With the sudden appearance of new infections, along with the need for up-to-date information and corrective action, real-time decision-making has never been more important for the advancement of hospital operations. When there are delays, opportunities are lost, and patient safety is placed at risk.
Yet hospitals can sometimes take too long to make important decisions, due to the lengthy review process of their committees. Initiating a new policy or changing an existing policy may require six months to a year, as change can often require the review and approval of multiple committees. Usually, the larger the hospital is, the more convoluted and difficult the process can become.
Hospitals can move from a complex committee structure to a system of decision-making that is more nimble. But such a change will require strong CEOs and administrative teams committed to moving hospitals forward for meeting the demands of a fast-paced health care world.
Hospital operations and committee structures differ from other businesses due to the regulations imposed by regulatory agencies. The overall mandate for hospitals is to ensure a flow of communication from their committees to their governing body. Some facilities call this process the joint practice, which is composed of the quality committee, the medical executive committee and the board of trustees.
The QC serves as one of the governing committees of the hospital reporting to the MEC and then to the board. The QC is responsible for accreditation by outside agencies such as The Joint Commission and state health departments, as well as for the granting of physician privileges, patient and environmental safety and performance improvement activities. The QC also analyzes and aggregates the hospital’s performance data and reports hospital data to the appropriate state and federal agencies.
The MEC is the primary governance committee for the medical staff of the hospital. Today, this committee includes both independent and hospital-contracted practitioners. It, too, reports to the board.
The board serves as the governing body of the hospital. It holds final responsibility for the quality of patient care and patient safety, for oversight of the executive administrative branch and for the financial success of the hospital.
Ancillary committees of various hierarchical levels have gradually evolved to help these three major committees gather the data they need. A complication arises, however, when these lower committees evolve into more than just data collection and reporting bodies, as when they are granted approval privileges by the major committees. In such cases, a request to the QC must first be approved by all of the hierarchical committees reporting to the QC. If the request from a lower committee is not approved by a certain higher committee, the request must be taken back to the lower committee for revisions. The revisions must then be resubmitted to the higher committee for approval. If approval is granted, the request is presented again to the next higher committee and so forth.
Because committees usually only meet once a month, the approval process can be a tedious journey for the requesting committee, depending on the number of intervening bodies between it and the QC, MEC and board. Getting approval from the three major committees can take three months or more, even if no revisions are requested.
Most committee meetings are scheduled to last for one hour. Usually, 15-30 minutes are required for a person to get to a committee meeting. It usually takes another 15-30 minutes to return from the meeting to the person's duties. So, a one-hour meeting actually consumes from 1½ to two hours of a person’s time. If that person has three meetings each week, he or she is required to devote 4½ to six hours to committee work per week, or 18 to 24 hours per month.
Instead of multiple meetings each month, what if the organization could set aside one day month for the reporting of all committees – up to and including the QC – in the same room and at the same time? This approach would entail an investment of seven hours of meeting time for each committee member, plus 30-60 minutes to get to and from this “expanded” daylong meeting.
To expedite the committee process further, a representative or small subcommittee from the MEC and the board might also be present at the meeting. These representatives could be given approval privileges and then report decisions from the meeting to their respective committees. This process would satisfy the overall mandate for hospitals to ensure a flow of communication from their committees to their governing body. The process would also facilitate the operations of the MEC and the board, as they would be informed of changes and progress being made in the hospital in real time instead of many months later.
Benefits of this approach would include a time savings of between 10 and 16 hours per month for each committee member. Information and data would be heard by everyone present in the room at the same time. If approval was needed for a certain request, all committees would be available to reach a decision on the spot. Requesting committees would save months going through the various committees for approval. Once the decision-making process was shortened, the hospital would be able to operate in a more real-time environment.
If a new committee is formed to solve a particular problem, it should be formed with the understanding that an automatic stop date has been set. Knowing the committee has a definite length of time to function creates a sense of urgency to accomplish its goal. If no movement is made toward solving the problem, the committee should be dissolved, perhaps with the establishment of a different committee with different members. Or perhaps the problem should be set aside for the time being. If, however, the committee is making progress toward a solution, an extension should be considered but with the understanding that another evaluation will be made at the next automatic stop date.
Staff members who are responsible for a particular problem should comprise the members responsible for its solution. Sometimes, other departments may want members to be added to a committee, but this decision may hinder rather than advance the committee's purpose. If a committee has too many members, each member’s ownership and responsibility for solutions becomes diluted. An ideal committee should not exceed 5-10 members in size.
Hospital leaders may need to think about how many people actually need to review and sign off on a particular issue. Are there redundancies or multiple steps that are not truly needed for the process? If your hospital has a director of research, for example, why is it not that person’s sole responsibility to accept or reject proposals for research? Why is it necessary for the review committee, the nursing committee, the QC, the MEC and the board to give their approval to each proposed study? By simplifying the process, by trusting people to do the jobs they were hired for, much time and effort by other members of the leadership team could be allocated to their own projects. The director of research could report on approved studies and their progress during the monthly all-day meeting.
A CEO might also consider replacing committee membership periodically or establishing a rotation system of members to bring in fresh ideas and perspectives. Rather than always requiring approval by committee, the CEO might also consider giving decision-making powers to one or two key people in certain cases.
Challenging the status quo
After a thorough examination of all of the committees in a hospital, the CEO might consider eliminating as many as possible, such as subcommittees of subcommittees. But why is it so hard for a hospital to abolish a committee, even one that is no longer functioning? Perhaps there is a certain pride and perceived social status for employees who are “so busy they can’t see straight.”
In an article in the Harvard Business Review, researcher Ron Ashkenas asks why hospitals are reluctant to simplify their organizational structures. The author describes how “being busy” is associated with “importance,” meaning that an employee’s skills and talents are viewed as indispensable.
Everyone wants to believe his or her work is important. If it is not, what is the justification for a person’s position? Managers tend to take ownership of their committees, and abolishing them is perceived as a reduction of the manager's influence and importance.
Reducing complexity in a hospital is a difficult process. Any mention of committee reorganization will be met with strong opposition. All committee chairs will be defending their right to exist, that is, their right to importance. CEOs and administrative teams need to stand firm on this issue and resolve to move their organizations forward.
Change is always difficult and is almost always resisted. But in the end, as the committee system becomes less complex, the risk of error for patients will be reduced. With a courageous and strong CEO taking on this challenge, more real-time decisions can be made throughout the hospital, creating a facility better able to compete in the fast-paced world of health care today.
Sharon L. Kurtz, R.N., M.P.H., C.I.C., is an infection preventionist in Allen, Texas, and a doctoral candidate at Walden University.