Editor’s Note: An Invited Commentary by C.D. Stevens appears on pages 13–15.
The expanding and changing needs of academic health systems have prompted leaders of academic clinical departments to develop broad expertise among their faculty in each of the core mission areas (clinical care, education, and research). Consequently, focused and proactive approaches to faculty development are becoming increasingly necessary for both departments and individual faculty members to maximize their respective impacts in clinical care, education, and research. The varied approaches to faculty development seek to equip faculty members with the knowledge and skills to succeed in their careers, to diversify the expertise of the faculty as a whole, and to enhance their ability to work successfully in complex organizational structures, thereby meeting the needs of the department, the affiliated health system, and the medical school. Traditionally, faculty development efforts have focused on advancing the careers of physician–investigators, a faculty group that is critical to the success of research-intensive departments and the advancement of medicine and that typically requires substantial investments of time and resources to be successful.1 The development of clinician–educator faculty has become another important area of investment for clinical departments.2 Among the phenotypes of faculty that urgently require more proactive attention, however, are a new and growing cadre of faculty working in quality improvement and patient safety (QI/PS).3
Although the development of faculty with QI/PS expertise has incorporated a variety of approaches, most academic clinical departments do not have a sufficient number of QI/PS faculty to meet the growing need for individuals with this expertise. Indeed, a recent survey of attendees at the Association of Professors of Medicine (chairs of departments of medicine) meeting in February 2015, which aimed to identify priorities for faculty development, identified the need for more faculty with expertise in QI/PS as the top priority for departments of medicine. In this article, we describe the rationale and approaches to expanding the development of this new and critically important group of faculty in all academic clinical departments. Given the importance of developing faculty expertise in QI/PS, the Board of Directors of the Alliance for Academic Internal Medicine reviewed this article and unanimously endorsed its content.
The ability of health systems to meet societal needs is increasingly dependent on their improving the quality and value of care and reducing costs.4–6 The pressure to provide high-value care that enhances the patient experience and meaningfully improves clinician satisfaction while further developing academic research and education has increased the complexity of decision making and change management in academic health systems. In fact, early adopters of QI/PS practices are primarily nonacademic medical centers that do not have the education and research missions that have dominated efforts at academic medical centers. In addition, the shift in reimbursement from a fee-for-service model to one that is linked to quality of care and population health is accelerating fundamental changes in care delivery.7 Many academic medical centers continue to generate substantial revenue from performing high-cost procedures. Hence, these academic centers seek to provide high-value care but face challenges from the traditional academic culture, which is focused on discovery and research, and in having to navigate the conflicting incentives of evolving reimbursement systems.
The quality domains defined by the Institute of Medicine are a particularly useful framework for defining QI/PS. These domains include safety, timeliness, efficiency, efficacy, equity, and patient-centered care.8 In recognition of the growing importance of each of these quality domains, the Accreditation Council for Graduate Medical Education (ACGME) now requires graduate medical education training programs to include more rigorous educational programs in QI/PS. Changes implemented under the ACGME’s Next Accreditation System, including the Clinical Learning Environment Review, are intended to ensure that residents and fellows are meaningfully involved in improving the quality of care in institutions that sponsor graduate medical education.9 A similar initiative sponsored by the Association of American Medical Colleges, called Aligning and Educating for Quality, provides an integrated approach to quality across the educational continuum from first-year medical students to established clinicians, further emphasizing the importance of QI/PS in medical education and practice.10
For academic departments to improve the quality of care in their affiliated health systems and to succeed in new reimbursement models, they are compelled to foster innovation, intensify their respective programs in QI/PS, and prepare trainees to contribute to sustainable improvements in the delivery of health care.3,6,11 The key determinant of success in these efforts will be the development of faculty with expertise in QI/PS.3,5,12,13 Unfortunately, however, many academic departments currently do not have a sufficient number of faculty with this expertise to meet the clinical and educational needs of the department and the health systems.
Academic clinical departments have a rich tradition of improving approaches to the prevention, diagnosis, and treatment of disease. This intellectual tradition provides a useful framework for cultivating faculty with the ultimate goal of delivering safer and higher-quality clinical care. Developing this new cohort of faculty will require an examination of the challenges and potential solutions for developing faculty who are focused on QI/PS. Ultimately, academic clinical departments will need to support and recognize the achievements of faculty working in QI/PS.
Academic clinical departments face a number of challenges in developing faculty with expertise in QI/PS. Unlike traditional physician–investigators or clinician–educators, many departments lack senior or midcareer faculty whose careers have focused on QI/PS who could act as role models for younger faculty. In addition to this lack of available mentors, the paucity of senior QI/PS faculty limits the number of experts and advocates on promotions committees and in traditional academic leadership positions. Although academic leaders are beginning to call for greater efforts in QI/PS,3,11,14 advocacy for this field comes most consistently from health system leaders who vary in their understanding and appreciation for the traditional career development pathways in academic medicine.
Individual faculty members are beginning to receive formal training in the underlying science of QI/PS. In addition, the number of training pathways in QI/PS continues to grow with the implementation of the American College of Physicians High Value Care Curriculum for Educators and Residents, the Alliance for Academic Internal Medicine–Society of Hospital Medicine Quality and Safety Educators Academy, programs through the Institute for Healthcare Improvement, the Department of Veterans Affairs Quality Scholars Program, and local institutional and departmental programs.12–18 Nonetheless, many faculty still have not had sufficient training or time to develop expertise and experience in the quantitative and qualitative methods of QI/PS. Rigorous training and experience in QI/PS methods and scholarship have been less prevalent among faculty than training and experience in other academic disciplines. Although some health systems have developed proactive programs,19 career development awards for QI/PS work from federal and private agencies remain limited, thereby restricting the protected time faculty need to develop proficiency in QI/PS methods. With the increasing emphasis on dissemination and implementation science, new opportunities for funding in these areas from the National Institutes of Health and other funding agencies have emerged. These agencies should be applauded and encouraged to continue to grow these programs. In the meantime, more robust collaborations are needed among investigators in the fields of implementation and improvement science to enhance the methodological rigor, generalizability, and durability of QI/PS initiatives.14,19
Health systems are confronted with reporting a large number of quality measures required by government and private payers and by regulatory entities.7 Some of these measures are publicly reported or linked to reimbursements in a manner that raises the financial and reputational pressure on health systems. As a consequence, health systems may encourage faculty to work on improving too many different measures, resulting in a less focused and systematic approach to QI/PS initiatives. Moreover, working on these measures can conflict with faculty members’ personal QI/PS interests. Stakeholders at academic medical centers may need to adopt a more balanced approach to these competing interests so that local needs can be addressed through effective interdisciplinary and multispecialty QI/PS projects.20 Therefore, faculty and departments will need to work constructively with health systems to set priorities that are responsive to the needs of both the health system and individual faculty members.
The impact of QI/PS work may be constrained by several practical limitations. Data collection is improving with advances in the electronic health record, but the data available to individual faculty for QI/PS research can be restricted. Moreover, QI/PS measures may be limited by a focus on processes of care rather than outcomes of care, evaluations of clinical care that clinicians do not find meaningful, or a failure to rigorously assess the validity of the measures.7 Importantly, QI/PS activities in many health systems have disproportionately focused on eliminating treatment errors, whereas errors of diagnosis account for a large percentage of the errors reported.
Finally, sustainable positive change in health systems is dependent on the performance of multiple individuals from different disciplines within a complex organizational framework. Individuals in some disciplines may not be able to contribute meaningfully and consistently to the steps required for change. Thus, the interdependencies of successful change management among different disciplines can limit the ability of faculty to demonstrate the success of their efforts. Unless specific steps are taken to promote effective interdisciplinary teamwork, these aspects of QI/PS work may conspire to make it difficult for faculty to successfully complete QI/PS initiatives or to sustain improved performance.21
Strategies for developing faculty with expertise in QI/PS
A more proactive approach to faculty development is needed to get more physicians involved in QI/PS work, to overcome the aforementioned challenges in developing QI/PS expertise among faculty, and to address the broader need to provide faculty with more support to ensure their success. This proactive approach can be separated into three related but discrete areas: administrative structure, enabling resources, and advising and training (see List 1).
Strategies for Developing Faculty With Expertise in Quality Improvement and Patient Safety (QI/PS)
- Emphasize that QI/PS is critical to the success of the department and therefore an important career pathway for faculty/trainees
- Establish a clear reporting and leadership structure for interdisciplinary care teams and department faculty
- Establish clear expectations and position descriptions that ensure the alignment of QI/PS initiatives with faculty interests, department needs, and health system priorities
- Ensure that QI/PS leaders have sufficient authority to lead organizational change
- Hold department leaders and care teams accountable for their performance in the six Institute of Medicine quality domains (safety, timeliness, efficiency, efficacy, equity, and patient-centered care)
- Ensure protected time where possible
- Award pilot grants in QI
- Establish an evaluation science core
- Establish an information technology core
- Establish a biostatistical core
- Develop a centralized information portal for QI resources
Advising and training
- Provide successful role models from within and outside the institution and department to advise and mentor
- Create individual development plans for faculty
- Establish longitudinal faculty mentoring programs
- Award grants for faculty to take courses/symposia within and outside the institution
- Expand the QI/PS curriculum and project development for students and trainees at all levels
- Establish learning communities for faculty within and outside the institution with an interest/expertise in QI/PS
- Hold seminars targeting QI/PS faculty with topics such as:
- ○ How to start a QI/PS project
- ○ Determinants of successful QI/PS projects
- ○ Turning QI/PS work into scholarship
- ○ Navigating the institutional review board process for QI/PS work
- ○ Where to publish QI/PS findings
- Bring together faculty with expertise in implementation science and faculty with expertise in QI/PS using:
- ○ Formal education programs in implementation and improvement science leading to master’s degrees or certificates
- ○ Pilot grants for projects that require implementation and improvement science
First, the administrative structure of QI/PS work should be based on the need for departments to excel in all six of the Institute of Medicine’s quality domains. Therefore, success in QI/PS should be part of the department’s strategic plan, and department leaders should be held accountable for developing and implementing the related QI/PS initiatives.3,11 Faculty responsible for QI/PS initiatives must have clearly delineated responsibilities and sufficient operational authority to meet those responsibilities.
Second, an array of enabling resources is essential for faculty to successfully conduct QI/PS work. The funding necessary to support these resources may come from the department or the affiliated health system, particularly from clinical contracts that contain performance incentives on quality measures. Core resources in evaluation science, implementation science, biostatistics, and information technology may be valuable to a wide range of faculty investigators and clinicians to improve their efforts in QI/PS.22 A successful approach to foster value within large complex health systems has been the development of innovation/value institutes with the specific aims of fostering leadership, scholarship, education, and engagement of faculty. QI/PS-based system-wide institutes may have a similar benefit in developing faculty expertise in QI/PS.23
Finally, the challenges in advising and training junior faculty in QI/PS are particularly compelling. Positive role models can inspire individual faculty members and increase opportunities for mentoring and collaboration. Starting with medical students, the QI/PS curriculum should be expanded with the goal of developing “continuously healing systems of care.”24–26 In addition to a focus on individual patients and populations of patients, the QI/PS curriculum should enhance the collective expertise of clinicians in QI/PS and serve to stimulate interest in the field among students and trainees. Learning communities and peer mentoring across departments, disciplines, and institutions also are beneficial for faculty.27 Mentors should provide continuous input over time that should be supplemented by didactic course work within and outside the institution and involve QI networks across disciplines and institutions to facilitate collaborations. As noted above, the increased integration of improvement science with implementation science would help faculty to expand the impact of QI/PS initiatives.
As the breadth of activities conducted by faculty in academic departments increases in response to new academic and clinical opportunities, institutions must find new approaches to identify and measure excellence to recognize and ultimately promote faculty.28 In the traditional promotions process, efforts to recognize successful faculty in the field of QI/PS may be limited and inconsistent.12 As academic clinical departments increasingly will be compelled to recognize excellence in QI/PS to align with local, regional, and national imperatives in health care,12,24 the challenges inherent in this process should be acknowledged.
The first set of these challenges relates to practical aspects of QI/PS work, many of which are common to other areas of clinical investigation and innovation.12 For example, the work is not often supported by extramural grants, and therefore it may lack the benefit of endorsement by peers and sufficient funds to complete. Methodological limitations inherent in rapid-cycle QI/PS initiatives may make it difficult to publish the findings because the number of independent variables that impact an outcome beyond those attributable to the intervention may be large, unstable, and difficult to control. As a consequence, the intervention may be effective only in the local setting, thereby limiting the generalizability of the intervention. More powerful, multisite studies are fewer in number because of funding constraints. In addition, the successful outcomes of QI/PS initiatives may not be sustained over time, and therefore a long follow-up period is required. QI/PS initiatives frequently require an interdisciplinary team and robust analytic systems, which may obscure the contributions of an individual faculty member to the successful outcome (e.g., analogous to the challenges of recognizing individuals participating in “team science”).
The second set of challenges relates to the limitations of the traditional promotions process. Promotions committees are generally comprised of senior faculty who are not experienced in evaluating work in QI/PS or clinical innovation more broadly and may be less familiar with the journals in the QI/PS field. Because relatively few QI/PS faculty have been promoted to senior ranks, promotions committees may lack sufficient expertise to identify outstanding achievement by faculty working in QI/PS. Finally, rigorous and meaningful benchmarking of performance on quality-of-care measures across disciplines, institutions, and regions may be difficult. Consequently, the impact of the work of individual faculty members in QI/PS may be more difficult to identify and contrast with that of others in the field.
Strategies for recognizing faculty achievement in QI/PS
The key to promoting faculty for their achievement in QI/PS is to successfully implement faculty development initiatives such as those described in the Development section above and to use rigorous measures of excellence to ensure that outstanding achievement is recognized (see List 2). Although every faculty member should have a minimum competency in QI/PS, true emerging champions deserve specific recognition. Appointments and promotions committees will need to work with department leaders to proactively define the forms of achievement in QI/PS that should be recognized in the promotions process. Important journals, media, funding sources, national policy making groups, and awards should be identified to assist these committees in evaluating faculty. The recognition of outstanding achievement in QI/PS through the establishment of prestigious awards should become routine for sections, centers, departments, schools, health systems, specialty societies, and national organizations. These awards would encourage faculty in the field as well as provide a meaningful form of recognition in the promotions process.
Strategies for Recognizing Faculty Achievement in Quality Improvement and Patient Safety (QI/PS)
- Proactively develop a shared view of achievement and excellence that includes an inclusive view of scholarship in QI/PS with appointments and promotions committees
- Create sample dossiers for faculty to review
- Create awards for outstanding achievement in QI/PS to be given by sections, centers, departments, schools, health systems, specialty societies, and national organizations
Individual faculty members
- Consider methodological rigor and suitability for publication in designing QI/PS initiatives
- Participate in regional or national advisory boards and policy making bodies to facilitate collaborations and recognition in the field
- Establish collaborative networks outside the institution
- Benchmark QI/PS performance to national and regional peers and to historical performance
- Create materials for promotion (e.g., personal statements, annotated curricula vitae) that clearly explain the importance, impact, and duration of an individual’s achievements
Individual faculty members also have a crucial responsibility in the promotions process. They should view QI/PS initiatives as opportunities for scholarship and consider generalizability and methodological rigor in designing interventions.29 In addition, faculty should take advantage of opportunities to serve on national policy making committees and advisory boards to increase their recognition in the field and to establish meaningful collaborative networks. Consistent with institutional policy, promotions materials (e.g., personal statements, annotated curricula vitae) should clearly explain the importance and impact of an individual’s achievements. The development of a professional QI/PS portfolio, similar to a teaching portfolio, has been proposed to effectively document meaningful QI/PS scholarship.30 Wherever possible, faculty also should benchmark the outcomes of their respective QI/PS initiatives to those of national and regional peers, as well as to historical outcomes. These benchmarks ideally should address the impact and importance of the QI/PS work in one or more of the six Institute of Medicine quality domains, the durability of the successful change, and the adoption of the approach by other organizations. This information will greatly facilitate the evaluation process of appointments and promotions committees.
The improvements in the quality and value of patient care that are needed to advance health care in the United States will require a thoughtful and meaningful series of investments across the spectrum of health care services. Academic medical centers will face challenges and exciting opportunities as they make these essential changes because of their mission to provide patient care, educate trainees, and conduct research. The development of faculty with the required expertise, authority, and recognition to improve QI/PS will be crucial to the success of health systems and the welfare of patients. Academic clinical departments increasingly have become aware of the need to proactively develop and recognize faculty who make critical contributions to the mission of their respective departments, schools, and health systems in serving the public good. The development of the field of QI/PS creates an opportunity and a responsibility to expand the impact of faculty working in this area. In this article, we have outlined an approach designed to enhance the success of faculty in improving the quality of care in health systems and to create an exciting career pathway for the development of valuable new knowledge and education.
Acknowledgments: The authors thank Karin Sloan, MD, for providing advice in the composition of this manuscript and members of the Council of the Association of Professors of Medicine for their review of this manuscript.
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