When we launched our hospitalist program in 1995, I dreamed that many of our faculty would become leaders in quality and patient safety. That dream has come true, but we now must leap over two hurdles: getting these superb physicians paid and promoted.
I think we can do it, but there are a bunch of issues to sort out, at UCSF and everywhere else.
Traditionally, academic health centers have paid lip service to quality and safety. One could tell this by answering a few simple questions:
- Who were the academic Rock Stars? The great researchers.
- How was the promotional system structured? To support top-notch lab jocks and, to a much lesser extent, teachers.
- Where did the discretionary dollars go? To supporting discovery and education.
Don’t get me wrong… academia wasn’t completely disinterested in its clinical enterprise, but the coin of the clinical realm was prominence and profitability, not quality and safety. So while the marquee transplanter or neurosurgeon could expect academic fame and fortune, the faculty member who committed herself to improving the quality of care was asking for a lifetime of frustration, with no organizational interest in her work, little infrastructure and few resources to support it, and no trainees who wanted or needed to learn from it. These rare Don and Dawn Quixotes rapidly read the tea leaves and left for the greener pastures of large multispecialty groups or hospital systems that had made quality a strategic focus.
How times have changed! Since every hospital is now being strafed by a newly aggressive Joint Commission, public reporting of quality measures, pay for performance, and “no-pay-for-errors,” even the nation’s Academic Meccas have begun to get religion about quality and safety (there are no atheists in a foxhole, goes the old saying). Unfortunately, they’ve discovered that they have a desperate shortage of clergy. Sure, most academic hospitals have a quality department that’s been chugging along for decades trying to meet relatively wimpy compliance standards, but, as for faculty passionate about and engaged in quality and safety – until recently, nada.
Signs of the new landscape are best witnessed in academic hospitalist programs. In my division of 42 hospitalist faculty, more than a dozen are involved in quality improvement activities – and I mean really involved, not just warming a seat at a monthly committee meeting. And we’re supporting their interest with resources. In addition to the fine QI staff we get from our medical center, we have hired our own superb quality analyst, who attends all our divisional quality meetings and supports us with data and insights. We are also using our divisional dollars to cover some faculty time for QI work. Moreover, our department is stepping up to this plate, by hiring a new Associate Chair for Quality and Safety and a part-time quality analyst. This level of divisional and departmental investment in quality was unheard of 5 years ago.
The bottom line is that UCSF, like most academic medical centers (AMCs), now realizes that quality and safety are core to its success, and understands that a successful QI effort must be an academic, not just an operational, enterprise. In other words, if the hospital and medical school truly believe that we need to “do” quality, they will also need to “do” teaching, mentoring, innovating, and researching in quality: residents and students must learn the key skills, training programs must support those who wish to acquire expertise, research programs need to be nurtured, and faculty need a path for advancement.
Which brings me to a wonderful article in a last week’s JAMA written by my friends Kaveh Shojania and Wendy Levinson, both of the University of Toronto. In the article, Kaveh and Wendy argue that AMCs must create pathways to allow faculty engaged in quality improvement to be supported and promoted. They highlight the fact that AMCs faced this problem with educators a generation ago, and many responded by creating new promotional paths that recognize and reward excellent teachers, especially those who create new curricula and achieve national recognition. They argue persuasively that we need to do the same thing for faculty whose focus is quality and safety – with the main promotional criteria being innovation, along with regional or national dissemination of the work.
This is a thoughtful and important article, and I urge academic leaders to read it. Left a bit unaddressed, though, is the non-trivial issue of moolah. In the U.S. at least, socialism died in most AMCs a decade ago (a colleague of mine once correctly observed, “Oh, I think get it now… I’m an individual entrepreneur, and UCSF lets me use its letterhead.”), and so the faculty member who spends one day a week on QI or safety needs to find somebody to cover 20% of his salary.
Who should do that: the division, the department, the school, or the medical center? At UCSF, I’m mostly doing it at the divisional level, but that’s because I happen to be passionate about this stuff and because – as a prominent hospitalist program – we need to be at the cutting edge of this movement. But we’re the exception – more commonly, this game of hot potato will guarantee that nobody steps forward to fund the faculty time. All of our best intentions will ring hollow to the faculty physician who finds that he is volunteering his time doing QI.
This is tricky stuff, since in most AMCs (including mine) the rules are that the School-side pays for education and research (the latter, to the extent it isn’t covered by grants) and the Medical Center-side pays for clinical care (to the extent that desired care isn’t covered by clinical revenues). How to pay for the faculty member who is spending 20% of his or her time making the system better, engaging trainees in doing the same, and gathering data (and publishing some of it) about these changes?
My own bias is that there should be an expectation that all departments support at least 10% of one of their physician’s time to do QI, and that this expectation should grow with the size of the clinical operation (based on volume or revenue). The medical center should match the departmental contribution – with greater contributions, the med center should also provide more robust analyst support. So a huge department like mine (the Department of Medicine, with several hundred faculty) might be expected to support 50% of a faculty FTE focused on quality and safety, and the medical center would need to match that time (for a total of 1 FTE of physician time), adding in support for a full-time quality analyst. A smaller department like urology or dermatology might be expected to ante up only 10% faculty time, matched by the medical center (for a total of 20%); the latter would also supply 20-25% of an analyst’s time. Departments would then have to decide how to distribute this support between their central operation and their specialty divisions, but this starts getting a bit too arcane and Local Baseball-y (feel free to e-mail me if you’d like to bat around the details of this distribution off-line).
Until we hammer this out, a robust promotional pathway, as articulated in the JAMA article, will be necessary but insufficient to getting academic medicine where it needs to be in terms of systems improvement. The bottom line is that our faculty who take on the sometimes thankless task of improving systems need to be Shown the Love… through both promotion and compensation.