The role of the Chief Quality Officer

There is a common saying that you hear a lot these days, "If you've seen one hospital's organizational structure, you've seen one hospital's organizational structure!"  Having worked at two independent, free-standing children's hospitals, two children's hospitals affiliated with adult health care systems, and three military hospitals (you'd think they would be structured the same, right?), I can say for certain that this statement is absolutely the case!  While not universally true, the typical executive positions (Chief Executive Officer, Chief Operating Officer, Chief Financial Officer, Chief People Officer, Chief Nursing Officer, etc) are generally quite similar from hospital to hospital.  In contrast, the Physician Executive role varies the most from hospital to hospital.

Some physician executive positions have the same role but with different titles in different organizations - Chief Medical Officer, Chief of Staff, and Vice President of Medical Affairs are three common examples that typically cover similar roles.  However, at times the scope of a position with the same title (Chief Clinical Officer, Chief of Staff) may differ significantly between different hospitals.  Things get even more confusing when you start to look at academic medical centers.

One role that I am seeing more frequently at hospitals is the position of Chief Quality Officer (CQO).  I found an interesting article in the Journal of Healthcare Management (from a few years ago), "Winning at Quality and Safety: Do You Need a Chief Quality Officer".  The author, John Byrnes, first asked whether the CQO needed to be a physician.  He believed that it did, though in full disclosure, he is a physician.  His main justification is that "physicians are more open to advice and recommendations from peers and colleagues."  Given that 80% of clinical quality and costs are directly impacted by the decisions made at the bedside or orders written by clinicians, having a respected colleague and peer advocate for standardization and evidence-based care, both of which are associated with better quality and lower costs, is very important.  While I agree that physicians respond better to colleagues than other clinicians (and even more so compared to health care administrators), I think Dr. Byrnes discounts too much the care that nursing and allied health providers provide - they have a huge impact on quality and cost too!  In addition, advanced practice providers (nurse practitioners and physician assistants) make clinical decisions and can write orders (the extent of the order varies from state to state), so they have to be convinced to standardize and follow evidence-based guidelines too.  

Regardless of who is in the role, Byrnes suggested that the role of CQO is a full-time job that requires a full-time commitment.  He also provided what I thought was an excellent road map for the first 5 years or so of a CQO's tenure.  

1. Design a quality and safety program that adopts the same level of discipline and vigor as your financial management system.  Byrnes recommends embedding quality and safety into the organization's strategic plan.  Quality and safety metrics should feature prominently in the annual goal and incentives for every leader throughout the organization. 

2. Establish quality and safety reporting with the same scope as your financial reporting system.  In my experience, the hospitals that are close to being High Reliability Organizations are the ones where the executive leadership team and board pay just as much time and attention to quality and safety metrics as they do the financial ones.  

3. Develop a safety program that eradicates preventable errors.  There are a number of evidence-based, best practices for reducing the likelihood of errors at the bedside.  CQO's should be well-versed in safety science, and these error-prevention techniques should be taught to all clinicians and employees at the organization.

4. Improve clinical outcomes by eliminating preventable complications, readmissions, and mortality for your 20 to 30 most common diagnosis-related groups.  Every organization has about 30 diagnoses that cover 70-80% of their patient population.  These are the diagnoses that are most amenable to standardization and evidence-based care through clinical practice guidelines.  

W. Edwards Deming, one of the leading figures in the early years of quality improvement, said, "It is not enough that top management commit themselves for life to quality and productivity.  They must know what it is that they are committed to - that is, what they must do.  These obligations cannot be delegated.  Support is not enough; action is required."  Having a CQO working directly with both the hospital's executive leadership team and the board to set the right tone and keep quality and safety top of mind is foundational to becoming a High Reliability Organization.