Change management approaches can help health system leaders engage physicians in value-oriented efforts to reduce clinical variation.
Hospitals that pay for consultants and for IT and analytics personnel in efforts to reduce costs tend to think in terms of the ROI to the system. But efforts to improve the value of care, including through clinical variation reduction, will not be successful without changes in physician behavior.
Physicians who are asked to change their care approaches often fail to see how these initiatives benefit them and their patients. In our first installment of this article, we presented several practical ways to engage physicians in initiatives that improve value through cost reduction and quality improvement. In this continuation, we explore some of the critical interpersonal strategies that will help ensure success.
Ask physicians to help solve the problem. Often, nonphysician leaders meet to address a clinical problem, then present the solution to physicians and expect cooperation. Yes, it is often difficult to get physicians to participate due to their busy schedules and a lack of incentive alignment, but those factors should be addressed so physicians can be part of the solution.
First, physicians are often aware of reasons why proposed solutions will not work. Second, people are always more willing to cooperate in systems they help create. Finally, physicians are intelligent and problem solvers by nature. They may not have business training, but they understand constraints. When leaders present problems honestly to physicians and share the constraints (e.g., “We do not have unlimited funds to solve this—here is the budget”), physicians can be very insightful and clever in crafting the most efficient pathway to the desired end.
Make it easy for physicians to collaborate. Even if physicians do not get paid directly for improving the efficiency of care or improving quality outcomes, they certainly may want to help the effort for the sake of their patients. Clinical quality improvement feels good. Physicians get discouraged, though, when helping means taking extra time to fill out forms or input data. This is time that they cannot spend directly helping their patients and that is not billable. Instead, data input is tedious and decreases physician compensation.
To gain the cooperation of clinicians, it is incumbent on health systems to make data collection as easy as possible. Whenever possible, non-clinicians should input the data. Fields for data input should be made clear, and physicians should be oriented to the location of those fields. Drop-down menus, auto-fill features, decision support tools, touch-screen interfaces and other forms of electronic health record (EHR) optimization can reduce the burden.
Reward physicians for their time. Physician involvement entails meeting and interacting with health system leaders and with fellow physicians. Hospital administrators typically draw a salary, so a meeting with physicians simply is paid time to them. Physicians, however, must perform billable work to get paid. Meeting attendance costs physicians time and therefore revenue.
If a health system expects physicians to attend meetings, it should pay them for their time. This arrangement typically requires the preparation of a contract between the organization and the physician. The going rate of about $150 per hour may not replace what participating physicians could have made during the same hour of clinical practice (depending on their specialty) but is often well-received as a good-faith token that recognizes the opportunity cost of their participation. It also establishes an expectation for active participation and engagement in the meeting, thus increasing the likelihood of achieving the meeting objectives.
Even without offering compensation for participating in quality improvement or utilization management activities, organizations can generate goodwill by doing things that indirectly benefit physicians, such as providing desired procedural equipment with the savings generated by variation-reduction activities. Hospitals can also address staffing or IT-support deficits that hold physicians back from maximal productivity.
Anything the hospital can do to improve operational efficiency for physicians will engender cooperation. Health systems should also consider providing CME or maintenance of certification (MOC) credit for certain kinds of enriching activities associated with quality or utilization improvement efforts.
Provide external support. The amount of uncompensated time physicians will agree to dedicate to care variation reduction is minimal. Their involvement must be well-coordinated and made efficient by support staff. Project managers, Lean Six Sigma staff, change management consultants, and analytics experts all can serve important roles and maximize participation of the medical staff.
In addition, ensuring the correct care management model and appropriate staffing levels for care management and care navigation helps physicians optimize their participation. Other leverage points include embedded decision support in the EHR, clinical documentation support staff, and quality, utilization management, and social services staff.
Some health systems have created the role of Clinical Variation Nurse as a full-time agent to interact with physicians around the data, and specifically to support them in making changes to clinical practice in response to the evidence they receive. This intervention has proven to be effective, since physicians are likely to respond with skepticism when a non-clinician suggests making a clinical change. The clinical variation nurse can also bring physician input back to the design and analytics teams to make the reports more accurate and useful.
Remind physicians that clinical variation efforts provide personal rewards. Efforts to reduce clinical variation help physicians measure their own practices, compare their clinical activities with those of peers, evaluate what works best, and interface more rigorously with scientific evidence and best-practice recommendations from professional societies. In short, this is a way for physicians to improve the quality of their practices and ultimately serve their patients better.
Medicare and other payers are measuring physician quality though programs such as accountable care organizations and MACRA, and physician performance is being made available to the public through Physician Compare and other consumer-reporting services. This trend will only continue as patients become more consumer-focused due to cost shifting in the form of higher copays and deductibles.
Remind physicians what is not changing.The magnitude of this type of change requires skillful use of coaching and change leadership approaches. It is useful to remind providers what is not changing.
The majority of physicians and hospital leaders are strongly altruistic and entered medicine to help people in need. No matter how much healthcare payment models change, their purpose and mission does not change. We have found that emphasizing this continuity of purpose in describing the future vision helps physicians engage in the journey.
Leverage peer influencers. No strategy is more powerful for influencing physicians (or anyone) to change a behavior or adopt a new idea than the persuasion of a peer whom they respect. Physicians who adopt a new way of doing things, particularly those who were former skeptics, should have opportunities to tell their story to as many other physicians as possible.
Even if the message is the same as it would have been coming from an administrator, it will be much more effective.
Develop relationships. As simple and obvious as this strategy is, health system administrators often fail to take the time to develop relationships with physicians. Often, a physician first meets a system leader because the physician is in some sort of trouble or the leader is asking the physician to do something that benefits the system. Positive rapport goes a long way toward gaining cooperation, and repeated positive experiences help relationships get past the occasional rough spot.
Investing in relationships is not a trivial activity. Administrators often spend eight to 10 hours a day in meetings, and they must consciously prioritize rounding and meeting with physicians at the expense of other activities. These meetings are most effective when they take place in the physician’s work environment. Effective leaders must have the discipline to schedule this time and keep it protected.
Health system leaders should invest in the development of designated and informal physician leaders. Physicians want to help solve healthcare problems, and they benefit from formal training in quality improvement, Lean operations, health IT, business principles, and change management techniques. Health systems can provide some of this training and exposure directly and can underwrite the attendance of physicians at courses and seminars that improve their skills.