The Essentials of QI: It Starts with Leadership — A Conversation with Dr. Eric Howell

SHM’s Center for Quality Improvement is the hospitalist’s home for quality improvement (QI). QI became a foundational theme for SHM early in the growth of hospitalists. It’s not a coincidence that many of our leaders, such as Bob Wachter, Win Whitcomb, Greg Maynard, and Mark Williams are QI leaders as well.  As hospitalists, we were and are best positioned to impact quality in the hospital.

The Center provides a comprehensive set of resources and programs to support hospitalists and other hospital clinicians as they work to improve quality and safety in their hospital. SHM’s Mentored Implementation (MI) is one example of how hospitalists are supported to facilitate systems change and improving hospital outcome, in which SHM pairs a hospital team with a physician mentor. The MI model is an evidence-based framework developed to support QI teams via planning and implementation of interventions. Mentored Implementation programs and resources have been implemented in hundreds of US hospitals to improve quality and safety for patients.

Recent mentored implementation projects include opioid prescribing and monitoring through our Reducing Adverse Events Associated with Opioids (RADEO) program and improving the care of glycemic inpatients through the Glycemic Control Mentored Implementation Program. Presently, 18 hospitals are enrolled in the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) Mentored Implementation program. The hospitals are implementing key interventions to improve their medication reconciliation practices and reduce unintended medication discrepancies. The AHRQ funded SHM I-PASS Mentored Implementation program in 16 hospitals to improve handoffs of care and reduce medical errors. This is just a small sample of the over 20 active projects in The Center.

Dr. Eric Howell serves as the Senior Physician Advisor for The Center, while Jenna Goldstein runs the day-to-day aspects of The Center at SHM headquarters. I discussed The Center with Dr. Howell by phone a couple of months ago. We discussed how he started in QI, the role of SHM’s Center, and how hospitalists can receive effective QI training. The following Q and A is edited for conciseness and clarity. This is part 1 of the conversation, focusing on quality improvement. Part 2 will follow tomorrow for more about The Center.


You’ve been a leader in QI for many years; how did you get started in QI?

I trained as an electrical engineer before I went to medical school, which helped me when I went to residency. When I was a chief at Hopkins Bayview in 1999, there were a number of systems-related issues, including throughput from the Emergency Department. I became involved with QI because I looked at these systems, thinking they could be better if I used the lens of an engineer. The hospital was very interested in reducing costs, and the physicians, including myself, were interested in making things safer. I was successful because I didn’t just focus on QI, but on both sides of the value equation. In the early 2000s, I started to do more and more reengineering and system improvement projects, and I found them very rewarding. As I showed some success, I was asked to do more QI.

What you are describing is hands-on training: learning by doing. It seems a lot of your QI training was hands on as opposed to structured coursework. Was there formal training? Or is getting your hands dirty in a project the best way to start learning QI?

There is no replacement for actually doing it. My training was in leadership, which is an integral part of QI. It’s pretty hard to get people to change for quality if you can’t lead them through that change. Initially, I did a lot of work to improve my leadership potential. As faculty, we taught teaching skills, which is a part of leadership. I spent time teaching residents best practices. That’s why I became involved early on with SHM’s Leadership Academy from its start in 2005. I also read a lot of books and still read often to improve my weaknesses. I have my own physicians go through Lean Six Sigma training, get their green belt or black belt. But there is no substitute for doing it, and as they say, “bruising your knuckles” in QI.

Culture and change management are essential aspects of QI. I don’t think I hear that enough to start with leadership and similar skills.

Change management is part of the essential elements for QI training. Remember the story of Semmelweis? He was basically a QI doc, but he failed, even though he had the tools and the data to make things better. Why? Because he couldn’t lead the change. Eventually, he was kicked out of the hospital. He died insane and penniless.

In addition to leadership and change management curriculum, are there formal QI training courses that you would recommend to those starting out, within or outside of SHM?

SHM’s Leadership Academy is something I will always recommend. It will make sure you are not a Semmelweis and can lead through change when you have the supporting data.

One of the great things about The Center is that I started off as relatively junior improvement person but was able to advance thanks to mentors. I started in transitions of care before it became known as “Project BOOST” and partnered with folks like Mark Williams and Greg Maynard. From these mentors, I learned how to truly “do” QI. I received a grant through the Hartford Foundation and grew along with BOOST as this became a juggernaut of hospital medicine QI.

What are some books you that you are currently reading, or that you recommend for others around QI?

  1. I still think Good to Great by Jim Collins is still a great book. I recommend it all the time. It talks about Level 5 leadership, and QI is essentially leading through change.
  2. Another book that is simple, that transformed my life years ago, is Getting to Yes, penned by Roger Fisher and William Ulry. That really helped me figure out how to negotiate more effectively. Negotiation skills are critical to leading through change.
  3. A recent book I like is The Signal and the Noise by Nate Silver. It talks about how to find information in an environment that could be “noisy.” I think that’s important in QI because there is a lot of noise when we are trying to look for a signal. I think administrators often confuse noise for signal. And physicians often refuse to believe that what is a signal is a signal and try to attribute it to noise.
  4. The one I’m reading now is Hidden Figures by Margot Lee Shetterly.
  5. Another one I also recommend Give and Take by Adam Grant. It’s about people who are givers. You know them – they give all the time, but don’t get anything in return. There are takers – people who take and are self-centered and are burned out. And then there are matchers: people who will give you something only if you give them something first. And it turns out that people who are least and most successful in life are the givers. And the people in the middle are the matchers and takers. It’s changed my outlook on how I interact with people who are givers and takers and matchers.

**Thanks to Jenna Goldstein, Director of SHM’s Center for Quality Improvement, for providing insight and overview of the Center.

Jordan Messler

Jordan is a hospitalist at Morton Plant Hospitalists in Clearwater, Florida. He currently chairs SHM’s Quality and Patient Safety Committee. In addition, he’s been active in several SHM mentoring programs, most recently with Project BOOST and Glycemic Control. He went to medical school at University of South Florida, in Tampa, and completed his residency at Emory University.

He recognizes the challenges of working in a hospital that lines the intracostal waterways of a spring break mecca. Requests that if you want to be selected as a mentored site, you will have a similar location with palm trees and coastline nearby. He tries to find time to sit on the beach with his family to escape the hospital’s miasma. While there, he looks forward to reading about the history of hospitals/medicine, and how it relates to quality (Anti-UpToDate reading material). But inevitably will get a five year old dumping sand on him, and then has to explain why she is buried up to her neck.

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