Summary of findings
This study provides a rich understanding of the core competencies and qualities of QIMs operating in NZ healthcare system. It sheds light on how QI can be facilitated in HOs by underscoring the core competencies and qualities of QIMs that are required in accomplishing the everyday and long-term objectives of QI in their HOs.
First, the study reveals that the QIMs largely associate their ability to successfully drive QI transformation in HOs with their personal competencies. Based on the interviews, three groups of competencies were identified: (1) expertise in QI which includes profound knowledge of QI methodologies and contextual competence (experience in healthcare); (2) leadership competencies comprising of long-term view, system thinking, sense-giving, and motivating abilities; and (3) interpersonal competencies represented by approachability, supportiveness and trustworthiness. These competencies allow QIMs to establish their legitimacy and lead the QI agenda with minimal resistance from the staff in their respective HOs.
Second, by differentiating between the two groups of QIMs, traditional and clinical QIMs, this study highlights the key challenges for both groups of QIMs, who often end up implementing QI in a ritualistic and superficial manner focusing on small pockets instead of a system-wide approach [
10,
19‐
21,
52]. Indeed, traditional QIMs who bring with them extensive QI knowledge and skills often cannot implement initiatives in a meaningful way as they lack an understanding of the context of this implementation, the needs and expectations of various stakeholder groups as well as the ways to achieve their cooperation essentially lacking contextual and interpersonal competencies. Unless they become the
insiders in the system, their efforts could be seen as ceremonial at best [
28]. However, clinical QIMs are not necessarily in a better position. While being an
insider—having internal knowledge and relationships required to get support for QI implementation—they overlook the need for such leadership competencies as systems thinking and long-term vision. Focusing on tools learnt during their short-term training, they implement QI at the unit-level, which often results in the transference of waste rather than eliminating it, impeding system-wide transformation [
19,
21,
28].
Comparison with existing literature
The existing literature undescores the importance of QIM competencies and suggests that different contexts may require different competence profiles from QIMs [
53]. However, there is limited literature on QIMs in the health sector [
29], and it has mostly focused on the QI implementations themselves rather than the QIMs’ role and expertise within these implementations [
54]. Our study builds on previous attempts to understand the requirements to QIM competencies in healthcare [
29,
30,
55]. It identifies the perspectives of the two key groups of healthcare QIMs, therefore, offering a refined understanding of key QIM competencies required in HOs.
While the QIM competencies mentioned in the findings are consistent with previous literature [
29,
53‐
56], the importance and relationships between these competencies are specific to the healthcare context. Thus, it supports the literature in proposing that the QIMs’ competencies and their priority can be industry-dependent—a competency can be more crucial in a respective industry than the other. In particular, our study suggests that contextual competence, as raised in previous studies [
34] (the expertise in healthcare environment and healthcare-specific knowledge), may be one of the key QIMs’ competence in healthcare [
57,
58]. This finding emphasises that to successfully drive QI in healthcare, QIMs need to have strong associations and understand well this context; more importantly, they need to be viewed as the
insiders by other employees [
28]. Without this embeddedness in the health context, it is very difficult to carry out QI initiatives in a meaningful way [
24] and ensure their sustainability [
9,
59]. While clinical QIMs are already embedded in the healthcare context, traditional QIMs may require intensive support and socialisation.
Further, our findings underscore an important role of interpersonal competencies in the healthcare context and the role they play in facilitating the implementation of QI. This is not surprising, as interpersonal (human or communication) competencies were highlighted as important by previous studies separately [
25,
29,
60,
61]. For example, the ‘house of’ competencies’ model developed by Ingason and Jónsdóttir put communication competencies at the top of the hierarchy [
53], which is most important for QIMs. However, our study suggested that the relationship between interpersonal competencies of QIMs and their performance in healthcare might be more nuanced. Our participants highlighted that interpersonal competencies were important not on their own but in relation to other competencies and worked as the enablers of those competencies. Traditional QIMs strongly emphasised that, without these competencies, the potential of other competencies could be weakened (see Table
2). This again highlights that hierarchy and relationships among QIMs’ competencies may be different in different industries.
Perhaps unsurprisingly, being well-socialised in the healthcare environment, the clinical QIMs did not emphasise the role of interpersonal skills and local expertise in their success [
62]. This suggests that clinical QIMs might be well positioned to carry out QI initiatives enjoying stronger trust, higher legitimacy and having a better understanding of the needs of healthcare. However, incumbent position may also come at some cost. Thus, we found that clinical QIMs did not pay much attention to driving change within their organisations which was reflected in the lack of mentioning of leadership competencies as necessary for successful QI implementation. The
insider position and strong links with the sector perhaps prevents them from seeing the need for a radical change [
63].
The development of leadership competencies is also not supported by the QI training for the clinical QIMs. One integral part of a QIM’s job is managing people across the HO and assisting them with QI initiatives. The training often provided to clinical QIMs in-house or within the healthcare sector is not necessarily comprehensive focusing on the application of QI tools to particular scenarios or situations. It lacks the exploration of QI as a systems improvement approach, characteristic of industrial QI training, thus not sufficiently developing such leadership competencies as long-term view and system thinking. This is why clinical QIMs often see QI as an ‘add-on’, rather than an integral part of the care process [
20,
28,
64,
65]. This potentially translates into a ritualistic application of QI methods which seldom leads to better patient care even when significant healthcare resources are committed to QI activities [
22,
25].
Overall, our study confirms the previous insights that QIM competence profiles need to be related to the contexts in which QIMs operate [
53]. Furthermore, it suggests that in complex settings such as healthcare, different types of QIMs with different competence profiles may be required to fulfil a HO’s QI agenda.
Limitations of the study
The data were collected only from the NZ healthcare system. Therefore, the findings regarding the QIMs may not be generalisable. While the NZ healthcare system closely resembles other national healthcare systems [
66], and has constantly used and implemented similar QI programmes and training activities such as The Productive Ward, Releasing Time to Care and Institute for Healthcare Improvement’s Open School and Model for Improvement [
67,
68], we still believe a future comparative multi-country study, focusing on a similar research question, could be valuable.
Second, while identifying QIMs’ account of the competencies and qualities they require in accomplishing the everyday and long-term objectives of QI in their organisations, this study does not test any relationship between and within these competencies and the actual QI performance of HOs. Therefore, further research seeking answers to the question of how competencies are related to each other and HO performance may be useful.
Interestingly, QIMs did not mention externally-oriented competencies—competencies, which are required for successful communication and interaction with external stakeholders. Given that HOs have multiple external stakeholders (e.g., patients, communities, governments etc.) interested in the improvement of health services quality, what are the implications of overlooking such relevant competencies by the QIMs? We believe that the context-specific competence profiles should pay special attention to these blind spots to understand why they appear and what are the implications of the absence of such competencies? Once again, a holistic approach to QI with a focus on co-design and co-production of health services may be a good start. Combining traditional QI with co-design can have significant outcomes [
9,
69,
70].
Finally, the findings from our study hint at the difference in perspectives of the two groups of QIMs. Since both groups work in HOs and, moreover, quite often work together in the same team, it is important to understand the implications of their different views and perspectives for QI practice. It would be interesting and important to understand how these differences in perspectives influence the team dynamics and the development and implementation of the QI agenda in HOs. Future studies can look at how the diversity in QI teams could be leveraged to address the QI dilemma, which explores the balance between exploration and exploitation in QI [
12,
71], and how the harmony between the different viewpoints could be achieved. Indeed, the medical professionalism logic based on patient care working along the managerial and QI logic of efficiency and continuous improvement tends to create tensions [
28]. Therefore, understanding how these tensions are approached and resolved in a QI team could be of significant importance.
Implications for practice and health policy
Our study differentiates between traditional QIMs and clinical QIMs suggesting how both of these groups can be better prepared and effective in their jobs. We believe that this study has crucial implications for practice. Both groups require a comprehensive socialisation and training process which should be designed to meet their specific needs, and HOs need to ensure such QIM needs are met so that their QI implementations have a higher rate of success.
For HOs, this study provides valuable practical insights. We believe that HOs need to provide better support for their QIMs, and ensure that they have the core competencies and qualities before they are required to conduct large-scale QI initiatives to improve their success rate. Thus, perhaps traditional QIMs can be educated to incorporate the concept of stakeholder value and multiple-stakeholder perspectives, a key feature of healthcare systems all around the world. More attention could be paid to the role of co-design methodologies in QI. In addition, traditional QIMs may require a comprehensive socialisation process when starting work in HOs with the emphasis on the understanding of the healthcare context. These approaches will enable traditional QIMs to better understand the context for QI and help them to gain support from different stakeholder groups within the HOs. Similarly, the training and development of the clinical QIMs should be widened and soft elements of QI—QI culture, philosophy and systems perspective—should be incorporated into it to provide them with the system perspective and prepare them to lead QI transformations. There is already some evidence to support our claims [
12,
13]. However, more studies are required to understand the effects of holistic QI training, comprising of hard and soft QI tools, on QIMs and their effectiveness in HOs. Perhaps developing QI teams that comprise of both the traditional as well as clinical QIMs could be a good start. Research already suggests that cooperation among clinical staff and QIMs should help to decrease resistance towards QI in HOs [
12,
28]. It should also help both of these groups to learn from each other and offset their weaknesses. However, further research into the efficacy of such QI teams is required.