Performance improvement and quality specialists know that regulatory compliance is about more than numbers. It is about using the numbers to identify opportunities to better meet patient needs and improve hospital performance relative to patient safety and quality of care.

Paying close attention to the “symptoms” listed below can help your organization detect early warning signs that might lead to major compliance problems in patient safety and CMS compliance:

Governance:

• Significant Board time is focused on finance, with little attention to clinical issues, outcomes, or patient and physician satisfaction. Even if scores are presented, little useful discussion follows.
• Data-rich reports are loaded with numbers, measures and graphs but do little to convey real clinical information. Clinicians rarely, if ever, provide Board presentations or engage in discussions about quality and outcome measures for patient care.
• The Board never receives any bad or concerning news on clinical care, even though all hospitals have suboptimal performance, never events and or near misses. Negative news is camouflaged or hidden.

Leadership:

• Information flow is tightly controlled or choked off from dissemination. Direct reports are discouraged from cross-organizational discussion or problem-solving. Administration is tightly organized into silos with little open flow of information.
• Only one voice (CEO, COO, Board Chair) is ever heard at management and Board meetings, with little discussion or questioning of the information presented.
• Clinical leaders (CNO, CMO, Chiefs of Service) present information, but rarely participate in discussions at leadership meetings.

Medical Staff:

• Hospital leaders manage the Medical Staff, speaking for them and minimizing their involvement.
• Medical Staff organization is highly siloed, with little cross-departmental communication and low participation on interdisciplinary teams.
• Only a few dominant Medical Staff leaders control organizational representation, governance structure and committee assignments.
• Medical staff leadership is comprised of the same few voices with little turnover or new blood to invigorate new ways of thinking.

Data:

• Data always looks “good,” all measures are consistently above average and opportunities for improvement are rarely highlighted.
• Quality management is focused on earning accolades and awards, rather than on directly improving patient care.
• Data is not used to change practices or initiate process evaluation.

As scrutiny by the Centers for Medicare and Medicaid Services (CMS) and state Departments of Health becomes more intense, compliance should be of greater interest to the hospital’s management. If you spot any of these warning signs in your hospital, it’s time to get hospital executives to wake up to the risks facing the hospital (as well as hospital patients).