Unifying Hospital Boards on Quality and Safety

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Tom Haederle
E Pluribus Unum - that's Latin for "out of many, one" - is the traditional motto of the United States and printed on the dollar bill. Out of many, one is also the goal for independent hospitals and their boards who merge into larger health systems and may face the challenge of maintaining safety and quality standards that are no longer just their own.

00;00;31;13 - 00;01;06;07
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Valley Health System serves a sizable patient population in Virginia. It was formerly six separate hospitals, all of which were governed independently by their boards. In this Safety Speak series podcast hosted by Sue Ellen Wagner, vice president of Trustee Engagement and Strategy with AHA, we hear how Valley Health System rearranged its governance system to overcome the hiccups of its growing pains and ensure that patient safety standards were kept up across the board.

00;01;06;09 - 00;01;18;26
Sue Ellen Wagner
Thank you Tom. Joining me for this podcast is Harry Smith, board chair of Valley Health System in Virginia, and member of the committee on Governance. Welcome, Harry, and thank you for joining me.

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Harry S. Smith
Thank you, Sue Ellen. Happy to be here.

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Sue Ellen Wagner
Great to have you. So can you tell us a high level overview of your health system?

00;01;26;21 - 00;01;58;29
Harry S. Smith
Be happy to. Valley Health System, and I've been involved with it and its largest subsidiary, Winchester Medical Center for 22 years. In two more years, I will retire. I will have termed out of Valley Health, and as a career banker, I have found health care to be - as a friend of mine said one time - you're performing God's mission. And I don't know of any organization in the world that does what hospitals and health care systems do to care for our population.

00;01;59;01 - 00;02;29;24
Harry S. Smith
So when I first started this journey 20 some years ago, I was on the Winchester Medical Center board, which is about 83% of the economic engine, the patient base of our system. We had five other hospitals. We did have a system, Valley Health System. We serve nine counties and a city in the northern part of Virginia. And some people will know it as the panhandle of West Virginia.

00;02;29;25 - 00;03;00;21
Harry S. Smith
So in addition to Virginia laws, rules and regulations, we also deal with West Virginia. So Valley Health System started back in the late 90s as starting to pull together a loose confederation of like-minded small hospitals to become a regional hospital. Over the years, 2 or 3 that we thought might come into that system actually sold to a for profit system, and that was their decision.

00;03;00;23 - 00;03;35;06
Harry S. Smith
So we ended up with the Winchester Medical Center, which is Level II trauma, to critical access hospitals and then three rural hospitals. It's been fun looking at this growth of this eclectic system of several different types of delivery in two different states. We realized early on, though, that we were somewhat disconnected, even though we had this holding company called Valley Health, we still had its board in six different hospital boards.

00;03;35;08 - 00;04;04;06
Harry S. Smith
And principally they were responsible for their hospital, their operations. They had their own president. For the most part they did some of their financial and some of their accounting, but a lot of that was at the system level. But they were really principally responsible for quality. And so I became more involved and then was on the hospital board at Winchester Medical Center and the Health System Board, I started realizing how complex this was.

00;04;04;09 - 00;04;39;01
Harry S. Smith
It should be more efficient, and we should be able to provide even better quality for our community. And how could we do that? And first is ask questions. One of the first questions I asked of our CEO was how many quality meetings? How many board meetings do you go to in a month? And it was astounding because remember, we had a quality hospital board meeting for each one of those, plus the system, and he was attending all of those, and each one was handling quality at a high level, but with its own standards.

00;04;39;04 - 00;05;09;03
Harry S. Smith
You can't take six hospitals that used to be independent and overnight, put them all under one system and say to their executive team and to their board, you are no longer independent. So that took a process of moving more functions to the system, which we started really with finance and then audit. They then were principally quality. Then it was, we've got to standardize quality.

00;05;09;03 - 00;05;41;12
Harry S. Smith
So Valley Health System hired its chief quality medical officer to system level. And then started working with the individual hospital presidents and their vice presidents of medical affairs to begin that process. As it started, we still were meeting a lot and I'm not sure really moving the needle as positively as we wanted with quality. So we then visited several systems, worked with consultants on how do we do this better?

00;05;41;15 - 00;06;06;29
Harry S. Smith
And what we came up with, what we did was Valley Health System then became the sole member of all of these separate hospitals. So we then evolved into one board, Valley Health System, which is the sole member of the six hospitals with one board. So early when they were independent hospitals, you had a lot of attention to quality, because that's pretty much what they did.

00;06;07;01 - 00;06;34;17
Harry S. Smith
Now it's one big board, not in each community, even though there's some community representation. How is it going to handle quality in a community that might be 70 miles away? That brought through the standardization process. And we did that at the Valley Health level, kind of just doing what we used to do, but now instead of 6 or 7 boards, it's one. Still wasn't working as well or as efficient as we thought.

00;06;34;19 - 00;06;57;27
Harry S. Smith
We then decided to form what we call QMAC. It's the Quality Medical Affairs Committee, which has the full authority of the board. The system board meets six times a year. Credentialing occurs more than six times a year. And we said the hospitals have to exist for credentialing. You just can't disband a hospital. It has to have a board.

00;06;57;28 - 00;07;37;20
Harry S. Smith
Well, its board is the Valley Health Board because it is a sole member-owned hospital. So representatives then of each hospital, their vice presidents of medical affairs, their lead administrators, their chief nursing officers, key physicians serve on the QMAC, Quality Medical Affairs Committee, which has the full authority of the board. And it meets monthly, and it has full authority to do credentialing to review all quality indices, KPIs and we then at the Valley Health Board, when we meet that six times a year, will open

00;07;37;20 - 00;08;03;00
Harry S. Smith
our meeting, will have a consent agenda. And let me go back, if I might, because in one of this morning's presentations talked about the board's priorities as days and days and years and years ago, it may well have been finance. I think we all understand our number one priority is quality, and we have taken a lot of the normal duties and responsibilities.

00;08;03;02 - 00;08;28;22
Harry S. Smith
Even the monthly financial report and the quarterly. And that's in a consent agenda now. So we don't have a long formal presentation on finance. So we save our time and our time is saved really at reviewing quality, educating the board on quality, but also taking time to educate. Our last meeting, we talked a lot about artificial intelligence and its impact on systems and quality and physicians

00;08;28;22 - 00;08;58;02
Harry S. Smith
and don't be afraid of it because it's just a tool. You still will have humans making those decisions. So I then chair the board. We'll go through the consent agenda of those items that used to take an hour or more. We then open the sole member meetings, and that's where the quality report flows up to our system. The chair of our quality committee and the chief medical officer for the system will make that presentation.

00;08;58;04 - 00;09;21;20
Harry S. Smith
And all this information is in our board package, and we have what we call an S-bar. You'll see the report. But then if you want literally the other 200 pages to go with that report, you can pull that up. That committee is populated, as I mentioned, from all of our hospitals are critical care. Our clinical administrators, our physicians assistants, nurse practitioners, chief nursing officers.

00;09;21;22 - 00;09;52;22
Harry S. Smith
So it's very well represented. And that's where the deep dive occurs. That's where the sausage is made. We at the system level who aren't on that committee have to have a very high level of trust, which we do, and have given that committee, again, full authority to act on the board for our quality initiatives, including credentialing. So I know I'm rambling, but just to give you an idea of what this committee does and then how we review it.

00;09;52;23 - 00;10;28;25
Harry S. Smith
So our QMAC committee reviews credentials. Our staff executive committee, which some would call their medical executive: committee minutes and reviews. Our performance improvement committee: harm scorecard quality scores, patient experience scores. They'll have special reports. They'll hear from our VHMG, which is our Valley Health medical group. That's the employed physicians. We have our entity presidents. There will have information that comes at a little bit of recruiting, is epic working as we would sentinel events, serious safety events.

00;10;29;01 - 00;10;59;21
Harry S. Smith
Again, this is for all six hospitals coming to one group. As I mentioned credentialing, we have advanced practice providers involved in that. We hear a report from each department: cardiology, emergency medicine, family, etc. Review in depth the Performance Improvement Committee which again includes harm patient experience. The annual quality plan which they review first recommend to the board. The board will review it, discuss it,

00;10;59;21 - 00;11;31;11
Harry S. Smith
at times we tweak it. That will become the annual plan of quality for our system. They look at falls, wrong site surgeries, lab issues, patient access, wound care. All of this happens on a monthly basis. You couldn't expect a board of 14 to 16 to really have that depth and level of knowledge to review every month, the thousands of hours that go into the details to come to that committee on a monthly basis, which typically meets for two to 2.5 hours.

00;11;31;14 - 00;11;40;23
Harry S. Smith
So they have figured out how to get this information. And what underlies that information is a tremendous amount of detail.

00;11;40;25 - 00;12;08;18
Chris DeRienzo, M.D.
Thank you for tuning in to this episode of Safety Speaks, the podcast series dedicated to patient safety, brought to you by the American Hospital Association. I'm Dr. Chris DeRienzo, the AHA’s chief physician executive and a champion of the AHA Patient Safety Initiative. AHA’s Patient Safety Initiative is a collaborative, data driven effort that lifts up the voices of individual hospitals and health systems into the national patient safety conversation.

00;12;08;21 - 00;12;40;18
Chris DeRienzo, M.D.
We strive to catalyze and connect health care professionals like you across America in your efforts to innovate and improve, and to bolster public trust in hospitals and health systems by helping you share your successes. For more information and to join the 1500 other hospitals already involved, visit aha.org/patientsafety or click on the link in the podcast description. Stay tuned to hear more about the incredible work of members of the AHA's Patient Safety Initiative.

00;12;40;20 - 00;12;47;13
Chris DeRienzo, M.D.
Remember, together, we can make health care safer for everyone.

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Sue Ellen Wagner
So that QMAC is a way to keep quality at that local community hospital level, and then weave it right up to the top to the system.

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Harry S. Smith
Absolutely. I'm not sure I'll say it's our challenge, but our opportunity now and this has been a ten year endeavor. But QMAC really in the last four years has come of its own to where the data, the conversation, the presentation, that's all very, very good. We still have some pockets though, where we could have better standardization of delivery of quality throughout our various entities, including our employed physicians.

00;13;29;11 - 00;14;02;12
Harry S. Smith
That's really the drive right now. We started in 2017 on a journey called High Reliability Organization, which is comprehensive, expensive in the short run, but will be very beneficial in the long run. And it's a journey that never ends. I think I've mentioned to you before, this really came from the Navy. And what does that mean? It means what happens 100% of the time should happen, and what shouldn't happen 100% of the time doesn't happen.

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Harry S. Smith
And that's not easy to do. But if that is your goal, if that is your mission, if you know that you want to do everything right. If you don't, you correct it, you learn from it, and then you have to have those standards across the system that everybody is operating in the same manner. And that's where we're finding still a little bit of some variables.

00;14;24;15 - 00;14;49;26
Harry S. Smith
The last thing they look at, and the most important thing that QMAC back presents to our board then would be our dashboard, our KPIs. This is approved. Our quality plan annually originates from this committee representing all of those constituents I mentioned earlier. Comes up to the board and is presented twice. Once - okay, here's what we think. You all chew on this for a month or two.

00;14;49;27 - 00;15;14;26
Harry S. Smith
We're going to come back and then receive formal board approval for our quality plan. In the last three years, the board has made a few tweaks. They never have just blindly accepted the QMAC report and quality plan. An example would be the mortality index. We were doing really, really very well on that. Because we were doing so well

00;15;14;28 - 00;15;33;22
Harry S. Smith
QMAC folks in executive management recommended, because the hurdle was already pretty high, that we should continue that for the next year. Board members said, we think you need to raise that. You've already obtained this level. And they go, yeah, but this is a great level when you look at peer. Yeah, but we think you can do better.

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Harry S. Smith
And they exceeded that.

00;15;35;11 - 00;15;37;11
Sue Ellen Wagner
Commend you for that. That's amazing.

00;15;37;14 - 00;15;58;23
Harry S. Smith
Thank you. And they did accept us. So currently we are looking at and this is where we had to tweak the mortality index. We look at whole house infection. We used to just look at sepsis. They made the change. I asked our quality medical officer, tell me what this whole house infection is. And he goes, well it's a new indices that CMS is looking at.

00;15;58;25 - 00;16;21;07
Harry S. Smith
And sepsis. We've got a pretty good handle on that in our system now. So we're now looking across the whole system i.e. the whole house at all infections not just sepsis. If we would see sepsis crop up, then we certainly would put a shining light on that and give that more attention. We are looking average length of stay.

00;16;21;08 - 00;16;48;04
Harry S. Smith
We think that is important, which ties a little bit into and we still have operating margin. And then last is engagement. Employee, outpatient, inpatient, ED - critically important to us. What people think about us, how do they feel about our quality. And we take that seriously. These are our major dashboard KPIs. And really only 20% of that is finance.

00;16;48;06 - 00;16;59;23
Harry S. Smith
You might say a little bit of length of stay is tied to finance. And I will tell you, a decade ago, 60% would have been financial indicators. Now it's 20%.

00;16;59;25 - 00;17;02;10
Sue Ellen Wagner
And the rest is quality or most of it.

00;17;02;13 - 00;17;27;15
Harry S. Smith
Most is quality. And again, working through that socially, politically and again when you're realigning boards and duties and we're wanting to get to a point where you never will get. And that's 100% perfection. But if that's your goal and if you can continue to improve on that goal, tweak it as you get there, then I think we've done our job.

00;17;27;17 - 00;17;47;15
Sue Ellen Wagner
Absolutely. Wow. So you've really described a great case example for other systems to follow and other hospitals. You're still keeping that quality local, but your reduced the number of meetings that boards have to go to. And that system is still seeing what's going on across all of your six hospitals. That's great.

00;17;47;17 - 00;18;12;27
Harry S. Smith
We are. We have independent trustees. The chair of QMAC has to be a trustee. Now we're lucky this happens to be a physician. So that's great. We have a trustee who is a nurse, actually dean of a nursing school who had been a practicing nurse. She is on that. So we have independent nursing validation. We then have several independent trustees who do not have a medical background.

00;18;13;00 - 00;18;33;08
Harry S. Smith
And we now require that members of the board who are not members of QMAC mandatorily have to attend at least one meeting a year. Because in one of our surveys a couple of years ago, members said they weren't sure that we were meeting our quality commitment. Those on the committee were going, what?

00;18;33;10 - 00;18;37;05
Sue Ellen Wagner
So you just weren't transferring the information more broadly.

00;18;37;08 - 00;19;13;20
Harry S. Smith
And we were bringing it up to the system board, but we were bringing it up through, you know, a monthly meeting report, but some probably weren't going to that S-bar or reviewing those 100 or so pages. Nor should they. They were newer learning how to trust this. Is it really working as we think it should? One way to get that is to have the experience of attending that meeting at least once during the year, to really see what these very dedicated professionals are committing to and doing, to continue to strive to improve quality, to again that 100% level.

00;19;13;22 - 00;19;37;27
Sue Ellen Wagner
It's a very important step to make sure that all your board members are knowledgeable about what's going on and understand. And I also think it's pretty phenomenal that you've modified the way your consent agenda is done, and you're talking more about quality. We talked earlier at the AHA Annual Meeting at our Age Friendly and Quality and Patient Safety program, how it's so important to have quality be front and center of your board members.

00;19;38;00 - 00;19;52;06
Sue Ellen Wagner
Any other words of wisdom for other boards in terms of what they should be focusing on, on quality and patient safety, or how they get buy in to make some changes to their board structure and how they should be talking about quality and patient safety.

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Harry S. Smith
I think the first is don't be shy that you don't know everything. You may not have a background in health care. That's where I think most of the apprehension might be. You have to be comfortable in giving up the perceived local control. You have to develop what your community, what your structure that will work for you and it.

00;20;19;29 - 00;20;49;01
Harry S. Smith
And I would say this would be more for those trustees that don't have that quality level of background. It's okay to ask a question. I mean, I'm a banker and I've started this years ago going, how many meetings do you attend and why are we spending so much time on this and why are we doing that? Getting involved in organizations like the American Hospital Association, attending meetings, listening to peers best practices.

00;20;49;03 - 00;21;14;08
Harry S. Smith
It really does help with efficiency, effectiveness. And it's okay to ask that question. It might not work for everyone. That's okay, but you can improve what you're doing in every single instance and circumstance in every part of this country if you just aren't comfortable with the status quo and just ask why, how, and maybe we can do things better, we found that you can.

00;21;14;10 - 00;21;19;06
Sue Ellen Wagner
Well, I think you've provided some great insights for our listeners, and I want to thank you for joining me.

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Harry S. Smith
Thank you, Sue Ellen.

00;21;20;26 - 00;21;29;05
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.