Quality improvement is something that UMass Memorial Medical Center (UMMMC) in Worcester, MA, has focused on since Robert A. Klugman, MD, senior vice president, chief quality officer, and medical director of managed care took over in 2007. One of Klugman’s main goals was changing the existing role of physician quality officers (PQO), which was similar to the traditional model, to a new and improved role.
At the time, the traditional PQO was responsible for a clinical department, and there was tremendous variation in the amount of work each was putting into improving the healthcare system. The variation between each department’s efforts in quality improvement work was one of the main reasons Klugman wanted to change the existing structure.
“A key component is engaging clinicians in this type of quality improvement effort and getting them on board with quality improvement work,” he says.
When Klugman took on the role of senior vice president in 2007, he wanted the new PQO model to engage the physicians. He decided to focus on a multidisciplinary role for PQOs in the quality department. The PQOs would focus on systems improvement and be centralized within one multidisciplinary office rather than focus on their separate clinical departments.
Even now, two years after Klugman instituted the new PQO model, physicians, other facilities, and national organizations continue to show interest in this model.
“Our model has been very successful,” says Klugman. “The PQOs are now highly regarded by their colleagues, which has fostered increased engagement by the medical staff in quality improvement initiatives. This is a big challenge in every organization.”
Traditional vs. new
Many facilities use the traditional model, with the chief medical officer handling medical staff issues, credentialing, and privileges, and the chief quality officer dedicated to handling quality improvement issues. The chief medical officer and the chief quality officer report to the CEO. It became apparent to Klugman that this structure wasn’t working at UMMMC.
“The lone ranger can’t really do the work, particularly in larger organizations, without the engagement of the medical staff,” says Klugman.
In the traditional model, each clinical department is responsible for its own quality improvement work. The department chair appoints a person in charge of quality improvement, who may not have had formal training and who works only in his or her department. Quality improvement work is not coordinated or organized between departments.
Klugman saw two major problems with this model:
- Variability in the energy, effort, and guidance the PQO received to get work done due to multiple quality departments that were not integrated
- Fragmentation in the division of work between departments
Klugman wanted to ensure that UMMMC’s quality improvement work continued to evolve alongside healthcare as it becomes more patient-centered.
“There is really a major push to take care from the bedside, and the patient perspective, and disease perspective, rather than divide it up into which department best fits,” he says.
Klugman’s model was devised to recruit physicians who wanted to work as PQOs and was not based on departmental assignment.
“The PQO would work for the department of quality, but not necessarily in the department related to their medical discipline,” he says.
PQO for hire, training, and work
Klugman and a selection committee made up of department chairs, nursing leaders, quality improvement experts, the chief quality officer, and the medical center president helped sort through the 25 applicants from UMMMC who applied for a PQO position.
The PQOs are required to:
- Be practicing physicians who bring clinical experience to quality improvement work
- Have excellent interpersonal and team building skills
- Have experience with change management
- Resolve issues through consensus building
- Demonstrate a passion and commitment to improve clinical performance
From the 25 original applicants, seven were chosen. They came from surgery, internal medicine, pediatrics, pediatric emergency medicine, OB/GYN, family practice, and cardiology.
The PQOs were required to take four two-hour sessions of Quality College, a program designed by UMMMC to educate the physicians on quality and patient safety, says Klugman.
Each session, conducted by UMMMC faculty, is attended by the whole department so there is a better understanding of quality improvement issues and how to resolve such issues. This includes nurse quality reviewers, the operations vice president, and the director of quality. Each attendee is asked to describe their background and ongoing quality improvement work. The sessions are also used as team building opportunities.
“These individuals were encouraged to gain additional training,” says Klugman. “And they gained leadership of the quality projects and programs across the organization instead of within specific departments.”
The PQOs are then assigned ongoing projects in quality improvement processes and work closely with members of infection control, pharmacy, nursing, radiology, and risk management.
PQOs are assigned tasks based on their particular interest and suitability for the job. For example, a surgeon PQO would be assigned to the National Surgical Quality Improvement Program.
Making the change and continuing forward
Obstacles are bound to arise during the implementation of a new process, and this was no exception.
During the initial implementation of the PQO model, there was some resistance from the departmental administration and some staff members, says Klugman. “Department leaders liked having independent control of their staff members,” he says.
With the new model in place, department leaders would have less control over their PQOs because the PQO would now be reporting to the chief quality officer.
Now, two years later, staff members’ reactions are a little different.
“In a recent quality meeting with all the departments of quality and administration, it was universal by all the chairs that this was a great model and a [huge] improvement from the traditional model,” says Klugman.
Word has spread to other physicians who found out about the PQOs and quality projects through seeing or participating in the quality improvement work taking place at UMMMC. Several more physicians have been added, bringing the number of PQOs to nine.
In addition to the program’s growth within the facility, UMMMC PQOs have grabbed the attention of many nationally recognized organizations.
UMMMC’s Mitch Gitkind, MD, a PQO, submitted a proposal to The Joint Commission for its annual conference on quality and patient safety and gave a course on one of his major assignments as a PQO—medication reconciliation.
The IHI has taken interest in the PQO model, and Klugman’s department, with the PQO’s involvement, expects to “be part of an international collaborative comparing and using quality measures.”
“The PQOs have been very visible as leaders, experts, and role models,” says Klugman. “They have been very effective in engaging other MDs in working on improvement of all of our big quality improvement initiatives.