Engagement—a reciprocal commitment from staff and their organisation

There is no universal definition of engagement: it may be an attitude, behaviour, an outcome—or all three.26 Schaufeli et al27 describe engagement as an employee's positive motivational state, characterised by ‘vigour, dedication and absorption’. A broader, more cooperative, position is that engagement is a two-way phenomenon, with an onus on the organisation to establish conditions encouraging engagement and the opportunities for it to be manifest.28 Clinical engagement, then, involves staff actively contributing ‘within their normal working roles to maintaining and enhancing the performance of the organisation, which itself recognises this commitment in supporting and encouraging high quality care’.28 This working definition makes it clear that real engagement is a very different entity to staff acquiescence, for which it is often confused.29 ,30

In QI, however, clinical engagement has been summarised simply as staff's ‘active involvement’,31 with no recognition of the possible dialogue between clinicians and those seeking to improve their performance. That no organisational contribution is expected may go some way to explaining why clinical engagement has been problematic. Although there is specific literature pertaining to physician engagement, in this discussion (unless specified otherwise) we group clinical healthcare professionals together. QI interventions are typically interdisciplinary, and securing greater engagement of a single staff group is not an end in itself, only a step towards an ‘organisational culture where all staff feel valued and involved’.30

Clinical engagement can be improved by co-design, local modification and strategic selection of QI interventions

Healthcare professionals have been reluctant to involve themselves in QI initiatives.31 This is especially apparent in periods of sustained organisational turbulence, but is a long-standing, multifactorial and international problem.31 Doctors are disproportionately hesitant to participate in safety behaviours like incident reporting,32 ,33 and active resistance from senior staff remains the most common barrier to the successful implementation of interdisciplinary safety checklists.34–38 The narrative of ‘automatic’ clinical resistance to new initiatives, or ‘change fatigue’,31 is seemingly widely accepted within the QI literature. Circumventing this fatigue is considered a major triumph, even fundamental to QI success. With few exceptions,24 ,25 local QI breakthroughs are attributed to good clinical engagement; conversely, failures are seen only through the prism of inadequate clinical buy-in.

Not all interventions are subject to the same clinical disengagement barrier, however: some programmes might have lower thresholds for participation.21 ,39 ,40 Conversely, problems with the introduction of a specific improvement strategy do not necessarily indicate a wider reluctance to change practice. The intervention's characteristics, at least in part, determine its reception. In our experience, iterative co-design of a structured quality and safety briefing intervention with physicians, to maximise its face validity, mitigated much of their expected resistance (see box 2). The process of co-design may also in itself improve staff ownership of the intervention. Other strategies may also have immediate appeal: interventions that used peer facilitation,41 wider reporting options and feedback,42–47 or engaging whole teams to identify problems48–50 all seemingly fell on fertile ground.

Even when QI strategies do not appeal intuitively to clinicians, generating clinical engagement need not prove an insurmountable challenge. Defining the ‘soft periphery’ of a QI programme—the elements that should be flexibly adapted to optimise the programme's acceptance, without invalidating the entire intervention—is key.51 Making the effort to appropriately modify QI tools for the context in which they will be applied (eg, creating separate versions of surgical safety checklists for different specialties) then makes those tools much more palatable for clinicians.34 In fact, local adaptation is the most commonly cited factor affecting checklist implementation, more so even than resistance from specific clinicians.34 This reflects each organisation's responsibility to create the opportunities for meaningful engagement: active clinical involvement is more likely when QI tools have been purposefully tailored, and when there is protected time for training to use them.31 ,34 In contrast, unmodified checklists are unlikely to be used as intended, nor improve patient outcomes—regardless of hospitals’ reported compliance.13 ,52

While co-design and local modification do improve the adoption of QI interventions, the financial and opportunity costs of pre-existing efforts represent a major challenge to any new initiative. Relentless organisational change, with little sense of an overall strategic direction, also contributes to a general ennui.31 Clinicians, believing that each ‘fad’ will soon be replaced with another, feel there is ‘little point in investing heavily in any one initiative’.31 The strategic selection of a limited number of QI interventions, appropriate to the organisation's capacity to implement them, is therefore crucial.23 ,53 Experts have identified 22 patient safety strategies with a sufficient evidence base to recommend their widespread adoption:54 ,55 organisations may choose to focus on these first, with a view to their specific local needs. However, if organisations are to select only the QI targets that they have the capacity and willpower to pursue, other potentially valuable initiatives need be deferred in the interests of preserving engagement and momentum. Regulatory bodies have an important role here: they should give institutions the time and space to develop these focused improvement strategies.56 It may seem odd to decry the slow pace of improvement, and yet advocate a more deliberate, institution-specific approach. With space for self-determination, however, organisations that strategically shape their QI attempts go on to see wider benefits, tackling deep cultural issues that go unaddressed with more haphazard approaches.56

Beyond clinical engagement: the role of managers in QI

Improving clinical engagement is only part of the solution to ineffective QI: ‘administrative engagement is equally important, or disillusionment… ensues’.29 Quality of care is not a leading priority for many hospital boards, however.57–59 Although board-level attention to quality issues has been associated with clinical quality,57 ,58 ,60 how this commitment translates, in practice, into front-line action remains unclear.61 A recent survey study provided a key insight: board and middle management practices are linked, and correlate strongly with hospital performance on clinical quality metrics.62 Certain board characteristics were specifically linked to middle management styles: board attention to quality was associated with management practices that monitored it, and the use of quality metrics at board level corresponded to good operational management and target setting.62 If good management is truly associated with clinical quality, the role of managers in QI deserves further attention.

Yet managerial participation in QI interventions is often assumed, rather than analysed in detail. Although senior hospital executives may participate constructively in collaborative safety programmes,14 ,63 more often, active managerial involvement goes no further than the ‘expressions of support’ described in many QI reports. More detailed evaluations describe difficulties recruiting executives to work with QI teams, even as part of major safety initiatives.25 When they do engage, managers have a different outlook on quality and safety programmes to clinical staff, perceiving different components of the programme to be valuable and holding more positive views of the overall results.64 Meaningful input from managers is important for the design, monitoring and evaluation of QI interventions;64 simply obtaining their permission to proceed is not enough.

There is little published work on the role of managers in QI, the majority of which relates only to senior (board-level) managers, rather than the middle managers under their supervision.59 ,61 Importantly, most improvement initiatives fail to specify how they engage these middle managers, with whom front-line staff interact directly and regularly. Middle managers are a particularly heterogeneous group, with diverse professional backgrounds,61 often promoted on the basis of a technical skill set rather than any specific leadership or management ability.65 Many have ‘hybrid’ clinical and administrative duties,61 ,66 with an inherent tension between those roles;67 their decisions are necessarily ‘constrained, contested and political’,68 but favour knowledge drawn from experience rather than research findings.69 ,70 Little more is known about the cognitive biases that affect middle managers’ judgements, but enthusiasm for QI is not automatic. For example, they may feel the operating costs of QI programmes are not justified by any potential future benefits.71 There remains a pressing need for research into how healthcare managers balance their multiple fiscal, statutory and service responsibilities.59

Influencing middle managers to facilitate effective QI: status, incentives and resources

It appears, then, that managers contribute to organisational quality; that their active involvement in QI has been taken for granted rather than proven; and that their decision making relating to QI is likely to be complex, with conflicting priorities that are not easily resolved. Yet middle managers, in particular, are uniquely placed to facilitate effective QI. They have the power to accelerate or impede the implementation of innovations,61 mediating organisational messages for front-line staff, but also upwardly influencing their seniors to draw attention to the high-level support needed for specific QI programmes.72 ,73 Acting as information brokers, translating organisational strategy into actionable tasks, and promoting innovative practice, middle managers can convince clinical staff to prioritise QI implementation among numerous competing demands.61

Harnessing middle managers’ ability to broker organisational and front-line attention to a QI programme may prove essential to its success: proactive commitment from middle managers does influence effective QI implementation.74 Although many advocate a clinician-led, ‘bottom-up’ approach to improvement,75 staff-driven initiatives that do not align well with strategic priorities have only limited impact or longevity.71 ,76 ,77 Clear tensions emerge when QI efforts are delegated entirely to clinicians without support for their direction and goals.71 Without more senior support, front-line staff are unable to marshal the resources required to spread change,78 and managers have an important role to play in navigating cross-departmental obstacles.59 Managers who effectively facilitate QI, without micromanaging it, are well appreciated by front-line staff.78 The subsequent pace of change may be slow, but a combination of top-down and bottom-up implementation results in a lasting impact.78

Senior managers play a role in determining middle managers’ commitment to QI. These senior managers should directly emphasise QI as an organisational priority, incentivise QI commitment in performance reviews, and—vitally—make available the necessary resources.72 In addition, encouraging middle managers to leverage the human resources and performance reviews at their own disposal also improves their commitment to QI implementation.72 Interestingly, a performance-related human resources management framework for clinicians has recently been described and implemented, encountering little of the expected physician resistance.79 Transparent negotiation of QI goals at each organisational level may therefore be feasible and necessary for high quality implementation.

A model of alignment for successful QI

We suggest that neither clinicians nor managers can make meaningful QI progress in isolation: their collaboration is fundamental to sustainably embedding practice innovations. The choice of a QI intervention, and its implementation model, both need coordination between clinical and managerial teams. We have discussed, in the preceding sections, how each group might be motivated to take part in this process. Yet their efforts need to be aligned, if QI is to form a significant part of their workload, and not be overwhelmed by other priorities.62 We highlight some examples of QI programmes in which the degree of collaboration between front-line and managerial staff may have contributed to the ultimate outcome (table 1). In trials reporting significant improvements, investigators ensured there was adequate managerial participation—or took on managerial roles themselves—to complement clinical involvement.11 ,12 ,15 ,80 Similarly, implementation and spread of a QI intervention in a real-world setting was best accomplished with the co-leadership of top-level administrators and front-line champions.78 Where managerial engagement was lacking, interventions did not improve outcomes significantly, or systems defects did not prove amenable to the efforts of clinical teams alone.13 ,17 ,81

With this in mind, we propose a simplified model for successful QI interventions (figure 1). This model emphasises, foremost, that QI interventions aiming to change healthcare providers’ practice should aim to meet the aligned needs of staff at multiple levels in the organisation. Failing to coordinate these interests renders interventions susceptible to failure, regardless of enthusiasm and engagement at the other organisational levels. In fact, the degree to which an intervention recognises, makes use of, or conflicts with existing staff priorities is fundamental to its success, and should not be considered in the accompanying implementation strategy only. This pre-emptive consideration of where an intervention is likely to garner support, and the conflicts that need to be resolved to allow wholehearted participation, reflect the ‘practical wisdom’ thought to be a critical element of successful QI.82 Throughout this narrative literature review, and reinforced by our recent practical experience (box 1), we identified specific facilitators that coordinate clinical, middle management and senior management participation in QI. To build a useful model, we then separated these factors into incentives (establishing each group's QI participation as a core expectation of their work) and actions (specific actions by that group that make QI implementation more effective). We also highlight important barriers to aligned QI, again identified from the narrative synthesis. For facilitators and barriers, we focused deliberately on modifiable factors, with a view to building a valid model that has immediate application in practice. Importantly, the inclusion of managers as core members of the QI team may augment what is actually ‘modifiable’: changes that remain frustratingly out of reach for clinical QI teams81 may fall within the remit of an expanded clinical-managerial group.

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Figure 1

The model of alignment. Strategically selected quality improvement targets and interventions successfully align the interests of clinicians and non-clinicians at multiple levels within the organisation. At each level, staff engagement with these interventions is facilitated by deliberate incentives to prioritise it, the recognition of competing priorities and barriers to involvement, and actions to address them.

How could this model be used in practice? Prospectively, clinicians and managers jointly establish and prioritise the challenges facing their service. Multidisciplinary tools systematically collect data relevant to front-line care delivery problems (from staff and patients).83 ,84 Teams then assess and rank the apparent safety threats, for example with streamlined versions of tools like Healthcare Failure Modes and Effects Analysis or Hierarchical Task Analysis.81 ,85 These tools inform the strategic selection of high priority targets for local improvement efforts.

Interventions are co-designed or adapted with clinicians, with a focus on the quality strategies for which effectiveness and implementation evidence is strongest. Clinicians’ participation is supported, recognised and rewarded, perhaps as part of a formal performance management process. Middle managers coordinate alignment of the improvement efforts with organisational goals, and are themselves heavily incentivised to see QI facilitation as a core role of their own. Influencing their supervisors to attract organisational support and resources for QI efforts, middle managers’ interest in quality is further reinforced by protected board time for quality issues, and board-level use of quality metrics. Board members may need to robustly engage with other stakeholders in the local healthcare economy to generate (and protect) an institution-specific quality strategy.

The model can also be used retrospectively, to describe how interventions were implemented in practice, and to explain their effects. We use the model to explore a recent interdisciplinary intervention in our own institutions, describing mutable influences on staff over the course of a trial (see box 2). Definitive progress on a number of key issues occurred only when front-line staff and middle managers agreed the need for change.

We feel the proposed model of alignment is a useful, novel concept for a number of reasons. First, it emphasises the need to go beyond clinical engagement. Second, it highlights the role of non-clinical staff in sustaining effective QI. Most importantly, it integrates separate literature streams on clinical and managerial influences on QI, lending itself to the prospective design of interventions as well as the retrospective analysis of why they achieved their goals or not. Interestingly, multilevel interventions (explicitly addressing patient, professional and organisational factors, for example) show the most consistent improvements in process and clinical outcomes.86 The model of alignment suggests how we might incorporate a similarly multifaceted approach into the design of any new QI intervention. Other authors have recently raised concerns about ‘colliding’ QI interventions, conceived in isolation but effectively competing in a limited marketplace.87 Our model encourages a broader analysis of the environment into which any new QI intervention is launched.

We hope this model will prove useful for future interventions, which will need to more explicitly link their assumptions with underlying theory.88 However, it does not negate the value of existing models, which remain well placed to structure QI reporting and evaluation.21–23 The model of alignment was derived from a narrative review of the literature, drawing on prior systematic reviews,31 ,59 and tested retrospectively against the experience of implementing a single intervention. It requires more empirical validation, particularly in the prospective design of novel interventions. Lastly, though parsimony is necessary for a ‘good’ theory of context,88 the model of alignment may be too simplistic for some analyses.