New Zealand Institute of Health Management

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New Zealand Institute of Health Management

• Engaging clinicians
• Professor Jeffrey Braithwaite
• Director, Centre for Clinical Governance Research
• University of New South Wales
• 28 March 2007

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1. Is there a problem?

• Poll question 1
• Who has worked in or experienced a department or
  unit where clinicians are hard to engage in
  issues outside of direct patient care?
• Poll question 2
• Who has worked in or experienced a department or
  unit where clinicians are impossible to engage in
  issues outside of direct patient care?
• Poll question 3
• Who works in or knows a department or unit like
  2 now?

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1. Is there a problem?

• So theres a bit of a challenge?
• The electronic sources say so
• A search of engaging clinicians yielded
• Google 875,000 websites
• Google scholar 9,100 articles
• PubMed 107 citations
• And NZIHM asked me to talk on this topic
  indicating theres a problem

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2. What is engagement? Origin 1515

• 1. the act of engaging or the state of being
  engaged.
• 2. an appointment or arrangement a business
  engagement.
• 3. betrothal They announced their engagement.
• 4. a pledge an obligation or agreement All his
  time seems to be taken up with social
  engagements.

• 5. employment, or a period or post of employment,
  esp. in the performing arts Her engagement at
  the nightclub will last five weeks.
• 6. an encounter, conflict, or battle We have had
  two very costly engagements with the enemy this
  week alone.
• 7. mechanics. the act or state of interlocking.
• 8. engagements, Commerce. financial obligations.
  

Source Dictionary.com http//dictionary.referen
ce.com/browse/Engagement
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3. Why engage clinicians?

• Every single person is capable, enabled and
  encouraged to work with others to improve the
  service they provide NHS 2007
• professional energy and engagement needs
  harnessed since one of the key sources of
  intelligence that any health care organisation
  has about the needs of its patient population is
  gathered every day by frontline staff in their
  interactions with both patients and their carers
  NHS 2004

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4. Characteristics of clinicians

• Clinicians are
• Driven by professional values
• Highly skilled
• Motivated to achieve excellence
• Stimulated to achieve professional-level incomes
• Relatively autonomous
• Self-esteem and status-directed
• Tribal

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4. Characteristics of clinicians

• Doctors personal traits
• IQ, individualist
• Perfectionist
• Doctors occupational traits
• Income
• Mobile then stable
• Decision-making role
• Work with risk, uncertainty

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4. Characteristics of clinicians

• Nurses personal traits
• Hands on
• Caring
• Nurses occupational traits
• Becoming
• More mobile than in the past
• Caring, compassion meets technology
• Cognitively collective

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4. Characteristics of clinicians

• Allied health staff personal traits
• Compassionate
• Empathetic
• Allied health occupational traits
• Construed in small-scale units
• Loyal
• Less obvious power structures
• Less certain

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4. Characteristics of clinicians
Source Braithwaite and Westbrook 2005
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4. Characteristics of clinicians
Doctors tend to respond here or here, decisively
AHPs tend to respond here
Nurses tend to respond in a block here or here
Source Braithwaite and Westbrook several
studies
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5. Nature of engagement

• Involvement
• Advocacy
• Consensus
• Support
• Working together
• Inclusive environment
• Collaborative
• Winwin

• Networking
• Communicate
• Provide information
• Use incentives
• Negotiate
• Be receptive
• Mutual benefit
• Funding mechanisms

Source Braithwaite 2007 - 107 References
content analysed from PubMed
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5. Nature of engagement

• Dont intimidate
• Draw in
• Meet needs
• Be clinician-focused
• Be an expert listener
• Build rapport
• Requires interpersonal competence

• Present data
• Meet clinical needs
• Engage in dialogue
• Integrate people
• Incorporate
• Create a central role
• Provide stimulation
• Match objectives with tasks

Source Braithwaite 2007 - 107 References
content analysed from PubMed
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5. Nature of engagement

• Open environment
• Transparency
• Create trust
• Provide feedback
• Cope with criticism
• Lack of time
• Provide opportunities for participation
• Opinion leaders

• Talk about the benefits
• Understand barriers to participation
• High opportunity costs for clinicians
• Valuing direct clinical work over other activities

Source Braithwaite 2007 - 107 References
content analysed from PubMed
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6. Barriers to engagement

• Doing own thing
• Disengagement
• Time, too busy
• Differing foci clinical vs organisational
• Politics of clinicians vs management
• Misunderstanding

• Fish out of water
• Benefits not clear or articulated
• Strength of evidence
• Case for change not made
• Sub-cultures
• Language

Source Braithwaite 2007 - 107 References
content analysed from PubMed
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6. Barriers to engagement
Source Braithwaite 1999
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6. Barriers to engagement
Throwing a rock or a bird? Systems or inanimate
object
?
y x2 b
f ma
Source Paul Plsek based on Richard Dawkins
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6. Barriers to engagement
Time
Source Bunce 2007
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7. Teams as a solution

• Teams in the NHS
• Having good teams ? effective patient outcomes
  (eg, mortality) better mental health for
  participants increased levels of motivation
  more innovation improved levels of retention and
  recruitment
• Source Borril et al (2001) who examined 406
  teams, consulted with 7,000 staff in the NHS

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7. Teams as a solution

• Teams in aviation and medicine
• Factors in good team performance provider
  characteristics (eg, personal attributes),
  workplace factors (eg, work organisation) and
  group influences (eg, communication,
  relationships)
• Barriers to good team performance include
  differences between doctors and nurses, failure
  to admit fatigue or error, reluctance of senior
  staff to accept input junior staff
• Sources Helmreichs and colleagues many
  studies (Thomas et al 2004 Helmreich 2000
  Sexton et al 2000)

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7. Teams as a solution

• Take account of the big five
• Team leadership
• Mutual performance monitoring
• Backup behaviour
• Adaptability/flexibility
• Team/collective orientation
• Source Burke et al 2004

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7. Teams as a solution

• But
• Research evidence and theory says you need to
  take into account all these factors
• However many people still find that their
  departments are dysfunctional and teams are in
  reality not teams
• I.e., people arent engaged

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8. A leadership solution

• Can leadership help?
• Edmonson, Bohmer and Pisano (2001) studied change
  in 16 cardiac surgery centres in the United
  States
• Some were more successful at adopting a new
  technique (minimally invasive cardiac surgery,
  MICS) than others
• What were the characteristics of successful
  leaders?
• They engaged people

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8. A leadership solution

• What successful leadership looked like

• Step 1 enrolment
• Select team members
• Leaders actions
• Select team members
• Define roles, responsibilities
• Set frame for learning
• Communicate
• Team members actions
• Listen
• Enrol

• Step 2 preparation
• Off-line practice session
• Leaders actions
• Reinforce learning frame
• Lead practice session
• Create psychological safety via discourse
• Team members actions
• Participate
• Observe leader

• Step 3 trials
• Trials of a new routine
• Leaders actions
• Ongoing signalling including
• Invite input, acknowledge needs, and dont reject
  new behaviours
• Team members actions
• Notice signals
• Try new behaviours

• Step 4 reflection
• Debriefing to learn from trials
• Leaders actions
• Review data
• Initiate discussions
• Listen
• Communicate
• Team members actions
• Collect, review data
• Join in discussions

Outcome New routine becomes accepted practice and
established routine in the organis-ation
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8. A leadership solution

• What failed leadership looked like

• Step 1 enrolment
• Leaders actions
• Ask people to participate without saying why
• Set frame of new plug-in technology
• Team members actions
• Show up for training

• Step 2 preparation
• Leaders actions
• Dont show up at practice session - view it as a
  team activity disconnected from the surgeons
  execution of new routine
• Team members actions
• Participate in practice sessions without leader
• Note that teamwork is not essential

• Step 3 trials
• Leaders actions
• Ongoing signalling including
• Take laissez-faire approach,discourage others
  input, reject new behaviours
• Team members actions
• Notice signals
• Re-evaluate new behaviours
• Hold back

• Step 4 reflection
• Leaders actions
• Data analyzed late in the process for academic
  publishing or departmental requirements, or not
  at all
• Team members actions
• Little or no reflection

Outcome New routine fails to take hold in the
organis-ation
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9. Culture change solution

• Culture sets of beliefs, ideas, practices and
  behaviours
• The way we do things around here
• Our worldview, assumptions, taken-for-granted,
  outlook, norms, values

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9. Culture change solution

• The 800 pound gorilla that impairs performance
  and stifles change is culture Pascale et al,
  1997
• Significant organisational failures and those in
  other systems are culturally determined
• Think about Enron The Titanic Bristol Royal
  Infirmary NASA 1929 stock market crash

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9. Culture change solution
Source Braithwaite 1999
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10. What to do to engage

• Stress the value of collaborative effort
• Connect or reconnect people
• Acknowledge differences in outlook
• Engender trust, transparency
• Tolerate dissent
• Understand that roles are flexible
• Focus on accountability individual and team

Sources NHS 2004 Braithwaite PubMed summary
2007
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10. What to do to engage

• Remember to evaluate
• Stress the importance but not the primacy of
  leadership
• Foster professional goodwill
• Educate
• Provide support for those who are interested
• Permit boundary-crossing

Sources NHS 2004 Braithwaite PubMed summary
2007
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10. What to do to engage

• Be sensitive to risk but not overwhelmed by it
• Support peoples progress, and tolerate the
  occasional stumble
• Influence through resource allocation
• Harmonise effort, collaboration, sharing
• Use information to oil the wheels of engagement

Sources NHS 2004 Braithwaite PubMed summary
2007
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10. What to do to engage

• Facilitate the development of skills and talents
• Work with change champions and opinion leaders
• Align where possible clinical, managerial and
  policy interests
• Overcome RTC
• Work on culture change as defined

Sources NHS 2004 Braithwaite PubMed summary
2007
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10. What to do to engage
Late Majority
Early Majority
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Early adopters
13.5
Laggards
16
Innovators
Create a tipping point
2.5
Low
High
Speed of adoption
Source Rogers Diffusion of Innovation 1995
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10. What to do to engage

• Clear advantage compared to current
• Simplicity of change and implementation
• Compatible with current system and values
• Ease of testing before full commitment
• Observability of the change and its impact
• Strength of evidence (specific to healthcare -
  Plsek et al)

Sources Rogers Diffusion of Innovation 1995
Bunce NHS 2007
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10. What to do to engage

• Tips
• No substitute for face to face discussions
• Early meeting to discuss proposed projects
• Clear structure to the project
• Time-line for actions and achievements
• Action plans and who to implement
• Celebrate success
• Plan sustainability of changes early in project
• Communication, communication, communication

Source Bunce NHS 2007
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11. Final advice

• Keep it all in proportion

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12. Useful documents

• National Health Service. Engaging clinicians.
  London NHS, 2005.
• National Health Service. Making a difference
  engaging clinicians in PCTs. London NHS
  Modernisation Agency and NHS Alliance, 2004.

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13. Useful references

• Braithwaite J. PubMed articles on engaging
  clinicians. Sydney Centre for Clinical
  Governance Research, 2007
• Braithwaite J, Westbrook, MT. Rethinking clinical
  organisational structures an attitude survey of
  doctors, nurses and allied health staff in
  clinical directorates. Journal of Health Services
  Research and Policy 2005 101 10-17.
• Perkins R. Leading health organisations in New
  Zealand Parts 1 and 2. Health Care and
  Informatics Review Online 2004 1 December,
  http//hcro.enigma.co.nz/website/index.cfm?fuseact
  ionarchiveissueissueid54
• Barnett P, Malcolm L, Wright L, Hendry C.
  Professional leadership and organisational
  change progress towards developing a quality
  culture in New Zealands health system. The New
  Zealand Medical Journal 2004 117
  http//www.nzma.org.nz/journal/117-1198/

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14. Useful websites

• NHS Modernisation Agency http//www.wise.nhs.uk/
  cmsWISE/ServiceThemes/acuteservices/engaging/clin
  icians.htm
• The Health Foundation http//www.health.org.uk/o
  urawards/clinicians/