Strategies for Emerging Physician Leaders to Advance the Quality Agenda

An organization’s ability to improve patient safety and quality of care and attain quality goals requires physician leadership and participation in the quality agenda.(1-6) Barriers to physician involvement in quality improvement (QI) include strong physician autonomy, underdeveloped physician management infrastructures,(7) institutional culture, and a paucity of trained physicians with dedicated time to advance the science and practice of safety.(4,6,8) As a result of these barriers, quality and safety activities often are delegated to other healthcare providers, physician skill is underutilized, and physicians resistant to QI hinder quality-improvement initiatives.(7,8)

An abundance of literature proposes strategies to improve physician engagement in QI work, with guidance often targeting a non-physician audience.(1,7-9) Advice to increase physician leadership frequently suggests changes to the physician infrastructure, including physician leadership development, greater support for physician quality leaders, and use of measures to create a chain of accountability from the hospital to physician leaders.(7) Unfortunately, guidance for physician leaders themselves is often abstract and theoretical, consisting of management-style advice on improving reporting relationships within the organization, creating attitude and culture changes among hospital staff, and implementing a corporate approach to thinking about quality.(2,6) A lack of concrete examples and actionable approaches reduces the impact of recommended strategies.

Strategies to Advance the Quality Agenda

We propose a series of tangible and practical strategies that emerging physician leaders can implement and tailor to their organization to advance the quality agenda. These strategies enable emerging physician leaders to succeed by taking specific actions to influence frontline peers, improve access to QI training for physicians, and develop partnerships with executives that increase alignment of physician quality goals and organizational improvement processes.

1. Set clear goals for a quality program and share them broadly.

Teams struggling to improve quality often lack a cohesive mission and have poorly defined goals.(10) Identifying specific QI goals within a department is an important step toward establishing oneself as a QI leader and effecting improvement. Sharing targets for performance motivates team members to change behavior.(11) When team members are aware of the targets and recent progress, they are more engaged with improvement initiatives.(12)

At the organizational level, most healthcare institutions develop an annual quality improvement plan (QIP), a formal blueprint of how the institution intends to address quality and safety with specific performance goals. These organizational QIPs are important drivers of change but often are high-level and may not lend themselves well to department-specific goals.(13)

QI leaders should familiarize themselves with the format and content of their institution’s QIP and develop a departmental QIP (see Table 1) to share with the department staff and relevant hospital leadership to engage them in reaching those goals. Where possible, leaders should connect departmental and organizational goals, as this provides an opportunity for partnership and potential access to additional resources.(1,9)

2. Assign and support a QI lead in the department.

Successful organizations develop an alliance between frontline clinicians and executives(9) and link the hospital and physician quality agendas.(1) Many healthcare institutions have formal physician leadership positions in quality and safety to improve physician engagement and support strategic planning.(2) While some guidance about how to define these roles is available,(2) physician leadership models for quality and safety remain underdeveloped(4) and physicians often lack the training and experience to be quality leaders.(7)

Select physician leads strategically. Physician quality leaders should have several intrinsic qualities, including (1) being frontline clinicians, knowledgeable about hospital processes; (2) being respected by colleagues and healthcare team participants; and (3) having a collaborative spirit with high emotional and social intelligence.(5,7)

Successful physician quality leaders attribute their success to the ability to provide clinical input around corporate initiatives, increase credibility of initiatives leading to more physician engagement, and exert influence across department structures and hierarchies.(2)

Providing support for physician leads is equally imperative and should be leveraged by the institution, including: (1) training in the science of quality and change management; (2) protected time; (3) dedicated financial resources and administrative support; and (4) access to reliable local data and analytics support.(2,4,5,7,14)

Without these supports, physician quality leads will have difficulty translating ideas into sustainable action and may feel limited in their influence of corporate decisions.(2) Conversely, physicians involved in key corporate initiatives who have protected time and remuneration see success through increased participation in QI initiatives, completed projects, and increased communication between clinicians and the hospital administration.(15)

3. Develop QI educational programming for physicians, by physicians.

Most physicians lack robust training in QI science and therefore have limited ability to serve as quality leaders.(4) Increasing organizational improvement capacity requires building physicians’ skills to lead QI efforts.(7) In fact, a primary factor in successful improvement initiatives in an acute medical setting is the availability of resources to support training in QI skills development within the team and building capacity within the organization more broadly.(16)

Physicians should have a minimum QI literacy; enhanced QI learning opportunities should be available for those physicians who are interested.(14) Because lack of time is a barrier to QI involvement,(8) opportunities to integrate QI learning into the existing educational rounds in which physicians already participate are important.(2)

A case study of physician leaders in quality and patient safety found that a successful strategy to improve physician participation in local QI projects is to deliver physician educational rounds on quality and patient safety topics.(2) For example, invite medical grand rounds (MGR) presenters with training and experience in QI(5) to share their experiences with improvement projects or to teach improvement science skills. Consider launching a cross-departmental rotating QI MGR series at which departments take turns hosting quality-focused rounds.

A similar strategy of an interdepartmental QI curriculum for medical residents helped overcome barriers of limited faculty with QI expertise to teach and improved sharing of institutionally relevant QI training.(17) This can help facilitate networking and create a cross-departmental culture of QI learning.

Departmental morbidity and mortality (M&M) rounds can be leveraged to role-model a systems approach to case analysis and introduce tools for root cause analysis such as the Canadian Incident Analysis Framework.(18)

Creating a structured M&M rounds model with physician training on analyzing cases, engaging interprofessional members, disseminating lessons learned, and creating an administrative pathway for action enhanced the quality of rounds and led to hospital-wide improvements.(19,20) Specifically, the authors noted improved attendance in M&M rounds, increased frequency of in-rounds discussions around cognitive biases and system issues, as well as a positive effect on clinical practice at individual and departmental levels.(19,20) Inviting hospital executives facilitates robust systems-discussion and catalyzes change within the organization.

Survey the local physician group for desired educational topics and create a series of workshops tailored to physician-requested topics; providing Continuing Medical Education credits promotes participation. Educational sessions should be tailored to the organization and opportunities for collaboration provided by inviting executives, managers, decision support, and other organizational leaders.

For example, schedule an educational session about how to access local reliable data to increase physician engagement, support physicians in leadership roles, and enhance partnerships between the organization and clinicians. Provide physicians with access to professional development resources (see Table 2). Finally, provide opportunities for mentorship relationships which, given the paucity of physician leadership in quality, may include mentors with other areas of expertise, such as change management or QI methodology.(14)

4. Foster the future generation of physician leaders’ interest in quality.

Creating capacity for QI starts by nurturing future leaders.(6) The prominence of QI and patient safety competencies in the Canadian CanMEDS(21) framework and the American Accreditation Council for Graduate Medical Education(22) highlights the importance of ensuring the next generation has a base competency in QI methodology.

Medical learners often are keen to participate in QI projects, which can support departmental work while integrating learning competencies(23) and can be operationalized through project mentorship opportunities.(14)

Effective educational methods for QI and patient safety include formal curricula, online modules, and experiential QI projects.(5,24,25) Other successful methods include asking attending physicians to recommend resident staff participation in improvement projects.(5)

Additional strategies can help foster the future generation of physician quality leaders:

• Involve resident physicians in quality committees.

• Create a dedicated QI stream at resident research day. Recruit physician quality leaders as judges to provide feedback specific to the science of improvement.

• Create an annual resident QI award.

• Create a task force that evaluates and improves resident education in QI and patient safety. Involve residents in the development, implementation, and evaluation of the curriculum.

• Pair residents who have QI leadership interest with a formal physician mentor in this role.

• Develop an interdepartmental curriculum to train residents on core QI principles to foster collaboration.(17a)

5. Build a local network of physicians with QI interest.

Physician quality leaders benefit from a local network of physicians in similar roles with whom to share ideas, collaborate, and increase organizational alignment. Consider creating a physician-led quality committee structure to add expertise, excitement, and engagement for medical staff.(5) While many organizations espouse an interdisciplinary, high-level quality committee that reports to the board, department-level quality committees with physician leadership can align the workforce on improvement projects and priorities.(14) This provides opportunity for partnership between physicians and the organization.(1,9)

In our center, physician quality leads from each department sit on a Physician Quality Committee, to which executive members are invited as ex officio, non-voting members. This allows for cross-departmental collaboration, discussion of common challenges, and sharing of tools, resources, and implementation strategies. Several physician quality leads are also members of hospital and university quality committees, further improving communication, alignment, and collaboration.(14)

Another strategy is to develop a working group of physicians with improvement science expertise to provide peer-to-peer feedback on departmental QIPs. This strengthens the quality of the QIPs, improves standardization across the organization, and provides feedback, advice, and mentorship.

6. Build an external network that connects physician quality leads with QI experts.

Connections between physician and non-physician quality experts external to the hospital can provide mentorship, create collaborative research opportunities, and elevate the profile of the quality program. In fact, it has been suggested that a hybrid of local participatory QI and central expert QI may be the best method for achieving quality care.(26)

While not all physician quality leaders have formalized training in improvement science, networking physicians with improvement science experts may help foster education and build capacity to enhance scholarly dissemination of QI research. These improvement science experts also can be invited to speak at physician educational events, which can elevate the knowledge of the entire physician group.

A case study of Canadian physician quality leaders identified that an external network of local physician quality leaders and other physicians interested in QI and patient safety across multiple organizations promoted discussion of common challenges, sharing of resources and implementation strategies, and collaboration across organizations on improvement initiatives.(2)

Finally, where possible, create collaborative relationships with formal education bodies, including graduate training programs, to elevate the profile of the program, advance the science of quality and safety, and create an environment in which science is translated into educational programs to develop the next generation of physician quality and safety leaders.(4) (See Table 2.)

7. Develop a QI academic promotion track.

Traditional academic promotion is based on a physician’s research productivity and clinical or teaching activity, with little consideration of involvement in QI activities.(8) Creating synergy between quality and safety activities and academic promotion supports scholarly work(8) and resonates strongly with physicians at academic medical centers.(27)

Clinician-scholars in QI should have equal opportunity for academic advancement compared with their researcher and educator colleagues, through the celebration, promotion, and support of the academic dissemination of their work and acknowledgment of the differences in the outputs of QIP academic work.(14)

Consider an internal peer-review process for quality grants within the institution and advocate for QI publications to be considered on par with traditional research publications.(8) Network with QI colleagues to develop a QI academic job description, outlining academic, educational, and administrative deliverables and promotable activities. Adapt such a job description from existing examples and modify according to the local context in collaboration with academic heads.

Consider advocating for awards for physician quality leads, workload or schedule arrangements to ensure protected time, and career advancement opportunities.(14) Regardless of the strategy, the reward mechanisms and incentive structures are an important element to promote continuing engagement and sustainability and must be developed by local stakeholders and be feasible within the local environment.(28)

8. Create opportunities to showcase physician quality projects and celebrate successes.

The Institute for Healthcare Improvement suggests that healthcare institutions ask how the hospital can engage in the physician quality agenda rather than asking how to engage physicians in the organization’s quality agenda.(1,9) One strategy is to hold a physician QI project research showcase where physicians can present completed projects, works in progress, or improvement ideas to solicit feedback. Hospital executives can learn about the physician quality agenda and hear about experienced barriers. This promotes a culture of physician partnership with the organization and gives physicians a voice within the organization. Invite patient experience advisors to provide feedback directly to physicians and executives.

Alternatively, a repository of physician-driven improvement projects will highlight active work and help physicians identify collaborative opportunities. The department’s annual report can be a vehicle to share successful improvement efforts.

Celebrate the frontline participants in quality initiatives. Create a departmental or hospital QI award, conferred yearly. Launch an internal peer-reviewed funding competition for QI projects akin to research grant competitions. These strategies will catalyze frontline engagement.

9. Use patient stories to inspire change.

Physicians, providers, and administrators are more likely to support change when they can attach weight to the reasons behind the initiative.(1) Often the most persuasive voices are those of the patients themselves. Hearing patient stories and reflecting on them through narrative medicine can increase provider empathy and communication.(29,30) Patient stories are memorable, are self-propagating, offer insights to providers, and can be understood by all stakeholders.(31)

Patient safety reporting systems are a means to gather patient perspectives, though when presented without narrative details, may not provoke the same degree of engagement or emotion. Enlist the institution’s patient experience representatives to identify patients amenable to sharing their stories. Patients encountered in clinical practice may also be willing to provide their anecdotes. Consider sharing some of this narrative in hospital M&M rounds or as an annual “narrative medicine rounds” whereby the cases embody the rationale behind ongoing QI or safety initiatives.(31)

10. Learn from the failures of others.

Leading change is a challenging endeavor and not every effort will succeed. As many as 20 percent of QI projects are unsuccessful,(32) but with thoughtful reflection, can provide valuable lessons. Learn from others’ mistakes, including one’s own, and attempt to avoid some QI leadership pitfalls.

Through an internal network of other QI leaders, physician quality leaders can informally discuss failed projects, problems with project initiation, and barriers to success. This informal collaboration and peer-mentorship can provide important insights into problems and is more likely than external influences like conference presentations to result in solutions because local experiences are context-specific. Showcase unsuccessful QI interventions at local research days and QI events and through discussion and review at physician quality committee meetings.

Another leadership pitfall is over-commitment, which is difficult to avoid when an enthusiastic new QI leader has many requests for their time.(12) Participation in committee meetings, a common QI responsibility, requires time and energy, often at the expense of productivity.(32) These non-value-added commitments can lead to a perceived lack of progress by others, thus undermining the leader’s reputation for effectiveness.(10,32)

Where possible, the quality leader should select no more than three goals for improvement at any time and limit the number of committee meetings attended, seeking alternative strategies of communication such as email or direct conversations to accomplish tasks.

Finally, stay connected to the frontline healthcare providers. Involvement with higher-level planning and project oversight can make leaders feel that they are at risk of losing some credibility at the front lines.(2) Ensure ongoing communication between healthcare providers and improvement teams through stakeholder engagement sessions or retreats.

Discussion

While much guidance exists for promoting successful physician leadership and engaging physicians in QI work, most written advice is theoretical, written with the organization as the audience, or focused on examples of established leaders.(2,4,5,14,33) As early-career physician quality leads in our respective departments, we sought to create a repository of concrete examples and actionable strategies to empower emerging physician quality leaders to try similar strategies and adapt them to their organizations.

While not all the provided examples are supported with literature, we have attempted to include evidence where it is available and draw from our own local experiences. With respect to the generalizability of our recommendations to other institutions, we recognize that although we are from the same academic institution in Canada, we draw from a vast array of literature in developing these strategies and recommend that these be adapted to the local context.

One of the challenges for physician quality leaders and organizations is defining and measuring physician success.(8) It is surprising that in a data-driven field such as QI and patient safety, there is a paucity of evaluation strategies to determine impact of a physician quality lead, a quality committee structure, or the level of engagement of the physician group. In fact, no form of measurement is being used and no such measurement tool has been established,(8) which makes it challenging for physician quality leads to know how their efforts are impacting the organization. This can lead to a sense of stagnation or demoralization.

Potential measurement strategies could include assessing the number of improvement projects that exhibit positive results, the extent of alignment between a departmental QIP and an organizational QIP, the number of physicians in a QI promotion track at an academic medical center, the number of physicians participating in educational events, and the number of residents becoming engaged in QI work.

Emerging physician quality leads and the organizations in which they work must acknowledge that sustained change requires time, continuous effort, and focused attention to goals. This is true for patient-centered efforts and quality leadership positions.

QI science espouses the model for improvement in which continuous cycles of tests of change are followed by evaluating outcomes and refining interventions until the desired outcomes are achieved.(34) This model should be similarly applied to the implementation and optimization of a physician quality leadership position.

While both physicians and organizations can be impatient in terms of their expectations, physician quality leaders should be supported to try out strategies to enhance physician engagement and be patient when anticipating change, as the culture of both the organization and the physician group are well-established and will take time and effort to transform.

Armed with concrete strategies, emerging physician quality leaders can be successful in their roles by influencing frontline peers, improving access to QI training for physicians, and developing partnerships with executives that foster increased alignment of physician quality goals and organizational improvements processes.

The authors have no conflicts of interest to declare related to this manuscript. There was no funding associated with this article preparation.

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