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Building Capacity in Health Professionals to Conduct Quality Improvement

Evaluation From a Collaborative Interorganizational Program

Plummer, Carolyn MHSc, RN; Ruco, Arlinda MPH; Smith, Kerry-Ann MN, RN; Chandler, Jillian MHSc, RN; Ash, Peter MBA; McMillan, Sarah MSW, RSW; Di Prospero, Lisa MRT(T), MSc; Morassaei, Sara MSc; Nichol, Kathryn PhD, RN

Author Information
doi: 10.1097/NCQ.0000000000000520

Abstract

Large academic teaching hospitals and other health care organizations are under constant pressure to deliver high-quality patient care, foster innovation, and secure and retain the best talent within a complex and changing environment. These organizations can strategically address such pressures by building academic practice capacity among its human resources. Academic practice may be defined as the application of evidence-informed knowledge to maximize health outcomes, patient experience, and the work environment. Specifically, point-of-care clinicians who engage in academic practice play an important role in offering new ways for health care organizations to attain a higher standard of health services and patient care.1,2 Furthermore, point-of-care clinicians are in unique positions to facilitate bottom-up solutions and act as agents of change.3 Building academic practice capacity among point-of-care clinicians is essential to enable health care organizations to adapt and evolve and deliver quality care.4–6

Several strategies to build academic practice capacity in point-of-care clinicians have been documented in the literature, including the establishment of internships or similar training opportunities,1,2,7–9 use of mentors for capacity-building, and development of key academic leadership positions.7,10,11 Evidence from a systematic review suggests that multilayered strategies that target enablers and barriers are key for promoting a positive change culture.10

Evidence also underscores that interprofessional collaboration and leadership capacity among point-of-care clinicians can translate into better outcomes for patients.12,13 Transformational leadership can facilitate significant organizational change and higher levels of organizational performance14 and is especially suited for health care organizations as it does not require a formal position of power for leaders. According to transformational leadership theory, individuals will follow a leader who inspires them through vision, passion, and enthusiasm.3 Higher levels of organizational performance occur as a result of the interaction between leaders and staff that leads to transformation in attitudes, values, and behaviours.15

Aligned with the Toronto Academic Health Sciences Network's (TAHSN) mission, the TAHSNp Health Professions Innovation Fellowship Program (Fellowship Program) was designed and piloted across organizations in 2014. The TAHSN includes the academic health organizations affiliated with the University of Toronto whose mission is to “serve as a leader in Canadian health care by developing collaborative initiatives that optimize, advance, and sustain a shared academic mission of high-quality patient care delivery, education, knowledge transfer, and research innovation.”16 This vision is supported by a number of subcommittees including the TAHSN Chief Nursing Executives and Health Disciplines Practice Committee (TAHSNp), which established the direction and support for the Fellowship through a Steering Committee.

The Fellowship Program was established to promote high-quality care services at the local level through capacity building among point-of-care clinicians in academic practice, specifically applied leadership, practice-based quality improvement (QI) and interprofessional collaboration. The TAHSNp Fellowship Program is a scale and spread of the Fellowship program successfully implemented at the University Health Network since 2010. This article reports on the key evaluation findings from the TAHSNp Health Professions Innovation Fellowship Program pilot as well as an update on current program status and sustainability.

METHODS

Institutional ethics board review was not required for this project as determined by the Ethics Review Self-Assessment Tool and confirmed with the Sunnybrook Health Sciences Centre Research Ethics Office.

Intervention

The objectives of the pilot program were 3-fold: (1) to improve the quality of patient care; (2) to build leadership, project management, and QI capacity in point-of-care clinicians; and (3) to work collaboratively with other TAHSN hospitals and academic institutional partners. To achieve these aims, the program provided point-of-care clinicians with paid, protected time away from the bedside (two 7.5-hour days per week for 6 months) to develop, plan, implement, and evaluate an innovative QI project and participate in educational curriculum on leading change. Funding was provided so that the participants could be released from their clinical service. The integrated educational curriculum was delivered in the form of weekly seminars (3 hours in length) facilitated by program or guest faculty subject matter experts. A list of seminar topics can be found in Supplemental Digital Content Table 1, available at: http://links.lww.com/JNCQ/A777.

The educational curriculum was also supported by a multipronged mentorship structure. Core program faculty (project managers from participating institutions with QI subject matter expertise) supported participants on a weekly basis through check-ins to discuss progress and problem solve, as well as by reviewing project plans and providing feedback. Participants also received and offered peer feedback during the check-ins and leveraged their collective knowledge following a small group learning model. In addition, participants identified at least 1 clinical mentor who could provide support during the program from an institutional and clinical perspective. Clinical mentors were expected to meet with participants biweekly or more often if needed. Participants were expected to provide regular project updates to their managerial team and present the findings of their project at midterm and at the end of the program.

Evaluation plan

The evaluation plan was developed in collaboration with the Fellowship Program Steering Committee and approved by the TAHSNp. The evaluation used primarily a pre-/posttest design for collecting data through participant surveys. In addition, focus group and individual interviews were conducted along with a survey with Steering Committee members.

Participant surveys and questionnaires

Participants in the program were asked to complete the following instruments pre and post:

  1. Leadership Practices Inventory-Self (LPI-Self)17,18
  2. Interprofessional Attitudes Questionnaire (IAQ)19
  3. Interdisciplinary Education Perceptions Scale (IEPS)20
  4. Project Management & QI Knowledge and Behaviour Questionnaire

The LPI-Self is a validated 30-item instrument that measures 5 leadership practices (subscales) consistent with transformational leadership.17,18 The 5 leadership practices are Modelling the Way, Inspiring a Shared Vision, Challenging the Process, Enabling Other to Act, and Encouraging the Heart. Participants were asked to identify the frequency at which they engage in various leadership behaviors on a 10-point scale (from 1 = almost never to 10 = almost always).17,18 Means and standard deviations for each subscale were calculated pre and post.

The IAQ is a 14-item instrument that asks participants to rate their level of agreement with statements related to interprofessional education on a 5-point Likert scale (from 1 = strongly disagree to 5 = strongly agree).19 Average scores on each item were calculated pre and post.

The IEPS is a validated 18-item instrument that assesses changes in attitudes about one's own profession on a 5-point Likert scale (from 1 = strongly disagree to 5 = strongly agree) as a result of interprofessional education.20 Average scores on each item were calculated pre and post.

Participants were also asked to self-rate their project management and QI knowledge and skills pre and post on a scale of 0 to 2 (0 = no knowledge or application, 1 = some knowledge or application, and 2 = good to advanced knowledge or application).

Focus group and interviews

A focus group and one-on-one semistructured interviews were conducted with the Fellowship participants to gather an in-depth understanding of their experience as well as to identify potential areas for improvement for the program. One-on-one semistructured interviews were also conducted with other key stakeholders including clinical mentors, managers, core program faculty, and Steering Committee members. Focus group and interview guides were developed in consultation with the Fellowship Program Steering Committee in accordance with the objectives of the evaluation plan. An experienced facilitator conducted the focus group with the Fellowship participants. Two experienced interviewers conducted the semistructured interviews after the Program had ended.

The focus group and interviews were audio-recorded and transcribed verbatim. A qualitative inductive approach was used to guide the analysis. Data were coded and emerging themes were identified. A second reading of the data was also completed to allow for further identification and definition of key themes. Key themes were then categorized according to evaluation objectives. The analysis was completed independently by 2 team members with experience in qualitative data analysis. The identified themes were then compared and discussed until agreement on the final themes was established.

Steering Committee partnership survey

Steering Committee members were asked to complete the UK Partnership Assessment Tool21 via an online, anonymous survey platform. The tool is a 36-item instrument using a 4-point scale that includes 6 questions related to each of 6 partnership principles: recognize and accept the need for partnership, develop clarity and realism of purpose, ensure commitment and ownership, develop and maintain trust, create clear and robust partnerships experience, and monitor, measure, and learn.

RESULTS

In the 2014-2015 pilot year, there were a total of 9 participants from 4 acute care organizations who participated in the program. One participant withdrew from the program for personal reasons, and another participant was brought on board to continue the project. Most participants (n = 6) were paired to lead a joint project while the remaining 2 led individual projects. Six-month follow-up data were available for 8 of the 9 participants (88.9%).

Participant surveys

Significant increases in self-reported leadership practices were found for all 5 leadership subscales (see Supplemental Digital Content Table 2, available at: http://links.lww.com/JNCQ/A778). The IAQ survey results revealed no major differences between the pre and postscores (data not shown). Fellows rated all items reflecting a positive attitude toward interprofessional education high and all items reflecting a negative attitude toward interprofessional education low. The IEPS presurvey demonstrated that the Fellows came into the program with positive attitudes about their own profession and how their profession interacts with other professions. For this reason, there was minimal measurable change observed between the scores pre and post (data not shown). Responses to the project management and QI knowledge and behavior surveys revealed that the average scores pre and post increased by 1.57 when participants were asked about their knowledge of project management and by 1.0 when they were asked about their knowledge of QI (on a 2-point scale).

Focus group and interviews

A total of 8 fellows (88.9%) participated in the focus group. Structured interviews were conducted with 8 mentors (100%), 6 managers (85.7%), 8 Steering Committee members (72.7%), and 3 program faculty (100%). Results showed changes in the following areas: clinical practice at both the individual and unit/team levels, capacity for leadership, QI and project management, and knowledge of QI and relationships.

Findings related to improving the quality of care in TAHSN hospitals were noted by both program participants and several mentors. Quality and safety of practices related to patient care and service delivery were considered findings related to improving the quality of care. For instance, several participants talked specifically about practice changes that had occurred at the clinician level as a result of participation in the program. “As a result of the project, I have changed my discharge practice with my geriatric patient population—I feel I am serving their needs much better than previously and I feel very good about this change.”

Several mentors and participants also commented on the changes in practice at the unit or clinical team level as a result of the project work. This included adoption of new processes that were in line with best practice as well as changes in the way staff on the unit worked with their interprofessional colleagues to deliver patient care. Unintended impacts on unit operations included scheduling challenges and lack of trained or appropriate staff to cover clinical service while participants were in the program. Participants were required to develop a comprehensive evaluation plan and formally track whether project activities resulted in care improvements.

Data also provided evidence of building leadership, project management, and QI capacity in point-of-care clinicians at TAHSN hospitals. Specifically, participants, mentors, and Steering Committee members all commented on how participation in the program allowed Fellows to see beyond their individual practice areas.

I've been at the bedside for a long time so I really appreciated and liked the opportunity to take a step back and to do things that I always wanted to do in my daily work that I never had the time for. [The Fellowship was] a chance to look at my organization from a different perspective because I wasn't overwhelmed with front line work and I could see the daily maneuverings and how our team works from a different lens then I normally do.

Interviewees discussed new knowledge acquired as a result of participation in the program, specifically, gaining new understanding of QI as a systematic approach and a distinct discipline of inquiry. A key benefit of the program that was articulated by participants, mentors, and Steering Committee members was how the experiential design of the program led to rapid leadership development and the demonstration of leadership ability.

Finally, both the interviews and focus group findings identified the strength of the program in building relationships. Participants described the relationships they built with each other, their interprofessional colleagues in their practice areas, and with their mentors and others across the organization who supported them in their project work. The participants also described a network of support that surrounded them throughout the program and helped enable project work as well as individual development.

Steering Committee partnership survey

Seven of 11 (63.6%) Steering Committee members completed the Partnership Assessment Tool. The mean scores for each of the 6 partnership principles fell into the highest possible range (see Supplemental Digital Content Table 3, available at: http://links.lww.com/JNCQ/A779). Based on the aggregate total of the scores across the 6 principles, the partnership was assessed to be working well so that further detailed work to enhance the partnership was deemed unnecessary.

Current program status and sustainability

Based on the results of the pilot, the program continues to be offered annually with 5 cohorts of graduates under the leadership of 2 TAHSN partners (University Health Network and Sunnybrook Health Sciences Centre). To date, 160 participants from 15 health professions and 9 participating health care organizations have successfully completed the program.

Demographically, the program has evolved to expand its number of entrants, number of health professions, and community-based health care organizations. The 2019-2020 cohort had 29 participants representing 12 different health professions from 3 acute care hospitals and 1 community-based health care organization. Of these participants, 76% and 24% reported being very satisfied or satisfied, with their experience in the program (mean = 4.76 on a 5-point Likert scale, SD = 0.44), and 100% reported that they would recommend the program to a colleague.

The program has also evolved its educational curriculum and project requirements to support quality. For instance, the program now offers 15 seminars to participants and requires all participants to complete the IDEAS Foundations of QI certificate course to support applied knowledge in QI.22 Furthermore, all participants are required to screen their QI projects for ethical risk to ensure that risk is minimized for patients, staff, and organizations. Finally, several graduates of the program have taken on leadership roles such as advanced practice nurse educators, care coordinators, managers, and project managers—impacting the system beyond the local level.

DISCUSSION

The TAHSNp Health Professions Innovation Fellowship Program evaluation demonstrated favorable results in several instruments showing increases in leadership practices, increased knowledge of QI and project management skills, improved quality of care, and overall leadership capacity-building across the various participating organizations. Interview and focus group data highlighted a positive experience of program participants and confirmation that this collaborative interorganizational program worked well.

The development and implementation of the Fellowship Program is in alignment with current literature around identified capacity-building frameworks and models.1,2,7,23,24 For example, a review by Slade et al23 identified 16 frameworks for research capacity-building in allied health professionals. Content analysis of these frameworks provided support for high-level policies to enable leadership, organizations, and individuals to embed a research and inquiry culture into practice.23 Evaluation of this Program provides evidence for all of these concepts supporting the notion that a well-planned program with appropriate supports in place can translate into successful development of leadership and QI capacity.

Despite the small number of participants in the pilot year, significant changes were observed in leadership practices. Using a transformational leadership approach that is accessible to point-of-care providers proved to be a successful strategy for building capacity. This evaluation provides preliminary support for the value of this program in building future organizational leaders and may constitute an important human resources retention strategy. However, to continue to harness the benefits of programs similar to this, systems will need to support various career pathways for point-of-care providers where these skills can be utilized.

While advanced practice and clinical educator roles have traditionally provided leadership opportunities, more support is needed to elevate QI and research career pathways for point-of-care providers. This remains perhaps the most underdeveloped trajectory of these clinicians whose work responsibilities encompass clinical practice, education, and inquiry. Lack of recognition and priority for allied health research among the scientific community outside of nursing and medicine has been reported in the literature.6,25–27 This has translated to relatively few allied health research scientist roles.6,25,26 To address this gap, organizations have embedded practice-based research and innovation departments, training opportunities focusing on the health professions outside of medicine, or have established allied health research positions to elevate the research agenda of these professions.5,7,10,27–30

The most important and innovative aspect of the Fellowship program included the interorganizational collaboration. The Steering Committee comprised representatives from other TAHSN organizations across the health system in addition to leaders from the participating organizations. Therefore, not only did the collaborative nature of this program allow for the sharing and maximizing of resources and interprofessional collaboration but it also allowed for system leadership outside of the silos of each participating organization. This infrastructure presents a tremendous opportunity for recognition and elevates the value of the program. Similar training opportunities have typically been organized within a single organization.7–9,11,31

CONCLUSION

The evaluation of the TAHSNp Innovation Fellowship Program showed promising results as a strategy for building leadership and QI capacity among point-of-care providers in large academic health centers. The collaborative aspect of the program allowed organizations to maximize resources while reaping the benefits of the program across the system through joint leadership and recognition. Health care organizations may benefit from implementing a similar program to build capacity and support point-of-care providers in their academic practice and leadership journey.

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Keywords:

capacity building; fellowship program; health professions; leadership; quality improvement

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