Research and experience both indicate that physicians, directly or indirectly, influence 70–90 percent of all medical activities. There is no question that the active participation of physicians in any clinical improvement effort dramatically improves its chance of success. Conversely, the lack of meaningful physician involvement in initiatives could spell failure. Most hospital executives recognize the importance of the rôle doctors play in quality improvement; the perennial question is, “How do we get doctors more involved in quality initiatives?”
Below is a compilation of the top 10 mistakes committed by hospital executives and managers that jettison their attempts at engaging doctors in improvement work.
Focusing on Financial Metrics Instead of Clinical Outcomes and Waste Elimination
By nature of their profession, doctors are particularly interested in two things: clinical outcomes and reduction of (their) wasted time. The reduction, if not elimination, of time wasters (e.g. unnecessary administrative tasks, directionless meetings, and delays in the flow of patients in the hospital system) allows doctors to spend more time with their patients, thus providing better care, and improves their professional satisfaction. Financial matters, though important to most doctors, are generally not their primary focus.
Inattention to Cultural Issues
Physicians possess a remarkable memory for past skirmishes with hospital administrators, e.g. over medical staff contracts, change of the elective surgery schedule, failed quality initiatives. If unaddressed, these conflicts negatively impact physician engagement in future quality improvement work. Hospitals that achieve significant physician engagement tend to be more sensitive to the issues that might cause tension among the medical staff and proactively approach them through dialogue before and after the fact.
Treating Doctors Like Customers, Not Partners
This situation is most often seen when a hospital wishes to implement a policy that they fear might offend a high-revenue generating physician. By treating each physician as a partner in the delivery of care, hospital administrators can create a milieu that is more conducive to physician engagement in quality improvement.
Promoting a Blame Culture
Often when things go wrong in healthcare (e.g. an adverse event), the “bad apples” are identified and punitive action is taken. This approach tends to reinforce the erroneous idea that quality outcomes are individual provider attributes, rather than system attributes, and is diametrically opposed to physician engagement in quality initiatives.
Generalizing Physician Engagement
There are some initiatives in which physician engagement is absolutely critical, and others in which it is not necessary. Requiring the involvement of doctors in every initiative is a waste of resources and might lead to loss of physician commitment for those initiatives in which their support is imperative.
Appointing a Nurse, Instead of a Physician, to Assume the Rôle of Champion, Structural Leader, or Project Leader
Initiatives such as those that aim to reduce healthcare-associated infection and improve reliability in evidence-based care require a physician champion. Generally, for such improvement work, teams that employ non-physicians, no matter how experienced or skilled those individuals may be, carry a significant risk of failure. Some initiatives require structural leaders, e.g. Medical Directors or Department Chairs, without which those initiatives will lack the leadership and political muscle to succeed. Another common mistake is selecting a non-physician to fill the rôle of project leader (which is distinct from champion and structural leader) when a physician is required. An alternative (more effective) strategy might be to appoint an administrative co-leader to perform the often-time-consuming project management tasks, thus freeing up the physician to perform his/her other duties, such as caring for his/her patients. In this way, use of the physician’s core skills is optimized.
Expecting All Physicians To Agree on a Standard Protocol From the Outset
For instance, in the use of heparin in the management of stroke patients, it might be preferable to have the majority of physicians agree on a standard protocol (and to conduct small tests of change) than to wait for all physicians concerned to agree on one (which might never occur).
Involving Physicians Only Midway Through Development of a Protocol
Inviting doctors to participate only in the middle stages of developing a clinical protocol or asking them to accept one that is fully developed often leads to lack of buy-in and any positive results achieved could be limited and/or unsustainable.
Not Communicating Openly, Frequently and Candidly
Many hospital administrators tend to withhold data and/or information when they are sensitive, strategic, or difficult. However, it is precisely these situations that call for candid communication, the continued practice of which will foster physician engagement.
No Written Physician Engagement Plan As the adage goes, “If you fail to plan, you plan to fail.”
- Reinertsen JL, Gosfield AG, Rupp W, Whittington JW. Engaging Physicians in a Shared Quality Agenda. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2007. (Available on www.IHI.org)