Morphing the Recalcitrant Physician

@IA_Mitchell

Outline

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

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”

DOCTOR PHYSICIAN/PROVIDER

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..

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

The Need for Change

•Improve the patient experiencesafe, engaged physician, environment enabling satisfaction

•Improve the health of populations•Reduce costs

“emotional involvement or commitment”

Stages of Physician Engagement

Aversion Apathy Engaged

Active support of the change• Trust it will improve patient

care/outcomes• View themselves as a stakeholder

Ever seen a recalcitrant physician?

6 Easy Steps

Seek Out Clinical Champion: Change Agent

• Need to be respected• Need to be inspirational• Need to be given time (!)• Need senior hospital support

1

Engage the head and heart*

* JP Kotter Heart of Change

Engage Physician’s Heart

•Help them see the need for changeLocal stories to allow understanding of the problem

•Allow them to feel they are hit with the reality of the problemPreventable harm is not acceptable, the “burning platform”

Eg: Reframing CVC-BSIs as a social problem*

•Use their energy use fully to change behaviourAllow them to take their emotionally charged ideas into action

*Dixon-Woods et al Milbank Quarterly2011; 89: 167-205

Engage Physician’s Intellect

• Provide data/literature (data are power)

• Inspire them that they too can do the same!

Establish a Common Purpose/Vision: The patient, the patient, the patient

2

Standardise what is standardisable

• Engage other physicians to help develop intervention/implementation strategy• Start small and make sure it is easy

3

Communication, Communication, Communication

• Create opportunities to talk with physiciansGrand rounds, unit meetings, safety and quality meetingsKeep 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

Communication, Communication, Communication

• The Messenger is critical to successRespected clinician who can work up and down hierarchyNon-threatening, listening style (value the dissenter)

• Data/LiteratureHow data are presented is importantCredibility of data/literature

4

Identify and overcome barriers

• Try physician engagement self-diagnostic toolhelps determine what the uphill battle will be like

• Clinicianoften know who these are likely to be

• Interventionwork through the likely challenges

• Systemdoes the system allow for these changes?

5

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

Morphing the Recalcitrant Physician1. Need a physician champion2. Create a vision3. Standardise what is standardisable4. Communication, communication, communication5. Workout barriers and overcome them6. Deal with the WIFM

Patient Deterioration 2006 2007 2009 p-value820 747 462

Respiratory rate 3.5 (0.31) 5.7 (0.30) 5.0 (0.21) <0.001Unplanned ICU admissions 14 (1.7%) 3 (0.4%) 7 (1.5%) 0.03 Unexpected Deaths 9 (1.1) 1(0.1) 7 (1.5) 0.008Hospital LOS median (days) 4.8 (2.3, 9.6) 5.7 (2.9, 10.9) 6.8 (2.9,13.7) <0.001MET referrals 22 (2.7%) 34 (4.6%) 33 (7.1%) 0.0003MEWS = 4,5 36 (35.6) 32 (64.0) 34 (91.9) <0.05

Period 1 Period 2 Period 30.64

0.66

0.68

0.7

0.72

0.74

0.76

0.78

0.8

0.82

Adjusted Hospital Standardised Mortality Ratio

31