Engaging Physicians: Insights and Actions for Results

Transcription

1 Session A14/B14 This presenter has nothing to disclose Engaging Physicians: Insights and Actions for Results Jack Silversin, DMD, DrPH Amicus, Inc Cambridge, Massachusetts Objectives Describe the impact of the quality of the organization-doctor relationship on physician engagement with 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 Jack Silversin 1

2 What It Looks Like When Physicians are Engaged in Improvement Beyond showing up. Invest time, demonstrate 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 Builds trust and partnership between physicians and management when physicians experience they have influence on outcomes Helps physicians move through psychological transition associated with change Jack Silversin 2

3 Authentic Engagement Is Difficult Managers or administrators Some like making decisions and controlling outcomes Experience pressure for timely decisions Have not been successful managing efficient and helpful process for engagement Are faced with physicians expectation that asking their advice should translate into actions that reflect it Experience sincere attempts have been met with cynicism or disinterest Physicians Perceive that past input has gone into black hole which leads to cynicism Paid for productivity, some will not participate in non-clinical work unless compensated Having the option to do what I want to do anyway makes investing time in improvement activity irrational Requires on going commitment to engage even when you don t get what you want in a given situation Actions That Foster Engagement Build trust: meet legitimate needs, be transparent, address baggage Take steps to make physician engagement an organizational expectation Avoid quick fix when change challenges core identity or has significant emotional dimension Ensure engagement process is fair and decisions merit-based Jack Silversin 3

4 Actions That Foster Engagement Build trust: meet legitimate needs, be transparent, address baggage Take steps to make physician engagement an organizational expectation Avoid quick fix when change challenges core identity or has significant emotional dimension Ensure engagement process is fair and decisions merit-based Build Trust: Meet Legitimate Needs A real situation: Scrubs unavailable when needed After multiple reports and no change, physicians conclude admin doesn t care Consequently physicians don t feel obligated when admin requests their involvement for improvement What are the no scrubs when needed issues in your institution? What hygiene factors do you need to respond to as a priority? Jack Silversin 4

5 Build Trust: Be Transparent Further trust by being proactive and transparent whenever possible Not sharing information fuels suspicion and prevents physicians from helping solve problems Build Trust: Address Baggage Baggage from past or recent interactions can get in the way of trust Mistrust usually flows both ways Invest in candid conversation if needed to let go of baggage What do I/we do that results in the other group having an impression of us that is unhelpful? What can I/we do to build greater trust? Act differently based on insights and discovery Jack Silversin 5

6 Actions That Foster Engagement Build trust: meet legitimate needs, be transparent, address baggage Take steps to make physician engagement an organizational expectation Step 1 = raise the heat Step 2 = craft shared vision that gets everyone on same page Step 3 = co-create reciprocal expectations (compact) that includes physician duty to engage and administration duty to listen/include Avoid quick fix when change challenges core identity or has significant emotional dimension Ensure engagement process is fair and decisions merit-based Step 1. Raise the Heat, Help Others Feel 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 Jack Silversin 6

7 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 Step 2. Shared Vision Alignment has to precede engagement. If our goals aren t aligned, why would I spend my time engaging with you? Jack Silversin 7

8 Shared Vision 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 Basis of Vision is Shared Interests Hospital s Interests Doctors Interests SHARED INTERESTS Quality patient care and safety Economic success Positive reputation Recruit and retain talent Jack Silversin 8

9 Step 3. Co-Create New Compact 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 Typical Implicit Physician Compact GIVE GET Treat patients Provide quality care (personally defined) Autonomy Protection Entitlement Jack Silversin 9

10 Clash Of Promise And Imperatives Traditional Promise or Legacy Expectations Autonomy Protection Entitlement Imperatives Improve safety/quality Implement EHR Reduce costs, become more efficient Be patient-focused Improve access Recruit and retain staff 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 Jack Silversin 10

11 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 Physicians give: What the org needs to achieve the vision Organization gives: What will help physicians to meet their commitment Jack Silversin 11

12 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 Jack Silversin 12

13 Actions That Foster Engagement Build trust: meet legitimate needs, be transparent, address baggage Take steps to make physician engagement an organizational expectation Avoid quick fix when change challenges core identity or has significant emotional dimension Ensure engagement process is fair and decisions merit-based A Helpful Perspective on Change Jack Silversin 13

14 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 Jack Silversin 14

15 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 Jack Silversin 15

16 Wisdom from Ronald Heifetz The most common cause of failure to make progress is treating an adaptive problem with a technical fix. Technical fixes Incentives or compensation Reorganization Issuing new vision statement 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 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 Jack Silversin 16

17 Actions That Foster Engagement Build trust: meet legitimate needs, be transparent, address baggage Take steps to make physician engagement an organizational expectation Avoid quick fix when change challenges core identity or has significant emotional dimension Ensure engagement process is fair and decisions merit-based Ensure Fairness of Engagement Process Outcomes matter, but no more than the fairness of the processes that produce them. W. Chan Kim and Renée Mauborgne Harvard Business Review, Jan 2003 Jack Silversin 17

18 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 preset 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 Jack Silversin 18

19 Actions That Foster Engagement Build trust: meet legitimate needs, be transparent, address baggage Take steps to make physician engagement an organizational expectation Avoid quick fix when change challenges core identity or has significant emotional dimension Ensure engagement process is fair and decisions merit-based No Matter What s Ahead Engaged Physicians Position Your Organization for Success Jack Silversin 19