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Recognizing Quality Improvement and Patient Safety Activities in Academic Promotion in Departments of Medicine: Innovative Language in Promotion Criteria

2016; Elsevier BV; Volume: 129; Issue: 5 Linguagem: Inglês

10.1016/j.amjmed.2016.01.006

1555-7162

Thomas O. Staiger, Lynnea M. Mills, Brian M. Wong, Wendy Levinson, William J. Bremner, Anneliese M. Schleyer,

Medical Malpractice and Liability Issues

Perspectives Viewpoints•Disseminating best practices for the role of quality improvement and patient safety activities in promotions could advance academic departments' efforts to achieve excellence in clinical care, medical education, and discovery.•We identified innovative language from existing promotion criteria in departments of medicine, and propose language for departments of medicine to consider including in promotion criteria to assess activities in quality and safety. •Disseminating best practices for the role of quality improvement and patient safety activities in promotions could advance academic departments' efforts to achieve excellence in clinical care, medical education, and discovery.•We identified innovative language from existing promotion criteria in departments of medicine, and propose language for departments of medicine to consider including in promotion criteria to assess activities in quality and safety. Academic medical centers (AMCs) strive to provide the highest quality of care, but the physicians who provide leadership for quality improvement find the academic environment challenging.1Pronovost P.J. Miller M.R. Wachter R.M. Meyer G.S. Perspective: physician leadership in quality.Acad Med. 2009; 84: 1651-1656Crossref PubMed Scopus (51) Google Scholar AMCs and their academic departments need mechanisms for documenting and rewarding efforts and achievements in quality improvement (QI) and patient safety (PS) to recruit and retain physicians qualified to lead and assist with QI/PS.2Stevens D.P. Kirkland K.B. The role for clinician-educators in implementing healthcare improvement.J Gen Intern Med. 2010; 25: S639-S643Crossref PubMed Scopus (9) Google Scholar, 3Taylor B.B. Parekh V. Estrada C.A. Schleyer A.M. Sharpe B. Documenting quality improvement and patient safety efforts: the Quality Portfolio. A statement from the Academic Hospitalist Taskforce.J Gen Intern Med. 2013; 29: 214-218Crossref Scopus (10) Google Scholar There are currently few widely recognized mechanisms other than peer-reviewed publications for identifying promotional scholarship in QI and PS. The limited methods for acknowledging scholarly work in QI and PS may discourage faculty from pursuing this area as the focus of their scholarship. Better alignment between physician involvement in QI/PS and promotion criteria could help AMCs and academic departments improve the quality and value of care they provide and more effectively lead the local and national health care quality/safety agenda.1Pronovost P.J. Miller M.R. Wachter R.M. Meyer G.S. Perspective: physician leadership in quality.Acad Med. 2009; 84: 1651-1656Crossref PubMed Scopus (51) Google Scholar, 4Shojania K. Levinson W. Clinicians in quality improvement: a new career pathway in academic medicine.JAMA. 2009; 301: 766-768Crossref PubMed Scopus (69) Google Scholar Although QI/PS achievements are viewed favorably by chairs of departments of medicine, traditional pathways for fostering the professional advancement, promotion, or tenure of medical school faculty members infrequently embrace these contributions.3Taylor B.B. Parekh V. Estrada C.A. Schleyer A.M. Sharpe B. Documenting quality improvement and patient safety efforts: the Quality Portfolio. A statement from the Academic Hospitalist Taskforce.J Gen Intern Med. 2013; 29: 214-218Crossref Scopus (10) Google Scholar In a survey of chairs of academic departments of internal medicine, the majority of respondents did not find their existing promotion criteria to be useful in assessing QI/PS work.5Staiger T.O. Wong E.Y. Schleyer A.M. Martin D.P. Levinson W. Bremner W.J. The role of quality improvement and patient safety in academic promotion: results of a survey of Chairs of Departments of Internal Medicine in North America.Am J Med. 2011; 214: 277-280Abstract Full Text Full Text PDF Scopus (13) Google Scholar Seventy-eight percent of respondents thought it would be helpful to have guidelines for evaluating the role of QI/PS work for promotions. By making participation in QI/PS more attractive to faculty, identifying and disseminating best practices for the role of these activities in promotions could advance AMCs' and academic departments' efforts to achieve excellence in clinical care, medical education, and discovery.5Staiger T.O. Wong E.Y. Schleyer A.M. Martin D.P. Levinson W. Bremner W.J. The role of quality improvement and patient safety in academic promotion: results of a survey of Chairs of Departments of Internal Medicine in North America.Am J Med. 2011; 214: 277-280Abstract Full Text Full Text PDF Scopus (13) Google Scholar Accordingly, we set out to identify innovative language from existing promotion criteria in departments of medicine and to propose language for departments of medicine to consider including in promotion criteria to assess activities in quality and safety. The authors developed a short survey intended to identify candidate departments of medicine in the US and Canada for promotions materials review. Institutions were asked: 1) Does your institution have promotion criteria it uses to successfully promote faculty who work in the areas of quality improvement and patient safety?, and 2) Are you willing to provide an example or copy of your institution's current promotion criteria? The survey was sent to 207 members of the Association of Professors of Medicine (APM) or of the Alliance for Academic Internal Medicine (AAIM) in February 2014. The APM is the organization of departments of internal medicine represented by chairs and appointed leaders at medical schools and affiliated teaching hospitals in the US and Canada. The AAIM is a consortium of 5 academically focused specialty organizations representing departments of internal medicine at medical schools and teaching hospitals in the US and Canada. This list of self-identified candidate institutions was supplemented with: 1) institutions identified in a survey published in 2011 that had promoted 2 or more physicians based predominantly on work in QI/PS, and 2) the authors' knowledge of institutions having possible best practices.5Staiger T.O. Wong E.Y. Schleyer A.M. Martin D.P. Levinson W. Bremner W.J. The role of quality improvement and patient safety in academic promotion: results of a survey of Chairs of Departments of Internal Medicine in North America.Am J Med. 2011; 214: 277-280Abstract Full Text Full Text PDF Scopus (13) Google Scholar Four of the authors (AS, BW, LM, TS) evaluated promotion criteria for each of the identified candidate institutions for their effectiveness in recognizing the role of quality and safety in promotions on a 1-5 scale. A score of 5 was considered ideal promotion criteria and a score of 1 indicated that no significant innovations were present. Language considered to be a possible best practice based on clarity, effectiveness, or innovation was abstracted, starting with the 4 institutions with promotion criteria with the highest average global ratings. Important themes were identified and representative language was selected. Language was included from the other candidate institutions' promotion criteria until all important themes and unique representative language were identified. Differences regarding which language to abstract were resolved by consensus discussion. Promotion criteria from a total of 20 institutions were identified and evaluated. Twelve institutions were included based on "yes" responses on both questions in the APM/AAIM survey. An additional 6 institutions were identified from the 2011 survey, and 2 were identified directly by the authors. We identified 3 innovative practices in our review of the promotion criteria from candidate institutions:1.Language specifically acknowledging that faculty contributions in quality and safety are essential to the core mission of the department.2.Expansion of the definition of scholarship to include the scholarship of application.3.An explicit framework in the promotions process for evaluating and recognizing activities in quality and safety. Given the increasing importance of quality and safety to the overall strategic mission of AMCs, this addition is an important step in acknowledging the value of quality and safety contributions. Placing quality and safety front and center within the promotions materials helps elevate these activities to the same level as that of other academic pursuits, such as research and education. The exemplary example of this approach we were able to identify is in the promotions document of the University of California at San Francisco (UCSF), which includes the following statement:"The goal of these guidelines is to highlight, foster, and reward faculty who are engaged in Systems Innovation, Quality Improvement and Patient Safety activities as part of the promotion process. The new guidelines recognize the growing need to explicitly acknowledge such faculty activities, and builds on recommendations for a 'Quality Portfolio' … that mirrors the Educator's Portfolio already in use at UCSF … We believe adopting these guidelines is a first step towards formally making our institution a leader of systems innovation in academic medical settings …" Ernest Boyer, in "Scholarship Reconsidered," proposed that scholarship includes: 1) the scholarship of discovery, 2) the scholarship of integration, 3) the scholarship of application, and 4) the scholarship of teaching.6Boyer E.L. The scholarship of teaching: from Scholarship Reconsidered: Priorities of the Professoriate.Coll Teach. 1991; 39: 11-13Crossref Google Scholar, 7Glassick C.E. Huber M.T. Maeroff G.I. Boyer E.L. Scholarship Assessed: Evaluation of the Professoriate. Jossey-Bass, San Francisco1997Google Scholar Six assessment standards for assessing scholarly work under this framework have been proposed: 1) clear goals; 2) adequate preparation; 3) use of appropriate methods; 4) achievement of significant results; 5) effective presentation and communication of results; and 6) reflective critique of one's work.7Glassick C.E. Huber M.T. Maeroff G.I. Boyer E.L. Scholarship Assessed: Evaluation of the Professoriate. Jossey-Bass, San Francisco1997Google Scholar A portfolio method in the health sciences has been recommended for documenting the objectives of the scholarship of integration or application activities, the rigor associated with the activity, and evidence of impact for scholarship.8Hofmeyer A. Newton M. Scott C. Valuing the scholarship of integration and the scholarship of application in the academy for health sciences scholars: recommended methods.Health Res Policy Syst. 2007; 5: 5Crossref PubMed Scopus (36) Google Scholar Several promotions materials included explicit reference to this expanded definition of scholarship. The scholarship of application, in which knowledge, rigor, and expertise are applied to important problems with results that can be shared with peers, represents the most useful frame to situate quality and safety activities. Some institutions that referred to Boyer's definition of scholarship introduced a formal mechanism for recognizing quality and safety activities that are impactful, but that may not align with traditionally recognized forms of academic achievement, such as grants and publications. For example, Harvard Medical School lists the following examples as evidence of scholarship within their "Clinical Expertise and Innovation" stream:"Associate Professor–Influencing Clinical Practice:Development of innovative approaches to diagnosis, treatment or prevention of disease, applications of technologies and/or models of care that influence care at a regional, and most often national level. Examples of activities (many others are possible) include the development of:• A clinical care model• Practice guidelines• An innovative application of an existing technologyScholarship• Development of guidelines and/or protocols for patient treatment or delivery of care that are adopted regionally, and in some cases, nationally"9Criteria for Appointment and Promotion. Harvard Medical School and Harvard School of Dental Medicine. Available at: http://facultypromotions.hms.harvard.edu/. Accessed February 12, 2016.Google Scholar The University of Toronto addresses the scholarship of application in its Clinician in Quality and Innovation role with the following language:"The Clinician in Quality and Innovation (C-QI) is a new job description in the Department of Medicine that recognizes applied, scholarly work carried out by Department members focused primarily on enhancing health outcomes through leadership and collaboration around improvement and innovation activities. This job category serves to broadly include members whose primary academic interest is that of engaging in quality improvement (QI), patient safety, knowledge translation (KT), or other forms of healthcare innovation (eg, advancing health informatics, developing new models of care)."10Clinical Academic Position Descriptions. Medicine. University of Toronto. Available at: http://www.deptmedicine.utoronto.ca/Faculty/appointments/domjob.htm#ClinicianinQualityandInnovation. Accessed February 12, 2016.Google Scholar However, only a minority explicitly linked Boyer's definition of scholarship of application with quality and safety activities. Drawing this direct linkage would serve to provide justification for expanding promotion criteria to include quality and safety activities as academically valuable pursuits. Despite acknowledging the broader definition of Boyer's scholarship of application, many promotions criteria still favor more traditional forms of impact, such as grants and publications. Therefore, there remains a need to create a framework within the promotion process to specifically allow for documentation of quality and safety activities and evaluation of their impact. A number of institutions have developed such frameworks (see Table). While each organizes its documentation requirements and activities slightly differently, the key tenets include a dedicated place for faculty members to list quality and safety activities as part of their promotions application. They also provide measures of dissemination and impact that guide the review of promotions materials.TableFrameworks for Evaluating and Recognizing Activities in Quality and Safety in the Promotions ProcessInstitutionDescriptionExample ActivitiesEvaluation of ImpactHarvard Clinical Expertise and Innovation MetricsInfluencing Clinical Practice: Key role in the development or local adoption of innovative approaches to diagnosis, treatment or prevention of disease, use of technologies or models of care deliveryExamples of activities (many others are possible) include the development of:•A clinical care model•Practice guidelines•An innovative application of an existing technology•Assisting with the creation of a novel interdisciplinary clinical service•Key role in development and local implementation of practice guidelines for care or to prevent medical errors•Developing treatment protocols or practice guidelines that influence the standard of careDevelopment of guidelines or protocols for patient treatment or delivery of care that are adopted:•Locally (Assistant Professor)•Regionally, and in some cases, nationally (Associate Professor)•Nationally, and in some cases, internationally (Professor)Oregon Health Sciences UniversityThose who aspire to this rank must have a satisfactory record of accomplishment in all of the following categories: teaching, scholarship, service, and a substantial record in at least one of these categories.•Participate or lead the development of innovative or complex clinical initiatives.•Demonstrated impact of practice initiatives on improved quality.•Produce innovative clinical programs that are disseminated and serve as models for other institutions.•Obtain external funding for practice innovations, new clinical initiatives, or innovative or complex shared scientific resources.Satisfactory achievement involves faculty participation in activity; substantial achievement involves faculty leadership, and demonstrated impact on improved quality; outstanding achievement involves dissemination of innovative programs to other institutions, or external funding for new initiatives.University of ColoradoPromotion "requires meritorious performance in teaching, scholarly activity, and service/clinical activity and excellence in one of teaching, research, or clinical activity."Clinical Activities include:•Activities that promote health care quality and patient safety•Evaluation of the effectiveness of care (quality, outcomes, patient safety, utilization, access, cost)•Significant self-assessment activities and audits of one's own practice that have led to improvements in quality, efficiency, or outcomes of care.Criteria define meritorious criteria as well as excellence criteria (for excellence, candidate should have demonstrated leadership, or creative, active participation in quality and safety practices).Medical College of WisconsinClinician Administrator Pathway: Full-time faculty appointed to the Clinician-Administrator path are expected to devote their professional effort predominantly to clinical practice or administration within the College or clinical/community partners.Examples might include:•Advancements for patients and clinical care (eg, development of a referral program or new clinical care pathway)•An administrative leadership role for a hospital or college activity•Innovative management of a clinical/administrative/educational unitNot specifiedUniversity of Texas HoustonClinician/Educator Pathway:Advancement on the Clinician/Educator pathway will be granted to individuals with documented excellence in clinical practice, teaching, peer esteem, and scholarly activity in the form of documentable contributions to the corpus of knowledge in their areas or in advances in clinical care or outcomes. Quality improvement and clinical effectiveness projects will also be considered for advancement.Clinician Track:Consideration for advancement will also include evidence-based quality improvement (QI) or clinical effectiveness criteria.Examples include:•Innovation in treatment programs that improve patient care or outcomes•Development of QI projects or comparative effectiveness studies that improve patient care or outcomes•Innovations that improve patient satisfaction compared with national benchmarks•Innovations that improve training of medical students, house officers, fellows, or faculty in patient safety and quality of careDocumentation should be provided in candidate's CV and if unpublished, should include the objectives, methods, findings, and results.University of TorontoClinician in Quality and Innovation (C-QI)C-QI is a new job description in the Department of Medicine that recognizes applied, scholarly work carried out by Department members focused primarily on enhancing health outcomes through leadership and collaboration around improvement and innovation activities. This job category serves to broadly include members whose primary academic interest is that of engaging in quality improvement (QI), patient safety, knowledge translation (KT), or other forms of health care innovation (eg, advancing health informatics, developing new models of care). For the purposes of this job description, the term "quality and innovation" is used in its broadest sense, and is intended to encompass activities relating to, but not limited to, quality improvement, patient safety, knowledge translation, or other forms of health care innovation.Expected Activities•Significant engagement in improvement, translational, or innovation activities, such as leading a divisional QI project, or contributing significantly to one sub-component of institution-wide/multisite QI initiatives•Piloting new models of care (eg, establishing a postdischarge clinic), innovations, or implementing established QI interventions (eg, implementing order sets to standardize care) in their local clinical divisionMeritorious activities•Leading major local QI initiatives where implementation issues are known to be complex (eg, leading the implementation of Computerized Physician Order Entry across an entire institution)•Major contribution to the implementation of health care innovations and new models of care•Significant leadership position either locally or nationally/internationally in fields such as QI, patient safety, or knowledge translation•Significant time mentoring learners to engage in improvement or innovation activities•All Clinicians in Quality and Innovation must maintain a formal CPA (Creative Professional Activities) dossier to document and reflect on their improvement or innovation activities and their impact on patient care.•Clinicians in Quality and Innovation will carry out improvement or innovation activities in a scholarly way with evidence of ongoing evaluation to assess the impact of their work on their local clinical practice. Open table in a new tab One of the best examples is the UCSF Systems Innovation, Quality Improvement, and Patient Safety portfolio:"Our guidelines focus on highlighting work that is not already captured in the CV … Similar to adoption of the Educator's Portfolio, we expect members of the promotions committee to weigh contributions in QI for its merit and importance. A QI Portfolio allows faculty to provide richer descriptions of their QI work, which is poorly organized across the current CV.The newly approved QI portfolio will have the following categories:• Summary of Systems Innovation, Quality Improvement, and Patient Safety Activities• QI Leadership/Administrative Activity• QI Project Activity• QI Honors/Awards/Recognition• QI Training/CertificationOur guidelines are adapted from a national effort to create and promote adoption of a "QI Portfolio"3Taylor B.B. Parekh V. Estrada C.A. Schleyer A.M. Sharpe B. Documenting quality improvement and patient safety efforts: the Quality Portfolio. A statement from the Academic Hospitalist Taskforce.J Gen Intern Med. 2013; 29: 214-218Crossref Scopus (10) Google Scholar To our knowledge, this article is the first report utilizing existing promotion criteria in departments of medicine to identify and highlight innovative language to assess activities in QI/PS. The innovative promotion criteria we identified include language that specifically acknowledges the essential nature of faculty contributions in QI/PS to the core mission of the institution, expands the definition of scholarship to include the scholarship of application, and provides an explicit framework for evaluating and recognizing QI/PS activities. Recent literature supports the need to develop and implement such QI/PS promotion criteria. Continuous improvement of quality and safety in health care is a national priority. The QI/PS field is growing rapidly, with novel or broadening emphasis on several important areas, including high-value care, patient experience, and the use of electronic data recording and extraction in the context of financial incentives for quality measurement such as the US government's Meaningful Use program.11Smith C.D. Teaching high-value, cost-conscious care to residents: the Alliance for Academic Internal Medicine-American College of Physicians Curriculum.Ann Intern Med. 2012; 157: 284-286PubMed Google Scholar, 12ABIM FoundationChoosing Wisely: An initiative of the ABIM Foundation. American Board of Internal Medicine, Philadelphia2012http://www.choosingwisely.org/Google Scholar, 13Ahmed F. Burt J. Roland M. Measuring patient experience: concepts and methods.Patient. 2014; 7: 235-241Crossref Scopus (147) Google Scholar, 14Coulter A. Locock L. Ziebland S. Calabrese J. Collecting data on patient experience is not enough: they must be used to improve care.BMJ. 2014; 358: g2225Crossref Scopus (234) Google Scholar, 15Weinick R.M. Quigley D.D. Mayer L.A. Sellers C.D. Use of CAHPS patient experience surveys to assess the impact of health care innovations.Jt Comm J Qual Patient Saf. 2014; 40: 418-427Scopus (16) Google Scholar, 16Centers for Medicare & Medicaid Services (CMS)Electronic health records (EHR) incentives programs. Centers for Medicare and Medicaid Services, Baltimore2011http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.htmlGoogle Scholar, 17Anderson J.E. Chang D.C. Using electronic health records for surgical quality improvement in the era of big data.JAMA Surg. 2015; 150: 24-29Crossref Scopus (39) Google Scholar, 18Reed M. Huang J. Brand R. et al.Implementation of an outpatient electronic health record and emergency department visits, hospitalizations, and office visits among patients with diabetes.JAMA. 2013; 310: 1060-1065Crossref PubMed Scopus (59) Google Scholar AMCs face an ever-greater push to develop infrastructure and expertise to meet these demands and lead the quality/safety movement. In addition, AMCs and their academic departments require faculty who can role model and teach QI, PS, and systems-based practice to the next generation of physicians.5Staiger T.O. Wong E.Y. Schleyer A.M. Martin D.P. Levinson W. Bremner W.J. The role of quality improvement and patient safety in academic promotion: results of a survey of Chairs of Departments of Internal Medicine in North America.Am J Med. 2011; 214: 277-280Abstract Full Text Full Text PDF Scopus (13) Google Scholar, 19Neeman N. Seghal N.L. Davis R.B. Aronson M.D. Quality improvement and patient safety activities in academic departments of medicine.Am J Med. 2012; 125: 831-835Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 20Wong B.M. Kuper A. Hollenberg E. Etchells E.E. Levinson W. Shojania K.G. Sustaining quality improvement in graduate medical education: Lessons from social theory.Acad Med. 2013; 88: 1149-1156Crossref Scopus (17) Google Scholar Accreditation Council for Graduate Medical Education mandates, including the Clinical Learning Environment Review program, help drive this need.21Accreditation Council for Graduate Medical EducationClinical Learning Environment Review (CLER) program. Accreditation Council for Graduate Medical Education, Chicago2011http://acgme.org/acgmeweb/tabid/436/ProgramandInstitutionalAccreditation/NextAccreditationSystem/ClinicalLearningEnvironmentReviewProgram.aspxGoogle Scholar, 22Myers J.S. Nash D.B. Graduate medical education's new focus on resident engagement in quality and safety: will it transform the culture of teaching hospitals?.Acad Med. 2014; 89: 1328-1330Crossref PubMed Scopus (28) Google Scholar The success and sustainability of QI/PS education depend on institutions embracing a culture that legitimizes and validates QI/PS work.20Wong B.M. Kuper A. Hollenberg E. Etchells E.E. Levinson W. Shojania K.G. Sustaining quality improvement in graduate medical education: Lessons from social theory.Acad Med. 2013; 88: 1149-1156Crossref Scopus (17) Google Scholar Academic promotion represents the cornerstone of institutional recognition of faculty members' contributions. If AMCs view leadership in safe, high-quality, high-value patient care and education of physicians-in-training as fundamental to their mission, they must recognize and reward that work accordingly.4Shojania K. Levinson W. Clinicians in quality improvement: a new career pathway in academic medicine.JAMA. 2009; 301: 766-768Crossref PubMed Scopus (69) Google Scholar, 5Staiger T.O. Wong E.Y. Schleyer A.M. Martin D.P. Levinson W. Bremner W.J. The role of quality improvement and patient safety in academic promotion: results of a survey of Chairs of Departments of Internal Medicine in North America.Am J Med. 2011; 214: 277-280Abstract Full Text Full Text PDF Scopus (13) Google Scholar, 19Neeman N. Seghal N.L. Davis R.B. Aronson M.D. Quality improvement and patient safety activities in academic departments of medicine.Am J Med. 2012; 125: 831-835Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 20Wong B.M. Kuper A. Hollenberg E. Etchells E.E. Levinson W. Shojania K.G. Sustaining quality improvement in graduate medical education: Lessons from social theory.Acad Med. 2013; 88: 1149-1156Crossref Scopus (17) Google Scholar, 23Morath J. Hain P.D. Deshpande J.K. Gitlin J.D. Churchwell K.B. Patient safety as an academic discipline.J Pediatr. 2009; 155: 318e23Abstract Full Text Full Text PDF Scopus (4) Google Scholar This is critical for faculty recruitment, engagement, and long-term retention.4Shojania K. Levinson W. Clinicians in quality improvement: a new career pathway in academic medicine.JAMA. 2009; 301: 766-768Crossref PubMed Scopus (69) Google Scholar, 19Neeman N. Seghal N.L. Davis R.B. Aronson M.D. Quality improvement and patient safety activities in academic departments of medicine.Am J Med. 2012; 125: 831-835Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Given societal imperatives to improve health care quality and control costs, and growing interdependence between academic departments and AMCs, departments of medicine that engage in efforts to improve their quality, safety, and efficiency of care are likely to be more successful in achieving their broad clinical care, education, research, and community service missions.24Lofgren R. Karpf M. Perman J. Higdon C.M. The U.S. health care system is in crisis: implications for academic medical centers and their missions.Acad Med. 2006; 81: 713-720Crossref Scopus (30) Google Scholar There are increasing calls for a greater percentage of QI/PS work to be owned by Departments of Medicine, rather than hospitals and medical centers, and for both departments and subspecialty divisions to develop and support projects and leadership positions in this domain.19Neeman N. Seghal N.L. Davis R.B. Aronson M.D. Quality improvement and patient safety activities in academic departments of medicine.Am J Med. 2012; 125: 831-835Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 25Fleming L. Subspecialist scholarship in quality improvement.J Am Coll Cardiol. 2014; 64: 1064-1065Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Establishing formal QI/PS roles in academic departments sends a clear message that excelling in QI/PS is integral to all other missions: patient care, education, and research—in academic departments.19Neeman N. Seghal N.L. Davis R.B. Aronson M.D. Quality improvement and patient safety activities in academic departments of medicine.Am J Med. 2012; 125: 831-835Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar This will require a systematic approach by which departments and divisions can evaluate, recognize, and reward work in the quality and safety field. A standardized framework for the documentation of faculty members' QI/PS work, largely for promotion purposes, has been endorsed by national organizations including the APM, the Association of Chiefs and Leaders of General Internal Medicine, and the Society of General Internal Medicine.3Taylor B.B. Parekh V. Estrada C.A. Schleyer A.M. Sharpe B. Documenting quality improvement and patient safety efforts: the Quality Portfolio. A statement from the Academic Hospitalist Taskforce.J Gen Intern Med. 2013; 29: 214-218Crossref Scopus (10) Google Scholar It is unknown to what extent these frameworks have been adopted across institutions, but well-defined guidelines for promotion around QI/PS work can serve as a crucial adjunct for institutions seeking to honor faculty members' contributions in this realm. The innovative promotion criteria we identified provide clear means for documenting QI/PS excellence in innovation, change management, mentorship, teaching, and leadership as well as achievement, productivity, and success.3Taylor B.B. Parekh V. Estrada C.A. Schleyer A.M. Sharpe B. Documenting quality improvement and patient safety efforts: the Quality Portfolio. A statement from the Academic Hospitalist Taskforce.J Gen Intern Med. 2013; 29: 214-218Crossref Scopus (10) Google Scholar, 4Shojania K. Levinson W. Clinicians in quality improvement: a new career pathway in academic medicine.JAMA. 2009; 301: 766-768Crossref PubMed Scopus (69) Google Scholar Formats should be standardized to support comparative and peer review.3Taylor B.B. Parekh V. Estrada C.A. Schleyer A.M. Sharpe B. Documenting quality improvement and patient safety efforts: the Quality Portfolio. A statement from the Academic Hospitalist Taskforce.J Gen Intern Med. 2013; 29: 214-218Crossref Scopus (10) Google Scholar The criteria called out here provide specific frameworks to document QI/PS activities and highlight their academic value, in alignment with what has previously been developed for clinician-educators.3Taylor B.B. Parekh V. Estrada C.A. Schleyer A.M. Sharpe B. Documenting quality improvement and patient safety efforts: the Quality Portfolio. A statement from the Academic Hospitalist Taskforce.J Gen Intern Med. 2013; 29: 214-218Crossref Scopus (10) Google Scholar, 4Shojania K. Levinson W. Clinicians in quality improvement: a new career pathway in academic medicine.JAMA. 2009; 301: 766-768Crossref PubMed Scopus (69) Google Scholar, 26Howell L.P. Poon B. Nesbitt T.S. Anders T.F. A Web-based data repository and review system for faculty evaluation and promotion.Acad Med. 2007; 82: 704-712Crossref Scopus (9) Google Scholar, 27Lubitz R.M. Guidelines for promotion of clinician-educators. The Society of General Internal Medicine Education Committee.J Gen Intern Med. 1997; 12: S71-S78Crossref PubMed Scopus (45) Google Scholar, 28Simpson D. Hafler J. Brown D. Wilkerson L. Documentation systems for educators seeking academic promotion in U.S. medical schools.Acad Med. 2004; 79: 783-790Crossref Scopus (67) Google Scholar Existing processes have elucidated the need to identify measures of success, productivity, and scholarship that expand historic definitions while maintaining academic rigor.4Shojania K. Levinson W. Clinicians in quality improvement: a new career pathway in academic medicine.JAMA. 2009; 301: 766-768Crossref PubMed Scopus (69) Google Scholar, 5Staiger T.O. Wong E.Y. Schleyer A.M. Martin D.P. Levinson W. Bremner W.J. The role of quality improvement and patient safety in academic promotion: results of a survey of Chairs of Departments of Internal Medicine in North America.Am J Med. 2011; 214: 277-280Abstract Full Text Full Text PDF Scopus (13) Google Scholar Outcome effectiveness and results of QI/PS initiatives must still be communicated, however, results may be qualitative in nature.3Taylor B.B. Parekh V. Estrada C.A. Schleyer A.M. Sharpe B. Documenting quality improvement and patient safety efforts: the Quality Portfolio. A statement from the Academic Hospitalist Taskforce.J Gen Intern Med. 2013; 29: 214-218Crossref Scopus (10) Google Scholar Augmenting the recognition of value beyond the more traditional peer-reviewed publications frameworks is crucial. The examples we identified embrace traditional scholarship but broaden and begin to creatively redefine assessment of QI/PS work.4Shojania K. Levinson W. Clinicians in quality improvement: a new career pathway in academic medicine.JAMA. 2009; 301: 766-768Crossref PubMed Scopus (69) Google Scholar, 29Levinson W. Rothman A.I. Phillipson E. Creative professional activity: an additional platform for promotion of faculty.Acad Med. 2006; 81: 568-570Crossref Scopus (17) Google Scholar Several possible limitations of this study deserve mention. Chairs of academic departments of medicine self-identified their institutions as having promoted faculty primarily on QI/PS work. QI/PS may be variably defined across institutions. In addition, our methodology may have failed to identify other promotion criteria that represent an innovative practice and that support QI/PS work in academic promotion. Our methodology did not allow us to determine how these promotion criteria are applied at a given institution or how successfully candidates seeking promotion on the basis of QI/PS were advanced and promoted. Future studies could examine how institutions apply these criteria and whether they encounter barriers in doing so. Our methodology relied on the expert opinions of the authors to identify and propose innovative language. Although the authors have substantial experience in QI/PS activities in Departments of Medicine and in AMCs, other experts could arrive at different conclusions regarding innovative language. As demand for physician faculty engagement in QI/PS grows, recognition of their contributions to the success of AMCs is critical to efforts to recruit and retain faculty with QI/PS expertise. These innovative practices in promotion criteria could help encourage academic faculty to lead QI/PS and teach QI/PS knowledge and skills to the next generation. This is critical to ensure the future success of AMCs' and academic departments' efforts to achieve excellence in patient care, education, discovery, and innovation. We would like to express our appreciation to the Alliance for Academic Internal Medicine and the Association of Professors of Medicine for their invaluable assistance in distributing our survey to their members.