Imogen Mitchell’s SMACC Chicago talk 'Morphing the Recalcitrant Clinician’ talks us through the steps to engage the reluctant physician when implementing change. Imogen initally touches on the stages of physician engagement from aversion, to apathy, to engaged and then outlines the steps to morphing the reluctant physician. 1. Seek out a clinical champion 2. Establish a common purpose/vision 3. Standardise what is standardisable 4. Communication, communication, communication 5. Work out barriers and overcome them 6. Deal with the ‘Whats in it for me?’WIFM

1. Morphing the Recalcitrant Physician
@IA_Mitchell

2. Outline
•Geographic orientation
•Patient safety and physicians in context
•Engaging physicians: 6 easy steps

3. Experience
•15 (long) Years ICU Director
•Territory wide clinical review system
•Territory wide patient deterioration system
•Facilitating national implementation of the “End of Life Consensus Statement”

5. DOCTOR PHYSICIAN/PROVIDER

8. Hospitals are Dangerous Places...
Harvard Medical Practice Study
•Size of problem was finally acknowledged
•Reviewed hospital charts in 1984
•Estimated 98,609 adverse events (3.7% hospitalisations) in New York State
•Poor delivery of health care accounted for 27 179 patient safety incidents (27.6%)
Similar data in Australia (16.6%) and UK (10%)
Brennan TA, Leape LL, Laird NM, et al. NEJM 1991;324:370-6.
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9. The Role of the Physician in the Delivery of Healthcare
Physicians
•Decide who to admit and who to discharge
•Decide on the diagnosis
•Prescribe medications
•Order investigations

10. The Need for Change
•Improve the patient experience
safe, engaged physician, environment enabling satisfaction
•Improve the health of populations
•Reduce costs

11. “emotional involvement or commitment”

12. Stages of Physician Engagement
Aversion Apathy Engaged
Active support of the change
•Trust it will improve patient care/outcomes
•View themselves as a stakeholder

13. Ever seen a recalcitrant physician?

14. 6 Easy Steps

15. Seek Out Clinical Champion: Change Agent
• Need to be respected
• Need to be inspirational
• Need to be given time (!)
• Need senior hospital support
1

16. Engage the head and heart*
* JP Kotter Heart of Change

17. Engage Physician’s Heart
•Help them see the need for change
Local stories to allow understanding of the problem
•Allow them to feel they are hit with the reality of the problem
Preventable harm is not acceptable, the “burning platform”
Eg: Reframing CVC-BSIs as a social problem*
•Use their energy use fully to change behaviour
Allow them to take their emotionally charged ideas into action
*Dixon-Woods et al Milbank Quarterly2011; 89: 167-205

18. Engage Physician’s Intellect
• Provide data/literature (data are power)
• Inspire them that they too can do the same!

19. Establish a Common Purpose/Vision: The patient, the patient, the patient
2

20. Standardise what is standardisable
• Engage other physicians to help develop intervention/implementation strategy
• Start small and make sure it is easy
3

21. Communication, Communication, Communication
• Create opportunities to talk with physicians
Grand rounds, unit meetings, safety and quality meetings
Keep on message, making sure everyone captured, listen and answer queries
• No surprises when implementation occurs
• Feedback opportunities when implemented
newsletters, grand rounds, unit meetings,
4

22. Communication, Communication, Communication
• The Messenger is critical to success
Respected clinician who can work up and down hierarchy
Non-threatening, listening style (value the dissenter)
• Data/Literature
How data are presented is important
Credibility of data/literature
4

23. Identify and overcome barriers
• Try physician engagement self-diagnostic tool
helps determine what the uphill battle will be like
• Clinician
often know who these are likely to be
• Intervention
work through the likely challenges
• System
does the system allow for these changes?
5

24. Tune in to What’s In It For Me?
• People resist loss not change
• Try to realise and mitigate real AND perceived loss
Physician’s time is likely a major concern
• Perceived losses are often much greater than reality
• Perceived loss high when communication is low
6

25. Morphing the Recalcitrant Physician
1. Need a physician champion
2. Create a vision
3. Standardise what is standardisable
4. Communication, communication, communication
5. Workout barriers and overcome them
6. Deal with the WIFM

28. Patient Deterioration 2006 2007 2009 p-value
820 747 462
Respiratory rate 3.5 (0.31) 5.7 (0.30) 5.0 (0.21) <0.001
Unplanned ICU admissions 14 (1.7%) 3 (0.4%) 7 (1.5%) 0.03
Unexpected Deaths 9 (1.1) 1(0.1) 7 (1.5) 0.008
Hospital LOS median (days) 4.8 (2.3, 9.6) 5.7 (2.9, 10.9) 6.8 (2.9,13.7) <0.001
MET referrals 22 (2.7%) 34 (4.6%) 33 (7.1%) 0.0003
MEWS = 4,5 36 (35.6) 32 (64.0) 34 (91.9) <0.05
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Adjusted Hospital Standardised Mortality Ratio