The Clinician in Quality and Innovation

The clinician in quality and innovation (CQI) academic position description grew out some ideas articulated in a JAMA commentary in 2009 and finally came to fruition in 2012, with the appointment of six faculty. Since then it has grown to include 39 faculty members, spread across almost every division in the department, as shown below.

The above 39 CQI faculty include six associate professors, 28 assistant professors, and five lecturers. Ten of these faculty members have undergone Continuing Faculty Appointment Review (CFAR) with a 100% pass rate. Four faculty members have gone forward for promotion – also with a 100% success rate. Yes, the 95% confidence for 4/4 is wide. Nevertheless, the success rate for both promotion and CFAR is something to celebrate. A new academic position description might well have stumbled more often coming out of the blocks.

It’s worth noting that in addition to the 39 faculty members in the CQI academic position description, we have about an equal number whose work focuses on healthcare quality but do so in different position descriptions (myself included).That is a notable fact in itself, attesting to the degree to which the department values quality improvement, supporting clinical teachers, educators, investigators and scientists who have made QI a major focus of their activities. But, it’s also worth answering the question: Why would a faculty member doing QI not necessarily switch into the CQI stream? Because anyone who has already passed CFAR can go forward for promotion on CPA. Once past CFAR, the academic position description does not matter quite so much.

But, at the time of faculty appointment, it matters a lot. For instance, we do not want to hire someone on as a clinician-teacher expected to focus on teaching excellence, if in reality that person wants to excel at quality improvement. That said, we also do not want to create an academic position description regarded as a path of least resistance to fill clinical service needs. The success we have had with CFAR and promotions will not continue without making sure that candidate faculty members really do want to spend their non-clinical time on quality and innovation, and that they have the training to do so.

The faculty briefly profiled below include a range of CQIs in terms of the amount of protected time they have for their QI work. Some have around 50% protected time and thus amount to a clinician-investigator in quality and innovation (CI-CQI) phenotype, while others resemble clinician-teachers (CTs) in having 30% protected time. But, as one can see below, all are making substantive contributions and all had formal training that prepared them to do so.

Janice Kwan, MD FRCPC

Assistant Professor; General Internal Medicine (Sinai Health System - Mount Sinai Hospital)

Dr. Kwan was attracted to quality improvement work in the first rotation of her first year as a newly minted physician. Her CTU attending’s mentorship sparked a curiosity, and over time, a passion for QI. “In medicine, as in life, we are faced with problems constantly,” Janice says. “As a resident, I used to think, there are those who lament these problems, and those who try and fix them. I was drawn to QI as it seemed to me – and still does – the perfect synergy between research and its application toward improving patient care.”

After completing a master’s in public health at Harvard, Janice returned to the University of Toronto and the Division of General Internal Medicine at Mount Sinai Hospital, where her research broadly focuses on diagnostic errors; a relatively neglected topic in patient safety and quality improvement until recent years. One current project characterizes the follow-up of pulmonary nodules suspicious for malignancy detected incidentally on CT pulmonary angiography. Other projects centre on test result management and communication, processes that commonly breakdown and undermine the diagnostic process.

Jerome A. Leis, MD MSc FRCPC

Assistant Professor; Infectious Diseases (Sunnybrook Health Sciences Centre)

“As an infectious diseases physician, combining my interests in infection prevention and antimicrobial stewardship with quality improvement/patient safety was a natural fit,” says Dr. Leis. His academic interests focus on developing new systems of care to minimize healthcare-associated infection and antimicrobial resistance.  Jerome’s master’s project (in quality improvement and patient safety at the Institute of Health Policy, Evaluation and Management) successfully reduced the treatment of asymptomatic bacteriuria by changing the way routine urine cultures are reported. This project was published in Clinical Infectious Diseases. Other  examples of Jerome’s work include the development of a medical directive for nurse-initiated urinary catheter removal (published in JAMA Internal Medicine), and pharmacist-led beta-lactam allergy skin testing (‘BLAST’) to improve outcomes in patients with reported allergy.

What Jerome enjoys most about this type of research is trying to match the solution to the problem while simultaneously addressing any unintended consequences that might arise. “Improvement science requires perseverance and patience, as new ideas rarely work the first time and change is difficult,” he says. “The small rewarding steps forward are what keep me coming back for more!” After a short pause, Jerome added, “That said, QI is also great if you’re an impatient person. In what other academic field can you have a direct impact on patients over the course of six to 12 months?”

Christine Soong, MD MSc

Assistant Professor; Hospitalist (Mount Sinai Hospital)

Dr. Soong’s interest in quality and safety began early in her career as a hospitalist when one of her patients suffered a major patient safety incident with significant morbidity. “At the time, I did not view the event through the lens of patient safety,” explains Christine. “I was thinking that errors could be prevented if providers were simply more careful. Through subsequent experiences in the United States among some of the world’s leading safety experts, I was exposed to a completely different approach to adverse events yet still lacked a true understanding of the field.”

Upon her return to Toronto, Christine enrolled in the master’s stream in quality improvement and patient safety at the Institute of Health Policy, Evaluation and Management. This program provided her with a much needed framework for improvement science that guides her work on resource stewardship (Choosing Wisely) and transitions of care. While there have been improvements in quality and safety, more work is needed, and for Christine this makes QI one of the most exciting fields in healthcare today.

Ilana Halperin, MD FRCPC

Assistant Professor; Endocrinologist (Sunnybrook Health Sciences Centre)

Dr. Halperin is an endocrinologist and graduate of the master’s stream in quality improvement and patient safety at the Institute of Health Policy, Evaluation and Management. She is co-PI on a multi-site project (funded by the AFP Innovation Fund) to develop a balanced scorecard for diabetes care. This project has established quality indicators for ambulatory diabetes programs that can be continuously measured to drive quality improvement. Building on this work she — along with Dr. Geetha Mukerji (below) — was invited to co-lead the patient reported outcomes and improvement science working group within a CIHR-SPOR team grant for diabetes and its complications.

Ilana is also the lead for the implementation and optimization of electronic medical records in the Sunnybrook Endocrine Division and in the Diabetes in Pregnancy clinic, aiming to standardize the monitoring of their patients and improve the care provided to them.

Geetha Mukerji, MD MSc FRCPC

Assistant Professor; Endocrinologist (Women’s College Hospital)

After completing the master’s stream in quality improvement and patient safety, Dr. Mukerji took a position as the clinical lead in quality at Women’s College Hospital’s Institute for Health Systems Solutions and Virtual Care (WIHV). In this role, she provides methodological expertise supporting the development and evaluation of multiple QI initiatives. Her work has included the design of innovative ambulatory care delivery models for patients with complex conditions and has facilitated the development of a new ethics process for QI initiatives. She also collaborates with Dr. Ilana Halperin (above) as the co-primary investigator on a multi-site initiative to develop a balanced scorecard for ambulatory diabetes care. She and Dr. Halperin also co-lead a CIHR-SPOR sub-group team that involves collecting patient reported outcome and experience measures to improve care for patients with diabetes.

Geetha is also committed to improving healthcare value. She has been leading the spread of a laboratory stewardship initiative through supervision of residents reducing unnecessary thyroid function tests. In addition, she has co-led the development and evaluation of an educational curriculum to improve communication around stewardship with residents with the aim of disseminating a toolkit to other programs. As part of her ongoing commitment to build capacity in QI and patient safety, Geetha has been extensively involved in education at all levels through curriculum design and delivery, project supervision and mentorship.

R. Sacha Bhatia, MD MBA FRCPC

Assistant Professor; Cardiology (Women’s College Hospital and University Health Network)

Dr. R. Sacha Bhatia is the director of the Institute for Health System Solutions and Virtual Care (WIHV) at Women’s College Hospital, where he also a staff cardiologist. WIHV is a newly launched innovation laboratory that develops and tests new ideas, new programs and new policy approaches in the world of ambulatory care, and then helps to scale them up across Ontario and beyond. As director of WIHV, Sacha leads evaluation for Choosing Wisely Canada, a national initiative managed through the University of Toronto in collaboration with the CMA.

Sacha’s research spans traditional health services research to characterize quality problems (he is an adjunct scientist at the Institute for Clinical Evaluative Sciences) to clinical trials to test improvement interventions to the development of innovative technologies to support high quality ambulatory care. Sacha’s training included clinical and research fellowships in cardiology at Massachusetts General Hospital and Harvard University. He received his medical degree and MBA at McGill University prior to his internal medicine and cardiology training in Toronto.

Samir K. Sinha, MD DPhil FRCPC

Associate Professor; Geriatrics (Sinai Health System and University Health Network)

Dr. Sinha is the Peter and Shelagh Godsoe Chair in Geriatrics and the Director of Geriatrics of the Sinai Health System and University Health Network Hospitals in Toronto and was recently promoted to associate professor on the basis of his QI work.

Samir’s work focuses on building better models of care for older adults that improve both patient and system outcomes.  His award-winning Acute Care for Elders (ACE) strategy — that has been implemented at Mount Sinai Hospital — continues to develop, implement and link together a series of evidence-informed but customized models of care and best practices to create a more seamless, integrated delivery system spanning the continuum of care for older patients. Samir and his colleagues were recently awarded $1M through the Canadian Foundation for Healthcare Improvement and the Canadian Frailty Network to help 18 other organizations across Canada and internationally implement similar models with on-going mentorship and support.

Samir — the architect of the Government of Ontario’s Seniors Strategy — continues to also consult and advise governments and health care organizations around the world and is currently working on the implementation of a National Seniors Strategy.