As healthcare systems transition to value-based care and population health, and an increased focus on patient and worker safety, the relatively new role of chief quality officer is often charged with overseeing a cultural transformation. But it is a challenging role to fill, with no clear job definition across the industry. In a Jan. 25 webinar put on by the Institute for Healthcare Improvement (IHI), two CQOs spoke of creating a “healthy tension” within their organizations to spark progress.
In the webinar, David Williams, Ph.D., IHI’s executive director for improvement capability, interviewed Petrina McGrath, R.N., M.N., Ph.D., executive transition lead: people, practice and quality for the Saskatchewan Health Authority, and James Moses, M.D., chief quality officer and vice president of quality and safety for the Boston Medical Center, about how they are redefining their positions.
Williams started out by noting that the CQO role is relatively new, and their responsibilities sometimes reside in another position such as chief medical officer. IHI has interviewed two-dozen CQOs in the U.S., Canada and Europe. It found that people were establishing this role in their organization, but there was not a unified theory of what that the role was or what they worked on.
Besides engaging other stakeholders, including the C-suite, interviewees often mentioned the idea of creating a culture around scientific improvement and the desire to fail forward.
Among the key priorities CQOs address are reducing infections and medical errors. But in the larger picture, this role needs to be able to link with stakeholders throughout the organization, including front-line leaders, Williams said. “They have to be able to activate a system of people working on improvement. They recognize that there is a significant need to develop a culture that supports people to work in favor of quality,” he said. “That requires a number of different skills that may not be traditional in some of the folks who get into that role — soft skills around relationship building and building will, and harder skills around change management.”
McGrath said that Saskatchewan had been focused for a few years on tools and events to do quality improvement but noticed that they were struggling to sustain some of the progress. “We shifted to a focus on how to build quality improvement and safety literacy into daily work at all levels of the organization,” she said.
“I find it important to test and model what I am asking others to do and expect the same of my team,” she said. “We are trying to create and embrace a healthy tension, because learning is uncomfortable.”
She has found observing behaviors important as a clue to employees’ depth of understanding and can guide her in terms of where to focus her efforts. She wants to see if leaders are taking methodological approaches to the problems they are trying to solve or instead just jumping to the solution. “In units and clinical areas, are the managers coaching or telling? That can help me understand where we have to do more work. Those can be leading indicators of whether we are getting that culture in place.”
Boston Medical Center’s Moses has been in the CQO position less than a year, although BMC, the largest safety net institution in New England, has had the position since 2008. He is the third CQO there.
Boston Medical Center’s mission involves serving vulnerable populations. Moses said his job is determining how quality and safety fits into that mission and get the institution to embrace quality and safety as a core value of taking care of the poor. Other Boston-area health systems have more resources to invest in quality initiatives, he admits. “We need to make meaningful investments in quality and safety and reducing inefficiency and waste to maximize the care we are providing,” he said, echoing McGrath’s comment about creating a “healthy tension” in the organization to change the culture around quality.
Unlike his predecessors in the position, Moses reports to Boston Medical Center’s chief medical officer, which he thinks makes sense. “It leads to better alignment because the CMO is physician-in-chief for the institution,” he said. “You need providers at the table and you need a strong physician leader to facilitate culture change. My role is centered on quality as a strategy. This allows a specific focus.”
With the rise of accountable care organizations comes an increased focus on value, Moses said. The CQO role at BMC traditionally has been about inpatient and ambulatory outcomes, and largely hospital-based. But BMC is all in on Massachusetts’ Medicaid ACO. “My role in that effort was undefined, but clearly over the last several months, I have been having more doctors knock on my door asking me to help out. So that is on the horizon. As CQOs, value-based care is one of the key pivots in this role.”
In the Q&A portion of the webinar, the CQOs were asked about the growing number of quality programs tied to payment. There has been huge growth in the number of bonuses and penalties designed to get hospitals to focus on quality. To some extent, this has led to managing the measures instead of focusing on quality of care, Moses said. “You can’t ignore those measures, because it is not just about finances; those measures impact the quality reputation of the organization as well,” he said. “We have to do well on those and have enough resources to do other work, such as asking patients what matters to them. You have to do both.”
McGrath said one challenge in Saskatchewan is how to get good data to help show the impact of improved quality in a financial way. Culture and continuous improvement is a multiyear effort. Some people assume that you would be showing dollar improvements in the first year, she said. “It takes many years to build capacity and get the depth of culture where you need to. It takes five to 10 years. We are able to show cost avoidance but it takes time.”
She added that Saskatchewan is reorganizing to create one health authority for the whole province. “We are removing boundaries and really looking at the health of our population, focusing on improved quality and safety. It is a time of change and an opportunity. We have been building a quality mindset. Now we can accelerate to the next level.”
The IHI is launching a Chief Quality Officer Professional Development Program starting in June 2018. “We hope this can act as a starting point to help new and current CQOs,” Williams said.
