OLP Final Report Mandy Lowery Lead 640

SUPPORTING PHYSICIAN PARTICIPATION 1
© Mandy Lowery, 2015
SUPPORTING PHYSICIAN PARTICIPATION IN
ORGANIZATIONAL IMPROVEMENT INITIATIVES
By
MANDY LOWERY RN
Higher Diploma in Health Studies, Teesside University, 1999
An Organizational Leadership Project submitted in partial fulfillment of
the requirements for the degree of a
MASTER of ARTS
in
LEADERSHIP – HEALTH
We accept this Final Report as conforming
to the required standard
Astrid Levelt MSc. Project Sponsor
Tony Williams PhD. Academic Supervisor
Brigitte Harris, PhD. Committee Chair
ROYAL ROADS UNIVERSITY
August, 2015

Executive Summary
Providence HealthCare (PHC) is a non-profit, faith based organization and an affiliate of
Vancouver Coastal Health (VCH) Regional Health Authority. PHC has 16 sites, St. Paul’s
Hospital (SPH) being the largest. SPH is a 450-bed acute care academic teaching facility situated
in downtown Vancouver, British Columbia. Physician leaders are influential and have
considerable impact on decision-making processes at PHC; they have the ability to lead, support
or discourage the advancement of change (Baathe & Norback, 2013, p. 480; Lingdren, Baathe &
Dellve, 2013, p. 138).
“Change in healthcare, relating to quality improvement (QI), is imperative for staff within
organizations to practice, and maintain, the highest possible standards” (R. Carere, personal
communication, July 13 2014). In order for change initiatives to be successful however,
collaboration and agreement with the entire team is necessary. Physicians are an important part
of this collaboration. However, physician engagement, participation and collaboration in QI
initiatives are a challenge, not just for PHC but also in many health systems.
This study sought to find out why, and what encourages and prevents physicians from
collaborating on quality initiatives. In preparation for this inquiry, members of the senior
leadership team (SLT) at PHC were interviewed. Several shared the same concern, highlighting
physician participation and collaboration as an area for improvement.
Given that one of several challenges in ensuring optimal implementation of QI initiatives
is effective, and sustainable participation of physicians and physician leaders is key, this inquiry
addressed the readiness of the Medicine Program at SPH to support physicians in participation in
QI initiatives by addressing the following question:
What strategies can the Medicine Program at St. Paul’s Hospital adopt to optimize
physician participation in quality improvement initiatives and processes?
The sub-questions were:
1. What barriers limit consistent physician participation in quality improvement
initiatives?
2. How do physicians want to participate in quality improvement initiatives?
3. What recommendations and suggestions do physicians have that can be incorporated
into practice?
To inform the inquiry, a literature review was conducted. The first topic examined was
physician participation, collaboration and engagement in healthcare improvement. This review of
the literature identified existing barriers to participation and highlighted opportunities for change
(Snell, Briscoe & Dickson, 2011; Baathe & Norback, 2013; Lindgren, Baathe & Dellve, 2013;
Cherry, Davis & Thorndyke, 2010; Clark, 2012 and Milliken, 2014). The second topic reviewed
was quality improvement and organizational change in healthcare. The review demonstrated that
the literature supports advancement in healthcare through introduction of QI initiatives, and
introduced concepts that included readiness for, and resistance to change (Goodman & Loh,
2011; Holmboe & Cassel, 2007 and Walsh, Ettinger & Klugman, 2014).

In order to answer the research question, methods from both quantitative and qualitative
traditions were used, and specifically applied using an action research (AR) methodology. AR is
a participative approach and its purpose was to engage the physician group identified as
stakeholders. To answer the research question, an electronic survey followed by four narrative
inquiries in a sequential priorities research design (Morgan, 2014) was used. For the survey, a
purposive sample of 70 attending male and female physicians, from within the SPH Medicine
Program was used. Inclusion criteria were (a) remunerated through fee-for-service, (b) attached
to internal medicine including its clinical teaching unit (CTU) and visiting specialists. Exclusion
criteria were (a) physicians in residency programs on a different remuneration scheme and (b)
physicians outside of the Medicine Program specialties. Three physicians self-nominated and one
other lead physician was invited directly. AR is predicated on foundations of democracy, justice
and freedom of participation and throughout the inquiry the requirements of the Tri-council’s
policy statement on research ethics were adhered to (Canadian Institutes of Health Research, Tri-
council policy statement: Ethical conduct for research involving humans, 2010).
The survey and the narrative inquiries brought out the following findings:
Survey finding #1: The timing of meetings related to QI is integral in determining
consistent participation.
Survey finding #2: Lack of time and conflicting workload is the main barrier to consistent
participation.
Survey finding #3: The majority of respondents agreed that geographical placement of
physician teams could improve participation in QI.
Four themes emerged from the analysis of the narrative inquiry data.
1. Authoritative, non-collaborative communication between leadership and
administration leads to inconsistent and in some instances non-existent physician participation.
2. Remuneration structure and compensation, physician recognition and physician
availability are factors influencing participation among physician leaders.
3. System structure, inter-team collaboration and relationships and appropriate
stakeholder involvement are factors that affect consistent participation in QI.
4. Overall physician culture negatively affects physician participation in QI.
As the findings from the survey and the narrative inquiries were collated the following
conclusions arose:
1. Early and detailed communication is imperative in optimizing physician participation
in quality improvement initiatives.
2. Relationships and teamwork and an integrated work environment contributes to
effective physician participation.
3. The current physician remuneration and recognition structure at PHC are disincentives
to physician participation in quality improvement initiatives.
The research findings have the potential to positively impact PHC from a perspective of
organizational learning by enabling consistent physician participation in quality improvement
initiatives.
The findings from an analysis of the data led to the following recommendations.

1. Invite, communicate and collaborate with physician leaders early when adopting and
implementing organizational change initiatives.
2. Build a work environment conducive to relationship building and teamwork.
3. Consider a compensation and recognition scheme for physician services related to
organizational change.
If physician participation is to improve, any and all change strategies must incorporate
the voice of the physician. The implications of not adopting this approach would mean quality
and other initiatives would continue to have minimum support at best, and open sabotage at
worst. The recommendations are derived from a collaborative process with physician leaders and
their ownership of the recommendations might promote sustained change among their peers.
These recommendations may invoke broader change among other disciplines. They may forge
new linkages and collaboration, reduce resistance to future change initiatives, promote regular
discussion, even dialogue, and identify early adopters as points of leverage for encouraging
commitment to initiatives. Implementing these recommendations can be achieved by small
incremental steps, but for them to be integrated into the operations and the culture of the
Medicine Program at SPH, it will require ‘persistent’ be added to ‘small incremental steps’.
This study shows that physician participation is imperative in the overall success of a
healthcare organization. PHC could advocate that physician participation is essential, and not
optional, among physician leaders and make concerted efforts to facilitate this participation. This
study identified some of the ways to achieve this, by creating a climate of engagement, and
offering resources and incentives that encourage physician involvement across the board (Snell
et al. 2011, p. 960). Conversely, if Canadian healthcare systems continue to believe that
physician participation in quality improvement initiatives is optional, the current state of minimal
program participation by physicians will persist. When considering change in any healthcare
organization, the ultimate focus however, should be on the benefit to the patient, though
consideration must be given to all affected stakeholders (Langley, Moen, Nolan, Nolan, Norman
& Provost, 2009, p. 110).

Acknowledgements
This learning journey, culminating in the Organizational Leadership Project has been an
enormous part of the last two years of my life. I have been encouraged and supported by many
and would like to take this opportunity to express my sincere thanks.
To cohort 2013; you are an amazing group of people without whom, I doubt, I would
have gotten this far. To the Health Leadership faculty at Royal Roads University; your ongoing
passion and belief has inspired me beyond words.
To the project participants; my utmost gratitude for your precious time, participation and
for your honesty. Without your participation and suggestions, the Medicine program would not
have been able to consider a new way of being. My hopes are that I have been able to represent
your thoughts clearly.
To Tony; you have been a supportive and encouraging advisor. Without your guidance
and clear direction, I’m not sure I would have managed to get to the end, thank you. To Astrid,
Rich and Claire, my inquiry team; although small in number you were more than generous in
your advice and support throughout this process. Rich, your encouragement was unfaltering.
Cheers.
And finally, my biggest thank you goes to my wonderful husband, Shaun and daughter,
Lauren. You have cheered my accomplishments, offered me shoulders to cry on when things
were not going so well, but above all have been, and continue to be, my unwavering fan club.
You both reminded me that time would fly by and you were right. I’m finished, it’s done! I love
you both. Thank you from the bottom of my heart.
It’s been a crazy but immensely rewarding couple of years.
‘Life Changing’ in fact!

Table of Contents
Executive Summary .................................................................................................................... 2
Acknowledgements ..................................................................................................................... 5
List of Figures ............................................................................................................................. 8
Chapter One: Focus and Framing................................................................................................ 9
Significance of the Inquiry................................................................................................... 13
Organizational Context ........................................................................................................ 14
Systems Analysis of the Inquiry........................................................................................... 17
Chapter Summary................................................................................................................. 20
Chapter Two: Literature Review............................................................................................... 22
Topic One: Physician Participation in Quality Improvement .............................................. 23
Physicians as part of the team. ........................................................................................ 23
Physician leaders and physician champions.................................................................... 25
Barriers to physician participation. ................................................................................. 28
Topic Two: Quality Improvement and Organizational Change in Healthcare .................... 31
What is QI in healthcare?................................................................................................ 31
The role of teamwork in QI............................................................................................. 32
Readiness and resistance for change in QI...................................................................... 33
Chapter Summary................................................................................................................. 34
Chapter Three: Inquiry Approach and Methodology................................................................ 35
Inquiry Approach ................................................................................................................. 35
Project Participants............................................................................................................... 37
Inquiry Methods ................................................................................................................... 39
Data Collection Methods...................................................................................................... 39
Study Conduct...................................................................................................................... 41
Data Analysis ....................................................................................................................... 45
Ethical Issues........................................................................................................................ 46
Chapter Summary................................................................................................................. 48
Chapter Four: Action Inquiry Project Results and Conclusions ............................................... 49
Study Findings...................................................................................................................... 50
Study Conclusions................................................................................................................ 70

Scope and Limitations of the Inquiry................................................................................... 76
Chapter Summary................................................................................................................. 77
Chapter Five: Inquiry Implications ........................................................................................... 78
Study Recommendations...................................................................................................... 78
Organizational Implications ................................................................................................. 84
Implications for Future Inquiry............................................................................................ 86
Report Summary .................................................................................................................. 87
References ................................................................................................................................. 89
Appendix A – VCH Engagement Strategy ............................................................................... 96
Appendix B - Providence HealthCare Organizational Chart .................................................. 101
Appendix C – Providence Healthcare Mission, Vision and Values........................................ 102
Appendix D – Inquiry Team Member Letter of Agreement ................................................... 103
Appendix E – Sponsor Email Invitation with Survey Link .................................................... 105
Appendix F – Survey Questions.............................................................................................. 106
Appendix G – Survey Information and Consent Letter .......................................................... 110
Appendix H – Email Invitation Letter..................................................................................... 112
Appendix I – Narrative Interview Consent Form.................................................................... 114

List of Figures
Figure 1. Systems diagram ……………………………………………………………………...18
Figure 2. Respondent age ranges ………………………………………………………………..51
Figure 3. Specialities of respondents…………………………………………………………….51
Figure 4. Length of time at SPH ……….………………………………………………………..52
Figure 5. Traits of a physician role model ………………………………………………………53
Figure 6. Preferred time of meetings ………………….……………………………………….. 54
Figure 7. Traits of a physician champion ………………………………………………………. 55
Figure 8. Strategies to optimize participation …………………………………………………...56

Chapter One: Focus and Framing
Healthcare organizations perpetually face the need to initiate, implement and sustain
change in process, culture and strategic direction (Armenakis, Harris & Mossholder, 1993,
p.681; Choi & Ruona, 2011, p. 46; Goodman & Loh, 2011, p. 242). “Change in healthcare,
relating to quality improvement (QI), is imperative for staff within organizations in order to
practice, and maintain, the highest possible standards” (R. Carere, personal communication, July
13 2014).1 Although external system-wide QI initiatives can be mandated by the Ministry of
Health (MoH), members of the healthcare team themselves often identify QI projects, which will
improve the patient experience in the populations their organizations serve, whilst adhering to
best practice guidelines.
In order for these initiatives to be successful, or addressed and considered an option for
trial in the acute healthcare setting, collaboration and agreement with the entire team is necessary
(Goodman & Loh, 2011, p. 242). “Involvement of those…affected by [any] change is essential;
utilizing their expertise in the initiative will allow for… participation and ownership” (M.
Wilson, personal communication, May 20, 2014). Having worked as a nurse in healthcare for
over 20 years, and practised both in Canada and in the United Kingdom, I have seen first hand
how challenging physician engagement, participation and collaboration in QI initiatives is in
both health systems.
Employee engagement appears to be the topic of interest in many health organizations.
Terms relating to engagement appear to have become fashionable recently, however “as is often
the case with words that acquire popular currency, they are frequently misused and lose specific
meaning” (Spurgeon, Mazelan & Barwell, 2011, p.114). In business, the term “engagement” is
1 Personal communications are included and provided with permission.

defined around the mutual relationship, where the organization values the employee and the
employee values the organization (Milliken, 2014, p.244). The National Health Service (NHS)
delves a little deeper and defines engagement as:
The degree to which an employee is satisfied in their work, motivated to perform well,
able to suggest and implement ideas for improvement and their willingness to act as an
advocate for their organization by recommending it as a place to work or be treated.
(NHS Employers, 2012).
Maslach and Leiter (2008) define engagement as “an energetic state of involvement with
personally fulfilling activities that enhances one’s sense of professional efficacy (p.498). These
descriptions incorporate personal views of involvement. It is these views of personal
involvement that this study seeks to better understand, particularly as they relate to physicians.
More specifically, instead of using the broader term ‘engagement’, the study will explore
physician participation, a term that I will use interchangeably with collaboration.
Providence HealthCare (PHC) is a non-profit, faith based organization and an affiliate of
Vancouver Coastal Health (VCH) Regional Health Authority. PHC has 16 sites, St. Paul’s
Hospital (SPH) being the largest. I am a clinical nurse leader (CNL) in the Medicine Program at
SPH. The role encompasses leadership of a 26 bed acute unit, one of five within the program.
My leadership extends to collaboration between clinical lead peers, operations and physician
leads. My role includes leadership of allocated nursing staff and coordination of patient care. I
collaborate with all members of the healthcare team, including: patient, nursing, allied health
disciplines and physicians. I have held this position for five years.

My role as action researcher enables my active participation in this inquiry, while
facilitating clarity and resolution around issues identified by the sponsor and other stakeholders
(Stringer, 2014).
One issue in particular came up repeatedly: the minimum involvement of physicians in
initiatives related to quality improvement. In preparation for this inquiry, I interviewed members
of the senior leadership team (SLT). Several shared the same concern, highlighting physician
participation and collaboration as an area for improvement. “Much of the work we… do and/or
improve requires the input of physicians; they play such a pivotal role in the acute care
setting...However, they [physicians] are not as involved as they could be” (C. Elliot, personal
communication, May 18, 2014). It became apparent that a study to investigate the factors that
enabled and deterred physicians from consistently participating in QI initiatives had the support
of leaders in my clinical area. With this information, leaders might then influence the
environment to make consistent participation by physicians relevant, rewarding and convenient.
Many stakeholders are involved in creating, implementing and sustaining new QI
initiatives. These include, but are not limited to, government, patients, nursing staff, allied health
disciplines and of course, physicians. Success requires time, effort and commitment from all
members of the healthcare team, yet achieving effective physician participation and sustained
collaboration is a recurring challenge for many healthcare organizations (Baathe & Norback,
2013, p. 479).
I attend many meetings in my role as CNL; daily meetings to prepare for patient
discharge, weekly meetings to assess needs for difficult to discharge clients, monthly meetings to
review quality and safety initiatives within the program and ad-hoc meetings as needed.
Attending physicians, who’s input at all these meetings is important, are often absent. Without

their voices at the table, the other attendees cannot make decisions relating to patient care or the
advancement of a new initiative.
One important case-in-point are the daily discharge rounds. Daily discharge rounds are
known as TeamCARE. The Medicine Program has worked diligently over the last six years to
perfect TeamCARE with the aim of improving positive patient outcomes. These rounds are
attended by professionals from different disciplines, and are most successful when the whole
physician team attend; in these cases, there is one plan and the entire team hear the plan with
little potential for misinterpretation.
This quality practice relies on optimum participation by representatives from all of the
involved disciplines. It is demonstrative of a broader quality culture where optimal
implementation benefits from full knowledge, support and agreement of the multidisciplinary
team. However, an ongoing challenge for optimal implementation of QI initiatives is effective
and sustainable participation of physicians and physician leaders. Therefore, this inquiry
addressed the willingness and readiness of the Medicine Program at SPH to support physicians in
participation in QI initiatives and responded to the following question:
What strategies can the Medicine Program at St. Paul’s Hospital adopt to optimize
physician participation in quality improvement initiatives and processes?
The following sub-questions were used to provide depth to the inquiry:
initiatives?

3. What recommendations and suggestions do physicians have that can be
incorporated into practice?
Significance of the Inquiry
In 2005, a survey of Chief Executive Officers (CEOs) across North America highlighted
challenges with physician engagement and participation in healthcare processes (Guthrie, 2005).
In response to a question about their top 10 challenges, ranked fifth was physicians and lack of
engagement. In 2009, VCH released an agenda to improve stakeholder engagement, with an
entire section concentrating on physician engagement (Appendix A). Much has been written on
this topic and it is clear that the physician engagement agenda at VCH has much to do (Clark,
2012, p. 437; Hogan, Basnett & McKee, 2007, p. 615; Snell, Briscoe & Dickson, 2011, p. 952).
During my preparation for this inquiry, a number of leaders in SLT cited the inability to
consistently achieve effective physician participation as a major concern. From conversations
with senior leaders, including this study’s sponsor, I determined that the end goal for this inquiry
should be to identify strategies that would encourage physicians in the Medicine Program to
collaborate and participate fully in QI initiatives. As Coghlan and Brannick (2013, p. 55) said,
issues warrant investigation as organizational members identify them. The focus of this inquiry
therefore related to physician participation and collaboration in acute healthcare.
The nature of daily work of fee-for-service physicians is different from salaried
professionals in the other disciplines. Physician work is intense, time-critical, and often dispersed
between hospital, clinics and offices. Creating an environment for physicians to participate in QI
initiatives requires a collective sensitivity, by members of all disciplines, which show that the
host organization welcomes and values physician participation. Baker (2003, p. 12) stated “good
strategic alliances have the potential of multiplying the effectiveness of any organization” and

that mutual ownership of identified challenges, shared between direct care agents and operations,
as well as improvement in communications between the healthcare team are also beneficial.
Key stakeholders within the SPH Medicine Program include, the program director and
operations leader, physician leaders, physicians and physician champions, clinical nurse leaders,
the nurse practitioner, the clinical nurse specialist and medical affairs. Leaders agree that the
absence of physicians in multidisciplinary teams reduces team effectiveness. “The absence of
effective physician engagement is a barrier to team collaboration” (personal communication, R.
Carere, July 13, 2014). “Leadership partnerships based on shared responsibility and
accountability for increasing quality and patient safety, to improve the patient’s care experience
and outcomes” (Buckley, Laursen & Otarola, 2009, p. 24) will directly benefit key stakeholders,
ultimately leading to overall better care for the patient. These stakeholders are not only internal
but external, the latter including other acute clinical programs, patients and their families,
primary care providers and community services.
If this issue is not addressed, the divide between physicians and the remainder of the care
team will remain; if the care team cannot work collaboratively, the quality of patient care and
patient satisfaction will ultimately suffer. “There is no single solution; [however] concentrating
on one aspect of collaboration will [be a significant step toward ameliorating] existing challenges
at PHC (A. Levelt, personal communication, August 13, 2014).
Organizational Context
PHC is divided into seven acute clinical programs. Access Services, (including
Emergency and Intensive Care), Heart and Lung, Maternity and Surgery, Mental Health, Renal,
Urban Health (HIV/AIDS and Addictions) and, the Medicine Program. The Medicine Program is
divided over two sites: SPH and Mount St. Joseph’s Hospital (MSJ) (Appendix B).

SPH is a 450-bed acute care academic teaching facility situated in downtown Vancouver,
British Columbia (Health, 2014). Within PHC, there are approximately 970 affiliated medical
staff members, most of whom are physicians; and close to 100 funded leadership physician
positions. These physician administrator and academic roles are awarded stipends that total $3.4
million yearly and come with contractual expectations stipulated by PHC (A. Levelt, personal
communication, June 13, 2014).
PHC’s Strategic Plan (Providence Health Care Strategic Directions, 2012 – 2015) will
focus on achieving [the] new vision “Driven by compassion and social justice, we are at the
forefront of exceptional care and innovation.” Accordingly, a cultural shift is needed, from an
open ended paradigm, where an assumption that all workers within the organization will attest to
the vision, to one that is more focused and accountable. The goal is for staff at each level of the
organization to understand how they support the organization’s aims and objectives, and how
they can develop activities to achieve them. PHC’s values (HealthCare, Mission, Vision and
Values, 2013) are based around the SISTER acronym; spirituality, integrity, stewardship, trust,
excellence and respect.
To achieve SPH’s strategic objectives and to live into its vision, values and mission, full
engagement of the professions is essential. Physicians play a vital role. Physician leaders are
influential and have considerable impact on decision-making processes at PHC; they have the
ability to lead, support or discourage the advancement of change (Baathe & Norback, 2013, p.
480; Lingdren, Baathe & Dellve, 2013, p. 138).
PHC faces the same challenge identified in the literature: inconsistent physician presence
and ineffective participation in healthcare change initiatives. Choi and Ruona (2011, p.49)
suggested that organizations can only improve through the collaborative actions of their

members. In 2012, PHC’s Gallup Survey interviewed the physician group; 52% (n=544) of the
listed staff responded. The results suggested clear opportunities for improvement relating to
physician engagement; in that 41% of medical staff were actively disengaged.2 There were
various reported reasons and themes for this disengagement; among them, lack of confidence in
physician leadership, lack of respect and support in their roles and an inability to influence
organizational decision making (Gallup, 2012).
Historically, physicians have had greater influence on healthcare organizations through
medical advisory committees (MACs) (Clark, 2012, p. 438; Lindgren, Baathe & Dellve, 2013, p.
140) and have perceived themselves as being in charge of the team. Although a MAC remains at
PHC, corporate leadership teams and boards, which combines lay members with physicians from
varying disciplines, bring a spectrum of expertise to bear on decision making which appears to
reduce the overall influence of the physician voice (R. Carere, personal communication, July 13,
2014).
If physicians are to be more involved in QI initiatives, this perceived lack of input should
be addressed. Snell et al. (2011, p. 959) suggested creating an organizational culture in which
physicians feel they are part of the team rather than in charge of it. However, Schein, (as cited in
Coghlan and Brannick 2013, p. 116), described organizational culture as “patterns of basic
assumptions which have been passed on through generations of organizational members and
which are unnoticed and taken for granted”. This culture may be difficult to change as habits and
values are hard to shift. The interdisciplinary team involved is extensive; any changes that affect
the physician group will affect other stakeholders in the organization. “Everything changes,
everything is connected, pay attention” (Hirshfield, n.d).
2 Disengaged was defined as active emotional detachment and antagonismin the workplace.

Systems Analysis of the Inquiry
The outcome of this inquiry was not only to suggest ways of facilitating physician
participation in QI initiatives in an acute care program, but to suggest ways without requiring
additional resources. Healthcare funding is allocated to VCH from the MoH and VCH allocates
approximately 25% of that budget to PHC; this funding is then strategically assigned to the
various acute care programs.
The executive committee (a CEO and nine Vice Presidents) allocate funds to the various
programs. In turn, these funds and the associated outcomes are managed within a fiscal period by
program directors. The programs directly connected to this inquiry are Acute Clinical and
Medical Affairs, while Patient Safety and Innovation, Public Affairs, Communications and
Stakeholder Engagement and Human Resources and General Counsel are indirectly connected.
Although almost 9,000 people work at PHC (Providence HealthCare, 2013), not all are
directly employed by the organization. Some attending physicians are contracted by PHC and
paid a fee for their services. This relationship has caused conflict between stakeholders related to
participation. “The structure of remuneration for physicians is completely separate from the rest
of the care providers and unintentionally sets up an ‘us-and-them’ situation” (personal
communication, C. Elliot, May 18, 2014). This perception is deeply held. Senge (2006) noted
that deeply ingrained assumptions or generalizations may affect the way change is addressed (p.
8). This suggests any attempt to focus on facilitating and enhancing physician participation must
account for perspectives from other stakeholders within the Medicine Program at SPH.
The Medicine Program at SPH has both internal and external stakeholders. Externally
organizations that influence its operations and success include the government, unions, the
Catholic Church, and physician associations. Internally, the program is part of Providence Health

Care and is governed through a senior management team. It is a complex systems of inter-
connected agents and agencies all influencing the care of its patients. This inter-connectivity is
illustrated in fig. 1
Figure 1. The system diagram identifies how relationships and stakeholders are connected within the Medicine
Program.
If the Medicine Program is to be inclusive and collaborative as a program then the leaders
must be systems thinkers. Senge (2006) described systems thinking as “seeing the wholes”,
THE MEDICINE
PROGRAM
Nursing Staff
and Allied
Health
disciplines
Patients,
Families &
Visitors
Director &
Operations
CEO & VP’s(Senior
& Clinical
Leadership)
Housekeeping,
Maintenance &
Volunteer
Services
Physician
Governance
The Catholic
Church
Quality
Improvement &
Change Initiatives
Physician
Champions
The
Ministry of
Health
Physician
Leaders
Nursing
Leaders
Patient &
Family
Council
Nursing
Unions -
BCNU & HEU
Allied
Health
Leaders
Professional
Practice
Medical
Affairs
VCH
Labor Relations,
Human Resources
& Finances
Other
Programs

appreciating the interconnectedness of relationships and how change affects others (p.68).
Bolman and Deal (2008, ch. 15) also advocate systems thinking for leaders. They defined
organizational life as having events that can be interpreted four different ways or through four
lenses or frames: structural, human resource, political and symbolic. The significance of this
inquiry and features of the study may be illustrated through the four organizational ‘lenses’ of
Bolman & Deal (2008).
Bolman and Deal’s (2008) structural frame addresses the rules, relationships and roles
within an organization and illustrates the importance of clarity of these rules, regulations and
relationships (p.73). Specifically, around physician relationships, Milliken (2014, p. 244)
suggested “physician engagement can sometimes seem like code for ‘managing physicians’
which creates polarity. Unless physicians and …administrators engage equally in a respectful…
way the polarity will continue”. In some organizations, physicians are not employees of the
organization; therefore the organizational rules may be different for them than for employees of
the organization.
Relationships among a multi-disciplinary team are essential for collaborative practices.
Bolman and Deal’s (2008, p.117) human resource frame focuses on what organizations and staff
do to and for one another; the ability for disciplines to work together to improve the current state
of their interactions. Cherry, Davis and Thorndyke (2010, p. 38) recognized “teamwork [as]
essential to achieve the goals outlined in any strategic plan. Physicians are critical stakeholders
who must be invested in realizing organizational … goals”. Viewing the current situation
through this lens, allowed us to appreciate challenges such as contractual conflicts among and
between employees and non-employees. These conflicts may have led to indecision between
disciplines, but collaboration can still allow for organizational resolution.

Another consideration when viewing this study through Bolman and Deal’s (2008)
Human Resource frame is my relationship to the medical community. Based on opinion and
guidance from key stakeholders, this study considered strategies that could align and improve the
current participation of physicians. As the main researcher, and a nurse, I am sensitive to my role
in this study, particularly as it relates to physician processes and involvement.
Bolman and Deal (2008) described the political frame as a “realistic process of making
decisions and allocating resources in a context of scarcity and divergent interests” (p. 190). The
literature around physician participation suggests that if engagement and participation are to
improve, physicians should be paid for their time at meetings (Walsh, Ettinger & Klugman,
2009, p.295; Snell et al., 2011, p. 960). However, another goal of this inquiry was to offer
strategies for enhancing physician participation in QI initiatives without using additional
resources. This remains difficult as the current ‘old boy’ culture embodies different ideals than
those to be hoped for in the future.
Their remaining frame is the ‘symbolic frame’ which “focuses on how people make sense
of the chaotic, ambiguous world in which they live” (Bolman & Deal, 2008, p. 248). This frame
led me directly to the defined values PHC shares with its employees (Appendix C). Bolman and
Deal (p. 254) identified that organizations are constantly changing and causing ‘corporate chaos’
and highlighted the need for an organization to have a clearly defined mission, vision and values
to offer purpose and resolve to all employees. These employees or associates of the organization
should then promote the mission, vision and values, regardless of their employment status.
Chapter Summary
This chapter explained how change appears to be perpetual in healthcare and
collaboration and participation between all team members is vital to success and sustainment.

Based on my personal clinical experience, and conversations with the senior leadership team, I
recognized there was opportunity to improve an ‘age-old’ challenge in healthcare: the
inconsistent physician participation in quality improvement initiatives and processes. Without
consistent physician representation within any organizational change process, it is difficult to
optimize the overall patient outcome and experience.
Organizational context and background of PHC was offered along with explanation of
my role within the bigger system. Evidence was introduced which highlighted that this is not a
new problem, though organizations seem to have difficulty identifying a solution. The chapter
concludes with an analysis of the larger system, the need for systems thinking around this issue,
and the impact the ‘missing voice’ has on the organization as a whole.
The next chapter reviews the relevant literature on the subject of physician participation
in quality improvement initiatives in healthcare.

Chapter Two: Literature Review
The question I posed in this study using an action research approach was:
What strategies can the Medicine Program at St. Paul’s Hospital adopt to optimize physician
participation in quality improvement initiatives and processes?
The following sub-questions provided depth to the inquiry:
initiatives?
This chapter focuses on two main areas, physician participation and quality improvement.
In the former I examine physician participation, physician leaders and champions, barriers to
engagement, physician identity and culture, conflicts between physicians and administration and
rewards and remuneration. In the latter I examine quality improvement and organizational
change in health care.
The first topic examined is physician participation, collaboration and engagement in
healthcare improvement. This review of the literature identifies currently existing barriers to
participation and highlights opportunities for change. The second topic reviewed is quality
improvement and organizational change in healthcare. The review shows the benefits to
advancement in healthcare through introduction of QI initiatives, and introduces associated
topics including readiness for and resistance to change.
The rationale behind focusing on physician participation emerged from responses from
various members of SLT around the lack of consistent physician collaboration and participation

in QI initiatives. The purpose of this focus was to identify conditions that will support consistent
participation among the physician group. This part of the literature review concentrated on
physicians as part of the team, physician leaders and champions and the barriers related to
physician participation.
The rationale behind focusing on QI in healthcare is the acknowledgement we cannot
remain static and complacent about patient care. Quality Improvement is an in situ process that
considers all variables impacting improvement and works through participation of all of the
disciplines involved in that improvement. It also appreciates that perpetual change affects
individuals differently. The purpose of the review is to affirm that change is necessary if we are
to continually improve, and how change can be successfully incorporated into practice.
Specifically this part of the review centred on defining quality improvement and the role of
teamwork in QI, then taking a deeper look at readiness for and resistance to change.
Topic One: Physician Participation in Quality Improvement
Physicians as part of the team.
From my experience as a nurse on two continents, I conclude that in general physicians
feel they are in charge of the healthcare team, rather than part of it. Snell at al. (2011, p.959)
supported these observations by interviewing physicians about their own interpretation of
engagement in their individual settings. Other authors emphasized the importance of multi-
disciplinary teams in the management of the sick and infirm. “All members of the healthcare
team need to be engaged…to succeed in making quality and safety improvements; the need for
trans-professional collaboration has been stressed by practitioners in developing healthcare”
(Baathe & Norback, 2013, p. 479; Lindgren et al., 2013, p.138). Cherry et al. (2010, p.38)
suggested teamwork is essential to achieving strategic goals, and physicians are crucial

stakeholders who must work collectively alongside other professionals to realize successful
quality improvement.
Clark (2012) stated that doctors are more like shareholders than stakeholders and
suggested physicians are more interested in management, leadership and service improvement
than working in partnership with other experienced clinical and non-clinical leaders (p. 438).
Baathe and Norback (2013, p. 480) noted physicians cannot achieve performance improvement
alone. They are in powerful positions from which they can arrest advancement in any initiatives,
therefore their involvement in quality improvement is imperative. Conversely, Spurgeon et al.
(cited in Clark, 2012), described how, in the 1950s and 1960s, physicians helped run hospitals
through medical advisory committees, rather than collaborating with others in system
improvement, while Baathe and Norback (2013) said physicians are “supposed to act
independently and autonomously” (p. 485).
In 1983, a report came out of the National Health Service (NHS) known as the Griffiths
report (Griffiths, 1983).The report recommended introducing physician directors who would
work with nurse managers; in this way physicians hoped to have a stronger clinical voice within
the management structure. Three decades later however, Lindgren et al. (2013) noted that as the
physician’s voice becomes demystified, other professionals are questioning the physician’s
traditional role in management and requesting increased input in decision making (p. 140).
In this context, Lindgren et al. (2013, p. 148) introduced the concept of “workplace
continuity”, describing an environment where physicians regularly work alongside the same
people from one day to the next, fostering a sense of belonging and “feeling at home”. In my
observation, the current situation in the Medicine Program is in direct contrast to Lindgren’s
concept. Attending physicians spend weeks, rather than months, rotating through their schedules

between facilities and private practices. Lindgren et al. (p.150) described such short-term
rotations as less conducive than long-term rotations to improving physician participation in
healthcare management.
Reinertsen, Gosfield, Rupp and Whittington (2007) reported on the Institute for
Healthcare Improvement’s (IHI) position that team learning, shared across disciplines, increases
respect and communication amongst team members. Milliken (2014) supported this approach
when he said relationships between hospital staff should be collaborative and not based on rank
or position, and identified teamwork as necessary to consistently improving standards and
providing quality care (p.245).
Physician leaders and physician champions
Physician leaders and physician champions play influential roles in the overall quality
and well being of patients and staff in the healthcare system. Some describe these leaders
strategically, while others describe them at the working level. Snell et al. (2011) defined
“physician leadership [as] the ability to assume responsibility to set direction for positive change
in health and wellness in the healthcare system.” Spurgeon, Barwell & Mazelan (2008) defined
physician leadership as “the active and positive contribution of doctors, within their normal
working roles, to maintain and enhance the performance of the organization which itself
recognizes [the] commitment in supporting and encouraging high quality care” (p. 214). This
seems to be in direct contrast to my own assumptions where physicians’ contributions are as
being trained to make a difference in their patients’ health and well-being, though not necessarily
to effect change in health care and the broader organizational system. Baathe & Norback (2013)
said the focus must move away from individual physician-patient relationships and towards
examining issues at an organizational level. Clark (2012) and Snell et al. (2011) show physicians

do not receive formal training in effective leadership at a systemic organizational level, though
Snell et al. (2011) note that healthcare leaders are now addressing this gap in training, and
medical schools are introducing leadership modules in their programs.
Snell et al. (2011) also stated physicians have a major role in healthcare, and medical
leadership is necessary to organizational change. Physicians have “considerable impact” on
developing healthcare and can determine peer participation according to Lindgren et al. (2012),
while Cherry at al. (2010) described physician leadership as vital in enabling success and
sustainability in healthcare change and achieving the goals in any organizational strategic plan.
It is clear that the physician role is more than the doctor-patient relationship. Physician
leaders are responsible and accountable for service delivery, quality and safety, productivity and
performance. Holmboe and Cassel (2007) concluded that physician leaders and physician
champions can help to overcome overwork by embracing care management processes (p.19).
Though Clark (2012) notes that historically it has been difficult to encourage physicians to
accept leadership roles, there appears to be “a global movement towards medical engagement
and leadership” and encouragement for physicians to work alongside other non-clinical leaders
to advance healthcare. Milliken (2014) suggested physician leader involvement be supported in
order to direct and guide the activities of the organization.
Reinertsen et al. (2007, p.2) said “very little happens in the health care system without a
physician’s order,” and changes or improvements to healthcare design and delivery requires at a
minimum, physician acceptance. However, in today’s healthcare environment, physician leaders
need to be comfortable affecting change through influence rather than authority (Snell et al.,
2011). At the same time, Lindgren et al. (2013) noted senior physicians have expressed

disappointment in their involvement in previous efforts at quality improvement claiming that
investment in time and energy failed to achieve sustained change.
The literature shows physicians tend to view participation in quality improvement as
voluntary unless it has been specifically assigned or mandated. However, physicians can be
encouraged to embrace this involvement as a valuable professional undertaking. Its rewards are
personally fulfilling, that has been found to motivate their engagement (Lindgren et al., 2013).
This is where the idea of the physician champion becomes important. Reinertsen et al. (2007)
defined the physician champion as “an individual, with courage and social skills who can
communicate the benefits of change to peers in physician-relevant terms in order to make a
critical difference in clinical projects”. Hiss, MacDonald and David (as cited in Holmboe &
Cassel, 2007, p19) identified in the 1970s that physician champions “possessed expert
knowledge and were effective teachers and communicators with others”. They suggest physician
champions adopt a strong “ethic of volunteerism” as the majority are not paid for their additional
services (Holmboe & Cassel, 2007, p.19).
Guthrie (2005) suggested involving informal physician leaders who are partners in
quality improvement as a strategy central to organizational success; champions are ideal for this,
as they are among the few key players with the personal characteristics, clinical credibility and
quality improvement goals to connect with hospital administration. Snell et al., (2011) suggested
“behaving like a leader is committing to a new direction, putting oneself at the forefront of
change.” They further described top-down decision making as a barrier to engagement and noted
that involving a champion enhances peer participation. Cherry et al. (2010) identified leadership
development from within the physician group, as well as recruitment of champions who can

mentor others. They see this as imperative for quality improvement initiative success and long-
term sustainability of organizational change.
Barriers to physician participation.
Barriers to physician participation and collaboration can be viewed from many
perspectives. Snell et al. (2011) indicated that few studies have concentrated on what physicians
themselves consider as barriers in engaging in QI (p.953). Often perspectives on lack of
involvement by physicians originate from perspectives, opinions and attitudes of non-physicians.
Attitudes of physicians about involvement, reported by physicians, are scant. An examination of
physician culture sheds light on this condition.
Physician culture in itself can be considered a barrier to participation. Baathe and
Norback (2012, p.484) cited various definitions of professional culture and occupational identity
as they attempted to explain whether an organization has these cultures within its system or
whether the organization itself is seen as a culture. Schein, (as cited in Baathe and Norback 2012,
p. 484) claims that professional culture “provides them [physicians] with a sense of who [they]
are and, since [they] want to stick to [their] habits, values and meanings, [they] do not want to be
a deviant in the group that [they] value”. This means that an individual physician may appreciate
the need for and want to be involved in QI, though due to being embraced by a bigger group,
may feel the group culture as the greater driver for their non-supportive actions towards
participation.
Understanding that physicians have an occupational identity influences what and how
they learn, and how they understand their profession. For example, the majority of physicians
have not had leadership and systems training in their education, therefore are not able to think
systemically and collaboratively (Doctors of BC, 2014, p.5; Clark, 2012 and Snell et al., 2011).

The work of physicians is medically oriented and they are expected to be competent in their field
and make informed medical decisions. This means they make decisions based on their own
judgment, acting independently and autonomously, identifying with their profession rather than
with the employer (Baathe & Norback, 2012, p.485). This seems to be in direct conflict with the
literature relating to teamwork in healthcare (Baathe & Norback, 2012; Cherry et al., 2010;
Clark, 2012; Lindgren et al., 2013). It seems physician engagement is not just about engaging an
individual; it is about engaging the members of a group who are attached to their profession and
its values and norms.
A barrier to physician participation is the conflicts between physicians and organizational
leadership. Various studies identify the conflict “when top-down decisions regarding… change
reaches clinical departments” (Choi, Holmberg, Lowstedt and Brommels (as cited in Lindgren et
al., 2012). The use of top-down strategies has increased frustration and reluctance to implement
the changes. Physicians are not always involved from the inception of ideas and are often
directed to implement change initiatives without taking their clinical expertise or experience into
account. Their perceptions are that stakeholder negotiations around change and improvements
occur at different times and in different rooms, with boundaries between each. Lindgren et al.
(2013) reported the physician group feel professionally fulfilled when their opinions are regarded
as useful. If organizational leadership disregard suggestions made by the physician team in their
clinical practice, it can lead to disengagement. However, physicians tend not to rely on
recognition from organizational leadership as they receive “a good dose of daily recognition
from their patients, which allows them to be less dependent on management” (Baathe &
Norback, 2012).

It can often be difficult to engage physicians in system reform, as their schedules are fully
booked around patient care (Doctors of BC, 2014). Physicians report limited amount of
scheduled time for improvement work, whilst being expected to do full time clinical practice.
This often leads to participating in QI in their leisure time (Baathe & Norback, 2012, p.489).
Physicians may not be asked to take part in organizational QI due to limitations in the
amount of time they can be in one area. “Short placements during their specialization does not
prepare physicians for an integrated role” (Baathe & Norback, 2012, p. 489). Short term
workplace rotations are cited as creating less incentive to take part in healthcare improvement
initiatives. Continuity in placement was described as facilitating reward and fulfillment (p. X).
Regularly seeing and working alongside the same people was deemed important to keeping
quality improvement fresh and sharing meaningful results (Lindgren et al., 2012, p.148).
Finally, remuneration, lack of resources and misaligned payment incentives are cited as
barriers to participation. Snell et al. (2011, p. 959) suggested organizations do not seem to be
proactive in facilitating the participation of physicians. Inefficient meetings have been described
as meaningless and not producing a sense of efficacy or professional development. This has led
to reports of physicians withdrawing from scheduled meetings (Lindgren et al., 2012, p.149).
Difficulties around physicians attending meetings during their work hours, or performing
leadership activities on unpaid time, are cited as the cause for feeling undervalued (Snell et al.
2011, p. 960; Doctors of BC, p.5; Walsh, Ettinger & Klugman, 2009, p. 295, Lingdren et al.,
2012, p 9 & Holmboe & Cassel, 2007, p.20).

Topic Two: Quality Improvement and Organizational Change in Healthcare
What is QI in healthcare?
In healthy, successful healthcare organizations quality improvement is a continuous
endeavour. In some situations change is imposed by external bodies, and organizations are
obliged to react (Goodman & Loh, 2011, p. 243). Snell et al. (2011) state “healthcare delivery
must be transformed to manage spiralling costs and preserve quality care” (p.952). Commitment
to quality is seen as a core professional value (Holmboe & Cassel, 2007, p.18). To relate this
topic to the study, I will explain the definition of QI within the healthcare environment and
describe how continual change is necessary.
Esain, Williams, Gakhal, Caley and Cooke (2012) define QI as “a service improvement
that satisfies patient demand, clinical needs and patient and carer wants”. The Institute of
Medicine (2003) add to the definition of quality in healthcare with “the degree to which health
services for individuals and populations increase the likelihood of desired health outcomes and
are consistent with current professional knowledge” (Marjoua & Bozic, 2012).
Change, in order to improve system-wide patient experiences and outcomes, is often
driven by government initiatives. These require organizational effort, during and after any new
processes have been put into effect. Following successes with system-wide healthcare
improvement ventures, and as technology advances, the ultimate aim is to share knowledge
across the system (Slaghuis, Strating, Bal & Nieboer, 2013). Whether the change is imposed
externally or emerges internally, teamwork in implementing and sustaining change in the
healthcare environment is crucial.

The role of teamwork in QI
Quality improvement in healthcare is an iterative process that requires collaboration
between all stakeholders to be effective. Holmboe and Cassel (2007, p.18) supported this
highlighting that physician involvement alongside other healthcare leaders was imperative to
change healthcare quality. “Teams are being asked to be more effective than ever, at a time when
they are under more pressure than ever before” (Goodman & Loh, 2011, p.243). The IoM (2003)
believes that “working in interdisciplinary teams is a core competency for all health care
providers” and suggested specifically that competency in teamwork was noted as a valued
attribute of the physician champion (Holmboe & Cassel, 2007). Walsh, Ettinger and Klugman
(2009) agreed, stating that the multi-disciplinary approach to QI was an organizational strength
that can be built upon, in order to improve quality and safety (p.296). The ultimate purpose is,
that all patient safety and QI initiatives are driven through one central location rather than within
individual programs or departments.
The Medicine Program at SPH has their own quality and safety committee who meet
monthly. The committee consists of physician leaders, operations and nursing leaders,
performance improvement consultants and leaders representing the allied health professions.
Each discipline brings forward their perspective relating to new QI initiatives, and dialogue
occurs with consideration to each. As new initiatives are launched within the Medicine Program,
stakeholders within the committee change and there is an ongoing need to build new
relationships and concentrate on continuous collaboration (Goodman & Loh, 2011, p.243).
Committee members realize the importance of communicating and collaborating. Sharing
knowledge within an organization involves communication about goals, improvement processes
and development of initiatives (Slaghuis et al. 2013). Baker (2003, p.11) said that collaboration

in the workplace “is not simply, a good thing to do, it is absolutely critical to the long-term
success of [the] organization”.
Readiness and resistance for change in QI
When change is suggested from anywhere in the organization, there are individuals that
will embrace it and, those that will oppose it, and in between will be a range of commitment.
Although healthcare organizations seem to be in constant change, the pace of its implementation
can vary. All change involves people; and it is these people that affect the change, and in
particular the pace of change. “For many individuals, change is demanding, personally and
emotionally, as things which were important in the past are put aside, and new ways of working
take their place” (Goodman & Loh, 2011, pp. 242-243). As a result there can be positive
outcomes such as renewal and invigoration, and negative outcomes in the form of resistance and
sabotage.
Too succeed in its change goals, organizations need to ensure that there is readiness for
change among those affected. This will be seen as positive beliefs, attitudes and intentions of
individuals within the organization. “Readiness for change, may pre-empt the likelihood of
resistance…increasing the change efforts to be more effective (Hung, Wong, Anderson &
Hereford, 2013; Schein, 2010; Choi & Ruona, 2011; Armenakis et al., 1993).
In contrast to readiness, resistance to organizational change can be a major factor in
advancement in healthcare. Resistance to change is defined as “the action taken by individuals
when they perceive that a change that is occurring is a threat to them” (Minds, 2000). Senge, (as
cited in Goodman and Loh, 2011) stated that “people don’t resist change, they resist being
changed”. He points out that resistance can be, in part, feelings of uncertainty about the future
and not having control over one’s situation. Bushe (2010, p. 44) suggested that resistance to

change is prevalent in organizations as change is forced upon the staff in a crisis when current
processes cannot be sustained. Weisbord (2012) argued however, that “resistance is as natural as
eating” (p. 338) and Senge (2006) supported this by stating that resistance arises when traditional
norms are threatened. These authors generally agree that organizations need to investigate
readiness to change, and look for strategies to overcome resistance before change can occur.
Chapter Summary
This chapter examined the literature surrounding physician participation and their
involvement in quality improvement initiatives in healthcare. The chapter covered two broad
topics, physician involvement and quality improvement. In the former, involvement and barriers
to the same were presented. In the latter, a definition of quality improvement and the importance
of readiness for change were discussed. This topic also presented evidence in relation to
collaboration and teamwork in a healthcare organization and the literature relating to specific
barriers to participation and collaboration.

Chapter Three: Inquiry Approach and Methodology
This chapter concentrates on how I approached the data gathering and analysis, and
identifies who was involved. I explain the structure in which the research was conducted with
evidence supporting the methodology. I introduce my participants including the criteria for
inclusion and exclusion. I discuss the methods I chose, along with the associated rationale. I
explain how I interpreted the raw data and conclude the section with how the study adhered to its
ethical obligations.
Inquiry Approach
The research question I posed was: What strategies can the Medicine Program at St.
Paul’s Hospital adopt to optimize physician participation in quality improvement initiatives and
processes?
The following sub-questions were used to answer the primary question:
initiatives?
In order to answer the research question and gain a deeper understanding through the sub-
questions, I used methods from both quantitative and qualitative traditions, specifically using an
action research (AR) methodology. Quantitative research offers deductive, objective and
generalizable data; this is in contrast to qualitative research, which is subjective, inductive and
contextual (T. Williams, personal communication, November 4 2014).

AR was first introduced in 1946 by Kurt Lewin. He suggested this form of research is
ideal where individuals perceive a need for change. AR is an iterative process in which
individuals gather information about the identified issue and then change elements of the
process. From there they evaluate the changes in sequential iterations. Lewin stressed that for
any change to be effective there must be participation and collaboration among those directly
involved in the issue (Burnes, 2004, p.232). Stringer (2014) defined AR as “a systematic
approach to investigation that enables people to find effective solutions to problems they
confront in their everyday lives” (p.1). Glesne (2011) added that the purpose of AR is to change
something about an identified problem (p. 15) with the goal of improving practice (p.22). AR is a
“problem-solving relationship between researcher and client” with the purpose of generating new
knowledge to improve an identified challenge (Coghlan & Brannick, 2013, p.44).
AR is a generic term encompassing multiple methods concentrating on action and
research in a collaborative manner (Coghlan & Branick, p.43). I approached the methodologies
through an appreciative stance. Bushe (2010) proposed that an appreciative stance promotes
what is working well and what the organization wants more of, in contrast to what the problems
were and the organization would like less of (p. 243). As such, I concentrated on what was
effective in enrolling physician participation and examined what solutions were useful in gaining
physician participation; with the aim of encouraging these positive practices into the Medicine
Program at St Paul’s Hospital. This is in contrast to conventional issue-based approaches that
fixate on the deficiencies that currently exist relating to physician participation. My aim was to
build on current successes through positive narratives and thereby encourage the physicians to be
consistently present.

AR is a participative approach; its purpose is to engage the physician group identified as
stakeholders. The research findings have the ability to positively impact Providence HealthCare
from a perspective of organizational learning by enabling consistent participation in quality
improvement initiatives.
In order to gather data to answer the research question I chose to use an electronic survey
followed by four narrative inquiries in a sequential priorities research design (Morgan, 2014).
Project Participants
For the survey, I used a purposive sample of 70 attending male and female physicians,
from within the SPH Medicine Program. Inclusion criteria were (a) remunerated through fee-for-
service, (b) attached to internal medicine including its clinical teaching unit (CTU) and visiting
specialists. Exclusion criteria were (a) physicians in residency programs on a different
remuneration scheme and (b) physicians outside of the Medicine Program specialties.
Anecdotally, remuneration was identified as one of the reasons why consistent participation in
QI was lacking. For this reason I did not approach residents, as their contractual terms differ
from those of attending physicians.
The purpose of the project was to liaise with individuals who are able to encourage
change within their current environment. Stringer (2014) said action research that includes those
involved in the issue has the potential to increase the effectiveness and efficiency of their work
(p.1). This purposive sampling was a strategy for selecting a representative sample from which to
draw generalizations (Glesne, 2011, p. 44) before moving onto a more purposeful, narrative
inquiry technique which generated richer data.
I used a purposive, narrative inquiry method with four attending physicians. For the
remainder of the paper, the four participants are called informants (Bauer, 1996). I included an

invitation within the electronic survey asking those who wished to be involved further to contact
me directly. I received three responses to participate further and chose to approach the divisional
head for the Medicine program to complete my desire for four narrative inquiries. Those who
responded to the survey for further participation, included physicians who encourage and
actively participate in current team processes and who consistently engage in daily discharge
planning rounds and QI initiatives. Coghlan and Brannick (2013, p.74) said observing
individuals in their work environment generates learning data that may advance the project.
These observations of dynamics and culture provide the basis for inquiry into the assumptions
and effects on the individuals’ work (Schein, as cited in Coghlan & Brannick, 2013).s
As a nurse examining an identified issue relating to participation by the physician group,
I was conscious that there may be a “power under”3 situation relating to my role. This however,
was a personal pre-conceived mental model. There was no conflict of interest or coercion used to
secure the subjects; they participated freely with informed consent (Canadian Institutes of Health
Research, 2010).
An inquiry team assisted in this project. This team comprised the project sponsor, a
physician advisor and an administrative assistant. The sponsor provided contact details and
distributed an email introducing me, my role within the organization and the purpose and intent
of the research. The attending physician adviser ensured the survey questions were framed
appropriately in order to obtain the data I needed to frame the narrative interview phase. The
administrative assistant was used as a transcriptionist in the narrative phase. Each member of the
inquiry team signed a letter of agreement relating to his or her roles and confidentiality
(Appendix D).
3 “Power under” is in contrastto “power over”. Power over is defined as control exerted in a worki ngrelationship
which places undue pressureon prospectiveparticipants (CIHR,2010).

Inquiry Methods
This section describes the data collection methods I used, the study conduct and the data
analysis of the inquiry project. All survey recipients and narrative informants were formally
invited to participate through an email invite with an attached letter of information relating to the
research project. The information letter outlined informed consent, which also explained the
voluntary nature of their participation.
Data Collection Methods
I used a quantitative and a qualitative method of data generation. The quantitative survey
tool established themes about the topic of physician engagement in quality practices. The results
of the survey informed the second and priority method, the narrative inquiry. From this, I was
able to recommend determining strategies and recommendations for change in physician
participation. The purpose of linking the methods in sequence was to use what was learned from
the survey to inform how the narrative inquiry was framed (Morgan, 2014, p.68).
Survey:
I designed an electronic survey with assistance and influence from the project sponsor
and the project physician adviser. “A survey is a research instrument that involves asking a
sample of people a set of pre-prepared questions on a single occasion, in order to gather data
about their opinions and behavior” (Ballou, 2008, p.860). The survey, as a group method, hoped
to enhance ownership of the report findings and draft recommendations. The survey was
constructed and delivered through online survey software, ‘FluidSurvey ®’. (FluidSurveys.com,
2014).

The purpose of the survey was to reach a large number of physicians, with the goal of
raw data being obtained quickly and efficiently. The absence of a formal interviewer in a survey
encourages respondents to answer more freely (Ritter & Sue, 2007) thereby elevating the validity
and reliability of the responses. This allowed potential for all attending physicians, meeting the
inclusion criteria, to offer opinion and perspective relating to perceived engagement issues
identified by leadership.
The survey questions were developed in conjunction with the project sponsor and
physician advisor. A link to the survey was sent out in the form of an invitation email from the
project sponsor via the physician divisional heads (Appendix E). The questions were formulated
with the aim of answering the sub-questions and were pilot tested among the inquiry team and
Medicine Program CNLs. The survey questions are listed in Appendix F. The survey took
approximately five to fifteen minutes to complete depending on depth of response. The survey
included 19 questions comprising nominal data (demographic information), and ordinal data for
rated responses using the Likert scale. Ordinal ranking offered choices along a continuum
ranging from strongly agree to strongly disagree and always to never. Five questions had open,
free text responses (Stringer, 2014, p.119).
For a survey to be quantitatively credible it must follow an established process that can
use statistical methods to determine its reliability, validity and generalizability. This process is
rigorous and systematic (Converse & Presser, 1986). Such an approach ensured that the project
could be replicated as needed with the remainder of the physician team at PHC.
Narrative Inquiry:
I gathered qualitative data through narrative inquiry. Narrative inquiry provides
opportunities for informants to describe the situation in their own terms (Stringer, 2014, p.105).

Narrative discourse is discourse based in story form. Narrative inquiry is a tool allowing an
individual to focus on specific narrative examples to explain their dominant and competing
discourses. People have always told stories to make sense of their world, place things in time,
explain unknown phenomena and give voice to the disenfranchised (Clandinin & Rosiek, 2007;
Webster & Mertova, 2007). Using narrative inquiry to explore the research question promoted
authenticity and deep perceptions of the informant. Narrative inquiry provided a rich lens
through which I investigated the way physicians understand their world (Webster & Mertova,
2007). I asked the physicians to tell me stories and offer their perspectives relating to situations
where they have noted positive and negative impacts of contributions to QI initiatives. I
conducted narrative inquiries, in contrast to plain interviews, as I wished to explore emotive
questioning versus the more traditional guided format. The narrative inquiry encourages the
informant to tell stories about specific events in their lives and is useful when used in resistance
to change in organizational processes (Bauer, 1996, p. 1).
The narrative inquiry method was preferred to the standard interview as it is unstructured.
The purpose was not to impose specific questioning, however I needed to share the initial
findings from the survey to direct the informants. Bauer (1996, p. 3) suggested that interviewer
influence “should be minimal… and the setting arranged to achieve this”. One of the narrative
sessions in this study occurred in a quiet corner of a local restaurant over lunch, rather than in the
formal office space.
Study Conduct
The research inquiry was a two-stage process, comprising distribution of the electronic
survey followed by the narrative inquiries. The project sponsor, requested that the survey be
emailed before the end of March 2015, as a new Gallup ® survey was to be mailed to the

physicians’ mid-April 2015. The inquiry team had initially felt that 10 days would be adequate
time to complete the survey, however, when the survey date was decided, Spring Break was at
the same time, which may have affected the response rate. The decision was made to launch the
survey for three weeks. The survey ended at the end of March. I received four responses to
participate further in the form of the narrative inquiry. Due to my other commitments I was
unable to start arranging the sessions until mid-April. I distributed the invitation email to the
respondents and allowed two weeks for response to when they wished to participate.
Unfortunately I received only three offers to complete the second phase. My inquiry team
suggested I approach the program divisional head as the fourth participant. Again my work
commitments allowed scheduling of the narratives over three weeks, of which all were
completed by the end of May 2015.
The inquiry team included the project sponsor who had direct contact details for the
intended physician recipients. I was delighted to have secured the guidance and support of an
attending physician at SPH. His dual role of internist and gerontologist had provided valuable
insight regarding successful communication with the general physician group. In addition, I
asked an administrative assistant colleague to transcribe the narrative inquiry sessions.
PHC leaders have discussed concerns about the inability to contact the majority of
attending physicians by email. To address this, the project sponsor, who has email contact
details, assisted with the distribution of the electronic survey (Appendix E) I requested the
assistance of the inquiry team to pilot test the questions prior to the distribution to the recipients.
This was to ensure no biases were implicated in the formatting and that the questions were
written in plain language and could not be misinterpreted.
Survey:

The survey questions were distributed to the inquiry team for pilot testing via email. This
allowed for revision of question language, clarity and formatting as needed.
The project sponsor emailed a letter of introduction, purpose and attached consent to physician
divisional heads consisting of approximately 70 attending physicians. The email was sent by
blind carbon copy (bcc) to ensure individual physician’s participation remained anonymous. The
email also included a link to the survey. Each participant’s choice to continue was considered
acknowledgement of complete understanding of the purpose of the research project and their
subsequent consent. Inclusion criteria for these physicians included being associated with the
internal medicine team, also known as clinical teaching units (CTU), the parallel internal
medicine team (PIMs), the family practice physicians who have admitting privileges to SPH, the
gerontology team and hematologists (see Appendices E and G).
Respondents were asked to complete and return the survey within 21 days. A reminder
email was sent after 14 days. Informed consent was considered as granted when the survey was
completed. Although I hoped to obtain 50% of completed surveys by the end of the specified
time frame, I avoided using this to measure validity of the survey. Chung (2014) noted although
response rate is frequently used in this way, this approach is problematic because there is no
defined “sufficient” response rate.
The survey data was collected, themed and categorized. The information was stored in
electronic format at my home address on a password-protected computer.
Narrative Inquiry:
Following analysis of the survey data, I had four offers from physicians who wished to
participate further in the project, unfortunately one respondent chose to decline the offer to
complete the second phase of the study. My aim was for four informants and therefore, after

conversation with my inquiry team, felt it appropriate to invite the divisional head of the
program. The selection was purposeful based on response and on observed workplace behaviors.
I emailed a letter of invitation and consent (see Appendix H) to the identified physicians.
The research question was offered independently, asking the informants to concentrate
specifically on three areas: current barriers to participation in QI, an ideal world view relating to
physician participation and suggestions to strategize, with the ability to elaborate on occasions
where a positive and negative impact had been noted, thereby allowing the informants maximum
opportunity to offer opinions in their own terms and follow their own agenda (Stringer, 2014, p.
109).
At the beginning of the narrative inquiry I explained the purpose of the project and the
format to follow. The narrative format was to allow the informant to speak freely. There was no
structured questioning, although I took opportunity to ask the informant to elaborate when I felt
there was benefit. From there I encouraged the informants to speak freely in their own language.
The narrative inquiry was audio recorded for purposes of transcription and I took notes
throughout the session for purposes of clarification following transcription. This allowed
inclusion of field-notes to supplement the narrative analysis. I asked the informant to sign a letter
of consent relating to the use of audio recording equipment (Appendix I). At the end of the
narrative inquiry, I offered a recap of the conversation, capturing the highlights I had recorded in
personal field notes. This member-checking was to ensure validity of captured information
alongside the audio recording.
The audio tapes were given to the transcriptionist, after she had signed the confidentiality
agreement (Appendix D). The results were collated and shared with the project sponsor.

Data Analysis
“Data analysis involves what you have… heard and read, so that you can figure out what
you have learned and make sense of what you have experienced” (Glesne, 2011, p.184). Survey
data underwent analysis, theming and categorizing of the free text responses. Themes from the
survey data were used as markers in the narrative inquiry. The analyses from both the survey and
the narrative inquiries allowed for a deeper understanding of the factors that promote or deter
physician participation around initiatives related to quality. (Stringer, 2104, p.136). The
computer software calculated descriptive and inferential data. I coded, categorized and themed
the responses from the five, short answer responses. The results of the survey offered statistical
interpretation in the form of descriptive and inferential statistics. Stringer (2014) noted that “in
some instances initial interpretive work provides the basis for immediate action” (p.137)
however, the valuable, richer data was garnered from the narrative inquiries. “Numbers can [not
explain] what the information ‘means’ or suggest actions to be taken (Stringer, 2014, p.54).
After the narratives were transcribed, I reviewed the data and coded, themed and
categorized the raw transcription. The process of categorization and coding classifies the
experiences and perceptions of the participants into similar groups or categories (Stringer, 2014,
p.139). Following coding and categorization, I looked for elements or themes drawn from the
survey that were part of each of the four narratives, which were used to determine
recommendations. Themes are recurrent concepts or statements about the subject of inquiry
(Boyatzis as cited in Bradley, Curry & Devers, 2007, p.1760). I also examined each narrative for
elements of concurrence and elements of difference.
Stringer (2014) suggested AR is designed to foster the participant’s enthusiasm and keep
the participant actively involved with the process. These traits however, cannot be mistaken for

sound research processes of establishing reliability and validity of the research. The outcomes
and recommendations must not solely be the perspective of the researcher, they must be assured
to be trustworthy (p.92).
The study was credible and with qualitative designs. Prolonged engagement of the
participants and leadership, and their willingness to continue the iterative process confirmed the
project’s integrity. The project was transferrable and included a detailed description of activities
and events that will allow for replication. The results should stand up to external scrutiny.
Finally, I confirm the process occurred as reported above (Stringer, 2014, pp. 92-94).
Ethical Issues
“Ethics procedures are part of life and so they are part of research” (Coghlan & Brannick,
2013, p.132). AR is predicated on foundations of democracy, justice, freedom and participation.
Researchers have a “duty of care” with regards to the subjects who choose to participate; that is,
participants must come to no harm while engaging in any research project (Stringer, 2014, p.89).
Glesne (2011) added that ethics in AR has “emphases on informed consent, avoidance of harm
and confidentiality” (p.162).
Informed consent was obtained before any aspect of the research ensued. Informed
consent included a description of the purpose and aim of the research, how the results were to be
used and any consequences of the study (Stringer, 2014, p.89). Subjects had the right to refuse to
participate, the right to withdraw and the right to have information pertaining to them returned in
the event of withdrawal. All gathered data was stored in such a way that it could not be viewed
by others and could not be shared with anyone external to the research study without written
consent from the participant (Appendix G, H & I)

Glesne (2011) discussed researcher bias in the terms of validity and trustworthiness.
Researcher bias is a process whereby the researcher influences the results, in order to portray a
certain outcome; to discredit those that disagree with pre-conceived opinions and hypotheses
(p.50). To mitigate any potential for this, continuous questioning of the purpose in the study was
explored. The aim of the researcher is to be as unobtrusive as possible in order to not influence
the outcomes of the study (Stringer, 2014, p.20).
The Canadian Institute of Health Research (CIHR, 2010) suggests three ethical principles
should be observed when involved in research involving human subjects. These are (a) respect
for persons, (b) concern for welfare and (c) justice.
Respect for person is concerned with the basic value of human beings and the
consideration they are due. The principle entitles the subject to exercise autonomy and act upon
the conscious deliberation of decision making. The subject is entitled to make a free choice
without interference from the research team (CIHR, 2010, p.8). The research project addressed
this principle by offering full written explanation of the study, thereby enabling free, informed
consent. The letter of information offered explanation of the right to refuse to participate and the
ability to withdraw from the research project without consequence.
Concern for welfare addresses the physical, mental and spiritual health alongside the
economic and social well-being of an individual (CIHR, 2010, p.9). The research study offered
explanation to the participant explaining the potential risks and benefits. Survey and interview
data was confidential and every effort was made to ensure individuals were not identified. The
project was deemed as minimal risk and was reviewed by the Royal Roads University Board of
Ethics and the Providence HealthCare Research Institute in affiliation with the University of
British Columbia. The secondary review process was abandoned mid-way by UBC ethics as the

project was deemed purely quality improvement. Assurance was also given regarding the storage
of raw data ensuring privacy of the participant.
Justice refers to treating people equitably and fairly (CIHR, 2010, p.10). The inclusion
and exclusion criteria were justified by the research question. The opportunity to participate in
the survey was open to all who met the inclusion criteria. The physicians invited to the narrative
interview were chosen based on responses from the survey and behaviors the inquiry team felt
demonstrated ends of the participation continuum. The study information stipulated freedom to
withdraw from the inquiry at any time without prejudice or consequence. Since the participants
were peers and the researcher was not one of the populations, there was no ‘power over’
concerns related to the researcher’s influence on participant responses.
Chapter Summary
This chapter offered an account of the research methodology, including rationale to the
methods chosen. It described the inclusion and exclusion criteria of the selected participants. It
described explicitly the study conduct and how analysis occurred and finally I discussed ethical
issues in human research.
The following chapter describes the inquiry findings in detail. It offers conclusions to
identify the strategies the Medicine program can adopt to enhance physician participation in
quality improvement initiatives.

Chapter Four: Action Inquiry Project Results and Conclusions
This chapter presents the results and conclusions drawn from my action research project.
I offer themes that arose from the data analysis with supporting quantitative graphs and
qualitative respondent and informant comments. I gathered conclusions from the analysis and
provide relevant literature to support the findings. Finally, I describe the scope and limitations of
the inquiry.
I directed the inquiry in order to answer the research question: What strategies can the
Medicine Program at St. Paul’s Hospital adopt to optimize physician participation in quality
improvement initiatives and processes? The following sub-questions were used to add depth to
the primary question:
initiatives?
I present, in detail, the trends and themes that arose from both the survey and the
narrative inquiries. The themes are supported by anonymous excerpts from the free text
responses in the survey and narratives. Counterevidence will be presented, where appropriate, to
augment the validity of the project. I have separated the analysis into sections; the survey and the
narrative interviews, although to conclude, I have incorporated all themes together in order to
answer the overarching question.

Anonymity is maintained throughout using codes for each respondent to the survey and
narrative inquiry informants as follows: the survey respondents are identified as SR1 to SR15
and the narrative inquiry informants are identified as NP1 through NP4.
Conclusions are offered based on the data drawn from the project and are supported by
relevant literature described in chapter two. The conclusions are summarized to answer the main
question and the supporting sub-questions. Finally, conditions that limit the scope of the
findings, or any future application of the study and irregularities in the study conduct that may
impact the outcomes, are discussed and summarized.
Study Findings
Survey:
The online survey was distributed to 70 attending physicians (n=70). The survey was
open for three weeks. Initially, the inquiry team had felt the survey should be open for 10 days
only, however when the invitation was disseminated, spring break was about to take place and it
was felt appropriate to extend the response time to allow for those who may be on vacation. I
received 15 responses; a 21.4% response rate.
There were 19 questions comprised of demographic, rated and free text questions. I
wanted to gather information on gender and age, as literature suggests gender and age specific
responses. In this study, 78% of the respondents were under the age of 45, with equal
representation among the genders. Returns came from seven male (47%) and eight female (53%)
physicians. 14 respondents chose to offer their age range.

Age range 28-35 36-45 46-55 56 and above
# of participants 4 7 2 1
Figure 2. Respondent age ranges
I asked about medical speciality, as I wanted to gather information relating to views on
current program structure with regards to TeamCARE and opinions relating to ease of
participation. Although specific speciality was irrelevant to the survey results, what transpired
from the narratives later however, was debate relating to relationships among some of the
specialists.
All 15 respondents chose to provide their speciality.
Specialty # of respondents
Internal Medicine/Clinical Teaching Unit 8 (53%)
Geriatric Medicine 4 (27%)
Family Practice 1 (7%)
Other 2 (13%)
Figure 3. Specialities of respondents
Question four asked about the length of time the individual respondent has been
associated with SPH; 14 chose to answer. In retrospect, time served at SPH was of no specific
value in this study with regards to survey findings, though it is noted that over half of the
respondents have been associated with SPH for less than five years.

Time at SPH # of respondents
Up to 5 years 8 (57%)
6-10 years 3 (22%)
11-15 years 2 (14%)
16-20 years 1 (7%)
Figure 4. Length of time at SPH
Seven physicians (47%), five females and two males, answered they had taken some
form of leadership training. Three of the five females were below the age of 45, one 46-55 and
the remaining respondent chose not to answer. The two male respondents were between the ages
of 36-55. The literature suggests that physicians who have undertaken leadership training are
younger in age range. Due to this small sample size however, my study is not conclusive of that
statement. I offered a free text option asking which leadership program had been completed, no
one leadership program was predominant.
All respondents had a leader as a role model. The literature suggests that learned
behaviours can mould future conduct. 14 respondents chose to give specific examples of the
associated traits (one respondent answered “many” [SR10]). Some behaviors were discussed at a
deeper level in the narrative sessions. These are summarized in figure 5.

Figure 5. Traits of a physician role model
Overall participation in meetings showed that 40% rarely or never attend, with 20%
stating they attend often. This information is important and is in contrast, as when asked about
attendance at TeamCARE, 54% stated always or often attending, with 26% reported as rarely or
never attending. 40% of those who responded to often or sometimes attending meetings were
under the age of 45 years. There was no dominant age range to those always or often attend
TeamCARE, though when asked if the respondents felt that TeamCARE positively impacts
decisions relating to discharge planning, 93% agreed that TeamCARE positively affects patient
outcomes. One respondent felt that the current process did not.
The literature suggests that offering various ways of attending meetings improves
participation. When asked for their preferences, 53% stated they prefer to attend in person with
one respondent stating they preferred to connect by email (SR10). 27% stated they do not
participate through any format. On the preferred time of day for meetings, the majority of
respondents preferred the 13.00 to 15.00 time slot. The time preferences are shown on figure 6.
0
0.5
1
1.5
2
2.5
3
3.5
4
Traits of Physician RoleModels

Time of Day # of respondents
7am to 9am 4
9am to 11am 1
11am to 1pm 1
1pm to 3pm 6
3pm to 5pm 3
Do not wish to participate 2
Figure 6. Preferred time for meetings
When asked about barriers to attending QI meetings, participants claimed lack of time
(10 responses), conflicting workload (8 responses), time commitment (6 responses) and
remuneration (6 responses) as barriers. Insufficient notice was suggested by four independent
responses (SR1; SR4; SR11 & SR14).
The literature points to short physician rotations, multi placements and the inability to
build relationships with regular staff as leading to limited participation in QI. The current
physical location of teams at SPH is such that five internist teams (CTU), alongside associated
specialist teams, are shared among five wards. Specifically, all five teams alongside the specialist
teams, have patients on each of the five medical wards. The number of patients in each team is
the deciding factor on team composition, rather than geographical placement. 67% of
respondents agreed, or strongly agreed, that geographically placed physician teams will enhance
participation in ward based QI initiatives. One respondent felt that one physician team per ward
would not allow for increased participation (SR2).

93% of respondents said that physician champions were an integral component in QI
initiatives. Respondents described the traits of these champions as having good communication,
subject knowledge, diplomacy, and leadership as well as being non-egotistical. Fig 7 shows
participant ratings of these strengths
Figure 7. Traits of a physician champion
When asked if they saw themselves as QI champions, although all respondents stated that
QI is important, only 20% considered themselves a champion (SR4; SR6 & SR12). Although the
information yielded in relation to physician champions had no direct effect on the survey
findings, physician champions were discussed more deeply in the narrative inquiry sessions.
The final survey question gave the respondents opportunity to offer any other strategies
that could optimize physician participation within the Medicine program at SPH. Figure 8 gives
a summary of their responses.
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Traits of a Physician Champion

Figure 8. Strategies to optimize participation
The survey responses highlighted some key themes that illuminate why participation is
varied at QI meetings.
Survey finding #1: The timing of meetings related to QI is integral in determining
consistent participation. All disciplines in healthcare have their own priorities, however these
disciplines need to come together to address processes that have potential of improving patient
outcomes. If an issue is identified as a needing a resolve, or a process has been mandated by the
MoH, mutually agreed upon times to meet should be offered by individual discipline leaders.
Survey finding #2: Lack of time and conflicting workload is the main barrier to consistent
participation. Professionals have their own priorities with regards to patient care and often, it
seems, these priorities can conflict with others. My assumptions are that working in a teaching
environment can lead to conflicting priorities.
Survey finding #3: The majority of respondents agree that geographical placement of
physician teams can improve participation in QI. Current state within the Medicine program is
0
0.5
1
1.5
2
2.5
3
Participation Strategies

such that teams of physicians are grouped together by colour. There are five teams: green, pink,
yellow, blue and purple. Patients are admitted into the emergency department (ED) and are
referred to the internal medicine team or one of the associated specialities. If the patient is to be
admitted, they are triaged by the ED internal medicine consult team. The patient is then allocated
to a colour team depending on the patient count, rather than geographic placement. Patients are
then admitted to whichever unit has an appropriate bed by the program bed co-ordinator. There
are many associated factors on labeling an appropriate bed. Gender, mobility deficits and need
for a private room for communicable disease are but a few.
As a result, patients belonging to the green team, for example, may be spread across the
five units on two floors of the hospital. Literature would support geographical placement of
physician teams not only to improve ability to participate, but also potential of improving
relationship within a team setting.
Narrative Inquiry:
Coordinating convenient dates and times for the physicians who agreed to be part of the
narrative inquiry method proved challenging. After confirming session dates and times,
convenient to the participants, I informed each that I wanted them to speak as freely as they felt
comfortable. The survey data led to several themes that I asked them to consider. I wanted their
views and perspectives on the current state, an ideal state and the barriers to moving from one to
the other and finally, I asked them to consider strategies on how the Medicine program can
support consistent physician participation in QI initiatives. Four themes emerged from the
analysis of the narrative inquiry data.

1. Authoritative, non-collaborative communication between leadership and administration4
leads to inconsistent or non-existent physician participation.
2. Remuneration structure and compensation, physician recognition and physician
availability are factors influencing participation among physician leaders.
3. System structure, inter-team collaboration and relationships and appropriate stakeholder
involvement are factors that affect consistent participation in QI.
4. Overall physician culture is a factor negatively affecting physician participation in QI.
Details of these findings and data exemplars supporting these themes are described below.
Narrative Inquiry finding #1: Authoritative, non-collaborative communication
between leadership and administration leads to inconsistent or non-existent physician
participation.
Having introduced the purpose of the research to all participants at the beginning of each
narrative, I asked them to tell stories, through their own lens, relating to current state and
inquired about individual perspectives relating to barriers.
All informants described how new initiatives or change is mandated from executive
levels from administration, with seemingly little or no collaboration with physician leads. All
informants gave examples of their experiences about top-down initiatives. Typical of these views
were comments like, “[these initiatives are] just another example of imposing [their] will”,
there is “a unilateral group deciding what they [are] going to do, and asking another group to
conform” (NP1). With regards to new processes, comments about the authoritative
communication from administration were “we are doing this” and added “this has been done
4 For the purpose of this section,leadership is referringto physician leadership and administration isreferringto
the senior leadership team (SLT).

over and over again” (NP1). Comments suggested that this was frustrating to physicians. “If
decisions are already made, it is…frustrating” (NP1). Another informant stated “A big barrier is
simply not being asked, not being at the table when things are proposed”. She added “if there’s
pockets of expertise in the hospital, you should engage them in building policy around specific
patient populations” (NP2). Another contributor echoed these sentiments of top-down
administration. “Often we find out about these things as they are being rolled out, towards the
end”. She added “things get passed down from administration and we kind of side step it until it
affects us, or until we are forced to [comply]” She added, “trying to engage physicians at the
end, when you’re rolling things out – that’s going to be very hard”. She ended with “I like to be
involved from the beginning, I feel it’s like something I’ve been able to shape and have input to”
(NP3). Another informant stated “the politicians get elected, the government can make promises
and they can allocate money, which will be wasted unless you address things from the ground
up, and inform us [the physicians] what is happening” (NP4).
In addition to top-down dissemination of information, ineffective meetings or factors
related to meetings, seemed to be a topic of note among all informants.
“Another issue for me is the contents of meetings. Many meetings are not structured well
enough. The meeting really needs to be why we are here and what is the purpose of us
being together? We should be there for the contributions we make, not just to receive
information. Often there is no discussion, you can…comment, but you can’t change
things” (NP1).
He added, “If you’ve been invited to a meeting, we are talking about something that is happening
to that member, for them to give input, because it affects what the decision is going to be” (NP1).
In another narrative an informant added “I got an invitation that was sent…from somebody who
had said ‘oops’ we had probably invite the [specialist]” She added “we don’t want more
meetings, though there is no forum where we can say how we can improve care for people?” She

commented “there are big meetings happening with no real outcomes – that’s frustrating too”
(NP2).
There were suggestions on how to make meetings more productive for all who attend.
Taking responsibility to be informed, and to influence decisions was also brought out. “First of
all, meetings don’t start on time. I am really punctual. To come in late all the time is
disrespectful”. He went on to add “if people want to have input and they feel it’s important,
don’t miss the meeting. If I miss a meeting and don’t assign someone to go [on my behalf] and
something important is being discussed, it’s my problem”. He added “I like meetings where there
is no specific plan, where we can just meet to discuss the problems and have input to what the
issues are”. He ended his comments relating to meetings with,
“Start with a skeleton, but it’s important to listen to people. You should be able to say
things that don’t necessarily put you for or against somebody’s concept. To go to a
meeting and hear things you’re not expecting is really good” (NP1).
Another informant suggested formatting meetings as “planning or brainstorming
sessions”. She suggested to “define the goals and outcomes, using process mapping with formal
facilitators” adding, “you can get an enormous amount done quickly, we like to move fast, we’re
not that good at processes, physicians” (NP2). Having administrative support in meetings,
sending invites and taking minutes was suggested as facilitating physician participation.
“It was nice working with the shared care committee, because a lot of things that would
take a lot of time, like setting up meetings, doing minutes, doing a lot of emailing, I didn’t
have to do that. They wanted me there to get the physician engagement piece on board. I
didn’t feel I had to do everything” (NP3).
A colleague shared “providing administrative support too (with engagement), if you don’t have
administrative support, it will be dead” (NP4).

Narrative Inquiry finding #2: Remuneration structure and compensation, physician
recognition and physician availability are factors influencing participation among
physician leaders.
I shared with all informants the themes from the survey, relaying that the issue of
remuneration and physician recognition did not transpire as one of the main deterrents to
physician participation. There were some mixed responses with regards to this information. One
informant opened his narrative with,
“I don’t think people are being 100% honest, when they talk about the remuneration as
not being a barrier. Unless remuneration schedules are equitable it doesn’t matter what
they say. It comes down to how we are paid. We are paid as individual contractors. As
much as I want to work, is as much as I want to make. All I have to do is show up, make
money and leave, and not be accountable to anybody” (NP4).
His colleague echoed these sentiments stating “if you are paid per item, then that is how you
make your living. You can’t complain unless the playing field is level” He went on to add
however, that physicians complain about physicians too;
“ to have a meeting in the middle of someone’s day, for example, community physicians
who [have overheads], we ask them to participate… having to leave, though still having
obligations, we complain when they don’t show up – so and so doesn’t care, this is the
third meeting he’s missed, blah, blah, blah. I say, wow isn’t that interesting? Here you
are at the meeting, actually getting paid because you are on a salary. I know physicians
who want to have meetings outside of hours, then others say I can’t come, I’m not getting
paid. Each group looking at their own way of getting support” (NP1).
He added however that “there is now recognition from the BCMA (British Columbia Medical
Association) and the government that integration of physicians is important…there is going to be
support through funding that will allow physicians to be supported to go to meetings during the
day” (NP1). Another contributor felt that being “compensated for their time involved” would be
helpful to engage her and her physician colleagues further. She went on to talk about a different
employment structure when I asked about an ideal state.

“I think the issue is that physicians have a different employer; we get paid to see patients.
Currently there is no loyalty to the organization. There is no sense of… I should own part
of this. I think there is disconnect. We looked at some models in the states where
physicians were actually employees…and looking after patients is just part of what you
get paid to do. There are other responsibilities. I think money does play a part in this. I
wish that the non-direct patient stuff could be just as valuable as the time I spend with
patients. The current system doesn’t value that from a financial perspective. So ideally I
would be an employee of Providence and to have my responsibility to include not only
patient care, but things like QI too” (NP3).
Regarding remuneration, another informant stated,
“The money is a complete non-issue among [this specialty]. There is so much stuff that’s
not paid for. I don’t think the money is a massive thing. I think for some people the money
stands in for being appreciated or being recognized. I think [the money] is a surrogate
for being recognized” (NP2).
Other challenges among the informants, in relation to this finding, were connected to
their availability. There was remarks related to staff resources and availability to the
organization. One contributor stated “we are under resourced because we choose to be under
resourced” he added “[patients] are trying to petition people at various times…we try to make
ourselves available…this doesn’t work because they can’t make the time” (NP1). A colleague
added “people get bombarded with initiatives and it gets totally overwhelming…someone comes
with a bright idea, it’s like – go away, everyone has a bright idea, but I’m the one that’s got to
implement it” (NP2). Another informant reminded me however “it [QI] can’t be something that
will take more time, because of it does [we] won’t adopt it” (NP3). One informant remarked
“most physicians don’t have protected time at all, so they [survey respondents] may not
know what it could look like if you say – hey, listen, a week out of the month, this is going
to be your job, these will be your tasks and deliverables – I think that would set the tone
differently” (NP4).
He added “it’s about the time to think, not just time to sit around for a make work project. It’s to
provide time to think through the issues and come up with a comprehensive plan of attack”
(NP4).

Narrative Inquiry finding #3: System structure, inter-team collaboration and
relationships and appropriate stakeholder involvement are factors that affect consistent
participation in QI.
Throughout the sessions, the informants shared narratives about system structure,
teamwork and individual involvement, though each narrative conjured differing perspectives.
The general healthcare structure of delivering was seen as something that inhibited team
collaboration. With regards to a team environment one contributor stated “we have gone to a
team concept, which is just empty boxes. The patient doesn’t want a team, he wants a physician,
and we have destroyed the doctor-patient relationship by changing these concepts”. He went on
to say “the teams are artificial and unstructured, we don’t really function as a team. We function
as parts of a team. We have a self-imposed structure. We create teams…with different hours and
different responsibilities” He went on to add his expectations of his colleagues;
“I want them to be physicians, not components of a team. I want them to take ownership
of their patients and their responsibilities. Structure shouldn’t interfere with
performance, and when [it] does you have to question whether the structure is
worthwhile” (NP1).
With regards to team collaboration and structure another informant stated “it’s a battle each time
to engage across programs”. She added “if you’re not in the Medicine program (CTU), nobody
tells you anything”. She commented further “[our speciality] thinks systems and we engage
systems, we make the systems work which is why you find us more engaged” (NP2).
Two of the informants, coincidentally both younger physicians, appeared excited when
they spoke about a team environment. The first, who works primarily at another acute facility
within PHC, though occasionally is scheduled as a staff physician at SPH, said,
“I am very comfortable with the team I work with…I need to feel comfortable and
confident that the team I work with can rise to the challenge. When I think about SPH, I

don’t know the team well and that’s the difficulty. At [the other facility], there is less
turn over… I know their strengths and we have common goals” (NP3).
She added, “[Any change] involves multiple team members, not just physicians. It needs
everyone on the team. Why can’t we work together? So that we minimize the work that each of us
have to do”. She insisted “Physicians my age, recognize the value of working as a team, how
invaluable it is; [my speciality] tends to be a little more collaborative” (NP3). Another
contributor said, “I would be happy to make less money if it meant that my life was less stressful
and I had more people to work with” (NP4).
Three of the four informants talked in some way about the current state of physician
teams and ward settings. Survey data and earlier comments on ‘geographically situated physician
teams ‘came up in the narratives. Two of the three informants who spoke about geographic
placement of teams appeared to advocate for one physician team per unit. The third had some
reservations.
When one contributor was talking about current state of team composition, he became
animated as he spoke about geographically situated physician teams. “We must, absolutely, need
to do it, it needs to get done!” He went on to add “I worked at VGH (Vancouver General
Hospital) and it is the best. I don’t spend all my day walking back and forth between the wards”.
He explained,
“You can be educating and talking to staff and patients while the residents are doing
their work. If you spend all your intellectual capacity wondering where your patients are
and what you have to do next, you can’t think through issues. I could spend too much
time walking up and down ten floors to see my next patient” (NP4).
He added,
“You remove all those barriers, you are face to face with the team and you have removed
the phone call or the pager. When you remove barriers, its exponential, it’s not linear.
You do things that you couldn’t do before and efficiency improves significantly. From a

quality of life point of view – if you don’t feel good at work and you are burnt out or
tired, there is decision fatigue” (NP4).
He included some cautionary points, “the efficiency might be worn out with increased numbers
and in some ways…everybody is watching you, you are in a bit of a fish bowl. It is kind of
annoying because family members are there all the time”. He added, “Complexity of handovers
does increase and you would need an extra physician in the ED”. However he summed up his
thoughts saying “with a geographic ward, quality of life improves, stress decreases and
communication improves with staff on the ward, and patients and family members” (NP4). When
asked to expand on how VGH had managed to implement the ‘geographic ward’, when there
seemed to be resistance among some of his colleagues at SPH. He laughed and answered,
“People didn’t want to change. The only reason they changed at VGH is because it was
forced on them by administration. If you didn’t have a heavy handed – a person in charge
that was uh…firm in what they expected and demanded, then it wouldn’t have happened”
(NP4).
In another narrative, a contributor shared the following on teams,
“I rotate to SPH over a short period of time, and I haven’t had as many opportunities to
get involved here. I find at [my other facility] that a safe environment is important.
Physicians need to feel like they’re part of a team. You cannot possibly know everything
about the patient that you’re trying to look after. I’ve learned a lot about collaboration, I
think the more physicians work with allied, the more exposure they have, the better they
are at receiving” (NP3)
She went on to explain, “I think our training is actually shifting a little, so we recognize the
value of team. The residents in [my specialty] now understand the different roles of the allied
health team”. She laughed stating “they’re much better at reading the allied health chart notes
now” She continued to explain the differences in the settings between her other facility and SPH.
“It’s really funny because there are TeamCARE rounds at both sites. My other facility
has rounds with everyone there. The MRP (most responsible physician) is always there.
We don’t have a huge sprawling team of residents, but they come with the staff
physician” (NP3).

She added, “It’s a revolving door at SPH and CTU, you don’t ever feel like you get to know the
people as well” (NP3). She talked about relationships between team members. “It’s important to
let the team know that it’s valuable to have them all there. I think it fosters more than just
exchange of information, it fosters relationships too”. Her direction changed to that of the
geographic ward.
“When you’re not on one or two units consistently, you have the resident not knowing
that the person standing beside them in the hallway, is the physio looking after their
patient. You don’t get the kinds of conversation that you normally would” (NP3).
As I had mentioned, one of the participants had a negative perspective against moving
towards a geographically situated physician team.
“When I first started at VGH, you were assigned to a specific ward. That was when
occupancy was at 85%. We imposed a geographic units system here about 10 years ago.
We did it for a year. It was a gong show! We don’t have the right infrastructure to do it.
We have too many patients. We are usually at 100% capacity…forget it. If we had private
rooms for everybody…we would have so many reasons to move people. There was a lot
of to-ing and fro-ing. It didn’t work. There was chaos” (NP1).
He thought for a moment, “I recognize being on a ward has some familiarity of people being
together”, however he added,
“Their first contact is with the physician in the ED (Emergency Department), and they
see two or three people here and there. The relationship is important to establish, though
then to assign them to yet another team is unnecessary and a bit unsafe” (NP1).
He went on to suggest,
“If the proximity is an issue, and it is really important we work as a team, then the nurses
and allied health that work with a specific physician would follow their patients. So you
don’t have a physical structure, you have a mobile team. The geography of the ward is
the problem, we don’t have the right house”. (NP1).
He reminded me “we have to be careful about imposing structures that work for us just because
we think it is better. I don’t think that is a step in the right direction” (NP1).
In relation to this finding, two of the four narratives described physician champions.
These comments were made by the two younger physicians. One talked about having “the right

people in the right positions” and stated “finding the right physician is important”. She added
“it’s not just about me being engaged, we need frontline physicians to be engaged. It’s hard to
engage them, it’s a really big challenge”. One suggestion she had, was to invite colleagues to
focus groups and asking “this is something we need to address, would you be interested in it?”
She added “you only need one or two people to be champions and they can figure out what the
best approach is. You need to have ‘ins’ with the group” (NP3). Her colleague said,
“Not everyone is meant to do QI. You can provide a job title and provide remuneration
and administrative support. You will get applications for that job. It’s finding people that
have a passion for change. Certain people, based on their personalities and experience
have certain gifts and need to occupy those roles. People who aren’t good, who are going
to waste time and waste the money and resources allotted to them, need to be out of the
situation” (NP4).
Narrative Inquiry finding #4: Overall physician culture is a factor negatively
affecting physician participation in QI.
All four informants told stories about how their own culture, beliefs and actions among
their colleagues and peers, negatively affected willingness to consistently participate in change
and quality improvement. One contributor commented, “There are different rules for physicians
and the other components. The patient makes a commitment to an individual, the physician, not
to a system. The doctor-patient relationship is still at the centre of that commitment” He added,
“The trust that is built there allows the rest of the system to participate and function. If
there is a poor doctor-patient relationship, and the patient has no confidence in his
physician, it won’t matter what systems we put in place” (NP1).
Another informant stated,
“I think people think, either doctors aren’t interested, or they won’t come or they think
we’re going to steal the show and take off in our own direction and not listen to people.
All these are distinct possibilities and have previously happened” (NP2).
She went on to add “the medicine physicians have little respect for any other program. They are
very insular”. She explained her experience was supported by other specialists too. She laughed

and added “You can’t talk to them, you can’t tell them anything. They’re all nice people, it’s just
old patterns and…they’re old” (NP2).
These comments were supported by her colleague.
“There’s arrogance in our culture, there’s hierarchy. Probably less than there was, but
it’s still…ingrained that the doctor is the leader. The doctor knows everything about the
patient. I think that’s changing with more collaborative teams, but certain physicians still
seem less open to input from allied, and when I say allied I include nursing. Traditionally
it’s a very patriarchal profession” (NP3).
She added “A doctor’s identity is really core to who they are, so when you question something
that a doctor does, it…undermines their authority”. She laughed and said, “There are still
[those] that don’t like being told what to do, physicians can be obstructive too” (NP3). She went
on to comment, “CTU (internal medicine) has its own culture here [at SPH]. It’s not a very easy
culture. They…are their own entity”. She went on to add “physicians are a hard group, we don’t
like being told what to do. We don’t like being told that we can improve” (NP3).
One contributor had firm opinions on physician culture.
“Physicians are small thinkers and reductionist by virtue of their training. They’re
conservative by virtue. They’re self-selected to be conservative. You have a group of
people who come into a job where they know they will be relatively well off and they
don’t have to worry about money. They know that they will be relatively stable with
gainful employment and they know they have a job where they don’t really have to risk
someone looking down on them. They’re not risk takers. They’re not people who want to
change or challenge the system. They are people that want status quo. And then you train
them in this model where everything is reductionist and everything has an answer based
on science” (NP4).
He laughed as he added,
“That’s a very different mindset than “hey, if we try this, it may work or it might not
work”. There are risks associated with that. You might feel uncomfortable, you may look
stupid or it may not work. When you’re in a group of people that are all similarly
minded, if someone does fail, they’re looked upon in a different way” (NP4).
He went on to explain why there is generally resistance among physicians. “When you spend all
your time in one reductionist model and don’t have engagement in the creative side, it becomes

difficult to solve problems. Solving problems takes creativity and lateral thinking. Thinking
outside of the box”. He laughed as he added “If your brain isn’t set up for that, and your culture,
your time structures and method of education aren’t set up for that, then you’re screwed!”
(NP4).
Throughout the narratives, each informant shared ideas or strategies they thought may
improve the current state. One made suggestions around shared learning and closing the loop
relating to complaints and challenges among disciplines (NP1). Two of four contributors
suggested that change should be small and doable. They suggested that results should be able to
be seen fairly quickly. One informant stated “often things are just so massive, let’s target doable
things” (NP2). A colleague echoed these sentiments. “Start with small problems and have
feedback mechanisms so that you know what you’re doing is working or not working” (NP4).
The same contributor asked for emotional support.
“It’s a slog doing QI and trying to help people with changing culture. If you’re not
addressing the emotional interactions that take place on the ward in respect of the work
environment, then it’s going to be a challenge no matter what” (NP4).
He suggested “learning more from the business industry. There are multi-national corporations
that make money and are efficient, while at the same time are rated the number one places to
work” He added,
“We…take a little bit from each industry then we try to have healthcare people apply
those ideas to healthcare situations, perhaps it’s not the best idea to have physicians or
nurses or healthcare admin driving QI. Maybe it’s time to hire people from other
industries who have proven track records of getting things done…These people will make
a much larger impact than all the others running around” (NP4).
All stakeholders who participated in the narratives had valuable, personal insight into a
challenging issue, however one ended saying,

“There is a lot of satisfaction for me, as a physician, when I can be involved in QI. I feel
like this is the reason I became a doctor in the first place – to try and help people. QI is
just a different way of caring for patients” (NP3).
She ended “I was really encouraged when I heard about your research. This is an important step
to try and figure out how physicians can be valuable to quality improvement” (NP3).
Study Conclusions
The purpose of this study was to identify strategies that would optimize physician
participation in quality improvement initiatives in the Medicine Program at St. Paul’s Hospital.
Using a qualitative action research approach, four findings emerged. When supplemented by the
literature on this topic, I drew three conclusions.
1. Early and detailed communication is imperative in optimizing physician participation in
quality improvement initiatives.
2. Relationships and teamwork and integrated work environment contributes to effective
physician participation; however the current structure within the Medicine program
hinders dynamic collaboration.
3. The current physician remuneration and recognition structure are disincentives to
physician participation in quality improvement initiatives.
The synthesis of the research findings, conclusions and the supporting literature addresses
my research question: What strategies can the Medicine Program at St. Paul’s Hospital adopt to
optimize physician participation in quality improvement initiatives?
Conclusion #1: Early and detailed communication is imperative in optimizing
physician participation in quality improvement initiatives.

The main theme emerging from the survey and narratives was related to non-
collaborative communication between both physician and organizational leaders and program
administrators. Early and collaborative communication means being informed about new
initiatives, being informed and given opportunity to offer input into the new initiative and given
opportunity to participate; being able to change decisions that have already been made without
appropriate stakeholder involvement. Clark (2012, p. 438) suggested the need for greater
involvement by senior doctors as members of a stable leadership team, as they tend to be more
constant than healthcare executives. Data from this study suggests that senior doctors remain
uninvolved at the level needed. Milliken (2014, p. 245) states early collaborative conversation
between physicians and administrative leadership is the foundation for healthcare organizations
to deliver and improve patient care. Again, data from this study suggests that this does not occur
as well as it could. Milliken (2014) describes the negative impact the absence of meaningful
consultation can have on patient outcomes (p. 244). Duberman, Bloom, Conard and Fromer
(2014, p.24) identified challenges facing physician leaders. They state that communicating
effectively with physicians and other healthcare providers, limiting the ability to work as high
performing teams, a major challenge.
Choi, Holmberg, Lowstedt and Brommels, as cited in Lindgren et al. (2013, p.139)
identified major challenges when top-down decisions regarding change reached clinicians.
Inadequate communication has been found to be barriers to participation in other studies.
Lindgren et al. (2013, p. 146) showed that having impact on healthcare development was vital to
maintain physician participation. Their study described physicians as professionally fulfilled
when their knowledge and opinions were considered useful. Snell et al. (2011, p. 959) discussed
top down decision making as a factor leading to marked disinterest of physicians. Guthrie (2005,

p. 236) suggested that administrative leadership is responsible to ensure communication with
physicians, relating to program potential and the opportunity for mutual success. They also stated
that the invitation to participate and language used should be compelling and motivational,
therefore encouraging reciprocal support.
Effective communication included meetings and their efficiency. Lindgren et al. (2013, p.
149) highlighted in their study that physicians felt some formal meetings were meaningless and
did not produce professional or organizational development. This led to withdrawal from the
meeting structure. In a study conducted by Snell et al. (2011, p. 959), bureaucratic processes,
including ineffective meetings, were a contributor to disengagement from physician leaders.
Conclusion #2: Relationships and teamwork and integrated work environment
contribute to effective physician participation; however the current structure within the
Medicine program hinders dynamic collaboration.
The findings from the survey and the narratives suggested that the current state within the
Medicine program, where physicians are not considered part of the integrated team structure,
does not promote effective relationships between the physician teams and unit staff. The current
physical location of physicians, described earlier, impedes their participation. Other studies
(Baathe & Norback, 2013, p. 479; Lindgren et al. 2013, p.138) support reorganization of
physician allocations to each unit, with the purpose of encouraging interdisciplinary team
collaboration.
A multidisciplinary approach to quality improvement has been recognized by the Institute
of Health Improvement (IHI) (Walsh et al., 2009, p. 301). Baathe and Norback (2013, p. 480)
suggested physicians cannot improve healthcare singlehandedly, however their participation is
critical. Overall improvement in healthcare requires collaboration between all professional

disciplines. Inconsistent workplace environments contribute to workplace discontinuity, and
Baathe and Norback found that physicians have expressed a wish to have continuity in
workplace relationships (p. 489). They said that this same continuity was considered key in
maintaining meaningful results in healthcare improvement, by enhancing trust, creativity and
team effectiveness.
Participants in this study suggested moving forward with the concept of geographically
placed physician teams. Cherry et al. (2010, p. 40) cautioned that when some individuals are
“wedded to the old culture…it will take longer…for change to occur”. Snell et al. (2011, p. 958)
suggested, a multidisciplinary approach, appreciating all team members, “connecting with
people” and “building relationships” was imperative for integrated quality improvement. They
suggested that work environment was important in terms of sustaining high levels of engagement
and feelings of “fulfillment”. They found that working alongside and witnessing colleagues in
the immediate environment engaged in improvement work was “exciting”. Snell et al. (p.959)
supported findings from this study that participants felt their relationships with those in the
immediate surroundings were essential to their level of participation.
Lindgren et al. (2013, p. 140) supported the move towards geographically placed teams.
They suggested that poor physician participation was a result of inadequate working conditions
such as inconsistent workplace continuity. They suggested that consistent workplace allocation
facilitated fulfillment and working alongside the same people regularly was essential in
maintaining improvement initiatives. “Feeling at home” was described as promoting safety
where expression of new ideas would be embraced. In contrast, short term placements were
regarded as less conducive to collaborative involvement by the physician team (p. 148).

Conclusion #3. The current physician remuneration and recognition structure are
disincentives to physician participation in quality improvement initiatives.
The data from the survey and the data from the narratives contradicted each other. There
appears to be a preconception among salaried employees (non-physicians) that due to the
differences in pay structure, there is an obvious barrier for staff physicians to participate fully.
Upon further examination of the survey and narrative data, the reasons became clearer. In some
cases participation is influenced be remuneration or lack thereof, while in other cases it is
influenced by a lack of recognition of physician’s contributions. Walsh et al. (2009, p. 295)
stated that lack of physician participation is due to competing demands and absence of
compensation and Clark (2012, p. 441) supported this adding, when physicians speak about
participation, they are talking about what they already give that is not appreciated, valued or
supported by the administration.
The data suggests that pay for contributions is not the only issue. Lack of recognition for
services offered, including time and support were cited as challenges. Lindgren et al. (2013, p.
149) pointed out that physicians were expected to manage the same clinical workload, in
addition to attending meetings related to quality improvement. It was felt the absence of
scheduled time for QI activities gave the impression that participation was voluntary. This led to
disengagement between these participants. Snell et al. (2011) supported these findings.
“Disengagement was understood to be more likely when physicians were expected to volunteer
their time and were not compensated for their activities” (p. 964).
Snell et al. (2011, p. 956) found that simple recognition from both the organization and
their physician peers would promote participation in QI initiatives. Being acknowledged was a
motivator for many of their participants. Recognition of their efforts, feeling supported and being

appreciated was reinforcement for their actions. However, it has been recognised that physicians
are expected to take part in QI projects in their spare time (p. 958). Snell et al. (2011) reported
that participants felt supported by “occasionally having protected time for certain projects” (p.
958). They also concluded that it was not only the monetary value, but valuing physician opinion
by listening to and responding to it, was vital to encourage consistent participation.
Baathe and Norback (2013, p. 490) identified however, that there appeared a high level of
participation among their study participants, when it was deemed possible to improve healthcare
without adding extra resources. Cherry et al. (2010, p. 40) added “it’s not always about the
money”. They report that physicians often appreciate the greatest gain from situations that
enhance their own work life. Snell et al. (2011, p.960) suggested removing barriers such as
financial disincentives; lack of administrative support, consideration of the timing, location and
process of meetings and overall time commitment pressures.
Unexpected findings:
There were some findings from the survey and narrative inquiries that I would not have
predicted. I was unsettled to find that one survey participant believed that TeamCARE does not
have a positive effect on patient outcomes. There has been much conversation at PHC regarding
discharge planning and how to implement the process into everyone’s day. My assumption was
that all disciplines believed in its value, I was mistaken.
I was surprised to hear from three of the informants that relations between some
physician specialities were difficult or strained. There was mention of disrespect and
noncollaboration between the specialities and within the Medicine program itself. Although this
information is worrisome, I feel privileged to have been included in this conversation.

Scope and Limitations of the Inquiry
The scope and limitations of this action research study are primarily related to the
participants. Stringer (2007, p.179) stated “human inquiry, like any other human activity, is both
complex and always incomplete”. The study limited its population to fee-for-service physicians,
and as such concentrated on individuals whose remuneration structure is different from salaried
physicians within PHC. However, I purposefully identified this group, as discussion surrounding
physician pay structure was identified as a perceived barrier to consistent participation in QI
initiatives and projects. I chose to concentrate on one program only within the organization. The
findings and conclusions apply solely to this group. Conducting the research among other
programs may offer different insight and perspective and would be a recommendation for further
study.
My role as clinical nurse leader, created some preconceived mindsets and hesitancy and
as such may be perceived as a limitation. I believe some participants were cautious of my
intentions in carrying out the study, regardless of my explanations of why I was conducting the
research. However, the literature confirms that similar studies carried out by physicians produced
similar results.
A final limitation is the limited representation of the population in the survey.
Communicating with physicians within the Medicine Program proved difficult. Some staff
physicians refuse to have an organizational email address due to the amount of, what they
perceive as, ‘junk mail’. I needed to rely on the administrative assistants belonging to the
divisional heads, to disseminate the survey. Despite these efforts, my physician adviser informed
me that not all staff physicians received the invitation to participate. This likely affected the
response rate to the survey.

I intend to share the findings and conclusions through an appreciative inquiry summit
(AIS) (Ludema & Barret, 2007, p.202) which will comprise the project sponsor, medical affairs
and the PHC senior leadership team. The AIS will enable the physician group to develop and
take ownership of the recommendations. Unfortunately to date, there has not been opportunity to
undertake this intention, though I have met with the project sponsor and we have developed
some recommendations for consideration from the physician teams.
Chapter Summary
This chapter summarized the data into three key findings from the survey and four key
findings from the interviews. From these I developed three overarching conclusions related to
communication, the geographical and team orientation to the work, and the issue of remuneration
and incentives for physicians. For each section of this chapter I included literature that supported
the analysis. Finally, I described limitations to the research inquiry that may affect future studies.
The next chapter will describe recommendations to address this chapter’s conclusions.

Chapter Five: Inquiry Implications
In this final chapter, I offer evidence-supported recommendations that have arisen from
the action research study findings and conclusions. The actionable recommendations, will go
towards answering the research question: What strategies can the Medicine Program at St. Paul’s
Hospital adopt to optimize physician participation in quality improvement initiatives and
processes? To answer the overarching topic, I asked the following sub-questions which were
used to add depth to the primary inquiry:
initiatives?
3. What recommendations and suggestions do physicians have that can be incorporated
into practice?
This chapter also includes the organizational implications of implementing the
recommendations. It will discuss the changes that leadership and involved stakeholders need to
undertake in order to be successful with recommendation implementation. This chapter also
offers suggestions for future inquiry projects.
Study Recommendations
British Columbia’s Ministry of Health expects healthcare organizations to address
improvement processes that will positively affect patient outcomes. Historically, healthcare
organizations have attempted to address their quality agenda by engaging physicians. However,
the Institute for Healthcare Improvement (IHI) advocates a reframing of approach, by inquiring
how the organization can participate in the physician’s quality agenda. This approach recognizes
that physicians are concerned with quality with regards to patient outcomes (Milliken, p. 244).

The recommendations from my action research project are based on the findings and conclusions
presented in chapter four. These recommendations are to:
1. Invite, communicate and collaborate with physician leaders early when adopting and
implementing organizational change initiatives.
2. Build a work environment conducive to relationship building and teamwork.
3. Consider a compensation and recognition scheme for physician services related to
organizational change.
Recommendation #1. Invite, communicate and collaborate with physician leaders
early when adopting and implementing organizational change initiatives.
Communication is essential in improvement initiatives. However, information alone
should not be misinterpreted as engagement. Engagement includes being involved in decisions
and collaborative actions. Several authors support this principle. Cooperrider and Fry (2010)
stated that stakeholder engagement is imperative in moulding sustainable change. They
suggested the benefits of decision-making and taking action together, in a collaborative manner,
are essential for organizational success (p. 3). Guthrie (2005) stated “involvement, influence and
decision making about program direction are important motivators for some physicians” (p.237)
and that high performing healthcare organizations incorporate physician suggestions as the first
wave of operational change (p.238). Leaders of Doctors of BC (2014) said “physicians [who] are
not asked for their opinion, or are asked for their input after a decision has already been made,
discourage[s] engagement” (p. 5).
Within the Medicine program at SPH, there are a number of sub-specialities. It is
imperative that collaboration with physician leaders in the Medicine program, means engaging in
conversations with all physicians in the Medicine program to ensure that all specialities are

aware of potential change initiatives. Another engagement strategy is building physician
networks. Encouraging networking between physicians can be the most effective way to share
information, Although this can be time-consuming, physicians recognize that networking is a
most reliable way of gathering and disseminating information and perspectives (Guthrie, 2005, p.
238; Doctors of BC, 2014, p. 4), Informal networks are important ways of engaging physicians,
however, program leadership should not rely on physician networking alone to ensure complete
coverage of all specialities has occurred.
Recommendation #2. Build a work environment conducive to relationship building
and teamwork.
Building a work environment that is collaborative and inclusive builds a sense of team
and teamwork. If the Medicine Program is to offer strategies that promotes enhanced
participation, particularly of its physician members, then being intentional and purposeful about
being collaborative is a key behaviour by leaders. Baker (2003) supported this stating “building
collaborative relationships at work… is absolutely critical to the long term success of [the]
organization. He stated the benefits of relationship building can be measured, and suggested that
those who make the effort are more effective, are happier in their environment and are healthier
than peers who do not wish to take the same approach (p.11). There were suggestions offered
throughout the study, in relation to improving the current environment.
A part of building a collaborative, inclusive environment is being sensitive to the other
roles and obligations of team members. Timing meetings to be accommodating is a
demonstration of inclusive leadership. One such opportunity is with the TeamCare initiative. The
purpose of TeamCARE has rarely been disputed among its participants, though the timing has
been a matter of contention for the six years it has been part of the Medicine Program’s daily

schedule. Currently the 10:00 AM time slot conflicts with the educational needs of the physician
teams, and so representation at TeamCARE meetings is often minimal.
As results of the survey were analyzed, program leadership chose to present the findings
to the physician leaders. Physician survey participants suggested that meetings related to QI
would be appreciated between 1:00 and 3:00 PM. This relatively small but telling change would
show that program leaders are sensitive to physician schedules and are willing to adjust meetings
to make physician input more convenient.
There has been a long-standing request from program leaders, both physician and
operational, that all individuals involved be able to review a critical patient event. They
recognize the importance of the ensuing conversation, analyzing the processes used and making
appropriate adjustment to processes and practices where necessary. Already, as a result of data
from this study, leaders in the Medicine Program are making efforts to invite key players to these
critical patient reviews. However these actions are in their infancy and will need support and
follow-up to make it a common and continuous practice. A part of this engagement will be for
leaders to make sure that these reviews are psychologically safe places to express opinions.
The geographical location of physician teams is another condition that would illustrate
how program leaders want the contribution, collaboration and input from a broad representation
of physicians. The study data showed strong support for geographically positioned physician
teams in the survey, and from two of the four informants in the narratives. Although the
Medicine program recognizes the implications this format change will have, it is imperative that
operational and physician leaders have meaningful conversation about how this will positively
affect [participation] (Snell et al., 2011, pp. 958-959). The data illustrated that in a collaborative

inclusive work environment, physicians could welcome nurses into their morning meetings as
the geographical changes would make it more convenient.
Recommendation #3. Consider a compensation and recognition scheme for
physician services related to organizational change.
Recognizing people’s contribution is an important component of an engaged workforce.
Monetary and other forms of recognition send messages that contributions are valued and
important. Physicians want to feel that their contributions are valued and a reward and
recognition scheme would help reinforce that feeling. Feeling valued is increased when
physician leaders recognize contribution from their followers. Duberman et al. (2013) suggested
that “strong physician leadership, at all levels, is required to drive change and position
organizations for success” (p. 24). However, leaders have to be sensitive to the perception that
top down medical leadership can increase physician distrust (Doctors of BC, 2014, p.5), whereas
nurturing informal champions, thereby developing credible leaders, encourages change from
within the profession. Organizations that nurture those that aspire to lead others reap significant
benefits related to engagement. When leaders are chosen because of values and collaborative
principles rather than from length of service, it sends powerful messages about the culture of the
organization. Building the leadership capacity of the new generation of physicians will positively
influence the engagement culture throughout Providence Health Care (PHC). When these
individuals have interpersonal and management skills, they are influential in organizational
change (Guthrie, 2005, p. 236) and can promote ownership of change initiatives among their
peers.
Historically, medical education does not incorporate leadership development. Acquiring
leadership skills provides leaders with a broader and deeper understanding of healthcare as a

complex system. The cost-benefit ratio would favour stronger physician leaders. Costs for such
leader education and development could be shared among care committees who hold funds
specifically for physician education. They could sponsor informal physician leaders and
champions by “establishing an internal professional development program that is integrated with
the organizations vision, mission and values” (Cherry et al., 2010, p. 40). This will benefit not
only the physician as an individual, but also the organization as a collective.
Guthrie (2005) suggested that “goals… should be mutually rewarding; as [organizations]
become more successful, the physicians must see that their needs are being met” (p.236). A
reward and recognition scheme is not only about monetary reward. However, it is one of the
stronger symbols of recognition. Although paying for a physician’s time in quality improvement
work is becoming more frequent, it is not universal.
Doctors of BC (2014) suggest that [organizations] “must take practical steps to ensure
physicians have the time to adequately participate in quality initiatives”. They state “resources
are always scarce, but not engaging physicians is often more costly in the long term” (p.5).
Participants in this study suggest that PHC attempt to shift the current allocation of dollars
associated per procedure or visit, to an allocation based on total patient care. Total patient care
includes quality improvement, encompassed under the role of the most responsible physician
(MRP). Participants identified three supportive actions PHC could adopt: removing financial
disincentives for physician participation, employing efficient meeting structures, and offering
clerical support for physicians involved in committee work.
Currently, employees at PHC who have been seen as ‘going above and beyond’, are
recognized with a hand written card from the senior leadership team. This same level of
appreciation could be offered to physicians who are recognized by their leaders or nominated by

their co-workers. As Guthrie (2005) states, recognition of key individuals’ time and effort is
meaningful (p.237). A simple gesture tends to have deep effect on an individual’s behaviour.
Some health organisations have adopted employment contract and physician compacts
with mixed results (Guthrie, 2005; Doctors of BC, 2014), however, data from this study suggests
that development of such a compact can clarify roles, expectations and accountabilities of all
parties.
Organizational Implications
I have collaborated closely with my project sponsor and physician advisor for almost a
year. Without their advice, suggestions and support it would have been very difficult to move
forward with this action research study. I held preconceptions that being a nurse, addressing an
established organizational issue relating to physicians, had the potential to cause resistance
among the very stakeholders I was hoping to engage. However, with influence from my sponsor
and physician advisor, my preconceptions were never realized.
Although close and continuous involvement by sponsors of action research is not often a
realistic expectation, I was encouraged to continue because they affirmed that I was investigating
issues of importance for my sponsors that could have far-reaching impact on participation,
particularly of physicians. Coghlan and Brannick (2013, p. 6) described this collaboration as
second person inquiry, where I am investigating the work of others on challenges of mutual
concern.
Prior to this study, various leaders in the organization had expressed opinions regarding
the barriers limiting consistent physician participation in organizational change initiatives and
processes. Their opinions prompted me to voice these concerns to my project sponsor, realizing
that physician participation was a sensitive topic. However, I felt that if we were to improve

physician participation, any and all strategies must incorporate the voice of the physician. The
implications of not adopting this approach would mean quality and other initiatives would
continue to have minimum support at best and open sabotage at worst.
Since these recommendations are derived from a collaborative process with physician
leaders, their ownership of the recommendations might promote sustained change among their
peers. Coghlan and Brannick (2013) suggested that “action research is a collaborative,
democratic partnership” and members of the system being studied should participate actively in
the study (p.5).
These recommendations may invoke even broader change among other disciplines. They
may forge new linkages and collaboration, reduce resistance to future change initiatives, promote
regular discussion, even dialogue, and identify early adopters as points of leverage for
encouraging commitment to initiatives. Action research within any organization does not limit
itself to the group being studied. Stringer (2014) reported that the purpose and objective of action
research is to forge links with those that may be resistant to the recommendations, and negotiate
compromise that allows all stakeholders to enhance their work environment (p. 197). He
suggested that with any complex system, new processes or modifications to current structures
will affect others (Stringer, 2014, p.189) and collaboration with all stakeholders will be
necessary in order to implement the recommendations that have been offered. If regular
conversation and dialogue occur among program and discipline leaders, they are more likely to
reach amicable compromise as changes occur. With any change there is potential for resistance,
however time and effort is better spent on those who are willing to embrace new initiatives and
processes (Cherry et al., 2010, p. 40).

This study shows that physician participation is imperative in the overall success of a
healthcare organization. Providence Health Care could advocate that participation is not optional
among physician leaders and make efforts to facilitate physician participation. This study
identified some of the ways to achieve this, by creating a climate of engagement, and offering
resources and incentives that encourage physician involvement across the board (Snell et al.
2011, p. 960). Conversely, if Canadian healthcare systems continue to believe that physician
participation in quality improvement initiatives is optional, the current state of minimal program
participation by physicians will persist.
Implementing these recommendations can be achieved by small incremental steps, but for
them to be integrated into the operations and the culture of the Medicine Program it will require
‘persistent’ be added to ‘small incremental steps’. When considering change in any healthcare
organization, the ultimate focus should be on the benefit to the patient, though consideration
must be given to the affected stakeholders (Langley, Moen, Nolan, Nolan, Norman & Provost,
2009, p. 110). Showing consideration for these stakeholders can be in the form of early and
meaningful dialogue with involved parties in order for changes to be considered and
implemented successfully. The key to success will be to consider and trial small changes, rather
than to attempt a large overhaul of current processes and practices. Using the small-scale change
format, leaders will be able to obtain regular feedback from those involved and determine if the
small-scale changes are as effective as intended.
Implications for Future Inquiry
Further investigation into this subject will offer increased understanding of physician
attitudes and their connection between quality improvement and positive patient outcomes.
Throughout this action research, conversations from other disciplines outside of the study

participants suggested alternative ways to enhancing participation. Future inquiries might
explore and examine these alternatives, including studies to explore multi-disciplinary
approaches to enhanced team participation.
Since one of the methods of a culture of engagement is close and continuous dialogue, it
is important to have a vehicle through which to encourage participation in such dialogue. Data
from this inquiry identified the difficulties in contacting an attending physician by email because
they see little value delivered by this medium. Although seeming inconsequential, it poses a
significant barrier to involvement and engagement strategies. Difficulties connecting with lead
physicians is a problem that diminishes quality of care, quality of teamwork and the overall
quality improvement within the organization
The goal of this study was to identify ways the Medicine program at SPH could enhance
their current processes in order to foster improved physician participation without the need for
additional funds. A cost-neutral strategy may not be entirely possible and further inquiry may be
justified to determine resources needed to achieve monetary and other incentives for increased
physician participation.
Report Summary
This final chapter presented recommendations and suggested a plan for consideration and
implementation by senior and clinical leadership. However, they are not the only agents of this
change. Engagement is a condition where all the agents work together. “Organizations and
physicians each need to do their part to increase physician [participation]” (Snell et al. 2011, p.
964). The results of this study, and the associated literature, suggest that physicians are
committed to improving the health of their patients. In the case of Providence Health Care
generally and the Medicine Program specifically, close and continuous support from its leaders,

will build a culture of physician engagement that could extend across the organization as a
whole. As Snell, et al. (2011) point out, when physician participation is recognized as a positive
experience… success reinforces future adoption of processes (p. 966).
The chapter discussed organizational implications and offered suggestions how further
inquiries may build on this action research study. I will continue to suggest a forum where
stakeholders can collaborate and dialogue, as they determine next steps with regards to these
recommendations. Conversation is already underway among program and physician leaders, as a
result of the preliminary survey results.
I have been immersed in this process for almost a year and believe that, with
encouragement and commitment from our leaders, all disciplines have an opportunity to work
together more effectively. The result can only be improved patient outcomes and an improved
overall quality of work life. I believe that if these recommendations are implemented, that the
Medicine program at St, Paul’s Hospital will offer an environment where physicians will want to
participate to their fullest potential.

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Appendix A – VCH Engagement Strategy
Stakeholder Engagement Plan 1. BACKGROUND
VancouverCoastal Healthisleadingand/orsupportingawide range of chronicdisease managementand
consumerhealthinitiatives. Several of these programstargetcommonstakeholders. The Patient
Accessto QualityCare Projectbuildsonthe foundationsof manyof these initiativesandmust be
carefullypositionedsothat stakeholdersunderstandthe innovativeaspectsandkeybenefitsof the
Project,ratherthan feelingoverwhelmedatyetanotherinitiative forthemtosupport. Aswell,lessons
learnedfromthese otherprogramswill be soughtandappliedtothe PatientAccesstoQualityCare
Projectandsome stakeholderswill be engagedspecificallytoprovide thisinsightintothe Project
planning,implementation,adoptionandevaluationprocesses.
Phase 1 engagementactivitiesfocusedonclinical consultationtosupporthigh planning,and
reviewof previous,related,stakeholderconsultationreports. Thisinputhelpedtoguide the
StakeholderEngagementStrategyforthe PatientAccesstoQualityCare Projectandalso
demonstratedtostakeholdersourcommitmenttoalignwithexistinginitiatives,buildonpast
experience andlearnfrompreviousinput. Thisearlyconsultationalsoprovidedanopportunity
to cultivate championsforthe Projectandinitiate recruitmentforthe Clinical WorkingGroup.
Witha commitmenttothe long-termsustainabilityof the PatientAccesstoQualityCare Project,
engagementactivitieswill be linked,where possible,toexistingorganizational processesandstructures.
Thiswill helpkeystakeholdersunderstandthe relevance of thisProjectwithintheircurrentrolesaswe
workwiththemto shiftbehaviors,processesandmindsetstoanew way of working.
2. GOALS
• Supportand facilitate the effective design,development,implementation,adoptionand
evaluationof the PatientAccesstoQualityCare Projectbyengagingstakeholdersrepresentingall
aspectsof the multi-disciplinaryhealthcare teamincludingpatientsandtheircaregivers,inconsultation
and communicationactivities.
• Facilitate ongoing,two-waycommunicationbetweenthe ProjectTeamandstakeholdersto
supportcontinuousqualityimprovement
3. OBJECTIVES
• Engage organizational andclinical leadersaschampionsforthe PatientAccesstoQualityCare
Project,usingtheirinfluence andrelationshipsto:
o Generate interestandsupportforthe project
o Recruitclinicianstoparticipate inconsultationactivitiesandinthe projectitself byenrolling
theirpatients
o Supportthe alignmentof the PatientAccesstoQualityCare Projectwithotherchronicdisease
management/consumer-focusedprojectswithinVCH
• Work withstakeholderstodefine anddeliverthe keyvalues/benefitsassociatedwiththe
PatientAccesstoQualityCare Project.

4. ENGAGEMENT APPROACH
The PatientAccessto QualityCare StakeholderEngagementStrategywill initiallyfocusonrecruiting
clinical andadministrative championstohelpshape the ProjectPlanandguide the developmentof the
detailedengagementstrategy. Thisincludesthe formationof amulti-disciplinaryClinical Working
Group, a multi-disciplinaryChange ManagementWorkingGroup,anda multi-disciplinaryStakeholder
ReadinessAssessmentWorking
Group. The patientandcaregiverperspectivewill be providedvia aPatientReference Groupinitially
and ultimatelybyaPatientAdvisoryCouncil thatwillbe establishedincollaborationwithVCH
CommunityEngagementandthe provincial PatientsasPartnersProgram.
EngagementactivitiesduringPhase 1identifieda numberof potential champions/participantsforthe
above notedAdvisoryandWorkingGroups. See appendixE:Summaryof StakeholderConsultation. A
StakeholderMatrix (see appendix F) hasbeendevelopedtoidentifykeystakeholdergroups,theirneeds
and highlevel strategiesforengagingthem.
In additiontohighlevel consultationandengagement,amore tactical approachto stakeholder
engagementwill supportProjectimplementation,adoptionandevaluation. Thisincludestactical
engagementstrategies, linkedtothe operationalaspectsof the Project,suchas:
• PhysicianEngagement
• Patient/FamilyEngagement
• SpecialistEngagement(aspartof the integrationstrategy)
• OtherProviderEngagement(aspartof the integrationstrategy)
A LeadershipEngagementStrategywill involve aseriesof presentationstokeyleadershipgroupsacross
VCH. Inmost casesthese presentationswill be deliveredbythe Initiative DirectorandaPhysicianLead
(specialistorfamilyphysician,dependingon the audience),orthe Initiative Directoranda memberof
the Clinical WorkingGroup,representingadisciplineappropriatetothe audience. These sessionswill
aimto informand influence keyadministrativeandclinical leadersandseektheirinputinto how the
Projectalignswiththeirbusinessprocessesandpriorities.
Feedbackfromthe LeadershipEngagementStrategyandinputprovidedbythe ClinicalWorking
Group will linktothe developmentof acommunicationsandengagementplantosupportVCH
and local communityhealthservicesintegration.Thiswillfocusonbuildingawarenessof the
Projectandthe purpose of the sharedcare planso providersare aware of and accessthis
informationaspatientsmove acrossthe continuumof careplanning,andreview of previous,
related,stakeholderconsultationreports. Thisinputhelpedtoguide the Stakeholder
EngagementStrategyforthe PatientAccesstoQualityCare Projectandalsodemonstratedto
stakeholdersourcommitmenttoalignwithexistinginitiatives,buildonpastexperience and
learnfrompreviousinput. Thisearlyconsultationalsoprovidedan opportunitytocultivate
championsforthe Projectand initiate recruitmentforthe Clinical WorkingGroup.
Witha commitmenttothe long-termsustainabilityof the PatientAccesstoQualityCare Project,
engagementactivitieswill be linked,where possible,toexistingorganizational processesandstructures.

Thiswill helpkeystakeholdersunderstandthe relevance of thisProjectwithintheircurrentrolesaswe
workwiththemto shiftbehaviors,processesandmindsetstoanew way of working.
GOALS
• Supportand facilitate the effective design,development,implementation,adoptionand
evaluationof the PatientAccesstoQualityCare Projectbyengagingstakeholders
representingall aspectsof the multi-disciplinaryhealthcare teamincludingpatientsand
theircaregivers,inconsultationandcommunicationactivities.
• Facilitate ongoing,two-waycommunicationbetweenthe ProjectTeamandstakeholders
to supportcontinuousqualityimprovement
OBJECTIVES
• Engage organizational andclinical leadersaschampionsforthe PatientAccesstoQuality
Care Project,usingtheirinfluence andrelationshipsto:
o Generate interestandsupportforthe project
o Recruitclinicianstoparticipate inconsultationactivitiesandinthe projectitself
by enrollingtheirpatients
o Supportthe alignmentof the PatientAccesstoQualityCare Projectwithother
chronicdisease management/consumer-focusedprojectswithinVCH
• Work withstakeholderstodefine anddeliverthe keyvalues/benefitsassociatedwith
the PatientAccesstoQualityCare Project.
ENGAGEMENT APPROACH
The PatientAccessto QualityCare StakeholderEngagementStrategywill initiallyfocusonrecruiting
clinical andadministrative championstohelpshape the ProjectPlanandguide the developmentof the
detailedengagementstrategy. Thisincludesthe formationof amulti-disciplinaryClinical Working
Group, a multi-disciplinaryChange ManagementWorkingGroup,anda multi-disciplinary Stakeholder
ReadinessAssessmentWorking
Group. The patientandcaregiverperspectivewill be providedviaaPatientReference Groupinitially
and ultimatelybyaPatientAdvisoryCouncil thatwillbe establishedincollaborationwithVCH
CommunityEngagementandthe provincial PatientsasPartnersProgram.
EngagementactivitiesduringPhase 1identifiedanumberof potential champions/participantsforthe
above notedAdvisoryand WorkingGroups. See appendixE:Summaryof StakeholderConsultation. A
StakeholderMatrix (see appendix F) hasbeendevelopedtoidentifykeystakeholdergroups,theirneeds
and highlevel strategiesforengagingthem.
In additiontohighlevel consultationandengagement,amore tactical approachto stakeholder
engagementwill supportProject implementation,adoptionandevaluation. Thisincludestactical
engagementstrategies,linkedtothe operationalaspectsof the Project,suchas:
• PhysicianEngagement

• Patient/FamilyEngagement
• SpecialistEngagement(aspartof the integrationstrategy)
• OtherProviderEngagement(aspartof the integrationstrategy)
A LeadershipEngagementStrategywill involve aseriesof presentationstokeyleadershipgroupsacross
VCH. Inmost casesthese presentationswill be deliveredbythe Initiative DirectorandaPhysicianLead
(specialistorfamilyphysician,dependingonthe audience),orthe Initiative Directoranda memberof
the Clinical WorkingGroup,representingadisciplineappropriatetothe audience. These sessionswill
aimto informand influence keyadministrativeandclinical leadersandseektheirinputintohow the
Projectalignswiththeirbusinessprocessesandpriorities.
Feedbackfromthe LeadershipEngagementStrategyandinputprovidedbythe ClinicalWorkingGroup
will linktothe developmentof acommunicationsandengagementplantosupportVCHand local
communityhealthservicesintegration.Thiswillfocusonbuildingawarenessof the Projectandthe
purpose of the sharedcare planso providersare aware of and access thisinformationaspatientsmove
across the continuumof care.
Table 1: Stakeholder Engagement Milestone Summary
Deliverable Tasks Timeline
StakeholderMatrix 


Identifyall potential
stakeholdersIdentify
needs
Identifyexistingprocesses
for reachingthem
Nov. 30 - 08
Leadership Engagement  Identify keyleadership Nov.30 – 08
Strategy groups acrossVCH and Dec. 30 – 08
PHC Jan/Feb – 09
 Get on agendasfor
Jan/Feb meetings Mar. – June – 09
 Developpresentation
 Log questions/issuesraisedatmeetings
 Track on ActivityLog(see communicationsplan)
 Follow-uppresentationswithin3-6months
(dependingonquestions/issuesfrom
session 1)
Clinical Working Group  Develop draft Terms of Nov.08
Reference
 DevelopPlan Nov.08
 ImplementPlan Jan.09
Physician Engagement  Develop draft Plan Nov. 08
Strategy  Implement Plan June – September09

Patient Engagement  Develop draft Plan Nov.08
Strategy  Implement Plan June – September09
PatientReference Group  Developandimplement Jan. –
June 09 plan
Specialist Engagement  TBD – based on input TBD
Strategy fromClinical Working
Group (linked to
integration strategy)
“OtherProvider”
EngagementStrategy
 TBD – basedon
inputfromClinical
WorkingGroup and
linkedtoVCHand
local healthservices
integrationstrategy
TBD
Change Management
WorkingGroup
 Developtermsof
reference
March 09
Deliverable Tasks Timeline
 Developplan
Patient Advisory Council  Develop terms of July09
reference
 Developplan
“Disconnected” Physician  Identify appropriate July09
Engagement Strategy physicians,nurse

Appendix B - Providence HealthCare Organizational Chart
President and CEO
Vice President
Acute Clinical Programs
Director- Clinical Business
Operations & MSJ Site
Leader
Corporate Director –
Acute Clinical Programs
Acute and
Access
Services
Heart and
Lung
Program
Maternity
Servicesand
Surgery
Program
Mental
Health
Program
Program
Director &
SPH Site
Leader.
Physician
Director –
ER
Physician
Director -
ICU
Program
Director
Physician
Director -
Heart
Program
Director
Physician
Director –
Surgery
Physician
Director –
Maternity
Services
Program
Director
Physician
Director –
Mental
Health
Renal
program
Medicine
Program
Urban Health,
HIV/AIDS &
Addictions
Program
Program
Director
Physician
Director -
Renal
Program
Director
Physician
Director -
Medicine
Program
Director
Physician
Director –
HIV/AIDS &
Urban
Health

Appendix C – Providence Healthcare Mission, Vision and Values
MISSION
Inspired by the healing ministry of Jesus Christ, Providence Health Care is a Catholic health care
community dedicated to meeting the physical, emotional, social and spiritual needs of those
served through compassionate care, teaching and research.
VISION
Driven by compassion and social justice, we are at the forefront of exceptional care and
innovation.
VALUES
Spirituality – We nurture the God-given creativity, love and compassion that dwells within us all.
Integrity – We build our relationships on honesty, justice and fairness.
Stewardship – We share accountability for the well-being of our community.
Trust – We behave in ways that promote safety, inclusion and support.
Excellence – We achieve excellence through learning and continuous improvement.
Respect – We respect the diversity, dignity and interdependence of all persons.

Appendix D – Inquiry Team Member Letter of Agreement
In partial fulfillment of the requirement for a Master of Arts in Leadership Degree at
Royal Roads University, Mandy Lowery (the Student) will be conducting an inquiry research
study at St. Paul’s Hospital, Vancouver, BC to determine what strategies the Medicine Program
at St. Paul’s Hospital can adopt to optimize physician participation in quality improvement
initiatives. The Student’s credentials with Royal Roads University can be established by calling
Dr. Brigitte Harris, Director, School of Leadership, at (250) 391-2600 x4467 or email
Brigitte.3harris@RoyalRoads.ca
Inquiry Team Member Role Description
As a volunteer Inquiry Team Member assisting the Student with this project, your role
may include one or more of the following: providing advice on the relevance and wording of
questions and letters of invitation, supporting the logistics of the data-gathering methods,
including taking notes, transcribing, or reviewing analysis of data, to assist the Student and St.
Paul’s Hospital in the organizational change process. In the course of this activity, you may be
privy to confidential inquiry data.
Confidentiality of Inquiry Data
In compliance with the Royal Roads University Research Ethics Policy, under which this
inquiry project is being conducted, all personal identifiers and any other confidential information
generated or accessed by the inquiry team advisor will only be used in the performance of the
functions of this project, and must not be disclosed to anyone other than persons authorized to
receive it, both during the inquiry period and beyond it. Recorded information in all formats is
covered by this agreement. Personal identifiers include participant names, contact information,
personally identifying turns of phrase or comments, and any other personally identifying
information.
Bridging Student’s Potential or Actual Ethical Conflict
In situations where potential participants in a work setting report directly to the Student,
you, as a neutral third party with no supervisory relationship with either the Student or potential
participants, may be asked to work closely with the Student to bridge this potential or actual
conflict of interest in this study. Such requests may include asking the Inquiry Team Advisor to:
send out the letter of invitation to potential participants, receive letters/emails of interest in
participation from potential participants, independently make a selection of received participant
requests based on criteria you and the Student will have worked out previously, formalize the
logistics for the data-gathering method, including contacting the participants about the time and
location of the interview, and producing written transcripts of the interviews with all personal
identifiers removed before the transcripts are brought back to the Student for the data analysis
phase of the study.

This strategy means that potential participants with a direct reporting relationship will be
assured they can confidentially turn down the participation request from their supervisor (the
Student), as this process conceals from the Student which potential participants chose not to
participate or simply were not selected by you, the third party, because they were out of the
selection criteria range (they might have been a participant request coming after the number of
participants sought, for example, interview request number 6 when only 5 participants are
sought). Inquiry Team members asked to take on such 3rd party duties in this study will be under
the direction of the Student and will be fully briefed by the Student as to how this process will
work, including specific expectations, and the methods to be employed in conducting the
elements of the inquiry with the Student’s direct reports, and will be given every support possible
by the Student, except where such support would reveal the identities of the actual participants.
Personal information will be collected, recorded, corrected, accessed, altered, used, disclosed,
retained, secured and destroyed as directed by the Student, under direction of the Royal Roads
Academic Supervisor.
Inquiry Team Members who are uncertain whether any information they may wish to share about
the project they are working on is personal or confidential will verify this with Mandy Lowery,
the Student.
Statement of Informed Consent:
I have read and understand this agreement.
________________________ _________________________ _____________
Name (Please Print) Signature Date

Appendix E – Sponsor Email Invitation with Survey Link
Hello
I am the organizational sponsor of Mandy Lowery, a CNL within the Medicine Program, who is
principal investigator for a research study as part of her Master’s degree in Health Leadership out
of Royal Roads University.
The purpose of the study is to identify strategies for the Medicine Program at St. Paul’s Hospital
to optimize physician participation in quality improvement initiatives.
This part of the study involves participation in an online survey.
I would encourage you to take a look at the attached information and then if you choose to
continue, please click on the link below, or alternatively copy and paste the link which will take
you directly to the survey.
The survey will remain active for 21 days from March 6th 2015. A reminder email will be sent
after 2 weeks. The survey will close on March 27th 2015.
http://fluidsurveys.com/surveys/lowerym/physician-participation/
I would like to take this opportunity to thank you in advance for your time in responding to the
survey.
Kindest regards
Astrid Levelt
Director – Medical Affairs
Providence Health Care.

Appendix F – Survey Questions
1. Gender Male
Female
Prefernotto answer
2. Age Range 28 – 35
36 – 45
46 – 55
56 and over
Prefernotanswer
3. Whichservice doyou primarily representatSt.Paul’sHospital inyourrole asattending
physician?
Internal Medicine (CTU)
Parallel Internal Medicineteam(PIMs)
FamilyPractice
RespiratoryMedicine
GeriatricMedicine
Other___________________
4. How longhave youbeenassociatedasa physicianatSt. Paul’sHospital?
Up to 5 years
6 – 10 years
11 – 15 years
16 – 20 years
21 yearsand above
5. Have you undertaken leadershiptraining?
Yes
No
Prefernotto answer

6. Have you had a physicianrole model inyourmedical career?
Yes
No
Prefernotto answer
7. What traitsor behaviorsdidthe physicianrole modeldisplay?
8. I participate inmeetingsrelatingtoQualityImprovementatSt.Paul’sHospital…
Always
Often
Sometimes
Rarely
Never
9. I attendTeamCare (Multi-disciplinarydischarge planningrounds)
Always
Often(3-4 timesaweek)
Sometimes (Twice weekly)
Rarely (Once a week)
Never
10. Do youbelieve TeamCare positivelyimpactsdecisionsrelatingtodischarge planning?
Yes
No
Prefernotto answer
11. How doyou choose to participate inmeetingsrelatingtoQualityImprovementatSt.Paul’s
Hospital?
In person
Teleconference/telephone
Email
Other_________________________
I do notparticipate

12. What time of the day wouldyouprefertoparticipate inmeetingsrelatingtoQuality
Improvementinitiatives?
07.00 – 09.00
09.01 – 11.00
11.01 – 13.00
13.01 – 15.00
15.01 – 17.00
I do notwant to participate
13. In youropinion,whatare the barriersthat limitconsistentparticipationin QualityImprovement
initiativesatSt.Paul’sHospital?
Time
Workload
Commitment
Remunerationissues
Other__________________________
14. GeographicallyplacedphysicianteamsatSt.Paul’sHospital wouldimproveparticipation inward
basedQualityImprovementinitiatives…
Ie.CTU Greenexclusivelyon7a,CTU Pinkexclusivelyon7betc.
Stronglyagree
Agree
Neitheragree ordisagree
Disagree
Stronglydisagree
15. PhysicianChampionsare valuable inpromotingQualityImprovement
Stronglyagree
Agree
Neitheragree ordisagree
Disagree
Stronglydisagree
16. What traitsare suggestive of aphysicianchampion?

17. Do youconsideryourself…
A physicianchampionwithregardsto participationin qualityimprovement.
A physicianwhoagreesthatquality improvementisimportantbutprioritizesit
lowerthan my otherduties.
A physicianwhoseeslittle valuein qualityimprovementaschange isnot
sustained.
A physicianwhoseesnovalue atall inqualityimprovementinitiatives.
18. What otherstrategiesdoyoufeel couldoptimize physicianparticipationin quality improvement
initiativesinthe MedicineprogramatSt. Paul’sHospital
If you wouldlike toshare yourperspectivesaboutphysicianparticipationwiththe aimof improving
value forall stakeholderspleaseenteracontact email.
____________________________________________
Thank youfor participatinginthe survey

Appendix G – Survey Information and Consent Letter
What strategies can the MedicineProgram atSt. Paul’s Hospital adoptto
optimizephysician participation in qualityimprovementinitiatives?
My name is Mandy Lowery; I am the principal investigator and clinical nurse leader in
the Medicine Program at St. Paul’s Hospital. This action research project is part of the
requirement for a Master of Arts in Leadership Degree at Royal Roads University. My
credentials can be confirmed by my academic supervisor, Tony Williams at 604-374-2156. This
research project has been approved by Royal Roads ethic review board.
Purpose of the study and sponsoring organization
The purpose of this research project is to determine what strategies the Medicine Program
can adopt that will optimize physician participation in quality improvement initiatives at St.
Paul’s Hospital. The project sponsor is Astrid Levelt, Director of Medical Affairs at Providence
HealthCare; she can be contacted at 604-817-9662.
Your participation and how information will be collected
This part of the research will consist of an electronic survey. You are being invited
because you are an attending physician within the Medicine Program or one of its related
specialties. The Medicine Program would like to learn more about providing an environment
where consistent physician participation can occur; and your opinions and perspectives are
valued. The research project is anticipated to last six months, however your involvement will be
for an anticipated 15 minutes to complete the online survey.
Benefits and risks to participation
Responding to the survey will enable you to provide your opinions and perspectives to
the stated questions. The results will be used by the Medicine Program with the aim of providing
an environment where consistent physician participation can occur.
There are no perceived risks if you choose to respond and participation is completely
voluntary. There are no incentives for participating in the study.
Real or Perceived Conflict of Interest
There are no perceived conflicts of interest. I disclose this information here so that you
can make a fully informed decision on whether or not to respond to the survey.
Confidentiality, security of data, and retention period
I will work to protect your privacy throughout this study. The research will entail an
online survey hosted by a Canadian online survey company, FluidSurveys®. FluidSurveys© has
been selected as the survey company as it is a Canadian company meaning it adheres to

Canadian privacy legislation. All information I collect will be maintained in confidence with
hard copies (e.g. raw data) stored in a locked workplace office at St. Paul’s Hospital. Electronic
data (such as survey results) will be stored on a password protected computer. The final report
will also ensure the data sources are kept anonymous. At no time will any specific responses be
attributed to any individual unless specific agreement has been obtained beforehand. All
documentation will be kept strictly confidential for a period of five years and will then be
destroyed.
Sharing results
In addition to submitting my final report to Royal Roads University in partial fulfillment
for a Master of Arts in Leadership Degree, I will also be sharing my research findings with
Providence HealthCare senior leadership team. The data will be used to recommend strategies
that can be used in order to optimize physician participation. The recommendations will be
offered toward an appreciative inquiry summit where senior leadership, medical affairs and
physician leaders can formulate guidelines for participation.
The project will be submitted to the British Columbia Patient Safety and Quality Council
(BCPSQC) for the basis of a poster or seminar presentation. The final report will be submitted
for publishing at the discretion of the author.
Procedure for withdrawing from the study
Participants are free to withdraw from the study at any time. If you choose to withdraw
you should contact me immediately. If you chose to participate in the anonymous electronic
survey, it will not be possible to remove respondent data; however, attribution of individual
sources of the data will be protected, therefore it will not be possible to remove the data from the
final report.
You are not required to participate in this research project. Completing and returning the
survey is an indication that you have read and understand the information here and give free and
informed consent to participate in this project.
If you choose to participate in the survey please click submit following survey
completion.
If you have any questions relating to the survey or its purpose, do not hesitate to contact
me at 604-341-4727 or mlowery@providencehealth.bc.ca
Please keep a copy of this information for your records.
Regards
Mandy Lowery RN CNL
Medicine Program
St. Paul’s Hospital

Appendix H – Email Invitation Letter
Dear [Prospective Participant],
I would like to invite you to be part of a research project that I am conducting. This project is
part of the requirement for my Master’s Degree in Health Leadership at Royal Roads University.
The objective of my research project is to identify strategies for the Medicine Program at St.
Paul’s Hospital to optimize physician participation in quality improvement initiatives.
You have been chosen as a prospective participant because you chose to respond in the survey
offering your perspectives and opinions in further dialogue. Physician experts frequently have
the ability to empower and influence their peers and to foster change.
This phase of my research project will consist of a narrative interview, where you will be offered
opportunity to give opinion, perspective and assertions related to physician participation in this
topic. The interview is estimated to last 45 -60 minutes.
Confidentiality, security of data, and retention period
I will work to protect your privacy throughout this study. All information I collect will be
maintained in confidence with hard copies (e.g., consent forms) stored in a locked workplace
office at St. Paul’s Hospital. Electronic data (such as transcripts or audio files) will be stored on a
password protected computer. Information will be recorded through hand-written notes, and
conversations audio-recorded at the time of the interview. The audio tapes will be destroyed at
the end of the research project. Wherever possible this data will be stripped of any and all
identifying markers. The final report will also ensure the data sources are kept anonymous. At no
time will any specific comments be attributed to any individual unless specific agreement has
been obtained beforehand. The use of code numbers or pseudonyms to identify the results
obtained from individual participants will protect anonymity. All documentation will be kept
strictly confidential for a period of five years and will then be destroyed. This information allows
you to make a fully informed decision on whether or not you wish to participate. Please review
this information before responding.
Sharing results
In addition to submitting my final report to Royal Roads University in partial fulfillment for a
Master of Arts in Leadership Degree, I will also be sharing my research findings with Providence
HealthCare senior leadership team. The data will be used to recommend strategies that can be

used in order to optimize physician participation. The recommendations will be offered toward
an appreciative inquiry summit where senior leadership, medical affairs and physician leaders
can formulate guidelines for participation. The participants that engage in narrative interviews
will be offered a copy of the final report. In addition the project will be submitted to the British
Columbia Quality and Safety Forum (BCQSF) for the basis of a poster or seminar presentation.
The final report will be submitted for publishing at the discretion of the author.
I realize that due to our collegial relationship, you may feel compelled to participate in this
research project. Please be aware that you are not required to participate and, should you choose
to participate, your participation would be entirely voluntary. If you do choose to participate, you
are free to withdraw, without prejudice, until the time of transcription. Any information obtained
from an individual who chooses to withdraw from the research study following the narrative
interview will be returned to that individual. However when the interview has been transcribed
the information will then become part of an anonymous data set and your opinions will not be
able to be identified and withdrawn from the research.
If you do not wish to participate, simply do not reply to this request. Your decision to not
participate will also be maintained in confidence. Your choice will not affect our relationship in
any way.
Please feel free to contact me at any time should you have additional questions regarding the
project and its outcomes.
If you would like to participate in my research project, please contact me before____________
at:
Email: mlowery@providencehealth.bc.ca
Telephone: 604-341-4727
Sincerely,
Mandy Lowery CNL

Appendix I – Narrative Interview Consent Form
By signing this form, you agree that you are over the age of 19 and have read the information
letter for this study. Your signature states that you are giving your voluntary and informed
consent to participate in this project.
I consent to the audio recording of the narrative interview
Name: (Please Print): __________________________________________________
Signed: _____________________________________________________________
Date: ______________________________________________

OLP Final Report Mandy Lowery Lead 640

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OLP Final Report Mandy Lowery Lead 640