Audit of organ retention and post-mortem practices in Irish hospitals points to deficiencies in clinical and corporate governance

The Health Service Executive (HSE) in Ireland has published two reports relating to retained organs and post-mortem practices in Irish hospitals.

The first is an independent national audit of retained organs and post-mortem practices in Irish hospitals. Organs or tissues are sometimes removed and retained as part of a post-mortem examination, primarily to allow for analysis of the cause of death. In hospital post-mortem services, this follows a detailed information and consent process with families. Consent processes underwent significant change and improvement following public outrage in 1999 and 2000 about post-mortem and organ retention practices in the UK and in Ireland.

The national audit was led by Ms. Michaela Willis MBE, a former member of the Human Tissue Authority in the UK and former member of the Retained Organs Commission, which previously oversaw similar audits in England. Ms Willis conducted an independent audit of currently retained organs in the State both pre and post 2000 to assist the HSE in identifying areas of good practice and highlighting areas for improvement.

The audit found many examples of good practice in clinical governance relating to post-mortem services. In the course of the audit, however, specific issues arose at the Rotunda Hospital, Dublin, which required a separate investigation and report. This was undertaken on behalf of the HSE by a team chaired by Mr. Ian Carter, Chief Executive, St. James’s Hospital.

The Carter report found a range of issues at the hospital, which included weakness in consent policy and documentation, variations between the terms of the consent given by families and the post-mortems carried out, delays in carrying out examinations and delays in implementing family instructions for respectful burial of organs or tissues.

The report found that the issues at the hospital arose from individual professional practice, poor post-mortem systems and processes and weak management and governance oversight.

The Board of the Rotunda have assured the HSE that the clinical and corporate governance of post-mortem practice have been significantly strengthened in response to the investigation.

Download the audit and Carter reports here.

Irish investigation into patient safety concerns cites deficiencies in corporate and clinical governance

The Health Information and Quality Authority (HIQA) in the Republic of Ireland has published a detailed investigation report into the quality and safety of services and supporting arrangements provided by the Health Service Executive at the Mid-Western Regional Hospital (MWRH), Ennis.

The investigation by HIQA found “serious issues of patient safety” in the area of corporate governance and leadership at MWRH Ennis including:
- A lack of clarity around local accountability and the authority to make decisions with no single person at hospital level who is fully accountable for the quality and safety of services
- Limited systems in place for effective clinical governance in order to provide the necessary assurance for patients
- Risk management processes were not pro-active. Adverse events, complaints and claims processes were not formally integrated within MWRH Ennis and therefore the outcomes from these processes are not patient focused.

The report contends that it is unsafe to keep the service configuration at MWRH Ennis as it currently is. Consequently, in the interests of patient safety and quality, change for safety must happen. The report concludes that the findings are serious issues of patient safety that are at the heart of safeguarding the public and therefore the implementation of these changes is a priority and should not be compromised in the current fiscal climate.

The report provides two interesting, and potentially helpful definitions of clinical governance, viz:

• the framework through which all the components of quality including patient and public involvement are brought together and placed high on the agenda of each health organisation; or
• the behaviours, and systems and processes which promote accountability and encompass audit policies and procedures risk management incorporating complaints and incident management reporting and monitoring of the quality and safety of services behaviours including relationships and communication leadership of the staff managing and providing care.

 The full Report of the investigation into the quality and safety of services and supporting arrangements provided by the Health Service Executive at the Mid-Western Regional Hospital Ennis can be downloaded here.

USA report into ‘Competency-based governance’

The Center for Healthcare Governance, an American Hospital Association (AHA) affiliate, has released a report titled Competency-Based Governance: A Foundation for Board and Organizational Effectiveness. The report includes recommendations for hospital boards of trustees, educators and researchers to better understand and practice competency-based governance.

According to the report, any effective board members should be competent in at least 14 areas: accountability, achievement orientation, change leadership (defined as: “maintains an eye on strategic goals and values during the chaos of change”), collaboration, community orientation, information seeking, innovative thinking, complexity management, organizational awareness, professionalism, relationship building, strategic orientation, talent development and team leadership.

The report is available for sale here.

The report is mentioned in an interesting article titled ‘raising the bar for boards’ on www.modernhealthcare.com (click here for article – registration required).

Irish HSE board rejects good corporate governance?

An article in the Irish Times (7 March 2009) suggests that the board of the Health Service Executive (HSE) in Ireland is seeking to strip the CEO of the HSE of his authority by insisting on having the final say in the appointment of one of his reports – a new director of operations.

Such an approach would indicate a lack of understanding on the part of the board of the fundamental principles of good corporate governance and organisational control. Boards should govern effectively and not seek to ‘meddle’ in the affairs of management. Any board that seeks to diminish the authority of its CEO by making decisions normally reserved to him/her must, implicitly, have lost confidence in that CEO’s ability to manage. In most circumstances this would be a resignation issue for the CEO.

According to the Irish Times article, the HSE’s CEO, Professor Brendan Drumm, may consider resigning.

Read the full article here.

In the USA, hospital boards are leading the way on quality and patient safety

As part of the recently completed 5 million lives patient safety campaign by the Institute for Healthcare Improvement (IHI) in the USA, more than 2100 boards of over 4000 participating hospitals signed up for the “Boards on Board” intervention. In doing so, they were publicly embracing their responsibility for improving quality and patient safety.

Joe McCannon and James Conway from the IHI have written an article titles A new era for leadership of quality and safety in www.modernhealthcare.com

They say that as a result of the commitment demonstrated by boards, IHI and their partners working on healthcare governance were flooded with requests from board members for content, information, ideas, and help. And board members made great personal investments of time and talent. Thousands of trustees and executives went to the classroom, studied hard, and demonstrated relentless resolve. (After one recent nine-hour training session with nearly 200 board members and other executive leaders, more than half of those attending remained afterward for further discussion. They continued at their tables, with their teams, solving problems for patients and staff.)

Hospital boards and executive teams took on this challenge, when it has not been their traditional role practice, because they believed they must. Patients deserve it, standards-makers and regulators increasingly expect it, and they know medical errors can undermine the best-laid business plan. But, for the most progressive boards, a strong commitment to safety and quality also creates significant opportunities-for better patient outcomes, for managing costs (particularly with new Medicare reimbursement incentives), for gaining local market share, and particularly for bringing energy to professionals and staff who can reconnect to their own care-giving vocation.

Alongside executive leaders, the most progressive boards set clear organization-wide aims for quality that are transparent and that translate into clear action for every leader, clinician and staff member in the facility. Quality appears as the first agenda item in every meeting of the board and management. Quality meetings-once held quarterly, if at all-are now held monthly with a clear focus and priorities. Leaders are getting out on the floors, interviewing patients, families, and staff. They are observing barriers to progress and removing them. Expectations change, and a culture of quality and safety follows suit.

Further, McCannon and Conway cite promising examples of boards leading the way on quality and patient safety such as:

- At the Henry Ford Health System in Detroit, Mich., the board and executive leaders set a goal to reduce hospital mortality by 25% over three years, and they achieved it. With the board and leadership together at every step, they created the will, brought together the ideas and the plan, and then assured relentless execution.

- At the 159-bed Delnor-Community Hospital in Geneva, Ill., a “patient experience” story has been presented at board meetings since January 2006. Each story is specifically selected and connected to highlight a “Big Dot” or “Driver” measure on the Clinical Dashboard (i.e., “connecting the dots”). The story is told by a patient, a medical staff member and/or senior management, at the start of the meeting and usually lasts about 30 minutes.

- At one of the largest healthcare systems in the world, the New York Health and Hospitals Corporation, the board has set the goal of being the safest public hospital system by 2010 and has gone fully transparent on their key measures for every hospital.

According to McCannon and Conway, most of the hospitals that have adopted the “Boards on Board” intervention have not yet demonstrated this level of commitment, but a new trend is apparent. And, as a result of the 5 Million Lives Campaign and complementary governance initiatives, a permanent national learning network is now in place to help hospitals learn from and mentor one another on trustee accountability and additional important improvements.

 ”This mobilization could not be more timely. Tense external pressures-terribly difficult economic constraints chief among them-can distract organizations if their leaders lose resolve or fail to see quality as a force for organizational progress and prosperity. Instead they must make sense of competing demands, and give everyone in their facilities a sense of purpose.

“Hospital boards in the USA are now engaged as never before, and, more than ever, there is a belief that they need to lead the way.”

Read McCannon and Conway’s article here (free registration required).

‘Microgovernance’ – the latest fad to hit healthcare boards in the USA?

Here at Healthcare Governance Review we thought that with the introduction of Governance between Organisations, healthcare governance simply couldn’t become more of a ‘muddle.’

We were wrong.

Enter the latest fad to hit healthcare boards in the USA – MICROGOVERNANCE!

‘Microgovernance’ is the subject of a keynote talk by James E. Orlikoff at the US Center for Health Governance winter symposium on leading and governing healthcare organisations. The symposium, titled Rethinking Governance: The  Shifting Roles of Management and Governance takes place in Phoenix, Arizona on 15-18 February 2009.

Mr Orlikoff’s talk, aptly (?) titled ‘Finding Balance on Shifting Sands: Microgovernance and the Changing Roles of the Board and Management’, will examine the difference between governance and management. According to the symposium brochure, Mr Orlikoff believes that “As the forces and challenges affecting health care and the entire economy become more volatile and intense, the role of the board and the distinction between governance and management is quickly changing.There is a rapidly emerging new and necessary component of board work which at first glance seems less like governance and more like micro-management.Yet, this “microgovernance” is now a key and growing component of effective board work. [His] presentation will summarize and synthesize the trends that are driving this significant transition in governance, and outline how boards and CEOs can effectively re-examine and refine a unique and productive governance/management balance that is increasingly essential to ongoing organizational survival and success. It will outline the challenges facing boards which must also integrate microgovernance into their work and balance strategic governance with microgovernance to generate a robust and integrated system of effective governance in an unforgiving environment.”

Elsewhere on the symposium programme there is a presentation on ‘The Relationship between Governance Commitment and Clinical Outcome Performance’ by David B. Pryor,MD, Chief Medical Officer, Ascension Health, St. Louis, Missouri. Ascension Health has, apparently, “demonstrated remarkable clinical performance. As part of that work, they formally assessed the relationship between the commitment and involvement of Ascension Health boards to the quality outcomes observed. Dr. Pryor will describe the quality journey of Ascension Health and connect the outcomes observed to the key role of the board.”

Download the symposium brochure here.

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In the USA, a Joint Commission report finds that hospitals are showing gains in safety and quality

In some very critical areas, Joint Commission-accredited hospitals in the USA have steadily improved the quality of patient care over a six-year period, saving lives and improving the health of thousands of patients, according a Joint Commission report – Improving America’s Hospitals: The Joint Commission’s Annual Report on Quality and Safety 2008.

An analysis of National Patient Safety Goal compliance and hospital quality measures related to heart attacks, heart failure, pneumonia, or surgical conditions, provides scientific evidence of improved patient care.

There were some dramatic improvements over the six-year period of data collection, especially in providing smoking cessation advice. For example, hospitals provided this advice to 98.2 percent of heart attack patients in 2007 compared with 66.6 percent in 2002. Hospitals greatly improved their results from 2002 to 2007 in providing this advice to heart failure patients (from 42.2 percent in 2002 to 95.7 percent in 2007) and patients with pneumonia (from 37.2 percent to 93.7 percent). Other strong improvements included providing discharge instructions to heart failure patients (from 30.9 percent to 77.5 percent) and providing pneumococcal screening and vaccination to pneumonia patients (from 30.2 percent to 83.9 percent).

However, the report does show that, for the third consecutive year, not all hospitals deliver the same level of quality and that some hospitals perform better than others in treating particular conditions. For example, hospitals provided discharge instructions to heart failure patients on average 92.1 percent of the time in the highest performing state, but provided discharge instructions 56.5 percent of the time in the lowest performing state. The performance difference among states is greater than 10 percentage points on 12 of the 24 quality measures tracked by The Joint Commission in 2007. There are exceptions to this variability. For example, virtually all-99.1 percent to 100 percent-accredited hospitals in the United States report that they measure oxygen in the bloodstream of patients with pneumonia.

On some of the measures reported by the Joint Commision more than 90 percent of  hospitals perform at rates of 90 percent or more. “However, there is more work to be done,” says Mark R. Chassin, M.D., M.P.P., M.P.H., president, The Joint Commission. “Improvement is a continuous process and in health care especially, it’s one where the target is constantly moving. The wide range of performance on some measures serves as a reminder that we must continue to work to improve patient care.”

The performance results released in the 2008 report reflect The Joint Commission’s tracking of hospital performance on 25 individual quality measures reflecting the best evidence-based treatments. There are eight measures of care relating to heart attack, four to heart failure, eight to pneumonia, and five to surgical care. Data from more than 3,000 hospitals show:

- The heart attack care result improved from 86.9 percent in 2002 and from 94.4 percent in 2006 to 96 percent in 2007. (A 96 percent score means that hospitals provided an evidence-based treatment 96 times for every 100 opportunities to do so.)
- The heart failure care result improved from 59.7 percent in 2002 and from 84.1 percent in 2006 to 88 percent in 2007.
- The pneumonia care result improved from 72.3 percent in 2002 and from 87.3 percent in 2006 to 89 percent in 2007.
- On 11 of the 18 requirements of the 2007 National Patient Safety Goals, 90 percent or more of the 1,466 hospitals that received accreditation surveys during 2007 demonstrated compliance. National Patient Safety Goals provide strategies to prevent common health care errors such as medication mix-ups and surgery on the wrong body part.

Even with the improvements of the past six years, the report makes clear that more improvement is still needed. For example, treatments were still not being performed consistently in 2007 on some measures introduced in 2002:

- Discharge instructions for heart failure patients – only 27.5 percent of hospitals achieved 90 percent compliance
- Pneumococcal screening for pneumonia patients – only 38.6 percent of hospitals achieved 90 percent compliance
- ACE (angiotensin converting enzyme) inhibitor or ARB (angiotensin receptor blocker) prescribed at discharge for heart failure patients – only 57.7 percent of hospitals achieved 90 percent compliance
- ACE inhibitor or ARB prescribed at discharge for heart attack patients – only 68.8 percent of hospitals achieved 90 percent compliance

The Joint Commission has issued this report as part of its ongoing efforts to emphasize the importance of accountability and continuous improvement for hospitals, and to empower consumers with information that will make them more active participants in their health care. Hospital-specific performance on specific measures for Joint Commission accredited organizations can be found on Quality Check® at www.qualitycheck.org.

For a copy of the full Joint Commission report, click here.

In Ireland, the “HSE is placing clinical governance at the heart of its new structure”

The Health Service Executive (HSE) in Ireland is looking to improve patient safety and quality of care through putting clinical governance at the heart of the Irish health service’s new structure. So says a recent report by the HSE on a review of chest x-rays and CT scans reported by a Locum Consultant Radiologist at Louth Meath Hospitals from August 2006 to August 2007.

The review was prompted by a missed diagnosis in a small number of patients who later died from lung cancer.

The review found that 9 people in the care of Louth Meath Hospitals had their diagnosis of cancer delayed by some months as a result of radiological missed diagnoses. The delayed diagnoses had varying impacts on these patient’s care and treatment options, but included lost opportunities in relation to cure prospects, additional life-span and earlier palliative care. The delay in diagnosis led to worry uncertainty and distress for families and greatly reduced the time available to them to come to terms with the serious diagnosis and the impending death of their family member. In some cases this period of uncertainty prevented advance planning for and adjusting to the inevitable terminal phase of cancer. In the cases where a small chance of cure had been denied, by delayed diagnosis, the families concerned would have the added burden of trying to deal with that very difficult issue. This included the tragic impact on a family whose relative lost a major chance of cure for her cancer.

In response to the review, the HSE has initiated a project to enhance clinical governance in the radiological service in the north east hospitals group and therby improve patient safety and quality of care.

Download a copy of the review report here.

Launch of ACCA Corporate Governance and Risk Management Agenda and discussion paper ‘Corporate Governance and the Credit Crunch’

The Association of Certified Chartered Accountants (ACCA) will launch their ‘Corporate Governance and Risk Management Agenda’ at the House of Lords on 17 November 2008. Attendance at the event is by invitation only.

ACCA’s ‘Corporate Governance and Risk Management Agenda’ sets out ten principles for corporate governance and risk management which ACCA believes are fundamental to all systems of corporate governance that aspire to being the benchmark of good practice. They are intended to be relevant to all sectors, globally, including healthcare.

ACCA will also launch their discussion paper ‘Corporate Governance and the Credit Crunch’ at the 17 November House of Lords event.

Healthcare Governance Review readers can download a copy of the discussion paper ‘Corporate Governance and the Credit Crunch’ here. The paper contains, on pages 14 and 15, details of the principles of corporate governance and risk management contained in the forthcoming ACCA ‘Corporate Governance and Risk Management Agenda’.

The key principles are as follows (and further detail is provided in the above paper):

1. Boards, shareholders and stakeholders share a common understanding of the purpose and scope of corporate governance
2. Boards lead by example
3. Boards appropriately empower executive management and committees
4. Boards ensure their strategy actively considers both risk and reward over time
5. Boards are balanced
6. Executive remuneration promotes organisational performance and is transparent
7. The organisation’s risk management and control is objectively challenged, independently of line management
8. Boards account to shareholders and, where appropriate, other stakeholders for their stewardship
9. Shareholders and other significant stakeholders hold boards to account
10. Corporate governance evolves and improves over time

Following launch, the ‘Governance and Risk Management Agenda’ document will be available for download at http://www.accaglobal.com/governance

How healthcare boards can prioritise quality and patient safety

A new monograph from the Center for Healthcare Governance in the USA describes how hospitals boards can weave quality and patient safety into the fabric of their organisations.

In Putting Quality First: How Boards Can Make Quality Improvement a Higher Priority, the author, David Bjork discusses formal and informal processes boards can use for moving quality higher up on the organisation’s agenda, focusing on the components of performance management. The monograph also examines how less formal processes can be used to signal a greater emphasis on quality, and provides practical tips and tools boards can apply to improve quality in their own organisations.

For further information, and to order a copy of the monograph, click here.

The Center for Healthcare Governance is the American Hospital Association’s resource for governance information, tools and counsel to promote excellence in health care governance.

Connecting governance culture and hospital performance improvement

A freely downloadable ‘trustee workbook’ from the American Hospital Association’s Centre for Healthcare Governance encourages hospital boards to examine board culture and the board’s capacity to sustain a comprehensive hospital performance improvement programme.

The workbook suggests that boards review the following questions to understand their role and analyse their capability as a leader of performance improvement. The workbook further suggests that the board could also use these questions as a guide for discussing the organization’s performance improvement program.

1. Is your board enthusiastic about its own self-assessment process? Are board goals or an action plan for improvement developed based on the board’s performance evaluation survey?
2. Does your board have a formal process to evaluate the CEO’s performance in meeting predetermined goals? Do board members talk to the CEO about the evaluation in detail?
3. Does the board review and discuss a comprehensive, organized set of data, such as a scorecard or dashboard, to measure organizational performance improvement?
4. Is there a systematic board education process, including periodic retreats, with a focus on global health care trends and strategic issues? How does the board monitor and measure each trustee’s ongoing participation in board education?
5. Is the board’s work aligned with that of the CEO, its corporate structure, physicians and the community served? Do internal politics have a negative impact on the board’s tenor?
6. Does the board use its systematic performance monitoring mechanism-such as scorecards-and its education on global issues to develop a strategic position for the hospital?
7. Has the board analyzed the health care organization’s motivations for supporting performance improvement? Are there sustainable, intrinsic reasons to improve? Are the hospital’s public image, external requirements or financial concerns major drivers?

The workbook can be freely downloaded here.

Building an exceptional board – Effective practices for health care governance

The American Hospital Association’s Center for Healthcare Governance has published a report on building an exceptional healthcare board.

In 2007, the Health Research and Educational Trust (HRET), with funding from Russell Reynolds Associates and the Center for Healthcare Governance, convened a Blue Ribbon Panel to examine critical issues facing health care boards and practices that lead to exceptional governance. The BRP report includes the panel’s recommendations in specific areas, as well as sample tools and resources to implement them. It is intended to foster broader dialogue and sharing, among healthcare organizations and their boards, of perspectives and resources to further strengthen and improve health care governance.

Panel members included chief executives and board members of hospitals and health care systems, governance researchers and consultants and others with expertise in leadership and governance. They identified and focused their deliberations on five areas they believed were critical to effective governance:

- Being an Accountable Board: Earning and Maintaining the Public’s Trust;
- Building and Sustaining a Proactive and Interactive Board Culture;
- Laying a Foundation for Effective Decision-Making: Board Meetings and Information for Governing;
- Focusing the Board on Key Governance Priorities; and
- Clarifying Authority and Responsibility: The Buck Stops Where?

The report can be freely downloaded by clicking here.

Research report finds public release of performance results leads to improved quality of care

The Health Foundation has published a report, based primarily on research from the USA, that finds public reporting of performance results in improved quality of care.

In theory, according to the Health Foundation report, disclosing performance results increases the accountability of healthcare providers as managers will be concerned about maintaining their public image and increasing market share. It also motivates quality improvement activities in healthcare organisations, especially by targeting underperforming areas identified by the performance results. The report did indeed find that the public release of poor data was a major driving force in hospitals improving their quality of care. In New York, poor results also led to an increase in surgeons resigning.

The report also suggests that even in a country with an established market in healthcare, patient choice of hospital is not affected by poor results.

Download the report here.

In the USA, the Joint Commission issues its 2009 national patient safety goals

The Joint Commission has issued its 2009 national patient safety goals for hospitals, ambulatory care, behavioural care, disease-specific care, critical care, home care, laboratories, long-term care and office-based surgery.

The goals relate to:

1. Identifying patients correctly
2. Improving staff communication
3. Using medicines safely
4. Preventing infection
5. Checking patient medicines
6. Preventing patient from falling
7. Helping patients to be involved in their care
8. Identifying patient safety risks
9. Watching patients closely for changes in their health and responding quickly if they need help
10. Preventing errors in surgery

For full details of the Joint Commission’s 2009 national patient safety goals, click here.

View from the USA – Holding healthcare executives accountable for patient safety

An interesting article from ECRI Institute discusses the responsibility and accountability for quality improvement in healthcare organisations 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.

Download the article here.

USA: With surgical errors costing £750m per year, many states refuse to pay for ‘medical mistakes’

Separate reports on msnbc.com tell of surgical errors in the USA costing $1.5billion (approx. £750million) per year and of hospitals in 23 states saying they will shred bills for certain medical mistakes, including operating on the wrong body part or the wrong person, or giving someone the wrong blood.

These reports make very interesting reading. John R. Clarke, medical director of ECRI Institute, sponsor of Healthcare Governance Review, is featured in the ‘bill shredding’ report.

Read the ’surgical errors’ report here and the ‘bill shredding’ report here.

UPDATE 21/8/08: Re. surgical errors study, read AHRQ press release here and PubMed abstract here. Also, the World Health Organization (WHO) has issued a checklist for making surgery safer. Download the checklist here and read the associated WHO press release here.

Building a culture of patient safety through effective governance in Ireland

The report by the Commission on Patient Safety and Quality Assurance in Ireland is now published. Titled ‘Building a culture of patient safety’ the report sets out a governance framework for patient safety and quality in Irish public healthcare.

At 242 pages long, this is a comprehensive and extensive report (and it contains 219 mentions of the word ‘governance’ – Ed.).

The vision around which a health system-wide governance framework for patient safety should be based is stated in the report as “Knowledgeable patients receiving safe and effective care from skilled professionals in appropriate environments with assessed outcomes.”

Healthcare Governance Review spoke to Dr Deirdre Madden, Chairperson of the Commission on Patient Safety and Quality Assurance, about the report. In particular we asked her about the report’s focus on effective governance as a means by which a culture of patient safety and quality can be effected.

Dr Madden said that “Medicine is not a risk-free enterprise; errors occur in every healthcare system in the world. However, we must never be complacent about errors, and must recognise and face the serious consequences that errors have for patients, their families and the clinicians involved. We must develop a positive patient safety culture by putting in place structures and systems that ensure effective governance in our healthcare facilities based on strong and clear reporting relationships and delegated levels of authority, robust accountability mechanisms and patient involvement at all levels of healthcare decision making. We must ensure that the potential for error is minimised to the greatest extent possible by strong professional leadership on safety and quality, active participation in audit, and commitment to sharing lessons learned from adverse events. A system-wide approach to safety and quality will help to ensure that wherever a patient receives care, it will be safe and effective, delivered by appropriately skilled professionals in facilities that are well governed, fit-for-purpose and have patient safety as their paramount priority in all that they do.”

Readers are strongly encouraged to read the report, which, in the opinion of Healthcare Governance Review, paints the most complete and comprehensible understanding of healthcare governance that presently exists anywhere in the world.

Download a copy of the report here.

Related link.

Irish Investigation Report into the Pathology Service and the Symptomatic Breast Disease Service at University Hospital Galway

The Health Information and Quality Authority has published the report of its investigation into the provision of services to Ms A by the Health Service Executive (HSE) at University Hospital Galway (UHG) in relation to her symptomatic breast disease, and the provision of Pathology and Symptomatic Breast Disease Services by the Executive at the Hospital.

Ms A was a patient at Barrington’s Hospital, a private hospital in Limerick, but, as was the practice at the time, her pathology samples were sent to the pathology department in UHG for analysis. The Authority’s investigation focused on the services provided to Ms A by UHG, given that it is authorised to conduct investigations into HSE funded hospitals only. A separate investigation was conducted by the Department of Health and Children and Barrington’s Hospital into Ms A’s care in that hospital (published April 2008).

In relation to Ms A’s care, the main findings of the Report are as follows:

- Two different pathologists working in UHG misdiagnosed Ms A’s breast cancer – Dr B in September 2005 and Dr C, a locum pathologist, in March 2007;
- As a result of the misdiagnosis which occurred, Ms A’s treatment for breast cancer was delayed;
- There was no arrangement in place for pathologists from UHG to participate in multidisciplinary review of cases at Barrington’s Hospital and as a result, an important opportunity to correct for these interpretative errors was lost;
- Although UHG was paid for the service, the agreement between the two hospitals was based on an informal arrangement between clinicians, and no formal governance arrangements were in place to oversee the service.

To ascertain whether there was a need for wider concern about the work of Dr B and Dr C, and to ensure as far as possible that no other patient had received a misdiagnosis, the Investigation Team reviewed the caseload of the two pathologists. This entailed reviewing 200 breast histology patient cases reported on by Dr B and 747 breast and non-breast cytology patient cases and 123 gynaecological cytology cases reported on by Dr C. This review found that in the case of Dr B, a single interpretive error, the misdiagnosis of Patient A, occurred and there was no cause for wider concern about their work. The review of Dr C’s work identified 49 patients where the reviewers differed from Dr C in their findings. The discrepancies found in these 49 patients had the potential to affect the clinical management and care for those patients and therefore all patients were followed up by UHG and, where necessary recalled for consultation, further investigation or treatment. Of the 123 gynaecological cytology cases reviewed by the Investigation Team, 35 women whose specimens were reported on by Dr C were contacted for precautionary follow-up as a result of a difference of opinion between the review and Dr C’s reporting.

Although carried out according to guidance in place at the time, some aspects of Dr C’s appointment also raise questions for UHG and the wider HSE. A number of specific recommendations in the Report deal with this issue.

As in many countries, the current recruitment process for permanent, temporary or locum consultants does not include objective assessment of technical ability but relies on the subjective opinion of referees. Clear procedures for the recruitment of temporary or locum staff, including comprehensible guidance on the use of recruitment agencies and guidance on references should be developed and applied across the broader HSE. Such procedures are particularly important given the reliance on locum staff within the health services. The Minister of Health, Mary Harney, said: “The system’s over-reliance on locums, and the procedures used in recruiting them, is now being addressed by the HSE. The HSE is implementing a series of measures to strengthen its procedures for recruitment in this regard.”

Commenting on the Report, Jon Billings, Director of Healthcare Quality, in the Health Information and Quality Authority, said: “The fact that Ms A experienced two interpretive errors, separated by 18 months, by two different consultant pathologists serves to emphasise the importance of having fully functioning triple assessment and Multidisciplinary Team Meetings (MDTs) in place, irrespective of where the patient is cared for. Failure by the clinicians and institutions concerned to have such arrangements in place was a significant factor in her delayed diagnosis.”

“Overall, the Investigation Team found that the Symptomatic Breast Disease Services at UHG were well run – although it makes recommendations for improvements in the Pathology Department’s quality assurance systems. The Hospital was responsive once the interpretive errors came to light. Lessons learned by UHG in responding to this incident should be examined by corporate HSE to inform the approach adopted nationally,” said Jon Billings.

The Report makes 12 recommendations which it believes must be implemented by the HSE in order to safeguard the delivery of a quality service to patients. The Report states that the corporate HSE executive management team should nominate a specific Director accountable for ensuring the development of an implementation plan for these recommendations. This, it recommends, should include a clear timeframe with milestones. Progress against the plan should be made public and reported to the Board of the HSE.

 For further information, including access to the report, click here.

Irish report on ’system of governance’ for quality and patient safety imminent

According to the Irish Medical Times (18 June 2008) the Department of Health in Ireland has announced that the Commission on Patient Safety and Quality Assurance will publish its report on the licensing of public and private healthcare providers and services in July 2008.  Currently, there is no system of regulation for private healthcare providers.

The Commission will develop proposals for a system of governance based on corporate accountability for the quality and safety of health services, the Department stated. They will apply to both public and private providers, essentially creating one standard. The Commission will also devise:

* a system of leadership for clinicians and managers which would underpin robust corporate accountability for institutional and clinical performance;
* a statutory system of licensing for public and private healthcare providers and services;
* the process of quality assurance of clinical services (with an emphasis on clinical outcomes) for public and private healthcare providers and services;
* procedures for healthcare professionals and managers to anticipate risks and promote good performance through effective risk identification, near-miss and critical incident reporting;
* the governance of regulatory bodies in the health system and ways in which effective integration can be enabled between the various bodies.

The real signs of a strong board – a USA perspective

In an article titled ‘Leading from the Boardroom’ in the April 2008 edition of Harvard Business Review the suggestion is made that many of the criteria used by corporate governance ratings agencies to assess board performance do not have much to do with board effectiveness.

Professors Jay Lorsch and Robert Clark, respectively of Harvard Business School and Harvard Law School, conducted a survey of Fortune 200 companies in 2005 and found that three of the most rated factors concerned the specific background, knowledge and abilities of directors. Also among the highest rated factors were specific governance activities or processes, such as manageable board agendas, appropriate allocation of meeting time and timely dissemination of information to directors before meetings. Less favoured factors included structural attributes favoured by governance ratings agencies such as size of board, mandatory retirement age for directors and separation of CEO and Chairman positions. According to Lorsch and Clark “the search for talismanic indicators of [board] quality continues.”

In their article, Professors Lorsch and Clark also contend that “directors must lead from the boardroom.” Thanks to Sarbanes-Oxley, they believe that directors have become “more hands-on with compliance [issues.....and] more hands-off with long-range planning.” They say that “Directors need to do a better job of balancing compliance with forward thinking” in an effort to reduce longer term risk to shareholders.