A Self-Assessment Guide for Health Care Organizations - IFC

Why are Standards Important
Why should private health care providers be interested in promoting
standards of quality, safety and ethics
Of course, the consequences of poor standards can be disastrous. Stories
of unethical business practices are increasingly common in the news
media and have resulted in the demise of individuals and whole health
care organizations. No hospital executive wants to find their hospital or
one of their staff in the news because of a patient being caused serious
injury or death.
Ethical and responsible conduct is not only important for public relations,
but it is also a necessary element in risk management. The reputation
of a health care organization is critical in influencing patients seeking
services. And, for those organizations aspiring to attract medical tourism,
a good reputation is imperative. Hospitals with good reputations also
benefit from lower recruitment and orientation costs, as staff retention
is high and the most qualified professionals tend to seek jobs with them.
Solid, supportive leaders who work closely with the staff to improve
standards also find that patient and staff satisfaction increase. These
outcomes create a sense of achievement and pride in the organization.
Quality improvement is linked to performance improvement because
improving quality tends to reduce costs. For example, when clinicians are
uncertain about the best course of action to take, they tend to do more –
e.g. more tests, more procedures and more observation. Therefore, health
care organizations that undertake more analysis and promote evidencebased
medicine are more likely to reduce waste. In fact, some health
professionals state that “the opposite of quality is waste” — and waste
reduction requires removing process flaws and non-value adding processes.
From a commercial perspective, all of these outcomes can translate into
financial dividends.
Governance and Standards
What is governance
Good governance is of fundamental importance to improving standards
of quality and safety.
Governance is defined as the rules, processes and laws by which an
organization is operated. Typically, there are two groups that make up
the governance structure of an organization:
These groups share the responsibility of setting the strategic direction for
the organization and for achieving its goals. They are accountable for the
quality of services and the safety of the patients, visitors and staff.
The leaders of health care organizations carry out the responsibilities of
governance through their planning, decision-making, and performance
management functions.
Principles of good governance
Principles of good governance include 1 :
Stakeholder
rights:
Integrity &
ethical behavior:
Disclosure &
transparency:
Performance
orientation:
Stakeholders include investors and
employees, as well as patients,
community members and
organizations, and vendors. Some
rights are accorded by law and others
may be established by the
organization. Stakeholders should
know their rights and have a means
of redress for violation of their rights.
Decisions are based on the values held
by an individual or organization. It is
important, then, that the
organization defines and agrees on a
shared set of values and code of
conduct 2 , such that decisions are
based on a common understanding.
The organization implements
procedures to independently verify
and safeguard the integrity of its
operating and reporting systems.
Disclosure of material matters
concerning the organization should
be timely and balanced to ensure that
investors and other stakeholders have
access to clear, factual information.
The organization should establish
indicators to determine whether goals
and objectives are being met. All
aspects, including financial,
management, and clinical
performance, should be measured to
provide an overall assessment of the
organization.
• the governing body (e.g. board), and
• the chief executive officer (or president) and senior managers.
In the case of health care organizations, clinicians (e.g. medical and
nursing staff) also play a key role in governance. For example, physicians
who provide care in a health care facility are normally supervised by
a licensed medical practitioner; accordingly hospitals have medical
directors to fulfill this senior management oversight role. By driving
the clinical decisions of the organization, physicians also control the use
of resources — such as medications, procedures and tests — thereby
making a significant impact on the business.
Responsibility &
accountability:
Mutual respect:
The leadership of a health care facility
is ultimately responsible for providing
safe, high quality care. It is
accountable for its actions to the
relevant stakeholders, e.g. investors,
health authorities, community, and
individual clients.
Leaders should demonstrate mutual
respect and civility with a goal of
building trust. 3
1
OECD (2004) OECD Principles of Clinical Governance, OECD Publications: Paris. Available at www.oecd.org/dataoecd/32/18/31557724.pdf
2
IFC’s proposed Code of Conduct for Health Care Organizations is included in Appendix I.
3
The Governance Institute. (2009) Leadership in Health Care Organizations: A Guide to Joint Commission Leadership Standards. A Governance Institute White
Paper. The Governance Institute: San Diego, Ca.
IFC Self-Assessment Guide for Health Care Organizations 7