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Being a doctor is hard. Being a leader of doctors is even harder.
The greatest challenge physician leaders face is changing the practices of their front-line physician colleagues who control nearly all healthcare decisions and dollars.
Physicians don’t like being told what to do. Showing them evidence is ineffective—studies show that it can take years for well-publicized best practices to diffuse into standard practice. Even paying physicians to do the right thing (pay-for-performance) has mixed results. And discretely notifying physicians about individual performance data—such as their rates of readmission, hand-washing, and surgical site infections—doesn’t influence them either.
What then should the physician leader do? Go public with that data. Not World Wide Web public, but internally public—at section meetings, on display in the hallway, or in group emails. Sharing physicians’ key performance measures among peers will leverage two powerful forces that do change behavior: competition and social norms.
Physicians are competitive. The criteria for entering and thriving in medical training tacitly socialize physicians toward competitiveness, and this mindset persists long after residency ends. And when physicians make comparisons, they care more about the physicians down the hall than they do about the physicians across the state or country. (Similarly, when you want to convince households to use less electricity, you show them their neighbors’ rate of energy consumption, not the national averages.) Physicians, like all humans, subconsciously look to others for guidance on how they should perform. These social norms—the unwritten rules of how we should behave—govern physicians’ actions mightily.
No physician leader expects a warm reception from colleagues when this approach is first used. But there is some built-in credibility when the call for improvement is physician-to-physician. Even if the message is coming from the C-suite, it helps the reluctant front-line physician to know that the messenger also understands a C-reactive protein, a C-section, and CRP.
To be successful, the physician leader must present the data diplomatically. He or she must highlight top performers while ensuring that such praise is coupled with an obligation to share best practices. The leader must make sure that underperformers are not shamed, but rather supported publicly and privately in a quest to improve.
Health systems must change their culture to become continuously improving organizations. You can’t improve what don’t measure, but there is a long road between measuring a process and improving it. Posting data signals what the organization values. Posting data changes what people talk about and the language they use. And posting data, by leveraging social norms and healthy competition, changes behavior. When you change values, language, and behavior, you’ve changed culture.
Gurpreet Dhaliwal, MD, is Associate Clinical Professor, University of California, San Francisco, Department of Medicine.
Publication Date: Wednesday, June 04, 2014
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