Physician Engagement: Turning Skeptics into Allies

Turning Skeptics into Allies

Dr. M. G. Maharaj Chief of Surgery

NSQIP Surgeon Champion Langley Memorial Hospital

2014 Quality Forum, British Columbia

Background

Langley Memorial: 200 bed community hospital

NSQIP since 2011

Multidisciplinary action teams to reduce UTI and SSI rates

Pneumonia team on the horizon

ENT surgeon at LMH for 10 years, chief of surgery since 2008, surgeon champion since 2011

Advisory board company talent development

Goals

Understand that skeptics are common, and skepticism is a natural response to something new

Identify different categories of stakeholders and strategies which will help them align with your goal

Walk through a real example of managing skeptics in the setting of change to reduce postop UTI in surgical patients

Example: UTI

When LMH started with NSQIP, we had a high UTI rate in surgical patients, according to risk-adjusted data

We assembled a multidisciplinary team who identified that the best practice of early foley removal, or avoidance of indwelling catheter altogether, in total joint patients was not being adhered to consistently

We encountered some skeptics whose objections may sound familiar…

Prevalence of Skepticism

“We don’t need to change the current system. It works

just fine.”

Prevalence of Skepticism

“We can’t change anything until they give us more money.”

Prevalence of Skepticism

“We tried this before and it didn’t work”

Prevalence of Skepticism

“They should just fire all of the administrators – we physicians

know what’s best for our patients.”

Prevalence of Skepticism

Skepticism is a normal, healthy response of a critical mind

Physicians are increasingly trained to rely on evidence based practice

Any change or proposal is inherently flawed until there is convincing evidence to support it

A skeptical response is simply an indicator that the individual is a stakeholder

Stakeholders

Cast a wide net to include all potential stakeholders, including those impacting a change, and impacted by the change.

Failure to include and consult all stakeholders can result in a fundamentally flawed approach, giving strength to skeptics and undermining allies

Failure to Target the Real Issue

Stakeholders: Power Brokers

Those with ultimate decision-making over the change

Ability to allow or prevent what you are advocating from getting off the ground

Typically executive level

LMH: OR and surgical ward Manager

Stakeholders: Agents

Those responsible for enacting the change, carrying out the day-to-day implementation

Typically front line staff, including physicians

LMH: OR nurses, ward nurses, orthopaedic surgeons

Stakeholders: Constituents

Those impacted by the change, the targets or beneficiaries of the proposal

Typically patients

Often also includes the frontline staff and physicians

LMH: patients, OR and ward nursing staff, Urologists

Stakeholder Stance

Supporter: can be counted on to support and even promote the initiative – OR nursing staff

Undecided: uncertain, could be swayed to action either in support or in opposition – Orthopaedic surgeons, Ward nursing staff

Dissenter: actively opposed, unlikely to switch allegiance - Urologist

Urgency

Urgency

Urgency can be thought of as a means of influencing the degree of enthusiasm with which an individual becomes involved

Times sensitivity and personal importance can impact how strongly a support promotes, or a dissenter thwarts, an initiative

Urgency can be raised or lowered for any given individual

Strategic Approach to Stakeholders

Supporters: inflate urgency to inspire continued active support, but don’t continually preach to the choir

Dissenters: reduce urgency to reduce reaction, maintain in an inactive status; don’t expect to turn dissenters into supporters

Undecided: articulate the reasons why undecideds should become active supporters; this should be the group receiving most of your attention

Strategies for Agents

Supporter: designate responsibility for process improvement, give them ownership or the change

LMH: OR nurse charged with communicating the new policy, reporting on compliance

Strategies for Agents

Dissenter: find supporter with knowledge or data to counter negative messaging from dissenter

LMH: other Urologist tasked with presenting the data in support of the new policy

Strategies for Agents

Undecided: use information or data to design or refine the change, identify “what’s in it for them”, and how this change will serve their needs

LMH: emphasis on patient benefit to avoiding UTI happy patient = happy Orthopod fewer UTIs reflect positively on ward nursing care

The Power of a Group

Inflating and deflating urgency can be done individually; commitments to action should be done in a group

Groups allow individual expertise and perspective to work synergistically to the benefit of the collective

Groups also prove as “testing grounds” for more extreme views, and can be an effective venue to quash dissent

LMH: all stakeholders brought together in person to air their concerns, hear reassurances from colleagues, get a sense of the collective will to act to correct a proven problem with patient care

What Physicians Want

Respect Acknowledge their role as stakeholders Expertise Responsibility for patient care

Independence Patient advocates Ultimate responsibility is to the patient, not the

institution

Don’t Over Complicate

We’re all in this Together

At the end of the day, we want the same thing: optimizing patient care

Different ways of accomplishing the same goal

Skeptics should be respected, put in the context of the group opinion, and managed in such a way as to either become a supporter, or a non-disruptive dissenter

A track record of success will predispose prior dissenters to be less likely to dissent in the future

LMH: successful implementation of new policy resulting in ~30% reduction in UTI rate

Questions