Chair's Column: Results from the 2017 Faculty Survey: Clinicians in Quality & Innovation

Last week I had the pleasure of attending the Co-Learning Curriculum in Quality Improvement (QI) Final Presentation Day. The day was filled with presentations from joint teams of our faculty and residents on their quality improvement projects, and exhibited many examples of how QI can directly impact frontline care. QI is an exciting and growing area of focus in healthcare and medicine.

Here in the DOM, we now have more than 50 faculty members whose academic focus is quality improvement and innovation. I'd like to use this Chair's Column to share the results of the 2017 Faculty Survey section on Clinicians in Quality and Innovation. Let me begin by thanking Kaveh Shojania, Vice-Chair, Quality and Innovation, Brian Wong, Director of Continuing Education and Quality Improvement, and statistical wiz Ed Lorens for their analysis and summary of these results.

In 2012, the Department of Medicine established the Clinician in Quality and Innovation (CQI) job description to broadly represent Department members whose primary academic interests relate to QI, patient safety, resource stewardship, knowledge translation, or other forms of healthcare innovation, such as advancing health informatics, health policy or developing new models of care. In 2015, some further modifications were made such that individuals committing substantially more time to academic work in QI were classified under other position descriptions, like CI and CS.

The focus of these results is on the 45 full time faculty with a CQI position description. Currently, most divisions have two to three CQIs, with a range from zero (three divisions) to eight in GIM. 56% of CQI faculty members are female and the vast majority are in the first five years of their faculty appointment (71%). Most have 25 to 30 % of their time dedicated towards QI activities.

Figure: Number of CQI Recruits per Year (to 2017)

Interpreting the survey results provided below requires keeping this context in mind. The CQI faculty cohort may be more likely to face certain challenges on account of their being earlier in their careers, having limited protected time for academic work, and few peers in their clinical divisions. In our comparisons with non-CQI survey respondents, these differences have not been controlled for.

Of the 45 full-time CQIs, 25 responded to the faculty survey, giving a 56% response rate (vs 52% response rate overall). Common themes that emerged from the survey are summarized below.

Career Satisfaction

We're very happy to report that the majority of CQI faculty respondents (17/19 respondents; 89%) are satisfied (somewhat or strongly) with their career, while six indicated “prefer not to answer”. Nonetheless, several important signals warrant attention.

CQIs exhibited a trend towards greater dissatisfaction with the time that they have to fulfil academic obligations (42% among CQIs compared with 26% among other faculty; p=0.18). This finding may reflect an inherent challenge associated with the CQI job description. While 30% of non-clinical time may seem like a reasonable allotment, this time is often erratically distributed across weekly schedules, which makes it difficult to lead or oversee successful changes in complex clinical environment. While this problem can affect other job descriptions, it presents particular challenges for CQIs implementing changes that require substantial work and constant attention.

A perceived lack of support for QI work compounds CQIs' dissatisfaction with their protected time. CQIs expressed greater dissatisfaction with the amount of statistical support and research coordination they receive. And, they showed significantly greater dissatisfaction with research ethics (REB) processes (32% for CQIs vs 14% in other job descriptions; p=0.05). Some of our academic institutions have inconsistent policies and processes for handling submissions that relate to QI work, and all struggle with data transfer agreements for multisite QI projects.

Although our department has championed the academic merit of QI work for years, many CQIs somewhat or strongly feel that they have to work harder than their colleagues to be viewed as legitimate scholars (58% of CQIs vs 35% of other faculty; p=0.05). Clearly, we need to improve processes that support academic advancement and alleviate distinct disadvantages faced by CQIs.

Teaching Activities

With the integration of patient safety, quality improvement and resource stewardship into the CanMeds 2015 framework, there has been an increased demand for advanced training in QI in recent years. In our department, CQIs play a critical role responding to this demand and contributing to the educational activities related to quality improvement and patient safety. Roughly half of the CQI survey respondents perceived they are asked to do too much teaching. We reported previously that >80% of CE, CI, and CS faculty members felt that the quantity of teaching they were delivering was just right, while 21% of CTs and 37% of CQIs felt they were doing too much. What drives this perception is unclear, but a potential explanation is that CQIs are being asked to do formal teaching on clinical topics (e.g., rounds, lectures etc.) or other under-graduate or post-graduate non QI-related teaching on top of their QI teaching. Expectations are shown in the Table, below.

Table: Formal Teaching Expectations for CT and CQI Clinical Faculty Members

We will work with DDDs and leaders in undergraduate and postgraduate education to clarify teaching expectations for our CQIs.

Burnout

In general, the level of burnout among CQI respondents falls within the moderate range as compared with faculty members in other job descriptions, with fewer CQIs reporting burnout symptoms at the extreme end of the spectrum. When asked what the major barrier was to achieving satisfactory work-life balance, 69% cited work activities as the primary barrier versus 61% for others.

Sense of Inclusion

Significantly, CQIs were more likely to report feeling excluded from an informal network (53% vs 26%; p=0.02). Whether these responses reflect informal networks related to faculty members' clinical or academic areas of interest is unclear. However, we plan to examine closely the possibility that some CQIs feel excluded from the Department's QI community and rectify this problem if it exists.

Mentorship

Providing good mentorship represented a key, early strategy to foster the growth and success of CQI faculty. Drs. Shojania and Wong have worked hard with PICs and DDDs to ensure that existing and newly-appointed CQIs have an appropriate mentor. The Department has also invested in faculty QI advisor positions (Edward Etchells, Geetha Mukerji, Jerome Leis and Robert Wu) to coach others in their QI work, and Ed Etchells has led group mentorship meetings specifically for CQI faculty.

These efforts appear to have paid off. The majority of CQI faculty reported having a formal faculty mentor (90% vs 44% for other job descriptions, p>0.01), and most rate their level of satisfaction with the quality of mentorship that they receive very highly, with 89% of CQIs somewhat or strongly satisfied, compared with 64% for other faculty.

Summary & Next Steps

We have much to celebrate in our department in all academic areas – research, medical education and quality and innovation. Nevertheless, faculty in each job description face challenges, and we continually look for ways to alleviate these challenges. In the case of the new CQI job description, while the department has played a national (even international) role in championing and supporting faculty engaged in QI work, we still have some kinks to work out.

QI faculty come in different shapes and sizes, with those labelled as CQI representing only one group. Just as most educators are CTs, some are CEs and a few are CSs. So, too, some faculty with a focus on quality improvement are CQIs, some CIs and some CSs. Thus, we cannot have the same academic expectations for all faculty who work in QI – this is true of teaching and scholarship.

To address the concerns that have been identified in the Faculty Survey, the following strategies are proposed:

Renewed efforts to generate widespread recognition of QI as a legitimate academic endeavor, and elevate the profiles of CQI faculty. Dr. Shojania has presented to the Faculty of Medicine Clinical Chairs on the value of QI scholarship and the success of the CQI position description. He has worked with the Chair of the Faculty of Medicine Decanal Committee to include explicit language in the July 2017 version of the Manual for Academic Promotion. These revisions clarify the role of quality improvement activities in contributing to academic promotion.

As the scholarly output of CQIs will almost always occur as Creative Professional Activity or CPA, we need to better message what CPA looks like and how to assess it. As we have in the past, we will invite Drs. Ed Etchells and Brian Wong to provide workshops annually on drafting a CPA statement. This time, we will encourage PICs and DDDs to attend! But, we'll also need to get the message out more broadly within the department and to the Decanal Committee.

Fostering robust formal and informal networks for CQIs and making explicit that these are inclusive of all faculty. We will optimize the scheduling of periodic group mentorship meetings to allow as many CQIs to attend as possible. We will also harness additional touchpoints to foster a sense of community for the CQIs—adding a faculty-only retreat in conjunction with the Faculty-Resident Co-Learning Curriculum capstone event, and a networking event at the Quality Improvement and Patient Safety Forum held each fall.

Find ways to make the most of the limited protected time CQIs have for scholarly work. Career satisfaction depends so much on productivity, not just as perceived by others but also by ourselves. For some faculty, increased productivity may come from synergies between their own QI work and supervisory roles, for example with QI projects in the Co-Learning program. For others, it might require helping them teach to their strengths rather than being pulled into so much teaching of non-QI topics. Our department's leadership must also continue to advocate for change with respect to structural barriers (e.g., REB for QI, data sharing across institutions) that make it increasingly challenging to carry out scholarly QI work. Dr. Rob Wu at UHN and other members of the department's Quality Committee are working on this. Finally, improved access to performance data, whether through more formal linkages with hospital decision support, or by partnering with groups creating data registries such as GEMINI, would make data available to evaluate the impact of QI initiatives led by our CQIs.

As always, if you have additional thoughts or suggestions, send them our way!

With thanks to Drs. Kaveh Shojania and Brian Wong for their contributions to this column.