The Role and Function of Quality Assurance Officers in Ontario Hospitals

Transcription

1 The Role and Function of Quality Assurance Officers in Ontario Hospitals Kent V. Rondeau* and Nareshwar Birdi Department of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada T2G 2G3 Summary This article examines the role and job function of quality assurance officers in hospitals in Ontario, Canada. Results from a mail questionnaire suggest that hospital quality assurance professionals in our sample are much more likely to be female, at mid-career, and to have advanced graduate degrees, although most lack professional certification and formal training in quality management. Although the job duties of hospital quality assurance professionals are broad and varied, many report being engaged in traditional quality assurance managerial activities including hospital accreditation efforts, risk management assessment, and patient satisfaction measurement. Coordinating quality assurance activities, performance reporting, and leading the Total Quality Management (TQM)/Continuous Quality Improvement (CQI) initiative remain central functions associated with their work efforts. Nevertheless, limited formal training in the principles and methods of quality management and improvement may be placing significant constraints on their effectiveness. Copyright # 2005 John Wiley & Sons, Ltd. Key Words: hospital quality assurance officers; job role and functions; education and training of quality managers Introduction There is widespread agreement that adequate, appropriate training of quality professionals is essential to the development and implementation of effective quality management systems. Yet, as quality management principles and practices are becoming widely integrated into organizational activities, the role and responsibility of the quality assurance officer is changing and evolving. One perspective on the future of quality assurance professionals suggests that *Correspondence to: Kent V. Rondeau, Department of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada T2G 2G3. kent.rondeau@ualberta.ca their actions in the pursuit of quality improvement will increasingly become more indistinct from the usual activities performed by departmental managers. It is expected that regular line managers will subsume more and more of the roles once performed by quality professionals. As quality improvement becomes institutionalized as a preferred way-of-life in many organizations, the actions and functions traditionally performed by the quality manager may be seen as redundant. In a world where increasingly quality is everyone s business, the role of the quality manager is changing, and not always for the better. In some organizations, the quality professional is still the individual in charge of a team DOI: /qaj.335

2 180 K.V. Rondeau and N. Birdi of inspectors where management remains committed to the notion that quality must be inspected in. In other places, the role of inspector has been handed over to production or operations, requiring them to become data collectors and performance monitors. Yet in other organizations, the quality manager s job has moved into human resources and training for quality improvement. Nevertheless, for a variety of reasons the total elimination of the job of quality assurance officer is probably unlikely in the future. New roles and responsibilities will most likely emerge to reflect both the art and science of quality improvement. Quality managers will increasingly be required to achieve competence in the softer humanistic skills that focus on leadership, team building, and interpersonal relationship building, while becoming content experts in the philosophy, tools and techniques of quality assurance, quality management, and continuous quality improvement. Quality managers must be seen to support directly the primary aims of the business enterprise. They will be unable to unilaterally impose change plans on the organization, but rather they will be required to persuade and facilitate change led by others. Hind [1] suggests that for quality managers to be successful in the future they will need to move from being functional specialists to internal consultants. Effective skills at consultancy require the quality manager to facilitate change without taking control of it. A typical quality manager in healthcare has a complex function with diverse responsibilities that encompass the clinical as well as the administrative. The exact role of these individuals is rapidly changing and evolving as technology and new forms of work organization emerge and diffuse into healthcare institutions. Waddell and Mallen [2], in reviewing the changing role of quality assurance managers for the twenty-first century contend that such individuals will increasingly need qualifications and expertise in general management and leadership, engineering, psychology, adult education, sales, and customer service if they are to be effective in the future. In spite of the importance of the role of quality professionals to the management of quality, there are very few comprehensive studies that are directed at understanding the role and function of the quality manager. Within healthcare establishments, there is virtually no research concerning the typical career path, education, training or job functions of the quality professional. It is generally assumed that hospital quality professionals have a strong knowledge of the various health products that are produced as well as the organizational processes that are responsible for their production. Unlike some other industries, in healthcare this requires an extensive knowledge in clinical as well as administrative subject areas. It also requires a high degree of knowledge and skill in the philosophy and practice of contemporary quality assurance and improvement techniques. Healthcare quality managers have three main sources of education: (1) continuing education programs in quality management offered at a variety of colleges and universities, (2) seminars provided by a host of quality consultants, and, (3) professional training and certification programs, such as the American Society for Quality (ASQ) [3] and the National Association of Healthcare Quality (NAHQ) [4]. In addition, there is a very large practitioner literature on quality management and improvement subjects that has emerged in the past decade, providing a rich source of information for self-education of quality professionals. Yet, our results suggest that few quality professionals in healthcare organizations are taking advantage of opportunities to increase their knowledge and skills in quality management. This limited and uneven training of quality principles for quality professionals undoubtedly undermines efforts by organizations to effectively implement Total Quality Management (TQM)/ Continuous Quality Improvement (CQI) initiatives. The deficiency in formal quality-related education and training for quality officers is also evidenced in the organization s line managers where too few have received adequate training in quality improvement principles and practices, even after the wide-scale implementation of TQM/CQI in the past few years [5 7]. Service

3 The Role and Function of Quality Assurance Officers 181 industries, including healthcare, often lag behind other sectors in their commitment to providing training in support of TQM/CQI. In one of the few studies that have examined the training and development needs of quality managers, Stewart and Waddell [8] report that for Australian quality professionals, the current training and development regime does not adequately equip quality managers to perform their roles competently, [contributing] to the failure of many quality improvement programs and systems [p. 38]. In their sample of 235 quality managers, 483 courses had been taken by these quality professionals over the preceding five-year period. The majority of these courses were short in duration (29% were of eight hours or less), with the most frequent quality-related training topics focused on general management, quality principles/practices, internal auditing, and quality tools and techniques. Nevertheless, the study showed that one in five quality managers had undertaken no training in the past five years, while too few quality professionals were providing training to their line managers. Given the changing role of the quality professional in most organizations, it is essential that we gain insight into the evolving job functions of the quality officer in contemporary healthcare organizations. The healthcare industry has witnessed unprecedented change in the past decade. The pursuit of quality in the healthcare marketplace is of emerging importance. To date, we have a paucity of knowledge about the changing role, job function, and educational background of the healthcare quality professional. The purpose of this paper is to report on the job roles and functions of hospital quality managers. If healthcare quality is to be effectively managed and improved, their contributions will be seminal. Method Survey participants and procedure In January 2004, a survey questionnaire was sent to the executive director (or site administrator) in 125 acute care hospitals in Ontario, Canada. These individuals were asked to forward the questionnaire to the person most responsible for the quality assurance function in their establishment. Surveyed institutions were selected on the basis of hospital size. Included in the survey sample were larger hospitals (institutions with 50 or more beds), ostensibly because quality assurance is less a distinct and separate job function in small hospitals. Approval for this study was secured from the Health Research Ethics Board of the University of Alberta. All participants were informed about the nature of the study and that their participation was voluntary, confidential, and anonymous. Six weeks after the initial mailing, the same questionnaire was sent to all hospitals who did not respond to the first mailout. In total, 62 questionnaires were returned. After subtracting seven questionnaires that were returned because of refusal, were undeliverable, or indicated an inadequate response to the questions, 55 hospitals comprised our database, producing a response rate of 46.6%. It should be noted that this response rate may under-report the actual response rate. In a small number of instances, two (or more) survey questionnaires may have been sent to the same organization operating a multi-site hospital corporation. Participating hospitals were examined for non-response bias by comparing early and late responders according to hospital size and location. Early responders (first wave) were found to be statistically different from late responders (second wave) with respect to hospital size, suggesting that our sample may have underrepresented smaller hospitals. Profile of participating hospitals Table 1 provides a review of general hospital characteristics in which our study quality assurance officers work. The mean hospital size is 331 beds. Approximately 58% of these hospitals operate multi-sites. About 8% of our sample are located in rural areas (population under persons), 44% in small cities ( residents), 15% in larger cities ( persons), while about 33% of

4 182 K.V. Rondeau and N. Birdi Table 1. Hospital characteristics our quality assurance officers work in hospitals located in metropolitan areas (populations greater than residents). Approximately 24% of these hospitals are teaching hospitals affiliated with a school of medicine. Most of our study hospitals (98%) are accredited, while 71% have, at some time in the past few years, instituted a formal TQM/CQI program. Results Mean Standard deviation Hospital size (number of beds) Location (1 = rural to 4 = urban) Multi-site facility Teaching hospital Accreditation status Formal TQM/CQI program Hospital quality officer characteristics Table 2 provides a review of general characteristics for Ontario hospital quality professionals in our study sample. Descriptive information of subject demographics, work roles, work intensity, reporting relationships, as well as educational background, and quality-related training are included. Our data suggests that the hospital quality officer s job is predominantly performed by women (89%), at a mid-stage in terms of their career progression (mean age of 44 years), work about 28 hours each week, and have been in their present job for almost four years. Almost three quarters state that their job duties have changed in the past two years. Many report a highly varied work role, one that is increasingly moving them beyond the boundaries of traditional quality assurance. In fact, approximately one quarter state that they spend less than 20% of their work time engaged in traditional quality control duties (such as incidence reporting, accreditation reporting, and risk management functions, etc.), while 41% spend between 20 and 40% of their time doing these traditional activities. N Table 2. Hospital QA officer characteristics Mean N (%) Gender Male 6 (11.5%) Female 46 (88.5%) Age Years in present job 43.6 years 3.6 years Percent workweek doing traditional QA Less than 20% 12 (23.5%) 20 40% 21 (41.2%) 41 60% 11 (21.6%) 61 80% 4 (7.8%) % 3 (5.9%) Direct reporting relationship To hospital board 1 (1.9%) To hospital CEO 25 (47.2%) To hospital senior management 16 (30.2%) To medical director 1 (1.8%) To nursing director 1 (1.8%) To other 9 (16.4%) Multi-site responsibility for QA Yes 15 (28.8%) No 37 (71.2%) Change in job duties in past 2 years Yes 37 (71.2%) No 15 (28.8%) Highest education level attained Graduate degree 40 (81.6%) (Masters, Doctorate) Post-graduate diploma 2 (3.6%) Undergraduate degree 10 (19.2%) Secondary school 0 (0.0%) Professional designation in QA/QC Yes 9 (16.4%) No 40 (72.7%) Hours of quality-related training h in past 2 years None 11 (27.5 h) 1 15 h 8 (20.0%) h 9 (22.5%) h 4 (10.0%) More than 45 h 8 (20.0%) Quality officers in Ontario hospitals have a variety of reporting relationships, with many (47%) reporting directly to the chief executive officer (or site administrator), and about 30% report directly to the senior management of the hospital. Almost 30% of respondents state that they are responsible for the quality assurance

5 The Role and Function of Quality Assurance Officers 183 function at more than one site (multi-hospital system). Most hospital quality professionals have achieved a high level of formal education: 82% report having achieved graduate degree training at the masters or doctoral level. However, the level of professional certification and training in quality assurance is less impressive, with only 16% having attained a recognized designation in quality management. Quality professionals in our study sample report that they have received about 23 hours of quality-related training in the past 12 months. However, 28% of our quality officers received no training in quality-related topics over this time period. Of those persons who have received no formal quality-related training, only one has attained professional certification. Quality managers in our study sample who acquire more job-related training in quality assurance are more likely to have achieved a higher level of formal education. Hospital quality officer job functions Quality managers in Ontario hospitals report a high degree of variation in the nature of their responsibility for different job functions (see Table 3). Not surprisingly, quality managers are required to perform a diverse coterie of administrative and clinical tasks and duties, given the highly generalized objective of quality management in the hospital setting. Quality managers in our sample report having primary responsibility for several traditional job functions, including hospital accreditation (55% of respondents), quality staff supervision (50%), quality improvement planning (49%) and patient satisfaction tracking and measurement (47%). The highly inter-dependent nature of their jobs requires them to work closely with other healthcare managers and professionals. Shared job responsibility is more often seen in those activities that cross departmental/functional boundaries or for those that have a highly specialized clinical knowledge component in addition to the managerial and administrative aspect. Shared job responsibilities of hospital quality managers are found to be highest in the job functions of program evaluation (60% of respondents), utilization data and measurement (55%), risk management and assessment (53%), and quality assurance policy enforcement (52%). Hospital quality managers report higher levels of no responsibility for such mandatory clinical functions as health and safety compliance (36% of respondents), death and autopsy reporting (38%) and for infection control and management (47%). Approximately 56% of our hospital quality officers state that they have no responsibility for physician profiling, an activity Table 3. Hospital QA officer job functions Respondent perceptions (%) Statement about job function No responsibility Shared responsibility Primary responsibility Hospital accreditation Risk management assessment Patient satisfaction measurement Planning for quality improvement Incidence reporting Enforcement of QA policy Leading QA initiative Staff training in quality control Utilization data and measurement Supervision of quality staff Program evaluation Health and safety reg. compliance Death and autopsy reporting Infection control Physician profiling

6 184 K.V. Rondeau and N. Birdi associated with determining the amount of resources that hospital-based physicians consume. (It should be noted that an indication of no responsibility means the activity is done by another individual or the function is not performed in that organization.) Not all job functions, duties, and activities that hospital quality professionals perform are of equally high priority. Quality officers were asked to identify the top five activity areas from the thirteen identified areas that could constitute the bulk of their work (see Table 4). Hospital quality professionals report the following work activities have high priority in their daily work affairs: coordinating activities (57% of respondents), leading the TQM/CQI initiative (54%), reporting performance (50%) and analyzing Table 4. Hospital QA officer major work activities (N=54) % indicating top five work activity Mean Standard deviation Coordinating activities Leading the TQM/CQI initiative Reporting performance Analyzing (QA/QI) data Planning quality initiatives Converting attitudes Coordinating teams Ensuring execution of corrective action Encouraging innovative ideas Writing technical reports Enforcing policy Supervising staff Training staff data (46%). Quality managers in our sample report a low priority for traditional human resource functions such as training staff (6% of respondents) and supervising staff (11%). Hospital quality officers also report low priority for enforcing quality-related policy (15% of respondents) and for writing technical reports (19%). Results of correlation analysis Bi-variate correlation analysis allows us to examine the direction and magnitude of association between two variables. A simple correlation matrix has been constructed (see Table 5). Results from this analysis suggest that quality managers in our sample who have had the longest tenure in their present jobs are more likely to work in larger and urban hospitals ðp50:05þ, yet have received less quality-related training the past two years ðp50:05þ Nevertheless, hospital quality officers in our sample who work more hours per week performing their quality assurance functions are also more likely to report having received more qualityrelated training in the past two years ðp50:05þ Hospital quality managers, in our sample, who have received a professional designation or certification in quality assurance or quality control are more likely to be found working in larger hospitals ðp50:05þ to have received more quality-related training ðp50:05þ while hospital quality officers working in larger establishments are more likely to have received more qualityrelated training in the preceding two year period ðp50:05þ Table 5. Selected correlation results correlation matrix Job tenure * * 0.23 * Work intensity * Education level QA/QC designation * * Quality training * Multi-site QA Hospital size ** 0.60 ** 8. Hospital location ** 9. Teaching hospital 1.00 n p nn p50.01.

7 The Role and Function of Quality Assurance Officers 185 Discussion and Conclusion Results from this research study suggest that hospital quality assurance professionals are involved in a variety of roles and functions. For the most part, their job duties remain historical and traditional (i.e. hospital accreditation, risk management assessment, incidence and performance reporting), yet there is some evidence that a number of new roles and duties are beginning to emerge (i.e. planning and leading the quality improvement initiative, and staff development activities). Nevertheless, the majority of the functions reported by hospital quality professionals too often remain more administrative than clinical, suggesting that the role of persons doing quality management work in hospitals are engaged more in managerial and administrative data collection and reporting. Our results suggest that although hospital quality professionals (at least in the Canadian province of Ontario) have advanced academic preparation at the graduate level, their training in quality principles and practices seems not to be overly extensive. For hospitals engaged in implementing TQM/CQI, this lack of knowledge of quality principles by quality professionals may serve to seriously compromise the success in its deployment. This may be particularly problematic in smaller hospitals where many long-tenured healthcare quality professionals demonstrate significantly less formal education and training in quality principles and practices. The results from this study remain somewhat exploratory, as to date there has been a paucity of research on this topic. Some limitations of this research should be noted. First, our sample set is quite small (N ¼ 55), making statistical significance difficult to establish. Second, our sample of hospital quality professionals is drawn from Ontario, Canada, so our data may not be representative to other industries or jurisdictions. Nevertheless, our findings remain remarkably consistent with those characterizing Australian quality managers, as reported by Stewart and Waddell [8]. Finally, results reported here do not assess the overall effectiveness of the job that is presently being performed by hospital quality managers. Given their existing job functions, roles and preparation, assessments of hospital quality officer s job effectiveness would help us understand which individual and job-related factors contribute to their ultimate success at work. References 1. Hind M. Quality managers, from functional specialist to internal consultant. Training Qual 1995; 3(2): Waddell D, Mallen D. Quality managers: beyond 2000? Total Qual Manage 2001; 12(3): [26 April 2005] [26 April 2005]. 5. Chen IJ, Coccari RL, Paetsch KA, Paulraj A. Quality managers and the successful management of quality: an insight. Qual Manage J 2000; 7(2): Mathews BP, Ueno A, Periera ZL, Silva G, Kekale T, Repka M. Quality training: findings from a European survey. TQM Mag 2001; 13(1): Kanji G, Asher M. Education and training for total quality management. Total Qual Manage 1993; 4(Supp): Stewart D, Waddell D. Future considerations for the training and development of Australian quality managers. TQM Mag 2003; 15(1):37 42.