Physician insights on strategies for leading quality improvement

RESEARCH: Physician insights on strategies for leading quality improvement

Pamela Mathura, PhD, Sandra Marini, MAL, Elaine Yacyshyn, MD, MScHQ, Yvonne Suranyi, BSc, RN, and Narmin Kassam, MD, MHPE

Background: The Strategic Clinical Improvement Committee (SCIC) was established in 2015 to foster physician leadership in quality improvement (QI). In this study, we examined the experiences of physician committee members to determine leadership strategies perceived to support their involvement in QI.

Methods: A voluntary online self-assessment questionnaire was developed and sent to physician SCIC members. Descriptive statistics and thematic analysis were conducted, and identified themes were organized into two groups: strategies that support physician QI leadership and participation and strategies to improve their QI involvement.

Results: Twelve physicians (out of 35) completed the survey, revealing 17 strategy themes. Physicians joined the SCIC because of shared leadership goals, prior QI/research experience, or personal interest. Hands-on QI project experience, QI-personnel support, and sharing completed QI activities were perceived as beneficial for personal and professional growth. The coalitional leadership approach facilitated physician QI learning, involvement, mentorship, and interaction with medical trainees. Additional strategies for promoting physician QI involvement included: clarifying the project selection process, optimizing meeting frequency/duration, and involving medical divisions in establishing QI priorities. Requirements for physician QI participation and leadership included: formalizing QI roles and responsibilities, providing hands-on QI opportunities, sharing past project protocols, providing access to QI and data personnel, funding, peer mentorship, and communication and collaboration among physicians for broader intervention dissemination and implementation.

Conclusion: Evaluation of physicians’ experience revealed that the coalitional leadership approach and enabling strategies can provide others with a practical method for supporting physician QI leadership and participation. The SCIC’s next steps include development, trial, and evaluation of the additional strategies identified.

KEYWORDS: health care, quality improvement, physician, leadership, committee, Alberta

Mathura P, Marini S, Yacychyn E, Suranyi Y, Kassam N. Physician insights on strategies for leading quality improvement. Can J Physician Leadersh 2024;10(1):13-23 https://doi.org/10.37964/cr24778

Physician leadership is increasingly regarded as essential for enhancing the quality of care and sustainability of the health care system.¹ Physicians must take on leadership roles in quality improvement (QI) that they have not previously pursued.¹ The lack of physician leadership and involvement in QI is a result of numerous factors: high clinical workload, limited time, lack of trained practising physicians to teach and mentor QI skills,^2-4 lack of data, scarce assistance with QI-related activities, limited support from hospital or health organization administration, and no financial reimbursement or promotion for participation in QI projects.^1,5-8

Innovative approaches to overcome participation barriers have integrated QI education with a QI leadership project, such as the physician quality-officer program, a physician-mentored implementation model, and a clinician-directed program.^5,7,9-11 These approaches and the effectiveness of the incorporated strategies have lacked evaluation from participating physicians, making it difficult to determine which were impactful. This study asked physician members of an innovative physician-led QI committee to self-assess their experience, identifying the strategies they believe were effective in enhancing their QI knowledge, participation, and leadership, and identifying future strategies to sustain their involvement.

The Strategic Clinical Improvement Committee in action

In 2015, the Strategic Clinical Improvement Committee (SCIC) was established to develop physician QI leaders in the Edmonton health zone in Alberta, Canada. This physician-led committee strategically joined three health system partners — the University of Alberta (UA) Department of Medicine (DoM), Alberta Health Services (AHS), and Covenant Health (CH) DoM programs.¹² The goal was to advance physician QI knowledge, participation, and leadership while assisting the DoM and local health organizations in making strategic clinical improvements at all levels of the Alberta health care system.¹³ The committee physician members, AHS, and CH executive directors and quality management partners collaborated to establish six key approaches and ¹⁴ enabler strategies to reduce barriers to physician QI involvement in addressing clinical issues as change leaders.⁹ The SCIC used the LEADS framework to identify four priority areas — QI education, QI leadership, mentorship, and QI recognition — to guide members in leading self, developing hands-on QI skills, building QI interdisciplinary teams that mobilize knowledge, and leading frontline clinicians toward a culture of health system improvement.¹³

Since its inception, this approach¹⁴ has successfully increased the number of physician-led and physician-involved QI projects in the Edmonton zone. Leveraging improvement and implementation science to develop and test interventions aimed at improving clinical outcomes and the health care system. The SCIC has evolved into a platform for QI leadership development, mentorship, sharing QI projects, highlighting results, and, most important, fostering an improvement culture among physicians that encourages them to co-create interventions and identify health system improvement opportunities. However, sustaining and advancing this QI leadership approach requires evaluation of physician participation experience to determine enabler strategies.

Methods

A mixed-methods design was used to create a questionnaire.¹⁵ Closed and open-ended questions were complementary, where open-ended questions provided additional understanding. All SCIC physician members (n = 35) from the January 2020 membership list were eligible to participate.

LEADS capabilities framework

The LEADS framework, which was developed by practising leaders,^16-18 includes 20 capabilities, organized into one outcome domain (Achieve results) and four process domains (Lead self, Engage others, Develop coalitions, and Systems transformation).¹⁹ Lead self involves awareness of one’s assumptions, values, principles, strengths, limitations.²⁰ Engage others involves the people challenges of effective interpersonal relationships.²¹ Develop coalitions establishes relationships and develops support across departments/programs/organizations and with patients and the public.²² Systems transformation is strategic leadership, exercised through policy, procedure, structure, and culture.²³ Achieve results represents future outcomes from the processes of leadership, both personal and strategic.²³

Survey instrument development and recruitment

A 57-question self-assessment questionnaire was adapted from validated tools and anonymously administered.^24,25 It consisted of 47 scaled and 10 open-ended questions covering eight topics related to the SCIC: goals and collaboration, governance, decision-making process, members, leadership, capacity and capability, effectiveness, and institutionalization. An equal number of questions fell into each of the LEADS capabilities framework domains.²¹ A review of the draft questions by a non-committee physician researcher resulted in minor changes in sentence structure. The final questionnaire was entered into an organizational enterprise platform (see Appendix).

The organizational email addresses of committee members were provided to SM, who sent each participant an individually addressed email describing the study and the survey link. The questionnaire remained open for six weeks, during which two reminder emails were sent. The only mandatory question was the one seeking written consent. If consent was not obtained, the questionnaire would exit/close, and no results were included.

Data collection and analysis

For the scaled questions, descriptive statistics were used and Excel v. 2016 (Microsoft, Redmond, Washington) facilitated the analysis. For the open-ended questions, a thematic analysis was completed.²⁵ Two researchers (PM and SM) independently read and grouped the textual responses to generate themes. The researchers discussed and refined themes based on consensus. Themes were divided into two groups: strategies promoting physician QI leadership and participation and strategies to improve QI involvement. Both data sources were integrated into a joint table to determine further insights.^26-28

Ethics approval

The University of Alberta Research Ethics board provided an ethical waiver on 12 March 2021.

Results

Twelve (out of 35, 34%) physician SCIC members responded to the survey. Closed questions received a range of 10–12 responses, open-ended questions 5–10 responses. From the textual data, 17 themes emerged: eight identified physician strategies promoting their QI leadership and participation and nine determined strategies to improve their involvement (Table 1).

Table 1. Summary of responses (n = 12) to self-assessment questionnaire to determine the strengths and challenges of the Strategic Clinical Improvement Committee (SCIC) in increasing physician involvement in quality improvement (QI).

Lead self

Physician members initially engaged with the SCIC because it aligned with their personal goals (10/12, 87%), advanced QI/research experience or interest professionally (8/12, 67%), and was beneficial to their personal and professional growth. Most (10/11, 91%) viewed leading a QI project as organizational leadership development; 50% felt comfortable assuming a QI role. Respondents said the SCIC improved their awareness and understanding of improvement science (10/12, 84%) and increased their capability to participate in and lead QI projects (8/12, 67%). Almost half (5/12,42%) attended all or some meetings and many (9/12,75%) felt that they influenced SCIC priorities/projects.

Three themes influenced physicians to Lead self regarding QI: Previous QI or research experience, Personal interest in QI/innovation, and the fact that QI knowledge and application promotes personal and professional development. Respondents said: “[I did] previous work at different institutions in QI” and “[I joined] based on my previous research experience.” Others mentioned “innovation is important for the present and future, for our [physician] legacy” and “I have an interest in QI.” Another said, “It has spurred me to look into taking QI courses to improve my knowledge, taking on a formal QI leadership role.”

Two themes were identified in the area of improving physicians’ ability to lead themselves: QI project/protocol repository and Physician QI role and responsibility clarity. Respondents mentioned “sharing a database of QI project/protocols, to help physicians less experienced” and “A repository of information would be beneficial.” Another stated, “Knowing the [formal] physician QI role and expectations [is necessary].”

Engage others

SCIC chairs were recognized as dedicated to the committee’s ideals (11/12, 92%), and as collaborative (10/12, 83%) and credible leaders (9/12, 75%). All respondents felt valued and most thought their voices were encouraged (11/12, 92%). Half (6/12, 50%) were unsure of membership expectations, and many suggested developing documented roles and responsibilities (8/12, 67%). SCIC meetings were viewed as efficient (11/12, 93%) and a good use of one’s time (7/12, 58%).

To support physician QI involvement, three themes were identified: Strengthen communication and collaboration between physicians, Optimize committee meetings, and Engage division to establish QI as a priority. Communication and collaboration could be improved: “Knowing roles and hospital sites of each member could allow for collaboration or advice/mentoring” and “better communication of projects [interventions] between members” was also suggested. Respondents indicated that shortening meetings, but increasing the frequency could promote collaboration. One mentioned that the “reduced frequency of meetings has made it more challenging for collaboration.” Respondents indicated that each medicine division they represent should “have clear divisional QI priorities beyond just representation,” while recognizing the “challenge to engage others in the division [regarding QI].”

Achieve results

The SCIC defined key development strategies and goals and communicated them to its members. Many respondents (9/12, 75%) felt that the SCIC did well in terms of completing QI activities. All agreed that the SCIC QI personnel demonstrated improvement science expertise and provided support to members. The SCIC created experiential opportunities and mentorship while carrying out successful QI projects (7/10, 70%).

Four themes support members to achieve results: Hands-on QI experience, Formalized dissemination of physician involvement in QI, Dedicated committee QI personnel, and QI education for medicine trainees. One respondent remarked, [the SCIC provided an] “opportunity to do a project with support.” Three respondents highlighted the importance of “learning together,” “sharing QI projects [during committee meetings],” “having peer feedback and comments,” and “hearing about other projects being done.” One said, “annual QI day allows one to see the full scope of QI occurring.” Respondents recognized the need for dedicated support personnel, commenting “personal consultation and availability of QI personnel to assist members with project design, analysis, and presentation aided in QI completion.” They acknowledged that physician QI education is a learning continuum. A physician stated, “the training component has been possibly the most effective as it ensures medicine trainees have a good understanding of the principles of QI.” Another emphasized the importance of “[medical] students to engage [and assist] in QI projects.” Further, a respondent mentioned that this approach provides “an opportunity for trainees and staff to work in QI together.”

Two strategic themes would support achieving results: Clarify priorities for improvement/project selection and Improve access to QI and data personnel. One respondent suggested, “it is not clear how projects are chosen and supported by the committee” and another stated, “knowing what criteria are used would be helpful.” They mentioned the need for “access to QI and statistician personnel” to improve physician involvement.

Develop coalitions

This leadership approach encouraged collaboration and partnership among SCIC members, departments, divisions, and the larger health care community (10/12, 83%). Respondents indicated that the committee structure was good (6/12, 50%); however, 50% were unsure what processes could improve the approach. Many recognized established communication processes (9/12, 75%) and acknowledged that dedicated staff (8/12, 67%) and skillful resource stewardship (9/12, 75%) existed.

Respondents viewed the Committee leadership approach for QI as important because it “brings multiple members from different hospital sites together to share their projects and findings to allow collaboration and possible spread to other hospitals.” Another stated, “increases awareness, sharing QI ideas and the approach taken to address the issue.” In addition, a physician noted that this approach encouraged “diversity of members across the department. Breaking down silos of [QI] interested people.” Another mentioned the “focus is on building physician leaders in this space, building collaboration across divisions.” One respondent stated that the coalition provided a formal platform for “the benefits of QI work to be seen and [shared].”

Systems transformation

Respondents agreed that the SCIC promoted QI planning, implementation, and evaluation, provided support, and shared resources (10/12, 83%) through clearly defined roles, responsibilities, governance, and accountability (10/11, 91%). Participation was integral to their organizational leadership role (9/12, 75%), increasing their ability to participate in QI (10/12, 84%), and building confidence in mentoring colleagues (7/12, 58%). Most (11/12, 92%) said that they would encourage colleagues to join the SCIC because it is “a strong functional organizational structure, efficiently using our time, making available mentorship, and adding the presence of QI support.”

In terms of enhancing physician QI, two themes aligned with this LEADS domain: Physician peer mentorship with hands-on experience and Funding for QI projects. A respondent stated, “Teach how to do QI in a practical way, with more hands-on help and involve interested [physicians] in active projects just for learning and experience sake.” There should be “opportunities for members who are new to QI to assist or even an opportunity to observe.” Three respondents indicated the need for funding to support involvement.

Integrating the findings into a table identified the LEADS domains and strategic themes promoting physician QI involvement, revealing the need for a multistrategy approach. The domains of System transformation and Engage others lacked QI development strategies, suggesting associated challenges. Although strategies were aligned with Leads self and Achieve results, further strategies are needed to enhance physician QI involvement.

Discussion

The SCIC is an innovative approach to fostering physician QI leadership and participation.¹³ This study gathered physician members’ experiences and perspectives about the coalitional leadership approach and identified enabler strategies for QI leadership and participation. Seventeen strategic themes were identified and aligned with the LEADS framework,²¹ eight themes were effective in promoting physician QI leadership and participation, and nine themes needed development. These findings corroborate evidence that multiple strategies are necessary to enable physician QI leadership,^5,29 thereby mitigating barriers to participation.^2-4

Similar to other studies, SCIC member physicians felt that the coalitional approach facilitated physician QI leadership and participation.^30-33 By engaging individuals with expertise or interest in QI, the SCIC established a physician-to-physician QI community, cultivating QI leaders and leveraging formal and informal physician networks to expand influence and provide mentoring.^15,34 Physicians believed that receiving QI education — integrated with hands-on project application, mentoring medical trainees, and QI personnel support — contributed to their personal and professional growth.^5,33-35 Having a platform to share completed QI activities encouraged physician QI role modeling, mentoring, and involvement.^5,35

To improve and sustain the SCIC, development of internal processes for clarifying QI project selection and prioritization, optimizing meeting frequency and duration, engagement across DoM divisions, and improved communication and collaboration among physicians are needed for continued participation and committee sustainability.³³ Physicians believed that funding QI initiatives, providing physician peer mentorship with practical experience, ensuring access to QI and data personnel,^5,35 and developing a formalized physician QI role^33,35 are all necessary to establish physician QI leadership and participation. An interesting finding was the desire for a repository of QI project protocols to bridge the knowledge-to-practice gap, implying the need to understand how to complete a QI project from start to finish.

Limitations

The scope of the inquiry was cross-sectional, limiting the study to current SCIC members as of 2020, the low survey response rate could be attributed to the on-going increase in clinical service duties brought on by a COVID-19 outbreak wave. Although representation was broad across the DoM speciality divisions, it may not have captured the views of the larger physician population. The results do provide insights from physician QI experience and identify effective strategies that others can adopt. Respondents had the freedom to choose which questions to answer, leading to variations in response rates. The data collected relied on self-reported information, which could introduce social desirability bias.³⁶ To address this limitation and enhance the study, an additional method, such as semi-structured interviews, could have provided opportunities to validate and expand on the results. Because of the COVID-19 pandemic, this option was not available.

Conclusion and future direction

Evaluation of physician experience revealed that the coalition leadership approach and enabling strategies have the potential to provide others with a practical method to consider for supporting physician QI involvement. The SCIC’s next step includes development, trial, and evaluation of the additional strategies identified. Mathura-Appendix-Questionnaire

Acknowledgements

The authors are grateful to all the physicians who participated in the study survey and shared their coalition participation experience in pursuit of improving physician involvement in QI.

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Authors

Pamela Mathura, PhD Health Quality, is a QI scientist and an assistant clinical professor at the University of Alberta’s Department of Medicine and Alberta Health Services.

Sandra Marini, MAL, is a research coordinator at the University of Alberta’s Department of Medicine and team lead, Medical Affairs Corporate Projects, with Covenant Health.

Elaine Yacyshyn, MD, MScHQ, FRCPC, is a professor and deputy zone clinical department chair of the Department of Medicine, University of Alberta.

Yvonne Suranyi, BSc, RN, is executive director for the health zone medicine program and the University of Alberta emergency program.

Narmin Kassam, MD, MHPE, FRCPC, is chair of the Department of Medicine at the University of Alberta and head of the Clinical Department of Medicine.

Competing interests: None.

Disclosure: The authors declare that there is no conflict of interest.

Funding: None.

Ethics approval: A waiver to proceed was obtained from the University of Alberta Research Ethics Board on 12 March 2021.

Author contributions: PM led project design, analysis, wrote and reviewed the manuscript. SM assisted with analysis, writing, and editing the manuscript. EY, YS, and NK critically reviewed and edited the manuscript. All authors approve the final manuscript.

Correspondence to: pam.mathura@ahs.ca or mathura@ualberta.ca