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The National Context
Quality and safety of care has been a major focus over recent years and internationally significant efforts are being made to incorporate this as an integral part of all health systems. The HSE places safety and quality of care at the heart of service provision and delivery (HSE, 2017a). In Ireland, quality in healthcare is defined by the four domains set out in the National Standards for Safer Better Healthcare (Health Information and Quality Authority, 2012) i.e. person centred, effective, safe and better health and well-being.
The overall goal of the HSE quality and patient safety enablement programme as outlined in the HSE Code of Governance (2015) is underpinned by four key objectives:
- Services must subscribe to a set of clear quality standards that are based on international best practice
- Services must be safe and there must be a robust level of both quality improvement and quality assurance
- Services must be relevant to the needs of the population
- Patients must be appropriately empowered to interact with the service delivery system.
In 2016, the HSE launched the Framework for Improving Quality in our Health Service (HSE, 2016a) which outlines six critical success factors to enable services in achieving a culture that places the person at the centre, reliably delivers safe, effective, equitable, personalised care and continuously seeks improvement.
The six drivers in improving quality are: (i) Leadership for Quality, (ii) Person and Family Engagement, (iii) Staff Engagement, (iv) Use of Improvement Methods, (v) Measurement for Quality, and (vi) Governance for Quality.
Governance for quality and safety involves having the necessary structures, processes, standards, oversight and accountability in place to ensure that person centred, safe and effective services are delivered. Good governance supports strong relationships between frontline staff, service users and leaders within any organisation (HSE, 2016a).
Types of Boards in Ireland
Currently in Ireland there are an estimated 500 people participating on healthcare boards. The governing board leads the organisation using authority to direct and control provided by the owner and the legal act of formation (where applicable). They set initial direction and have the authority to act in the service user and services best interest. Governing boards function at arm’s length from the operational organisation. They focus on the big picture, future-oriented and act as a single entity.
There are a number of key policy documents and resources applicable to boards and executives within healthcare in Ireland (see Appendix 1 for a summary of policy context). When services do not have boards the CEO/General Manager and executive team take on this responsibility. There are different types of boards within HSE funded healthcare services which operate within the HSE Performance Accountability Framework see Appendix 2). These include:
Hospital Group Boards
Publication of The Establishment of Hospital Groups as a Transition to Independent Hospital Trusts (Higgins, 2013) led to the creation of seven hospital groups within Ireland. While the governance for Hospital Groups is currently in development and pending the necessary legal framework for hospital groups to perform their governance and assurance functions, interim arrangements are being progressed to establish Hospital Group Boards within the existing legal framework. Hospital groups are led by a group CEO who is legally accountable. These boards are created on a non-statutory basis and have an administrative capacity. During this administrative stage of the reform programme Hospital Group boards have no legal accountability in relation the Hospital the sole line of executive accountability for the group CEO is to the National Director for Acute Hospital Services. The boards are comprised of Non-Executive Directors with Executive Directors in attendance. Given the scale of these organisations, strong governance arrangements are critical to their success and to quality of care. This guidance document will take account of future arrangements as they emerge.
Voluntary Healthcare Provider Board of Directors (Section 38 and 39)
Many board members are on the boards of HSE funded Section 38 and Section 39 voluntary healthcare providers. These boards comprise of Executive and Non-Executive Director members (governance role – integrated corporate and clinical /care governance). Voluntary/non-statutory healthcare providers have a long history of providing health and personal social services in Ireland. These organisations vary in scale and complexity, ranging from large acute hospitals to local community based organisations providing social care services. There are a significant number of Section 38 Agencies - 24 voluntary acute hospitals and 22 social care agencies currently within the HSE Employment Control Framework (HR Circular 019/2017b). Section 39 Service Arrangements cover all voluntary and community agencies, other than the above, in receipt of funding over €0.250m. Traditionally Section 39 agencies have been involved in the provision of disability and social services in Ireland.
Some acute hospitals have an advisory Medical Board. It usually comprises of medical doctors who meet monthly/quarterly in an advisory capacity. This arrangement precedes the establishment of clinical directorates and is being changed as structures develop and evolve. Clinical directors lead each directorate and along with the chief clinical director are members of the executive management team.
Why is Governance for Quality and Safety so important?
The first Irish national study of adverse events in hospitals (Rafter et al., 2016) highlights the importance of shifting the focus towards quality and safety of care. A total of 1,574 randomly selected adult inpatient records from a sample of eight hospitals stratified by region and size across the Republic of Ireland in 2009 were retrospectively reviewed. The prevalence of adverse events in admissions was 12.2% to 15.5%, with an incidence of 10.3 events per 100 admissions. Overall 70 % of events were considered preventable. Irish adverse event prevalence is at the upper end of the range of other international studies (3% to 17%). This study quantifies the adverse event burden and provides an incentive to drive quality improvement. Achieving sustainable changes to quality and safety is not easy and requires a strategic, consistent and evidence informed approach at all levels in the organisation.
A report published by HIQA into the governance of patient safety within Tallaght Hospital (HIQA, 2012b) which focused partly on the role of the board, made a number of recommendations. Some of these focus on strengthening the arrangements to hold chief executives and chairpersons to account for the delivery and quality of the service. It also included a requirement for existing boards and executives of all health and social care service providers in receipt of state funds to assess themselves against the relevant recommendations within the report and to modernise the constitutional basis, composition and competency of such boards (HIQA, 2012b). Irish Boards can also learn from the experience in the UK, where Monitor (Independent Regulator of NHS Trusts) highlighted the following themes arising from their inspections of boards (2012):
- Leadership of quality is weak: Lack of awareness of quality indicators, lack of discussion and challenge, quality is not adequately prioritised.
- Failure to recognise a problem: Information provided to the board is insufficient to enable challenge/action (particularly proactive action) issues/risks are not communicated appropriately.
- Lack of assurance and challenge: Check and challenge of frontline compliance, the board has taken sensible actions but has no assurance process to check, the board has no mechanism to independently assure quality governance.
- Inadequate risk management: Inability to identify risk for itself and then put it right sustainably, too much reliance on third parties, ineffective risk management, lack of clinical engagement with some or all staff groups.
- Inadequate implementation of policies, procedures, protocols and guidelines: Effective implementation and appropriate use of policies, procedures, protocols and guidelines is not evident in practice.
There is a growing literature showing that hospital board activities matter for better, safer patient care (Botje, et al., 2013; Jones et al., 2017; Mannion et al., 2017). Board composition and board practices are found to be important factors related to quality and safety of care (Jiang et al., 2009).
Getting ‘Boards on board’ in Ireland
The benefit of board leadership in Ireland was recently demonstrated in a quality improvement project ‘Board on Board with Quality of Clinical Care’ (Mater Misericordiae University Hospital and HSE Quality Improvement Division, 2015). This project had an overall aim that the Board would individually and collectively get a picture of the quality of clinical care. The Board would have an understanding of same and act to hold the hospital accountable on the quality of clinical care delivered.
During the project the board and staff had the opportunity to meet with Sir Stephen Moss, former Chairman of the Mid Staffordshire NHS Trust Board to discuss how boards can ensure that quality and safety are priority agenda items for all board meetings. Based on his experience of leading healthcare boards responding to critical clinical incidents Sir Stephen Moss posed four questions for boards.
- If there is one lesson to be learnt, I suggest that people must always come before numbers. How is your board making this a reality?
- As a board, how do you ensure the right balance between strategy / operational issues in board meetings, and how do you use operational feedback relating to service user safety and experience to develop strategic intentions?
- How do you proactively seek out the views of the community you serve and how does the board use this intelligence to improve the quality of care?
- How do your board members get the evidence to assure them of the safety and quality of services you provide?
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