The field of quality improvement and patient safety (QIPS) has matured significantly in emergency medicine over the past decade. From standalone, strategically misaligned, and incoherently designed QIPS projects years ago, emergency department (ED) leaders have now recognized that developing a more robust QIPS infrastructure helps prioritize and organize projects for a greater likelihood of success and impact for patients and the system. This process includes the development of a well-defined, accountable, and supported departmental QIPS committee. This can be achieved effectively using a deliberate and structured approach, such as the one described by Harvard Business School Professor John Kotter in his seminal work, “Leading Change.” Herein, we present a blueprint using this framework and include practical examples from our experience developing a robust and successful ED QIPS committee and infrastructure. The steps include how to develop a “burning platform,” select a guiding coalition of leaders, develop a strategic vision and initiatives, recruit a volunteer army of members, enable actions for the committee, generate short-term successes, sustain the pace of change, and, finally, enable the infrastructure to support ongoing improvements. This road map can be replicated by ED teams of variable sizes and settings to structure, prioritize, and operationalize their QIPS activities and ultimately improve the outcomes of their patients.
Le domaine de l'amélioration de la qualité de la pratique clinique et de la sécurité des patients (AQSP) s'est considérablement développé en médecine d'urgence au cours de la dernière décennie. Alors qu'il y a quelques années, les projets d’AQSP étaient autonomes, mal alignés sur le plan stratégique et conçus de manière incohérente, les responsables des services d'urgence (SU) reconnaissent aujourd'hui que la mise en place d'une infrastructure d’AQSP plus solide permet de hiérarchiser et d'organiser les projets pour qu'ils aient plus de chances de réussir et d'avoir un impact sur les patients et le système. Ce processus comprend le développement d'un comité d’AQSP départemental bien défini, responsable et soutenu. On peut y parvenir efficacement en utilisant une approche délibérée et structurée, comme celle décrite par le professeur John Kotter de la Harvard Business School dans son ouvrage phare intitulé « Leading Change ». Dans le présent document, nous présentons un plan à l’aide de ce cadre et incluons des exemples pratiques tirés de notre expérience de l’élaboration d’un comité et d’une infrastructure d’AQSP de SU solides et réussis. Les étapes comprennent la façon d’élaborer une « plateforme brûlante », de sélectionner une coalition de dirigeants, d’élaborer une vision et des initiatives stratégiques, de recruter une armée de membres bénévoles, de permettre des actions pour le comité, de générer des succès à court terme, de maintenir le rythme du changement et enfin, permettre à l’infrastructure de soutenir les améliorations en cours. Cette feuille de route peut être reproduite par des équipes d'urgence de tailles et de contextes différents pour structurer, hiérarchiser et rendre opérationnelles leurs activités d’AQSP et, en fin de compte, améliorer les résultats de leurs patients.
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Since the publication of the Institute of Medicine’s seminal reports on quality and safety two decades ago, there has been significant growth in the operational and academic fields of quality improvement and patient safety (QIPS) [1, 2]. Yet, despite these advances, there remains a pressing need to improve the structure of our QIPS activities to produce measurable improvements in processes and care [3, 4]. This need has been exacerbated by the chronic lack of system capacity, the mounting burden of health care worker burnout and disengagement, and various acute crises (e.g., the COVID-19 pandemic) [5,6,7,8,9,10]. While there are now more educational offerings on the topics of QIPS and how to conduct local improvement projects, there is still a paucity of resources on how to build capacity and structure these activities at the departmental level . Having thoughtfully purposed departmental QIPS committees can be an effective way to structure improvement activities to ensure that they are cohesive and align strategically with the mission of the organization. These committees, if created, may also increase front-line providers’ professional engagement. However, they must be developed deliberately and organized intentionally for optimal impact and success.
The University Health Network is a tertiary care academic medical centre in Toronto with two emergency departments (EDs) that combined have more than 125,000 annual patient visits, with a growth rate of approximately 6% per year. The EDs are staffed by 85 physicians, four physician assistants, four nurse practitioners, over 200 registered nurses, and more than 50 allied health providers and support staff, as well as trainees for all health professions. Seven years ago, we set out to revamp our QIPS committee in an effort to have a measurable impact on patient experiences and outcomes. Our committee now has more than 50 interprofessional members (a dozen of whom have pursued formal training in QIPS), and we have achieved significant growth in engagement (e.g., patient focus groups driving project directions, contribution to governmental taskforces), grant funding (over $500,000 for QIPS initiatives), and academic dissemination (over 100 abstracts and 100 invited presentations, numerous social media articles read over 50,000 times in total). Over 30 quality and safety initiatives led by our QIPS committee members have been published, and Table 1 presents a selection of them with important lessons learned from each. They have ranged from improved patient care (e.g., faster diagnosis of acute myocardial infarction, more reliable collection of blood cultures, earlier provision of analgesia) and satisfaction (e.g., communication and education-oriented initiatives) to operational efficiency (e.g., optimized bed utilization and patient flow) [3, 4, 12,13,14,15,16].
Developing our QIPS committee has provided an opportunity to engage, support, and develop both leaders and staff in defining and implementing QIPS improvements on the front lines, where they have the greatest impact. This experience, driven and influenced by our collective professional experiences, has helped us crystalize our approach in a way that can now be shared as a blueprint for departments of various sizes and settings that are interested in better structuring their QIPS activities.
Building an emergency department quality improvement and patient safety committee
Given the numerous steps required and hurdles faced when developing a new committee—from team engagement, resource acquisition, and program organization—a structured approach is essential. An excellent approach is the Leading Change model developed by Harvard Business School Professor John Kotter , because it is sequential and additive, it aligns well with QIPS endeavours, and it is the most commonly used change management model in healthcare . Figure 1 shows the eight chronological steps in the Kotter framework, with the relevant descriptions and examples needed to develop an effective QIPS committee.
Create a sense of urgency
The phrase “Never let a good crisis go to waste,” attributed to former White House chief of staff Rahm Emanuel, among others , perhaps most appropriately frames the mindset required to spark the creation of a QIPS committee. To build a “burning platform” demonstrating to stakeholders that the status quo is an untenable solution and that a future state is both necessary and attainable, a number of principles must be considered. First, identify quality and safety issues that not only resonate with the local team (i.e., those who will drive the change) but also align with the organization’s broader strategic goals (which will help secure resources and create broader impact) by engaging with relevant hospital leaders. Second, demonstrate the magnitude and importance of these issues, through both data and narrative stories, to appeal to people’s intellect and emotions. And, finally, illustrate why the status quo is more problematic than change is, framing the journey in a solution-oriented and proactive way while ensuring that the destination is both attainable and meaningfully better. While there is no perfect indicator that the platform is burning “enough”, a useful sign consists of witnessing an increasingly large number of ED team members incorporating the platform’s themes in their own thinking and discussions.
Build a guiding coalition
Concurrent to articulating the urgency and building the value proposition, it is crucial to recruit driven, diverse, respected, and knowledgeable individuals to lead the QIPS committee . These people should share a common purpose and possess the influence needed to make the change efforts achievable . Important stakeholders include individuals from various professions who have relevant roles and responsibilities. Table 2 presents these individuals with some of the qualifications they may have and the roles they may play, and the CAEP 2018 Symposium paper focusing on QIPS describes possible models adopted and the level of technical proficiency required in the team . We believe that a dyad model of physician–nurse co-leadership (i.e., inter-professionally diverse) for the QIPS committee results in greater situational awareness and buy-in from the broader team. These co-chairs are typically charged with leading the remaining steps, supported closely by their guiding coalition. The co-chairs should be attributed both title and support, as feasible, to ensure their meaningful contribution, protected bandwidth, and legitimacy.
Form a strategic vision and strategic initiatives
Once the QIPS committee’s leadership has been established, a compelling vision is required to ensure that the “future state” represents a meaningful and specific improvement. While large interprofessional visioning exercises add value, our experience is that they tend to be even more useful after some element of buy-in and early successes have already been achieved to orient members to the opportunity at hand. Vision and mission statements should be developed by and refined with the core QIPS committee’s constituency, which may help ensure that committee objectives subsequently developed are as SMART (specific, measurable, actionable, realistic, and time-defined) as possible, much like in QIPS projects themselves . As shown in Table 3, numerous elements should be considered to increase the likelihood that the vision is accomplished.
Enlist a volunteer army
The members of the QIPS committee are those who will fulfill its vision, so their recruitment and engagement are the next priorities. Table 4 describes who these individuals can be, with relevant characteristics. The exact number of contributors will vary in each centre based on ED size and competing activities, but the key element is to enlist the support of those most dedicated and enthusiastic to effect change in their setting. Their identification can be facilitated by a stakeholder analysis exercise . The recruitment of these players can be accomplished through a multi-modal approach via targeted discussions with promising individuals, announcements at departmental huddles, and more generic email communications. The following approaches can be used to recruit QIPS committee members and keep them engaged:
Organize recurring meetings to increase the visibility of the work being done and attract new QIPS committee members. Ensuring that departmental leadership attends these meetings will demonstrate the importance of the work and keep current members encouraged and motivated. Ensuring that employees are protected from other duties to attend and compensating physicians’ time (e.g., from admin or group funding pools) for attendance will also increase participation. Figure 2 (in supplementary materials) shows a sample agenda (with topics and descriptions) for a typical 90-min QIPS committee quarterly meeting.
Encourage would-be members to contribute to initiatives that appeal to them (i.e., create projects from the ground up, rather than with a top–down approach), perhaps initially only so they can gain experience and confidence.
Encourage and support baseline QIPS professional development for all members of the department. This will serve to: (1) enlist interested individuals to join the QIPS committee; (2) empower members with newfound skill sets and confidence to create positive change; and (3) ensure that the broader team understands the rationale for change .
Select promising individuals for additional coaching and mentorship, including supporting them to pursue courses or certificates/degrees to increase their expertise .
Enable action by removing barriers
Once the QIPS committee has been established, its leadership team drives the actual improvement work. Successful QIPS projects improve patient care, and those that also enhance provider satisfaction and reduce their frustrations are more often sustained . If the perceived improvements to patient care and provider workflow are greater than the perceived efforts required to contribute to projects, providers will often want to be involved in or support QIPS projects . The following are typical barriers that are encountered and their possible solutions:
Novice QIPS project leads can fail to appreciate how the risk of scope creep and the lack of broad stakeholder engagement can affect the likelihood of project success. As a general principle, if either the status quo or a system change benefits or compromises the authority or influence of a stakeholder, they need to be engaged early. The completion of a project charter at the outset of project development helps avoid these traps. Box 1 illustrates an easy-to-use template, which typically results in a project charter less than two pages in length but containing all the important information. Projects that fail to progress adequately according to the agreed upon deliverables and timelines should be assessed to determine whether greater attention or resources are needed; occasionally, these projects may need to be stopped, so that efforts and resources can be concentrated on higher yield pursuits.
Project leads can influence local processes, but they may need the collaboration of stakeholders outside their department to ensure interdepartmental success. Departmental leaders should use their connections and clout to create relevant networking opportunities. For leaders, supporting fewer projects more closely (thereby increasing their likelihood of completion and success) will often lead to a greater overall impact than attempting to encourage more projects in a superficial fashion (which may lead to more project failures).
While advances in the field of quality and safety in health care have been numerous in recent years, it remains difficult for organizations to operationalize improvements in processes and outcomes at the departmental level. QIPS committees are an effective way to achieve this, especially if they are structured and empowered for success. The Leading Change framework can be applied sequentially and deliberately, as presented here in a blueprint with specific examples and tools. Importantly, departments of various sizes and types of settings can use this road map to ensure that QIPS activities are structured in ways that are most likely to lead to patient care improvements.
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The authors wish to thank the physicians, nurses, trainees, nurse practitioners, physician assistants, allied health, clerical staff, and other contributors who have been committed for years to improving the quality and safety of care of the patients we serve in our community. Special thanks go to Dr. Anil Chopra, whose vision enabled the transformation and positive impacts described in this manuscript. And final thanks go to Tayler Lee Young for creating the Figure 1 infographics, as well as Carol Hilton for her comments on the manuscript.
There are no funding sources.
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The authors declare that they have no conflict of interest.
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Chartier, L.B., Masood, S., Choi, J. et al. A blueprint for building an emergency department quality improvement and patient safety committee. Can J Emerg Med 24, 195–205 (2022). https://doi.org/10.1007/s43678-021-00252-2