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Physician Engagement: Turning Skeptics into Allies

Physician Engagement: Turning Skeptics into Allies



This presentation was delivered in session B5 of Quality Forum 2014 by:

This presentation was delivered in session B5 of Quality Forum 2014 by:

Mitra Maharaj
Surgeon Champion, NSQIP, Langley Memorial Hospital
Fraser Health



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    Physician Engagement: Turning Skeptics into Allies Physician Engagement: Turning Skeptics into Allies Presentation Transcript

    • 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