Hospital Board Best Practices 
 

Quality and Patient Safety 
 
 
 
 
 
 

A Report

Sponsored by

The Association of Wa Public Hospital Districts

The WA S

tate Office of Community and Rural Health

Presented at

Wa STate Hospital Association

Annual Rural Hospital Workshop

Lake Chelan, WA

July 28, 2006 

Glossary

For this study, a governance oversight best practice was defined as: 
 

• Intentional work of the Board or a committee of the Board

• That occurs with a predetermined frequency

• Which brings focus and accountability to an important Board matter

• In order to insure quality and/or patient safety

Scope

      The scope of the study was to: 
 

1. Define governance oversight best practices

2. Identify (QPS) governance oversight best practices being used in the United States, and

3. Validate the practices with hospital CEOs and Board members of Public District Hospitals in the state of Washington

4. Communicate the QPS governance best practices to Board members and CEOs at the WA State Hospital  Association Annual Rural Hospital Workshop in Lake Chelan, WA on June 28, 2006 
   

Methodology

      The methodology involved ten (10) steps. 
 

1. Review of literature

2. Interview health system CEOs in WA and other states

3. Design an interview guide

4. Interview a representative sample of hospital CEOs in WA

5. Interview a representative sample of board members

6. Interview staff at The Governance Institute

7. Interview staff of The American Hospital Association

Center for Healthcare Governance

8. Develop QPS governance best practices from information gleaned through steps 1-7

9. Validate QPS governance best practices with CEOs at Administrator-Only retreat on May 4, 2006 at Cave B conference center

10. Present findings to trustees and CEOs at the Rural Hospital                                                                                          Summer Workshop in Lake Chelan, WA on June 28, 2006 

Findings

It was found that hospital governing boards implement best practices for quality and patient safety when they: 
 
 

1. Require management to have an up-to-date medical staff development plan

2. Review a report of the organization’s patient satisfaction scores against comparative data at least quarterly

3. Require major new hospital clinical programs or services to meet quality-related performance criteria

4. Review a report of the organization’s physician satisfaction scores against comparative data at least every two years

5. Review a governance self assessment for quality and patient safety annually 
   

Findings

It was found that hospital governing boards implement best practices for quality and patient safety when they: 
 

       6. Review a report of the organization’s patient satisfaction scores       

             against comparative data at least quarterly 
 

       7. Require major new hospital clinical programs or services to meet                

            quality-related performance criteria 
 

         8. Review a report of the organization&r