Keeping things straight as a board

Medical administration is a rewarding profession, but it comes with challenges. So what is it like and what should you do if confronted with a monumental administrative difficulty? This is the podcast that takes unfortunate scenarios. and explores the essentials of clinical governance to find solutions.

I'm Dr. David Rankin, a very experienced medical administrator and lead fellow with the Royal Australasian College of Medical Administrators. And this is Safeguarding Healthcare, the Essentials of Clinical. Today, keeping things straight as a board. I think we've got to be really careful on this. That's Dr. Peter Lothian, a medical administration veteran with extensive board experience.

He served as Group Director Medical Services and Clinical Governance at a large private hospital in Melbourne, Victoria. and was the Executive Director of the Hospital's Education and Research Institute. He currently serves on the board of a large private hospital and the Australian Cardiac Surgery Research Institute.

And I'm presenting Dr. Lothian with a difficult scenario. If you're placed in that extraordinarily rare situation, where there's something that you're really not happy about and it can't be resolved, then I think you need to consider whether you should resign from the board. In today's scenario, you are a non executive director on a large hospital board and the chair of the Risk and Audit Committee.

In preparing for the meeting, you note a report that shows a rather alarming increase in the number of cases of pulmonary embolas, or VTE, over the past three months. You can't find any mention of an investigation or action to address these findings in your committee papers. When you raise the issue at the meeting, you were told that the imaging department has a new machine that is diagnosing asymptomatic VTE in a higher number of patients.

You are concerned that management are not treating these significant complications with the seriousness you would expect, and that this may be placements at risk. I start by asking Dr. Peter Lothian what key issues this scenario raises. The key issue to me is And I'm taking this from the point of view of the chair and someone with clinical governance background. The key issue to this is the failure of management to investigate or follow up thromboembolism events.

And these can be, as we all know, extremely serious events and they're one of the documented hacks. The other question and whilst they say, Oh well, they're small and they're not a problem, we're not getting any evidence to be reassured that that is the case. So we need a whole lot more information. It also raises though to me, if that's the attitude to this important event, what's not being investigated or followed up?

or what's actually being hidden that is not reported at all. So it's sort of raising a whole lot of questions. And then it also raises though the bigger issue of what the director's role is in terms of ensuring governance of a safe

Aaron Powell That's the question I'd really like to explore, particularly as a medical practitioner. On a board, what's your role? The role of the board as a whole and it is a collective is the governance and by that I mean the monitoring and oversight of quality and safety and therefore the quality framework. But also we've got to r remind ourselves that even though I'm a medical practitioner The board has a collective responsibility for financial culture risk.

and both a collective and individual responsibility, certainly in my state, for bullying and harassment. And the key aspect of the board director is asking the health the right questions. There's a need to always be inquisitive and that's in all of those domains, not just in the domain of the equality and safety.

I think it's also really important though, and it's an important issue from the management who are preparing reports, that they realise that the board is comprised of directors with different skill sets and therefore they're likely to be one or two people who do have a background in this area. It's important for those people though to realise they're not managing the organisation. We just need to make sure we're asking the right question.

Can we explore that balance? The board gets this sort of high level report. And yet as a medical practitioner on the board, you really want to know the details. You're curious about the details. So what level of reporting do you need to give you that assurance that things are well managed as a director? It's an interesting question because I think it's a very important thing.

all of us in this sort of situation when we sit back would like more. But it's not necessarily what should occur. I think in general we need and as I say, it's particularly in regards to all of the members of the board have to receive and understand information, at least to an extent. So I think it's important we're preparing a report. that management are aware that they explain reasoning well

They use simple language, non-jargon language, and they don't use acronyms. Having said that, in general, the board requires high level reporting. We require sufficient information to provide assurance that the required responses to that information and events are occurring. and that changes are occurring and often that aspect you can get lots and lots of pages of reports without any really good evidence of what the management thinks. How they're assessing it or where they're going with it.

So for example, we require high level reporting across a range of indicators. to cover the scope of services. And you can do that pretty simply with performance indicators which are agreed to, with rag rating against benchmarking. Because as a board You really don't need to be focusing if everything's going really well on ninety percent of the items. You need to know that it is going well, but you only need to be focusing on those that are underperforming.

So on the underperforming areas from the indicators, we need much more information. We need information, as I said before, on how the management's interpreting it. what's been done and what's planned to be done and I think quite importantly time frames. We don't need all of the nitty gritty of management, but we do need to know that. I think we also need to have reporting of serious incidents and they will be sentinel events.

the ISAR ones and and some of the twos. We also particularly need to know if there are clusters occurring in some of the not so serious events. We need to know there's evidence of investigation. We need to know their recommendations. And then we need to importantly know that management are monitoring the implementation of the recommendations and I think the board needs to at least have a an oversight that that is occurring. But the information on the serious incident

Again, I don't believe should be very, very detailed. I think it needs to be a high level summary type of information and not the sort of information that the people managing it and running it are. And it's an interesting question that we often

are asked, you know, should we be told the name of an individual doctor or an individual practitioner or the name of an individual patient for that matter? And my answer to that, my v general view to that is no. I I don't believe that should occur unless it's a specific event in which the board has to make a decision regarding a specific person or event. I think also the board needs to know incidents and issues which produce or may produce a reputation or regulatory risk.

And in most organizations, the chief executive's report usually signs off on that. If you're not happy with management's response

As a director, are you able to undertake your own research? Can you go down to the ward and talk to the unit manager about how they're managing a particular scenario? I think we've got to be really careful on this. And this is where the separation of management from being a director of the organisation is. And directors should only work via the board and via the approved

systems in place at that organisation. And you know, the lead for this is the terms of reference of board and or board committees. In most organisations, the chief executive is the key contact between management and the board, and the chair has the key relationship with the CEO outside of board meetings when we're all involved.

Some terms of reference of board committees of Clinical Governance Committee, for example, may specify that the chair of the committee has a relationship with the executive sponsor of the committee. who may be, for example, the chief medical officer. Personally, that's the situation I'm in. But nevertheless, if I'm ever going to email or speak to the chief medical officer, I always let the chief executive know. Individual directors are able to and indeed should and I think must

conduct their own research outside of the organization to inform them on topics. For example, I do clinical governance but I also do financial and general governance updates and research. As a director, the issue that is always the question is what do you do if you're concerned about the response of management? I think the initial discussion should and must be at the board. You can ask to meet with staff to understand the risk and potential remedial actions.

but only with the approval of the CEO. If you remain unhappy with the responses of the CEO, then you should raise it with the chair of the board. And if you're placed in that extraordinarily rare situation, where there's something that you're really not happy about and it can't be resolved, then I think you need to consider whether you should resign from the board.

There are legal liabilities on board members and if you can't fulfil your role as a director, then you should consider whether or not you should continue being a director. A a very, very nasty position to be in. What about your reports? Can you as a board director say I don't like this report, your graphs aren't the way I want them, and direct how your reports should be presented? I certainly think you can say you're not happy with them and I certainly think you can make suggestions

as to how they could be improved or changed. As I say, the reports have to be in a format to which all the members of the board can understand. And you need to work if it's a board committee with the executive sponsor or with the CEO. to ensure that you have what you need and when necessary you continue to ask for additional information. Again, you gotta be careful you don't cross the line into actually management. You can make it clear that what you need to understand is being reported

as well as the scope of what is in the reports. But at the end of the day it is up to the chief executive who is responsible for providing those reports to provide them. And as I've said before, if that relationship's breaking down, then there are steps that need to be taken to look into it. You get all the numbers, all the graphs.

They look okay, but how do you know whether they're best practice? You only know best practice by comparing with others, quite frankly. It's a bit like everyone thinks they've got the sickest and oldest patients and the most complex patients. data is what you need. And so you request benchmark data and reports and there are a whole range of sources of benchmarking data. The problem with benchmarking data though, and management need to look into this

is that the question is how is the data collected? What are the definitions and are they like organisations? But nevertheless there are benchmarking reports. And one of the things from your organization's point of view is the reports against benchmarks over time. Because if there are problems with what I've just discussed,

then they're going to be there all the way through. So it's a question of how you're coping. There's nothing also to stop yourself looking for information to inform yourself. Publicly available reports but also You know, you have discussions with other organiz with people in similar roles in other organizations. They can be confidential. They don't have to divulge confidential information. But that unofficial discussion source of information which all of us

in our practicing lives have been involved with. You've got to be careful though when you're a director and you've got to be really careful that you're not representing yourself as a director of organization ABC, but you're doing it in your own capacity. I think also though it's important that we've got to accept that Irrespective of how we benchmark, there may be areas or there will be areas where we have that we're not quite doing as well in or could processes that could be improved.

So I think all healthcare organizations should have a rolling plan for external reviews of critical high-risk areas such as maternity and intensive care units. One of the challenges with benchmarking is it pulls you to the norm. some adverse events I think any adverse event in healthcare is to be avoided. And yet we know benchmark for things like urinary tract infections or VTEs even. can give you comfort that your organisation's performing at or better than the industry average.

As a board director, is that industry average something you should aim for? I totally agree with you. Things like HSMR can hide large numbers of underperforming areas, particularly for a big organization. But I would flip it a little bit. Firstly, you certainly don't want to be performing at less than the industry average. But that's not saying you're a quality organization.

So you need to ensure that significant events, even if they're small numbers, all of them become really important to investigate and need to be improved upon. You can look for supposed exemplar organizations, but they may only be exemplar in certain areas. But again, this is where the management should be doing this and I think they usually do do that. So direct chief medical officers, directors of medical services and clinical governance

They've got their own network. They know what works and w where people are performing well, where they're not performing well. as an organisation and I think y they need to be encouraged to come to you and say, you've got to ask the question, is this the best organisation? Should we be benchmarking against if we're private, only against private?

If we're a private, should we be benchmarking against the best public? I think you've got to ask those questions and see what the management's response is. Yeah, I think that's a really important thing. Are there other organizations that do it better? And how do we get to that get state? One of the tensions of being on a board is that boards tend to focus on financial performance.

It's all about the bottom line. Avatar and all sorts of other acronyms about financial performance drive the v vast majority of board activity. How do you make sure as a medically qualified board director that there's a balance between financial and clinical performance? I think that's a great question and I'd again just

toss up a balloon and say boards should be focusing more on strategy than they are on what's happened last week. But having said that, now to your question, all healthcare organisations need to be financially viable. to enable ongoing delivery of quality services as well as sufficient income to enable investment for ongoing services and development. Doesn't matter whether you're a not-for-profit or a for-profit organization or for a public service.

All organisations need to be in that situation. And from a director's point of view, that's a big part of our fudiciary duties. Having said that, in healthcare, I'm strongly of the view we also have an equal clinical governance duty to our patients and staff and organisation and the community from that point of view, to ensure patients' safety and quality

and ongoing improvement of healthcare services. So you do need to ensure that there is sufficient time and space for the clinical performance reporting and assessment. You've actually got to be an advocate. Each director, as I've said before, brings to the board a set of skills and knowledge. So education of board members in clinical governance I think must be one of the areas for the board to consider for their annual education programme. In other words, we have to make

all of the board directors aware that this really is a core part of our being and what we're doing? Yeah, absolutely.

I guess one of the challenges is how do you as a board director gain assurance? that management's taken appropriate action. So often we get all the numbers and when we ask, the response is, oh, we referred that to the hematology committee or we referred that to the anaesthetist. How do you gain assurance that the organization's actually going to address and the risk that you've become aware of. It's really at times it can be quite difficult because as I say, we're not managing the organisation.

But we do have oversight and monitoring. We need to look for improvement in performance indicators. We need to be always trying to improve the performance. Now the the difficulty with that is that most reporting to boards are indicators where things have gone wrong. So yes, it's nice to say I want to see a reduction in that. But there's only a certain amount of reduction and that occurs or is possible and as people say, Oh well we're performing within the tolerance limits we've set.

So the answer to that should be well is it time to reduce the tolerance limits? So it's again a question of just asking and being inquisitive. Registry data, registry reports, again, they're fairly or they're very high level, but they will identify if things are going wrong.

I think consumer feedback and representation is really important. We want consumers who are able to ask our management questions and who can add their voice to committee and I firmly believe to board committees in clinical governance particularly. By being there and asking questions and and they're quite different, but also complaints and general consumer feedback. We're looking for surrogates, but if they're there and if they're a problem.

I think I like to see evidence of cycles of improvement. I don't like seeing a black box response. Oh, we've referred it to so and so. Okay, why? When are they f coming back to you? What are you looking for as an outcome? And then I think in involvement of medical staff's really important and I know I've already said the board shouldn't be delving down, but there are ways you can get a taste for what the medical staff are thinking.

The Clinical Governance Committee that I chair, we actually have at each meeting one of the divisions of the medical staff, the head of the craft group, who does a formal, you know, a presentation. and we have discussion and they present what they're doing, they discuss where they've got outliers, they discuss what their quality activities are. And I think that's really

If you like, they're the people who are at the coal face. And so if we're look and they're focused very much on patients and so they will be good indicators of how the organization's performing. Like assurance that the clinical governance team have done their research, they've identified the problem, they've narrowed it down to a patient cohort.

And if you like, a responsible group of clinicians who's accountable for that outcome and they're engaging with those frontline clinicians. Simply saying the organization's got a problem and we're working on it doesn't give me as a director assurance. that they're going to come up with a solution. So the challenge is

as a director to have assurance that the organization has taken practical steps that will make a difference. Clinical governance, as we talked about before, is about culture rather than compliance. Just having accreditation and the big certificate on the wall. doesn't give me as a director assurance that the organisation is providing high quality health care.

How can we be assured that the underlying culture of the organization is a learning organization, a curious organization, and one committed to continuous improvement? Firstly I'd agree totally with you that accreditation is something you have to do for regulatory compliance, but it's in many regards it is just a compliance situation.

Culture definition well that's the million dollar question. If you ask a group of people, almost anybody group, directors, managers, doctors, to define culture you'll get mm-mm, not sure. It means many different things to different people. a range of items that make up culture. I think to be happy or not to be happy, but to get an understanding of the culture of your organization, quite frankly I think you do need to get out there. And I think board walk rounds.

Again, with the approval of the CEO organized are really important, but not orchestrated presentations. You want to be able to actually just go around and and meet people and you know, how's it going? Have they any issues? Are things going well, things not going well. Because they know what's going well and not going well. I think assurance though comes we need to know that there's a proper education programme in place. It needs to address a number of issues.

We need to know there's measurements being done. and there's some surrogate measures of culture. things like staff turnover, absenteeism, if they're high, they suggest that there's something wrong either with the culture or with how the management is m place is being managed. I like meeting and asking the medical staff as well as the other staff when we do board arounds. With terms of education plan, it's got to address the areas of which people think make up the safety culture.

such as instant reporting, open disclosure, no blame culture, or, as I prefer to call it, a responsible culture respect, bullying and harassment, complaints, management, etcetera. There's no single measurement, and likewise The education program has to be ongoing. You need to get reports that it's actually occurring and that it's being developed. Culture surveys are done, but I have to say I think they've got limited value.

They're usually done as part of a larger people survey type of thing. The response rate usually isn't all that high, but even when it is high it's, you know, rarely higher than fifty percent. So again something that's done. Over time though and you know, you can say well people who feel those type of surveys are likely to be people who think things are wonderful or have a beef.

with something. But that doesn't matter'cause over time with repeated surveys we know that that repeating a a survey takes that into consideration. But I also need to see a transparent reporting of incidents, investigations. and recommendations delving into those problems. So all the things we've discussed earlier about what we're wanting to see, I think that's an indication of culture as well. I think

Complaint management's really important. We need to know how complaints are tracking. We need to know major complaints. We need to see, or I like to see, that complaints are actually embraced. And they're seen as being you know, they might be annoying at times, but there seem to in the main, there seem to be people don't complain easily. They complain when there's a significant issue and

I really like it when I see the management seeing them and treating them as an opportunity rather than a chore. So that's it's this whole group of things that I think you've got to look at. Culture's very hard to measure. But I think that challenge.

is one we as directors really need to take on board. Penny, in summary, uh as a board director, what are the sort of things that that you look for in your board reports to make you to to give you assurance? that the organization's f functioning well and managing its risk. I think we need to see evidence at high level. And we need to receive appropriate responses when we ask the questions. I think we need to seriously consider what the risks are. We need to ask the organization, we need to

as a group with the management, they're the people who have to do the in all of the initial work. But then the board needs to be happy that yes, that makes sense. that there the risks have been identified, that there are problems with the risks and the consequences are identified, that there are actions and a plan that's clearly there to try over time to reduce the risk.

So and the problem with risk management always is well what should come up because in an organization like healthcare there's a huge range of risks. from the sublime to the ridiculous. And so it's really but it is really important that the key clinical and other risks are identified, clearly, transparently identified, and the actions that are underway are there. And that there's ongoing reporting of it. I like to though also see that medical craft groups are reviewing their data.

and they have an involvement in the quality process and that's where we find it really helpful to have the head of the craft groups presenting how they see it to the our clinical governance or in this case the audit and risk committee. And again, I do want to see consumer feedback and complaints. Not every one of them, as I've said, but I do want to see that they're there. And the bottom line though is it is a never-ending task.

And you never can be absolutely sure. That was Dr. Peter Lothian, a medical administration veteran with extensive board experience. And that brings us to the end of this episode of Safeguarding Healthcare. I'm Dr. David Rankin. Follow safeguarding healthcare free on Apple Podcasts, Google Podcasts, Spotify, or wherever you listen to podcasts. This podcast is produced by Sound Cartel for the Royal Australasian Columbia. Administrators.