Quality improvement (QI) programs bridge the gap between standards of care and actual care delivered to patients. QI strives to enhance care delivered to patients1 and health outcomes by standardizing the processes and structure in health care.1–3 QI programs provide a means to implement QI. Given that this is a relatively new integration in the field of psychiatry, there are many gaps in the implementation of QI. The most prevalent being a lack of training opportunities, expertise, and faculty development to improve QI knowledge.4 Education programs involving collaboration,5,6 along with mentorship,7 are potential avenues for applying QI. Unfortunately, a way to integrate these ideas has not yet been fully developed.

QI is essential to improving patient care and providing practitioners with a means to develop professionally. Essentially, QI projects start with a problem that is impacting health care. Providers then work toward determining how to improve or solve that problem. This can play a role in reducing mortality and morbidity rates.8 The main goal of QI is to ensure that health services are in line with current professional knowledge and that desired health outcomes are achieved through consistent reflection and improvement.2 Formal QI includes structured programs and relationships facilitated by organizations, such as workshops, reading lists, online education tools,9,10 teaching practitioners about QI principles, or having them complete quality improvement projects under the supervision of more senior faculty.11 Collaborative participation from interdisciplinary teams with QI skills and the inclusion of all related stakeholders, such as patients, is also essential.13

Formal education programs involving collaboration have demonstrated positive results as QI initiatives. A University of Toronto study found that a colearning approach was effective in improving QI knowledge and skills among faculty and enabled faculty greater capacity to teach and mentor QI.5,6 A program designed with the purpose to aid and teach interprofessional health care teams on how to lead their own QI projects was also recently performed at several health- and science-focused schools. Most participants reported that the program adequately prepared them to lead a future QI project and that they would like to implement similar programs in their respective practices.16 Almost all the teams reported improved awareness of QI issues and tools, changes in processes and improved outcomes, and even an improvement in patient satisfaction and length of patient stay.16

A novel approach to collaborative QI is mentored implementation, which has been recognized by the Joint Commission and the National Quality Forum with the 2011 John M. Eisenberg Award for Innovation in Patient Safety and Quality at the National Level.22 Mentorship is a relationship used to foster development, growth, and learning between two individuals with a similar career, often including one person with more experience and one with less experience in that field.17 Mentors offer insight to their mentee by sharing their knowledge or skills in a field, rather than simply coaching a person by providing guidance. Different types of mentoring models outlined in medical literature generally include one-to-one mentoring between a mentor and a mentee, group mentoring, and mentoring among peers.7 These formal mentoring relationships involving organizational programs created to facilitate structured support are in contrast to informal mentoring, which is created through personal relationships and varies in content, length, or frequency of meetings.18

Despite the lack of randomized controlled trials on mentorship effects, systematic reviews suggest mentorship programs provide benefits to the mentee including personal growth, career assistance, career direction, confidence in the field, networking opportunities, and research efficiency for medicine.19,20 QI peer mentoring also aids the transition into new working environments, such as integrated, geriatric care settings.21 Because of these positive impacts, providing mentorship within medical professions has been cited as a “specific career advancement tool.”7 Mentorship programs are critical to professional development, starting in medical school, and continuing throughout postgraduate residency training. Therefore, mentoring has been found to have widespread implications for innovation within medicine in career growth, professional development, and QI advancement.

Collaboration is an essential component of QI. Mentorship may enhance the collaboration within QI and also advance continuing professional development (CPD). CPD involves any activity a health care professional engages in to update, develop, and maintain skillset and the ability to meet patient’s needs.14 Medical disciplines have been looking for approaches to integrate QI and CPD.4 The potential for a collaborative means of implementing CPD through QI was outlined by the 2009 Institute of Medicine report, Redesigning Continuing Education in the Health Professions. They stated “the continuing professional development (CPD) system will benefit when its providers and researchers collaborate with other professionals in the QI community; efficiencies gained from such collaborations could yield important benefits to patients.”15 Some examples include having proven educational techniques for health professionals based on quality improvement and continuous evaluation of their CPD activities to determine their effectiveness.15 This joint effort could be beneficial to improve patient care.

Mentoring seems to be an ideal means to integrate CPD and QI into academic medicine and related health care disciplines. It can also further the building of QI capacity among individuals within these fields. However, research has not yet identified potential ways in which this connection may be made. Furthermore, implementation of QI interventions depends on maintained leadership support, proper QI resources, dedicated staff time, robust systems, and change management.12 There is a need for QI to be integrated more fully into the culture of health care departments.4 Currently, there is limited insight on ways in which mentorship programs can be implemented effectively into academic medicine or what needs must be fulfilled to achieve this goal. These gaps highlight the necessity of more formal training programs to create experts in the field who can provide further training.4

Mentoring can allow for the dissemination of key skills to new learners and foster enhanced QI activity within organizations. Mentoring also allows for mentees to learn best practices in QI and have ongoing support for growth and development. Our project set out to understand mentoring needs within an academic setting through a qualitative assessment. Data collection will aid in our understanding of mentoring preferences, facilitators, and barriers to implementing mentorship models. The authors examined individuals' understanding of the goals of mentorship and how best to imbed formal mentorship initiatives within our CPD strategic plan of QI integration. More specifically, the current study set out to explore (1) possible models of implementation for mentorship within the Department of Psychiatry of a large Canadian academic center; (2) whether mentorship programs could be a potential vehicle for the alignment of QI practices and CPD within psychiatry departments; and (3) identified needs for the implementation of QI and CPD mentorship programs.

METHODS Study Design

In-depth semistructured phone interviews were conducted to allow flexibility for follow-up questions and to ensure interview standardization. This was an iterative process, with modifications to interview questions occurring based on emerging themes.23 Our Interview Guide (see Appendix 1, Supplemental Digital Content 1, https://links.lww.com/JCEHP/A218) contained interview questions which addressed mentoring needs; facilitators and barriers to the implementation of mentoring initiatives; and next steps for implementation. All interviews were over the telephone at the affiliated hospital and recorded to later be transcribed verbatim. Interviews were between 17 and 40 minutes and were conducted by a female undergraduate psychology research assistant (PL) trained in qualitative research with experience through previous qualitative studies. The interviewer described the project goals and purpose of the study. Only the interviewer and interviewee were present. Transcriptions were inputted into HyperRESEARCH, which is a qualitative data analysis program to code results (ResearchWare Inc, Randolph, MA). The interviewer created field notes of relevant information to discuss with other researchers after completing the interview. No repeat interviews were conducted.

Data Collection

This study included leaders in psychiatry and QI, psychiatry and CPD, and active clinicians involved in both CPD and QI initiatives affiliated with the Department of Psychiatry at the university. The department contains 19 hospital sites located in the city and the surrounding area. These individuals were targeted in our study to provide information and insight into potential challenges in QI and CPD for clinicians in this setting. Participants were English speaking, and there were no exclusion criteria. Participation was voluntary with no incentives.

Convenience, purposive, and snowball sampling methods were used.24,25 Convenience sampling involved emails sent through the Department of Psychiatry asking individuals to contact the study investigator to participate. In purposive sampling, QI leaders in psychiatry administrative positions (such as Psychiatrist-in-Chiefs at the affiliated hospitals) were asked to participate. Snowball sampling consisted of asking participants to send the study information to anyone else who met recruitment criteria. Participants were contacted by the study research coordinator to schedule a phone interview, and informed consent was obtained. Approximately 14 participants in this study were present, and no dropouts were found. Given the limited number of professionals in this setting at the academic institution, further demographic information was not collected (ie, to protect confidentiality).

Data Analysis

Open and selective coding were used to analyze the results applying a thematic analysis. Creswell26 and the COREQ guidelines27 led the analysis. The transcripts were then reviewed and coded by two researchers who jointly created and edited a codebook (MTS, psychologist, and PL, research assistant). To ensure a thematic consensus, coders met to discuss after separately reviewing and coding each interview. Data saturation was obtained after no more themes were found in subsequent interviews. Themes were joined to create a final thematic framework.28 In case of coding disputes, a third-party individual, who is a psychiatrist (SS), was available, to resolve disagreement. No disagreements occurred. To ensure accurate and reliable analyses, we used techniques from Cutcliffe.28 The first of which was using a constant comparative analysis to identify a framework for mentorship needs, challenges, and implementation. Member checking did not occur after the interviews, instead the interviewee paraphrased responses during the interviews to ensure that the meaning of their responses was accurately conveyed. This study was granted research ethics approval from the affiliated university.

RESULTS Themes

Through this process, we discovered a large amount of uncertainty regarding the terms QI and CPD. Some individuals believed they were the same, whereas others felt they were ambiguous and suggested further articulation was necessary for clarity. Because of this inconsistency, evaluating our research question of whether mentorship is a potential vehicle for QI and CPD alignment was challenging. An example of the need for this articulation came from P7 who stated, “Really defining what QI is so that people understand what it is. So that people recognize that if that is what you're doing that is what you're doing, so having a standard definition of this kind of work [is needed].” A second concern brought up in relation to this problem involved the creation of a community of practice. One interviewee stated:

I know it’s a term that we all use but we all often have different visions for it, even having regular quality improvement rounds would probably be helpful [laughs] in our department. Maybe twice a year where we have rounds that are clearly based on quality improvement activities, within the department to help people understand what we as a department think that the practice of QI is. Because there’s not even a very clear agreement on what people mean when they say quality improvement. So, trying to make a community around a lose definition is problematic I think (P8).

This extended to the alignment of QI and CPD, where it was noted that joining them was tricky. It was stated, “I would not have them be in the same discussion because they're two different things. There's like a significant content knowledge gap in quality improvement that is not necessarily seen in professional development” (P8). This outlines the need for further conceptual refinement before these two areas can meaningfully aligned.

Analysis of the remaining results focused on determining models and needs for implementation of QI and mentorship, revealing three themes related to the following categories: (1) organizational culture; (2) sharing of QI; and (3) relational experiences of mentoring. The relational experiences in QI mentoring indicate the need for a good match in mentorship. Discussions around organizational culture demonstrate a limitation to implementing mentorship and QI initiative. This indicates further steps are needed before the implementation of mentorship in this area. These themes are examined in more detail below and presented visually in Figure 1.

FIGURE 1.:

Visual representation of the codes

Organizational Culture

Participants suggested a major need in the implementation of mentorship for QI and CPD is adapting the culture around these practices to better adopt, facilitate, and support QI knowledge amongst individuals. Without the culture fully embracing QI, it can be extremely difficult for members to truly adopt QI within their practice. Respondents spoke about the need for cultural enablers and further organizational support of QI and the alignment of QI and CPD. Without recognition and support for QI within the culture of the organization, participants noted that feasibility is likely called into question. Participants spoke about needing a multipronged approach, specifically both a “bottom-up approach” (starting at the individual level) and “top-down approach” (starting at the organizational level) to building QI cultures within the department. For example, one participant remarked:

It’s maybe actually educating the chiefs. I think the chiefs need to understand the relevance of the QI world within their various departments…I think you have to do it from the bottom up but also from the top down (P7).

Another participant spoke about this bottom-up and top-down approach when it comes to understanding QI through enhanced CPD:

I think it requires a real cultural change of how we do things and how we talk about issues that needs to be a little bit bottom up. In terms of like, let’s train people to do this as they become health care professionals in all sorts of different domains, it’s not just related to MDs. And then how do we also speak in a language of QI and CPD from the top down so that when we see the higher up administrators within the department and the hospital saying that “this is important and this is how we are going to do things in the future.” (P2).

This participant emphasized that the goal of this cultural change is so that QI and CPD will eventually be “just how we do things” (P2), and a common part of practice. With respect to QI, participants spoke about making QI a “priority” (P11, P13), making people “aware” of what QI is (P2), and that it needs to be “important” (P1, P2). These elements were voiced as being critical to building capacity, increasing uptake, and ensuring that QI is firmly embedded across hospitals.

CPD and education were also mentioned as ways in which QI could be elevated within the department. For example, one participant advocated that “straight forward education as well as support, both direct and indirect, [are needed] for people to take this on as part of their work” (P8).

Sharing of QI

The theme of sharing QI work emerged in relation to methods of implementing mentorship and needs for applying this in practice. Participants reflected on the importance of sharing different elements of QI activities (ie, celebrate successes). Participants spoke about their experiences with informal and formal QI and CPD mentoring; many shared more informal mentoring. A community of practice was also discussed, with participants encouraging some forum in which QI successes can be shared and mentoring can be provided.

In informal mentorship, individuals spoke to mentoring relationships and encounters that emerged naturally without structure to guide this process. For example, one participant relayed, “I think a lot of the mentorship that is happening right now seems to be sort of more ad hoc and not as formalized and people having to just sort of network on their own” (P11). Participants also spoke about the significant benefits that have derived from these relationships.

Participants were also supportive of the idea of a community of practice. Remote access was established as the most successful means of, “the sharing of ideas, the sharing of momentum, sharing of the knowledge, and support,” (P1). Participants were concerned with the sustainability and feasibility of this type of an initiative in the long term. One participant described:

So, I think communities of practice are something that could be done over the internet, something maybe with tangible real time events like a speaker broadcast over the web, but also, I don't know, online chats that could be synchronous, so, you know, I might be interested in something or post something and then somebody a couple of days later, might post a reply cause he was busy with clinical work. So, I think that sort of community of practice for QI would be very important actually (P12).

Participants also spoke about sharing successes and challenges with mentors and how that can be very helpful, within a community of practice or otherwise. For example, one participant reported, “I think there is something about shared celebration of successes and challenges” (P2). Participants discussed the value of sharing their QI work with one another. One individual spoke about the importance of learning about QI and who does QI projects within the department:

It would be interesting to hear the kinds of activities people are engaged in and for people to learn, so maybe kinda, that kinda of a day where people engage in the activity can share some of their experiences, their challenges, some of their successes and see if we can learn from each other, because we’re all kinda working separately (P7).

Relational Experiences in QI Mentoring

Participants spoke about various aspects regarding the relational experiences of QI mentoring and mentoring in general. The mentorship dynamic itself was a key element necessary for successful mentoring relationships. Some noted that content-related experiences of the mentor were not a key factor in a positive and helpful mentoring relationship. However, others noted the benefits of working with an individual who has experience in their field.

The importance of the mentor/mentee relationship played a role in the success and helpfulness of mentoring. For example, one participant indicated, “I have a belief in the specificity of mentee mentor relationship developing trust and familiarity that allows for deeper explication of problems and questions. So, I would see that as the optimal strategy” (P5). It also emerged that “organic” (P7) and “natural” relationships are best for the mentor–mentee relationships and that these can be formed in a variety of ways. For example, one participant relayed:

I actually think that I could receive mentorship from someone who’s totally outside my domain or area of expertise, totally, if we had a similar, similar enough personality and working style that you can find some common group and I think those structured mentorship programs try to match [in this way] (P2).

Participants also spoke about the importance of a trusting relationship with their mentors and how a longitudinal relationship can allow for that trust to form over time. One participant remarked, “I would emphasize the value of a longitudinal trusted relationship, which is why I think the formal stuff doesn't work very well” (P5).

Individuals spoke about wanting to connect with QI colleagues who are committed to the profession and have them share that dedication and expertise. For example, “how do we get these people who are passionate and experienced and knowledgeable about QI, how do we get them to open doors for people that are just starting off and expressing an interest” (P10).

It was also suggested that an iterative element to the mentoring process could be very helpful. Growing and changing with the needs of the mentees was seen as being a positive element of the mentoring relationship. For example:

But what you need and what the mentorship provides is sort of an ongoing check and balance kinda phenomena where you know that there is somebody meeting with you, asking you what your plans are, helping you to tweak it and sort of bring it into fruition and I think that’s where it’s, it’s very crucial” (P10).

Another participant compared the iterative and long-term process of QI to the needs of the mentoring relationship, “Whereas QI interventions are sort of by definition iterative and can sometimes take place over many years, and that's sort of just not quite what we have, we don't have a longitudinal sort of iterative mentoring structure in place” (P8).

Participants identified a key focus of the relational experiences of mentoring in QI to be mentoring for academic promotion. This was readily cited as a common type of mentoring relationship that could be important in QI. For example:

Mentoring is helpful in terms of promotion by sharing strategies for how to take your activities and make them have kind of academic currency. So the whole process of how you create a portfolio, how you present your work, etc. that a mentor can help with and demystify” (P14).

DISCUSSION

A primary aim of this study was to explore the role of mentorship in facilitating the alignment of CPD and QI. However, we found that our participants were more focused on the role of mentorship in QI and felt that a greater understanding and teaching of QI was needed throughout the department. Thus, the need for a greater understanding of QI appeared as a more primary desire from our participants whereas mentoring and CPD seemed secondary. We also believed that CPD could be conceptualized as part of the methods by which QI could be made stronger and more available. An interesting discussion point is how mentorship can be understood as a form of CPD, given that mentorship can involve knowledge and skill development as well as ongoing professional development in career trajectory and advancement. Thus, in this regard, mentorship can be understood as the CPD vehicle through which QI advancement could occur.

Creating an organizational culture of QI emerged as a gap which still currently needs to be filled. Mentorship opportunities were cited by participants as providing growth for the understanding and value of QI. Results also illustrated ways in which QI knowledge could be shared through mentorship relationships. Many participants had some form of mentorship throughout their career. Participants spoke about receiving both formal and informal mentorship, with individuals citing organic mentoring relationships as beneficial in their QI development. The possibility of a community of practice was probed, and participants supported this idea. The alignment of QI and CPD could be built into a community of practice, depending on how this community is structured, membership and how it is maintained over time. Finally, relational experiences of mentoring were discussed as well as QI mentoring specifically, which speaks to the fit of mentor/mentee relationships and the experiential process of individuals coming together within a mentorship relationship. Individuals spoke about wanting to engage in an iterative and long-term mentorship relationship, aligning with the trajectory of QI work itself. One can imagine opportunities for CPD within a long-term QI mentoring relationship as individuals grow and develop within their career.

Our study adds to the literature by highlighting the importance of integrating QI capacity into the culture of an organization. A recent systematic review by Mery et al29 evaluated the investment in QI capacity building and found improvement in quality outcomes, although the return organizations specifically get back from these investments is still lacking in the literature. Nevertheless, research does seem to suggest that both organizational and individual QI capacity building can positively benefit patient and care outcomes.29 Choi, Moon, Steinecke, and Prescott30 wrote a commentary on the importance of integration of QI within an academic organization. They suggest that a “dynamic culture of mentorship” is critical and should be regarded as a strategic priority within the organization.30 They indicated that within such a culture, the following activities of mentorship should be taking place: advising, teaching, coaching, providing role models, and personal growth.30,31 Participants in this study spoke about these types of mentorship activities in different elements they had received and the importance of these activities in supporting QI growth and development.

How QI capacity is delivered across an organization and embedded within its culture is not completely clear. However, efforts through CPD are key,4 and the current results suggest that mentoring can serve as a type of CPD to enhance the organizational foundation of QI capacity. The way QI is shared across the organization was also discussed by participants, and a community of practice was cited as an initiative of interest. However, some concern was noted around sustainability and feasibility, and therefore, virtual communities of practice might may serve as one solution. Participants also noted the benefits of formal mentor relationships, as well as those that are organic and emerge naturally and more informally.

We were not expecting our participants to indicate as much ongoing confusion regarding QI and lack of QI knowledge dissemination. More specifically, participants believed that QI was very important but were not completely uniform on what QI was conceptually. Given this finding, our data suggest that it is important to understand the elements needed to establish further clarity regarding QI for faculty within academic settings. The context of QI is an important consideration worth further exploring when considering how to use mentorship as a CPD vehicle to drive QI capacity building.

Our results add to those described by Sockalingam et al,4 which highlighted how the first phase toward alignment in CPD and QI is through receiving appropriate training in QI and ensuring the creation of individuals with expertise in QI. Our results suggest that QI expertise can be developed, in part, through the vehicle of mentorship. Mentorship can be envisioned as an element of CPD through faculty mentors supporting each other and helping to develop continuing professional skills. Mentorship is often conducted through both formal and informal relationships throughout one's trajectory of CPD. For example, junior faculty in an academic setting will often receive mentorship with respect to grant writing, academic milestones (ie, publications), managing complex patient care, and handling ethical dilemmas. As professionals continue to grow and learn, benefitting from the support of mentors is often at the heart of ongoing CPD. Importantly, mentorship may further support the integration of QI and CPD by repositioning CPD (ie, mentorship) within QI, which has been described in the literature.32

Our study has limitations. Participants mainly focused on QI and mentorship. We did not gather as much information on mentorship and CPD as we had hoped. It might be possible that additional questions specifically targeting mentorship for CPD would have provided us with more information. It is also possible mentorship for CPD is not well understood, and participants might require further education to understand the depths in which mentorship can target the alignment of CPD and QI. Our sample size was also broad but limited within an academic setting. It is possible that QI experts working in smaller community settings might have very different viewpoints regarding what would be most helpful for mentorship relationships. The purpose of this study was to focus on building a model of mentorship within a larger academic setting. We also recognize the need for our model to be disseminated across other hospital settings, given the key role that mentorship can play in QI and CPD and enhanced patient support and professional development.

CONCLUSION

Overall, we believe our results contribute to the growing literature on fostering QI, CPD, and the needed mechanisms to align these areas of knowledge and practice. QI and professional development could clearly be enhanced through mentorship. Moreover, mentorship may serve as a vehicle through which CPD is delivered for QI. Mentorship relationships can be varied, but institutions may consider building communities of practice as a model for dissemination of QI skills, knowledge, and ongoing support. Future research is needed to understand the role of mentorship more fully for CPD. The model proposed within this article will hopefully help serve other programs to integrate mentorship as a mean for QI and CPD growth and alignment.

ETHICS STATEMENT

Ethics approval was granted from the University of Toronto, Canada.Lessons for Practice ■ An understanding of QI principles is key to fostering the integration of this learning into the culture of an organization. ■ Mentorship development can allow professionals to foster an understanding of QI and build this into their continuing professional development. ■ Mentorship may be conceptualized as a vehicle through which CPD can be provided for QI.

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