The Exec: In Quality Improvement, 'Focus on a Finite Number of Priorities'

In quality improvement initiatives, empower frontline leaders to help inform the priorities, chief medical officer says.

The biggest quality improvement initiative at UNC Hospitals has been advancing the journey to high reliability, says Chief Medical Officer and Vice President of Medical Affairs Thomas Ivester, MD, MPH.

Ivester has been chief medical officer and vice president of medical affairs at UNC Hospitals since April 2017. Previously, he served as medical director and physician service leader for obstetrics at UNC Hospitals, based in Chapel Hill, North Carolina.

HealthLeaders recently talked with Ivester about a range of topics, including his top challenges at UNC Hospitals, quality improvement, and patient safety. The following transcript of that conversation has been edited for clarity and brevity.

HealthLeaders: What are the primary challenges of serving as CMO of UNC Hospitals?

Thomas Ivester: The general challenges of chief medical officers tend to be that we are often saddled with vast areas of responsibility such as quality and the medical staff. At the same time, we don't always have clear lines of authority, especially since employment relationships can be different and different areas of the organization have different reporting relationships. In addition, we don't often have purview over revenue-generating activities, which can hinder our influence.

At UNC Hospitals, I have a couple of challenges. One is we have grown significantly over the past couple of decades, and our organizational structure particularly on the medical staff side has not necessarily kept up in terms of modernizing. That is a priority for me—getting the medical staff better organized to execute.

At the same time, we have also grown substantially as a system, which means governance over our big priorities is informed and influenced by a lot of other entities that were not a part of us 20 years ago. There are several positives that go along with that, but it also introduces several challenges in terms of governance and decision-making.

HL: How have you risen to the challenge of organizing the medical staff?

Ivester: We have done several things. One of my first activities was to revamp and standardize the job descriptions of each level of medical directorship and physician service leader at the institution. I had to make those job descriptions and their associated responsibilities and lines of accountability clear.

I have also had to engage an effective cascade throughout the medical staff to make sure that organizational priorities are disseminated all the way to the front line and that we are also being informed by what frontline leaders are observing and having a pathway of getting it back up to the senior levels of the organization.

Another key strategy is learning to delegate more effectively, and that is a skill that I am still learning. We need to enable and empower a group of lieutenants to help to execute and lead strategy across the multiple domains that I have to oversee.

HL: How have you risen to the growth of the organization and the challenge of governance?

Ivester: I have been forging relationships with my CMO colleagues across the health system, so that we can connect one-on-one or in small groups. We also convene as a larger group at a monthly roundtable to discuss topics that cut across our organization, to present ideas and to work together to solve challenges.

Thomas Ivester, MD, MPH, chief medical officer and vice president of medical affairs at UNC Hospitals. Photo courtesy of UNC Hospitals.

HL: What are the keys to success in implementing quality improvement initiatives?

Ivester: One of the keys for us has been to focus on a finite number of priorities. That relies upon the principle that we truly believe we can do anything, but we certainly cannot do everything. So, we need to select the right priorities and de-select the priorities that are not right for the moment.

We also work diligently to empower our frontline leaders to help inform the priorities. We try to enable those local leaders to identify and select their local priorities from our broader strategy, so initiatives are much more relevant to the folks that they are overseeing at their local unit, clinic, or area of service.

Finally, the engagement piece is critical. We do that by supporting the work of frontline leaders including our medical directors with project resources. We set clear expectations. We provide the right data at the right time. We make commitments that last longer than the current fiscal year.

HL: Give an example of a quality improvement initiative you have been involved in at UNC Hospitals.

Ivester: Our biggest quality initiative has been the launch of what we call Carolina Quality, which is our multi-year strategy that forms the foundation of our journey to high reliability. This is based on a full commitment to the tenets of just culture, daily huddles, leadership rounds, and safety reporting. This is all supported by a robust data strategy and ongoing optimization of care team and patient experience.

This is the biggest quality initiative in our history, and it is based on things we already do. We just need to do them better and in a more integrated way.

HL: What are the keys to success in implementing patient safety initiatives?

Ivester: In a lot of ways, they are similar to implementing quality initiatives. Oftentimes, our safety initiatives are focused on faster, more agile decision-making and change management. That requires gathering a guiding coalition, with clear accountability and expectations as well setting timelines for execution.

It is also important to continually remind folks of the "why." There must be a compelling reason for doing what we are doing. The "how" becomes infinitely easier if you can get people to understand and buy into the "why."

HL: Give an example of a patient safety initiative you have been involved in at UNC Hospitals.

Ivester: Probably the most important thing for us was implementing our daily safety huddles. We did this a couple of years ago in the middle of the pandemic. This has been a fantastic platform, and we borrowed ideas from many colleagues across the country to develop our system. It starts in the morning with more than 300 Tier 1 safety huddles taking place across the entire medical center. They are escalating issues around operations, quality, and safety to a Tier 2 huddle that involves director-level leaders across the institution. Ultimately, it culminates in our Tier 3 safety huddle that occurs daily at 10 a.m. and involves every member of our executive team hearing every escalation from the preceding 24 hours.

We have demonstrated that we are able to solve between 85% and 90% of escalated issues within the same day, often within just a few hours. Every other issue is resolved within one to two weeks, or it is converted into an improvement project.

Along with the huddles, we have instituted a formal mechanism for managing the array of root cause analyses that are taking place across the institution, so that performance is being monitored and we are executing with far greater fidelity through enhanced accountability.

HL: You have a clinical background in obstetrics and gynecology. How has this clinical background helped you serve in physician leadership roles?

Ivester: Having a clinical background does lend substantial credibility to physician leadership roles. Whether you are a CMO, a quality leader, or serving in another role, to be able to demonstrate that you are still rolling up your sleeves and can work alongside colleagues in a clinical arena can be helpful. The variety of my practice in obstetrics gives me insights into several areas. I work in the inpatient setting. I work in the operating room. I do imaging. So, I have insights into the work of clinical folks across the spectrum of clinical venues.

HL: How would you characterize your leadership style?

Ivester: I tend to be relational. I connect directly with people in smaller, more intimate settings where we have an opportunity to get on the same page as well as understand one another's priorities and concerns. I work to find common ground.

I certainly do not mind at all being on stage and trying to rally the troops. I am a visionary person and work a lot on strategy. I try to coalesce people under a unifying vision, but I make sure that vision is not just mine. It reflects the input of folks across a unit or the institution. I want to strike a balance between inclusiveness and consensus. However, there are times when I need to step in and make an executive decision.

Another piece is I put a lot of thought in trying to connect seemingly disparate priorities or areas of work, then try to find a common ground. It has helped me to bring together folks from across the institution, and it gets back to operating under a unified vision or set of goals.

Ivester is a contributor to the HealthLeaders Exchange. The HealthLeaders Exchange community is a private idea-sharing network for senior executives in hospitals, health plans and physician organizations. To join, please visit the HealthLeaders Exchange LinkedIn page.

Related: The Exec: Transparent Leadership Crucial Element in Physician Engagement