Strategies for enabling physician leadership and involvement in quality improvement: a scoping review

Pamela Mathura, PhD student, Tarek Turk, Liz Dennett, MLIS, Karen Spalding, PhD, Lenora Duhn, PhD, Narmin Kassam, MD, and Jennifer Medves, PhD

Background: The importance of physician advocacy and leadership in quality improvement (QI) in health care is well recognized, but achieving physician involvement is challenging. The purpose of this scoping review was to describe strategies used in physician-led QI models/approaches that include learning about the science of improvement and may enable physician QI capability, participation, and leadership.

Methods: Articles were identified through electronic searches of MEDLINE, Embase, CINAHL, and Scopus, and reference lists were reviewed. For each model/approach, descriptions of strategies were extracted and the frequency of each strategy was determined. Thematic analysis was conducted.

Results: Eleven articles representing nine unique models/approaches were included. From these, 20 enabler strategies were identified, and eight themes emerged: dedicated support staff; operational alignment and leader support; evidence-informed care; sharing QI to encourage QI; financial investment; formal QI leader role and responsibility; physician mentorship; and QI capability. No model/approach included all the strategies, and the number of strategies aligned with each theme varied. Heterogeneity in reporting physician-led QI approaches and broad use of the term “physician-led” increased search complexity.

Conclusion: Comprehensive models/approaches that encourage physicians to participate in and lead QI while learning the science of improvement have not yet been developed. Research on physician QI participation and strategy evaluation, including effectiveness, is required. This review offers a road map of enabler strategies that can be used to support future models.

KEY WORDS: health care, quality improvement, leadership, education

Mathura P, Turk T, Dennett L, Spalding K, Duhn L, Kassam N, Medves J. Strategies for enabling physician quality improvement leadership and involvement: a scoping review. Can J Physician Leadersh 2022;8(4):133-141

https://doi.org/10.37964/cr24761

Over the last decade, there has been a greater appreciation of the value of physician engagement in quality improvement (QI) in health care, in recognition of physicians’ unique perspective, experience, and skill set.1 The requirement to improve clinical outcomes, patient safety, experience and satisfaction, and financial performance has positioned physicians to assume leadership roles with an increased emphasis on QI. Physician QI leadership has been identified as an important factor for successfully “establishing a QI culture… for guiding the group [multiprofessional providers] toward meaningful and relevant improvement efforts.”1 However, physician involvement in health care improvement, at any level of clinical practice, hospital, or health region, is challenging.2-5

To address this issue, physician QI engagement approaches are emerging.6,7 Expansion of physician QI leadership — defined as “the active and willing participation of physicians in local and regional QI projects that develop a strategic partnership with healthcare operations to improve healthcare delivery”8 — has been modest. There is a paucity of QI models/approaches that include developing one’s science of improvement (SI) knowledge, wherein physicians can initiate involvement and lead QI. The Institute for Healthcare Improvement defines SI as “an applied science that emphasizes innovation, rapid-cycle testing in the field… [and uses] the combination of expert subject knowledge with improvement methods and tools.”9

Physician-led QI models/approaches described in peer-reviewed articles include strategies that have not been thoroughly investigated. The objective of this scoping review was to map and describe the existing peer-reviewed literature about the strategies used in physician-led QI models/approaches that include the learning of SI, which may enable physician involvement in and leadership of QI and safety. The research question was: How are physician-led QI models/approaches described in the literature, and what enabler strategies in these models/approaches promote physician QI capability (SI knowledge and application), participation (QI-initiative involvement and motivation), and leadership (champion/lead a QI-initiative)?

Methods

A scoping review was completed following the framework of Arksey and O’Malley10 and applying the PRISMA-ScR checklist for reporting.11 For this review, a physician is defined as a medical doctor practising in any medical discipline and not a medical trainee (resident/housestaff or fellow). A physician-led health care QI model/approach is defined as one in which physicians are in a leadership position (i.e., quality or safety lead, quality officer, QI mentor) with a focus on QI and or patient safety (PS) and are leading the model/approach; there is collaboration among physicians to lead the learning of SI while participating in QI/PS projects with other health care professionals; and a physician is leading QI implementation.

The initial search was completed on 28 April 2020 by a health sciences librarian (L Dennett) and updated on 18 February 2022. The following databases were included: MEDLINE, Embase, CINAHL Plus with Full Text, and Scopus. The search strategy included an extensive list of terms representing two concepts: physician leaders/physician groups and QI. To improve precision, a “relevancy forcer” concept required any one of the following words to be in the title: network, coalition, collaboration, committee, alliance, collaborative, framework, model, physician, clinician, specialist, doctor, leader, or mentor. The reference lists of relevant selected articles were searched manually.

Included articles were from any country, written in English, about descriptions or assessments of any model/approach about health care QI/PS led by physicians, with inclusion of SI learning. The rationale for the focus on physician-led models was to understand the challenges faced by physicians in engaging in and leading QI and to identify strategies used to address barriers. There were no restrictions regarding publication date, study design, research quality, physician specialty, practice area, or type of QI initiative. Excluded articles included models/approaches co-led by physicians with other health care professionals, educational approaches, models led by other health care professionals or learners, models in which physicians were leading only the implementation activities, or models where the primary emphasis was data registries without the inclusion of SI learning.

All citations were uploaded into Covidence, citation management software (Covidence, Melbourne, Australia). Two of the authors independently reviewed all titles and abstracts to exclude irrelevant articles; there was substantial agreement between reviewers (Cohen Kappa was 0.80).12 Full-text articles were retrieved and reviewed independently to determine final inclusion. Discrepancies were resolved by discussion and consensus. A data extraction Excel form (version 2013; Microsoft Corp., Redmond, Washington, USA) was developed to facilitate data collection. Both PM and TT independently read the included articles to determine the final list of strategy topics. JM confirmed the included articles and data extraction. A descriptive analysis was conducted to determine the frequency of each strategy topic in the included articles. A thematic analysis13 was performed by PM, who organized the strategy topics into themes. TT and JM independently confirmed the themes.

Results

A total of 11 919 citations were retrieved. After removing duplicates, 5602 abstracts, published between 1955 and 2022, were screened, and 5556 were excluded. From these, 46 full-text articles were reviewed, and 11 articles are included in this review (Figure 1).

Based on the 11 included articles7,14-23 (Table 1), physician-led QI models/approaches that include learning SI and are exclusively physician-led are few in number and the designs and formats vary. Among the 11 articles, we identified nine unique physician-led models/approaches. The model, HELP consortium, was described in two articles15,16: one about the model’s proposal and the other about findings after two years. The same model (physician quality officer) is mentioned in two articles19,21 and, in another, the authors refer to the model website.22 Articles were published from 2005 to 2020 and were model/approach descriptions with or without evaluation.7,14-23 Most articles represent North American experiences (eight from the USA and two from Canada), with one from the United Kingdom. The models/approaches were referred to as a program (n = 5)14,19,21-23, a committee (n = 3)7,17,18, a model20 (n = 1), or consortium (n = 2).15,16 Funding came from a hospital, a grant, the government, a combination of the three,7,15-17,19-23 or was not provided.18 Geographic coverage and influence is large, with six of nine models/approaches structured across a province, state, region, or country, and three within hospitals. The number of physician members ranged from 7 to over 100, and medical specialties varied.

Based on the included articles, 20 “enabler” strategy descriptions were identified (Table 2).

Themes

Eight themes emerged from the strategy topics (Table 3). No model/approach included all the strategies, and the number of strategies per article aligning with each theme varied. No article included an evaluation to determine physician participation experience or strategy effectiveness.

Dedicated support staff

In all but one article, a significant enabler was dedicated staff with specialized skills in QI, safety, data analytics/statistics, and project management, who provide direct support to physicians with limited experience and demanding clinical schedules to lead QI.14-23 Authors discussed how clinical improvement requires researching best practices, project design and management, knowledge of QI/PS concepts, and collection and analysis of data — time-consuming work that is difficult for a busy clinically practising physician.14-23

Operational alignment and leader support

Authors described the concept of operational alignment as an enabler of physician-led QI in eight articles, implying that for the model to function effectively, it must be internally linked to the hospital or health organization.7,14-19,21,22 In all articles, the authors emphasized the importance of QI/PS objectives, including a reporting structure or linkage to senior organizational leaders to ensure that the quality agenda is aligned with and supported by the hospital or organization.7,14-23 This is indicative of the importance of mutual collaboration regarding shared QI goals. Another important aspect of engaging physicians in QI is having physicians lead or assist in the selection of QI-project priorities that are meaningful and make sense for clinical service improvement. This strategy is reported to be critical to their enthusiastic participation.7,14,17,19,21,22

Evidence-informed care

In most of the included articles, the authors described evidence-informed interventions implemented by physician champions as a key strategy to raise awareness of best practices and SI and to influence peers to change practice behaviour.7,14-17,19-23 The physician leader was often mentioned as presenting the evidence-informed practice to frontline physicians, seeking their input, and implementing the change. With a physician as QI leader, authors reported faster implementation and better communication between frontline physicians and hospital administrators.7,14-17,19-23

Sharing QI to encourage QI

Often mentioned was tracking of QI projects and goals that are shared broadly. Communicating information about a QI project as well as the outcomes (i.e., clinical, patient, and health system) is facilitated by using hospital and organizational webpages or locally in the hospital community with multiprofessional providers.14,17-23 Formally sharing physician-led QI-project posters at annual events (i.e., quality summit17) was described as an important enabler, not only to recognize and encourage the physicians involved in the project, but also to influence other physicians to participate in future QI efforts.14,17,22 To acknowledge physicians’ QI leadership, QI-project posters include photographs of the physicians who were involved,17 and QI involvement is part of the annual performance review process.18

Financial investment

To ensure implementation and sustainability of the model, several authors identified securing funding and making a financial investment in physician QI leadership as a significant enabler. Funding sources described were hospitals, external grants, government programs, and a combination of funders (i.e., hospital, foundations, grants, and government).7,14-16,19-23 In one model, physicians received a financial bonus for achieving the QI goals19,21 and for a few models, project financial outcomes were calculated, which was suggested to have strengthened the financial case for long-term investment.14,19,21 However, in one article, the authors explained that projects that are not financially beneficial may have a positive effect on physician QI participation experience; thus, intangible benefits and perspectives should be evaluated.14

Formal QI-leadership role and responsibilities

The role of physician leaders in these models is described as an unpaid, non-formalized role assumed by physicians with an interest in QI and accepted in addition to their clinical duties, suggesting a strain on physician time.7,15-20,22,23 Infrequently, the physician leader role is a formal, paid organizational role, with a job title (i.e., physician quality officer, patient safety and medical quality officer, physician quality lead, and clinical-directed performance improvement medical director) and recruitment process, with protected time for leading QI projects.7,14,19,21 In one article, the authors reported that participation in QI is mandatory for early career physicians.18 Described less frequently, the physician role includes teaching SI to medical students, residents, and practising physicians.7,18-22 Some authors suggested that, in the case of academic hospitals, linking physician-led QI efforts to teaching and research is necessary and effective.19

Physician mentorship

In all the models/approaches, an essential enabler is the ability of physician QI leaders to mentor, influence, and encourage peer physicians and multiprofessional providers to participate in QI.7,14-23 In one example, the authors described how one physician QI leader was successful in recruiting frontline physician champions for several QI initiatives.7 At a corporate and strategic level, physician-led QI models positioned physicians to lead a clinical QI team and provide feedback regarding clinical impact, feasibility, and perceptions of frontline physicians, which can lead to modifications in implementation plans. This approach can increase physician leader credibility and result in greater success.7,14

QI capability

Providing physicians with QI knowledge and skills is a recognized enabler. Most authors reported the need to provide formal education about SI to physicians.7,14-16,18,19,21,22 To support physician capability beyond SI, additional training in leadership, scientific methods, communication, conflict resolution, and patient-centred care concepts, with the opportunity to attend conferences, were mentioned.19,21,22 In all articles, physicians were provided peer mentoring, with hands-on QI skill and leadership development through the completion of QI projects. In six articles, the authors mentioned collaboration with academic physicians7,15,17-19,21,23; however, knowledge dissemination (i.e., manuscript development and submission) was rare.19,21,22

Discussion

From the 11 articles reviewed, nine unique models/approaches were discovered, and, from them, enabler strategies were organized into eight themes. The frequency with which these strategies are used can be an indication of their importance and ease of implementation.

It is important to unite senior physician leaders with hospital/organizational leaders committed to and providing long-term financial investment for physician QI leadership. In addition, dedicated quality and analytic staff, QI education, peer mentoring, and the inclusion of a multiprofessional team are all needed. Furthermore, the findings emphasize the need for protected paid time, recognition in performance reviews, annual QI events, and a joint (physician and hospital/organization) QI agenda with shared goals. The identified strategies position and support physicians to develop SI skills and to actively participate in and lead health care improvement. Leveraging the formal and informal influential relationships physicians have with each other is also an important factor.7,14

The diversity of geographic coverage suggests that physician-led QI models/approaches, either localized within a hospital or aligned with a large regional span, are of benefit in encouraging practising physicians to learn and apply SI while improving clinical outcomes. Our review revealed enabler strategies similar to others, such as promotion, recognition, engaged and supportive leadership, QI education and training, appropriate compensation, realignment of financial incentives, data collection and analysis support, and protected time.4,25 For physician and organizational leaders and institutions, this review may aid model design, educational programs, and formalize physician QI roles. This information provides additional insights to stakeholders interested in scaling up and spreading physician-led improvements.

An obstacle to synthesizing findings across the articles is the scarcity of global health care representation, heterogeneity of reporting, and the broad use of the term physician-led. The strict criteria of including articles about exclusively physician-led models to isolate enabler strategies may have introduced selection bias and may not have captured all the relevant articles.

Conclusion

Physician-led health care QI models/approaches based on the general premise of encouraging physicians to participate in and lead QI are relatively new. There is currently minimal research on the experience of physicians participating in QI from which to determine the effectiveness of strategies, making it difficult to draw firm conclusions. Further research is needed to evaluate models/approaches, analyze the effectiveness of enabler strategies, and conduct a qualitative exploration of physician motivation to engage in QI, as well as to standardize the reporting of health care QI models. This review may serve as a roadmap that outlines enablers and may aid future models/approaches.

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Authors

Pamela Mathura is a PhD student in the Health Quality Program at Queen’s University and a QI scientist for the University of Alberta’s Department of Medicine and the Edmonton zone medicine program  at Alberta Health Services, Edmonton.

Tarek Turk is a PhD candidate in the University of Alberta’s Department of Medicine and Dentistry, Edmonton.

Liz Dennett, MLIS, is librarian (Health Sciences) in the University of Alberta’s Department of Medicine and Dentistry, Edmonton.

Karen Spalding, PhD, is an adjunct associate professor at Queen’s University, Kingston.

Lenora Duhn, PhD, is an associate professor at Queen’s University, Kingston.

Narmin Kassam, MD, MHPE, is chair of the Department of Medicine at the University of Alberta and head of the Clinical Department of Medicine, Edmonton.

Jennifer Medves, PhD, is acting director, Student and Enrolment Services, Bader International Study Centre, Queen’s University, and professor emerita, Queen’s University, Kingston.

Author declaration: No funding was obtained for this research. The authors have no conflicts of interest to disclose. This manuscript is a component of a study that is a partial requirement for PM as a PhD health quality student at Queen’s University, and will be presented as a chapter in a dissertation.

Author contributions: PM led and conducted the scoping review design and analysis and wrote the manuscript. TT assisted with data analysis and reviewed the manuscript. LDennett completed the library searches and reviewed the manuscript. LDuhn, KS, and NK reviewed and edited the manuscript. JM, academic supervisor, reviewed the research design and analysis and edited the manuscript. All authors approved the final version submitted for publication.

Correspondence to:

pam.mathura@ahs.ca or

mathura@ualberta.ca

This article has been peer reviewed.