studer group presentation to health choice network jackie gaines, executive coach the challenging...

Studer Group Presentation to

Health Choice Network

Jackie Gaines, Executive Coach

The Challenging Physician

COPYRIGHT © STUDER GROUPPlease do not quote or disseminate without Studer Group authorizationSlide 2

So Who are We Talking About?

- Physician who comes in late often, but happens to see the most patients and generate the most revenue

- Physician who is always behind in their tasks (labs and notes unsigned as per policy etc.)

- Physician who is rude to patients and staff

- Physician with illegible handwriting and not improving

- ??? What are the behaviors of your disruptive physicians??


So…what do you want to know by the end of this session?

What cements our Mission and Values to our Actions?

What guides how we live and serve patients, colleagues, our organization and our community?

5

All Life’s Variables Impact Our Behavior in the Workplace

Family/Personal

Medical Training/Previous work experiences

Genetic Hardwiring

Organizational Expectations

Misaligned values

External pressures/politics

6

Successful Physician Collaboration Starts Prior to Hire Clarity is the Essential Ingredient!

7

What was conveyed to you prior to hire? Did it match reality?


Define behavioral expectation consistent with mission, vision, training, measurement, orientation and organizational culture

Foster positive and reduce negative/disruptive behavior by clarifying expectations upfront

Standards of Behavior


Can you name one standard? How is it currently enforced?

Physician “Code of Conduct”

• Creates physician commitment to more specific behaviors within the “standards” positioning physicians and their organizations for success

• Puts in place a process to address and correct deviation from standards.

Reality Check:

In 2009, the Joint Commission introduced new

standards requiring more than 15,000 accredited

health care organizations to create a

code of conduct that defines acceptable and

unacceptable behaviors and to establish a formal

process for managing unacceptable behavior

~Joint Commissions, 2009

Physician Behavioral Standards/Code

Barriers ……

Physician culture has traditionally been one of independence and autonomy – results

Code of conduct / standards may be – Ignored– Rejected– Attacked

Physicians are more receptive when…

• Physicians create the Standards/Code

• Standards/Code reinforce the strategy and vision of the organization

• There is a compelling and understood need for consistency throughout the organization

• Physician leaders make it a priority

• There is consensus on the content of Behavioral Standards

Behavior Standards Impact

• High– Used for orientation/signed

– Used for “Selection”

– Consistent with “Vision”

– Physicians trained in Behavioral Standards

– Supported and projected by Leadership

– Consequence for violation

• Low– No upfront

signing/orientation

– No training of physicians

– Low leader visibility

– No consequences for violations of Behavioral Standards

Six Competency Areas Adopted by Joint Commission

Patient Care - that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of healthMedical Knowledge - about established and evolving biomedical, clinical, and cognate sciences and the application of this knowledge to patient carePractice-Based Learning and Improvement - that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care

Professionalism - as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient populationSystems-Based Practice - as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal valueInterpersonal and Communication Skills - that result in effective information exchange and teaming with patients, their families, and other health professionals

Physicians’ Major Priorities

1. Responsiveness of Administration to the ideas and needs of medical staff members

2. Ease of Practice: Facility makes caring for patients easier.

3. Agility: Administration has positioned health center to deal with changes in the health care environment

4. Trust: Confidence in the Administration to carry out its duties and responsibilities

5. Communication between Administration and physicians.

…at least one third of all physicians will experience...a period during which they have a condition that

impairs their ability to practice medicine safely

Leape LL & Fromson JA. Annal Intern Med.2006;14(2);107-115

www.TheResilientPhysician.com

Prevalence of Physician Performance Problems

• Disruptive Behavior–4% - 5% of physicians

• Distress

• Impairment

What Does Disruption Look Like?

Aggressive PassiveAggressive

Passive

Derogatorycomments

(5%)

Refusalsto do tasks(20%)

Chronically late or not

responsive tocalls

(15%)

Inappropriateor inadequate

documentations(15%)

Samenow CP et al. Phys Exec. 2008.34(1):32-40

Outbursts(90%)

Intimidation(20%)

Harassment(10%)


Most Frequent Source of Abuse?

Rowe MM & Sherlock H. J of Nurs Manag. 2005;13(3):242.

“Lateral Violence”Nurses, Pharmacists

Radiology, LabInst for Safe Medication Prac. 2003 www.ismp.orgRosenstein & O’Daniel. Amer J Nur.2005;1:54-64

Most Common Disruption…

What is Considered Disruptive?

• Apprehension and Anxiety

• Loss of Focus

• Team Effectiveness

• Communication

Federation of State Medical Boards, 1998www.TheResilientPhysician.com

What is Considered Disruption?

The Obvious

• Profane or disrespectful language

• Demeaning or intimidating behavior

• Sexual comments or innuendo

• Inappropriate touching, sexual or otherwise

• Comments that undermine patients trust in physician or health center

• Racial or ethnic jokes

• Outbursts of rage or violent behavior

• Throwing

• Inappropriate criticizing colleagues in front of pts. or staff

• Boundary violations w staff, pts, surrogates or key third parties

Federation of State Medical Boards, 1998

The Somewhat More Subtle

• Inappropriate chart notes

• Unethical or dishonest behavior

• Difficulty working collaboratively with others

• Repeated failure to respond to calls

• Inappropriate arguments with patients, family, staff, or other physicians

• Resistance to recommended corrective action

• Poor hygiene

Federation of State Medical Boards, 1998

• Adverse medical events... 60% attributed to “out-of-control physicians”

(Atlantic Information Services, Report on Medicare Compliance. 2005

14(17):1-8.)

• “Between 53% and 75%.. Say they saw a strong link between disruptive behavior and negative clinical outcomes

Rosenstein AH & O’Daniel M. Neurology. 2008.70:1564-70.

The Consequences


• Turnover

• Risk

– 4 or more complaints over 6 yrs ~16x likelihood of 2 or more risk management complaints

Hickson GB et al. JAMA. 2002;287:2951-7

The Consequences


What Is Disruptive Workplace Behavior?

• Focus on– Communication Behaviors– Physical Intimidation

• Subjective? – “Offensive” “Frightening”– In Eyes of Beholder?

• Def. In Terms of Effects on Work Environment– Interferes with Patient Care– Interferes with Efficient Operations

Fooks, C & Maslove L. Coll of Phys and Surg of Ontario, Oct, 2003.


Drivers of Physician Change

• Visionary Leadership

• Trust and Confidence in the Leadership team

• Knowledge of Performance

• Clarity of Expectations

• Logic for Efforts

• Behavioral training

• Colleagues doing the same

• Recognition for doing well

• Incentives to achieve Goals

When Expectations are not Communicated…

• Difficult behaviors are addressed reactively instead of prevented proactively

• Consistency of care is difficult to achieve and “behavioral variance” becomes the norm

An Organization IS what it DOES all of the time

Expected Behaviors: Treatment of Patients

• Physicians will introduce themselves to patients and family and clarify their role in the care of the patient

• Physicians use curtains and doors, and conduct conversations in private areas to protect patient privacy

• Each patient is an individual and will be treated honestly and with kindness

• Each patient should understand treatment needs, treatment options and potential treatment outcomes

• Medications will be explained including the purpose, therapeutic intent, duration of use and possible side effects

Expected Behaviors: Treatment of Staff

• Speak positively about your staff to patients and families when an opportunity arises

• When difficulties with staff arise, take ownership, speak-up and educate in private to improve performance

• Communicate your whereabouts if your staff may need you for patient care issues

• Thank your staff for the hard work they do

Effective Standards/Code are Specific and Observable

Always ask, “What does it look like?”

• “Courteous” is not specific or observable. What does “courteous” look like?

– “Makes eye contact with patients and peers”– “Introduces self in interactions with patients and families”– “Uses patient’s name during clinical encounter”

Physician Orientation Standards/Code of Conduct

History of InstitutionHeavy emphasis on

culture, character and values

Train and develop evidence-based behaviors

Clarity of physician expectations. “Who we

are.” Sign Code of Conduct

Aligned New Physician

“Code of Conduct” Must Haves

• Are defined and process documented

• Impact Behavior

• Violation have consequences that are in place and understood

When Breakdowns Occur

Have a process in place

• Fair

• Consistent

• Matching values & standards

• Peer driven

• Legal

• Evidence based – best practice

• Start Collegially

• Separate the Person from the Problem Behavior

– Clarify Underlying Issues

• Focus On the problem behavior

How to Confront Inappropriate BehaviorThe Resilient Physician (Sotile & Sotile, 2002)

• Do not debate: Each topic deserves it’s own conversation

• Convey hope beyond tension

Process

• Incident reported - any source

• Investigated – Informal first

• Reviewed by Chair/CMO

• Meeting called with Chair/CMO - “cup of coffee”

• Escalated to leadership if repeated behavior or clearly egregious.

• Moved to a corrective action plan.

Language Matters

• Some things you might say...

– “We are here to discuss your behavior, and your behavior is not consistent with...”

– “Recall that we have a Professional Behavior policy, and behavior was not...”

– “We expect that our team acts...”– “We have __ episodes documented when you did [or failed to

do]__”

Discouraging Disruptive Behavior. Vanderbilt School of Medicine. Nov, 2008.

Confronting Disruptive BehaviorAnticipated Reactions

• Flight

• Subject-Changer• Apologizer • Denier

Virginia Beeson. The Advisory Board, 2009

Confronting Disruptive BehaviorAnticipated Reactions

• Fight

• Rationalizer• Blame-Shifter • Score-Keeper • Negotiator

Virginia Beeson. The Advisory Board, 2009

Confronting Disruptive BehaviorLanguage Matters

• Use “Nevertheless, the fact remains....”

• Separate process issues from the point of this intervention

“In the meantime...”

Intervention Guidelines

• Don’t Ignore the Obvious

–Anticipate responses ranging from acceptance to denial to anger to hurt

–Remember: The higher the hierarchy, the higher the shame and guilt

Language Matters

–Explain that You Will Follow-Up

• “If things don’t improve, or if you don’t comply with the plan, the consequences will be...”

Discouraging Disruptive Behavior. Vanderbilt School of Medicine. Nov, 2008.

Document

Document

Document

Document!

• Follow-up

• Manage Post-Disruptions Turmoil–Provide staff protection against retaliation–Decreased productivity–Workarounds–Turnover–“Lost” Administrative Time

How to Confront Inappropriate BehaviorThe Resilient Physician (Sotile & Sotile, 2002)

In the Final Analysis:

a preemptive plan most effective

• Appointment of Excellent Physicians

• Orient heavily on Vision and Culture

• Build trust between Physicians & Leaders

• Set and communicate expectations

• Coach and train physician behaviors

• Measure performance vs. expectations

• Provide feedback on performance

• Coach to improve poor performance

Transformation Requires

An appeal to the “Heart”, not just the “Head”

~Comments from The Heart of Change by John Kotter

“Changing behavior is less a matter of giving people analysis to influence their thoughts, than helping them to see a truth to influence their feelings.

Both thinking and feeling are essential, and both are found in successful organizations, but the heart of change is in the emotions. The flow of see-feel-change is more powerful than that of analysis-think-change.”

Promoting Resilience

1. Protect Happiness

2. Focus on Uplifts

3. Believe in Something Bigger

4. Accept the Call to Character

5. Manage Your Coping Style

6. Rethink “The Balanced Life”

7. Embrace Good Work

8. Lead with Passion!

9. Deepen Your Relationships

10. Be a Hero

Source: Sotile, WM & Sotile MO. Letting Go of What’s Holding You Back. 2007

A hero is someone who creates safe spaces

for other people

—The Resilient Physician. Wayne & Mary Sotile (2002)

Hero

Striking a Balance in Physician Selection !

Everyone else isEveryone else is

Word of mouthWord of mouth

New physiciansNew physicians

ReferralsReferrals

GrowthGrowth

Specialty gapSpecialty gap

Unique talentUnique talent

Primary CarePrimary Care

Need Interest

Leaders must own the process!

Effective Physician Selection

• Organizational Needs

• Organizational Values

• Process of recruitment – we or they formally or informally - Pre application

• Meets criteria - send application

• Process of evaluation – gather information

• Process of selection – Peer interview – committee deliberation - is there a fit?

Teamwork is:

• The ability to work together toward a common vision.

• The ability to direct individual accomplishments toward organizational objectives.

• It is the fuel that allows common people to attain uncommon results.

Andrew Carnegie


Evidenced-Based System

Behavior and Performance Management

Process and

Technology

Goals and Skills


"Culture outperforms strategy every time; and culture with strategy is unbeatable."

Quint Studer


Questions?


“Always bring it back to values . . .”

Quint Studer


2014 Studer Group Institutes


September 3-4 Indianapolis, IN

www.studergroup.com/institutes

Attendees will learn how to: Improve patient loyalty and the patient experience Utilize best-in-class communication techniques to drive performance in

CAHPS, mitigate risk and promote patient adherence Engage and lead physician colleagues to integrate and execute system goals Create a physician measurement system to track performance & productivity Align physician behaviors with organizational objectives to create a shared

mission shared, purposeful mission built around the patient

The Physician Partnership Institute: A Path To Alignment,

Engagement and Integration

Post-Conferences Available! Visit our website to view topics and dates.

Value of Learning for both days rated 95%

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