Getting Hospital Boards on Board with Patient Safety

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Russell Mannion (HSMC) and Ross Millar (HSMC)

Hospital trust boards have a statutory duty for upholding quality and safety of care in its organisation. However, recent high-profile reports and inquiries into serious failings in care, most notably the appalling standards of care at Mid-Staffordshire, raise concerns over the ability of trust boards to discharge these duties effectively.

Against this background, Russell Mannion and Ross Millar with colleagues from the Universities of Middlesex and St Andrews have authored a new National Institute of Health Research report on the first large-scale mixed-methods study of hospital board activity and behaviour related to the oversight of patient safety in the English NHS. The three year research project investigated the linkages between hospital board governance and patient safety processes and clinical outcomes based on the collection and analysis of national quantitative patient safety data across all hospitals in England and in-depth ethnographic case studies.

We found that what boards do and focus on is related to how their hospital reacts to and deals with patient safety issues. In particular, in the national surveys we found a significant link between self-assessed competencies of boards and whether or not its staff felt able to openly report patient safety-related problems and incidents. This clearly links to the current NHS agenda around the promotion of open cultures in NHS organisations and current policy aimed at supporting whistleblowing. The report provides fresh empirical evidence that hospital boards matter and have a key leadership role in promoting such values and practices in their organisation. 

We also found that most boards do allocate a considerable amount of time to discussing patient safety- and quality-related issues. The responses obtained indicate that only one-fifth of trust boards reported that less than 30% of its time was spent discussing safety and quality issues. In the case studies we found similar evidence, with only one study site allocating less than 30% of its board time to debating quality/safety matters.

Through our case study work, we discovered that boards used this time allocated to quality/safety rather differently. We found that hospital boards were using a wide range of hard performance metrics and soft intelligence to monitor its organisations with regard to patient safety, including a range of clinical outcomes measures, infection rates and process measures, such as medication errors and readmission rates.

Softer intelligence, used organisationally and reported at all board meetings, was more variably reported, with discussions with clinicians and executive walkabouts being most often reported, alongside use of patient stories. However, in only about two-thirds of trusts did board members shadow clinicians and report back to the board.

We found a very high proportion of trust boards reported the kinds of desirable characteristics and board-related processes that research says may be associated with higher performance, with all having quality subcommittees and proactive procedures in place to address patient safety concerns, and almost all having explicit objectives related to improving patient safety. Eighty-seven per cent of trusts reported that board members had actually received any received training in patient safety issues.

Our ethnographic exploration of the symbolic aspects of board activities highlights the role and differences in local processes of organising in relation to the governance of patient safety. Although each case study identified different approaches in different situations, it was clear that the setting and historical context in which board decisions and deliberation take place have an important bearing on how trusts approach the oversight of patient safety. These local differences should be taken into consideration when attempting to overlay a top down ‘one size fits all’ approach to enhancing board oversight of patient safety across the NHS, something that is all too often a temptation in a health service subject to strong national direction.  Our research has revealed an encouraging focus on quality and safety within NHS hospital boards – the challenge is for these boards to hold fast to this commitment in tough financial times. 

Research project related publications

Freeman, T., Millar, R., Mannion, R. and Davies, H. (2015) Enacting corporate governance of health care safety and quality: a dramaturgy of hospital boards in England, Sociology of Health and Illness, DOI:10.111 (first published online 4 August) 

Mannion R, Freeman T, Millar R, Davies H (2016) Effective Board Governance of Safe Care: A (Theoretically underpinned) cross-sectional examination of the breadth and depth of relationships through national quantitative surveys and in-depth qualitative case studies  Health Services and Delivery Research  (need to put volume number when published) 

Mannion, R., Davies, H., Millar, R., Freeman, T., Jacobs, R. and Kasteridis, P (2015) Overseeing oversight: governance of quality and safety by hospital boards in the English NHS, Journal of Health Services Research and Policy, Vol 20 (15) 9-16. 

Mannion R., Davies H (2015) Cultures of silence and cultures of voice: whistleblowing in healthcare organisations, International Journal of Health Policy and Management, DOI 10 15171 

Millar, R., Mannion, R., Freeman, T. and Davies, H. (2013) Hospital Board Oversight of Quality and Patient Safety: A Narrative Review and Synthesis of Recent Empirical Research, The Milbank Quarterly, Vol. 91 (4) 738–770. 

Millar, R., Freeman, T. and Mannion, R. (2015), Hospital board oversight of quality and safety: a stakeholder analysis exploring the role of trust and intelligence. BMC Health Services Research 15: 196, DOI 10.1186/s12913-015-0771-x