Community representation in hospital decision making: a literature review.

Objective Advancing quality in health services requires structures and processes that are informed by consumer input. Although this agenda is well recognised, few researchers have focussed on the establishment and maintenance of customer input throughout the structures and processes used to produce high-quality, safe care. We present an analysis of literature outlining the barriers and enablers involved in community representation in hospital governance. The review aimed to explore how community representation in hospital governance is achieved. Methods Studies spanning 1997-2012 were analysed using Donabedian's model of quality systems as a guide for categories of interest: structure, in relation to administration of quality; process, which is particularly concerned with cooperation and culture; and outcome, considered, in this case, to be the achievement of effective community representation on quality of care. Results There are limited published studies on community representation in hospital governance in Australia. What can be gleaned from the literature is: 1) quality subcommittees set up to assist Hospital Boards are a key structure for involving community representation in decision making around quality of care, and 2) there are a number of challenges to effectively developing the process of community representation in hospital governance: ambiguity and the potential for escalated indecision; inadequate value and consideration given to it by decision makers resulting in a lack of time and resources needed to support the community engagement strategy (time, facilitation, budgets); poor support and attitude amongst staff; and consumer issues, such as feeling isolated and intimidated by expert opinion. Conclusions The analysis indicates that: quality subcommittees set up to assist boards are a key structure for involving community representation in decision making around quality of care. There are clearly a number of challenges to effectively developing the process of community representation in hospital governance, associated with ambiguity, organisational and consumer issues. For an inclusive agenda to real life, work must be done on understanding the representatives' role and the decision making process, adequately supporting the representational process, and developing organisational cooperation and culture regarding community representation. What is known about the topic? Partnering community is recognised as a fundamental element of hospital quality improvement strategies and the implementation of the Australian agenda for advancing the quality of health service standards. It is also known that developing collaborative environments and partnerships can be a challenging process, and that it is good practice to consider the factors that will influence their success and develop an approach built on the identification of potential challenges and the incorporation of facilitators. What does this paper add? This paper draws out key obstacles that can challenge the process of involving community representation into hospital governance structures. What are the implications for practitioners? There is little published on the challenges to community engagement in the hospital governance setting. By doing this, this paper encourages the recognition that although partnering with the community is an essential aspect of achieving quality of care, it requires significant effort and support to be an effective aspect. The paper highlights challenges and facilitators that practitioners should consider if planning for successful community representation on hospital committees.