Academic medical centers (AMCs) and their academic departments are increasingly assuming leadership in the education, science, and implementation of quality improvement and patient safety (QI/PS) efforts.1–3 To do this well, faculty engagement and leadership in QI/PS are essential. However, AMCs face challenges in enlisting faculty to participate mean ingfully in these activities, partly related to limited recognition for the work as “academic” and an ambiguous pathway for promotion and success. Importantly, top-performing academic institutions recognize that QI/PS activities are imperative for strategic survival, and most academic department of medicine chairs are in favor of promoting faculty on the basis of QI/PS work.4,5 Yet, the majority of those chairs have reported that their organization fails to have useful methods to assess QI/PS activities as part of the promotion process.5
In 2009, the Association of Chiefs and Leaders in General Internal Medicine and the Society of General Internal Medicine’s Academic Hospitalist Taskforce developed a quality portfolio to help meet this unmet demand.6 The tool was “intended to formally organize and document one’s activities in quality improvement”6 and to mirror the educator’s portfolio (EP) that is widely used to document achievement and success in education. The specific goals of the quality portfolio were to better capture the activities of faculty engaged in this work; allow faculty to demonstrate productivity in QI/PS; acknowledge and recognize this work; improve faculty retention; guide individual faculty development through self-reflection and mentorship; and raise the value of QI/PS in one’s home institution.
In this report, we describe our adoption, adaption, and implementation of the quality portfolio into our Department of Medicine’s promotion process. We share our process and the early lessons learned, including the impact of its adoption for faculty who used the tool as part of their academic advancement in the past two years.
The University of California, San Francisco (UCSF) is a health science campus with schools of dentistry, medicine, nursing, pharmacy, and a graduate division. Our department of medicine is the largest department, with more than 750 full-time faculty, which is nearly 30% of the school of medicine’s full-time faculty. The department is known for its research and consistently ranks in the top two for National Institutes of Health funding across the country. Our faculty provide clinical care at multiple campuses, including UCSF Health, San Francisco General Hospital, the San Francisco Veterans Affairs Medical Center, and UCSF Fresno.
UCSF advancement process
UCSF’s Academic Senate provides an online “Faculty Handbook for Success” that includes written guidelines and criteria for promotion. Our department also provides an accompanying guide that more explicitly outlines criteria used, which is consistent but not identical to other departments’. Faculty in our department have the opportunity to electronically vote to support nominations for promotion that are then reviewed beyond our department at the university level. The key context worth noting is that UCSF’s academic promotion tracks are not organized around functional role types (e.g., clinical investigator, clinical educator, etc.). The primary pathway for an investigator would be through our “In-Residence” series, whereas faculty engaged in education or quality improvement (QI) work would traditionally advance in either a “Clinical X” or “Health Sciences Clinical” series. The primary distinction between the latter two series is that Clinical X is part of our Academic Senate and the expectations for promotion are more focused on substantial scholarly activities compared with the Health Sciences Clinical series, which is more focused on clinical expertise and teaching. With that context, our organizational adoption of an EP and our department’s adoption of a quality portfolio were designed to largely assist faculty with their promotion in the Clinical X series, though this was not an explicit requirement.
Our department’s promotion process focuses on two types of academic review. A “merit advancement” (e.g., assistant professor, Step 1 to Step 2) occurs every two years and is awarded after review by the department’s promotion committee. A “promotion” (e.g., assistant to associate professor) requires a more systematic and robust review, which includes internal and external references, career narratives, and a university-level approval.
Tool development and adaptation
Using the available quality portfolio as a starting point, we began a series of local discussions and focus groups to determine how best to adapt the tool. We engaged department leadership, division chiefs, selected faculty already demonstrating career commitments to QI/PS, and a few QI leaders in other clinical departments to best understand how to better recognize faculty contributions in QI/PS. A clear consensus was reached to adopt the portfolio concept but also avoid having its elements duplicate what was already in our UCSF curriculum vitae guidelines (e.g., teaching activities, research, publications). Instead, we wanted to focus our quality portfolio on elements that were not documented well enough in the existing promotion materials. This was the single greatest point of feedback from faculty who were asked about the utility of creating the portfolio in the first place. Appendix 1 outlines what we renamed as our “Systems Innovation, Quality Improvement, and Patient Safety Portfolio” (QI portfolio) and its sections to better brand the type of work encapsulated in the document. Appendix 2 provides an example of the QI project activity we developed, because this was the section that generated the most questions about how faculty were to complete it. We believed that this structure for describing project involvement would further delineate “I sat on a quality committee,” from “I led a quality committee and our team helped improve rates of A from X to Y,” from “I also presented our team’s work at our national society meeting and submitted it as a manuscript.” The latter would more explicitly illustrate the desire to demonstrate scholarship and dissemination of local improvement work. Finally, the QI portfolio was accompanied with an online guide that provided background about its adoption, the guidelines for use, and additional details about completion.7
Once our QI portfolio was finalized, we presented it for approval by our department’s promotions committee, which is a diverse representation of our faculty (e.g., basic scientists, clinical investigators, educators). The committee was supportive of the need and endorsed its adoption in summer 2011 with dedicated implementation efforts beginning in early 2012. An announcement about the portfolio’s adoption was sent from the chair’s office, communicated by the associate chair for quality and safety in a quarterly e-newsletter, and then presented at a division chiefs meeting to raise awareness and address questions among the leadership. Working with our department’s promotion staff, every faculty packet request for advancement materials included the portfolio in their checklist with the option to complete and submit it. Communications about the portfolio were included annually in the winter Quality and Safety e-newsletter in anticipation of the advancement process cycle. Of note, during this time period, UCSF transitioned to an online management system for academic advancement that includes a curriculum vitae tool. Our QI portfolio was added to the options of accompanying documents similar to our EP. Finally, our promotions committee members received instructions to evaluate the QI portfolio in the same way that they had evaluated the EP, which is as an adjunct to a faculty member’s other submitted materials.
Faculty use and characteristics
We tracked the number of portfolios submitted through each of the last two advancement cycles. These cycles were for advancement actions made effective July 1 in 2013 and 2014 (packets were submitted at least a year in advance). Overall, there were 67 QI portfolios submitted during the first two years after implementation in 2012. This was 13% of all packets submitted during this two-year period (n = 533)—18% (25/137) of all promotion packets and 11% (42/396) of all merit advancements. All of these faculty received their requested academic advancement compared with 100% and 96% of all faculty seeking merit advancement and promotions, respectively, during the same time period.
Women represented 61% (41/67) of the QI portfolio submissions. There were more submissions at the assistant professor rank (55%; 37/67) compared with the associate (28%; 19/67) and full professor ranks (16%; 11/67). Approximately 60% (40/67) of the submissions were from faculty in the divisions of hospital medicine (33%; 22/67) and general internal medicine (27%; 18/67). The remaining 40% (27/67) were from 10 different specialty divisions, with the most coming from hematology/oncology (n = 5), cardiology (n = 5), endocrine (n = 3), infectious disease (n = 3), and nephrology (n = 3).
We sent a brief three-question survey in January 2015 to faculty who submitted a QI portfolio to learn about their attitudes (81% response rate). Using a five-point Likert scale ranging from strongly agree to strongly disagree, 80% strongly agreed or agreed that our QI portfolio “was an effective tool for systematically documenting your QI activities”; 83% strongly agreed or agreed that our QI portfolio “was an effective tool for helping to better recognize faculty contributions in QI work”; and 85% strongly agreed or agreed that our QI portfolio “was an effective tool for elevating the importance of QI work in our department.”
In reflecting on our outcomes, the biggest challenge is the lack of benchmarks for comparison. Should our target for faculty submitting a QI portfolio be 10%, 20%, or 40%? For such a large department, we were pleased to see an 18% rate for promotion packets in the first two years, particularly as it represents a promotion cycle for only a small percentage of faculty who could potentially submit one. A second observation was that, while 60% of the submissions were among generalists for whom the national effort was motivated, 40% of our submissions came from specialists. This holds promise for helping faculty across our department use the QI portfolio to better document their efforts in improving their clinical microsystems. We were also surprised to find that faculty in our in-residence series (i.e., investigators) found value in submitting a QI portfolio (9%; 6/67) when their criteria for promotion were potentially less likely influenced by the presence of the additional documentation. Finally, the survey findings supported our initial hope that the adoption of the QI portfolio would create value beyond simply academic advancement. The effort was in fact a mechanism to explicitly recognize faculty doing improvement work. Our advancement rates may be higher than comparable institutions’, so it was reaffirming to see that it served as a tool to recognize a strong commitment by our department for QI contributions.
Within our department
We intend to continue efforts to promote the use of our QI portfolio among faculty who are increasingly engaged in leading systems improvement work. There is also opportunity for further evaluation of the QI portfolio, but the high initial utilization does suggest feasibility. It is important to note that the adoption of our QI portfolio was only one aspect of our broader program to create opportunities to recognize and support faculty who are leading, teaching, and mentoring improvement work.8 Anecdotally, the relative ease in acceptance from our promotions committee and the faculty reflected these broader efforts. For instance, in our fifth year of an annual Quality and Safety Innovation Challenge, we had more than 90 poster presentations at our last spring symposium to highlight improvement projects conducted across our clinical campuses.9 We also feature interviews on a quarterly basis with a faculty member and a trainee to further highlight great people and their stories of improvement work. Finally, we need to continue working with our promotions committee to better understand how they are specifically using the QI portfolio in their review process and what would make it a more effective tool from their perspectives.
Dissemination within UCSF
Given the continued evolution of our online academic advancement process at UCSF, there is a renewed opportunity to scale our department’s adoption and implementation of the QI portfolio. The tool is already part of the online system, so it is embedded for sustainability. We will share our early lessons and advocate for the role that a UCSF commitment to the QI portfolio could play in benefiting faculty, their clinical departments, and our clinical enterprise more broadly. Anecdotally, the current interest among our other clinical department leaders is inspired by our faculty’s message that the portfolio was as much about valuing them and their QI work as it was about the promotion process.
Dissemination within AMCs
AMCs have an imperative to lead innovation, education, and health services research that drives improved health for the populations they serve. Adoption of a QI portfolio is a small but critical piece of fostering, recognizing, and cultivating greater faculty involvement in these efforts. Our process of taking a nationally developed tool and adapting and implementing it locally is in many ways our own QI project. We identified a gap, designed an intervention, measured its impact, and will take the early lessons learned to improve the tool and process moving forward. Although our tool and processes may resonate for other institutions doing the same, it does require adaption to local promotion guidelines and culture for QI work. We hope other AMCs and their academic departments embrace a similar strategy to catalyze much-needed faculty career paths in QI/PS.
Acknowledgments: The authors would like to thank their department’s promotions committee for supporting the adoption of the Systems Innovation, Quality Improvement, and Patient Safety Portfolio (QI portfolio), and Edmund Chang and Donna Portillo for their assistance in organizing the data from our advancement process.
1. Fisher ES, Berwick DM, Davis K. Achieving health care reform—how physicians can help. N Engl J Med. 2009;360:24952497.
2. Brindis RG, Spertus J. The role of academic medicine in improving health care quality. Acad Med. 2006;81:802806.
3. Neeman N, Sehgal NL, Davis RB, Aronson MD. Quality improvement and patient safety activities in academic departments of medicine. Am J Med. 2012;125:831835.
4. Shojania KG, Levinson W. Clinicians in quality improvement: A new career pathway in academic medicine. JAMA. 2009;301:766768.
5. Staiger TO, Wong EY, Schleyer AM, Martin DP, Levinson W, Bremner WJ. The role of quality improvement and patient safety in academic promotion: Results of a survey of chairs of departments of internal medicine in North America. Am J Med. 2011;124:277280.
6. Taylor BB, Parekh V, Estrada CA, Schleyer A, Sharpe B. Documenting quality improvement and patient safety efforts: The quality portfolio. A statement from the academic hospitalist taskforce. J Gen Intern Med. 2014;29:214218.
8. Neeman N, Sehgal NL. Perspective: A road map for academic departments to promote scholarship in quality improvement and patient safety. Acad Med. 2012;87:168171.
9. Neeman N, Ranji SR, Sehgal NL. Perspective: Engaging trainees in performance improvement projects: The quality and safety innovation challenge. Am J Med Qual. 2012;27:345347.
The University of California, San Francisco Department of Medicine’s Systems Innovation, Quality Improvement, and Patient Safety Portfolioa
SUMMARY OF QI ACTIVITIES
Please provide a personal statement summarizing the highlights of your involvement and activities in systems innovation, QI and patient safety since your last advancement; please limit to 1–2 paragraphs.
QI LEADERSHIP / ADMINISTRATIVE ACTIVITY
Please list your involvement in Clinical and/or QI leadership roles (e.g., Director of Quality, Director of Ambulatory Clinics, committee chair, etc.) For each role please provide:
- Leadership/Administrative Title
- Roles and Responsibilities (1–2 lines)
QI PROJECT ACTIVITY
Please describe your activity in QI projects. Note, projects listed in this category may be local to your institution, regional (for example, part of a hospital collaborative), or national (for example, a multi-institutional collaborative; providing QI and patient safety consultation services to other AMCs, etc.). In general, document a description of the activities as well as the quantity and quality of the work. Projects listed can also include mentored ones for trainees, and those completed as part of the Maintenance of Certification’s Performance Improvement Modules for board recertification (See “Example of QI Project Activity” table).
Specifically, detail the following for each activity:
- Project Title (committee name, project name, etc.)
- Project Timeframe
- Estimated time commitment (in hours per month and duration of the project)
- Project Description/Goals (1–2 line summary of the project goal(s))
- Role/contributions (1–2 line summary of your role and specific duties: e.g., Chair, committee member, project mentor, etc.)
- Other Project Members (physicians, nurses, therapists, etc.)
- Project outcomes/results (describe how project effectiveness was measured and provide results if available. Results can be qualitative or quantitative)
- Dissemination of project (have any aspects of the project been disseminated locally, regionally, or nationally?)
QI AWARDS / HONORS / RECOGNITION
Exemplary work in quality improvement may be recognized with awards and honors. Please list those here including the following:
- Award/honor name
- Awarding organization
- Criteria for selection (1–2 lines)
Please include any additional training you may have in Systems Innovation, QI or Patient Safety (e.g., Advanced degree, certifications, content-specific Seminars or Conferences, Lean training, etc.)
Abbreviation: QI indicates quality improvement.
aReproduced with permission from: University of California, San Francisco Department of Medicine. Systems Innovation, Quality Improvement & Patient Safety Portfolio. http://medicine.ucsf.edu/safety/docs/dom-qiportfolio-201104.pdf. Accessed March 10, 2016.