issues

    Aust Health Rev

    (2000)
  • MD Connelly

    The sea change in nonprofit governance: a new universe of opportunities and responsibilities

    Inquiry

    (2004)
  • DD Pointer et al.
  • SY Lee et al.

    An empirical taxonomy of hospital governing board roles

    Health Serv Res

    (2008)
  • LD Prybil

    Size, composition, and culture of high-performing hospital boards

    Am J Med Qual

    (2006)
  • BJ Weiner et al.

    Corporate and philanthropic models of hospital governance: a taxonomic evaluation

    Health Serv Res

    (1993)
  • CA Goeschel

    Quality, Patient Safety, and Boards of Trustees: Implications for Creating Safer Healthcare[dissertation]

    (2010)
  • MJ Succi et al.

    Physician involvement in management and governance: the moderating effects of staff structure and composition

    Health Care Manage Rev

    (1999)
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    Editor's note: This review addresses the 13th topicin the core curriculum of the ongoing Medical Ethicsseries. To view all articles from the core curriculum, visit http://chestjournal.chestpubs.org/cgi/collection/ medethics.—Constantine A. Manthous, MD, FCCP, Section Editor, Medical Ethics

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestpubs.org/site/misc/reprints.xhtml).

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