The Clinician in Quality and Innovation at Ten Years

The origins of the quality movement have been ascribed to three major forces:

1. Growth of the evidence base to support improved treatment practices, e.g., through conduct of randomized controlled clinical trials.
2. Public demand for greater provider accountability and better patient outcomes, and
3. The growing costs of medical technologies alongside data showing area variations in their use that could not be explained by differences in patient populations nor justified by differences in outcomes.

These forces were mounting concomitant with the development and refinement of new research methodologies - clinical epidemiology, decision- and cost-effectiveness-analysis, and meta-analysis – that could be applied to address noted quality gaps. By the time the US Institute of Medicine (IOM) published the seminal report “To Err is Human” in 2000, the University of Toronto had established a very strong international presence in these research methodologies under the leadership of DoM faculty members Claire Bombardier, Allan Detsky, Howie Abrams, and others, and had established the Institute for Clinical Evaluative Sciences (ICES) under the leadership of David Naylor. Thus, we were already at the forefront of health services research and evidence-based medicine, setting standards for health care delivery. We were poised to play an important role in the quality improvement and patient safety movement, but lacked the skills, and perhaps motivation, to fix the problems we were identifying.

Thus, we were incredibly fortunate to have Dr. Kaveh Shojania - DoM Vice Chair, Quality and Innovation - join us at UofT in 2008. Kaveh had been a key player in the quality movement from its inception, completing a fellowship at UCSF under the tutelage of Bob Wachter, now UCSF Chair of Medicine, where he was integral to the seminal series of publications sponsored by the US Agency for Healthcare Research called Closing the Quality Gap.

Kaveh brought his QI expertise and skills to the DoM and, with my predecessor, Dr. Wendy Levinson, laid the foundation for a major focus on building capacity in the field of Quality Improvement and Patient Safety – taking best evidence and putting it into practice. To encourage the growth and development of clinicians with QI expertise, in 2012, they established a new academic position description (APD) within the DoM – the Clinician in Quality and Innovation.

Flash forwards a decade, we have asked our faculty members and leaders what’s gone well and what could still be done better to enhance the success of the CQI track.

For an impartial perspective, we invited Joanne Goldman PhD, an adjunct member of our department and scientist at both CQuIPS and the Wilson Centre, to conduct a 10-year review of the CQI APD. She interviewed 22 CQI faculty, who varied in career stage, specialty, and hospital affiliation, and 7 Department Leaders, including 3 Physicians-in-Chief (PICs) and 4 Department Divisional Directors (DDDs). Thanks Joanne!

Key Findings

• The CQI job description has seen tremendous growth, from just four faculty in 2012 to 78 full-time faculty (and an additional 11 part-time) as of 2022. These faculty span all of the major teaching hospitals (UHN 28, Sunnybrook 18, Unity 15, Sinai 11 and WCH 6) and 16 of the Department’s 20 Divisions. Many of these CQIs have gone on to assume leadership roles, including medical directors of quality, informatics and infection control…and even a PIC (Kathryn Tinckam).
• The CQI position has met its principal goal of providing an ‘academic home’ and formal recognition for faculty focused on quality improvement and other forms of innovation. A few example quotes:

"In many ways, the existence of the CQI job description was the first glimmer of hope I had that what I was doing was actually academically meaningful. As opposed to, that it was a barrier. Actually, for me, it was the first like, "So what I am doing could be academic? Excellent!" And so, in many ways that CQI role description was a game changer for me because it gave some legitimacy to what I was doing. So I think in that way I consider it a big gift."

"Having that [CQI job] description gave validity to what I was already doing. And it gave me a career path within academia that valued the type of work and said ‘Yes, the problems that you're seeing and the things you're trying to solve, Yes, that is academic work and Yes, we do value it.’ So I think that was important. And that wasn't a challenge. That was an opportunity."

• The existence and growth of the CQI position has also fostered awareness amongst Department leaders and would-be faculty members of the academic legitimacy of QI/PS work. As one department leader said “…they really bring an important structure even if it's just the analytic approach and approach to evaluating, intervening, and then disseminating the results of an initiative …. It's one thing to have really good ideas and say, "We should do this. We should do that. This doesn't make sense," but they seem to be the ones who are able to really take an organized approach and get it done”.
• Just as in other scholarly areas, the CQI academic trajectory is characterized by sequential development of projects that build upon prior work. For example, initial understanding of the clinical practice or healthcare process relevant to a quality problem of interest, followed by development of an improvement strategy, examination of practice changes and expansion of the practice/program, e.g., developing guidelines or working with external organizations to expand the scope of impact.
• Areas of focus have been broad, including improving health care processes, resource stewardship, developing new models of care, responding to COVID, clinical informatics, and further developing QI capacity through education and training. Many CQIs are conducting clinical and health services research to characterise quality problems.

Critical enablers of CQI success include strong interdisciplinary collaborations and the development of processes and structures within the DoM, its divisions, and at the affiliated hospitals to support the work of CQIs. Challenges identified include variability in access to the above-noted enablers, limited CQI funding opportunities, a plethora of opportunities and requests to address local quality problems that can distract from focus on core body of academic QI work and, more recently, clarifying the role of CQI faculty members in the context of a health care system in crisis. As one CQI faculty member commented:

"I think a lot of people are feeling this way…The scope when I think of my unit, it feels a little bit inadequate or unsatisfying, given [the] scale of crises. I don't know what the right training is because I don't know what the aim of quality [ought to] be right now. Is it another checklist or alert, or PDSA safety cycle at this micro level? Or is it actually trying to understand what skills are required to engage in broader change?"

This perspective is consistent with the commentary by Dr. Shojania published in the CMAJ earlier this year entitled: What problems in health care quality should we target as the world burns around us? CMAJ. 2022 Feb 28;194(8):E311-E312.  doi: 10.1503/cmaj.220134, in which he writes:

"The mainstream approach to improving health care quality amounts to eking out marginal increases in the delivery of care, which itself has mostly small benefits, which seems inappropriate in the face of current crises with large impacts on health, such as the COVID-19 pandemic, the climate crisis, ever worsening economic inequality, systematic racism, and the opioid epidemic."

The commentary concluded that efforts in quality improvement focused on increasing resilience of the health system, devising better models of care, and addressing the social determinants of health would offer larger impacts on health care quality and population health than continued efforts to implement clinical practice guidelines. I don’t think any of us would claim to know what the right balance ought to be in terms of work targeting big picture problems versus more incremental efforts, but I remain hopeful that we can manage both.

Summary

As we pass this ten-year milestone for the CQI APD, our healthcare system is crumbling, in crisis. While I’m not sure any one of us knows what the solutions will be, it is clear that we need people who are intimately familiar with frontline clinical work, understand the healthcare system and know what it takes to make change happen, to identify and implement the solutions. Our CQIs are such people – they will help us to meet the fundamental challenges the health system faces. For this reason, and because of the many impacts the CQIs have already produced, I am deeply grateful for having had the chance to play a role in creating and sustaining this academic pathway in our department. And thanks to Kaveh and his colleagues for their dedication, hard work, persistence, and leadership.