I think this requires a change in mindset in two key areas, firstly that physicians’ role is more than just delivering the technical aspects of medicine and, secondly that quality and safety is the main criteria in customer service in healthcare.

Practically, one way to do this is to educate all physicians in the concept of Clinical Leadership. It develops the above mindset as well as promoting clinical governance.

If the physician is not interested in the quality of his/her activities, he/she obviously has made a false choice of the profession and more or less nothing can be done about it. Principally the responsibility remains at the level of the head of the department - he/she must take care, that the results are appropriate and require corresponding level from his/her coworkers.

The whole issue is not as easy as thought, as a rule you can distinquish between structure, prosess and outcome quality, as described be Debenedian ca. 50 years ago and activities/responsibilities in all these aspects are necessary to achieve an overall improvement.

I'm not sure what is meant by "clinical governance", but the centrality of randomly-assigned, controlled clinical trials in proving efficacy/safety/efficiency, and the surprisingly

low rate of RACC Trials supporting most of medical practice is well established (see Tracking Medicine by Jack Wennberg). What is needed is cultural change where physicians practice conservatively when we don't know what we are doing, and a much more vigorous pursuit/support for intervention trials.

Apologies that this is not open access.but the title of my recent thoughts on this I think is relevant

Quality Improvement: The need to believe it is necessary:

http://adc.bmj.com/content/early/2013/11/14/archdischild-2012-303563.abstract

All the best

Damian

Thanks all.

Is there any experience of using a model or tool or scenario to physicians involvement in quality improvement activities?

our clinicians (not all) do not support the activities in hospitals. they don't believe it to work! they don't have the roll of a clinical leader!!

I think the quality improvement need to build a systems which mainly consist of guidelines for each activity regarding health services provision, including all activities of the physicians

Dear Imad,

The system control is only help to improve the process ,and provide more information for the GP in OPD or at CLINIC level.

The procedure to handle patient and diagnostic have to learn from the mentor or the senior supervisor , when you are still a MO. But, the experience in diagnostic is very important , this is how the patient perception toward you .

Regards

Realization of impact of" Team -work"' among the stakeholders of hospital is very important. As a team and through integrated approach we provide medical care to the patients and physicians play an important role likewise in the implementation of quality improvement activities they should act as leaders.

Dear Imad, If you need to have good guide for clinical quality improvement programme , you can try our web site : Academy of Family Physician of Malaysia . The stage one QC process are available could be free of charge .

Formal quality is often seen by the most of physicians as a burden, an extra work, an innecesary task surrounding thing that matters: the clinical practice ( under their point of view). As you can observe this problem is worldwide...

There are not magic recipes. In my experience one way to solve this issue is creating leading groups Taking ordinary physicians, no need the best ones, but with good prestige among their colleagues and involving them in a education programme (no only theorical but visiting and sharing quality initiatives that work in your organization). The idea is that this physicians put into their practice quality actions experiencied in their education (no needed a lot, a few and with no great efforts) becoming a living example among colleagues. Part of them should be trainers of others an so an so.

My experience is that the problem you describe is common in most industries with a large number of highly educated experts. They often choose their education because of an interest in the subject, may it be medicine, engineering or some other area of expertise.

In small expert organizations the management problems are small, they can be solved by gathering the staff, and discussing the problems. As the organization grows the problems grow exponentially. As a consequence of the advances in medicine and the increased knowledge and new methods of treatment many health care organizations are today very complex organizations. The complexity makes it difficult to understand the logic driving the organisation, creating well functioning patient processes, handling problems of queues and overcrowding and so forth.

The classical approach to adress the problems is to say that "all we need to do is to make the experts interested in the problem", in this case doctors. It worked when the organisation was smaller, why does the strategy not work now?

Well it does still work for local problems, that can be solved locally. It does not work for more complex problems such as structural problems, and or process problems that involve several departments. In my experience these are the main issues that have to be adressed in a patient-centric approach to the design and delivery of care.

Most of the quality improvement work I have seen, if done correctly, works on a local level, but the methodology does not bear the solutions for structural problems, something else is needed. To address the structural problems requires more knowledge (expertiseI) in areas such as production management, logistics, supply chain management and so forth. An area that has its own experts.

So what you need to use the old approach is a person with double expertise, which is not possible, due to lack of time. What you end up with if you try is an expert in medicine with some knowledge of management, or an expert in management with hopefully some knowledge of medicine, which is not good enough, both are needed to make it work.

So the trick is to bring two different types of experts into the equation and make them work together. My experience is that this combination is successful. Physicians are well educated and critical to new management practices, and often they are right in their scepticsism. Compared with other industries there is a lack of operations management expertise and many new initiatives are consultancy driven, and with a lack of the right competence. From my point of view the problem is not primarily the physicians but the management expertise.

Empower them and incentivise them

Paul,

What type of incentive do you propose when dealing with physicians?

Hi Mohammad,

We did some work in South London back in the 1990's on engagement with the then newly emergent CG agenda. We found the approach to be effective but intensive. I have uploaded the report to my page if you are interested see:

Smith et al. (1999) Implementing policy in complex organisations: Participatory planning in Clinical Governance education. Faculty of Health and Social Care Sciences, Kingston and St George's University of London.