Promoting digital transformation in healthcare

Analysis of the competency profile from the perspective of quality and risk management

Healthcare is facing a multitude of major challenges, for which attempts are being made to find beneficial solutions with the help of various legislative initiatives and the efforts of all healthcare stakeholders [1-3]. These challenges have diverse causes. Human resources and financial challenges, as well as their significant and drastic effects on the healthcare situation, are currently the most frequently discussed. Beyond these challenges, there are other challenges. Another challenge, which also represents an opportunity, is the digital transformation of healthcare [4, 5]. Digital transformation measures are linked to a number of legitimate expectations. For example, care structures should be tailored to needs [6], care processes should be sustainably oriented [7], care data should be stored securely, without redundancies, and in a format that can be evaluated [8], care outcomes should be tailored to the needs and goals of the insured person, and the benefits for society should be demonstrable [9]. The legislature has drafted a series of laws to underpin these expectations with objectives and to support healthcare institutions in achieving these goals [10-12]. The sustainable implementation of digital innovations requires organizations and individuals who implement the requirements of digital transformation in a structured and sustainable manner. Organizations are encouraged to view their structures and processes as disruptive, critically evaluate them, and, where appropriate, align them with patient benefit through digital innovations. Digital transformation measures can be implemented within individual structures and processes, at interfaces between partners within and outside an organization, or between insured persons and healthcare institutions [13].

>> In each of these scenarios, different professional groups are required to establish digital innovations in the healthcare process. These professional groups include therapeutic staff providing direct care, such as doctors, nurses, and healthcare professionals, along with staff who are not directly involved in the provision of care. This second group includes, for example, employees in IT, logistics, purchasing, medical controlling, patient management, and quality and risk management. Due to this multitude of different professional groups, centralized control is necessary for the implementation of digital innovations [14]. An organization's quality and risk management already coordinates between all professional groups and acts on behalf of the organization's top management [15]. Therefore, it is predestined to serve as the link between all structural units of an organization for digital transformation.
The conception, development, implementation, and evaluation of any innovation requires qualified personnel. These personnel should be able to identify the potential of (digital) innovations, implement them, and evaluate them. It is unclear what skills healthcare facility personnel should possess to sustainably promote digital transformation in the healthcare system.
The aim of this article is to analyze the competency profile of quality and risk management officers in healthcare institutions, to critically examine established competencies and to identify relevant competencies to promote digital transformation in order to adequately meet the demands placed on this professional group and to promote digital transformation in the healthcare sector through their contribution.
method
A semi-structured literature review was conducted on existing competency requirements for quality and risk management officers, initiated by the "Digitalization and Quality Management" working group of the German Society for Quality Management in Healthcare (GQMG). The GQMG is a Germany-wide, interdisciplinary, and multi-professional medical association that addresses the content and areas of work in the field of quality and risk management.
The literature review was designed and conducted by the authors within the Digitalization and Quality Management working group. They opted for a semi-structured approach that goes beyond the scope of a narrative review. Search criteria, databases to be included, and keywords were defined in advance by the working group members.
The conception was preceded by a development process within the working group, which defined generic activity contents and work areas
• currently by quality and risk management officers in healthcare facilities and
• from the working group’s point of view, will in future be the responsibility and handled by quality and risk management officers.

Based on these results, generic competency clusters were formed that represent the job content and work areas of quality and risk management representatives. The generic competency clusters included
• personal skills (personal, social-communicative, activity and action skills),
• professional and methodological skills and
• Skills to promote digital transformation.

As part of the research, an initial attempt was made to assign each of the identified competencies to one of the three generic competency clusters. If competencies were identified that could not be assigned to a generic competency cluster, the working group was consulted and a consensus was reached on the assignment.
The search criteria were the names of the three competency clusters: Quality Management Representative/Risk Management Representative or QMB/RMB, as well as the competency or requirement. Scientific and user-related journals, books, and websites were defined as databases. The PubMed, EBSCO, and CINHAL databases were used to search the scientific journals. The websites included (medical) professional societies of other professional groups. German and English-language publications were included. During the search, identified publications were screened by a person, and the competencies mentioned therein or the requirements required of a person to promote digital transformation from a quality and risk management perspective were extracted. The results were compiled into the generic competency clusters, presented to the working group, and a consensus was reached between each competency and a generic competency cluster.
Results
During the research, 89 competencies were identified, which were grouped into three generic competency clusters. Since competencies were listed in multiple publications, for reasons of traceability, they are cited using the name of the generic competency cluster. Since not all competencies are self-explanatory, selected competencies were described in more detail, and their source text was directly noted.

Personal competencies [16-24]
31 personal competencies were identified: initiative, empathy, decision-making ability, flexibility, friendliness, growth mindset, interest in other individuals and organizations, intercultural competence, communication skills, cooperation skills, creativity, customer sensitivity, ability and willingness to learn, problem-solving skills, media skills, networking skills, openness, (self-)organizational skills, problem-solving skills, reflection skills, resilience, risk-taking, independent work, social behavior, team building, leading, motivating, teamwork skills, dealing with failure, entrepreneurial action and willingness to change as well as assuming responsibility.
The following personal competencies must be addressed separately: Growth Mindset [16, 17] comprises a continuous striving and learning for the improvement of one's own actions. This idea of improvement can have a positive impact on the direct individual environment and influence the entire organization. For this to happen, both the individual and the organization must support and implement a continuous improvement idea. This results in a cyclical learning process that allows the individual and the organization to constantly develop further. The communication skills and the ability to cooperate of the people involved are of particular interest. These serve to communicate potential for improvement in a targeted manner and to anchor them correctly in the respective context [18]. In this context, the ability to cooperate also serves to correctly classify the role of the quality and risk management representative [19]. Depending on the organizational culture, it is necessary to consider which activities can be undertaken by the individual and at what point the network to other professions (within an organization) is sought. Other professions are among the first customers towards whom one must act sensitively, to whom expectations and requirements must be queried, and to whom trust and satisfaction must be established (customer sensitivity) [20-22].
In order to differentiate the individual competencies within the group of personal competencies, a subdivision into “inward-looking competencies,” “outward-looking competencies,” and “future-oriented competencies” was decided upon (Table 1).

Technical and methodological skills [25-37]
38 professional and methodological competencies were identified for quality and risk management officers. These include knowledge of auditing, interviewing interested parties, terminology of quality and risk management and patient safety, complaint management, Critical Incidence Reporting System (CIRS), diagnostic skills, document management, management review preparation, evidence-based decision support, error management, fundamentals of quality and risk management (such as developing mission statements), implementation of quality management systems, information literacy (knowing when information is needed, identifying valid and reliable information, and using it effectively for a given problem), healthcare institutions, key performance indicator creation and measurement, clinical risk management, competency management, continuous improvement management, standards, project management skills, process management skills, quality assurance, regulations, structured procedures, handling agile methods, vigilance towards change in the environment and value chain, knowledge of agile working, and certifications.
Terms of quality and risk management as well as patient safety encompass a multitude of topics and represent their foundation. These topics range from general definitions, such as quality, customer or provider, to the definition of the various techniques and instruments of quality and risk management [25]. Auditing is one of the oldest professional instruments of quality and risk management and has been used continuously under various names, such as clinical audit, medical audit or TQM audit. The methodological principles of the audit have remained unchanged [26]. With the help of the audit, it is possible to come into contact with different professions, to jointly identify potential for change and to address possible solutions. The joint development creates the basis of trust, to identify and understand potential, to take the identified problem seriously and to establish the relevance of one's own actions for the organization. Even if the time expenditure is greater than with other instruments, the benefits for the individual and the organization are sustainable [27].
Surveys are another tool for engaging with a wide range of stakeholders. Surveying interested parties is particularly important in the context of digital transformation, as insured persons and patients, employees, and other stakeholders can provide relevant feedback on the further development of healthcare structures and processes [28-31]. For the targeted introduction of (digital) innovations, it is essential for quality and risk management to support evidence-based decision-making for individuals and organizations. The evaluation options of quality and risk management can be expanded and combined with methods from research areas such as health services research, epidemiology, public health, or health economics. This makes it possible to evaluate individual aspects of healthcare with regard to their benefit to the patient and to derive evidence-based decisions [32-34].
Due to the multitude of different technical and methodological competencies, the competencies were divided into four subgroups: “Quality and Risk Management”, “Patient Safety”, “Project and Change Management” and “Scientific Work” (Table 1).

Competencies to promote digital transformation [38-61]
Twenty knowledge areas were identified as digital competencies. These include agile working, data analytics and artificial intelligence, dialogue and conflict management skills with knowledge of digital innovations, digital ethics, digital learning, digital literacy, digital collaboration, innovation skills, mission orientation, user-centered design, use of the digital workplace, use of standard software, understanding the differences between algorithms and artificial intelligence, understanding the differences between digitalization and digital transformation, and judgment and change management skills for digital transformation.
The competencies required to promote digital transformation encompass various concepts and knowledge. Individuals and organizations must be enabled to design, understand, and evaluate digital applications (digital literacy) [38]. Building on this basic digital competency, a strategy for dealing with digital innovations should exist and be continuously pursued (mission orientation) [39, 40]. Within this strategy, a distinction between the forms of digital transformation – digitization, digitalization, and digital transformation [41] – is helpful. This distinction helps users understand the differences between digitalization and digital transformation and the forms of change that can result [42]. For users, the assessment of change is most evident in the usability of digital innovations (user-centered design). The determination, suitability, and evaluation of usability can be carried out using various methods [43-46]. Quality and risk management officers can apply these methods as part of an evaluation to supplement feedback on satisfaction with additional perspectives. Further possibilities for evaluating results from any type of survey are offered by applications in the fields of data analytics and artificial intelligence [47,48]. The required knowledge varies depending on the application and organization.
Digital transformation also offers new opportunities for teaching new content. These are summarized in the terms digital learning and digital collaboration. The advantages of these approaches are the increased interactivity of the applications with the learners, asynchronous and permanent access to content, and the high acceptance of the offerings [49-51].
The use of digital innovations also requires considerations for individuals and organizations. These decisions can affect insured persons, patients, and employees, as well as the organization or society itself. Ethical considerations in the use of digital innovations (digital ethics) [52-54], as well as security measures, must be considered in the design, implementation, and use of digital innovations (judgment). The judgment and change management skills required to promote digital transformation encompass topics from the areas of design, implementation, interoperability, operation, and security in their use [55].
The competencies of digital transformation were divided into four subgroups: "basic digital competencies," "technological competencies," "key digital competencies," and "transformative competencies" (Table 1).
Overview of competencies
After completing the assignment of the individual competencies to the generic competency clusters, it was decided to rename the competency clusters into operationalizable dimensions. The personal competencies group was renamed "Personal Self," the technical and methodological competencies were renamed "Technical Self," and the competencies for promoting digital transformation were renamed "Digital Self" (Table 1).
discussion
The competencies identified for the professional group of quality and risk management officers reflect their extensive field of activity, which is being expanded with additional competencies due to digital transformation. These new competencies underpin the new areas of activity and support, job content, and work areas. Competencies initially represent starting points for guiding knowledge transfer. The application of knowledge is equally important for making effective decisions based on theoretical and experiential knowledge.
The extent and depth to which the identified competencies are applied by quality and risk management representatives depends on their operational framework, particularly the size and culture of the organization. Quality and risk management representatives are encouraged to examine which of the competencies are more deeply recognized by other professional groups (cooperation skills). To utilize these competencies sustainably for the organization, appropriate internal networks must be established. These networks can be used to comprehensively analyze issues and create a broad basis for decision-making. Organizations are encouraged to promote collaboration between professional groups with corresponding competencies and to embed this in their organizational and leadership culture.
Demonstrating the usefulness of existing competencies is highly relevant to ensuring their effectiveness for the organization. Concepts and models exist that can be used to demonstrate competency and identify potential for strengthening individual competency areas [62]. This verification exceeds, for example, a training evaluation in the form of a test, is very comprehensive, and requires a significant amount of time and human resources. The extent to which this can be adapted for individual organizations or applied holistically must be examined within the organizations themselves.
Other professional groups are analyzing their competency profiles with regard to digital transformation to the same extent [63-66]. The results are comparable to the competency profile of quality and risk management officers. An expansion of competencies to promote digital transformation is taking place. As was the case in quality and risk management, no loss of existing competencies is observed. The synthesis of all results clearly shows that every professional group must acquire the same competencies to promote digital transformation. This is understandable, as digital transformation impacts all economic sectors and professional groups. Similar competency bases across professional groups are necessary to communicate valid and consistent expectations and requirements. The level of detail of the competencies varies depending on the individual and organization.
Digital transformation is associated with the expectation that healthcare structures and processes can be simplified for users and bureaucracy reduced [67]. This possibility exists with the acquisition of the same skills in different professional groups, as the same knowledge bases exist and can be used. Dissolving so-called "knowledge silos" represents a major opportunity for healthcare. Healthcare structures and processes can be designed in such a way that necessary information is continuously available and (short-term) results are already used for the subsequent sub-process.
Quality and risk management is not exclusively an activity within an organization, but can also have a steering character within and across healthcare regions. With the help of digital innovations, the redesign of healthcare structures, and the present competency profile, quality and risk management officers are enabled to support service providers and other professional groups across organizational boundaries in designing care processes that are beneficial for patients.

Strengths and limitations
This paper provides a comprehensive overview of the competency profile in quality and risk management. For the first time, the requirements of digital transformation for this professional group are analyzed and operationalized. The development of the content by the GQMG's Digitalization and Quality Management working group represents a strength of this paper, as it allowed for insights from different healthcare institutions, organizational sizes, and organizational cultures to be taken into account. This is highly relevant for determining a comprehensive yet targeted competency profile for quality and risk management officers. A further strength is the approach used to assign the respective competencies to the generic competency cluster. The assignment was made by consensus among all authors, allowing for the collaborative discussion of each competency and establishing a common understanding of its content.
One limitation of this study lies in its design. Conducting a systematic review would have allowed for a broader publication base. The possibility that a different methodological approach could have identified additional competencies cannot be ruled out. A further limitation lies in the naming of the individual competency clusters. Names were chosen by the authors. Alternatively, a more inductive approach could have been used to derive a name from the individual competencies of a cluster. A further limitation of this study is that only competency and associated requirements were considered. Existing knowledge areas of individual quality and risk management representatives were not consulted, as no searchable databases exist for this purpose.

Further questions for research
The identified competency profile provides an initial basis for providing quality and risk management officers with access to the necessary knowledge. The available results can be used to assess the adaptability of the competency profile to different types of healthcare facilities. Furthermore, the forms and extent of collaboration with other professional groups in promoting digital transformation can be examined. For this purpose, networks (within) an organization can be analyzed and examined with regard to their syntactical relationships. A further research question encompasses whether and to what extent the contents of the present competency profile exist among the quality and risk management officers of healthcare facilities. For this purpose, the individual competencies and their interactions must be prepared for a survey so that it can be used for organizations, regions, and/or for widespread use in all healthcare facilities.

Implications for practice
Using the results, healthcare institutions can assess which competencies are available within their organization and to what extent adjustments or expansions are necessary. In addition, the identified competency profile offers the possibility of being operationalized as a catalog of learning objectives for continuing education and training in quality and risk management, as well as in the area of patient safety.
Conclusion
The analysis of the competency profile of quality and risk management officers represents a critical assessment of their own actions and a comparison of the professional groups. The increase in competencies highlights the need to acquire separate and specialized knowledge for digital transformation. The identified competencies provide a foundation for supporting all stakeholders in the digital transformation, identifying and promoting synergies, and enabling a benefit-oriented development of healthcare for patients.