Sixty percent of top quality leaders in health care are seriously concerned about building a culture of accountability and transparency in their organizations.

IHI recently conducted a survey of 90 US quality leaders to find out more about the challenges they’re facing. Leaders in a convenience sample responded from health systems, primary care practices, and standalone hospitals. Whether they’re managers, directors, senior directors, vice presidents, or chief quality officers, these health care leaders are facing pressures in many directions: lowering costs, improving population health, and managing their health system’s reputation in the age of online reviews.

Here are some of the issues these leaders are grappling with:

• Culture is a big issue, just as it is in safety: 60 percent of senior leaders — quality vice presidents and C-level quality officers, especially — reported concerns about building a culture of accountability and transparency. One CQO said that staff buy-in is still a huge issue at her ACO. “People take seemingly harmless short cuts, but that causes drift,” she said. “We really need nurses involved in quality — they should be joined at the hip.” Quality leaders can help develop a culture of transparency and accountability by embedding quality improvement methodology and training into every level of work, as the East London NHS Foundation Trust has done with impressive results.
  
• The CQO is also seen as a key player in navigating the transformation from volume to value. The vast majority of organizations represented in the survey — 43 of the 46 organizations — are taking on some kind of financial risk for improving health and lowering costs for their patients. Forty percent of respondents said reducing costs is a major challenge, and 70 percent reported that they’re just beginning or have moderate experience with adopting new payment models and reducing costs. One vice president, who reports in to the CMO/CQO and heads up the medical group, felt his team is making progress. They realized that the value of the population health department is to help primary care practices stratify patients by risk, including rising risk and high risk, to help them focus resources on the people who need it most. “After a few more projects, we can say, ‘here is what we’ve seen work.” A key part of promoting the transition from volume to value is setting up a measurement system to support population health.
  
• Many of the respondents felt that their organizations were experienced or even expert at developing QI capability. But the next frontier is developing a true quality management system with robust data collection, a method to spread best practices from successful QI initiatives, and improving the reliability of care. About 60 percent of respondents said managing data collection and reporting were major concerns. In a recent white paper, the IHI innovation team presented a framework for how to manage quality at every level of a health system, from the front line to senior leaders.

• Finally, quality leaders are also facing the challenge of inspiring change among people who are increasingly burned out. The CQO at one health system in Pennsylvania said, “All [primary care doctors] want to do is take care of patients. … Their hearts and minds are engaged, but they don’t understand MACRA and the complexity of the calculations. They just want to know what to do to perform well.” She felt it’s her team’s role to re-engineer the practice workflow so that providers can focus on patients and not worry about how they code.

It was clear from the survey that the person responsible for quality in an organization varies widely, and is often shared across multiple leadership roles, such as CMO or CQO.

But no matter their title, the leaders who are held accountable for quality within health systems are playing an increasingly critical and challenging role. To be effective, they must be equipped with technical knowledge of quality improvement methodology as well as an understanding of the human side of change.

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