Doc speak: How to get them on board with quality
Six step plan to getting buy in
It might feel like you're speaking a different language when you try to get physicians on board for your quality initiatives. And you actually are, according to one lawyer and health care consultant well versed on the topic. But it doesn't have to be this way. You communicate differently depending on who you're talking to — that's common in business and life. You just have to understand your audience.
The truth is the idea of helping the hospital work on core measure sets isn't what gets physicians out of bed in the morning. Not generally, at least, says Alice G. Gosfield, JD, a Philadelphia-based attorney and consultant specializing in quality improvement. And year and year, in response to the annual Hospital Peer Review reader survey, you tell us that one of your toughest challenges is getting physicians on board. Gosfield has some answers on speaking effectively with your physician colleagues to engage them where you need them.
"The basic message," she says, "is that the reason physicians are standoffish when it comes to quality is that when hospital people try to engage them, they don't speak to physicians in terms that are meaningful to physicians." So it's like speaking in foreign terms. But, she grants, "on the other hand, they have common cause — physicians and hospitals — around patient safety and quality. And if the hospital were to speak to the physicians and engage with them around the business case for quality, they would make enormous headway. Because physicians are really enormously compelled by this stuff."
Recognize physicians' need, fears
What's the most precious resource to physicians? Time, says Gosfield. So keep this in mind when eliciting their help.
"It is a quality problem that they need more time in their day. Anything a hospital can do with regard to standardizing order sets, facilitating documentation around guidelines that saves physicians time, the more likely they are to do it," she says.
They are also more likely to adopt a new practice if they are involved in its inception. Gosfield says a small group of physicians, the right ones, must be at the table when something like an order set is being established. Some hospitals have gotten beyond this cultural tension between physicians and administration, but in most hospitals, she says, physicians "live in a mild state of perpetual paranoia" with a lack of trust between what the administration and medical staff say.
Getting at the central tension is integral to successful collaboration. Gosfield says "every hospital has some freight train of baggage driving around that no one talks about. They all know about it, but no one talks about it." In her work with the Institute for Healthcare Improvement, with which she coauthored a white paper entitled "Engaging Physicians in a Shared Quality Agenda," she has created a tool to gauge how physicians feel about the culture of the hospital and the support they receive.
The tool involves asking physicians about the medical staff culture within the hospitals, with questions such as:
- How long has the medical staff culture been stable?
- What does the medical executive committee represents? Is it fair and balanced? Does it represent the medical staff? Does it represent individual physician rights?
- How well and thoroughly does the board engage with the medical staff?
If staff don't feel they're listened to and heard — for instance, if they've brought up suggestions or comments that are never acted on — they often feel a disconnect and might not be motivated to engage further in a team.
Also, acknowledging the unique fears of physicians is essential to truly working hand in hand with them, Gosfield says. "Nobody really acknowledges the fears that physicians have, the anxieties they bring to the table, and the terrible pressure they're under to do right for their patients, make the right decisions using imperfect information in an imperfect system on the fly," she says, adding that physicians feel this "accountability profoundly."
She says when she's talked to physicians about this, she's literally seen their walls melt away at being understood, at somebody voicing the unique pressures they feel. She acknowledges that many feel physicians must be specifically catered to to get their engagement. But she thinks that makes sense. Physicians "have what's called plenary legal authority. The doctors have the broadest scope of authority of anybody in the health care system. They admit people, they order services, they discharge people. Nobody else really does all that... everything that happens in a hospital is ultimately derivative of the physician order. And you don't need physicians involved in every quality and patient safety initiative, but if they aren't supportive, it can bring your program to a grinding halt. Just by their recalcitrance," she says.
Her framework for engaging physicians, which she created for the IHI white paper, includes six points:
1. Discover common purposes.
Finding common cause comes first, Gosfield says, and recognizing the most important thing to physicians: time, time, time.
Flip the story around. Instead of telling them you need their help, she suggests asking them what the quality department can to do help them. As for the pervasive thought that what gets physicians on board is constantly putting peer-reviewed literature in front of them, Gosfield says that's not it at all. "There's studies that show that physicians are ultimate empiricists. What they really believe is what has happened to them personally," and they actually discount peer-reviewed literature.
"Secretly," she says, "they discount it because they believe all those guys who are writing peer-reviewed literature are writing their way up the academic food chain and that the purity of literature never publishes negative studies."
Frame the quality discussion in terms of what affects physicians: reducing needless deaths and readmissions. Not "make our scores look better" or "reduce length of stay."
And use data. Don't try to make something mandatory or penalize people who don't do something until "you've got 95% of people who are the 'target market' doing it."
2. Reframe values and beliefs.
Physicians are passionate about their own patients, Gosfield says. As health care has changed, they have had to feel that sense of responsibility for all the patients in a hospital. That's a "very significant cultural change," Gosfield says. "If you can get them to look at the context in which their patients are being served, it becomes easier to get to the place where they believe that the entire institution ought to be functioning in the same way. But what we talk about is that you want to help them standardize the science, so they can custom craft the art of medicine, which means making the right thing to do the easy thing to do."
She uses an example from Park Nicollet, a health care system in Minneapolis. Physicians and nurses sat down with nurses in the coronary care unit to create a standing order set for AMI. Then it became mandatory to use it; for every patient admitted with AMI, the order sheet was attached to the outside of the record. "So when the physician came in for the initial visit to do the orders for the patient's stay, he could either check off the things he wanted on the standing order set or open the medical record and confront the blank and empty page for which he now has to write a Russian novel," Gosfield says. What do you think happened, she asks then. "They all used the standing order set and their compliance with evidence based [care] shot up to like 97% in 14 minutes."
To reframe administrators' values and beliefs change this sentence "Physicians make care decisions; we run the finances and facilities" to "Physicians are our partners in running the system."
To reframe physician's values and beliefs change "I must have complete autonomy for everything" to "I need autonomy for the art of medicine, but I share it with other physicians for the science of medicine."
3. Segment the engagement plan.
"You may think that you have a medical staff. That does not mean that they're all interested in the same stuff or working together the same way or as enthusiastic each to the next," Gosfield says.
For each quality project, there's going to be a few people who get it and are interested in participating. "They're not necessarily the leaders," she says. "They're not what I call the guys with the crown and scepter all the time." They might be younger people who are more innovative, enthusiastic, eager to get involved with new things. They'll say, "Oh yeah, I want to try that!" Those are the champions, she says.
Then you need the people who will try it after the first innovators do it, saying "That looks interesting. We'll try it, too." Those aren't the people who'll be first in line to try something new, but they're willing to give it a go next.
Then, figure out who wears the "crown and scepter." Those are the people, Gosfield says, "who are willing to stand up and be proponents for this."
To what she terms "cautious critics" — maybe an older doctor more set in his or her ways and less likely to quickly adopt a new way — "go talk to them first," she suggests. "When you get your idea, go say, 'You're so good at figuring out what's wrong.' Frequently, they actually have an important piece of information to share about what's wrong with the way you're going about it."
Segmenting the engagement plan is discerning and identifying who plays these different roles in your organization and the likely players for any specific initiative.
4. Use "engaging" improvement methods.
Ask yourself: Are you trying to standardize too much? Do you have endless meetings to discover the right answer, as if this opportunity is the only one you'll have to find it?
Don't ask the same eight guys to do everything a billion times, Gosfield advises. "They get burn out." And don't have endless meetings where nothing ever gets done. That's a way to snuff out motivation quickly. She suggests using "small pockets of people who try things in rapid cycles of improvement."
She suggests the following four things:
- "give physicians raw data; they don't trust interpreted data"
- be aware of which doctors are really respected in your organization;
- make involvement of physicians visible; people should know they're involved;
- build and rebuild trust.
The last is a tough one, she says. And she has a very simple phrase to illustrate what must happen to garner this trust: "Do what you say, say what you do, consistently over time. That means you have to be able to articulate what you're doing and then you have to do what you said you were going to do. And do it again and again and again," she says.
5. Show courage.
From the board and the administration to nursing, don't have a culture in which if someone stands up and says, "I don't think this is right," the thought and the person get squashed. Back your staff up. "That meaningful, constructive inquiry is really important, and showing courage is when you adopt a policy, it is real. And when doctors say they're not going to abide by the policy, and everybody has voted on it [and you already had the 95% compliance rate], you don't let them get away with it," she says.
6. Adopt an engaging style.
Adopt all of the practices and you will have an engaging style. For instance, involving doctors from the outset, building trust, and communicating frequently will help you get physicians not only on board but involved and committed to the outcomes both of you will want.
It might feel like you're speaking a different language when you try to get physicians on board for your quality initiatives. And you actually are, according to one lawyer and health care consultant well versed on the topic.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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