Mastering Physician-Hospital Collaboration

2nd Annual Ellison Pierce Symposium Positioning Your ORs For The Future Mastering Physician-Hospital Collaboration Kenneth H. Cohn, M.D., MBA, FACS Cambridge Management Group May 18, 2006 11:30-12:00pm

In your opinion, which of the following factors is has the MOST impact on healthcare? QUESTION: • Nursing shortage • Consumer expectations • Aging/Demographics • Regulations • Cost & Reimbursement pressures • Outpatient migration 0/0

Regarding their approach to their jobs, how different are hospital administrators from physicians? QUESTION: • Completely different • Very different • Somewhat different • Not different 0 / 10

Overview • Context for collaboration • Appreciative inquiry • Structured dialogue

National Trends Impacting Practice

Trends in Physician Compensation and Practice Costs 1996-2002* • Compensation • Down 1.2% for primary care • Up 8.1% for specialists • Expenses • Malpractice insurance up 19.3% • Support staff up 52.3% • Medical supplies up 70.1% • Inflation • CPI up 14.6% On average, physicians’ reimbursement did not keep up with practice expenses and inflation. * Holm CE. Allies or Adversaries: Revitalizing the Medical Staff Organization. 2004. Health Admin Press, 90.

Some Cultural Differences Physicians Paid for seeing patients Focus on patient survival/ practice Rapid-fire decisions based on personal judgment and experience Hour-day-week time horizon Responsive to needs of patients, families, and colleagues Administrators Largely salaried Focus on organizational survival Deliberative decisions based on consensus Month-year time horizon Responsive to needs of patients, families, physicians, employees, community organizations, and Board Gill S. Can doctors and administrators work together? Physician Exec 1987;13(5):11-16.

Understanding Complexity: A Path to More Realistic Expectations • Complicated problems • Require coordination, expertise, and knowledge sharing • For example, preparing for JCAHO site visit • Complexproblems • Relationships are key • Experience is no guarantee of future success, but people remain generally optimistic (cf child-rearing) • For example, patient flow, risk management, clinical priority setting • Glouberman S, Zimmerman B. 2004. Complicated and Complex Systems: • What Would Successful Reform of Medicare Look Like? www.changeability.ca.

Improving Predictability • Advantage of improved communication: predictability • Physicians: better use of time and energy • Management: improved competitive position, survival • Through their collective decision-making, physicians influence hospital costs, revenue, quality and safety • Creating an environment that celebrates learning can lead to competitive advantage • Effective dialogue is in both parties’ enlightened self-interest

Conflict Resolution Framework • Physicians are used to hierarchical, command-and-control settings, but most organizations are matrices, where people have influence but lack control • Our only control is our choice of response • Teams go through stages of forming, storming, norming, and performing • Teams cannot perform well without storming • Conflict, if well managed, leads from creative abrasion to innovation • Avoid “Always, never, why, but, just, I disagree, cost” • Send “I” rather than “you” messages to deescalate conflict

Tips for Successful Confrontations • Start from a position of safety: • Maintain respect • Use contrasting to reassure what is not going to happen • Establish mutual purpose • End with a question • “I am concerned about a problem that is affecting all of us. • One of our veteran OR nurses quit because she felt that the stress in the room was affecting her health. • This is not a witch-hunt. I value your service to the hospital, just as I value hers. I would like to understand better if there is anything that I can do to limit the stress that builds up here. I welcome your suggestions. • Is there a time next week that might be convenient for us to discuss the situation?”

Successful Confrontations, II • Motivate by exploring natural consequences • Make the invisible visible • Introduce hidden victims • Hold up a mirror • Link to shared values • Focus on long-term benefits of changing behavior rather than relying on perks or power for persuasion • Make a plan that specifies who, what task, and when • No “we” in accountability Patterson K, Grenny J, McMillan R, Switzler A. 2005. Crucial Confrontations. New York: McGraw Hill.

Principles of Active Listening • Concentrate on the speaker, maintaining comfortable eye contact • Listen with multiple senses • Open one’s stance to convey receptivity • Suspend judgment, to maintain objectivity • Empathize, trying to put oneself in the speaker’s frame of reference • Use summary questions, such as, “Do I understand you to say….,” Caro J. The Power of Effective Listening, Shawnee Mission: National Seminars Publications; 1989

Fundamental Collaborative Skills • Inquiry • Appreciative Inquiry • Structured Dialogue

Inquiry • Inquiry is an open process designed to foster the exchange of ideas • Decision making is not an event, but a process • Tests of strength among competing positions suppress innovation • Inquiry encourages critical thinking and constructive conflict • Effective leaders: • pay careful attention to the way that issues are framed • convey openness to new ideas • make clear that initial opinions are provisional and subject to change Garvin DA, Roberto MA. What you don’t know about making decisions. HBR Sept 2001, 110-116.

Appreciative Inquiry • Focuses on learning from success instead of uncovering deficits, problems, and individual or collective weaknesses • Based on assumptions that: • people within organizations respond to positive knowledge • both the shared vision of the future and the process for creating the shared vision create the energy to drive lasting change • the power of affirmation and envisioning goals increases the likelihood of transforming those goals into reality

Problem-Solving Identify problem Perform root-cause analysis Brainstorm solutions Pick best solution Develop action plan Metaphor Organizations are problems to be solved Appreciative Inquiry Appreciate what is going well Imagine what might be Determine what should be Design what will be Metaphor Organizations are a solution/ mystery to be embraced Differences Between Problem-Solving and Appreciative Inquiry Cooperrider et al. Appreciative Inquiry Handbook. Lakeshore Publishers, Bedford Heights, 2003.

Adverse Consequences of Deficit Thinking • Defensiveness re: blame • Fragmentation and turf battles • Yesterday thinking, mired in the past • Voices without shared vision • Negativism and fatigue pervade culture • Slow response time

AI: Story-telling • Obtaining anecdotes and stories, approaching the data in a fresh way • Writing the stories in the first person in the quoted language of the person who told them • Sharing them with the rest of the organization generates shared imagery and more energy to improve than pointing out problems and attributing blame Johnson G, Leavitt W. Transforming organizations through an appreciative inquiry. Public Personnel Management. 2001;30(1):129-135.

The Power of Story-telling Stories: • Decrease the inhibiting effects of hierarchy upon an organization • Flesh out metaphors, which summarize important messages and make them vivid • Provide vignettes that are remembered much more readily than facts Cox K. Stories as case knowledge. Med Educ 2001;35:852-6

Ways to Build on Physician Responses • Be proactive • Rounding, passing on compliments from patients and staff* • Reward positives • Look for what can agree with vs oppose • Show that you value physicians’ time • Take a task off their plates, remove an obstacle, modify an inefficient process, close the loop * Studer Q. Hardwiring Excellence. 2003. Fire Starter Publishing, Gulf Breeze, FL.

What is Structured Dialogue? • A process that helps physicians articulate their collective, patient-centered self interest. For example, structured dialogue can help physicians establish clinical priorities for the next 3-5 years: • Led by a panel of high-performing, well-respected clinicians • Who review and recommend clinical priorities based on presentations by the major clinical sections • Clinical priorities are a physician-led statement of the direction in which the hospital should be heading, not capital-intensive budget items

Clinical Priority Setting Process Management Board of Trustees Medical Advisory Panel prioritized recommendations Medical Staffs/ Physician Organizations set guidelines; appoint presenters written documents; oral presentations Clinical Presenters Clinical Presenters and peer participation in departments, sections, and services

Value Proposition For those interested in: • Developing physician engagement and a sense of ownership among their medical staff • Deterring physicians from skimming off profitable services, or at least initiating discussion of opportunities for financial collaboration • Decreasing the cost and variability of medical care

Value Proposition The Structured Dialogue Approach: • Addresses major issues, such as revenue,costs,financial collaboration, and clinical outcomes • Creates an environment in which physicians are accountable to one another and thus open to facilitating long-term change • Helps channel hospital investment into high-priority services based on community needs and clinical strengths • Facilitates solutions to service problems that do not require major capital expenditures

Deliverables • A three-year clinical operating plan, expressing the vision of practicing physicians for where the hospital should concentrate its resources • A list of approximately 100 prioritized recommendations, most of which can be implemented without major capital expenditures, improving quality of care and morale • A group of 10-15 clinicians, knowledgeable in all major aspects of the hospital’s business, who become a major source of formal and informal medical staff leadership and trust-building • An improved work climate, which strengthens employee morale and facilitates recruitment and retention

Report Summary • Panel members have had a unique opportunity to consult with their colleagues and take stock of current medical practice. • It has become abundantly clear that we have lost touch with each other. Forces are being brought to bear which many of us have ignored or dismissed, perhaps because we have felt powerless to influence them. • Our professional, ethical charge is to provide our services in the manner which is most beneficial to the welfare of our patients. We are now reminded that the hospital has the same responsibility. • Our task is to work together to find solutions which will benefit all three- patient, physician, and hospital- and in so doing, gain strength from one another

VI.Ten Steps Hospital Executives Can Take NOWTo Engage Physicians and Improve Care • Encourage practicing physicians to articulate future clinical priorities • Include doctors who are users of radiology, anesthesiology, pathology, and emergency services to draw up contract specifications and monitor performance • Establish a hotline for process improvement issues • Treat top 20% as accounts, with (at least) quarterly visits • Ask “go-to” docs, “What can we take off your plate,” at least semiannually

Ten Steps, continued • Map out steps of policies and procedures to improve effectiveness and refine handoffs • Have the CIO and programmers round periodically with physicians • Develop hospitalist surgical service to off-load call burdens • Celebrate and reward all healthcare professionals who exceed their job descriptions to care for patients • Establish a pool with fines from using hot-button words and killer phrases to support a worthwhile service or celebration

Asking the Right Questions • Instead of asking: • When are they going to tell us what is going on? • Who’s going to solve the problem? • When is somebody going to train me? • Who dropped the ball? • Why is this happening to me? • Substitute: • How can I help? • How can I adapt to the changing healthcare marketplace? • What can I do to develop my talents? • How can I understand others’ challenges and frustrations? • What can I do today to excel at my work? • How can I become part of the solution? Miller JG. QBQ: The question behind the question. Putnam, NYC, 2004

QBQ Prayer God grant me the serenity to accept the people I cannot change, the courage to change the one I can, and the wisdom to know… it’s me!” Miller JG. QBQ: The question behind the question. Putnam, NYC, 2004

Conclusions and Recommendations • Promoting effective communication is in both physicians’ and hospital leaders’ self-interest • Obtaining quick wins builds momentum and credibility, which are key to successful collaboration • Admitting cluelessness is an underutilized way to bring in fresh approaches and energy • Start now rather than waiting for crisis

Mastering Physician-Hospital Collaboration