All About Governing Structures and Committees: Collective Decision Making in Healthcare
Introduction:
Hospitals represent challenging form of human organization. Many professionals and disciplines work side by side in these complex facilities.The collective decision-making process in healthcare is often seen as “a group of logically decentralized agents that cooperate to achieve objectives”. Decision making in healthcare is complex and often intricate. Participants of one decision-making process have to integrate multiple point of view that are not necessary in harmony. (1)The process of collaborative decisions affect the standard of these decisions and solutions in healthcare. The whole process should carefully involve assessment of merits of all the available options leading ultimately to the best choice of single solution. To achieve a collective and democratic proposal, there has to be a structured approach to decision making which involves various governing structures.
While firm leadership is imperative in any complex environment, collaborative models for decision-making and information exchange must be established and respected as integral components of the hospitals. (4) Committees play a key role in governance of the healthcare organizations. They are tools for combining distributed expertise and abilities of various parts of organization at format of one active and integrated unit. They often include members of the organization who are not on the board but allows them to get invovled and demonstrate leadership At the same time, committees can also be used as suitable method to prevent person dictatorship approach.(2) Hospital Management relies upon multidisciplinary committee structure to advise and guide the administration on issues arising from the operation of assigned roles.
Since present-day healthcare continues to be characterized by exponential and unprecedented change, the role of governing structures and committees needs to be extensively brought up to date to offer administrators and clinicians strategies to handle the real challenges faced today and tomorrow. Most organizations have the same committee structure from year to year with little thought given as to what the committees do or whether they are still relevant to the organization. As a result , the committees have vague objectives, committee meetings are often endless discussions with no work achieved, and the members of the committees become bored or frustrated. To avoid this, the organization and leadership should review and access its planned work for the board each year and establish only those committees that it will need. Organizations should avoid the inclination to form too many committees.(3) Each organization and board must determine which committee structure works best for it. The committee structure should be flexible and revise the changing needs of the organization. This strategy will be a great investment which frees the organization from doing things the same way each year.
As the role of hospital committees is increasing and their productivity and performance improvement is very important, the participation and necessary planning for the committees in advance is vital.(2) Kind of committees, committees function and the minimum period of holding committees should be determined by the healthcare organization. Adding new committees, number and kind of committee members, setting internal regulations of committees and choosing kinds of decisions should be determined by the hospital. The hospital should assess and analyze the structure and performance of the committees annually for the success and effectiveness of committee structure. The size of the committee must be practicable and attainable allowing for exchange of view and healthy difference of opinion, ideal being 5-10 members. (4) It is an obligation to ensure that the committees are well run with regard to attendance, policies, procedures, and leadership. The goals of various committees should be strategized, outlined, and planned at the conception of the committee. Presence of vital information is necessary for enhancement of productivity. Documenting the actions, setting the agenda related to hospital committee session and sending the copy to higher levels for planning is imperative for the success of the committee. Also, hospital committees should be more active in planning such as participating in setting strategic and operational programs in hospitals.
To enhance the effectiveness and improvement of the committee structure and functions following criteria should be reviewed:
Committee purpose, specific role, scope of activity and authority should be stated in the hospital bylaws.
Members must be chosen carefully and thoughtfully. It’s makeup should recognize the need for balanced input. Members should not be on more than two committees. There should be replacement or rotation of committee membership.(4)
The size must be viable permitting for clear discussion and healthy disagreement in a timely manner. Ideal size is 5-10 members.
Regular meetings should be held as stated in the bylaws. Meetings should be strategized, outlined and planned. It should have clear and valuable goals or mission which should be shared well in advance. A timed agenda helps keep the group on track.
Minutes should be recorded and finalized with the chairperson. Approved minutes should be circulated among all members of the committee for feedback.
Chairpersons of the committees should be appointed annually based on the performance. There should also be evaluation or assessment of committee performance.
Decisions of the committees should be implemented in a timely manner for outcomes.
A strong leadership with managerial and communication skills should not be underestimated to run a successful committee.
There are generally two types of board committees:
Standing committees or operating committees are the committees that exist year round. It is organized on continual basis and established in bylaws or protocols with set meeting times and structures.
The majority of the board’s work should be done through the working committees. Some boards have board members circle through the different committees to acquire a superior understanding while others let members to remain with the same committee each year to get a deeper understanding of the subject area and provide a greater service to the hospital.
Ad-hoc committees are the committees that transiently exist to accomplish a specific goal or purpose and then cease to exit. Once the objective is achieved the committee can be disbanded. An ad hoc committee may exist for less than a year, for a year or more than a year depending on the extent of work allocated to them.
The following list is not intended to propose that all of these committees should exist. It is ultimately up to the organization to determine which committees should exist and what they should do.
Executive committee: It is a small committee, three to seven member, designed to meet between board meetings and act as a bridge between CEO and full board. It is permitted to meet and take actions between board meetings when it is unfeasable to get the full board together. It reviews and reports on CEO’s actions.The members of the Executive committee are often on the committee because of the position they hold and enjoy within the organization. The chair and any vice-chairs are usually on this committee.
Audit Committee: This committee was infrequent a few years ago but is now becoming a standing committee at many organizations. It is a small committee, three to five members, designed to select and meet with auditor and the actual auditing of the board. Members of this committee should be financially well-versed as they may be charged with auditing the expenses of the board and the CEO. It should not include chair of finance committee or the board chairma
n.
Governance Committee: This committee contains both hospital administration and medical staff. The medical staff exists because it is accountable to the governing board for the quality of care that is dependent primarily on the practitioners who are granted privileges. The focus of the governance committee in the hospitals has evolved over the years. The focus from stewardship, civic duty and fundraising over the years has shifted to management oversight, financial management, and strategic performance. As such, the Governance committee is responsible for board recruitment, orientation and training of new members, regular self assessments, and board managements. It ensures that hospital policies and procedures are in place and in compliance with federal and state laws and meet the requirement of the Joint Commission on Accrediation of Health Care Organizations.
Finance Committee: Finance committee also called Budget committee is accountable for managing the hospital’s investments, setting compensation for staff, overseeing hospital’s performance in meeting the budget and presenting the information to the full board. Members of Financial committee
Membership Committee: The charge of the Membership Committee is to promote and advance the coninuing growth and diversity of membership. Along with staff it facilitates the development of the criteria for membership and credentialing. Membership committee usually oversees elections and work with staff to recognize and develop programs that meet the changing needs and requirements of the membership and credentialing.
Quality and Patient Safety Committee: This committee oversees quality improvement, reduction in medical errors and advances in patient safety. It assists with the development and implementation of an integrated hospital quality assurance plan. The committee studies patient care data, including safety and infection control, looking for trends, possible problems area or defeciencies and helps to evaluate any corrective action taken. In addition, the committee makes recommendations to the Board on any matter related to quality and patient safety referred to it by the board.
Ethics Committee: There has been a dramatic growth in ethics committee in US hospitals from 1% in 1980’s to 90% in 2000.(5) Another study iby Csikai at Pennsylvania 88% had ethical committee.(2) This committee develops and applies guidelines for ensuring ethical behavior and resolves ethical conflicts. The common responsibility of ethics committee is to teach and guide clinical staff and patients about ethical issues in patient care, initiate and establish institutional policies, and provide and arrange professional advice.(4) Members should have an understanding and recieve knowledge of mission and duties of the committee, ethical concepts, types of ethical hiccups, and health law. Difference between legal and ethical considerations should be carefully analysed. At the same time, Ethics committee should remain advisory and should not proxy for courts.
Program Committee: Program committee is involved with long-range development and planning of the hospital or organization. There are several committees dedicated to programs like Events, Technology, Education, Innovation.
Task Forces: Any group of people brought together to achieve a focused goal in a short amount of time. It can be for joint activities, new program development, special events etc.
Advisory Council: These are the groups that may exist for several years to oversee or advise items but have no governing power or responsibility. Examples include President’s Council or Professional Expertise Council.
Bylaws Committee: This committee ensure that the Bylaws of clinical satff are consistent with hospital’s operational needs, current Joint Commission Standards, and other rules and regulations of the hospital. The president of the clinical staff shall serve as Chair. The Bylaws Committee shall meet as necessary but at least annually and provide an annual report to the Clinical Staff Executive Committee. This does not need to be a standing committee.
Stategic Planning Committee: Every successful hospital develops short and long term growth through the constant evaluation of future-focused operational and financial goals. The strategic planning committee evaluates and assists in identifying opportunities for growth. The committee recommends and provides a plan of these goals for the approval from the board. It also reports its progress to the board. This committee works closely with Finance Committee, the Membership Committee, and the Program Committee.
Pharmacy and Therapeutics Committee: One of the targets of hospital in today’s environment is to find and discover treatments that provide positive clinical and cost effective outcomes. This committee is responsible for drug therapy management, education and monitoring. It is focused on the hospitals formulary both scientifically and ecnomically. Decisions are made to add or delete medications based on relative safety, efficacy, and effectiveness of the prescription drugs within a class presription drugs.(4) Thus the committee provides the unbiased clinical prospective on the preferred drug list.
The committee consists of Department medical directors, external physicians, pharmacists, consumer advocates and specialists as needed for drug class reviews.
Infection Control Committee: Every healthcare facility uses infection control committee as an intergral part in the care of its patients and employees. The role of the infection control committee is very multi-faceted. It is involved in planning, monitoring, evaluating, updating, and educating which will create the safest healthcare environment.(6) It lays general infection control policy and gives input into particular infection control issues like prevention and control of nosocomial infections. The objective of the committee is not to reduce the individual responsibility that each employee has, but to provide the leadership throughout the hospital. It helps to standardize infection control procedures throughout the hospital to control and maintain the hospital’s environment and ensures the same level of care in all departments. The committee consists of representatives from physician staff, nursing staff, infection control particitioners, risk management, quality assurance, members from microbiology, surgery, central sterlization, environmental services, etc to bring together the expertise and knowlwdge from different areas of healthcare and develop the best solutions.
Groupthink:
Groupthink is the social phenomena where people of the same group with similar opinions become more attached to their specific views and become less open to other concepts. Without allowing others with dissimilar ideas or building in systems into the groups and committees to force alternative views to be addressed, these groups can become entirely disinterested in improvement or changes that differ from their concepts of “correct”. The desire to fit in with the group can cause a type of “falling in line” known as normative conformity. Due to this conformity, even those who may disagree internally with the group decisions will not dissent due to fear of being rejected, allowing groupthink to continue. Therefore, groupthink is an incredibly detrimental factor to committees who hope to continually increase efficiency, efficacy, and their ability to “Keep up” with constantly changing medical science. Below is an example of a possible scenario where the effects of groupthink can lead to severe limitations in a committee’s abilities to function.
1) Organ donor
An organ donor committee reviews cases on which organs to send to which departments of the hospital. Many of the members hold similar opinions and, thus, tend to favor certain department’s needs over others. As time goes forward, the committee allocates increasing numbers of organs to their preferred departmen
ts. Due to no built-in mechanism to present opposing opinions, the issue is never rectified, causing severe inefficiency in the distribution of highly critical organ transplants.
2) IRB
An IRB at a local hospital have specific guidelines on the proper way to present an informed consent form. In an attempt to be systematic, the group agrees that any form not following their guide will not be approved. Soon after, the group believes that their method works sufficiently and no further modifications or alternate formats should be perused. Due to the small number of possibly dissenting voices and the effects of normative conformity, no member is willing to challenge this protocol, even though they have valuable ideas that increases the readability to average patients. Thus, the clinical trials approved by the IRB continuously have Informed Consent forms that lack as much clarity as possible.
3) Ethics Board
A hospital’s ethics committee has a training policy for new members, which brings the member up to speed on ethical guidelines. The group created this policy years ago, and suggested that they revisit it “when necessary”. Despite changing clinical practices and insurance formulas, the board feels confident in their dated ethics training, and new members are too few and feel too “green” to suggest alterations. Due to the board lacking a system where they are forced to review the policy at specific intervals, the hospital is left with dated ethics that do not agree with or even cover current medical treatments.
VIGNETTES
Most nonprofit organizations have too many committees doing too little work. The fact is adding a committee is more common than eliminating a committee. Too many committees not only drain human and finanicial recources but also paralyze the process of decision making and delay the response or action.
Vignette 1- An example of an organization with too many committees, where decisions become paralyzed in the process and response to market forces is unacceptably delayed.
As surgeries for organ transplants in HIV-positive to HIV-positive patients become more prevalent in the American Medical system (Bichell, 2016), a hospital is interested in creating standard operating procedures (SOP) and implementing such surgeries in their own procedures. After a decision is passed at the higher executive boards, multiple committees begin creating SOP’s for HIV-surgeries in their particular field. Due to large sums of committees that require each to report back on suggested SOP’s and clear any changes made, a circular pattern of reviewing, changing, reviewing again, and declining to pass the SOP’s begins to form. Even then, if an SOP is approved by these committees, additional, more executive-level groups must approve the procedures. Meanwhile, the continuously growing desire for these surgeries begin to be filled by other hospitals in the local area, allowing them to gain a foothold as the “go to” institution.
Vignette 2 – An example of an organization with optimized committee structure, where decisions flow smoothly and response to market forces is prompt and well measured.
Seeing the potential for organ transplants in HIV-positive to HIV-positive patients being viable in multiple areas of their hospital (Bichell, 2016), the executive board passes the approval for Standard operating procedures (SOP) to be designed and implemented by various departments. These department based committees then create ad hoc committees to design the SOP’s in an efficient and timely manner. Task Forces are set in place after SOP creation to follow the implementation of the surgeries. Once the programs are smoothly operational, higher up executive committees view the entire process and approve it. Thus, this hospital manages to catch onto the growing demand for the surgeries and becomes the “go to” institution for HIV-positive to HIV-positive organ transplants
Leadership:
Committees must have effective leadership. Good leadership is more than important for the success of the healthcare organization. It is criticalMany physician leaders assume their leadership roles because they are acknowledged as respected clinicians. Good clinician does not automatically translate into a good leader. Leaders should have the opportunity to participate in leadership trianing and development.
THIS COULD BE IN THE SUMMARY
In today’s contemporary healthcare where healthcare is delivered in diverse settings like outpatient clinics, medical poly clinics, urgent care centers, ambulatory surgery centers, or individual hospitals, productivity is the main concern of these organizations providing health services. The truly successful healthcare organization is characterized by better solutions to achieving high quality patient care while simultaneously ensuring the success of both staff and the hospitals.