Successfully Leading Quality and Safety Initiatives in the Clinic

"Patience, Persistence, and Pivoting"

Have you ever tried to implement quality and safety initiatives, such as incident learning or prospective risk analysis, in your clinic? Did you identify great ways to improve quality and safety, but no one ever changed their practice? It takes unique leadership skills to motivate and sustain change. What are the secrets to effectively implementing safety initiatives? The AAPM Work Group on Prevention of Errors in Radiation Oncology asked Todd Pawlicki, one of the leading physicists in quality and safety, to share his experiences, insights, and tips for success.

You have successfully built a quality and safety program in your department. What was your approach?
We have a unique situation here in the sense that when I came to UC San Diego, the Chair was rebuilding the department so including quality and safety management naturally fit in. Partly because of my background, I thought that quality and safety was something we should emphasize from the beginning. Then, it was just a matter of finding the opportunities to introduce structure, tools, and techniques along the way.

What are the biggest challenges to implementing changes?
If you're trying to implement something new, whether it's new equipment, a program, or tool, then you have to be aware of the clinic's ability to assimilate and implement the change. It's easier to motivate people if you're addressing an acute safety-critical issue or an actual event. For example a wrong site treatment becomes a lever to get a multidisciplinary group focused on making changes. Most of the time we're not dealing with actual incidents like that. We are trying to incrementally improve our processes, so you have to be aware of whether the clinic is ready at a particular moment to engage and implement a change.

Participating in new quality and safety initiatives requires time and effort. How do you overcome that challenge when staff already have full workloads?
Additional time and effort is a real concern. Your response, especially if you're in a leadership role, can't be, “well I know it's more work but it's really important.” We only have so many hours each day to get things done. You can't just add more work on everyone's plate and not expect them to feel the stress. If you do that, you'll likely put the whole clinic in an even more unsafe state than it was before. There must be a balance between improvement efforts and routine clinical work. If you can find ways of changing what they do so that the net amount of work is roughly the same pre- and post-intervention, then you have a real shot at making it stick.

Patience and persistence are the two characteristics that will help you along the way. You always want to move things forward as soon as possible, but sometimes you can't do that, so you need patience. At the same time, you don't want to take your eye off of the long-term vision of what you want to achieve. That's where persistence comes in. It's a lot more difficult than it sounds.

How do you motivate staff to comply with new changes introduced in the clinic?
It's helpful to be aware of some change-management strategies. There are people in the department that aren't in leadership positions but that others look to for what is acceptable and unacceptable. You should find out who those folks are and get them on your side. It's also beneficial to create a long-term vision of why you need to make a change. This helps people look past the bumps in the road during a change event.

The other thing to remember when implementing a change is that you should be comfortable with the fact that you're likely not going to get it right on the first try. Keep everyone informed that you're not going to give up if the change effort doesn't work perfectly the first time. You want to communicate that we plan to make the change, but then we're going to evaluate the change and make adjustments if it's not working.

If the clinic knows you're listening and you're willing to pivot, to make changes based on their input, towards a more appropriate and sustainable solution, then you're earning their trust along the way. Over time, people will be more willing to give whatever change you're recommending a chance because they know that you're not going to be wedded to a solution that may not be workable or preferable for them. As long as the final implementation achieves your long-term vision, then you have success.

What advice can you give to people who want to implement a new quality and safety initiative, but aren't in a leadership position?
That can be challenging but I think you need to find out where your boundaries of control are. In general, most people have more control than they realize even if they're not in an official leadership role. They just don't exercise it in the right way.

If you want to implement a broad process change or a broad quality and safety tool, then you have to be prepared that it may be a longer sell. Finding some early allies in a particular area can be helpful. Try to be clear about your long-term vision or implementation plan, and why you think it's important. Be prepared for pushback. You'll likely need to modify your ideas based on their concerns [pivot] and then come back around to sell it again at a later time. Being successful at change is all about relationships, and the strongest relationships are built on respect and trust.

Even if you're the one in charge, you're not really in charge. Especially with a physics team— you have a lot of incredibly bright and motivated people who have their own ideas. Being in the leadership role doesn't mean that they're just going to do everything that you want them to do. So what you do to successfully implement a new quality and safety initiative is basically the same whether or not you're in a leadership role. You really have to cultivate buy-in. In order to get buy-in, you need to have built good relationships. The only difference about being in a leadership role is that you will be able to implement the change faster than if you're not in a leadership role.

Safety culture is an important aspect of a quality and safety program, but can be difficult to create. How do you establish and maintain safety culture across an entire department?
What I've tried to emphasize for myself over the years is a focus on people: to care about how people are doing, are they happy at work, are they stressed out or frustrated. This applies not just to physicists but to others in the department as well. As you begin to engage with them, hear their issues and try to make improvements, what you're doing is team building and that improves safety culture. When you feel comfortable in a team, you can talk more openly about difficult or challenging topics.

You're also very involved in numerous national societies. Can you share what is being done at the national or international society level to support quality and safety?
There is a lot going on but I can highlight some areas that I'm aware of. The IAEA hosts courses for developing countries to share quality and safety tools as well as good clinical practices. The IAEA also has SAFRON, an international incident learning system. ESTRO has the Radiation Oncology Safety and Quality Committee (ROSQC), which developed and hosts the ROSEIS incident learning system. ASTRO has one of its councils dedicated to quality and clinical affairs (the CAQC) and the Chair and Vice-Chair of ASTRO's councils are also a member of ASTRO's Board of Directors. Out of that council comes APEX accreditation, ROILS in collaboration with AAPM, and practice guidelines. The CAQC also has the multidisciplinary QA committee that is working on “Safety is no Accident”, ASTRO's guidance document for quality and safety in radiation oncology. And of course, the AAPM has the Workgroup on Prevention of Errors and other really great efforts such as Dr. Bruce Thomadsen's task group on incident narrative formatting. There are other AAPM efforts that may not be directed at quality and safety but will have a large impact there. Specifically, I'm thinking about MP3.0 and the future of physicists in medicine.

Is there anything else you would like to emphasize about leading quality and safety efforts?
I think medical physicists need to treat quality and safety as an active area of research. While TG-100 was a wonderful document for pointing our quality and safety compass in a new direction, it emphasized three quality and safety tools to the exclusion of dozens of others. This has created a hyper-focus on those three tools, as opposed to focusing on the overall direction and letting the research identify the best tools and strategies to improve quality and safety. The tool used makes a difference in the results. We need to identify the best tools for the job.

Quality and safety is accessible to everyone because it's intuitive. While it's great to have opinions, the solutions need to come from the application of the scientific method to quality and safety. There are so many areas that are wide open for research to help get us to that next level. My hope over the coming years is that there will be a lot of research in many different directions that culminates into guidelines and best practices for raising all clinics to the highest possible level of quality and safety.

Editor's Note: The opinions expressed in this interview are that of Todd Pawlicki, not necessarily the WGPE. An invited editorial on this topic has been submitted to the Journal of Applied Clinical Medical Physics.