From Ward to Board

Findings from the first phase of the project were published in From Ward to Board, and are summarised below.

Key points

• With the right support from the board, nurse executives can help to drive the clinical quality agenda at the highest level, helping to deliver improvements that make a real difference to the quality of care patients receive.
• Nurse executives are likely to have the greatest impact where the organisation has robust reporting processes around clinical quality in place, and where the boardroom environment is open and interested in the quality agenda.
  
• Crucially, the nurse executive needs a range of leadership abilities, skills and expertise. But boards also need to play their part by prioritising clinical quality at board level, and across the organisation.

Action points for boards

• Three key building blocks are needed: the right information, effective working relationships and governance systems, and strong clinical leadership and clinician engagement.
• A robust framework must be adopted to ensure that boards receive regular and reliable clinical information.
• They need to get the message across that improving care is everyone’s responsibility, and is not just down to clinical staff.
• Strong financial management is important: it's easier to focus on improving care when the organisation’s finances are in good health and there’s a readiness to respond to change.
• Boards should be clear about what types of clinical information they want and need in order to monitor improvements in care.
• Discussion of clinical quality should be given high priority on the agenda of board meetings.
• Chairs and chief executives need to work together to provide a strong lead on clinical quality.
• Clinical quality needs to be an issue of concern for the whole board, and not just rest with one or two members (who can often be the target of blame when things go wrong).
• Where the board delegates assurances about clinical quality to sub-committees or other structures, they must ensure these provide effective flows of information back to the board.
• Boards need to be more open about discussing patient experiences that fall below the required standards of quality and care. They also need to show that they’re willing to learn from mistakes and to act on what they’ve learnt to ensure they don’t happen again.
• This openness needs to extend to the public – boards should discuss difficult patient experiences during sessions that are open to public scrutiny, rather than holding them back for ‘part two’ of the meeting, usually held in private.
• The chair in particular has a key role to play in creating a culture in which the patient experience can be discussed openly.
• Non-executive directors should be prepared to probe and challenge their executive colleagues to seek the assurance they need that clinical quality is being prioritised right across the organisation. In order to do so, they need access to good-quality data.

What nurse executives can do

• Help to create the right environment to hold open discussions about quality.
• Lead by example and keep plugging the importance of quality of care to all departments and teams.
• Encourage discussion about what kinds of information the board needs and wants to know.
• Bring reliable data to the board and help to analyse and interpret it.
• Bring the patient experience (whether good or bad) to the board, in a way that will engage all board members (making use of ‘soft intelligence’ such as patients’ own stories).
• Help board members to receive negative feedback from and about patients by personally role-modelling appropriate and non-defensive responses.

To have the greatest impact at board level, nurse executives need to develop strong abilities and skills in the following areas:

• The nurse executive needs exceptional communication skills to be able to talk convincingly about the business of the whole organisation, not just about patient care.
• Strong interpersonal skills are required – the key is to develop a style, tone and body language that reflect authority, confidence and competence. It’s important to strike the right balance between using hard data about what’s happening, while still getting across personal accounts based on patients’ own experiences.
• The nurse executive must be able to draw on financial and business acumen, but also keep their unique clinical focus and their ability to communicate the patient experience at ward level to those running the organisation at board level. 
• It’s crucial that they build good relationships right from the start with key individuals, including the chief executive and medical director.

Putting Quality First looks at how NHS boards can make continuous quality improvement their top priority. These are our main observations from the second phase of the programme: 

• Clinical quality occupies a fragile position in many NHS boardrooms.
• Leadership, culture and having the right systems in place are critical to the ability of boards to focus effectively on the business of caring.
• Nurse executives need to develop their consultancy, coaching and facilitation skills so that they move from their traditional role of ‘doing’ to one of enabling others.

It  also sets out the top ten things that boards can do to sustain engagement with quality improvement in the longer term:

1. Set the context for engaging in quality – be clear about what quality means for your organisation, define its relevance to different aspects of the business, and be prepared for the fact that engaging with quality may at times be an uncomfortable experience.
2. Shape the culture and tone of your organisation so that clinical quality becomes the top priority – the board needs to adopt the right behaviours and leadership style, and communicate the value it places on quality to managers and staff, patients and families.
3. Develop a strategy for quality improvement or, at the very least, make explicit commitments in relation to quality.
4. Have a dedicated quality sub-committee to oversee quality assessment, quality improvement and quality assurance, and to reassure the board that these tasks are being fulfilled effectively.
5. Pay attention to dynamic administration, including the length of meetings, the volume of papers, and appropriate breaks. If the basics are not right, the board will not be in a position to give its full attention to quality.
6. Review the use of sub-committees and ensure that the correct breadth and depth of information regularly reaches the board.
7. Put quality at the top of the agenda for board meetings and devote at least 25 per cent of time to discussing quality issues.
8. Draw on a mix of both qualitative and quantitative data to form a rich picture of the quality of care being provided by the organisation, including using patient stories and information from ward ‘walkabouts’.
9. Make good use of clinical executives on the board and clinical leaders throughout the organisation to drive the quality agenda.
10. Develop the board’s capability to understand and promote continuous quality improvement – non-executives in particular may need support to do this, but also executive directors who do not have a clinical background. This may require building knowledge and skills in quality improvement approaches, quality assurance systems and data analysis.