Leadership Matters
List quality and safety expertise as a top competency for new board members*
Receive continuous education on this topic*
Have some board members who are not confident in their skill to guide safety and quality oversight**
Board members do not feel their knowledge of safety and quality is adequate for their fiduciary duty**
*(AHA, 2019); **(Goeschel, et al, 2011)
Joint Commission Resources Can Help
As the role of the board and its members in quality oversight continues to expand, it’s more important than ever to prioritize the focus on your board’s effectiveness. CMS is putting a focus on board involvement, including that hospitals must develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program. The governance/board must:
- Engage in oversight of QAPI for all services provided, including contracted services
- Document board member attendance at board quality committee and that QAPI is included in every agenda and in board meeting minutes
- Approve a number of annual QAPI projects that represent the complexity of an organization
- Ensure the focus is on high-risk; high-volume; problem-prone areas
The Joint Commission’s leadership requirements note that the governing body is ultimately accountable for the safety and quality of care, treatment, and services in the hospital and provides the resources needed to achieve this goal.
*The use of Joint Commission Resources consultative technical or advisory services is not necessary to obtain a Joint Commission Accreditation award, nor does it influence the granting of such awards.
