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Physician  Coaching:  A  Tool  for      Performance  Improvement    

                                                                                                                                                   by  

Elizabeth  R.  Becker,  LCSW    Oct.  31,  201  

 Inner  SoluLons  for  Success  ebeckerlcsw@yahoo.com    

 (619)  370-­‐9679  

     www.innersoluLonsforsuccess.com    

       

Today’s  ObjecLves:  •  Why  coaching?  •  Understanding  the  difference  between  coaching  and  other  resources  or  intervenLons.  

•  BeZer  understand  the  process  of  coaching  and  the  coaching  model  

•  Learn  how  coaching  can  improve  performance  reduce  risk,  and  increase  well-­‐being.  

•  Case  presentaLon    

Q:  Why  Coaching?  •   It’s  the  most  posiLve  and  effecLve  method  for  addressing  the  

many  ‘human  factors’  that  contribute  to  performance  related  issues,  including  well-­‐being  and  professionalism.  

•  It  is  supporLve  and  prevenLve  in  nature  and  keeps  potenLal  problems  out  of  the  realm  of  disciplinary  acLon.  

•  It  helps  good  doctors  become  more  effecLve  doctors  and  leaders  by  developing  the  ‘so^  skills’  (EI)that  are  not  adequately  taught  through  medical  educaLon.  

•  The  Coaching  Model  is  a  PI  process  that  addresses  The  Joint  Commissions  requirements  designed  to  improve  paLent  safety  by  addressing  the  human  factors.  

   

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The  Joint  Commission  set  standards  and  made  specific  recommendaLons  

•  Standard  MS  11.01.01  says  hospitals  must  “idenLfy  and  manage  maZers  of  individual  health”  for  physicians  that  are  separate  from  disciplinary  acLon.  

•     Standard  LD  03.01.01  mandates  that  leaders  “create    a  culture  of  safety”  

The  commissions  suggesLon:  “Provide  skill-­‐based  training  and  coaching  for  all  leaders  and  managers  in  relaLonship  building  and  collaboraLve  pracLce,  including  skills  for  giving  feedback  on  unprofessional  behavior,  and  conflict  resoluLon.”  

The  Coaching  Model  Emphasizes:  •  Professional  growth  and  development  through  reflecLon,  skill  development,  new  behaviors,  and  increased  mindfulness.  

•  Personal  effecLveness,  responsibility  and  accountability  (less  nurse  blaming)  

•  Partnership  based  upon  trust  and  personal  moLvaLon  

•  Strength  based  •  Future  oriented  •  Goal  directed  (specific  and  measurable  PIP)  

•  Value  driven  

 

Philosophy  of  Coaching:    •  Coaching  seeks  to  meet  the  physician’s  need  for  personal  and/or  

professional  growth  and  development.    •  It  assumes  physicians  are  prefer  a  professional  growth  and  development  

model  rather  than  correcLve  acLon  based  on  a  series  of  failures.    

•  It  assumes  physicians  will  strive  towards  improved  performance  through  personal  effecLveness  if  given  sufficient  support  and  opportunity  to  learn  relevant  skills.  

 •  It  assumes  problems  and  dysfuncLons  are  the  result  of  ineffecLve  skills,  

lack  of  knowledge,  lack  of  resources,  lack  of  opportunity,  or  some  combinaLon  of  these  (not  psychopathology).  

 •  Future  oriented  and  goal  directed;  past  mistakes  are  for  reflecLve  learning.    •  The  goal  of  coaching  is  to  partner  with  physicians  to  support  them  in  

learning  to  be  a  more  effecLve  physician.    This  can  and  does  include  behavioral  changes  that  negaLvely  impact  performance.  

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The  Benefits  of  Using  a  Coaching  Model:    

•  Aligns  individual  goals  with  organizaLonal  mission      •  Increases  personal  responsibility  by  connecLng  behavior  with  goals.    

 •  Creates  a  sense  of  posiLve  partnership  between  wellness  commiZee  and  physician.  

 •  Increases    trust  and  aligns  physician  with  moLvaLon/goals/outcomes.  

 •  Improves  team  work  through  improved  leadership  skills  (e.g.  communicaLon)  

Benefits  of  Coaching  Model  (cont.)  

•  Improves  commitment  and  moLvaLon  if  physician  feels  that  his  needs  and  goals  are  being  heard  and  addressed.  

 •  Improved  performance  and  producLvity.    •  Improved  level  of  professionalism  (and  all  related  outcomes,  such  as  pt.  saLsfacLon)  

 •  Improved  relaLonships  with  other  team  members  (colleagues,  peers,  family,  etc.)  

 •  Improved  organizaLonal  culture  

Mentoring  vs.  Coaching  A  ‘mentor’  is  based  upon  a  relaLonship  

•   Uses  the  relaLonship  to  support  the  physician  •  It  can  be  acLve  or  passive  (lack  of  goals  or  accountability)  •  Usually  a  power  differenLal  •  Mentee  usually  choses  the  mentor;  based  on  connecLon    

‘Coaching’  is  an  acLve  process  that  is  less  focused  on  the  relaLonship  (although  the  relaLonship  is  important)  

•  Success  or  outcome  focused  •  Goal  driven  and  forward  thinking  •  References  the  past  for  reflecLve  learning  based  on  paZerns.  

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Coaching  v.  Supervision  Coaching:                                                                    Supervision:  Shared  agenda                                                OrganizaLons  agenda  (e.g.  MEC)  

Growth  oriented                                          Mission  focused  Strength  focused                                          Problem  focus  Personal  accountability                  Fault  seeking        Self  moLvated                                                  CompeLLve    Feed  forward    process                      Feedback  process  Thought  partner                                          Hierarchical    SupporLng/encouraging              DirecLng/telling  Facilitator                                                                  Manager  CelebraLng                                                            Punishing/  correcLng  

Coaching  v.  Psychotherapy  Differences:  •  Not  focused  on  providing  treatment  for      psychopathology.  

•  Focuses  on  professional  development  and  experiences.  •  Does  not  diagnosis  based  on  DSM.  •  A  PIP  is  developed  rather  than  a  treatment  plan.  •  Professional  boundaries  differ  in  coaching  relaLonship.  •  AcLvely  gives  opinion,  shares  experiences,  and  provides  direct  feedback  or  direcLon.  

•  Coach  can  ‘fire’  client.  

Coaching  v.  Psychotherapy  SimilariLes:  •  Uses  an  assessment  process  that  includes  bio-­‐psycho-­‐social  

component;  defense  style,  coping  skills,  insight,  etc.    •  Based  on  trust  and  open  disclosure.  •  Guidelines  for  confidenLality  are  similar.  •  DysfuncLonal  thought  and  behavioral  paZerns  are  idenLfied  

and  addressed.  (cogniLve  process,  ethnic  and  gender  bias)  •  MoLvaLon  and  readiness  for  change  are  assessed.  •  Goals  always  include  increased  self-­‐awareness  by  aZending  to  

feeling  states.  •  Coping  and  self-­‐care  strategies  are  always  part  of  PIP  •  Process  involves  asking  powerful  quesLons!  

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The  Coaching  Process  Step  1:  Assessment/EvaluaLon  •  Bio-­‐psycho-­‐social  includes  basic  demographics,  

developmental  hx,  and  medical  educaLon  training.  •  Health  and  medical  hx  •  Hx  of  substance  use,  abuse  and  paZern,  treatment  hx  •  Sx  of  depression  (PHQ9),  anxiety  (GAD),  thought  disorders,    •  Recent  or  current  stressors  •  Coping  and  defense  style  •  Sources  of  support  •  On-­‐set  and  percepLon  of  problems/issues  •  Level  of  insight  and  self-­‐awareness  •  Level  of  moLvaLon  and  readiness  for  change        

Coaching  Process  (cont.)  Step  2:  Stakeholder  Input  •  MeeLng  with  key  stakeholders  in  the  organizaLon  to  get  their  perspecLve,  learn  concerns,  and  prior  efforts  at  PI.  

•  Determine  paZern  or  trends  .  •  Discover  impact  on  others  and  potenLal  risks  to  organizaLon.  

•  OrganizaLonal  assessment  (level  of  dysfuncLon).  •  Clarify  and  agree  upon  coaching  expectaLons.  •  Establish  methods  to  measure  improvement  and  success.  

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Coaching  Process  (cont.)  Step  3:  Contract  •  Inform  and  process  stakeholder  perspecLve  with  MD  •  Discuss  expectaLons    •  Review  coaching  contract,  including  confidenLality  •  Conduct  PI  SWOT  (strengths,  weaknesses,  opportuniLes,  threats)  •  Establish  goals  as  part  of  the  PIP  (e.g.  goal,  acLon  steps,  

obstacles/challenges)  

•  Agree  to  Lme  frames  and  process  (e.g.  phone  calls  2x  month  for  1  hr    per  call  for  6    mos.)  

•  Start  immediately  with  skill  development  and  ‘Stop  Doing’  list.  

Coaching Model to Improve Performance

Requires that we make a paradigm shift and understand that we cannot motivate the right behaviors from people who have significant EI deficits:

•  Little or low self-awareness •  Lack empathy for others •  Ineffective communications skills •  Poor impulse control •  High levels of stress •  Ineffective Coping Skills

Physician Communication (conflict) (skill)

Empathy (EI)

Impulse control (both)

Emotional regulation(both)

Insight (EI)

Problem-solving (skill)

Awareness of self and others (EI)

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What is Emotional Intelligence?

Definition: Emotional intelligence is the dimension of

intelligence responsible for our ability to manage ourselves and our relationships with others.

v  Emotional Intelligence explains why, despite equal

intellectual capacity, training, competency, or experience, some people excel in life while others with comparable knowledge or skills (or even superior intellectual capacity) fail or flounder.

The Importance of EI •  Relationship between EQ and professionalism –

“There are three recognized elements of professionalism: empathy, teamwork, and lifelong learning.” (D Stern, 2006)

•  Relationship between EQ and conflict management – “Studies comparing superb leaders with mediocre ones have found that the competencies that distinguish the best from the worst in human services have little or nothing to do with medical knowledge or technical skill, and everything to do with social and emotional intelligence. What distinguishes leaders in medicine goes far beyond that knowledge, into interpersonal skills like empathy, conflict resolution and people development.” (D Goleman, 2006)

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“This process of critical self-reflection depends on the presence of mindfulness. A mindful practitioner attends, in a non-judgmental way, to his or her own physical and mental processes during ordinary everyday tasks to act with clarity and insight.” – R Epstein, 1999

ACGME  Core  Competencies  •  Professionalism, measured by the following

characteristics and behaviors: •  Compassion •  Integrity •  Respect •  Accountability •  Sensitivity •  Responsiveness

•  Interpersonal skills and communication including: •  Effective communication •  Teamwork •  Leadership role •  Empathy

EI Personal Competency Self –awareness: •  Emotional self-awareness •  Accurate self-assessment •  Self-confidence

Self-Management: •  Emotional self-control •  Transparency •  Adaptability •  Achievement •  Initiative •  Optimism

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EI Social Competence Social awareness: •  Empathy •  Organizational awareness •  Service Relationship Management: •  Ability to inspire others •  Influence •  Develop/mentor others •  Change catalyst •  Conflict management •  Building Bonds •  Teamwork and collaboration

Relationship between EI and ACGME Core Competencies

•  Professionalism (EI = achievement, service, impulse control, initiative, integrity, transparency, confidence, clinical competency)

•  Interpersonal skills (EI= self-awareness, empathy, mentoring)

•  Communication skills (EI= conflict management, building bonds, influence, self-awareness, transparency, optimism)

•  The ability to work as part of an interdisciplinary team (EI= adaptability, collaboration, organizational awareness, empathy, building bonds)

Support for EI Development

In fact, in the June 2010 edition of the Journal of Academic Medicine, Lucey and Souba address issues related to the core competency of professionalism by stating:

“Principles of emotional intelligence, reflective practice, and mindfulness can be applied to enhance professionalism and overall physician performance.”

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Performance Improvement Myth:

Physician behavior will change when they see the data that demonstrates their conduct impacts patient care and they are ‘outliers’ among their peers (this is more accurate related to clinical outcomes!)

Fact: Emotions, values and beliefs have a far greater influence over behavior than knowledge. Under stressful circumstances, human factors and conditioned responses usually trump knowledge and intellect.

Why Behavioral Change is Difficult •  Behavior effects performance, but how we think

and feel effects our behavior! •  Changing behavior is difficult because it often

involves a process of thinking about thinking. •  Motivation for change is frequently the result of a ‘pain point’, rather than a reward.

•  For this reason, addressing performance problems through policies, guidelines, etc. is usually ineffective at changing behavior or incentivizing behavioral change.

•  The reward is often a change in how the person feels (this is why feedback is important!)

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The  StarLng  Gate  and  Cornerstone  of  Professionalism  and  EmoLonal  Intelligence  

   PIP  Goal  and  Focus  of  Coaching:  •  Awareness  (self  and  others!)  •  Empathy  •  Impulse  Control    

Choosing  an  EffecLve  Coach    •  Specific  training  as  a  coach!  

•  Experience    and  understanding  of  the  unique  aspects  and  dynamics  of  healthcare.  

•  Understands  the  world  of  physicians  and  the  stress  and  demands  of  the  healthcare  team.  

•  Can  conduct  effecLve  and  thorough  assessments  of  the  individual,  but  also  able  to  have  a  systems  perspecLve.  

•  Able  to  ask  powerful  and  relevant  quesLons.  

•  Has  credibility  and  authority  among  the  organizaLons  leadership.  

 

Choosing  an  EffecLve  Coach  (cont.)  •  Able  to  respecsully,  but  firmly  challenge  and  push  back  on  

the  physician  and  hold  them  accountable.  

•  Able  to  effecLvely  uLlize  a  variety  of  assessment  and  feedback  tools  to  measure  progress,  provide  feedback,  etc.  (360’s,  leadership  inventories,  etc.)  

•  Able  to  build  rapport  and  establish  high  level  of  trust.  

•  Teach  EI  skills  and  understands  how  that  translates  to  the  healthcare  setng.  

•  Can  inspire  and  moLvate  change,  and  assist  with  the  integraLon  of  EI  skills.  

•  Understands  what  a  PIP  is  and  how  to  hold  MD  accountable  for  implementaLon.  

     

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Case  PresentaLon  

Ideal  MD  :  Patrick  from  Kaiser        Worse  Case  Scenario:  Dan  from  Bay  Area