a12/b12: engaging physicians: insights and actions for...

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IHI 2011 Forum

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Jack Silversin 1

A12/B12: Engaging Physicians: Insights

and Actions for Results

Jack Silversin, DMD, DrPHAmicus, Inc

Cambridge, Massachusetts

This presenter has nothing to disclose.

Objectives

• Describe how the quality of the organization-doctor relationship impacts physician engagement and improvement efforts

• Identify management attitudes and behaviors that enable physicians to stay on the sidelines of care improvement efforts

• Describe specific behaviors and steps to authentically engage physicians in creating and achieving an institution’s quality agenda

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What It Looks Like When Physicians are Engaged in Improvement

Beyond “showing up.” Investing time, demonstrating curiosity and a desire to contribute and have

influence.

Benefits of Physician Engagement

• Contribute knowledge and expertise; solutions will be better for physician input

• Develop more realistic expectations of what is possible

• Have greater commitment to solutions; successful implementation more likely

• Helps physicians move through psychological transition associated with change

• Builds trust and partnership between physicians and management when physicians experience they have influence on outcomes

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Actions That Foster Engagement

1. Create conditions for engagement

– Meet legitimate needs

– Communicate urgency/heat

– Develop shared vision

– Craft reciprocal expectations/aligned compact

2. Avoid quick fix when change challenges core identity or has significant emotional dimension

3. Ensure process for engagement is fair

4. Help physicians develop their capacity to work collectively


– Meet legitimate needs (Does the institution respond to basic, legitimate needs?)

– Communicate urgency/heat (Why do I need to engage?)

– Develop shared vision (What are we trying to achieve together?)

– Craft reciprocal expectations/aligned compact (What are the ground rules for working together?)





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Create Conditions for Engagement:Meet Legitimate Needs

• No scrubs at time when needed

• Physicians conclude admin couldn’t care less after multiple attempts to remedy the situation

• In turn physicians are suspect of admin request for their involvement

• What are the “no scrubs when needed” issues in your institution? What “hygiene factors” do you need to respond to as a priority?

Create Conditions for Engagement:Urgency

”

““Establishing a sense of urgency is crucial to gaining

needed cooperation. With complacency high,

transformation usually fails because few people are

even interested in working on the change

problem….People will find a thousand ingenious ways

to withhold cooperation from a process that they

sincerely think is unnecessary or wrongheaded.”

— John Kotter, Leading Change, 1996

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Raise the Heat

• Create pull for excellence, desired future, or reputation

• Help doctors discover there is urgency by making the invisible, visible– Cold, hard facts on performance– Gap between aspiration and reality– Trends– The personal impact of incidents

• Expose doctors to the consequences of the status quo by removing protections, work-arounds, other “asbestos booties” that keep heat at bay

Alignment has to precede engagement. If our goals aren’t aligned, why would I spend my time engaging with you?

Create Conditions for Engagement:Shared Vision

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• Energizes individuals to respond to strategic imperatives (not a “feel good” statement)

• Opportunity to build “business literacy;” to share policy aims as well as financial, health and other data to develop shared urgency for change

• Provides opportunity to discover interdependence

• Process allows airing of difficult issues, divergent perspectives, and discovery of common interests

• Taps into shared aspirations and uses language meaningful to doctors

Shared Vision

Basis of Vision is Shared Interests

Hospital’s

Interests

Hospital’s

Interests

Doctors’

Interests

Doctors’

Interests

SHARED INTERESTS• Commitment to patients• Economic interests• Recruit and retain talent

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• Compact refers to expectations members of an organization have that are:

– Unstated yet understood

– Reciprocal

›Gives

›Gets

– Mutually beneficially

– Set up & reinforced by society and the organization

Create Conditions for Engagement:Reciprocal Expectations

GIVE GET

•Autonomy

•Protection

•Entitlement

•Treat patients

•Provide quality care (personally defined)

Typical Implicit Physician Compact

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• Autonomy

• Protection

• Entitlement

• Improve

safety/quality

• Implement EHR

• Reduce costs,

become more

efficient

• Be patient-focused

• Improve access

• Recruit and retain

staff

Traditional “Promise” or Legacy Expectations Imperatives

Clash Of “Promise” And Imperatives

Consequences When Compact is Out of Synch with Strategy

• Erosion of morale when tenets of original deal are changed

• Slow improvement

• Mistrust of leaders who sponsor change

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Proactively Develop New Expectations

• When old deal crumbles without conversation, anger and frustration result

• Dialogue about what is changing and why accelerates support for new deal, new behaviors

Vision Sets Context for Compact

• Societal needs• Local market• Competition• Organization’s strengths

STRATEGIC

VISION

STRATEGIC

VISION

Physicians

give:

• What the org

needs to

achieve the

vision

Organization

gives:

• What will help

physicians to

meet their

commitment

• What is

meaningful to

physicians

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Sample Physician-Hospital Compact

Physicians give:• Actively engage in quality improvement

• Select and empower leaders in synch with shared vision

• Treat all with respect

• Engage in collaborative practice

• Promote hospital through clinical innovation and outreach

Physicians get:• Include medical staff leaders

in significant decisions

• Be transparent regarding hospital finances and decisions

• Demonstrate appreciation for physicians’ contributions

• Ensure a well-run hospital

• Improve access to clinical data and physician performance relative to benchmarks

Deep Conversation

• Make it safe to be honest

• Multiple times…not one off

• Share assumptions and beliefs

• Ask questions

• Avoid judgment

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A Helpful Perspective on Change

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Two Kinds of Challenges Ronald Heifetz

Technical

• Problem is well defined

• Solution is known can be found

• Implementation is clear

Adaptive

• Challenge is complex

• To solve requires transforming long-standing habits and deeply held assumptions and values

• Involves feelings of loss, sacrifice (sometimes betrayal to values)

• Solution requires learning and a new way of thinking, new relationships

Technical Change

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Adaptive Challenge

Adaptive Challenge

• Takes longer than technical work

• Involves changing hearts and minds

• Incompetence must be tolerated as new competencies are developed

• Requires experimentation

• Is risky to lead

• Generates disequilibrium, distress and work avoidance

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“The most common cause of failure to make

progress is treating an adaptive problem with a

technical fix.”

Wisdom from Ronald Heifetz

Technical fixes

• Incentives or compensation

• Reorganization

• Issuing new vision statement

• Placement of hand sanitizing solution

• Branding a “service line”

Adaptive solutions

• Giving authority to solve problems to the implementers

• Discussion that allows respectful airing of difference

• Bringing conflict to the surface and constructively resolving it

• Having difficult conversations

Implications

• If the change is going to challenge long held assumptions or professional identify, invest in widespread engagement

• People will want to avoid this work. You need to bring people back to the point

• Attempting a quick fix in these situations is likely to be short lived or generate cynicism

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“”— W. Chan Kim and Renée MauborgneHarvard Business Review, Jan 2003

Outcomes matter, but no more than

the fairness of the processes that

produce them.

Ensure Fairness of Engagement Process

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Engage Others in a Transparent, Merit-Based Process

• First...when seeking input into a decision, clarify– Boundaries – what is fixed and what is not– Criteria against which ideas will be evaluated– Opportunities– Process for making final decision including who ultimately decides

• Allow for a fair hearing of all points of view

• Examination the merits of all ideas/suggestions relative to criteria explained at outset

• Rely on the merit of ideas – fit between ideas and pre-set criteria – to drive decision-making

• Explain the decision – close the loop with explanation

Close the Door to “Opting Out”

• After engagement in fair process, getting on board a decision or change should be expected

• Opting out should have consequences otherwise engagement is seen as having low value and business-as-usual carries on

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Individualistic Orientation Decreases Influence

• Trained and socialized to act independently, physicians don’t naturally join up, delegate authority to a leader or speak with one voice

• “When you’ve talked to one doctor, you’ve talked to one doctor.”

• Physician autonomy sub-optimizes their influence in the institution

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Support Physicians To Work Together

• Clarify why physician influence is diminished when each speaks for him or herself; demonstrate the value of physicians speaking with one voice

• Develop and support effective physician leaders who can facilitate fair process and hold doctors to account

• Ensure the role of physician leaders is more than cop

• Reward teamwork and collective action

Physician Engagement Prepares Your Organization for What’s Ahead

a12/b12: engaging physicians: insights and actions for...

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