Engaging physicians, nurses, and, staff can lead to improved quality and better patient care. However, getting engagement is tricky. This is the first of a three-part series in how hospitals can successfully engage their clinicians. Part one will cover physicians, part two, nurses, and part three, staff.
Successful Engagement: Physicians
Most Americans would agree the U.S. healthcare systems provide the best care possible anywhere in the world. The ability to save and extend life as well as reduce the suffering of those who are in the final stages of life is nothing short of miraculous. According to Journal of Patient Safety preventable medical errors are now the third leading cause of death in the U.S., behind only heart disease and cancer. In addition, more than 10,000 serious complications are also attributed to medical errors and are estimated to cost the U.S. $1 trillion dollars annually.
The U.S. ranks first in the world for per capita health expenditures, two and a half times the average for industrialized countries. Approximately half of the $2.9 trillion spent annually in healthcare expenditures could be saved by taking waste out of the system.
Healthcare Revolves Around Physicians
In order to reduce waste, hospitals will need to engage physicians. After all, physicians play a critical role in every aspect of healthcare. Physicians guide processes and decisions that are made inside and outside the hospital walls.. Every strategy to fix problems in healthcare today revolves around the buy-in of one critical group—the physicians. Physicians determine 75 to 85 percent of the decisions that drive quality and cost. Gallup reported that at one health system whose physicians were in the top quartile for engagement increased outpatient volume by 17.5 percent, while disengaged physicians in the bottom quartile saw their outpatient volume decline by -11.7 percent.
Physicians are also impacted by the changes happening in healthcare—and not always for the better. The industry is transforming, leading clinicians to experience a shift in autonomy and possible changes in income and social stature.
Overwhelmed and ill equipped (along with a limited understanding of risk-based payment models or how their behavior contributes to healthcare waste and inefficiency), physicians are going through something akin to the five stages of grief. While most are beyond the denial phase, many are stuck at the anger stage.
Adding to the frustration, providers and payers are focusing only on employment as a means to engage physicians. Organizations over-weigh the importance of compensation to influence physician behavior. Most physicians are not business people, so financial incentives rarely influence their behavior.
Physicians are working long hours, are not compensated for their assistance, and are uncertain if management supports them. Malpractice concerns, a lack of meaningful measurements, and poor data analytic support also contribute to the feeling of frustration.
In my own experience, I have found implementing a new EMR resulted in clinicians working several more hours after seeing patients just to complete their documentation and other EMR functions. Although it would seem that an EMR system should help a clinician practice more efficiently, this is not always the case. Finding information is more streamlined, but there was also an increase in the EMR functions assigned to the physicians as well.
That’s not to say physicians are completely unwilling to change their behavior to remove waste from the healthcare system—it just depends on where the waste is coming from.
When changes were instituted for clinical integration programs at Intermountain Healthcare, it was determined there weretoo many elective deliveries occurring before 39 weeks. Many of the physicians looked at this and said, “It really isn’t a problem for us.”
When shown the data, however, physicians realized that there was a problem within the system. They saw that too many of these patients delivered early and the newborns were being harmed by this practice. When the physicians accepted the evidence presented and understood the reasoning, implementation and enforcement best practice policies began.
The conclusion? If the change has a direct impact on patient care (making patient care safer) physicians are more likely to respond positively. Today, we see a great deal of discussion around financial benefits as a reason to get physicians engaged. But, surveys show that if the change is only a cost benefit to the hospital, there is less interest from physicians. This cost benefit approach doesn’t drive engagement or change physician behavior.
Stages of Physician Engagement
Similar to the stages of grief, there are also stages of engagement. Generally, physicians either don’t like change (aversion), or are okay with the change but not really enthusiastic about it (apathy). Finally, only after a lot of education and when they can see the value, does commitment to the change occur (engaged).
A Matter of Trust
So what can healthcare organizations do to deepen the engagement of physicians? First, physicians must believe the hospital can be trusted to consistently deliver on its commitments, such as promising to make OR slots available so surgeons can perform surgeries in a timely fashion. Even when seemingly simple things like creating a space for physicians to gather comes to fruition, trust is built between the hospital and the clinician. Physicians must also believe the hospital has integrity and they will always be treated fairly with satisfactory resolution for problems that may occur.
Physicians want to feel good about using the hospital and want to be sure that hospital use reflects positively upon them. This translates to having the hospital create services to support the delivery of exceptional patient care.
Physicians are passionate about caring for their patients. They view the hospital as irreplaceable and an integral part of their lives and their practice of medicine. When hospitals focus too much on the bottom line and cut services, physicians may no longer feel that the hospital is irreplaceable or functions as an integral part of their practice.
Max Weber, a German sociologist, said there are four things that motivate and drive people to change. These four levers must be implemented together, not in isolation. The Institute for Healthcare Improvement calls this a “Shared Quality Agenda.”
- Discover a Common Purpose
The idea of identifying a common purpose cannot be overemphasized. The entire purpose of why doctors became doctors is to care for—and improve the lives of—patients. This must be the primary focus of everything done at hospitals or facilities or anywhere that engages physicians. This is what drives the physician base.
Healthcare organizations must also refrain from asking physicians to increase their time, busyness, or activities. Organizations must be very cognizant to ensure changes are implemented efficiently. Hospitals must also understand the culture of the local organization. Are the physicians, nurses, caregivers, and the hospital administration ready for change? A readiness assessment may be necessary, and, if possible, learn best practices from other industries that have successfully implemented quality initiatives.
The organization’s leaders must also understand the legal opportunities and barriers. Physicians are concerned about possible litigation, and although it may not be in the forefront of their thoughts, there can be a tendency to over-order tests and over-order procedures to protect themselves from malpractice concerns.
- Reframe Values and Beliefs
Physicians should be treated as partners with the hospital, not customers of it. Many times hospital administrators appease physicians because physicians are viewed as customers. By partnering with physicians, hospitals can ensure better care for patients, which is the key focus of clinicians anyway.
Accountability for quality must be promoted for both the system and the individual. Personal responsibility for quality is powerfully engrained in all physicians. They do what’s best for patients. Many physicians are willing to spend an extra 20 minutes, even though it may mean delaying other appointments for the remainder of the day. Personal responsibility for quality is very much engrained in what clinicians do each and every day.
3.Segment the Engagement Plan
At the very beginning of the implementation of the quality initiative, identify and activate champions. Don’t overlook participants who may not have a senior title, as many clinicians who aren’t department chairs or in any type of management role still hold a position of influence within the community.
It’s important also to educate and inform structural leaders, such as department heads or medical directors. Show them the evidence and be transparent about the data because these leaders have the authority, given the natures of their positions, to influence change.
- Provide Support and Education
The development of project management skills in these leaders can be provided by support and education; and not only for them, but for the rest of the staff as well. Physicians do not work well in an environment when there is a lack of understanding as to the strategy and purpose of the initiative.
- Engage the Physician’s Intellect
Help the physician understand why the changes are taking place. Allow her to review improvement ideas or tests of change. Much like Deming’s 14-Point Philosophy, showing physicians how they fit in to the process and why they are important to the success of the initiative will increase the level of engagement and support.
- Use “Engaging” Improvement Methods
It’s important to not only understand how the change will be implemented, but also the best way to gather support and commitment. Oftentimes checklists and institutional practices are viewed as cookbook medicine. It needs to be clear that what should be standardized will be standardized and no more. Physicians need to engage in those areas that fall outside these standardized practices.
Data must be used sensibly with a focus on the system’s performance first, not the individual’s performance.
All protocols that are changed need to be implemented in an open and transparent manner, making it easy to do the right thing while allowing for change as the initiative progresses. Nothing is written in stone.
- Build Trust
Building trust is the most important piece of the process. Communicate often and candidly. Address concerns and issues in a timely and obvious manner. Identify and overcome barriers to engagement. The administration and leadership within the organization must be very responsive.
- Show Courage
Sometimes physicians don’t feel it’s really safe to change due to doubts of the commitment and support of senior leadership or lack of proper resources. It is important for physicians to understand that their requests for resources are not falling on deaf ears. Leaders must have the courage to ask, especially if the request is in the best interest of the patient.
- Adopt an Engaging Style
Physicians want to be involved from the very beginning. Ask them how patient care can be improved. Because the underlying supposition is that improving patient care will allow for fewer mistakes, reduce waste, and provide patients the right care at the right time in the right place.
Working with the real leaders and early adopters and the early majority will come and follow. Don’t waste time on the laggards because they may never get on board. Spending more time and energy engaging the leaders and early adopters will move the entire curve.
Choose the messages and messengers carefully to ensure the message is delivered in a positive manner that appeals to physicians and encourages engagement.
Make physician involvement very visible. Physicians feel camaraderie with other physicians—a closed club perhaps. As physicians are placed in leadership positions, others will take notice and begin to believe the administration supports them because colleagues they respect and understand are part of the process.
Allow the clinicians to feel ownership even if it’s an issue like supply chain management that may be viewed as topic they wouldn’t care about.
Communicate early, candidly, and often. Value the physicians’ time as the culture and the workflow of physicians is very different from others in the hospital. Remember, for a physician to attend a meeting means taking their time either before clinic or during clinic hours, impacting their ability to see and care for patients.
Physician Engagement Requires Leadership and Trust
People, including physicians, resist loss (or possible or perceived loss), not the change itself. Keep the patient as the “North Star” with the end goal being the delivery of better care for patients.
Identify real leaders and early adopters; those who drive change from within the hospitals, clinics, and the organization. Equip them with the right tools, the right education, and the right resources.
Create a support structure and align resources within the institution to provide the infrastructure for change. Without this, it is really difficult to implement and sustain change.
Understand and mitigate real and perceived loss and realize it may take a lot of discussion and a lot of contemplation. There is no magic formula or cookie-cutter solution that can be mandated across the entire organization. It must be addressed at the local level.
And finally, create trust. Whatever promise is made, must be delivered upon. Use each success as a building block to drive long-term, sustainable change in the future.
Stay tuned for part two of this series: how a hospital can engage nursing staff.
Dr.Bryan Oshiro Chief Medical Officer