Methods

Contact information for quality managers at all acute care hospitals in Ontario, Canada, was obtained from a research consortium (http://www.hospitalreport.ca) that regularly interacts with hospitals. Quality managers were defined as the individual with designated overall responsibility for QI. A single response from multisite hospitals was considered to represent that entity. Ethical approval for this study was granted by Sunnybrook Health Sciences Centre, Toronto, Ontario.

Based on concepts in the QI literature, a questionnaire was developed to elicit information on QI managers (rank, training, experience, support staff, activities), objectives (individual, organisational, influencing factors) and infrastructure (importance, implementation, recommendations).20–22 Most questions were closed with binary or five-point scale response options. Questions about performance objectives, important activities and recommendations were open-ended. The questionnaire was pilot-tested with two managers and mailed with a stamped return envelope and personalised cover letter identifying academic affiliation of the researchers. A complete package was mailed to non-responders after 2 and 4 weeks, and remaining non-responders were contacted on two occasions by both electronic mail and telephone.24 25 Initial distribution took place on 10 January 2007 and reminder contacts concluded on 26 March 2007.

Frequencies were calculated for each question overall and by subgroups: QI experience (years in current role, total years in quality roles categorised as <1, 1–5, 6–10, >10 years), rank (report directly to CEO), training (master's degree, clinical degree), support staffing (0, 1–3, 4 or more) and hospital type (academic, <100 beds, others). For activities (nominal), statistical significance of responses by subgroup was established using the χ² test. For factors influencing QI objectives, and implementation of QI structures and processes (ordinal), statistical significance of responses by subgroup was established using the Mann–Whitney U test for binary independent variables (rank, training) and the Kruskal–Wallis test for multicategory independent variables (experience, staffing, hospital type). To assess discrepancies between views of which factors should influence and which factors do influence QI objectives, as well as QI infrastructure that is and should be implemented, the number of respondents choosing 4 or 5 on a scale (representing much or very much) were compared using McNemar's test. Statistical analyses were performed using SPSS V.16.0. Open-ended responses were analysed using standard qualitative methods.26 27 Two researchers independently identified key themes, grouped responses by theme, then compared and resolved findings.

Results

Respondents

The response rate was 79.4% (77/97). Twelve (15.6%) of 77 respondents reported their hospital had no manager responsible for quality, thus completed questionnaires were returned by 65 individuals from 26 hospitals with <100 beds, 28 hospitals with 100 or more beds, and 11 teaching hospitals. Respondents represented 13 of 14 Ontario health regions, with the two largest regions returning 21 of 65 questionnaires (32.0%). Nineteen respondents (29.2%) held senior positions including chief executive, operating or nursing officer. Two were managers of health records. The remaining 44 (67.5%) possessed a quality title at the level of vice president (1), director (26), and leader, coordinator or manager (17). Thirty-five (45.5%) respondents reported directly to the CEO. Many held master's degrees (44, 68.8%) in health services (21), health administration (12) or business administration (15). Several had clinical training (41, 64.1%), 33 in nursing. Some had other certification in QI (13, 20.0%). About one-third of respondents had >10 years of overall experience in QI (22, 36.7%). Most had been in their current position <5 years (46, 76.7%) or <1 year (13, 21.7%). Many said they had no full-time (27, 43.5%) or part-time (44, 71.0%) support staff for QI activities.

Responsibilities and activities

Quality was not the sole focus of most positions (64, 98.5%). Apart from executive portfolios, other roles included emergency preparedness, chief information officer, privacy officer, library services, research ethics, ombudsperson, patient relations, infection control, occupational health and safety and volunteer services. QI-related responsibilities included patient safety (58, 90.6%), risk management (54, 83.1%), professional education (33, 54.1%), utilisation management (32, 50.0%), organisational development (25, 40.3%), decision support (22, 35.5%) and clinical education (19, 31.1%). Other associated activities included accreditation, project evaluation, committee membership and strategic planning (table 1). Those with a master's degree were more likely to perform data analysis (p=0.047) and strategic planning (p=0.051); those with more total years of experience in quality roles were more likely to perform strategic planning (p=0.031); and those with greater years in their current position were more likely to undertake data analysis (p=0.010), data interpretation (p=0.002) and communications (p=0.013). Activities did not differ significantly by rank, staffing or hospital type. Top-ranked activities of importance to QI were education and training, communication, monitoring of adverse events, working with or supporting teams and clinical staff, and fostering a QI culture (table 2), defined by one individual as a “quality management system with active participation of senior management, medical staff, supervisors and front line team members”.

QI strategic goals

When asked to name individual and organisational QI goals, 13 (20.0%) did not respond and another 6 (9.2%) said there were none. Individual QI goals included monitoring of performance indicators (29), strategic planning (12), QI project completion (7), accreditation (6) and reporting to the board or senior management (4). Organisational QI goals included monitoring performance indicators such as adverse events or patient satisfaction (65), achieving goals within strategic plans (17), accreditation (12), delivering quality care (12) and managing litigation (4). Several factors were perceived to influence QI goals including management, accreditation, adverse events and performance data (table 3). Those with a master's degree were less likely to perceive accreditation (p=0.026) and patient recommendations (p=0.046) but were more likely to view performance data (p=0.048) as factors influencing QI objectives. Those with more total years in quality roles were less likely to think that senior managers influenced QI objectives (p=0.028). Views did not differ significantly by rank, staffing or hospital type. Respondents thought that many factors including research, staff, physicians and patients should have greater influence on QI goals than they currently did, whereas accreditation bodies, government, adverse events and hospital executives and boards should have less.

Infrastructure

Accreditation was the QI structure or process reported as most widely implemented (table 4). Respondents at hospitals with <100 beds were more likely to report implementation of accreditation (p=0.008) and staff QI training (p=0.010). Those with more support staff (p=0.025) and greater years in current position (p=0.048) were more likely to report implementation of reward programmes. Respondents thought that most QI structures and processes could be better implemented (table 4). This included explicit strategic plans, dedicated quality leaders, data management tools and staff training. Commonly recommended QI enhancements were increased QI resources, dedicated QI positions to eliminate the “which deadline do I have to meet next?” approach to problems rather than systematic assessment and improvement, better integrating QI activities and engaging clinical staff (table 2).

Discussion

This study examined QI capacity at acute care hospitals in one Canadian province to identify whether and how this support could be improved. Many hospitals had no QI manager, and many were new to their position. Nearly all QI managers were responsible for multiple roles, but many had no support staff. Respondents thought that QI objectives should be less reactive to accreditation bodies, government, adverse events or hospital executives or boards, and recommended investment in QI, including dedicated managers to develop and proactively apply explicit QI strategic plans. Findings were consistent regardless of rank, staffing or hospital type. Those with master's training and greater experience were more involved in strategic planning, data analysis and communication. As hypothesised based on initial interviews, it appears that QI capacity is underdeveloped, and these organisations may experience difficulty undertaking improvement initiatives or providing support to clinical teams.

These findings are limited by the accuracy of self-reported data and the lack of details, which cannot be collected by questionnaire. The results may not be applicable to healthcare organisations other than acute care hospitals or in other jurisdictions. This is the first study to comprehensively describe quality manager roles in the context of QI infrastructure so we have no comparative data with which to comment on generalisability. Despite these limitations the results are important to decision-makers who seek guidance for enabling QI.

There is little empirical evidence on the QI infrastructure that leads to improvements in care delivery. Attributes theorised as essential include executive, manager and physician engagement, investment in dedicated resources, standing quality committee, clearly articulated strategic objectives, organisation-wide communication, use of performance data and accountability among functional service lines.11–13 19 20 22 Respondents reported variable implementation of these elements (34–80%, table 4) and agreed they could be improved. Future research should investigate the association of these features with objective measures of hospital performance. It would also be important to identify successful strategies for QI strategic planning and implementation through interviews or focus groups with QI and executive managers. This combined knowledge could inform a core set of QI capacity indicators that would provide payers and executives with guidance on investment and evaluation.28

Longitudinal evaluation of healthcare organisations in the USA undertaking redesign to strengthen QI revealed that few achieved substantial or sustained changes.29 30 Successful efforts were characterised by knowledgeable and engaged leadership and staff who were able to integrate QI with clinical care. Few studies have evaluated QI training. Theoretically, individuals must first be aware and accepting of new processes before adoption can occur.31 32 Further research should explore the features of training programmes that foster QI knowledge and capacity development among executives, managers and clinicians. There are many models for health leadership training, but none that include the knowledge and skills required by professional managers of quality, so further description of their roles and competencies would be useful for developing health administration curriculum.33

In conclusion, QI is not well resourced in most acute care hospitals in Ontario. Recommended improvements included dedicated quality managers, QI training for executives and clinical staff, and proactive implementation of explicit QI strategic plans. Further research should empirically establish objective performance measures of QI capacity to guide investment and evaluation.