The important characteristics of
effective governance of healthcare quality
Fi Mercer caught up with Alison Brown who has just finished her PhD study that examined the characteristics of effective governance of healthcare quality.
Alison has an extensive background in the health sector as a physiotherapist, quality manager, past director of ACHG, founder of Alison Brown Consulting, director of Darebin Community Health and accredited convener for Governance Evaluator.
Alison’s work in quality and clinical governance has led to her involvement in numerous expert advisory groups, both at the state and national level, advising on issues related to healthcare quality and safety. Over the past decade, Alison has focused on the challenges of board governance. She has been involved in the development of innovative new approaches to healthcare governance, such as the development of guidelines and resources for the internal audit of clinical areas.
Alison’s PhD at the University of Melbourne, examining the characteristics of effective governance of healthcare quality in health services in Australia, has given her the opportunity to explore in depth the challenges and successful approaches in the contemporary governance of healthcare.
As Governance Evaluator will be talking about the characteristics of effective boards in their 2018 Benchmark Report we thought it would be the perfect lead-in to hear from Alison about what her amazing research has highlighted in relation to this.
Research findings for characteristics of effective boards
Alison said that her PhD was an in-depth comparative case study of 8 hospitals in Australia and that one of the key outcomes was the description of the four main characteristics of effective governance within these boards. These four characteristics of effective boards were:
Alison went on to describe in more depth what these four areas meant.
Definition of engaged: Board and managers actively undertaking all governance processes required to fulfil governance responsibilities.
She said that engagement has been linked to better healthcare outcomes in the literature. However, she found that engagement in processes of healthcare quality governance varied markedly between the cases studied. Alison went onto describe some of the key processes that boards engaged in and her findings. For example, she found the responsibility of evaluating healthcare quality involves the following processes:
- Defining what quality healthcare is
- Selecting appropriate data to reflect the definition of quality and the programs at your service
- Reporting regularly on healthcare quality
- Identifying performance variation
- Identifying action
- Monitoring effective implementation of action
Of interest, Alison said that many board members were not clear about the responsibilities and associated processes involved in governing healthcare quality. For example, for the task of evaluating healthcare quality, she said board members tended to focus on the process of monitoring data and neglected the other processes. This meant that either the data coming to the board was not suitable and/or the analysis of the data was not undertaken to foster board insight.
Alison noted that the literature focuses on the use of dashboards and having an agenda item for quality and she has seen this focus in hospitals. She said that “In fact, dashboards don’t vary much between hospitals and often have a focus on a lot of indicators drawn from performance agreements.” Alison believes there is a difference between measures for performance and measures for improvement. Performance measures are often the ‘low hanging fruit’ of indicators, that is easier to measure and compare between services, but not necessarily sensitive enough to inform the evaluation of healthcare quality.
Interestingly, she found that stand-alone reports were often much more informative. Stand-alone reports included those on quality systems (e.g. patient feedback reports), programs areas and areas of risk (annual thematic reviews of falls or pressure areas). However, these reports varied in comprehensiveness. Alison discussed a case where one indicator, from a patient experience survey that related to pricing for quality incentives from the Department, was used to inform the board about patient experience. This contrast with another case that undertook an in-depth analysis of the patient experience survey and presented this to the board along with other internally generated measures and walkarounds, compliments and complaints to give a sophisticated picture of patient experience.
Therefore, those who were truly engaged in monitoring the evaluation of quality had a deeper level of reporting and analysis than just dashboard reports with indicators derived from performance agreements. The evidence showed that effective boards engaged through a much deeper review and sophisticated analysis of a broad range of qualitative and quantitative data.
Definition of focused: board members and senior management had a clearly articulated and aligned focus on healthcare quality.
Alison found boards usually exhibited one or more of the following focuses on quality:
- Focus on compliance
- Focus on quality system development
- Focus on excellence in healthcare outcomes – Open transparent – quality improvement culture
She concluded that cases more highly engaged in healthcare governance demonstrated activity in relation to all three focuses but had an emphasis on excellence in healthcare outcomes. This focus was usually associated with a strong quality improvement culture in which managers felt comfortable to discuss issues with healthcare quality.
Definition of vigilant: Board members and senior management who recognised health as a high-risk environment and promoted active scrutiny of healthcare quality.
Alison noted that these cases were characterised by boards that moved away from the use of compliance measures to provide the board with “comfort” that they were meeting external requirements, to generating internal data or seeking external data to actively “problem seek”. These cases used innovative internal methods (such as internal audits, comprehensive clinical audits of clinical pathways or the development and assessment of program standards) to assess program-level risks and identify underperformance.
She summarised that this approach recognised that quality of care varies between programs and can sometimes be hidden by data aggregated in dashboards. Underperformance was an opportunity for improvement.
Definition of reflective: boards that created opportunities for reflection in their approach to governing and in improving healthcare quality.
Alison said that boards exhibited reflexivity in several ways and gave the following examples:
- They reflected on the data and reports they received and whether they enabled the board to fulfil its responsibilities. These boards had transparent data reporting frameworks that were reviewed periodically.
- They periodically reflected on the effectiveness of their quality committees in meeting the needs of governance.
- They allowed enough time for reflection in meetings through questions and discussion by controlling the agenda and volume of information in a meeting. This discussion promoted a shared understanding of healthcare issues among board members, but also prompted senior managers to critically reflect on the causes and responses to healthcare underperformance.
- Finally, these boards actively and eagerly debated and reflected on evidence of new approaches to healthcare quality and governance
It was wonderful to catch up with Alison and hear from her these four ‘hot off the press’ characteristics for effective governance of healthcare quality. These will be incredibly helpful for assisting boards to understand how to be effective for governing clinical care in the future.