Because there are many requirements within the Conditions of Participation, it is beyond the scope of this article to explain the far-reaching topics that must be affirmatively managed to assure compliance.

However, there are Board Member “symptoms” of regulatory vulnerability that can be observed in “at risk” organizations.

1. The Board spends most of its time on finance and business development, and dedicates little attention to clinical operations, outcomes, or patient and physician satisfaction.

It is not surprising that Boards like to focus on the financials and business development. Most Board members are familiar with financial and business issues, but have little familiarity with clinical operations or the indicators of clinical performance. People, especially successful people like Board members, tend to spend time on things that they understand and have mastered. When talking about familiar issues, one feels comfortable asking questions and making a contribution to the discussion. But talking about finances isn’t going to ensure that the organization complies with the CoPs. While every business needs to be financially successful, the business of the hospital is, at its core, clinical. Patients, like business customers, aren’t attracted to a hospital because it has a great balance sheet. They come because the hospital can care for them and their medical problems. Finances are important, but a Board that focuses on finances to the exclusion of the primary business is acting like a Finance Committee, rather than a true Governing Body. Managing a hospital by just watching the finances is like managing a baseball team by watching the scoreboard. The scoreboard doesn’t help you win the game; it only shows that you are winning or losing.

2. The Board does not hear what physicians and nurses think about the quality of care.

Physicians and nurses have first-hand knowledge of the quality of care on a daily basis. While their perspectives may contain biases, their concerns are worthy of Board investigation. We know of one hospital that ignored Medical Staff complaints about poor nursing care until CMS made a finding of Immediate Jeopardy related to medication administration. Not all complaint reports are valid, but consensus opinions and concerns should warrant Board attention. Yet, rarely are clinicians’ opinions, especially unfiltered opinions, shared with the Board. Designing a pathway for physician and nurse input need not be complex nor undermine the authority of the senior management. For example, satisfaction surveys, which are conducted in the vast majority of hospitals, are a good route for aggregated data on physician and nurse concerns to be presented to the Board. Additionally, compliance officers and patient advocate staff members receive information on individual issues, but also can compile trending information for an annual presentation to the Board. The Chief Medical Officer and President of the Medical Staff are also very important sources of information and should routinely address the Board on the subject of physician satisfaction.

3. The Board never receives any bad or concerning news about clinical care.

Hospital executives generally want to show the Board how well the institution is being managed. So, they bring information to the Board that shows that everything is under control, as if to say, “Don’t worry. We’ve got great scores; we’re winning awards.” In these organizations, management rarely presents evidence that suggests problems. Boards need to penetrate the filtering of information. Even though most Boards don’t necessarily know what information needs to be presented to them relative to the CoPs, one sure warning sign is not hearing about bad events. Every hospital has suboptimal performance, “never” events (a list of 28 things that should never happen to hospitalized patients) and “near misses” (when bad things almost happen to a patient). These problems represent potential risks to the hospital’s compliance and reputation. Frequently, they also represent tips of an iceberg. Yet, at some hospitals, Boards are presented with information about awards and rankings rather than hearing about the problems. We know of a hospital that was recognized as a clinical leader by a hospital ranking system mere days before it was decertified by Medicare. Hospital executives should be presenting information about operational problems that are being addressed. If the Board doesn’t hear about them, the Board should ask “what else should we be measuring that hasn’t been reported?”

4. Information flow is tightly controlled and discussion is choked off.

Boards need to find out how information is shared within the organization. Organizations where mid-level managers are discouraged from discussing issues across organizational boundaries promote secrets and defensiveness. Containment, rather than problem-solving, becomes a dominant management effort. While peer review data is confidential, other operational information is widely shared in a transparent organization. Transparency demonstrates that there are no secrets, and the organization is committed to improving performance and correcting shortcomings. In addition, transparency allows for the constructive sharing of perspectives and ideas. For example, people who are not directly involved with a particular problem may be able to suggest a solution that is not obvious to someone deeply immersed in that situation. Innovation often involves transferring an application from one setting into a new setting. Consequently, organizations that control the distribution of information limit innovation and resources available for problem-solving. An atmosphere of tight control can lead to a culture of mistrust, cloaking suboptimal performance until issues fester and eventually explode.

5. Top-down discussions dominate meetings.

Higher-level people (e.g., CEO, COO, Board Chair) are the only vocal participants in management and Board meetings. Discussion from others is discouraged and limited to superficial comments and clarifying questions. Conflicting opinions are not welcomed, nor are inquiries about assumptions or alternative approaches. Meetings should not be social events, where everyone is supposed to uphold social conventions and appear to agree. Rather meetings should be held to broaden the analysis of issues. If meetings exist to “rubber stamp” existing management plans and actions, then there is no reason to bother with management or Board meetings. Effective Boards encourage challenging and provocative questions from members and executives. Such robust discussion clarifies issues. In fact, challenging ideas and assumptions is the primary value of group discussion. Many committees and Boards try to avoid disagreement because they fear relationship conflict. However, effective groups differentiate between task conflict and relationship conflict. In dysfunctional boards, clinical leaders (CNOs, CMOs, Chiefs of Service) are invited to present information, especially when it showcases outstanding work. But, they are usually carefully restricted in what they can say and generally are not invited to participate fully in discussion at leadership meetings. In these situations, discussions are limited to answering factual or “softball” questions, and open discussion is strongly discouraged.

RELATED:

Medical Staff: Are You Doing Enough to Ensure Compliance with CMS’ Conditions of Participation (CoPs)?