The Board’s Role in Quality and Patient Safety

In the new era of focus on quality and patient safety, the hospital or health care system governing board's oversight is a recognized core responsibility.


In the new era of focus on quality and patient safety, the hospital or health care system governing board’s oversight is a recognized core responsibility. Indeed, it is central to everything the board does. The board has moral, legal, and fiduciary duties to monitor, evaluate, and improve patient care. Increasingly, boards are subject to regulatory and accreditation accountability.

There are vital levers board members can utilize and must embody to effectively fulfill this responsibility and support the organization in promoting quality care and preserving patient safety.

Setting the Tone: The hospital governing board sets the tone for the rest of the organization. An organization’s culture is comprised of the beliefs and patterns of behavior that become its norms. Boards play an important role in setting the tone and establishing an organization’s culture, as culture originates from the top. They must lead in creating a culture of safety and set annual quality and patient safety goals. Board members represent the community and every individual in it who may one day become a patient in the hospital and depend on the delivery of safe, high-quality care. Their commitment and emphasis on these aspects set the expectations for all staff members.

Policy Development and Compliance: The board is responsible for developing and approving policies, strategies, and goals for patient safety and quality improvement. These policies guide the organization’s efforts to enhance care delivery. The board should ensure that necessary policies are in place and are reviewed regularly. The hospital governing board is legally obligated to ensure that medical care is safe and that quality standards are met. The board ensures that the organization adheres to regulatory requirements and accreditation standards for patient safety and quality of care. The hospital governing board is also responsible for ensuring the organization’s leadership and staff submit an annual quality improvement plan; the board generally reviews and approves the plan. A quality improvement plan provides a framework for a collaboratively planned, systematic and organization-wide approach to improving patient care and organizational performance. The quality improvement plan is a valuable tool for tracking the hospital’s performance in high-priority areas, including patient safety, timely access to care, infection control, quality, and emergency management.

Resource Allocation: The board allocates necessary resources, including funding and personnel, to support quality improvement initiatives and patient safety efforts. The board may integrate quality and patient safety priorities and goals with fiduciary responsibilities. For example, the budget and use of financial resources should align with achieving quality and patient safety goals.

Monitoring Performance Metrics: The board reviews key performance metrics related to patient safety and quality, such as infection rates, patient outcomes, medication errors, and patient satisfaction scores. Regular review of these metrics helps identify areas for improvement. Data about errors and near misses should be collected and analyzed continuously to evaluate processes and identify areas for improvement. This analysis may focus on systems thinking – understanding a system by examining the linkages and interactions between the system’s components – and human factors. To track progress appropriately and effectively, well-run boards establish clear goals.

Risk Management: The board oversees identifying, assessing, and managing risks that could impact patient safety and quality. This responsibility involves understanding potential risks, developing mitigation strategies, and ensuring appropriate reporting mechanisms are in place. Quality and patient safety should be part of the board’s risk management conversation.

Workforce Oversight: The hospital governing board must hold the CEO and leadership accountable for implementing quality and patient safety strategies, reporting, and compliance. In the governance hierarchy, the hospital’s CEO is directly accountable to the board for quality and patient safety, and the board is responsible for monitoring the CEO’s performance. One method hospitals use to do this is by tying part of the CEO’s compensation or bonus to the hospital’s quality of care and patient-safety performance. The board can adopt annual incentive programs that reward executives for achieving year-end goals. Some health systems have long-term incentive programs encouraging leaders to achieve targets over multi-year periods.

Additionally, one of the board’s most significant duties is approving appointments to the medical staff, and physician credentialing is an essential step in the approval process. While the board may delegate this responsibility to a medical staff committee, ultimately, the board is accountable for the competency of the hospital’s medical staff.

Strategic Planning: The board should integrate patient safety and quality goals into the organization’s long-term strategic planning. Doing so ensures that improvement efforts align with the organization’s mission and vision. Identifying indicators and measuring progress are critical components of effective oversight.

Measures help boards prioritize areas of importance and identify opportunities for improvement. The board does not need to receive reports on all quality indicators monitored throughout the hospital. Instead, the board should receive a broad, representative sample of indicators that address hospital performance, including identified opportunities for improvement. There should be a rationale for selecting the measures presented to the board, and the board should understand the use of specific measures and what will be done with the information.

Education and Training: The board should promote ongoing education and training for staff members on patient safety practices and quality improvement methodologies. Learning is valued among all staff and leadership and enables the hospital to stay updated on best practices, learn from mistakes, and seek new opportunities for performance improvement.

If board members are to answer the challenge of achieving better, safer care and hold the hospital’s leadership fully accountable for quality and patient safety, they must fully understand the terms and concepts discussed in the board setting. Board members must carefully review and absorb the data presented in reports and ask appropriate questions. Beyond orientation, board members need ongoing education to stay abreast of new developments and trends in today’s rapidly changing regulatory environment.

Communication, Transparency and Accountability: The board should communicate with hospital leadership and staff to emphasize the importance of patient safety and quality, reinforcing the organization’s commitment to these principles. Open communication is supported by encouraging transparency in reporting adverse events, near misses, and quality improvement efforts. They must also hold leadership accountable for meeting quality goals and improving patient safety. A blame-free environment exists where individuals are free to report errors or near misses — unintended events that could have led to an adverse event but didn’t — without fear of reprimand or punishment. This level of communication and transparency requires high trust among employees. A culture of safety recognizes errors as system failures rather than as individual failures, but individuals are also held accountable for their actions. Collaboration is encouraged across ranks and disciplines to seek solutions to patient-safety issues and the reporting of those issues.

Ultimately, the board’s involvement in quality and patient safety oversight reflects their dedication to the well-being of patients and the overall success of the health care organization. There is no magic solution to improving outcomes; quality is related to consistency in performance and delivering the right care, based on scientific evidence. Improving quality and enhancing patient safety is a constant activity and the job of everyone in a hospital or health care organization. For the governing board, it is Job One: The board must be persistently vigilant in its oversight and should lead initiatives to improve performance and patient outcomes.