Why Clinicians Are the Missing Link in Healthcare Quality Improvement and Three Principles to Solve the Problem

Everyone in healthcare understands the importance of healthcare quality improvement (QI), which is defined by the Health Resources and Services Administration (HRSA) as “systematic and continuous actions that lead to measurable improvement in healthcare services and the health status of targeted patient groups.” QI is essential in healthcare because it can enhance the efficiency of processes, reduce costs, and increase the reliability and predictability of systems of care—all of which lead to improved patient outcomes.

Given the industry’s consensus about the importance of QI in healthcare, why is there a major disconnect between QI initiatives and the day-to-day work of clinicians? This article takes a close look at the important role clinicians play in health systems’ QI programs—and examines why they tend to be the missing link. This article also shares three vital principles healthcare organizations should live by to make the most of their QI projects.

Successful Healthcare Quality Improvement Focuses on the Frontline

Quality improvement done right makes it easy for clinicians to deliver high quality care to their patients. Effective QI does more than acknowledge clinicians’ expertise—it depends on it. And, rather than punish clinicians for not strictly adhering to QI-driven protocol, the most successful QI initiatives balance standardization with customization.

Unfortunately, many healthcare organizations’ QI efforts are hindered by their unwillingness to harness the power of the frontline. By ignoring clinicians, these organizations create a culture of disenchantment, in which clinicians see QI initiatives as just another top-down requirement that adds to their already full plates, takes them away from their patients, and punishes them for practicing their craft and using their hard-earned clinical judgement. Therefore, it’s no surprise clinicians can be wary of QI projects.

What the Frontline Really Thinks About Quality Improvement Work

QI work has existed in healthcare for a very long time. In fact, The Accreditation Council for Graduate Medical Education (ACGME) has designated six core competencies that all residents from all specialties are expected to develop over their time in residency. In addition to ones like Patient Care and Medical Knowledge, they include topics like Practice-Based Learning and Improvement, and Systems-Based Practice. And many healthcare systems require employed physicians/mid-levels to complete a QI project yearly. There’s no doubt clinicians care about quality improvement and acknowledge its value in healthcare; clinicians want to improve processes.

But healthcare leaders asking the frontline to do their part to improve operating time efficiency can lose sight of the fact that a clinician’s primary concern is, for example, ensuring proper surgical margins for the removed tumor—not improving the system’s bottom line. Therefore, clinician perceptions vary regarding their systems’ QI efforts. From actively opposing QI on one end to enthusiastically embracing it on the other end, most clinicians fall somewhere in the middle.

Turning this overwhelming majority of hesitant clinicians into QI champions requires a massive cultural shift—a shift that sees the frontline as the beginning of QI work, not the end; a shift that sees improvement work as a way to reduce the burden on clinicians, not add to their workload; and a shift that values both the scientific and artistic nature of medicine by balancing standardization with necessary and appropriate customization.

Add the Missing Link Back into Quality Improvement: Three Clinician-Focused Principles

Health system leaders responsible for implementing successful QI initiatives face the challenge of reengaging their frontline (the missing link). The system wide culture changes required to do this may seem insurmountable, but there are three clinician-focused principles that will help healthcare leaders get on the right path. Effective QI acknowledges the important role clinicians play in improving and sustaining processes, understands that clinicians are dedicated, first and foremost, to their patients, and makes it easy for clinicians to prioritize their clinical work and do what they do best: deliver care.

Principle #1: Quality Improvement Starts at the Frontline

The frontline (nurses, physicians, etc.) knows better than anyone what’s happening in their hospitals. Among the most educated in any industry, the healthcare frontline takes pride in their work. QI initiatives tend to feel like top-down administrative mandates, but they should start with the frontline. Leaders can start to move clinicians from the oppositional end of the spectrum of QI perception to the enthusiastic end by more than just inviting them to be a part of the QI team—but by giving them ownership of the QI work. By seeking their input and asking where they have seen barriers, what problems they would like to address, and what their solutions are, they are given more ownership of the QI work.

Healthcare leaders need to abandon the Tayloristic view of process improvement mentality that believes management knows best and should tell frontline workers what to do and how to do it. Dr. William Edwards Deming flipped this archaic approach on its head by proposing that frontline workers actually drive improvements because, unlike leaders and administrators, they are the process experts. In a stunning role reversal, Deming believed it was leadership’s job to support the frontline’s ideas and provide the necessary resources for them to execute on them.

The core message of the first principle is that QI initiatives should be identified and driven by the frontline. When the frontline says there’s a problem, administrators should open a discussion rather than saying, “That’s not part of our five-year plan.” A health system’s vitality depends on the frontline—recognizing their importance and expertise due to being on the front line, and conducting projects that address their barriers and priorities to help maintain a happy, engaged group.

Principle #2: Quality Improvement Makes It Easy for Clinicians to do the Right Thing

The most successful QI projects do more than improve outcomes—they make it easy for clinicians to provide good care to their patients. Leaders need to tell clinicians, “Here’s how this project will not only improve outcomes for your patients, but also make your job easier.” QI initiatives that reduce the burden on clinicians are more likely to be adopted and sustained.

The goal with this QI principle isn’t to oversimplify QI implementation, it’s to make it easier for clinicians to treat patients—to maximize clinicians’ time with patients so they can deliver high quality care. The last thing health systems want to do is add another filter or check box that makes it harder for clinicians to do their jobs. According to one study, it would take a physician 7.4 hours per workday to just fulfill preventative screening requirements let alone address the problems or questions the patients have: an unreasonable, if not impossible, protocol that doesn’t take the demands of a clinician’s work demands into account. QI projects can quickly become myopic, failing to consider how new requirements and steps as a part of a required protocol impact clinicians’ daily work.

The core message of the second principle is that QI initiatives should remove barriers to good work rather than increasing the amount of work clinicians must do. For example, one health system’s QI project involved providing physicians with a nurse and a scribe. The nurse roomed patients while the scribe followed the physician typing the conversation. Eliminating the burden of typing not only made physicians’ jobs easier, but also maximized facetime with patients, improved the quality of the note in the EMR, and allowed the physician to see more patients. Instead of saying, “Here’s what we decided to do, now do it” the system said, “We’re adding staff to your team to make it easier for you to do your job and interact with your patients.”

Principle #3: Empower Clinicians to Adapt Care (Even if it’s Not QI Protocol)

The most effective healthcare QI culture protects a clinician’s autonomy and craftsmanship, and understands how medicine is an art. After all, biological systems are more variable than mechanical ones. No single improvement process can treat everything and no one approach is right for every patient. Clinicians worry about patients who are exceptions to the QI rule. Leaders need to review outcomes and ask the frontline if protocols need to be revised, which emphasizes the importance of engaging and involving clinicians in all QI work, from beginning to end.

Not empowering clinicians to exercise clinical judgement and appropriately adapt care is extremely dangerous, with severe potential impacts on patient outcomes. For example, during my residency, there was a best practice alert that would fire to indicate that a patient might have sepsis. The next steps, per the sepsis improvement project protocol (and sepsis best practices), was to draw lactate, get blood cultures, and start antibiotics and fluids. The problem with the protocol was clinicians were not allowed to opt out based on their clinical judgement (i.e., if a sepsis alert fired and it was inappropriate for the patient), resulting in potentially bad care and outcomes for patients. The alert fired on a patient of mine who was clearly not septic, and had other health conditions that would have caused him harm if he were given large amounts of fluid. The system was rigid enough that I had to include multiple members of the team to avoid being punished for not following the sepsis protocol.

In medicine, it’s common sense that no single patient can be treated entirely by protocols, and no single protocol can treat all patients. Systems need clinicians’ expertise as much as they need standardization—these two must work in tandem. In the sepsis example, the system needs to have a feedback loop in place to identify when and why clinicians chose to follow treatment or chose to opt out in order to determine the appropriateness of the decision and either revise the protocol or provide additional frontline training and education. Set-in-stone protocols ignore clinical judgement, eliminate clinician autonomy, and may result in significant harm to patients.

The core message of the third principle is that healthcare organizations need to empower clinicians to adapt care according to their clinical expertise, even if it’s outside the QI protocol. Using a feedback loop to evaluate decisions, systems can continue to enhance protocols and clinical knowledge.

Three Principles in Action: The Ideal Healthcare Quality Improvement Experience

What happens when health systems turn to the frontline—their resident experts—for QI direction? What happens when leaders prioritize QI projects that make it easier for the frontline to do the right thing? What happens when systems embrace the science of QI and the art of medicine at the same time? When these three clinician-focused principles drive healthcare QI, processes and outcomes improve, and the culture required to implement and sustain successful QI projects is fueled.

One of my experiences as a surgery intern demonstrates these three QI principles in action. As an intern, I rotated on a different surgical service every four weeks. Each service had their own processes, including how they discharged patients. Every service used a different discharge summary, which provided varying instructions and information (overview of the patient’s stay, follow-up care instructions, prescription instructions, etc.). The discharge summary was a huge part of my job, but every time I switched services I had to relearn a new discharge process. What should have been streamlined, consistent, and straightforward, was complicated and made it harder for me to do my job.

Finally, two interns proposed standardizing discharge summaries to the department. The interns developed a template that standardized what needed to be standardized but allowed individual services to adapt the summary based on their unique needs with an easy-to-use electronic check box. Everyone in surgery was excited about the improvement but, more importantly, it resulted in a smoother, more effective discharge for patients. It showed how the three clinician-focused QI principles could work together effectively:

  • The improvement idea came from the frontline.
  • The improvement idea made it simple and easy for the frontline to do the right thing.
  • The improvement idea encouraged clinicians to adapt the protocol.

Unifying Leaders and Clinicians to Improve Healthcare Quality

In an industry in which administrators and clinicians are in different (often oppositional) tribes—one focused on patient outcomes and one focused on bottom-line financials—healthcare leaders on both sides (clinical and administrative) should be striving to bridge the gap and unify. With contrasting cultures and goals within these two tribes, leaders can start developing a common language by incorporating the three clinician-focused principles into their QI work: engage the frontline, ease the burden of providing care, and allow clinicians to adapt to individual patient circumstances without punishing them.

At the heart of each of these principles is communication—communication about cost, time commitment, and outcomes—and remembering the frontline’s firmly rooted commitment to patients by outlining how, specifically, the QI project will improve the quality of care patients receive.

Healthcare quality improvement culture changes are hard to make when health systems are stuck in the inertia of having done QI projects the same way for so long. But changing the direction of the QI ship can happen by believing in the value of the frontline, the importance of making it easy for people to do the right thing, and the art-science balancing act that is healthcare.

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