“Quality has been used as a weapon in the fight against limits to healthcare funding. In one corner of the ring stands the clinician, outraged that a paper pushing manager concerned with throughputs and efficiency does not understand or care that quality of care is adversely affected by cost cutting. In the other corner stands the manager, convinced that quality is the last refuge of the medical scoundrel – a convenient, vague and all embracing term used to block any attempts to question or change clinical behaviour” Buchan 1998 In Davies H. et al. Healthcare professionals’ views on clinician engagement in quality improvement. A literature review. The Health Foundation, 2007 The Problem?
The Paradigm Clinicians’ primary professional focus is their own practice. At best, clinicians have little time to spare for quality agendas of their organisations. At worst, relationships are strained because the clinicians’ quality agendas conflict with those of their organisations. Very little happens without a clinician order
A day in the life of… AM – 1. New protocol received by all clinicians. 2. At 1 st patient clinician finds dispenser empty so cannot clean hands. 3. New computer system not known to clinician so makes paper record 4. Finds ward manager on leave when trying to discuss new procedures 5. Poor turnaround times then mean start clinic/theatre late with incomplete prep and kit. PM – 6. Unable to use new communication system clinician repeatedly sends JHO out for communication. 7. Then clinician not informed of patient move. 8. Unaware of new discharge procedure so clinician fails to give patient adequate info 9. Clinician ends day having technically discharged their duties. 10. End of the day and the MD approaches clinician with opportunity to be part of quality idea!!
Clinicians involvement in improvement Can it be made better? I believe so and offer the following as a framework for making the involvement of clinical colleagues in improvement efforts better and more rewarding.
Discover Common Purpose Improve patient outcomes Reduce hassles and wasted time Understand the organisation’s culture Understand the legal opportunities and barriers
Knowledge is mostly perception “We tend to start with the things that we know, the things we hold to be important, our view of the world, forgetting that it is inevitably just a view, seen from one fairly unique perspective”
The Doctors’ Quality Agenda “Physician-led, evidence-based, data-driven” Better outcomes –When all was said and done, how did my patient do? –Professional reputation –Personal sense of excellence Less wasted time –Hassles –Bottlenecks and delays –Rework –My day was going well until…
Reframe Values and Beliefs Make doctors partners, not customers Promote both system and individual responsibility for quality
Types of values in organisations Attributed Those that organisational members attribute to their organisation Located at the level of the collective actor Identified by asking members to state what they recognise to be the value priorities of the organisation as a whole Espoused Those that are sanctioned by the organisation’s top managers Located at the level of the top managers Identified by content analysis of documents, formal statements and managers’ expressions Aspirational Those considered desirable for the organisation by some or more members Located diversely in the organisation Identified by asking organisational members to state what the values ought to be at some future time Shared Those reflected in the personal values of organisational members. Located at the level of the individual member Identified by assessing similarities in members’ personal values priorities Embedded Intended organisation Individual What are your values? What matters to you? What matters to your patients? What matters to your colleagues? What matters to your organisation?
Common Agenda: Keys to Success Frame the quality challenge in terms that are important to doctors –“Reduce Needless Deaths, Readmissions, Nosocomial Infections, Hassles…” –Not “Reduce LOS” or “Improve Productivity” Measure and display the results on important things—show them that together, you’re actually making these things better
Reframing Managers’ Values, Habits, Beliefs… Doctors are important customers Doctors make care decisions, we run the finances and facilities The patient is the only customer Doctors are our partners in running the system FROM TO Example: Clinical Directorships
Reframing Doctors’ Values, Habits, Beliefs… I must have complete autonomy for everything I am personally responsible for the patients I take care of directly I need autonomy for the art of medicine, but I share it with other physicians for the science of medicine I am responsible for the care given broadly throughout the system that I am part of, including my own patients FROM TO
Clinician Compacts: Clinician compacts have been talked about for years. The UK medical profession and the DH have been talking about ‘clinician compacts’ since (at least) the 1990’s – the Quality Outcome Framework started as a ‘compact’ in principle. Wales has a compact between the Voluntary sector and the government. What do you believe needs to be included in a ‘Clinician compact’ with this organisation? (Your starter for 10…) What will you do and what do you expect the organisation to do?
% Compliance with Hand Hygiene – Medical Wards External audit by ICT Some staff aware of audit Poster Campaign Meeting between ward consultants & juniors
Segment the Engagement Plan Use the 20/80 Rule Identify and activate champions Educate and inform structural leaders Develop project management skills Identify and work with “laggards”
Questions Which doctors must be engaged in this initiative, if it is to succeed? (And which doctors are not relevant at all?) Who is on our short list of potential champions for this initiative? How will we select one or two champions? What is our plan to support them? What will be the role of the formal leaders: Clinical Executive Management, Department Heads, and Clinical Directors in this initiative? Does a doctor need to be the “project leader” for this initiative? If so, how will we train and support that doctor so that the project will be effectively led? Which doctors are likely to vocally oppose and potentially derail this initiative? How could we mitigate that risk?
Leadershi p Engagement Participation Develop ability Cultivate Willingness Segmenting and developing Clinicians to achieve improvement Speciality & Improvement areas Control Benefit Relief Support Focus Skill Professionally and clinically competent Clinicians ClinicalProfessional
The basics, if nothing else consider making this happen… Getting clinical colleagues to be involved in ‘quality improvement’: How to help make clinician participation, engagement and leadership real. Step 1. Provide relief (solve my problems) Build skill (make me more competent) CoE/CoS Clinical rounds Full cycle learning (FEEDBACK!) Clinician complaint protocol Step 2. Embed Benefit (make it fit for us) Create Focus (don’t waste my time) Intrinsic driven opportunity Role specification Step 3. Cede control (give me freedom) Secure support (give me responsibility) Clinician driven initiative Targeted Support Management time optimisation
Medicine Reconciliation Post Pharmacy intervention
Use “Engaging” Improvement Methods Standardise what’s standardisable, and no more Generate light, not heat, with data Make the right thing easy to try Make the right thing easy to do
Strategy A Form the committee of experts Spend at least 6 months and many hours developing the perfect solution Educate all the staff over 2- 3 days Implement house-wide tomorrow Strategy B “Stack the deck” 1 doc, 1 nurse, 1patient, 1 time Reassess and learn from initial test Repeat, progressively increasing confidence in solution then Test under varying conditions before Spread Overcoming The Need For Perfection
Questions Are you trying to standardize too much? Do your data reports to doctors make things worse? Do you have endless meetings trying to decide on the “right answer,” as if this is the one and only opportunity you’ll ever have to get it right? Have you ever faced a doctor rebellion after implementing the “right answer?”
Adopt an Engaging Style Involve doctors from the beginning (but don’t make them do everything) Work with the real leaders (they may not be most senior) Work with early adopters (they will help you and the improvement) Make doctors involvement visible (credible and not shameful) Build trust within each quality initiative (make it part of the way things are done around here) Communicate candidly, often (if your lips aren't bleeding you haven't communicated enough) Value doctors time with your time (don’t waste either!)
How would you use the diffusion of innovation theory to influence? No need! Mention it! Show a working example! Prove it! Change the rules!
How do you help skill the early adopters? Leaders: (early adopters) Understanding systems & processes Intro to Quality Improvement Using data for improvement Dev powerful ideas for change Testing ideas Implementing changes Working with people Models for Improvement
How do you help skill the early majority? Engagers: (early majority) Organising info Understanding systems & processes Intro to Quality Improvement Using data for improvement Gathering info Scoping improvement efforts Dev powerful ideas for change Testing ideas Implementing changes Working with people Models for Improvement
How do you help skill the late majority? Participants: (Late majority & some ‘laggards’) Intro to Quality Improvement Organising info Understanding systems & processes Using data for improvement Gathering info Models for Improvement Dev powerful ideas for change Testing ideas Implementing changes Working with people
Questions What standard protocols will be necessary to adopt in this initiative? Do we have a plan to use the “new way” of standardisation for these protocols? Do we plan to use individual doctor performance measures? Are we ready to use them? Is the “project setup” for this initiative based on lengthy design of a big change to be implemented all at once, or is it a series of multiple small tests of change? How could this initiative move to implementation in a way that fits easily into the daily workflow of doctors?
An engaging method… Scripts leaving a practice with ‘As directed’ instructions rather than specific directions… PDSA
Show Courage Provide backup all the way to the Board
Wicked Example A complaint comes to you from a patient that they heard a consultant using bad language on a ward when dealing with a trainee doctor. This consultant has been involved in two recent clinical incidents where patients required urgent transfer to ITU. The nurse specialist working with the consultant says she will resign unless “something is done”
Doctors… See the world one patient at a time Have strong, specific, largely unspoken bonds based on shared experiences Overestimate the risk of change Behave collegially about knowledge, autonomously about individual patients Are influenced by credible data Value “due process”
Principles for Working with Doctors Involve them at the beginning Identify and work with the –real leaders –early adopters Display doctor involvement to all Display credible results to all Don’t “package” the data Show that you value their process and their time
The Role of Opinion Leaders technical expert formal leader supportive committed enthusiastic optimistic leading by instruction conformist professional, technical peer informal, emergent leader hostile ambivalent disaffected cynical leading by example deviant executive, managerial Dopson and Fitzgerald 2005
Influencing Behaviour Change (Gollop and Ketley 2007) ProcessActivities Consciousness raisingBecoming more aware of a problem and potential solutions Dramatic reliefEmotional arousal, such as fear of failure to change, and inspiration for successful change Self re-evaluationAppreciating that the change is important to one’s identity, happiness and success Self liberationBelieving that a change can success and making a firm commitment to it Environmental re-evaluationAppreciating that the change will have a positive impact on the social and work environment Reinforcement managementFinding intrinsic and extrinsic rewards for new ways of working Counter-conditioningSubstituting new behaviours and cognitions for the old ways of working Helping relationshipsSeeking and using social support to facilitate change Stimulus controlRestructuring the environment to elicit new behaviours and inhibit old habits Social liberationEmpowering individuals by providing more choices and resources
Strategies for Engagement StrategyDescriptor Appealing Making direct appeals to focus on something already identified by staff or patients as an important area for reform Asking sceptical staff for help with something known to be of interest to them in order to draw them into a project Asking reluctant staff to become involved as a personal favour Demonstrating Presenting data to illustrate current activity Showing a particular improvement technique, e.g. process mapping Bribing Offering a temporary increased level of resource Providing additional resources – equipment or staff Shaming Exposing sceptical staff to pro-change peers at meetings Focusing on pro-change staff, isolating sceptics Hiding Avoiding innovation terminology – “pilot” for PDSA Testing a change without involving sceptical staff
The Creative Climate DimensionDescriptor Challenge People experience joy and meaning in work and invest high energy Freedom People make contacts, exchange information freely, discuss problems, make decisions, take initiative Idea support People listen to each other, ideas and suggestions are received in a supportive way by bosses and colleagues Trust and openness High-trust climate, ideas can be expressed without fear of reprisal or ridicule, communications are open Dynamism and liveliness New things happening all the time, new ways of thinking and solving problems, ‘full speed’ Playfulness Relaxed atmosphere with jokes and laughter, spontaneity Debates Many voices are heard, expressing different ideas and viewpoints Conflicts Conflict of ideas, not personal, impulses under control, people behave in a mature manner, based on psychological insight Risk taking Decisions and actions prompt and rapid, concrete experimentation is preferred to detailed analysis Idea time Opportunities to discuss and test fresh ideas that are not part of planned work activity, and these chances are exploited From Ekvall 1996
Leadership Contributions Chief ExecutiveProject ManagerConsultant Provides strategic direction and ensures that the project or programme has a high profile within the organisation Steers the project or programme, provides operational support and expertise, and influences teams to take ownership of the change Endorses the change, provides continuity, influences sceptical colleagues, and gives the project or programme credibility with other staff groups
But don’t forget its all about perspective! And what you do about it!
A starter reading list: ‘Engaging clinicians in a quality agenda.’ NLIAH (April 2008) (www.nliah.wales.nhs.uk) [ strategic framework for clinician involvement in Wales ]www.nliah.wales.nhs.uk ‘Engaging Physicians in a shared quality agenda.’ Draft Working paper (March 2007) (www.ihi.org) [ strategic framework for clinician involvement in USA]www.ihi.org ‘Diffusion of Innovations.’ (5 th ed.) Everett. M. Rogers Free Press (2003) [ where and how to focus efforts ] ‘Clinical Engagement: Primary care leading by design.’ NLIAH (Jan 2008) [ academic research on clinician engagement ] ‘A healthier healthcare system for the UK,’ Castro P, et al. The McKinsey Quarterly (Feb 2008) [ clinician involvement ] ‘A safer place for dangerous truths: using dialogue to overcome fear and distrust at work,’ New York: AMACOM, (1999) [ CE walk rounds ] ‘Engagement vs. satisfaction among hospital teams,’ Blizzard R, www.gallup.com accessed May 5 th 2009. [ why engagement matters ]www.gallup.com ‘Clinicians at the helm: engaging clinical leaders in hospital reform,’ Conference papers unpublished May 20 th 2009. www.advisory.com [ structure for participation, engagement and leadership ]www.advisory.com ‘Healthcare professionals views on clinician engagement in quality improvement,' Davies H et al, (April 2007) The Health Foundation. [ importance and difficulties in clinician engagement ]