Board Room Meeting

COVID-19 has brought into focus the role of the board in preparing organisations for crisis. In healthcare, the role of the board in clinical governance has led to even greater scrutiny regarding board performance.

Over the last six months, we have seen many large health services respond well to COVID-19. These organisations have leveraged strengths in clinical governance to minimise staff and patient harm. Conversely, we have seen clinical governance failures lead to tragedy. Quality and safety deficits have been blamed for COVID-19 cases and deaths in numerous Victorian and NSW aged care homes, with many residents transferred to hospitals to be cared for.

Healthcare and clinical governance will continue to be tested into 2021. Organisations will face further COVID-19 peaks, changes from several Royal Commissions, and the continued risk of future health events. In the spirit of ‘never wasting a crisis’, healthcare boards should learn from the current pandemic to better anticipate and respond to future change.

Feedback from Victorian healthcare directors in July revealed four key lessons for healthcare boards - the importance of identifying new risks and new ways of working, doubling down on clinical governance capabilities, and finding opportunities in a crisis.

New risks and new ways of working

Like many organisations, healthcare boards have faced complex new risks and changes to ways of working. Adapting to these changes has been critical to success in responding to the pandemic.

Directors highlighted a swathe of new challenges faced, including unexpected expenditure and workforce-related issues. Effective boards identified emerging risks quickly and monitored key indicators, e.g. COVID-related staff absences and personal protective equipment (PPE) supplies. Many boards increased cash flow reporting frequency to understand solvency in the face of unexpected expenditure.

Healthcare boards must proactively identify and measure new risks, ensuring management responds appropriately. Directors should consider their liability should they fail to do so, particularly when it comes to workplace safety. More than ever, healthcare directors face the possibility of employees suffering occupational harm – directors must do what they can to ensure a safe environment including leading a safety-first culture, much like a mining or building company would.

Board processes also changed rapidly. With executives working overtime on preparedness, many healthcare directors and chairs reconfigured what they needed from leadership. Most respondents noted they reduced non-critical reporting requirements and began proactively supporting executive morale and organisational culture. ‘Much non-core governance work was suspended, including some committees’, noted one chair of a large health service.

Reduced committee meeting frequency did not diminish the importance of communication between the board and management. Many chairs noted they took a lead in managing this. Several boards implemented brief informal daily or weekly briefings for directors.

External communication also became crucial, including with patients, residents and the public. Many boards and chairs worked proactively with CEOs to ensure relevant stakeholders felt reassured and informed, particularly in the aged care sector.

When facing crisis or change, there is much healthcare chairs can do to support management. This can start with changing board processes while supporting communication and morale. Directors, and particularly chairs, should consider what process changes introduced during COVID-19 should be continued beyond the current crisis and which processes could be improved in future.

Double down on clinical governance

Directors noted strong clinical governance was crucial to success during COVID-19. Improving capabilities and rigour in oversight was crucial for boards that felt they had room to improve in clinical governance functions.

Some boards spent time bolstering capabilities at the beginning of the pandemic. Several boards appointed new directors with clinical governance experience, or clinicians to provide a clinical perspective. No matter their level of capability, most boards heavily relied on expert guidance from external agencies including health departments.

If they have not done so already, healthcare boards should be reviewing their clinical governance capabilities. Matrices may include dimensions such as clinician experience, time in healthcare organisations, and experience in clinical governance roles previously. Healthcare boards lacking experience in these dimensions should consider a range of options to bolster capabilities.

Clinicians on boards or clinical governance committees can bring an ‘on the ground’ understanding of clinical governance, asking key quality and safety questions. Clinical governance consultants can provide input where experience is not otherwise available. Lastly, organisations can grow the clinical governance capabilities of existing directors through external training.

With capabilities in place, clinical governance functions must be confident their organisation is ensuring quality and safety. Clinical governance committees should ensure clinical policies are up to date with constantly evolving advice. New policies may be required to maintain a safe environment, such as those on pandemic leave or movement between organisations.

If there is any doubt as to the robustness of clinical governance structures, these should be tested. Management should be able to identify where responsibility lies for clinical governance across all clinical functions, risks inherent within each function, and actions that have been taken to ensure safety across organisations. While time consuming, these exercises can reveal critical gaps that need addressing.

Organisations with mature clinical governance functions should know with confidence that they have the right policies in place, that these policies are up to date, and most importantly that they are being followed. Data is critical on key clinical risks and key metrics should be updated regularly. Internal audits can be used to measure compliance, and external audits (particularly infection control audits) that may have been delayed due to COVID-19 should be made a priority. Random audits are a useful tool (e.g. measuring correct PPE usage) and data from these should be reviewed by clinical governance committees.

With the right experience, processes, structure and data in place, clinical governance committees should feel confident that their organisations are doing everything they can to ensure safety, even in the face of uncertainty.

Find opportunity in a crisis

Every cloud has a silver lining – COVID-19 is no exception. Boards with a culture of being open to opportunity have found ways to succeed during the crisis. Several community health services created new pop-up and at-home services. RPA Hospital accelerated ‘Virtual RPA’, enabling home monitoring of COVID-19 patients while unlocking a new model of care for use. A culture of opportunism can strengthen resilience through future crises.

Many boards have also found positives from their new ways of working. Healthcare boards reported being more cohesive and effective. Virtual meetings enabled boards to access an increased range of external experts. Positive changes from the COVID-19 crisis should not be lost, and chairs should reflect on how to codify learnings into long-term practice.

Where to from here

No matter how successful healthcare organisations have been at weathering COVID-19, there is no time for resting on laurels. Boards must resist the temptation to return to ‘business as usual’. Healthcare boards must learn from each other and become more resilient before we face the next major challenge. We have a responsibility to do better in future for our patients, clients, staff and communities.