Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

The Path of Least Resistance: Engaging Healthcare Professionals in Change

8/26/2014 3:37:38 PM | 0 comments

Four years into healthcare reform, change fatigue is pretty common among healthcare providers. We're overwhelmed with metrics and mandates. We're held responsible for patient outcomes we sometimes feel helpless to control.

On top of it all, we're expected to provide excellent customer service. The patient experience piece often draws resistance from change-weary providers. After all, they're providing excellent clinical care. Isn't that enough?

As a practicing emergency physician, I definitely have empathy for this viewpoint. But recently, a colleague told me a story that really drives home the link between patient experience and outcomes.

An Avoidable Tragedy

Mr. Shoemaker (not his real name) was a retiree and long-time hospital volunteer who was much loved by the staff and patients. He contracted cellulitis, and the oral antibiotics his doctor prescribed didn't work. So he was admitted to the hospital for IV antibiotics.

On the night before he was due to be discharged, he hit his call button to let the nurse know he needed to use the bathroom. There was a shift change in progress and no one came. So after about 15 minutes and a few more unanswered calls, he decided to take matters into his own hands.

As he struggled to get himself out of bed, he got tangled up in IV and oxygen tubing; he fell and fractured his hip. Instead of discharge home, he went into surgery the next day. He was transferred to a nursing home where he ended up dying tragically of a nosocomial infection.

His care team back at the hospital was shocked by this news. After all, they really knew Mr. Shoemaker well and cared about him. And to their credit, they decided to face what had happened and use it as a catalyst for change. Mr. Shoemaker became their noble cause.

The Transformative Power of Social Motivation

Any successful initiative to improve patient experience requires buy-in from the doctors, nurses and staff on the front lines. So I was excited to see Toby Cosgrove (CEO of the Cleveland Clinic) and Thomas H. Lee (CMO of Press Ganey) tackle on this topic in a recent article in the Harvard Business Review.

To achieve buy-in for patient experience initiatives, Lee and Cosgrove suggest looking to the "four motivations for social action" conceptualized by economist/sociologist Max Weber. (While the authors focus on physicians, I believe that many of these ideas also apply to nurses, PA/NPs and ancillary staff.)

1. Shared purpose

When leading discussions about change, it helps to rally the team around a central cause: something "positive, noble and important."

For example, at CEP America, we've worked hard to put the patient at the center of our culture — putting a face to our initiatives rather than just focusing on the numbers. One way we do this is to challenge team members to imagine themselves in patients' and family members' shoes. What if your grandfather was the one who needed to go to the bathroom and no one responded to the call? It may sound obvious, but on a busy shift, we sometimes forget that our patients are basically us — and that they really do come to us for help.

Patient stories can also be a source of shared purpose. "No more Mr. Shoemakers" became a rallying cry at the hospital described above. The organization soon embarked on a new initiative in which no one — administrators, physicians, nurses, housekeeping, food service staff and so on — can walk by a patient's room where the call light is lit without responding. (Hospital employees receive training that helps them route the patient's request appropriately.) The staff has been enthusiastic in implementing the program, and gains in patient safety and satisfaction have been significant.

2. Self-interest

I agree strongly with Cosgrove and Lee that shared purpose should be the foundation of your engagement strategy. In the absence of a noble cause, other motivators may backfire. However, once your team has embraced its mission, it's helpful to incorporate other inducements into your plan.

One way to do to this is to appeal to self-interest. Being human, we tend to pay close attention to factors impacting our compensation and job security. Perhaps the most obvious way to leverage this is to link a portion of compensation to individual performance goals.

Another approach is to link compensation to team performance. For example, an entire nursing team might receive bonuses if they succeeded in raising patient satisfaction scores in the area of call-light response.

3. Respect

As professionals, we're naturally motivated to seek the admiration of our peers (or at least to avoid looking foolish or incompetent in front of them). Leaders can leverage this natural tendency by encouraging team members to hold one another responsible for certain tasks and behaviors.

For example, if team members at Mr. Shoemaker's hospital see a colleague walk past a lit call light, they immediately prompt the person to respond — no matter who it is.

Another practice Cosgrove and Lee advocate is the sharing of unmasked performance data for both departments and individuals. For example, if you're working on doctor-patient communication, you might break patient survey data down by physician and report the results.

Now while I think transparency is a good thing, I do think you need to tread carefully here, because sharing individual data can provoke a lot of anxiety. Poor patient experience scores can feel really personal. Not only does the underperformer wonder if she's a bad doctor or nurse, she feels like a bad human being.

So how can leaders cushion the blow while still keeping the lesson meaningful? For one, start slow. Maybe as a first step, show each physician their place within a masked data set. Then, once everyone's used to that, move on to unmasked data. At each step of the process, emphasize your shared purpose and how transparency benefits patients.

4. Tradition

Finally, team members will often do things simply because it's "just the way we do it around here." Each organization has unique expectations that foster pride and consistency. At Dr. Shoemaker's hospital, for example, it's become unthinkable to walk past a lit call light without responding.

Is it possible to create new traditions? I definitely think so. If we persevere and hold one another accountable, there comes a point in the change process where the change is assimilated into our culture. And that's when we know we've been truly successful as leaders.

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