Q&A: Quality Improvement Program

Quality Improvement Program provides tools for lifelong learning

In 2020, CPSO launched its Quality Improvement (QI) Program for all physicians in Ontario. In transforming our approach, we’ve moved from a single point in time assessment model to a proactive approach. The core principles for our QI Program are:

1. A philosophy of assessment that focuses on continuous improvement 
2. Use of a platform that supports and integrates with physician needs and practice demands 
3. A proactive approach that facilitates interaction and self-reflection and strengthens practice

CPSO’s suite of QI tools are designed to allow Ontario physicians to engage in self-reflection and practice improvement while meeting their quality requirements in five-year cycles.

The two QI Program streams at the CPSO align and fulfill our QI requirements. In addition, physicians participating in a CPSO Quality Improvement Program are eligible to claim CPD credits through the CFPC or the Royal College Maintenance of Certification program . This new program replaces our existing random peer assessment program for those under age 70. Those invited to participate in the QI program always have the option to defer for one year. And if there are other barriers for physicians in participating in the program, we want to hear about it so we can help. 

The program is operated through an online Learning Management System, developed by the CPSO. Each learning module has been tailored to fit our new philosophy: self-directed physicians reflecting on their own delivery of health care and looking at data about their practices in relation to their peers and the associated standards of practice. These activities include chart review, peer feedback, setting goals, and outlining a plan for practice improvement. This process allows us to connect with more physicians, more regularly, in a more meaningful way — creating the conditions most favourable to ensuring their success at all stages of their career.  

Below we talk to CPSO Medical Advisors, Dr. Mary Manno, an Oakville family physician, and Dr. Ted Everson, a Mississauga emergency physician and family physician, about the College’s QI Program.  

Can you give us a broad overview of what the new QI program is?
MM: The new QI program takes a proactive and needs-based approach to Quality Improvement rather than a QA approach which tends to be reactive and “one size fits all”. We plan to engage with each physician every five years through the QI program. QI is known to shift the quality curve over time. 

Can you tell us more about the Hospital Partnership Program? 
TE: CPSO partners with hospitals to develop and align QI initiatives for eligible hospital-based physicians reducing administrative burden on physicians by streamlining quality requirements for hospital-based physicians. The Partnership Program recognizes the oversight that already exists for hospital-based physicians and the quality activity they may already be doing. Eligible hospital-based physicians use the individual tools from the Learning Management System rather than submitting a PIP, as they work on their hospitals’ quality initiatives. 

What are physicians saying so far about the new QI program? 
MM: Most find the Program interesting and valuable: here is an opportunity to step back from the pressures of daily patient care and look objectively at one’s own practice of medicine, exemplifying continuous, lifelong learning.  

Can you elaborate on the feedback?
MM: Well, we have had more than 2,000 physicians engage in the program and overwhelmingly, physicians who completed the program have described it as a worthwhile, rewarding experience — even those who were skeptical at the outset. 

Some comments we have heard include: 

“On the whole, it was a very worthwhile experience and made me honestly reflect on my practice and future plans to practice safely. I would recommend it to anyone and would gladly partake again.” 

“I am glad to be part of it; it was quite a learning experience with a great opportunity for self-reflection.” 

“It was quite insightful on ways that I could help myself as well as my patients.” 

 “Helped me structure some of my goals and set timelines/ develop strategies for changes so that they were more concrete.” 

How do you respond to those physicians who suggest such a program is a burden on an already packed schedule? 
TE: We recognize physicians are busy and are feeling stretched. When we developed the program, we deliberately looked at ways to reduce duplication of physician efforts. Participating physicians can fulfill their CPSO Quality requirements, claim CPD credits and, in the case of the Partnership Program, meet any quality activity/patient safety requirements their hospital may have as part of their annual reappointment process. By streamlining the quality requirements for hospital-based physicians with a single oversight quality program, participants will save time and reduce administrative burden. And we are hearing that many physicians are grateful for the opportunity to really reflect on their practice and identify gaps of where they can improve.  

How many physicians do you expect will participate in 2021?
MM: We plan to have another 3,000 physicians in the QI for individuals’ program, as well as engaging 20 hospitals in the partnership program. We are expanding from 1,600 in 2020 to 3,000 in 2021 and we are expanding the group of selected participants to include some non-hospital-based specialists, such as pediatricians and psychiatrists. 

Can you explain how this program aligns with the way physicians work?
MM: In everyday practice, we routinely use data to assess the patient’s current state (e.g., blood pressure readings) and compare to a gold standard (e.g., CHEP guidelines), looking to identify areas for improvement. The QI Program uses the same process on a practice level to guide continuous improvements in care. 

 It is only in the last five years or so that QI principles and their implementation have been included in the training of physicians. It can be challenging to think in QI terms at the practice level when we are used to focusing on the patient in front of us. QI asks us to look at the forest, while we are most comfortable looking at trees, or even leaves. 

TE: For the Partnership Program, physicians can collaborate with their hospital colleagues on QI initiatives that are relevant to their hospital practice and align with the strategic direction of their organization. 

Can you please explain the self-directed aspect of the work and why it was considered to be crucial to the success of the QI Program?
MM: The Program’s online activities are evidenced-based and designed to help participants know themselves through critical reflection. This will enable them to determine their own improvement needs, formulate goals, identify resources for learning, choose and implement appropriate strategies, and evaluate the outcomes. 

“This will contribute to improved quality of care, patient safety and help to reduce physician burnout.”

Physicians enrolled in the QI for individuals stream are required to submit a Practice Improvement Plan (PIP). Can you describe what a physician’s PIP might look like?
MM: Most PIPs contain two or more goals for improvement, at least one of those being data-driven and focusing on improving patient care. Goals are developed and structured using SMART (Specific, Measurable, Achievable, Relevant and Timely) criteria because research shows that improvement goals are more likely to be achieved if they are data-driven and SMART.  

Can you provide an example?
MM: Yes, a family physician uses data from her Screening Activity Report (SAR) from Cancer Care Ontario (CCO) and observes that the mammography rate in her practice is 50 percent, falling well below the Ontario average of 65 percent. She structures a goal for improvement: interventions could include educating target patients with respect to benefits and risks of breast cancer screening; communicating with patients regarding their screening status; and any other mechanisms to promote and enhance uptake of mammography. At the end of the 12-month intervention period, the screening rate will be reassessed (outcome of the intervention) and used to inform ongoing improvement strategies. 

Who sees the submitted PIPs?
TE: The practice improvement plan is reviewed by a QI coach, all of whom are physicians and educators. 

How have the activities developed originally for primary care been adapted to meet the needs of physicians working in other capacities?
MM: The QI Program is evolving in order to support the QI needs of all CPSO members.  

For medical psychotherapists, for example, there may not be as many sources of practice-level data from third parties, such as CCO.  However, there are always other opportunities. For example, could more patients benefit form cognitive behavioural therapy? How about looking at gaps in immunizations for pediatricians?

What happens if physicians need more support?
TE: In many cases, one-on-one coaching is provided to participants who need support with their quality improvement goals. Coaches will discuss how to develop and refine QI goals to make them more achievable.  These one-on-one interactions are supportive interactions — they are not assessments. Physicians also have an option of calling and speaking to a Medical Advisor prior to engaging in the work. People may not have the experience in identifying a SMART Goal — and we can help with that. Upon submission of QI work, we are intersecting with almost 20 percent of participants to help them identify a clear goal to make them achievable. On the rare occasion the QI Program is not able to adequately support the physician in their quality improvement activity, a focused assessment may be recommended by CPSO’s Quality Assurance Committee. 

Can you please describe how this program fits into our right-touch regulation approach?
MM: Right-touch regulation in the world of quality improvement is a proactive opportunity to engage with the profession using QI tools to ensure lifelong learning. Helping physicians reflect on their own practice is an opportunity for physician-driven improvement. We are currently working with the OMA who is interested in building a suite of QI tools that will be accessible to physicians.  

TE: In addition, for the Partnership Program, it is recognized that physicians already have existing oversight within the hospital environment and as part of their privileging process. Right-touch regulation is about keeping it simple, not adding layers. 

The QI Program launched a week before the World Health Organization declared the pandemic. How did the Program adapt?
MM: The impact of COVID-19 on CPSO members has varied. Early in the course of the pandemic, some participants found they had more time to complete the online activities because they were conducting fewer patient visits. As time wore on, some physicians were experiencing higher demands on their time and energy, requiring them to defer their participation. We give every physician the option to defer this for a year.  And again, if there are other barriers for physicians in participating in the program, we want to hear about it so we can help. 

Have you gone through the QI program yourself? If so, were there any new insights about how you practised?
TE: Yes, I completed the QI Individuals Program. As practicing physicians, we all frequently have ideas and interests in modifying and improving our practice, but do not necessarily get around to actioning them. The Program helped support me in developing and implementing a medication review QI project focused on minimizing medication interactions and adverse effects. 

How much of an impact will this program have?
TE: The redesign of our Quality Programs provides physicians options to do QI that is relevant to their clinical practice and decreases redundancy in meeting professional requirements that already exist. This will contribute to improved quality of care, patient safety and help to reduce physician burnout. The format will allow us to interact with more physicians, more frequently than was possible through our previous program.  

MM:  I am confident that widespread use of the quality improvement skills embedded in the CPSO’s QI Program will result in significant benefits to patients, providers, their staff and, ultimately, the healthcare system itself. 

The QI Program Overview

The QI Program is operated through an online Learning Management System (LMS), developed by CPSO to engage physicians in quality improvement. This learning module has been tailored to fit our new philosophy around quality improvement: that it should be self-directed and focus on physicians reflecting on their own delivery of health care, looking at data about their practices in relation to their peers and the standards of practice, and developing practice improvement plans that will help strengthen the great work they’re already doing. 

The QI program is comprised of multiple parts. Here is an overview of each: 

• The QI Survey is a questionnaire that provides the College with current, detailed information about a practice. The information disclosed is used by QI program staff to better understand a physician’s practice and may be used in combination with the Practice Improvement Plan to assist in implementing ongoing QI.  
• The Practice Profile is an independent self-assessment designed to educate physicians about the evidence-based risk and support factors that could impact their practice. The Practice Profile’s aim is to provide resources to help reduce risk and enhance positive practice.  
• The Self-Guided Chart Review allows physicians to engage in self-guided learning to enhance their compliance with the CPSO’s Medical Records Documentation policy. This self-directed chart review engages physicians in both self-reflection and conversations with their peers when developing a practice improvement plan.  
• The Data-Driven Quality Improvement tool is designed to get physicians looking at their own practice data to reflect on how they deliver health care to their patients and to identify opportunities for improvement.  
• The Practice Improvement Plan is to be completed by physicians in the Individual stream. In their Practice Improvement Plans, physicians identify areas of strength and areas for potential improvement in their practice. After the completion of this activity, the practice improvement plan will be reviewed by a physician QI coach.  
• One-on-one Coaching will be available when appropriate. QI coaches will offer the necessary knowledge, skills, and tools to coach physicians as they complete the various tools in the program and develop their own practice improvement plans.