As healthcare delivery in the U.S. undergoes profound change from volume-based to value-based, patient-centered and more transparent care, there is increasing emphasis on quality and safety. In moving toward a culture of safety, leaders and policymakers have experienced both frustration and success while engaging physicians in this necessary transformation. The purpose of this article is to offer insights and potential success factors for healthcare leaders, risk managers, patient safety professionals and others who want to implement physician safety and quality initiatives.
Physician knowledge gaps
Many physicians tend to overemphasize the potential negative effects of change and are skeptical of the motivations for system changes. In addition, medical school and residency may not adequately prepare physicians for important aspects of healthcare delivery, such as systems thinking, the science of quality and patient safety, leadership and followership, teamwork science, non-technical skills and even key elements of professionalism. These knowledge gaps offer cognitive and experiential pathways to improving patient care quality and safety awareness through dialogue, presentations, reviews of root causes and near-misses, educational programs, coaching and mentoring. It is interesting to explore the drivers of physician perception and behavior change, particularly to assess whether they are focused more on “stories” or more on the data. Most physicians state that “it is all about the data,” but on deeper analysis, there is great power in stories. For stories to be effective for individual change, they must be real (not contrived), believable, relevant to a physician’s practice and encourage tenable solutions that may have prevented unfortunate outcomes. When physicians deeply understand that a story-based adverse event could have happened in their practice, there is often an openness to change.
The importance of physician values and change
Engaging physicians in organizational and personal change requires an understanding of their values and closely held beliefs. It is fair to state that many physicians emphasize efficiency, autonomy in practice and decision making, pride and excellence in individual clinical skills and knowledge, and concern for patient outcome. On the other hand, they are annoyed and resentful of (perceived) interference, inefficiency and bureaucracy, and “cookbook” approaches in medicine. There is an increasing paranoia about imposed changes, regulator interference, destruction of the doctor-patient relationship, and questionable motivations driving many quality and safety initiatives. However, just as with other complex negotiations, this analysis opens the door to necessary collaboration among nurses, physicians, administrators, patient safety professionals and patient advocates.
Safety culture
What are the main dimensions of safety culture? [1]
- Leadership commitment to safety
- Open communication founded on trust
- Organizational learning
- A non-punitive approach to adverse event reporting and analysis
- Teamwork
- Shared belief in the importance of safety
Physicians need to have a clear, simplified understanding of a safety culture in healthcare. An excellent summary of the dimensions of safety culture was set forth by Halligan and Zecevic. [2] This starts with the premise that it is not possible to have quality care without safe care. Thus, one pathway to engagement has been to personalize “the case” for patient safety, and translate the principles of behaviors that physicians can use to improve their patients’ outcomes and avoid errors that might tarnish their pride and reputation. Among these principles are educating physicians to be better team leaders, creating and executing clinical plans, and improving communication with colleagues, nurses, patients, their families and technicians.
Effective teamwork skills and behaviors can be taught using simulation, during day-to-day care delivery with coaching, and in educational environments using practice and feedback. Since many physicians are skeptical about “training,” and in spite of the strong engagement potential, it has been difficult to get physicians to come to workshops and training programs such as TeamSTEPPS®. One of the most helpful approaches includes recruiting and creating physician champions who are clinically respected and influential, and can make the case to colleagues that enhanced teamwork will improve clinical outcomes, decrease preventable harm, increase satisfaction and create better days at work. These champions can answer the ever-present question, “what’s in it for me?” When these answers align with physician values and strongly held beliefs, the early adopters can rapidly engage in patient safety culture and change initiatives. Many health systems are incentivizing physicians to attend these important learning activities and to participate in efforts to improve care with payment for time away from their practices. When training is respectful of adult learning principles, and there is a continued emphasis on shared values with goals to improve clinical outcomes, decrease harm, improve efficiency (if true) and reduce frustration, engagement and participation occur.
Successful approaches
A thoughtful hospital leadership team used a creative and effective approach to maximize physician participation in the TeamSTEPPS workshops. They announced that a full-page advertisement was going to be published in the local paper in six months describing the benefits of effective teamwork for patients and the community. The planned ad would also list the names of all the physicians who attended the training and were committed to using evidence-based communication skills. The physician participation rate was outstanding!
The following items top the list of the potentially effective strategies to engage physicians in patient safety initiatives:
- Customize the message(s); segment the types of physicians you wish to include and don’t expect that one size fits all
- Engage them early and often
- Over-communicate for clarity and consistency of vision
- Identify and develop effective clinical champions
- Be sure to let them know how they can be successful
- Consider formal leadership training for key physicians before they assume leadership responsibilities; leadership academies are powerful pathways to success
- Make sure engagement methods are respectful of physicians’ time constraints, and that workshops and educational approaches respect the principles of adult learning
- Teamwork training (e.g. TeamSTEPPS) should be incentivized so physicians can fill known knowledge and skill gaps
- Offer psychological safety to all participants, but encourage practice of skills and effective feedback in real time
- Use physician-nurse partnership teams at the unit level for quality and safety initiatives to enhance implementation and to assure sustainment; partnership teams should review data, support continuous improvement actions, provide peer coaching and demonstrate effective clinical leadership
- Frame the initiatives and engagement efforts relative to values and beliefs of physicians including efficiency, enhanced clinical outcomes, reduced patient harm, reduced work frustrations, professional reputation and personal accountability
- Draw on physicians’ natural competitiveness as a motivator in data analysis, clinical leadership, public reputation and patient outcomes
- Consider that carrots and sticks may motivate physicians when properly used and customized
- Carrots include improved communication and teamwork, appropriate incentives and the benefits in patient outcomes as described above
- Sticks may include bylaw changes that mandate teamwork and patient safety training for initial or renewal of practice privileges, fines similar to those imposed for delayed chart management, and posting of transparent data about compliance and outcomes
- Set expectations and consistently hold professionals accountable for behaviors and actions; include an effective professional behavior policy
- Emphasize the opportunity for front-line physicians to develop and refine effective clinical leadership, teamwork and communication skills that improve patient outcomes
- Often, having a respected physician or nurse colleague simply ask them to participate is effective; this presumes a respectful relationship exists based on trust
- Make clear exactly what is being requested
- Remember the “what’s in it for me?” aspect must be part of the expectation
As our healthcare system continues to experience unprecedented change to improve population health and maximize limited resources, the engagement of physicians as leaders in quality and safety is imperative. With pressure to decrease cost, increase efficiency and demonstrate value in the care provided across the continuum of health delivery systems, physicians are critical team members that must be engaged to achieve new levels of success in quality and safety.
John Webster M.D., MBA, MSEL, Sedgwick physician consultant
References
- BMJ Quality & Safety 2011 20:338-343 “Safety culture in healthcare: a review of concepts, dimensions, measures and progress”
- Halligan M, Zecevic A. BMJ Quality & Safety. Safety culture in healthcare: a review of concepts, dimensions, measures and progress. April 2011. http://qualitysafety.bmj.com/content/20/4/338.abstract.
Resources
- Reinertsen JL, Gosfield AG, Rupp W, Whittington JW. Engaging Physicians in a Shared Quality Agenda. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement. 2007. (Available at www.IHI.org)
- Physician Leadership Education. American Hospital Association. 2014.
- Silversin J, Kornacki MJ. Leading Physicians through Change. American College of Physician Executives, Tampa, FL. August 2000.