B d G
Boards,
Governance, & Q
Quality
li off C
Care
among
g MinorityMinorityy-Serving
g Hospitals
p
Ashish K. Jha, MD, MPH
H
Harvard
d SSchool
h l off P
Public
bli H
Health
lth
VA Boston Healthcare System
June 28, 2010
AcademyHealth ARM
Background: Quality and Disparities

Americans often fail to receive the right care
 Modest
to large disparities exacerbate the quality
problem

C ffor minorities
Care
i i i concentrated
d
 Focusing
g
on these providers
p
mayy help
p reduce
disparities
Background: Governance,
Governance Leadership

Increasing attention on boards and governance
May be a lever to drive improvements in care
 Part of the fiduciary responsibility


Boards of high performing hospitals are different
More likely to be engaged in quality
 More likely to prioritize it as a board responsibility


We know little about what boards of minorityserving hospitals do regarding quality of care issues

Understanding priorities, activities can help guide interventions
Research Questions
1
1.
How do boards of minority hospitals engage in
quality visvis-à-vis nonnon-minority hospitals?

Specifically, how do board chairpersons perceive:




Their board’s training and expertise in clinical quality?
I
Importance
off clinical
li i l quality
li ffor b
board
d oversight,
i h CEO
performance evaluation?
Agenda
g
setting
g and specific
p
board activities
Disparities in Care
Methods
Focused on nonnon-profit U.S. hospitals
 Random sample of 1,000
1 000 hospitals

 “Minority”

hospitals:
Hospitals in top decile of proportion of elderly black patients
 “Non
“Non--minority”

hospitals:
National Sample from other hospitals
Analysis

National portrait
 Based
upon weighting
 Accounting for complex sampling design

Comparison of minority and nonnon-minority
hospitals
Results


922 Board Chairpersons oversaw 1,000 hospitals
722 responded to the survey
 Response
rate 78.1%
Characteristics
Minority
Non-Minority
Hospitals N=235 Hospitals N=532
P-value*
Small (<100 beds)
%
26 0
26.0
%
45 1
45.1
Medium (100–399 beds)
51.5
45.8
Large (≥ 400 beds)
22.6
9.0
Private
62.1
37.9
78.2
21.8
0 001
0.001
M j T
Major
Teaching
hi H
Hospital
it l
21 3
21.3
60
6.0
<0 001
<0.001
Urban Location
80.9
74.6
0.09
Proportion of Patients Who Are Black
45 0
45.0
47
4.7
<0 001
<0.001
HQA Quality Summary Score
82.0
84.4
0.03
Variable
Size
Ownership
Public
<0.001
Qualityy as a priority
p
y for oversight
g
Percentage of respondents reporting that quality of care is one of the top two priorities for Board Oversight. P-value = 0.09
Qualityy as priority
Q
p
y for CEO evaluation
Percentage of respondents reporting that quality of care is one of the top two priorities for evaluation of CEO
performance. P-value =0.05 for comparisons between minority and non-minority hospitals.
Influence of Board on Quality
Percentage of respondents who report that the Board is one of the top two influences on the quality of care
delivered. P-value =0.008 for comparisons between minority and non-minority hospitals.
Board Training in Quality
MinorityHospitals
Non-Minority
Hospitals
P-value
The Board Chair reports that the Board:
Has moderate or substantial
expertise in quality of care
68%
79%
0.04
Has a formal training for the
board that covers clinical quality
26%
36%
0.07
Board’ss Functions Around Quality
Board
MinorityHospitals
Non-MinorityHospitals
P-value*
60%
68%
0.13
Board has a quality
subcommittee
57%
66%
0.10
Board has quality dashboard that
it reviews regularly
66%
81%
0.001
Quality on agenda at every
meeting
Perceptions of Disparities
Minority
Mi
it Non-minority
N
i it P-Value
PVl
Hospitals
Hospitals
General Views
Exist in society at large
67%
50%
0.002
Vary among U.S. hospitals
59%
51%
0.16
14%
8%
0.05
At my hospitals
Disparities exist among my patients
Perceptions of Hospital Boards
Around Disparities
Minority
Mi
it Non-minority
N
i it P-Value
PVl
Hospitals
Hospitals
Activities around disparities
Analyzes quality data by race
11%
9%
0 58
0.58
Analyzes HCAHPS data by race
9%
6%
0.22
Cultural competency training
47%
34%
0.02
Discussion


National portrait of governance among minorityminorityserving hospitals
M d
Moderate
diff
differences in
i governance


True in nearly every area examined
Main findings visvis-à-vis quality of care:
N as high
Not
g a priority
p
y amongg minorityy hospitals
p
 Few boards have formal training
 Many minority hospital boards don’t:
don t:




Have a quality subcommittee
Examine dashboards
Stratify data by race/ethnicity
Limitations


Non-response bias
NonSelf--reported data
Self
There may be some sociallysocially-acceptable responses
 No independent verification


Limited to nonnon-profit hospitals


Over 80% of U.S. hospitals are non
non--profit
No way to assess causality between Board
activity
i i andd higher
hi h quality
li
Implications

Large number of minority hospital boards not
engaged
g g in quality
q
y
Don’t believe quality is a priority
 Lack of concern about disparities
p
in care at their institution
 Not based on data


Ample opportunities for improvement
Targeting information, data
 Formal
F
l training
i i
 Introduction of a subcommittee, dashboards

Acknowledgements

Alan Zaslavsky and E. John Orav


Hauser Center for non
non--profit governance & RX
RX-Foundation


for statistical input
For grant support
Arnold M. Epstein

Colleague, mentor, partner in crime