Effective board governance of safe care: a (theoretically underpinned) cross-sectioned examination of the breadth and depth of relationships through national quantitative surveys and in-depth qualitative case studies

Background: Recent high-profile reports into serious failings in the quality of hospital care in the NHS raise concerns over the ability of trust boards to discharge their duties effectively. Objectives: Our study aimed to generate theoretically grounded empirical evidence on the associations between board governance, patient safety processes and patient-centred outcomes. The specific aims were as follows: (1) to identify the types of governance activities undertaken by hospital trust boards in the English NHS with regard to ensuring safe care in their organisation; (2) in foundation trusts, to explore the role of boards and boards of governors with regards to the oversight of patient safety in their organisation; (3) to assess the association between particular hospital trust board oversight activities and patient safety processes and clinical outcomes; (4) to identify the facilitators and barriers to developing effective hospital trust board governance of safe care; and (5) to assess the impact of external commissioning arrangements and incentives on hospital trust board oversight of patient safety. Methods: The study comprised three distinct but interlocking strands: (1) a narrative systematic review in order to describe, interpret and synthesise key findings and debates concerning board oversight of patient safety; (2) in-depth mixed-methods case studies in four organisations to assess the impact of hospital board governance and external incentives on patient safety processes and outcomes; and (3) two national surveys exploring board management in NHS acute and specialist hospital trusts in England, and relating board characteristics to whole-organisation outcomes. Results: A very high proportion of trust boards reported the kinds of desirable characteristics and board-related processes that research says may be associated with higher performance. Our analysis of the symbolic aspects of board activities highlights the role and differences in local processes of organising the governance of patient safety. Most boards do allocate considerable amount of time to discussing patient safety and quality-related issues and were using a wide range of hard performance metrics and soft intelligence to monitor its organisation with regard to patient safety. Although the board of governors is generally perceived to be well-meaning, they were also considered to be being largely ineffective in helping to promote and deliver safer care for their organisations. We did not find any statistically significant relationship between board attributes (self-reported) and processes and any patient safety outcome measures. However, we did find a significant relationship between two dimensions of the Board Self-Assessment Questionnaire and two specific-and-related national staff survey organisational ‘process’ measures: (1) staff feeling safe to raise concerns about errors, near-misses and incidents and (2) staff feeling confident that their organisation would address their concerns, if raised. We also found that contracting and external financial incentives appeared to play only a relatively minor role in incentivising quality and safety improvement. Conclusions: Our research is the first large-scale mixed-methods study of hospital board activity and behaviour related to the oversight of patient safety in the English NHS and the key findings should be used to influence the design of future governance arrangements as well as the training and support of board. Funding: The National Institute for Health Research Health Services and Delivery Research programme

Decentring patient safety governance: case studies of four English Foundation Trust hospital Boards

This chapter focuses on the decentred governance literature as a framework to examine the enactments of Board governance of patient safety at several Foundation Trust hospitals within the English National Health Service (NHS). It describes conceptual framings of corporate governance that may inform local practices, and outlines the regulatory context of patient safety governance within the English NHS. The chapter explores the situated agency of Board members in relation to the governance of patient safety within case study sites. It also focuses on the findings from a larger National Institute for Health Research funded study of the governance of patient safety. A range of competing conceptual framings have been used to understand the governance role of Boards, and which inform the situated agency of local actors. Local hospital Trust Boards were first introduced in the English NHS in 1990. Public service reforms in England typically emphasise performance and accountability, rather than renewal and entrepreneurship

Meta-regulation meets deliberation: situating the governor within NHS foundation trust hospitals

NHS Foundation Trust (FT) Hospitals in England have complex internal governance arrangements. They may be considered to exhibit meta-regulatory characteristics to the extent that Governors are able to promote deliberative values and steer internal governance processes towards wider regulatory goals. Yet, while recent studies of NHS FT Hospital governance have explored the role and experience of FT Governors and examined FT hospital Boards to consider executive oversight, there is currently no detailed investigation of interactions between Governors and members of hospital Boards. Drawing on observational and interview data from four case-study sites, we trace interactions between the actors involved; explore their understandings of events; and consider the extent to which the benefits of meta-regulation were realised in practice. Findings show that while Governors provided both a conscience and contribution to internal and external governance arrangements, the meta regulatory role was largely symbolic and limited to compliance and legitimation of executive actions. Thus while the meta-regulatory ‘architecture’ for Governor involvement may be considered effective, the soft intelligence gleaned and operationalised may be obscured by ‘hard’ performance metrics which dominate processes and priority setting. Governors were involved in practices that symbolised deliberative involvement but resulted in further opportunities for legitimising executive decisions.

Enacting corporate governance of health care safety and quality: a dramaturgy of hospital boards in England

The governance of patient safety is a challenging concern for all health systems. Yet, while the role of executive Boards receives increased scrutiny, the area remains theoretically and methodologically underdeveloped. Specifically, we lack a detailed understanding of the performative aspects at play: what Board members say and do to discharge their accountabilities for patient safety. This article draws on qualitative data from overt non-participant observation of four NHS hospital Foundation Trust Boards in England. Applying a dramaturgical framework to explore scripting, setting, staging and performance, we found important differences between case study sites in the performative dimensions of processing and interpretation of infection control data. We detail the practices associated with these differences - the legitimation of current performance, the querying of data classification, and the naming and shaming of executives – to consider their implications

Parameter inference in mechanistic models of cellular regulation and signalling pathways using gradient matching

A challenging problem in systems biology is parameter inference in mechanistic models of signalling pathways. In the present article, we investigate an approach based on gradient matching and nonparametric Bayesian modelling with Gaussian processes. We evaluate the method on two biological systems, related to the regulation of PIF4/5 in Arabidopsis thaliana, and the JAK/STAT signal transduction pathway

Overseeing oversight: governance of quality and safety by hospital boards in the English NHS

Objectives: To contribute towards an understanding of hospital Board composition and oversight of patient safety and health care quality in the NHS. Methods: A review of the theory related to hospital Board governance and two national surveys undertaken about Board management in NHS hospital trusts in England. The first was issued to 150 Trusts in 2011/12 and completed online via a dedicated web tool. A total of 145 replies were received (97% response rate). The second online survey undertaken in 2012/13 targeted individual Board members using the Board Self Assessment Questionnaire (BSAQ). A total of 334 responses were received from 165 executive and 169 non-executive board members, providing at least one response from 95 of the 144 NHS Trusts then in existence (66% response rate). Results: Around 42% of Boards had 10-12 members and around 51% had 13-15 members. We found no significant difference in Board size between Foundation and non Foundation trusts. Around 62% of Boards had three or fewer serving Board members with clinical backgrounds. For about two-thirds of the Trusts (63%), Board members with a clinical background comprised less than 30% of the Board members. Boards were using a wide range of hard performance metrics and soft intelligence to monitor their organisation with regard to patient safety. Hard, quantitative data were reportedly used at every Board meeting across most hospital Trusts (>80%), including a range of clinical outcomes measures, infection rates and process measures such as medication errors and readmission rates. A much smaller proportion of Trusts (57%) routinely report morbidity rates at every Board meeting. Softer intelligence, used organisationally and reported at all Board meetings, was more variably reported, with discussions with clinicians (in 89% of Trusts) and executive walk-arounds (88%) being most often reported, alongside use of patient stories (83%). However, in only about two-thirds of Trusts did Board members shadow clinicians and report back to the Board (65%). The BSAQ data showed general high or very high levels of agreement with desirable statements of practice in each of the six dimensions. Aggregate levels of agreement within each dimension ranged from 73% (interpersonal) to 85% (political). Conclusions: The study provides the best account to-date of English NHS Boards and their actions around health care quality and patient safety. While systematic differences between Trusts of different types were rare, there was nonetheless variation between individual Trusts on both Board composition and Board practices. These findings lay the groundwork for further empirical research exploring the dynamics, influences and impacts of Boards

Do Hospital Boards matter for better, safer, patient care?

Manifest failings in healthcare quality and safety in many countries have focused attention on the role of hospital Boards. While a growing literature has drawn attention to the potential impacts of Board composition and Board processes, little work has yet been carried out to examine the influence of Board competencies. In this work, we first validate the structure of an established ‘Board competencies’ self-assessment instrument in the English NHS (the Board Self-Assessment Questionnaire, or BSAQ). This tool is then used to explore in English acute hospitals the relationships between (a) Board competencies and staff perceptions about how well their organisation deals with quality and safety issues; and (b) Board competencies and a raft of patient safety and quality measures at organisation level. National survey data from 95 hospitals (334 Board members) confirmed the factor structure of the BSAQ, validating it for use in the English NHS. Moreover, better Board competencies were correlated in consistent ways with beneficial staff attitudes to the reporting and handling of quality and safety issues (using routinely collected data from the NHS National Staff Survey). However, relationships between Board competencies and aggregate outcomes for a variety of quality and safety measures showed largely inconsistent and non-significant relationships. Overall, these data suggest that Boards may be able to impact on important staff perceptions. Further work is required to unpack the impact of Board attributes on organisational aggregate outcomes

Large scale grain mantle disruption in the Galactic Center

We present observations of C2H5OH toward molecular clouds in Sgr A, Sgr B2 and associated with thermal and non-thermal features in the Galactic center. C2H5OH emission in Sgr A and Sgr B2 is widespread, but not uniform. C2H5OH emission is much weaker or it is not detected in some molecular clouds in both complexes, in particular those with radial velocities between 70 and 120 km/s. While most of the clouds associated with the thermal features do not show C2H5OH emission, that associated with the Non-Thermal Radio Arc shows emission. The fractional abundance of C2H5OH in most of the clouds with radial velocities between 0 and 70 km/s in Sgr A and Sgr B2 is relatively high, of few 1e-8. The C2H5OH abundance decreases by more than one order of magnitude (aprox. 1e-9) in the clouds associated with the thermal features. The large abundance of C2H5OH in the gas-phase indicates that C2H5OH has formed in grains and released to gas-phase by shocks in the last aprox. 1e5 years.Comment: In press in Astrophysical Journal Letters 7 pages, 1 table, 1 figur

Atomic Diagnostics of X-ray Irradiated Protoplanetary Disks

We study atomic line diagnostics of the inner regions of protoplanetary disks with our model of X-ray irradiated disk atmospheres which was previously used to predict observable levels of the NeII and NeIII fine-structure transitions at 12.81 and 15.55mum. We extend the X-ray ionization theory to sulfur and calculate the fraction of sulfur in S, S+, S2+ and sulfur molecules. For the D'Alessio generic T Tauri star disk, we find that the SI fine-structure line at 25.55mum is below the detection level of the Spitzer Infrared Spectrometer (IRS), in large part due to X-ray ionization of atomic S at the top of the atmosphere and to its incorporation into molecules close to the mid-plane. We predict that observable fluxes of the SII 6718/6732AA forbidden transitions are produced in the upper atmosphere at somewhat shallower depths and smaller radii than the neon fine-structure lines. This and other forbidden line transitions, such as the OI 6300/6363AA and the CI 9826/9852AA lines, serve as complementary diagnostics of X-ray irradiated disk atmospheres. We have also analyzed the potential role of the low-excitation fine-structure lines of CI, CII, and OI, which should be observable by SOFIA and Herschel.Comment: Accepted by Ap