How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England

TLDR

Health systems worldwide increasingly hold boards accountable for care quality, yet little is known about how boards govern for quality improvement. The study aimed to examine how boards govern for quality improvement in 15 English healthcare organisations over 30 months and to identify characteristics of mature QI governance. Data were collected via 65 board member interviews, 60 hours of board meeting observations, and 30 sets of board documents, and analysed using a framework linking board practices to quality of care to map governance maturity. Boards with mature QI governance explicitly prioritised QI, balanced short‑term and long‑term priorities, used data for improvement, engaged staff and patients, fostered continuous improvement, and were especially enabled by board‑level clinical leaders.

Abstract

Health systems worldwide are increasingly holding boards of healthcare organisations accountable for the quality of care that they provide. Previous empirical research has found associations between certain board practices and higher quality patient care; however, little is known about how boards govern for quality improvement (QI).We conducted fieldwork over a 30-month period in 15 healthcare provider organisations in England as part of a wider evaluation of a board-level organisational development intervention. Our data comprised board member interviews (n=65), board meeting observations (60 hours) and documents (30 sets of board meeting papers, 15 board minutes and 15 Quality Accounts). We analysed the data using a framework developed from existing evidence of links between board practices and quality of care. We mapped the variation in how boards enacted governance of QI and constructed a measure of QI governance maturity. We then compared organisations to identify the characteristics of those with mature QI governance.We found that boards with higher levels of maturity in relation to governing for QI had the following characteristics: explicitly prioritising QI; balancing short-term (external) priorities with long-term (internal) investment in QI; using data for QI, not just quality assurance; engaging staff and patients in QI; and encouraging a culture of continuous improvement. These characteristics appeared to be particularly enabled and facilitated by board-level clinical leaders.This study contributes to a deeper understanding of how boards govern for QI. The identified characteristics of organisations with mature QI governance seemed to be enabled by active clinical leadership. Future research should explore the biographies, identities and work practices of board-level clinical leaders and their role in organisation-wide QI.