Title: Effective Board Governance of Safe Care: A Mixed-Methods Study
Funder: Department of Health (England)

Abstract: Setting / contextGiven the diversity of views and approaches to understanding Board Governance of patient safety and the intrinsic complexity of any relationships between Board governance and patient safety processes and outcomes we propose to adopt a multi-method approach integrating a national quantitative survey of Board practice and national performance datasets on patient safety processes and outcomes with intensive case study methods and qualitative approaches to explore Board dynamics and the governance of patient safety in four hospital Trusts. This will allow us to examine these relationships in both breadth and depth. To ensure that the study is grounded in the latest empirical work and new threats to patient safety associated with the latest system reforms we will undertake a prior scoping study to inform the empirical work.(a)Scoping studyIn a fast changing policy context there is a need to identify and contextualise broad literatures related to the governance of patient safety especially in times of organisational / system transition. Our approach combines database searches and literature review with interviews of leading policy advisors / commentators (n = 10) to identify emergent challenges and threats to patient safety which will inform our empirical work. Full details are given in the 20-page outline of research.(b)National analysis of Board practice and patient safety To capture the breadth of associations between Board practice and patient safety we will conduct a national quantitative survey based on the annual dr Foster Hospital Guide Questionnaire which has been completed since 2001 and uses a standardised format approved by The Review of Central Returns (ROCR). The national survey of hospital trusts in England will also include the Board Self Assessment Questionnaire (BSAQ) to be completed by hospital Board members (executive and non executive). Analyses will explore statistical associations between Board activity and patient safety processes and outcomes; descriptive statistics will be obtained for each relevant survey question and multivariate analysis undertaken to explore differences in Board activity and patient safety processes and outcomes. This will be done by linking the main questionnaire and BSAQ data with hospital administrative data including the Secondary User Service Commissioning Data Set (SUS-CDS) and the NPSA’s patient safety incident reports. Data analysis is further detailed in the 20-page outline of research(c)Case StudiesWe will utilize a comparative case-study design across multiple study sites to generalise theoretically from within and between cases (Yin 1994). Cases will be selected on the basis of performance trajectory over the last 3 years on a range of safety / quality indicators selected from the dr Foster database including measures of death rates compliance with NPSA guidelines and incident reporting. We will work with four case study sites:• two hospital Trusts with a ‘downward’ performance trajectory as indicated above; • two hospital Trusts with an ‘upward’ performance trajectory as indicated aboveOur focus is to explore (a) how the management and governor Boards hold the organisation accountable to patient safety / risk [conformance’]; (b) how they strategically respond to patient safety events [‘performance’]; and (c) the context of the health economy within which the acute case study sites are operating. Full details of our theoretical framework are included in the 20-page document.(a) Conformance:- Non-participant observation of management and governor board meetings (n-32 (x4 each of Management and Governor Boards x4 sites). Analysis will follow the framework developed by Hajer (2004) to reveal the ability (or otherwise) of governors / managers to ensure action. Full details of the analytic framework are available in the 20-page supporting document.- Semi-structured interviews (n=80 [20 x4 sites]) with representatives from each tier of governance (governor management board) to explore participants’ experience of Board meetings relating to patient safety issues. Informed by our theoretical framework we will inductively analyse data to explore participants’ self-understanding and follow up issues revealed during observation data and documentary analysis of board meeting minutes relating to performance and conformance. - Semi-structured interviews (n=40 [10x4 sites] sampled from clinical / corporate / combined governance committees directorate managers patient representatives and lead clinicians to explore the impact of board discussions on practice. Within each case study we will focus on one of two specific ‘tracers’ related to patient safety activity and follow how this is dealt with from Board to ward. The tracers are: how the hospital deals with implementation of actions around Rapid Response Reports; and Patient Safety Alerts. (b) Performance:- In addition to the observation and interviews in 1 and 2 above we will undertake semi-structured interviews (n = 40 [10x4 sites]) in response to emerging critical incidents. We will follow how each case study site deals with a patient safety incident from ‘Board to ward’ drawn from the typology of categories listed in the ‘Learning from Serious Incidents’ national framework. The exact sample depends upon Trust governance arrangements and will include management clinical and patient representation. This will enable us to explore in real-time board reactions to events; the ability of the Boards to mobilise action in the face of difficulties; to identify the ‘reach’ of proposed actions into the wider organisation; and explore the impact of interventions. (c) Context:- Interviews with key staff from commissioners related to the governance of patient safety (n= 20 [5 x 4 sites]) will be triangulated to generate a ‘360 degree’ understanding of the dynamics in each health care economy. These will focus on the governance of patient safety across care pathways for the two ‘tracer’ activities.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE