When it comes to successful quality improvement (QI) in healthcare, clinicians tend to be the missing link. Fortunately, the disconnect between QI initiatives and the day-to-day work of clinicians can be explained and resolved if health systems adopt and embrace three clinician-focused principles: Principle #1: QI starts at the front line (initiatives should be identified and driven by clinicians). Principle #2: QI makes it easy for clinicians to do the right thing (removes barriers to good work rather than increasing the amount of work clinicians do). Principle #3: QI empowers clinicians to adapt care (even if it’s not QI protocol). Although some clinicians are enthusiastic advocates of their systems’ QI efforts, most are suspicious because they’re frequently cut out of the decision-making process or forced to ignore their best clinical judgement. Health systems that work to close the gap between leaders and clinicians by embracing these three principles will add the missing link—clinicians—back into successful healthcare QI.

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

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Solving Healthcare Quality Improvement
Everyone in healthcare understands the
importance of healthcare quality improve-
ment (QI), which is defined by the Health
Resources and Services Administration
(HRSA) as “systematic and continuous
actions that lead to measurable improve-
ment 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.

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Solving Healthcare Quality Improvement
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 presentation 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.
It also shares three vital principles healthcare
organizations should live by to make the
most of their QI projects.

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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.

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Successful Healthcare Quality Improvement
Focuses on the Frontline
What the Frontline Really Thinks About Quality Improvement Work
The Accreditation Council for Graduate Medical
Education (ACGME) has designated six core
competencies all residents from all specialties
are expected to develop over their residency.
In addition to Patient Care and Medical Knowledge,
topics like Practice-Based Learning and Improve-
ment, and Systems-Based Practice are included.
Many healthcare systems require employed
physicians and mid-levels to complete a QI project
yearly. There’s no doubt clinicians care about quality
improvement and want to improve processes.

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Successful Healthcare Quality Improvement
Focuses on the Frontline
What the Frontline Really Thinks About Quality Improvement Work
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, most clinicians fall somewhere
in the middle.

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Successful Healthcare Quality Improvement
Focuses on the Frontline
What the Frontline Really Thinks About Quality Improvement Work
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.
It’s a shift that sees improvement work as a way
to reduce the burden on clinicians, not add to
their workload.
A shift that values both the scientific and artistic
nature of medicine by balancing standardization
with necessary and appropriate customization.

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Successful Healthcare Quality Improvement
Focuses on the Frontline
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 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.

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Successful Healthcare Quality Improvement
Focuses on the Frontline
Add the Missing Link Back into Quality Improvement:
Three Clinician-Focused Principles
Effective QI acknowledges the important role
clinicians play in improving and sustaining
processes, understands that clinicians are
dedicated to their patients.
That makes it easy for clinicians to prioritize
their clinical work and do what they do best:
DELIVER CARE

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Successful Healthcare Quality Improvement
Focuses on the Frontline
Principle #1: Quality Improvement Starts at the Frontline
The frontline (nurses, physicians, etc.)
knows better than anyone what’s going
on 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.

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Successful Healthcare Quality Improvement
Focuses on the Frontline
Principle #1: Quality Improvement Starts at the Frontline
Leaders can start to move clinicians from the
oppositional end of the spectrum of QI perception
to the enthusiastic end.
This is done by more than just inviting them to be
a part of the QI team—but by giving them owner-
ship 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.

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Successful Healthcare Quality Improvement
Focuses on the Frontline
Principle #1: Quality Improvement Starts at the Frontline
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.

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Successful Healthcare Quality Improvement
Focuses on the Frontline
Principle #1: Quality Improvement Starts at the Frontline
The core message of the first principle is that
QI initiatives should be identified and driven
by the frontline.
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.

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Successful Healthcare Quality Improvement
Focuses on the Frontline
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.

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Successful Healthcare Quality Improvement
Focuses on the Frontline
Principle #2: Quality Improvement Makes It Easy
for Clinicians to do the Right Thing
The goal with this QI principle isn’t to
oversimplify QI implementation, it’s to make
it easier for clinicians to treat patients.
It’s 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.

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Successful Healthcare Quality Improvement
Focuses on the Frontline
Principle #2: Quality Improvement Makes It Easy
for Clinicians to do the Right Thing
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 respond
to patient’s questions.
It is an unreasonable, if not impossible,
protocol that doesn’t take the demands of
a clinician’s work demands into account.

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Successful Healthcare Quality Improvement
Focuses on the Frontline
Principle #2: Quality Improvement Makes It Easy
for Clinicians to do the Right Thing
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.

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Successful Healthcare Quality Improvement
Focuses on the Frontline
Principle #2: Quality Improvement Makes It Easy
for Clinicians to do the Right Thing
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.”

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Successful Healthcare Quality Improvement
Focuses on the Frontline
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.

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Non-sepsis patients exposed to
potentially bad care and outcomes.
Team members could be punished
for not following sepsis protocol.
Clinicians were not allowed to opt out
based on their clinical judgement.
• Draw lactate
• Get blood cultures
• Start antibiotics
• Administer fluids
Successful Healthcare Quality Improvement
Focuses on the Frontline
Principle #3: Empower Clinicians to Adapt Care (Even if it’s Not QI Protocol)
Not empowering clinicians to exercise clinical judgement and adapt
care is extremely dangerous, with severe potential impacts on patient
outcomes. Consider this real-world example:
In one hospital, a best
practice alert would
fire to indicate a
patient might have
sepsis triggering the
sepsis improvement
protocol.
System Problem

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Successful Healthcare Quality Improvement
Focuses on the Frontline
Principle #3: Empower Clinicians to Adapt Care (Even if it’s Not QI 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.
The sepsis exampled showed a feedback loop
must be in place to allow physicians treatment
options for the good of the patient.
Set-in-stone protocols ignore clinical judge-
ment, eliminate clinician autonomy, and
may result in significant harm to patients.

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Successful Healthcare Quality Improvement
Focuses on the Frontline
Principle #3: Empower Clinicians to Adapt Care (Even if it’s Not QI Protocol)
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.

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Three Principles in Action: The Ideal Healthcare
Quality Improvement Experience
One of my experiences as a surgery intern
demonstrates these three QI principles in action.
My rotation took me through a different surgical
service every four weeks. Each service had
their own processes, including how patients
were discharged.
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.

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Three Principles in Action: The Ideal Healthcare
Quality Improvement Experience
Two interns proposed standardizing
discharge summaries to the department.
They 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.
The result was a smoother, more effective
discharge for patients. It showed how the
three clinician-focused QI principles could
work together effectively.

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Three Principles in Action: The Ideal Healthcare
Quality Improvement Experience
The major takeaway from the surgical discharge
summary improvement QI is:
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.
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Unifying Leaders and Clinicians to Improve
Healthcare Quality
Healthcare 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
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
Empower clinicians to adapt patient care
>
>
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Unifying Leaders and Clinicians to Improve
Healthcare Quality
At the heart of each of these
principles is communication—
communication about cost, time
commitment, and outcomes.
Remember, the frontline’s firmly
rooted commitment to patients by
outlining how, specifically, the QI
project will improve the quality of
care patients receive.

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Unifying Leaders and Clinicians to Improve
Healthcare Quality
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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For more information:
“This book is a fantastic piece of work”
– Robert Lindeman MD, FAAP, Chief Physician Quality Officer

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More about this topic
Link to original article for a more in-depth discussion.
Why Clinicians Are the Missing Link in Healthcare Quality Improvement and Three
Principles to Solve the Problem
Five Deming Principles That Help Healthcare Process Improvement
Dr. John Haughom, Senior Advisor
6 Steps for Implementing Successful Performance Improvement Initiatives in Healthcare
Bobbi Brown, VP of Financial Engagement; Leslie Falk, Customer Engagement, VP
Healthcare Performance Improvement Readiness Assessment:
The Key to Achieving the IHI Triple Aim
Ann Tinker, Engagement Executive, VP; Susan Easton, Engagement Executive, VP
6 Proven Strategies for Engaging Physicians—and 4 Ways to Fail
Dr. Bryan Oshiro, Chief Medical Officer, Senior VP

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Dr. Daniel Barlow joined Health Catalyst in October of 2016. Prior to Health Catalyst, he was
a resident in General Surgery at Dartmouth. Dan has an MD from the Geisel School of
Medicine at Dartmouth and an MS in clinical research from The Dartmouth Institute of Health
Policy and Clinical Research.
Other Clinical Quality Improvement Resources
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