John Britt and Karen ProctorHealth Sciences Advisory Services, Ernst & Young LLP
Clinicians generally favor routine over the dramatic, protocol over chance and predictability over variance. Their clinical training has helped to shape a conceptual framework that has quality patient care at the nucleus. In the healthcare industry, pressures to improve financial performance can create tension between senior managers who are facilitating initiatives to improve revenues and/or reduce costs and clinicians who may view such initiatives as a potential threat to how they care for patients.
While senior managers often view change initiatives as opportunities for themselves and their business, clinicians view change as disruptive and intrusive. The meetings, manuals and mandates only serve to draw the clinicians’ attention away from taking care of patients. The frustrations are intensified for those clinicians with a productivity standard. They may begin to believe senior leadership has placed unrealistic expectations on their time and thus the gap between senior managers and clinicians widens.
To obtain the clinicians “buy-in” to the change initiatives, senior managers must understand the currency and exchange rate of clinicians; that is, what has value for the clinicians and what are they willing to accept in exchange for changing their work behavior. What senior managers offer must be at least to equal to or greater than the value the clinicians perceive from the status quo. If senior managers want to influence sustainable change in clinicians’ work behavior, they should be prepared to answer these two questions:
Patient Care
In most healthcare organizations, the mission drives reinvestment of at least some of the profits back into the organization. Unfortunately, senior management does not consistently articulate this to clinicians in a personal and meaningful way. The unwritten rule is that the details of the financial performance of the organization belong in the board room or are at least stalled at the management level just as the condition of the patient is confidential and protected at the clinical setting.
The interdependence between producing good clinical and financial outcomes can hardly be argued. Senior managers must be poised to communicate the “change effort request” in the context of financial outcomes which, in turn, can have an impact on patient outcomes. Clinicians who can envision how changes in their day-to-day operations can ultimately lead to increased or better resources which can have a positive impact on patient care are more likely to abandon the known, current work method or behavior for an unknown work method or behavior. In essence, clinicians will calculate a return on investment (ROI) of their time and energy much the same as a banker would calculate the ROI of a cash investment. The perceived reward must be greater than the perceived risk.
Example: Dr Jones, a hospitalist employed by the hospital, admits and follows a large portion of the patients admitted to the hospital. An audit clearly reveals that Dr. Jones is under-documenting which leads to under-billing. Since the hospital employees Dr. Jones, the opportunity cost (dollars unrealized) associated with the under-billing belongs to the hospital. Dr Jones acknowledges his opportunity to improve his documentation but couches any intended change of his actions in perceptions of overwork, high volume of patients and limited resources.
The intended change for the hospital in this scenario is improved documentation leading to improved coding and thus improved reimbursement. Dr. Jones has calculated the ROI of the proposed change and has determined that the time and energy to improve his documentation, in short, is time spent that could have been spent managing the care of his patients.
One potential solution to this dilemma is for the hospital to run a pro-forma which estimates the anticipated increase in the revenue had the physician had complete documentation. With these additional revenues, the hospital could consider potential additional resources to leverage the physician’s time (physician assistant, nurse practitioner or perhaps refined documentation tools) which leads to a sound financial ROI for the hospital and a sound patient-centered ROI for the physician. It is this type of thinking and communication in which senior management can legitimately influence clinicians’ work behaviors.
The Clinician
Clinicians are not immune to personal motivators. Once the question of how the proposed change will affect the patient care has been cleared, the clinician will naturally consider the impact of the change personally. This question of, “what does this change mean for me” must be addressed as senior managers consider the introduction of change. Areas to consider in regards to motivating the clinician on a personal level include their:
Calendar. The point here is that time is a precious resource to the clinician and should not be squandered. While the creation of buy-in is important, senior managers should exercise caution in how they approach clinicians who are, by and large, very intelligent people. A straightforward approach with attention to the clinicians’ opinion demonstrates respect. In the face of a proposed change effort, clinicians will want to know how fast (urgency) and how much (quantity) of their time will be required.
Curriculum vitae. The curriculum vitae is a metaphor for the psychological dimension that should be considered in a change effort. An organization with a system (formal and/or informal) of recognizing employees and others for their commitment to the organization (including change efforts) find that this practice can be an effective motivator or, at least, reinforcer of work behavior change. Be careful not to trivialize the psychological rewards. Overuse may lead to a feeling of superficiality actual become a de-motivator for the clinician.
Wallet. Money motivates some people. Agreements that equate dollars to performance are not uncommon. In the healthcare arena, such proposed agreements should be removed by the organization’s attorney prior to memorializing the agreements and the issue of parity should be considered. Money could also become a de-motivator so make sure the terms of the expected work behavior or outcomes are clear and easily measured.
Summary
Change management requires-well management. While this article has dissected what change means for the patient and the clinician in the mind of the clinician, the two concepts are, in fact, inextricably linked and not so easily separated functionally. In healthcare, when the change spills over into the clinicians’ arena, senior managers must be cognizant of the medium of exchange (currency) and the relative value to the clinician. A business case for change is appropriate for clinicians but it must be a business case that does not stall in the category of profitability but one that circles back to relate the benefit in a currency with an exchange rate that is worth the clinicians’ investment in change.
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The views set forth herein are those of the authors and do not necessarily reflect the views of Ernst & Young LLP.
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