Executive Summary: Clinicians in Quality and Innovation Review

In 2012, the Department of Medicine at the Temerty Faculty of Medicine created a new academic job description, the Clinician in Quality and Innovation (CQI). This change reflected the desire to provide an academic home for faculty whose scholarly work primarily relates to assessing and improving healthcare quality, developing new models of care, or pursuing other forms of scholarship and innovation outside of traditional ‘discovery research’. The number of Department members in the CQI job description has grown from one full-time faculty in 2012 to 78 in 2022. As the position description enters its tenth year, the Department of Medicine funded an independent review to examine the development of the position over time, its impacts, and challenges.

Methods

Using a case study approach, the external reviewer conducted semi-structured interviews, analyzed

internal documents and administrative data related to the CQIs, and reviewed online publications and reports of their work. The interview study sample consisted of 23 CQI faculty and 7 Department Leaders, including 3 Physicians-in-Chief (PICs) and 4 Departmental Division Directors (DDDs). In selecting CQIs to approach for interviews, variability in training, specialty, institution, and year of CQI appointment was sought. The study sample consisted of CQI faculty with representation from 13 of the 16 Divisions including at least one CQI faculty member.

Findings

Growth of the CQI Job Description

The CQI role has seen tremendous growth in 10 years—from one to 78 full-time faculty and an additional 11 part-time. These faculty work at all of the major teaching hospitals (Mount Sinai Health, Sunnybrook Health Sciences Centre, University Health Network, Unity Health, and Women’s College Hospital), as well as Trillium Health Partners, Michael Garron Hospital, and William Osler Health System. Of the Department’s 20 subspecialty Divisions, 16 include at least one CQI faculty member.
The full-time CQIs include 9 Lecturers, 53 Assistant Professors, 13 Associate Professors, and 3 Full Professors. Promotion has been successful in so far as all 29 applications for promotion of CQIs have succeeded on the first attempt. The CQIs have also had a 100% success rate for Continuing Faculty Appointment Review (CFAR).
Despite the success with promotion and CFAR, some CQIs reported challenges getting to the stage of being considered ready to apply for promotion. There were also concerns that successful promotion still seems to occur most easily using traditional metrics of research (e.g., publications and grants) rather than taking into account the full range of impacts included in the University’s Creative Professional Activity (CPA) framework.
With time, the CQIs have increasingly taken on leadership roles. The Medical Directors of Quality and Safety at all of the major teaching hospitals are CQIs. CQIs also play key roles in major hospital operations like informatics and infection control. And, the PIC at UHN is a CQI as was the past PIC at Trillium.

Scope of the CQI Position and Perceived ‘Fit’

Numerous quotes from the interviews indicated that the ‘Clinician in Quality and Innovation’ position has largely met its principal goal of providing an ‘academic home’ for faculty focused on quality improvement and other forms of innovation (hereafter abbreviated as Q&I). The existence and growth of the CQI position has also fostered greater awareness amongst Department Leaders and would-be faculty members about the value and academic legitimacy of Q&I work.
Areas of focus for the CQIs have included: improving health care processes, reducing unnecessary tests and treatments, antimicrobial stewardship, infection prevention and control, developing new models of care, responding to COVID, clinical informatics, further developing QI capacity through education and training, research identifying or characterizing quality problems, and policy work.
The widespread perception that the abbreviation CQI stands for Clinicians in Quality Improvement (not Clinician in Quality and Innovation) and the emphasis in local education programs on quality improvement, has sometimes left CQIs who do not carry out traditional QI projects wondering how they ‘fit’ in this role. For instance, some CQIs might evaluate a new model of care or pursue other innovations that do not fit the mold of the classic Plan-Do-Study-Act (PDSA) quality improvement project.
A small number of participants discussed the need for the CQI position description to be responsive to developments in the field and to changes in the nature of CQI work that an individual might engage with throughout a career. Some participants also referred to problems amplified by the pandemic, such as equity issues and the social determinants of health, fundamental problems with how the health system is organized, as well as the impacts of impending threats such as the climate crisis.

Collaborations and Enablers

Collaborations are at the core of CQI work. As one Department leader commented “The [C]QIs have a broader scope. They're very good at collaborating within their [sub]specialties and across specialties...” Other comments from interviews and reviewing CQI publications identified frequent collaborations across subspecialties of medicine, across medical specialties and Departments (e.g., Surgery and Pediatrics), across health care professional groups (e.g., Nursing, Pharmacy), as well as across hospitals in TAHSN and the Greater Toronto Area. CQIs also frequently worked with provincial and federal agencies and national professional organizations. CQIs have also collaborated with each other to a substantial extent. In the most recent 5 years alone, CQIs published 135 papers with at least 2 CQIs as authors and some had multiple CQIs as authors.
The past ten years have seen progress in the development of enabling processes and structures within the Department of Medicine, the hospitals and Faculty of Medicine and external organizations to support the work of CQIs. For instance, DDDs have facilitated Division-wide Q&I strategic priorities and work; CQIs have been appointed to hospital leadership positions and committees related to healthcare quality; and hospital infrastructure has been created to support Q&I work. The UofT Centre for Quality Improvement and Patient Safety has also provided learning, teaching and mentorship opportunities. And, national organizations with a strategic focus on Q&I work (e.g., Choosing Wisely Canada) have afforded opportunities and support for CQIs.
There is variability in enabling processes and structures depending on the individual CQI and the Division and hospital in which CQIs are located, pointing to the need for continued attention to developing supporting infrastructures for CQIs. CQIs also reported continued challenges with funding for CQI work. Participants reported variable access to mentorship depending on whether their Division or hospital included more senior colleagues with expertise in Q&I work. The increasing numbers of mid- and senior-career CQIs presents an opportunity to improve the consistency of mentorship for the CQIs.

Tensions between hospital priorities and academic success

Department Leaders (PICs and DDDs) reported that CQIs are highly valued in hospitals for their work in healthcare improvement. There was recognition of the need to support CQIs and align them with hospital priorities and senior CQIs at their hospitals. However, there was also recognition that some instances of CQI work on hospital priorities did not necessarily align with university academic expectations. These include leadership activities such as creating hospital infrastructure to support quality and safety as well as addressing local quality problems that have little academic value because the solutions are not innovative enough to generate peer review publications or garner invitations to present at national/international conferences.

Summary and Recommendations

The work of CQIs has had clear impacts at local, regional, provincial, and national levels. The number of publications and reports highlighted in this report demonstrate impact by the accessible metric of publications. Further demonstration of impacts were clearly evident through CQIs’ descriptions of changes in clinical practices, organizational processes and patient care outcomes in their healthcare contexts. This work has been accomplished through individual knowledge and skills, new understandings of academic work and impacts, changing relationships within hospital organizations, evolution of the Q&I field, forging of collaborative approaches, and revisions to strategic areas of focus of academic units and healthcare organizations.

Looking forward, opportunities to optimize continued progress for clinicians in the CQI academic position and the impacts of their work include the following:

Recruitment to the CQI academic pathway:
1. Ongoing efforts are needed to expose trainees to Q&I during training years, particularly in Divisions with a smaller number of CQIs.
2. Department Leaders play a key role in supporting potential new faculty who may not see the fit of their work with the Q&I academic position, and therefore ongoing communication is needed about the role and its opportunities.
Recognition of impacts other than the traditional metrics of publications and grants: While progress has occurred on this front, additional efforts are needed to support CQIs when it comes to academic promotion:
1. Continued advocacy for assessment criteria that align with CQI work to ensure that assessments of impact reflect the nature of CQI work and outcomes beyond traditional metrics of grants and publications.
2. The processes and structures (e.g., forms, committee membership) require ongoing attention to ensure they are structured to collect information that is relevant to the CQI pathway and provide relevant feedback and assessments.
3. Attention to the above will prevent clinicians from choosing another academic position that is perceived to be an ‘easier’ pathway to promotion despite their main focus being Q&I.
4. Resolve tensions between work valued by hospitals and activities likely to garner academic credit and recognition. An analogue to ‘sustained excellence in teaching’ for CQIs might be helpful in this regard. Sustained excellence in teaching is demonstrated using scores on evaluations from trainees as well as winning teaching awards. Sustained excellence in Q&I would probably involve compiling a dossier with enough details about the projects undertaken and their impacts that a referee could judge the body of work as meritorious or not. Supporting letters from hospital leaders might also play a role.
5. Provide training and resources (e.g., exemplars letters of support) for Department Leaders who provide guidance and feedback to CQI faculty.
CQI position
1. Increase support and recognition for broader Q&I work, with particular attention to legitimizing the ‘innovation’ of Q&I (e.g., through courses, language used, profiling examples, mentorship) so that CQIs not engaged in PDSA-type improvement projects feel included and relevant training, job expectations, and mentorship are available.
2. Support opportunities for CQIs to engage in work in response to ‘bigger picture priorities’ (e.g., social determinants of health, climate crisis, the need for fundamental changes to the organization of the healthcare system) while not undermining ongoing attention to microsystem problems in clinics and on hospital wards.
3. Continued attention is needed to ensuring transparency about work expectations of the CQI position and its alignments with other academic positions (e.g., protected time for academic work, billing targets, number of clinics, funding allocation processes).
Mentorship
1. The growing number of more mid-career CQIs should now be seized as an opportunity to formalize mentorship opportunities and provide CQIs with formal recognition for the mentorship work that they are doing.
2. New models of mentorship for early career CQIs should be developed as relevant to contexts given the recognition that successful Q&I work is contingent on alignments with experienced mentors, hospital priorities and resources.
Training and continuing professional development
1. Continued attention is needed to ensure potential CQI faculty demonstrate a combination of relevant graduate training for their particular interests that could be complemented by QI training offered at places such as CQuIPS as well as workplace experiential training.
2. Further continuing professional development programs can be developed that reflect the range of knowledge and skills CQIs require given the diversity in their work and work trajectories over time.
Continued CQI community development
1. CQIs in hospital leadership roles are playing key roles in fostering CQI activity as well as their relationships and collaborations with other healthcare providers. Their work should be recognized and learnings from across hospitals can foster infrastructures that are supportive to CQIs across all of the hospitals in which CQIs are located.
2. The above includes efforts to support recognition for Q&I work, with particular attention to legitimizing the ‘innovation’ of Q&I so that all CQIs feel connected to the community of CQIs and that their work is supported.

Read the full Clinicians in Quality and Innovation Review.