Incentives for Patient Safety: Holding Healthcare Executives Accountable

Traditionally, governing boards of healthcare facilities have focused more on the business and financial side of operations than on patient safety and quality. More recently, as a result of the patient safety movement, pay-for-performance plans, stricter regulations, and calls to action from organizations such as the Institute for Healthcare Improvement (IHI), the Leapfrog Group, the National Quality Forum, and the Joint Commission, governing boards are receiving education on patient safety and quality issues and becoming responsible for ensuring that their organizations perform well in terms of patient safety and quality. In addition, some facilities are holding chief executive officers (CEOs) and other senior executives accountable for meeting patient safety and quality goals by ensuring that some of their pay depends on it.

This article discusses the responsibility and accountability for quality improvement in healthcare organizations from the top down: from the governing board’s responsibility for overseeing patient safety and quality efforts, to CEOs’ and other executives’ accountability for meeting patient safety and quality goals, and to all other staff’s commitment to improving patient safety and quality as part of their job descriptions and performance reviews. In addition, selection of patient safety and quality measures, challenges to implementing such efforts, and the future of governing board involvement and executive accountability are discussed.

Patient safety and quality has only recently become a significant issue for healthcare governing boards. According to Robert M. Wachter, M.D., professor and associate chairman, department of medicine, University of California, San Francisco (UCSF); chief of medical service, UCSF medical center; and editor, Agency for Healthcare Research and Quality WebM&M and PSNet, the 1999 Institute of Medicine (IOM) report To Err Is Human got the focus on quality and patient safety started, but governing boards “didn’t automatically jump up” and focus their efforts on quality. “What the IOM report did was create a momentum that focused everyone’s attention on patient safety and quality,” says Wachter. After the IOM report, governing boards were starting to make efforts related to improving patient safety and quality, but they were often unaware of errors occurring in their organizations. However, several factors, including requirements for healthcare facilities to report events publicly, more aggressive efforts by the Joint Commission, and heightened engagement from regulators, “made the traditional board stance of ‘hear no evil, see no evil’ untenable,” says Wachter. He adds that a few healthcare organizations’ governing boards were engaged in quality at the time of the IOM report, but it was often because they either had a visionary leader or they had experienced a critical error. For most organizations, the focus on board involvement in quality efforts began about three or four years ago.

In 2006, IHI called attention to board involvement in quality efforts and executive accountability with its 5 Million Lives Campaign. The campaign strives to prevent five million cases of patient harm from December 2006 to December 2008 by recommending 12 interventions for participating healthcare facilities; one of the interventions is “getting the boards on board,” or getting governing boards fully involved in efforts to improve safety and quality. One way boards can do this, according to IHI, is to establish executive accountability for meeting specific quality improvement goals. In its Getting Started Kit for governance leadership, IHI states, “An activated board, in partnership with executive leadership, can set system-level expectations and accountability for high performance and the elimination of...