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New Zealand Institute of Health Management

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. 1. Is there a problem?. Poll question #1:

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New Zealand Institute of Health Management

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  1. 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

  2. 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?

  3. 1. Is there a problem? • So there’s 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 there’s a problem

  4. 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. 2. What is engagement? [Origin: 1515] [Source: Dictionary.com: http://dictionary.reference.com/browse/Engagement]

  5. 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]

  6. 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

  7. 4. Characteristics of clinicians • Doctors – personal traits: • IQ, individualist • Perfectionist • Doctors – occupational traits: • Income • Mobile then stable • Decision-making role • Work with risk, uncertainty

  8. 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

  9. 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

  10. 4. Characteristics of clinicians [Source: Braithwaite and Westbrook 2005]

  11. 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]

  12. Involvement Advocacy Consensus Support Working together Inclusive environment Collaborative Win:win Networking Communicate Provide information Use incentives Negotiate Be receptive Mutual benefit Funding mechanisms 5. Nature of engagement [Source: Braithwaite 2007 - 107 References content analysed from PubMed]

  13. Don’t 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 5. Nature of engagement [Source: Braithwaite 2007 - 107 References content analysed from PubMed]

  14. 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 5. Nature of engagement [Source: Braithwaite 2007 - 107 References content analysed from PubMed]

  15. 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 6. Barriers to engagement [Source: Braithwaite 2007 - 107 References content analysed from PubMed]

  16. 6. Barriers to engagement [Source: Braithwaite 1999]

  17. 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]

  18. Energy Fun? Anger Continuous improvement Lost Denial Start Learning Despair Understanding Clues 6 to 9 months: stop right here! 6. Barriers to engagement Time [Source: Bunce 2007]

  19. 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]

  20. 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: Helmreich’s and colleagues’ many studies (Thomas et al 2004; Helmreich 2000; Sexton et al 2000)]

  21. 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]

  22. 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 aren’t engaged

  23. 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

  24. 8. A leadership solution What successful leadership looked like • Step 1: enrolment • Select team members • Leader’s actions • Select team members • Define roles, responsibilities • Set frame for learning • Communicate • Team members’ actions • Listen • Enrol • Step 2: preparation • Off-line practice session • Leader’s 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 • Leader’s actions • Ongoing signalling including: • Invite input, acknowledge needs, and don’t reject new behaviours • Team members’ actions • Notice signals • Try new behaviours • Step 4: reflection • Debriefing to learn from trials • Leader’s 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

  25. 8. A leadership solution What failed leadership looked like • Step 1: enrolment • Leader’s 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 • Leader’s actions • Don’t show up at practice session - view it as a team activity disconnected from the surgeon’s execution of new routine • Team members’ actions • Participate in practice sessions without leader • Note that teamwork is not essential • Step 3: trials • Leader’s 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 • Leader’s 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

  26. 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

  27. 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

  28. Above the waterline lie the observable workplace behaviours, practices and discourse: this is ‘the way we do things round here’. Figure 1: the iceberg model of culture Below the waterline lie the underlying beliefs, attitudes, values, philosophies and taken-for-granted aspects of workplace life: ‘why we do the things we do round here’. 9. Culture change solution [Source: Braithwaite 1999]

  29. 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]

  30. 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]

  31. 10. What to do to engage • Be sensitive to risk but not overwhelmed by it • Support people’s 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]

  32. 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]

  33. 10. What to do to engage Late Majority Early Majority 34% 34% Early adopters 13.5% Laggards 16% Innovators Create a tipping point 2.5% High Low Speed of adoption [Source: Rogers Diffusion of Innovation 1995]

  34. 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]

  35. 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]

  36. 11. Final advice • Keep it all in proportion

  37. 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.

  38. 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; 10:1; 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?fuseaction=archiveissue&issueid=54 • Barnett P, Malcolm L, Wright L, Hendry C. Professional leadership and organisational change: progress towards developing a quality culture in New Zealand’s health system. The New Zealand Medical Journal 2004; 117: http://www.nzma.org.nz/journal/117-1198/

  39. 14. Useful websites • NHS Modernisation Agency: [http://www.wise.nhs.uk/cmsWISE/Service+Themes/acuteservices/engaging/clinicians.htm] • The Health Foundation: [http://www.health.org.uk/ourawards/clinicians/]

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