Hospitals and health systems are formalizing leadership roles focused on clinical excellence and professionalism — particularly at academic medical centers. Leaders say their institutions see the value in this approach to improve patient safety, strengthen workplace culture and support clinician well-being.
In September, Nashville, Tenn.-based Vanderbilt University Medical Center appointed Bill Cooper, MD, senior vice president for professionalism and clinical excellence, overseeing efforts to support professionalism and clinical performance among faculty, staff, trainees and students.”
Other organizations have carved out similar roles or focus areas — whether in title or departmental scope — including Klaus Kjaer, MD, associate dean for policy and professionalism at Weill Cornell Medicine in New York City; Brijen Shah, MD, associate dean at Icahn School of Medicine at Mount Sinai and vice president of medical affairs at New York City-based Mount Sinai Health System; and Jamile Ashmore, PhD, chief wellness officer at Baylor Scott & White The Heart Hospital-Plano (Texas).
Becker’s connected with these leaders to discuss the drivers that led their organizations to elevate this focus, how they link it to strategic goals, and examples of meaningful success.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: What internal or external drivers led your organization to elevate clinical excellence and professionalism into a formal leadership role?
Dr. Bill Cooper: Internally, we recognized that sustaining high reliability requires a balance between well-designed systems and professional accountability. At Vanderbilt Health, we have used data from patients, families and co-workers for more than 30 years to identify and address patterns of unprofessional behavior. Our early work focused on physicians, but in recent years we have expanded to include advanced practice professionals, trainees, nurses, surgical techs and medical assistants in our accountability model. We have also extended these programs to our regional affiliate hospitals to ensure alignment and achieve the best possible results. Creating a systemwide approach to professionalism and excellence was a natural next step.
A complex organization like Vanderbilt needs everyone operating at their A game. Professional accountability is not about being punitive, it is about providing timely course corrections that help someone move from an A-minus back to an A game. That is how we continue to excel and innovate as an organization.
Externally, the healthcare landscape increasingly recognizes that patient experience, safety and workforce well-being are deeply interconnected. Research — including ours and our partners’ — shows that how clinicians interact with patients and team members directly impacts surgical complications, sepsis, mortality, clinician well-being and workforce engagement. Elevating leadership for professionalism and clinical excellence to the system level signals its importance across the enterprise and ensures integration into strategic priorities such as quality improvement, patient safety, workforce engagement and retention.
This role is a driver of cultural transformation. By aligning objectives with organizational pillars such as operational efficiency, patient experience and clinician well-being, professionalism becomes a measurable component of performance and a catalyst for sustainable excellence.
Organizations are investing in professionalism as a strategic differentiator, and we believe it is essential to remain at the forefront. By elevating this work to a formal leadership role, we send a clear message to clinicians, patients and partners: professionalism is not peripheral or assumed — it is core to our mission and long-term success.
Dr. Klaus Kjaer: When we fall short in our performance — whether that be compliance with regulatory standards or optimal teamwork performance in the clinical arena — it’s not because people aren’t smart enough or hardworking enough or skilled enough. It’s because our teams don’t come together effectively. In many ways, what allows teams to come together successfully is a set of soft skills, including team building, interpersonal communication, establishment of trust and relationship management — all of those things that don’t really get taught formally in our educational and training systems but are key drivers of performance. So we set up a system to detect where the opportunities are and fill those gaps when they exist, especially gaps in soft skills.
Dr. Brijen Shah: We began engaging in this work six or seven years ago. We realized early on that this was a key element of patient safety and workplace safety. Our leaders felt we needed a program to help address those areas.
Another reason was that, over time, this work can help reduce clinical malpractice. We’re always looking for ways to reduce our malpractice costs, especially since New York is a very high-cost malpractice state. Having strategies to decrease that risk is always attractive.
We did pause the work during COVID, but when we came back to it, we realized this was a critical part of improving workplace culture and ensuring people felt psychologically safe and heard — something that really emerged during the pandemic.
Around the same time, we also leaned more into our patient experience and engagement work. These roles help create structure and processes for addressing both patient grievances and staff observations of unprofessional behavior.
Dr. Jamile Ashmore: What really drove it was the national conversation and the data that’s been coming out for decades. Healthcare worker well-being, burnout, professional fulfillment — those terms and catchphrases that we use in the context of well-being — have become national priorities. The reason, of course, is because they’re associated with negative outcomes for both the healthcare worker and the patient.
The Heart Hospital recognized this and said, “We need to do something about it.” We needed to bring someone on board to focus on this issue. When you think about professionalism, it’s a component — and a driver — of burnout and lack of fulfillment, and all the other negative consequences that come with it.
The way I think of it is that professionalism is one piece of the bigger picture. We have to focus on all the pieces, but professionalism is an important one.
Q: How do you link the leadership role focused on professionalism and excellence to your institution’s broader strategic goals to ensure it’s integral, not peripheral?
BC: At Vanderbilt Health, professionalism and clinical excellence have long been foundational to our mission of delivering world-class care. That commitment and the research it inspired led to the creation of the Vanderbilt Center for Patient and Professional Advocacy in 2003. CPPA’s focus is to make medicine kinder, safer and more reliable by equipping leaders and teams with data-driven programs, education and research that promote professional accountability and reduce risk.
Today, CPPA partners with more than 300 health systems worldwide. Organizations using these programs have documented strong engagement and measurable improvements over time.
Professionalism data from PARS and CORS serve as leading indicators that integrate into performance dashboards and risk mitigation efforts. A tiered accountability model — peer-led, supportive and non-punitive — helps embed professionalism into daily practice.
We also recognize that professionalism is never static. Life events can influence behavior over time. As our organization grows and new clinicians join, maintaining alignment is critical. A sustained, data-informed approach ensures support and accountability stay relevant and right-sized.
KK: My role was envisioned by our Office of General Counsel and our senior associate dean for clinical affairs. They realized we didn’t have a dedicated function to laser-focus on this. The reason that policy is included in that associate dean portfolio is that if you’re going to set standards of professionalism, you need to have those codified in policy.
As chief quality and patient safety officer, I saw how often lapses in professionalism — especially poor communication — contributed to safety events. Psychological safety and team performance are deeply linked, and they affect both outcomes and workplace culture.
We use four pillars in our professionalism framework: trustworthiness, humility, respect and excellence. These support stronger teams and individual growth, whether or not someone holds a formal title.
BS: We have an annual quality and safety plan. We now incorporate professionalism into safety event reviews. If team climate or professionalism contributed to the issue, we address it directly.
We also provide peer feedback on quality and safety protocol compliance, with a clear path to accountability if behavior doesn’t improve.
JA: You can’t reach clinical or financial goals without focusing on the workforce experience. Professionalism, culture and clinician well-being are interrelated. All of them influence patient outcomes and system performance.
Our leadership saw that and acted. We’ve made professionalism part of the culture, just like we do with patient experience.
Q: What has been the biggest challenge in making clinical excellence and professionalism a shared responsibility — and what has helped you gain meaningful engagement from clinical leaders?
BC: Our research using CPPA’s database and other national registries such as the trauma database and NSQIP has shown that professionalism is a key contributor to patient outcomes — such as patient safety and team resilience — which has helped clinical leaders see its direct impact on their success.
Engagement grows when leaders recognize that fostering a respectful, high-performing culture is not just aspirational, but essential for delivering exceptional, safer care.
Through the implementation of our professionalism programs and embedding them into our day-to-day processes, our leaders know that promoting professionalism through robust, data-driven programs is not just a cultural imperative — it is a strategic necessity that empowers each of them to take meaningful action to improve patient outcomes and ensure continuous improvement across the organization.
KK: Professionalism is one of those terms that has the potential to be misinterpreted. It’s a loaded term to say to someone, “That was unprofessional,” because labeling is inherently oversimplifying and inherently judging.
We’ve changed the wording a bit. Instead of talking about unprofessional behaviors, we often talk about “behaviors that undermine a culture of safety.” That safety in speaking up is essential.
It’s not about being nice. You don’t have to be nice to everybody. You just have to be in learning mode and humble enough to realize others may have something to contribute that you didn’t think of.
Dismantling defensiveness has been the greatest challenge. The second big challenge is reporting. If you think I behaved unprofessionally, you may hesitate to share that with others. That isn’t great, because I miss out on the opportunity to do better next time.
BS: When we started, people worried the program was about punishing or disciplining staff, but that’s not the focus. The program is built on a peer-mediated intervention as the main intervention we engage in. Framing it that way helped people understand the program.
A second challenge was making sure certain individuals weren’t exempt just because of their seniority or business they bring. This program helps ensure consistent application across the board. That’s a big part of my role — maintaining fidelity to the process.
JA: One challenge is helping physicians shift from seeing professionalism lapses as a disciplinary issue to viewing it as a support opportunity.
So instead of taking a punitive or corrective approach when there’s a lack of professionalism, we ask: What’s going on? How can we support you? How can we build better systems — broadly or individually — to support professionalism and the organization’s culture?
Another challenge is helping people understand what we mean by “professionalism” and “culture.” Level-setting that language has been key. We define professionalism as individual conduct, and culture as shared workplace norms — and they influence each other.
