Question: Of every six Medicare patients admitted to the hospital for nonsurgical reasons, one will return within 30 days.  Beginning October 2012, CMS started reducing pay to hospitals for such readmissions.  About 80 times a week, U.S. patients undergoing surgery experience mistakes that safety advocates say should never happen.  Whose job is it to address these concerns:  the Medical Staff, Hospital Administration or the Board?

Answer: The easy – and correct – answer is that it’s the job of the Medical Staff, Hospital Administration and the Board.  And, most importantly, that these three groups work together, not individually.

But, the strongest legal answer is the Board.  That’s because the Board is legally responsible for the conduct of the hospital as an institution.  That’s from federal law, state law, and accreditation standards.  And, emerging research shows that Boards can make an enormous difference in improving quality and patient safety.

How to do this?  By working with the Medical Staff and Administration in developing good policies, procedures and criteria for credentialing, privileging, peer review and ongoing performance improvement.  By spending 25% of Board time on quality and patient safety.  By creating a Board Quality committee.  And these are but three actions; there are many more.

These are all important improvements that are a necessary part of a hospital’s mission.  But there is also the hard reality that unless a hospital can shape (or reshape) itself to be paid on its quality outcomes, and not just its procedures, that hospital could find itself in a poor fiscal position to care for its community.  And, that is definitely on the Board.

To learn about the Board’s role in quality, and how critical this role is, join HortySpringer attorneys Linda Haddad and Alan Steinberg for an audio conference on July 2, The Board’s Role in Quality and Safety.