- 01:36 Getting started
- 05:01 Formal training
- 08:27 What are areas of expertise to get good at?
- 16:27 Typical Day
- 19:27 Challenges
- 23:56 Metrics
S: Hey everyone. This is going to be our fourth and final episode in Careers series…at least for now. And for this episode with ACP, we are diving into the world of quality improvement or QI. A couple decades ago, QI wasnt even a thing – and now it’s hard to imagine healthcare systems without it! Today, there are so many names for it – QI, QA, Q&S – but it all comes down to the same thing – thinking about the healthcare delivery system in which you work in and how to make it better.
For this episode, we won’t be getting into the technical stuff — fishbone diagrams, lean, PDSA cycles. This episode is about crafting a career in QI:
- How do most people get started in this path?
- What areas of expertise are needed to be successful in QI?
- What does a typical day look like depending on what QI hat you wear?
- What are the challenges that can come with QI work and how do you navigate it?
I am Dr. Shreya Trivedi. And here it is:
How do most get started?
S: When I spoke to our guest discussants, I quickly realized that if there were to be a so-called illness script for a how careers in QI usually, it seems it often starts with a moment of frustration or curiosity about something not working well in the system. For Dr. Maren Batalden, now the Chief Quality Officer at Cambridge Health, her moment came when she was a young hospitalist…
Dr. Batalden: And I had really been working at the Cambridge Health Alliance for about five years, I think before I saw patient satisfaction data which was sort of an epiphany for me because our patient experience of care data was not so great.
S: She was shocked because she and her colleagues were really doing their very best, working hard, only to learn that their unit was producing poor experiences for patients.
Dr. Batalden: And that was a real kind of galvanizing conundrum for me because I felt like I was working hard and I felt like I was a good doctor bringing a lot of myself to the job every day. And I felt like the people around me were working very hard and bringing a lot of themselves to the job every day. And so that the net effect of all of these good people doing good work and working really hard at it was actually not producing the outcomes that we had expected was a real beginning place for me.
S: And to unpack that, she had to understand her workplace in a completely different way – something she calls the “clinical micro-ecosystem.”
Dr. Batalden: A unit, a hospital ward is a clinical micro system… it’s a group of people that come together every day, uh, to produce a set of shared outcomes. But in actual fact, the people who work on that unit, they all have different bosses. They report up through the organization in different ways. You know, there’s a nurse manager, who’s responsible for the nurses. And then there’s a group of hospitalists who have a boss who is a doctor, and those people rotate in and out of care of patients on that unit. And then there are consultants that come in and out, and there are residents that come in and out, and there’s physical therapist and there’s a respiratory therapist and there’s housekeeping staff. And there’s all of these different kinds of people that come together and they are in fact, a part of a system that is producing an outcome, but they don’t necessarily see themselves as part of that same system.
S: She became curious. Where were the blindspots were in the clinical microsystem? And so, similar how most careers in QI start, she also raised her hand and volunteered to get involved.
Dr. Batalden: Because we realized that one of the first things that a patient might hear when they wheel up to the unit was, “Does anybody know whose patient this is?” And we decided that probably wasn’t a great start to your hospital experience.
S: So it didn’t matter as much that she was working so hard and doing such a good job as a clinician in her silo. So she had to think about outside the box to the waiting room, how the staff was talking about patient care, to what kind of magazine side table to the overall culture of the place — that is the clinical ecosystem and that was what the patients were experiencing.
Dr. Batalden: And then you get sort of bitten by a bug, uh, that actually finds the, the system and its complexities interesting in and of themselves. And you build a kind of expertise through projects, through problem-solving, one problem at a time.
S: An expertise in problem-solving, one problem at a time. So it makes me wonder does one need to have a masters or a fellowship in QI to to be that expert problem solver? To answer the question on formal training, I purposefully went to Dr. Anjala Tess, who is the Associate Chair for Education at Beth Israel Deaconess Medical Center and actually runs the Masters in Healthcare Quality and Safety at Harvard Medical School.
Do you need a Masters?
Dr. Tess: Even though I should be the first person to say yes to that question, given what I do, I think the answer is no. I think that there are a lot of people who are out doing this work, including myself and others, at least 15 years, junior to me who have learned this on the job.
S: That is with the caveat that in the future more employers may be looking for formal training to be competitive and what Dr. Tess currently sees is that her graduates are getting jobs out of her training at much higher echelons in quality leadership. And that may be formal training is much more than just learning quality science, and growing that problem-solving mindset.
Dr. Mort: It’s getting to know your instructors. It’s spending some time in their institutions. It’s asking can they come to your meetings?
S: This is the voice of Dr. Elizabeth Mort, a primary care doctor and senior vice president of Quality and Safety at Mass General Hospital.
Dr. Mort: It’s having a mentoring cup of coffee and saying, is there a problem you can, I can help you with? Then what about career opportunities? So during your fellowship, you are not just learning to get your expertise but you’re networking. And you’re beginning to chart your course through mentoring as to where you might go next.
S: Time and time again I’m always surprised at how much networking gives that a leg up and leverage in the real world. But what if you just aren’t in a position to do a masters or some certificate program?
Dr. Mort: So if you want to move into quality and safety and you can’t access a training program at the moment, but you want to get some applied experience, here’s what you need to do. You need to talk to people and you need to ask them what are your problems? Is there anything I can help you with? What are you worried about? What keeps you up at night?
S: You know, I’ve never thought to ask a leader so directly, what can I help you with? I always thought it was a cop out to actually ask others for projects. For whatever reason, I feel like I’ve always thought I needed to come in with my own unique ideas and passions.
Dr. Mort: So I would say you need to be open-minded and strategic in the sense that you may really want to solve… oh, reduction in readmissions after pneumonia. That may be your passion. But if that is not the pressing issue for a leader in the institution, they might ask you to work on employees slips and falls because let’s just say they had an uptick in it. And they say, “Oh, you know, I’m worried about employees slips and falls.” I think everybody is looking at their iPhone. So we need you to something about it. And if you say, well, I’m not interested in that, I’m interested in pneumonia then you’ve missed an opportunity. Learn something about employees slips and falls.
S:And that makes sense bc in QI you are expert in processes, regardless of the problem. This really clicked for me when I compared QI to research – research is a field where you hold near and dear to your heart, one or two topics – in QI, you can be working on a project for fall risks then on team huddles, then clinic A1c goals. Okay so now that QI a bit more, what are big areas of QI that one really needs to understand or get good at to be successful in QI?
Big Areas of QI
Dr. Mort: One of the main areas in quality and safety is basically learning from errors, learning from errors. How do you learn from error as well? Most organizations have some kind of a safety reporting system or event reporting system. I learned a lot about an organization. When you look at their rate of safety reporting, the way in which events come in, who submits them, are they events with harm? Are they near misses? How people analyze them in an organization and how you learn from them. So I think one of the biggest buckets, one of the most important areas of expertise is really understanding safety, reporting and improvement. I think clinical compliance is really important. There are regulatory agencies that we all need to understand and literally abide by the rules and help shape the rules.
S: Hmm, I never really thought about safety reporting or clinical compliance and understanding it seems pretty complicated. But Dr. Mort said there’s a pretty obvious way that it shows itself, if you just look. And that, is in the pretty obvious safety culture.
Dr. Mort: That is a vague term culture. I like to think about it as in your organization, what does business as usual look like when it comes to patient and provider safety? If you walk down your hallway and you see a spilled cup of coffee, do people walk around it or do they stop call somebody on their cell phone and look to see if there is a, a tent, you know, these little plastic tents and grab it off the wall and put it down on the floor so nobody slips. That’s something that you can see visibly that says something about the business as usual approach to spilled up beverages in your hallway. And there are many timeouts, labeling specimens in front of patients, et cetera.
S: And obviously another area of expertise is all that formal QI language and tools
Dr. Mort: Improvement skills, process improvement, six Sigma lean. There are many, many different labors I would say of process improvement. Most organizations pick one or two methodologies and use it consistently. Um, so, but that is an area of expertise that people should understand.
S: And the last area of expertise.
Dr. Mort: Human factors, huge. We’re all human beings. And despite the fact that we have the good fortune of lots of technology, they’re human beings involved in just about all of them and the delivery of care. And we need to understand how human beings work, what they can and cannot do, what makes them successful, what makes them make errors and adjusting things around human factors is very, very important.
S: Man I feel it’s just a homework assignment to get really good at. What is the safety culture at my hospital? How are errors reported? Maybe I learn whats the difference between six sigma and lean, and how work with regulatory agencies. Dr. Mort gave us a lot to chew on. And of that, Dr. Batalden says that perhaps the biggest area to master is the human factors piece.
Dr. Batalden: Systems are thorny and interconnected and complicated. And so it’s almost never the case that you identify a problem that can be solved within the silo that actually noticed it first. So it’s usually the case that you need to cross over into other people’s territory in order to bring people together to solve a problem. And you know, it’s the five blind men and the elephant. They see it as a, as a long narrow rope, if they’re standing next to the tail or they see it as a fat hose, if they’re standing next to the trunk or a big fat wall, if they’re standing next to the side.
S: And it’s so important to understand all the silos and stakeholder perspectives early on. Which side of the elephant are they standing on? What do they see? Because you will need it for two reasons:
Dr. Tess: If you’re going to be a QI person, that’s your job – is to help figure out what is actually going on so you can help solve it. Then the second half of your job becomes convincing people to do things differently… which is a challenge.
S: So you’ll first need to make the right diagnosis(s) of why– for example, why the sepsis protocols aren’t being followed and understand it from multiple stakeholders perspective and then you need to go back to all of them and get them on the same page about making a change, which is no easy feat.
Dr. Tess: And right now a lot of people are burned out and they want control over their lives. And don’t want someone from quality improvement coming and telling them how to do things. And so figuring out what would help them move forward and what would motivate them is an important part of quality improvement. Sometimes it’s about “How can I make your work better for you?” How can I free up your time so that you’re using your time to work to the top of your license? How can I set a processes around you so that when you intend for something to happen, it has a higher likelihood of actually happening.
S: Perhaps the best angle to take, and hopefully the biggest motivator for everyone in healthcare is the patient.
Dr. Batalden: And so every time you can redirect to a patient story, to a patient voice, to putting a patient on your team, to diagramming the patient’s journey, the patient’s process through the experience.. that tends to bring people together in ways that when you nurses and doctors and medical assistants kind of fighting it out from their own, from their own vantage point that gets sad, gets messy.
S: That really made me wonder. You know, a lot of times people in QI are not the bosses of all of those groups of different workers, how do they set themselves up to be successful? That brought up the very underappreciated area of interpersonal skills – specifically cultivating a habit of asking good questions and listening.
Dr. Tess: And that’s why asking questions helps. You, have to really understand why people are upset or what they care about so that you can speak to that emotion.
S: It seems like this aligns with the skill set we use with good patient care – putting the work in up front to listen, to ask questions to diagnose that very often multifactorial the problem and building that relationships to actually give recommendations.
Dr. Batalden: This is such a relational science. You know, there’s all of the tools that have come to us from the world of manufacturing, uh, process mapping and run charts and, uh, checklists, and, uh, really sort of sophistication about the processes that we are designing and implementing and improving. But behind those processes are people, both people who come to work every day with the hope that they’ll do something that makes a difference for somebody else with their own fears and joys and insecurities and their own desire for mastery. In the end, the work that we do together is never going to be separate from the people who are doing the work.
S: And the mastering of relational science never ends – whether you are the project lead on Unit 6 improvement or the CMO, CNO, CQO. The very last skills are skills to mention are ones you want to look to if you really want to move up the leadership ladder.
Dr. Mort: From there you want to gain more managerial experience. Do you manage people? Do you know how to hire and fire folks? Do you know how to organize teams? And eventually, budgetary responsibilities and so on and so forth. So you want to go from your training fellowship, project-oriented portfolio, accountability, managerial experience, eventually budgeting.
S: With that big picture wisdom on QI in mind, I want to know what QI people’s days actually look like? Sure on paper, they are navigating x, y, z projects but what does the actual behind the scenes look like?
Day to Day in QI
Dr. Mort: You ask what is a typical day in quality and safety? Well, most of us use outlook or some scheduling program to lay out what we expect to do in a day. What I would say is that is a hypothesis in quality and safety. Maybe that’s what you end up doing, but you may be interrupted because there might be a department of public health surveyor who’s shown up, or the joint commission, or there might be someone who really needs to talk to you because they’ve just been part of an adverse event or found out they’ve been sued, or you may need to peal off and go round in an area that really needs your attention, because they’re trying to solve a problem on the unit.
S: The caveat is that your day may look a little different if end up taking up more of an operational or administrative leadership role with a QI hat on.
Dr. Batalden: At some point you have a branch in your career where you get to think about okay, do I want to do this work as an operational leader? Do I want to be a division chief or a department head? Because there’s a significant amount of quality and safety work that is a constituent part of being a leader. So, you could decide that you actually want sort of an operational line leadership role, and you want to be a quality and safety advocate and manager and director and problem solver from that vantage point as an administrative leader. Or alternatively, you want to stay in the quality and safety infrastructure, and you want to sort of stay in that kind of technical substructure, which is the quality and safety kind of department in some ways.
S: Both QI hats – the more boots on the ground QI or operational leadership – seem like pretty busy outlook calendars
Dr. Mort: So you have to be sort of quick on your knees, quick on your feet and enjoy some flexibility. But as far as what you’re doing in the outlook calendar, a lot of it is talking to people, is leading, is helping people navigate their way through their portfolio.
S: The other QI hats people can wear is if they cross over into the world of QI in MedEd and QI in research. And those day to day activities can clearly differ depending on which the QI vantage point you’re at.
Dr. Tess: If you’re an educator, your time is spent more taking cases that didn’t go well and trying to figure out how to fit it into frameworks and explain it to trainees or other faculty. Or you’re thinking about creating new programs that allow you to teach, which is where I’d love to spend all my time. And then if you’re in the research side, you’re writing grants, you’re working with some of the people who are doing the clinical operations, or you may be looking at large data sets… that’s more likely to be 80% kind of research time. And so there are people who wear all three hats and so their days are very varied and do different things depending on what part of the day they’re in.
Challenges And Pitfalls
S: And so with those days that can be quite variable, I really wanted to understand what are the challenges come with being in QI? The first one comes from the notion that the systems we work in are quite intertwined, and so, there is always a risk of unintended side effects.
Dr. Tess: You may try to solve that one thing and then all of a sudden create other holes in the system that are now even more risky than what you were trying to fix. And so recognizing the actual risk and the impact of the problem you’re dealing with is important as you decide what to fix.
S: Dr. Tess has really seen this happen time and time again when a QI intervention entails just an EMR solution or information system or IS solution.
Dr. Tess: If they could just put it on alert in to stop me from ordering two medications that interact with each other. If they could just do this, if IS could just do. And if you start a sentence with, “if IS could just do” I want you to stop and think to whether that fix will actually cause unintended consequences somewhere else… so delaying care for some patients who really need it or creating so much fatigue that the providers don’t see it anyway.
S: Which brings us to one of common pitfall – NOT studying the long-term impact of your intervention.
Dr. Tess: You fixed something in June, everything looks great in July and you’re like, hey, we’re done. I’m all set. You know, instead of actually recognizing that you need to follow up in August and September and October to actually know, because most change is short-lived.
S: Short lived indeed – we have to factor in how solutions involve humans. They often get tired overtime or how sometimes out context changes, but old protocols are still in place. I can imagine this is even harder because other often isn’t a large grant or other resources to support these long-term evaluations.
Dr. Tess: Picking solutions that aren’t sustainable is another major pitfall.
S: This happens to the best of us. I am guilty of it. We care so much about a project that we end up being the person that connects all the dots, and monitors everything. But what happens when we leave or when our plates get filled with something else?
Dr. Tess: So starting to think once you’ve tested it enough that, you know, it’s something that you think is going to work and be a value then actually starting to think about sustainability. Can this survive past the individual champion? And then the corollary to that is if you test something and it doesn’t work, then you gotta let it go. So that you’re not spending a ton of time, resource, emotion, energy on something doesn’t really work.
S: I feel like I’d have a really hard time letting go of something that I believe in,that work but I think that’s a good mindset to take on – be prepared for your intervention to not work. Always anticipate the null hypothesis. But even in thinking of null hypothesis, truth of it is there can be a lot of noise in the data.
And that is tough when you may not be able to collect robust data – Data is messy
Dr. Batalden: When you’re doing quality improvement, you’re often doing it in a small context, single site, single unit, a single clinic and the data that you have is kinda messy, it’s not research quality data. And so you’re working with kind of good enough data that you can use to try to understand whether the change that you introduced actually accomplished what you hoped it would. But it often doesn’t have the same degree of confidence that you might be expecting or looking for.
S: The cherry on top and the last challenge is just the countless number of metrics. To me, this is the toughest challenge in QI. If these metrics aren’t met, healthcare systems either loose a bunch of money or reputation. I’ve seen over and over how we can get lost in trying to keep up with those metrics.
Dr. Batalden: I think that we’ve created a metric monster that’s eating us for lunch. I think that we have way, way, way too many performance metrics and too many of those metrics are metrics that are used for accountability. And it’s very difficult to use accountability metrics for improvement, because if the stakes are too high and you can’t fail, then you can’t learn and improve on those metrics.
S: It is eye-opening to break down metrics into metrics for accountability and metrics for actual improvement. Come to think of it, I’m struggling with thinking of metrics that have to do with actual improvement.
Dr. Batalden: At their best, improvement metrics are metrics where you are free to fail because you’re learning from what you’re doing. But we have hardly any energy leftover in our kind of reporting and analytics infrastructure for metrics that don’t have a high stakes associated with them. Because it’s basically taking all of our energy to just produce the numbers so that we can report them externally. And so then there’s not a lot of energy leftover to use those metrics for actual learning and improvement.
S: And don’t get me wrong here, metrics do matter. But it seems that like are chosen because they can be measured, not necessarily because they represent excellent care. So maybe one way to navigate these metrics challenge is to step back and understand some of the shortcomings with the metrics.
Dr. Batalden: So we can pay a primary care doctor more or less based on the hemoglobin A1C average of their patient panel. But we also know that the hemoglobin A1C of a diabetic is actually not produced by the primary care provider, even if we punish them by cutting their salary, because the hemoglobin A1C is a lived outcome in the body of another human being.
S: I asked Dr. Batalden how she navigates the tensions that metrics bring- she seems like someone who so driven to do good for the healthcare system but we live in a metric monster. How does she continue to keep her eyes on the patient and do good?
Dr. Batalden: It’s also the job of a leader and a quality and safety leader to help set priorities. So we can’t improve on 500 things at once, even if we have 500 metrics that we have to report externally. So it’s our job to help set institutional priorities in a way that makes sense. That makes sense clinically. That makes sense morally. That makes sense strategically.
S: That makes so much sense – anytime I speak to someone who has worked in multiple healthcare system they speak to that difference in culture that probably happens because of what is being prioritized by that healthcare system. At some places, people are running around tense about discharge patients before 12 – other places you are constantly judged on their documentation and costs of tests. It makes me really appreciate the leaders in QI who fight back against unreasonable metrics. And so, we hope this episode we inspired some of you to really consider a career in QI and be one those QI leaders to help move the healthcare system in a better direction.
Dr. Mort: I think expertise in quality and safety should be a precondition for leadership in healthcare. Why do I say that?? Um, well, because I believe it, but when I look at CEOs, COO CNOs, CMOs, um, those that have a sensibility about quality and safety… I believe are better leaders. Because, we put leaders in charge of healthcare to make some tough decisions. A lot is about finance. A lot is about operations, but to have leaders who have that sensibility about quality and safety, my premise is that they will make better trade-offs because they understand the trade-offs better. And they understand what the opportunities are from improvement in a way that people who haven’t experienced this just simply don’t. So, one thing I would advise listeners is that you may not know exactly where you want to be in your career… spending some time in quality and safety in a fellowship job for a year or two is time well spent. Just about anywhere you end up in a career in healthcare.
S: And to close out we wanted to leave you with some food for thought -there a lot of great work being put into the quality. But there’s one place we haven’t done a good job thinking about.
Dr. Mort: And then the last and most important frontier that I think is really shaking the walls, the hallowed walls of healthcare institutions is this idea about equity.. and that I think healthcare institutions historically have felt well, we’re here, we’re in this, we’re in these four walls. And these facilities we have, we have reached to here, and that’s not enough. The reach has to go beyond the healthcare institutions, into the community in a way that has impact. And people have talked about that for a long time. I think what is different and what is wide open for quality and safety to be leaders in is how do we branch in legislation, work with the communities, engage with schools, employers, religious organizations, businesses, people, and address social determinants of health through our influence.
S: And that is a wrap. Thanks for joining us for the Core IM Careers in general internal medicine podcast, and we want to thank our partners at the American College of Physicians. Thank you to my dear friend Dr. Michael Shen for co-producing this series with me. If you found this episode helpful, please share with your team and colleagues and give it a rating on Apple podcasts or whatever podcast app you use! It really does help people find us!
If you want to add any of your own tips or share challenges, tweet us and leave a comment on our website page, on instagram or facebook page. We’d like to thank Daksh Bhatia for the audio editing and Preeyal Patel for the accompanying graphics. And thank you to Sofia Kennedy for off-air producing this episode. As always we love hearing feedback, email us at firstname.lastname@example.org. Opinions expressed are our own and do not represent the opinions of any affiliated institutions.