Turning Skeptics into Allies
Dr. M. G. Maharaj Chief of Surgery
NSQIP Surgeon Champion Langley Memorial Hospital
2014 Quality Forum, British Columbia
Background
Langley Memorial: 200 bed community hospital
NSQIP since 2011
Multidisciplinary action teams to reduce UTI and SSI rates
Pneumonia team on the horizon
ENT surgeon at LMH for 10 years, chief of surgery since 2008, surgeon champion since 2011
Advisory board company talent development
Goals
Understand that skeptics are common, and skepticism is a natural response to something new
Identify different categories of stakeholders and strategies which will help them align with your goal
Walk through a real example of managing skeptics in the setting of change to reduce postop UTI in surgical patients
Example: UTI
When LMH started with NSQIP, we had a high UTI rate in surgical patients, according to risk-adjusted data
We assembled a multidisciplinary team who identified that the best practice of early foley removal, or avoidance of indwelling catheter altogether, in total joint patients was not being adhered to consistently
We encountered some skeptics whose objections may sound familiar…
Prevalence of Skepticism
“We don’t need to change the current system. It works
just fine.”
Prevalence of Skepticism
“We can’t change anything until they give us more money.”
Prevalence of Skepticism
“We tried this before and it didn’t work”
Prevalence of Skepticism
“They should just fire all of the administrators – we physicians
know what’s best for our patients.”
Prevalence of Skepticism
Skepticism is a normal, healthy response of a critical mind
Physicians are increasingly trained to rely on evidence based practice
Any change or proposal is inherently flawed until there is convincing evidence to support it
A skeptical response is simply an indicator that the individual is a stakeholder
Stakeholders
Cast a wide net to include all potential stakeholders, including those impacting a change, and impacted by the change.
Failure to include and consult all stakeholders can result in a fundamentally flawed approach, giving strength to skeptics and undermining allies
Failure to Target the Real Issue
Stakeholders: Power Brokers
Those with ultimate decision-making over the change
Ability to allow or prevent what you are advocating from getting off the ground
Typically executive level
LMH: OR and surgical ward Manager
Stakeholders: Agents
Those responsible for enacting the change, carrying out the day-to-day implementation
Typically front line staff, including physicians
LMH: OR nurses, ward nurses, orthopaedic surgeons
Stakeholders: Constituents
Those impacted by the change, the targets or beneficiaries of the proposal
Typically patients
Often also includes the frontline staff and physicians
LMH: patients, OR and ward nursing staff, Urologists
Stakeholder Stance
Supporter: can be counted on to support and even promote the initiative – OR nursing staff
Undecided: uncertain, could be swayed to action either in support or in opposition – Orthopaedic surgeons, Ward nursing staff
Dissenter: actively opposed, unlikely to switch allegiance - Urologist
Urgency
Urgency
Urgency can be thought of as a means of influencing the degree of enthusiasm with which an individual becomes involved
Times sensitivity and personal importance can impact how strongly a support promotes, or a dissenter thwarts, an initiative
Urgency can be raised or lowered for any given individual
Strategic Approach to Stakeholders
Supporters: inflate urgency to inspire continued active support, but don’t continually preach to the choir
Dissenters: reduce urgency to reduce reaction, maintain in an inactive status; don’t expect to turn dissenters into supporters
Undecided: articulate the reasons why undecideds should become active supporters; this should be the group receiving most of your attention
Strategies for Agents
Supporter: designate responsibility for process improvement, give them ownership or the change
LMH: OR nurse charged with communicating the new policy, reporting on compliance
Strategies for Agents
Dissenter: find supporter with knowledge or data to counter negative messaging from dissenter
LMH: other Urologist tasked with presenting the data in support of the new policy
Strategies for Agents
Undecided: use information or data to design or refine the change, identify “what’s in it for them”, and how this change will serve their needs
LMH: emphasis on patient benefit to avoiding UTI happy patient = happy Orthopod fewer UTIs reflect positively on ward nursing care
The Power of a Group
Inflating and deflating urgency can be done individually; commitments to action should be done in a group
Groups allow individual expertise and perspective to work synergistically to the benefit of the collective
Groups also prove as “testing grounds” for more extreme views, and can be an effective venue to quash dissent
LMH: all stakeholders brought together in person to air their concerns, hear reassurances from colleagues, get a sense of the collective will to act to correct a proven problem with patient care
What Physicians Want
Respect Acknowledge their role as stakeholders Expertise Responsibility for patient care
Independence Patient advocates Ultimate responsibility is to the patient, not the
institution
Don’t Over Complicate
We’re all in this Together
At the end of the day, we want the same thing: optimizing patient care
Different ways of accomplishing the same goal
Skeptics should be respected, put in the context of the group opinion, and managed in such a way as to either become a supporter, or a non-disruptive dissenter
A track record of success will predispose prior dissenters to be less likely to dissent in the future
LMH: successful implementation of new policy resulting in ~30% reduction in UTI rate
Questions