Nothing is more critical to managing an efficient emergency department than getting physicians on board for new innovations and operational change. A particularly hot topic these days among ED directors and health care executives is how to lead physicians through change. Even the most change-averse physician groups are finding it difficult to stay the same. With new regulations levied from the Joint Commission on medication delivery and performance metrics for reimbursement in the works at the Centers for Medicare and Medicaid Services, a static approach to emergency medicine is no longer practical or viable.
Emergency medicine groups can't afford to approach their practices with a business-as-usual posture. Rather, we are all at risk of change fatigue, as they call it in America's boardrooms, from the many practice changes being mandated and the breakneck pace at which they are arriving at the front lines. (Silversin J, Kornacki MJ . Leading Physicians Through Change, Tampa, FL: ACPE Press.)
The focus on physicians comes from the recognition of the centrality of physicians' work in our health care system. As Reinertsen et al points out in the IHI white paper on physician engagement, very little in a health system happens without a physician's order. By virtue of a physicians' plenary legal authority, almost all actions in health care derive from physician decisions and recommendations. Failure of ED quality projects, initiatives, and improvements when the physicians are not on board is well recognized. (Engaging Physicians in a Shared Quality Agenda. IHI Innovation Series White Paper, 2007, ihi.org, accessed 1 May 2007.)
It is important to have a working knowledge of three conceptual elements when assessing the difficulties in getting physicians to change. An understanding of the old paradigm of medicine, what is called the craft of medicine, physician culture, and the physician compact. These elements influence the ease with which physicians engage in change and by understanding these influences, managers can craft strategies that are effective in leading physicians through change.
Until the middle of the 20th century, medicine was learned and practiced much like a guild. Experienced physicians imparted their knowledge to younger colleagues at the hospital, like bricklayers or silversmiths. Local medical organizations and doctors lounges were where physicians learned “tricks” from colleagues. In the craft of medicine model, individual practitioners maintain a specific body of knowledge, draw on extensive experience, put their patients first, and police their own medical practices for quality. Medicine's promise was that all of this would result in the best care for the patient. One problem, though: The paradigm didn't deliver. With every practitioner developing a customized treatment plan for each patient, best practices are neither identified nor adhered to, and the profession does not build on a body of knowledge.
With practitioners basing their care on anecdote and experience, they crafted care for individual patients with a goal of perfection. For the first time in history, in the mid-20th century, the chance of a patient who sought care from a physician having a good response to treatment was better than 50:50. Sterile techniques and rudimentary medicines, especially antibiotics, were an advance over bloodletting and leeches! On the other hand, health care has failed to become safe and reliable under this scheme. With individual practitioners crafting idiosyncratic treatment plans for their patients one by one, we do not produce the best possible care for each patient and more rigor must be brought to the practice of medicine.
While other professions and service industries embraced standardization and quality improvement principles and the work of Deming, Juran, Motorola, and Toyota has been widely implemented, medicine has continued to operate the way it did in the early 20th century. Individual practitioners with goodness in their hearts and purity in their motives attempt to develop treatment plans for their patients. This heroic individualism has led physicians to reject any attempts at standardization in medicine. In this model, the physician intuitively knows what is right, what is best. Again, this is not a sustainable or effective model in the medical world of the 21st century.
Though most physicians would not be able to articulate the change, medicine began in the latter half of the 20th century to experience the inklings of transformation from guild and the craft of medicine to a profession-based practice. Some of the principles of process improvement began making their way into the medical world. In the new model, groups of peers attempt to coordinate health care to develop standards of care and improve outcomes. In the new model, evidence from research is scrutinized by medical specialty groups, and the white kernel of truth which may be applied to clinical practice is sought. Regulatory bodies such as the Joint Commission and the CMS are setting standards for practice performance that will be required for accreditation or payment.
Hand in hand with the old paradigm were the expectations of men and women entering the profession. The old model promised that if a physician studied hard, worked hard, and maintained his skills and credentials, he would have autonomy, respect, and a good income. Physicians expected to trade years of training and debt for professional autonomy. Now, however, business and regulatory pressures make most physicians feel a loss of autonomy and as though they are doing more for less with increasing risk. This has led to falling morale among the profession.
Add into the mix another set of subtle changes involving physicians and hospitals. Out of necessity hospitals now employ many physicians who may be in direct competition with members of the medical staff. Conversely, many subspecialists are performing procedures from endoscopy to plastic surgery at free standing centers or subspecialty hospitals that draw revenue from the primary hospital or health system. This can create barriers to change and distrust within factions of the organization. Further confounding the situation is the fact that many physicians are maximally challenged by the demands of their daily practices and no longer available to participate in the organization's committees and task forces, severing old connections and ties. Such connections helped physicians and administrators better understand the constraints each works within and helped them cross these cultural divides. (Health Affairs 2007;26:w31-43; Epub 5 December 2006.)
Combine the demands of professional and business lives, including onerous administrative burdens, lowered reimbursement, escalating malpractice premiums, and overall decreased satisfaction with their roles as physicians, and you have a recipe for a change-adverse environment.
Physician culture also influences physicians relative to their response to change initiatives. Physician culture, like the air we breathe, is individual and collective. It embodies the values, attitudes, and beliefs that translate into behavior. Another definition of physician culture: “A pattern of shared assumptions learned and used to solve problems.”
Physician culture is inherently conservative, a throwback to the guild model, in which seniority and experience trumped all. There is no standardization in physician culture and high variation. Physician culture blocks change and, in fact, builds barriers to future change. Paul Shebel in the Harvard Business Review in 1996 first articulated what he called the physician compact. He defined the almost universal expectations of physicians relative to the health system or organization within which they work. In the physician compact, physicians expected that in exchange for their years of training and expertise, they would have autonomy, protection from market forces, and entitlement referrals. Once again the paradigm has shifted and the ground under the physician's feet is unsteady.
The old compact has given way to a new deal in which the physician is expected to be market-sensitive and compensation is frequently tied to performance parameters. In the old model, the physician was autonomous and delivered quality as he defined it. In the new model, his care is delivered interdependently, with other professionals evaluating it. He has to function as a part of a team, and team behaviors are not intuitive. He is held accountable, sometimes for things he may not control, such as the boarding burden causing waits and walkaways in the ED.
The expectations created by the old compact are no longer being met, and this leads to disappointment. On the other hand, this old compact which favored individual work, goals, and incentives impeded change in a variety of ways. It kept physicians in their own microcosm and subverted collaborative improvement. It also undermined leadership and authority, and had a negative impact on physician morale because of the unmet expectations it created and that are no longer valid or legitimate in the contemporary world of medical practice.
The Change Team
So how to approach physicians when change is necessary in their world? Managers and directors do not face the work of the day without pondering some variation on this question. What are the elements and strategies that have been effectively applied in other settings? Can they be used with physicians in the emergency department? What can we learn from so-called change management methodologies and the diffusion of ideas literature?
The adoption of change follows a normal curve with a small percentage of people being ready to come on board early on. These people are the innovators responsible for change ideas and the early adopters. It takes work and campaigning to bring along first the early majority and then the full majority. At the other end of the curve are the late majority and the late adopters (also called laggards). The laggards have never met a change they didn't oppose!
First, understand that effective change involves a change team. Important members of the change team include the sponsor, the change agent, and the champion. Before a change is introduced, all stakeholders are invited to participate in the brainstorming about the problems and the processes. Careful attention is paid to resistance and the late adopters are identified along with the early adopters, who may have potential as champions. Sometimes laggards can be effectively persuaded and converted into effective champions. There is nothing more powerful to witness than the skeptic who now becomes a proselytizing champion. In addition, remember that the laggard might occasionally voice an objection to a change that is valid and may be otherwise overlooked.
The sponsor is often a high-level administrator who quite visibly supports the change and can align incentives appropriately. It could be a board member or a medical officer. The more comprehensive the change initiative, the more sponsors who may be solicited. The sponsor's involvement needs to be visible and pervasive, and he must be able to articulate the organization's vision relative to the change. When resistance is met, he needs to articulate the organizational goals and support for the innovation. It helps if the hospital and organizational goals and vision can mirror those of individual physicians. This is called alignment, and is a critical element of effective change.
The change agent may be a physician or non-physician who understands the details of the change and effectively manages implementation on the front lines. Guide, educator, facilitator, cheerleader, this individual orchestrates all of the details of the change, tracks the progress and data, and reports back to the organization.
Lastly, the change team must have a champion. This person is a well respected member of the physician group or medical staff who throws his support and influence behind the change initiative or innovation. He is vocal about his support and can speak the physician's language. He reaches out to colleagues, acts as a role model, and contributes expertise regarding the change.
Implementing a Pilot
It is important to understand the difference between a pilot program and the implementation of change. A pilot is a small test of change during a specific time frame. Usually the change is trialed with innovators and early adopters, what Thom Mayer, MD, calls the A Team. The change is trialed on a small scale, and defects are identified and improved before the change is implemented on a broader scale. Too often the implementation of change is attempted before laying appropriate groundwork. For physicians the case must be made for the change. More specifically, why is this change needed? What will the change be? Who is responsible for the change behaviors? In the pilot, stakeholders who are champions at best and people who embrace innovation at the least. Not surprisingly and for reasons alluded to above, the trial or pilot effort often outperforms the actual innovation in terms of data.
Strategies for effective change include involving physicians early in the process. In particular, invite all stakeholders, including the physicians you expect to be laggards, in on the ground floor to participate in the process and raise their concerns. It helps to have scripted responses and display active listening skills: “I hear your concerns, and we will take them into account as we design and implement this change.”
Valuing physicians' time and working with the leaders and early adopters are good strategies for launching an improvement initiative. Communicating candidly and frequently is a good strategy, and when thinking about messages and messengers, consider this: Talk about saving dollars for the institution seldom motivates physicians while discussions about improving outcomes and patient care are extremely effective in swaying physicians. A messenger with credibility — an emergency physician versus the president of the medical staff from another department — makes a stronger case. Additionally, talking to physicians about saving time and hassles and reducing waits are effective messages when making the case for change efforts.
Physicians are lifelong learners and data-driven. We can take advantage of this by framing a change effort as an effort to find the best practices for a particular clinical or operational problem. A learning culture is a change culture. Using pilot studies to generate excitement, we can launch a project as a learning project. The well designed change initiative should have five features: the ability to be observed, relative advantage, understandability, compatibility, and the ability to be trialed.
The project is visible and the advantages are obvious. All observers can see the process change and understand what it has done. The project should involve a process that is readily incorporated into existing processes and is compatible with current culture. Lastly, the change should be relatively easy to trial and even easier to implement.
One last word about using data to change physician behavior: Use data to generate light, not heat, meaning use data to illuminate behavior, not to assault a physician. Physicians and other health care professionals are generally a competitive lot. They do not want to be outliers, and will tease themselves toward the mean. You can get effective responses and keep a congenial workplace for the physicians by blinding the data to specific physician name and using coded identification.
Understanding the physician, his culture, and his training helps to set the stage for change in the ED. Also, there are strategies that help lead physicians through change by taking into account their background and beliefs. Getting physicians on board with improvement initiatives has many advantages. The change is more likely to be successful with physicians on board, the work itself can help teach and instill team behaviors, and their participation will likely improve the morale of the physician group as their world and their ability to care for patients is improved.
Strategies for Change
- Involve physicians early.
- Work with leaders and early adopters.
- Choose messages and messengers carefully.
- Communicate candidly and frequently.
- Value physicians' time.
- Standardize what you can but no more.
- Make the change easy to trial and implement.