Effective Hospital Board Governance of Safe Care

Failures arising from poor hospital Board leadership and governance are a frequent theme of investigations into hospital scandals dating back at least as far as the inquiry into the mistreatment of long-stay patients at Ely hospital and illustrated most recently in the Francis Inquiries into events at Mid-Staffordshire hospital trust which highlighted the following:

“Francis, 2013 (p9) "It [the board] did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to the Trust’s attention. Above all, it failed to tackle an insidious negative culture involving a tolerance of poor standards and disengagement from management and leadership responsibilities.”

Hospital Trust Boards have ultimate responsibility for upholding the quality and safety of care delivered by their organisation. As corporate entities with statutory oversight responsibilities, Hospital Trust Boards have a fundamental role to play in the governance of patient safety through defining the objectives, the strategy, the priorities, the culture and the systems of control for their organisation to ensure that they discharge their statutory duties with respect to the quality of the care they deliver to patients.

Despite a plethora of guidance available to NHS Boards on effective governance, both in general terms and with specific reference to safe care, we still have a weak evidence base on which to offer guidance around effective Board practice with regards to patient safety. In particular we lack a full understanding of what Boards actually do in relation to promoting patient safety. So, for example:

  • How do Boards attempt to embed and sustain a culture of safety throughout the organisation?
  • What information (hard and soft) do Boards review on a regular basis to determine whether they are providing safe care?
  • What is the impact of external commissioning arrangements and incentives on Board oversight of patient safety?
  • How are Board agendas constructed?
  • What is the relative role of Boards versus Councils of Governors in Foundation Trusts with regards to patient safety?
  • How do Boards respond to adverse events, seek to learn from them and put systems in place and engage with operational practices to prevent them recurring?

Above all we have little robust evidence on how different Board practices actually impact on patient safety processes and outcomes. Moreover, it is clear that Hospital Boards do not act in a vacuum, but operate in a complex and at times (especially now) rapidly changing environment. Commissioners and strategic oversight agencies such as the Care Quality Commission also have a role in shaping the debates and practices of
Hospital Boards, and it is important to understand these contingencies if we are to better design not just safe organisations but safer systems.


Against this background we are undertaking a three year NIHR-funded research project which addresses these and related questions and is generating empirical evidence on the associations between Board practice and patient safety processes and outcomes with the aim of improving Boards’ understanding and accountability for patient safety. The
specific aims of the project are to: 

  • Identify the types of governance activities undertaken by Hospital Trust Boards with
    regard to ensuring safe care in their organisation. 
  • Explore the role of Boards versus Councils of Governors in Foundation Trusts with regards to the oversight of patient safety in their organisation. 
  • Assess the association between particular Hospital Trust Board oversight activities and patient safety processes and clinical outcomes. 
  • Identify the facilitators and barriers to developing effective Hospital Trust Board governance of safe care. 
  • Assess the impact of external commissioning arrangements and incentives on Hospital Trust Board oversight of patient safety.

Given the diversity of views and approaches to understanding Board governance of patient safety, and the intrinsic complexity of any relationships between Board governance and patient safety processes and outcomes, we have adopted a multi-method approach,
integrating qualitative and quantitative elements in order to examine these relationships in both breadth and depth. In order to capture the breadth of any associations, we are undertaking (in collaboration with Dr Foster) national surveys of Hospital Board activity, which are linked to national quantitative data on patient safety processes and clinical
outcomes. In order to explore these associations in depth we are undertaking longitudinal case studies in a number of Hospital Trusts which involve the observation of Hospital Boards in action and the analysis of the way in which patient safety incidents are handled from ‘Board to ward’. Our goal is to make evidence informed recommendations for effective Hospital Trust Board oversight and accountability, and Board member
recruitment, induction, training and support - both in the NHS and other health systems.


Mannion, R, Freeman, T, Millar, R, Davies, H (2016), Effective board governance of safe care: A (theoretically underpinned) cross-sectioned examination of the breadth and depth of relationships through national quantitative surveys and in-depth qualitative case studies. Health Services and Delivery Research 2016: 4(4).

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.






Russell Mannion, Tim Freeman and Ross Millar 


View all HSMC research projects