Transcript Health Choice Network

Studer Group Presentation to
Health Choice Network
The Challenging Physician
Jackie Gaines, Executive Coach
So Who are We Talking About?
-
Physician who comes in late often, but
happens to see the most patients and
generate the most revenue
-
Physician who is always behind in their
tasks (labs and notes unsigned as per policy
etc.)
-
Physician who is rude to patients and staff
-
Physician with illegible handwriting and not
improving
-
??? What are the behaviors of your
disruptive physicians??
Slide 2
COPYRIGHT © STUDER GROUP
Please do not quote or disseminate without Studer Group authorization
So…what do you want to
know by the end of this
session?
Slide 3
COPYRIGHT © STUDER GROUP
Please do not quote or disseminate without Studer Group authorization
What cements our Mission and Values
to our Actions?
What guides how we live and serve
patients, colleagues, our organization
and our community?
All Life’s Variables Impact Our Behavior in the
Workplace
Family/Personal
Medical Training/Previous
work experiences
Genetic Hardwiring
Organizational
Expectations
Misaligned values
External pressures/politics
5
Successful Physician Collaboration Starts Prior to Hire
Clarity is the Essential Ingredient!
6
What was conveyed to you prior to hire?
Did it match reality?
7
Standards of Behavior
 Define behavioral
expectation consistent
with mission, vision,
training, measurement,
orientation and
organizational culture
 Foster positive and reduce
negative/disruptive
behavior by clarifying
expectations upfront
Slide 8
COPYRIGHT © STUDER GROUP
Please do not quote or disseminate without Studer Group authorization
Can you name one
standard?
How is it currently enforced?
Slide 9
COPYRIGHT © STUDER GROUP
Please do not quote or disseminate without Studer Group authorization
Physician “Code of Conduct”
• Creates physician commitment to more specific behaviors within the
“standards” positioning physicians and their organizations for
success
• Puts in place a process to address and correct deviation from
standards.
Reality Check:
In 2009, the Joint Commission introduced new
standards requiring more than 15,000 accredited
health care organizations to create a
code of conduct that defines acceptable and
unacceptable behaviors and to establish a formal
process for managing unacceptable behavior
~Joint Commissions, 2009
Physician Behavioral Standards/Code
Barriers ……
Physician culture has traditionally been one
of independence and autonomy – results
Code of conduct / standards may be
– Ignored
– Rejected
– Attacked
Physicians are more receptive when…
• Physicians create the Standards/Code
• Standards/Code reinforce the strategy and vision of the organization
• There is a compelling and understood need for consistency throughout
the organization
• Physician leaders make it a priority
• There is consensus on the content of Behavioral Standards
Behavior Standards Impact
• High
– Used for orientation/signed
– Used for “Selection”
– Consistent with “Vision”
– Physicians trained in
Behavioral Standards
– Supported and projected by
Leadership
– Consequence for violation
• Low
– No upfront
signing/orientation
– No training of physicians
– Low leader visibility
– No consequences for
violations of Behavioral
Standards
Six Competency Areas
Adopted by Joint Commission
• Patient Care - that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health
• Medical Knowledge - about established and evolving
biomedical, clinical, and cognate sciences and the application of
this knowledge to patient care
• Practice-Based Learning and Improvement - that involves
investigation and evaluation of their own patient care, appraisal
and assimilation of scientific evidence, and improvements in
patient care
• Professionalism - as manifested through a commitment to
carrying out professional responsibilities, adherence to ethical
principles, and sensitivity to a diverse patient population
• Systems-Based Practice - as manifested by actions that
demonstrate an awareness of and responsiveness to the
larger context and system of health care and the ability to
effectively call on system resources to provide care that is of
optimal value
• Interpersonal and Communication Skills - that result in
effective information exchange and teaming with patients,
their families, and other health professionals
Physicians’ Major Priorities
1. Responsiveness of Administration to the ideas and
needs of medical staff members
2. Ease of Practice: Facility makes caring for patients
easier.
3. Agility: Administration has positioned health center to
deal with changes in the health care environment
4. Trust: Confidence in the Administration to carry out its
duties and responsibilities
5. Communication between Administration and
physicians.
Prevalence of Physician Performance Problems
• Disruptive Behavior
–4% - 5% of physicians
• Distress
• Impairment
…at least one third of all physicians
will experience...a period during
which they have a condition that
impairs their ability to
practice medicine safely
Leape LL & Fromson JA.
Annal Intern Med.2006;14(2);107-115
www.TheResilientPhysician.com
What Does Disruption Look Like?
Aggressive
Outbursts
(90%)
Intimidation
(20%)
Harassment
(10%)
Passive
Aggressive
Derogatory
comments
(5%)
Refusals
to do
tasks
(20%)
Samenow CP et al. Phys Exec. 2008.34(1):32-40
Passive
Chronically
late or not
responsive to
calls
(15%)
Inappropriate
or inadequate
documentations
(15%)
Most Frequent Source of Abuse?
Most Common Disruption…
“Lateral Violence”
Nurses, Pharmacists
Radiology, Lab
Inst for Safe Medication Prac. 2003 www.ismp.org
Rosenstein & O’Daniel. Amer J Nur.2005;1:54-64
Rowe MM & Sherlock H. J of Nurs Manag. 2005;13(3):242.
Slide 20
COPYRIGHT © STUDER GROUP
Please do not quote or disseminate without Studer Group authorization
What is Considered Disruptive?
What is Considered Disruption?
•  Apprehension and Anxiety
•
 Loss of Focus
•
 Team Effectiveness
•
 Communication
www.TheResilientPhysician.com
Federation of State Medical Boards, 1998
The Obvious
• Profane or disrespectful
language
• Demeaning or intimidating
behavior
• Sexual comments or
innuendo
• Inappropriate touching,
sexual or otherwise
• Comments that undermine
patients trust in physician
or health center
Federation of State Medical Boards, 1998
• Racial or ethnic jokes
• Outbursts of rage or
violent behavior
• Throwing
• Inappropriate criticizing
colleagues in front of pts.
or staff
• Boundary violations w
staff, pts, surrogates or
key third parties
The Somewhat More Subtle
• Inappropriate chart notes
• Unethical or dishonest
behavior
• Inappropriate arguments
with patients, family, staff, or
other physicians
• Difficulty working
collaboratively with others
• Resistance to recommended
corrective action
• Repeated failure to
respond to calls
• Poor hygiene
Federation of State Medical Boards, 1998
The Consequences
• Adverse medical events... 60% attributed to “out-of-control physicians”
(Atlantic Information Services, Report on Medicare Compliance. 2005
14(17):1-8.)
• “Between 53% and 75%.. Say they saw a strong link between
disruptive behavior and negative clinical outcomes
Rosenstein AH & O’Daniel M. Neurology. 2008.70:1564-70.
www.TheResilientPhysician.com
The Consequences
• Turnover
•  Risk
– 4 or more complaints over 6 yrs ~16x
likelihood of 2 or more risk management
complaints
Hickson GB et al. JAMA. 2002;287:2951-7
www.TheResilientPhysician.com
What Is Disruptive Workplace Behavior?
www.TheResilientPhysician.com
• Focus on
– Communication Behaviors
– Physical Intimidation
• Subjective?
– “Offensive” “Frightening”
– In Eyes of Beholder?
• Def. In Terms of Effects on Work Environment
– Interferes with Patient Care
– Interferes with Efficient Operations
Fooks, C & Maslove L. Coll of Phys and Surg of Ontario, Oct, 2003.
Drivers of Physician Change
• Visionary Leadership
• Trust and Confidence in the Leadership team
• Knowledge of Performance
• Clarity of Expectations
• Logic for Efforts
• Behavioral training
• Colleagues doing the same
• Recognition for doing well
• Incentives to achieve Goals
When Expectations are not Communicated…
• Difficult behaviors are addressed reactively instead of prevented
proactively
• Consistency of care is difficult to achieve and “behavioral variance”
becomes the norm
An Organization IS what it DOES all of the time
Expected Behaviors: Treatment of Patients
• Physicians will introduce themselves to patients and family
and clarify their role in the care of the patient
• Physicians use curtains and doors, and conduct
conversations in private areas to protect patient privacy
• Each patient is an individual and will be treated honestly and
with kindness
• Each patient should understand treatment needs, treatment
options and potential treatment outcomes
• Medications will be explained including the purpose,
therapeutic intent, duration of use and possible side effects
Expected Behaviors: Treatment of Staff
• Speak positively about your staff to patients and families
when an opportunity arises
• When difficulties with staff arise, take ownership, speak-up
and educate in private to improve performance
• Communicate your whereabouts if your staff may need you
for patient care issues
• Thank your staff for the hard work they do
Effective Standards/Code
are Specific and Observable
Always ask, “What does it look like?”
• “Courteous” is not specific or observable. What does “courteous” look
like?
– “Makes eye contact with patients and peers”
– “Introduces self in interactions with patients and families”
– “Uses patient’s name during clinical encounter”
Physician Orientation
Standards/Code of Conduct
History of Institution
Heavy emphasis on
culture, character and
values
Aligned New
Physician
Train and develop
evidence-based behaviors
Clarity of physician
expectations. “Who we
are.” Sign Code of
Conduct
“Code of Conduct” Must Haves
• Are defined and process documented
• Impact Behavior
• Violation have consequences that are
in place and understood
When Breakdowns Occur
Have a process in place
• Fair
• Consistent
• Matching values & standards
• Peer driven
• Legal
• Evidence based – best practice
How to Confront Inappropriate Behavior
The Resilient Physician (Sotile & Sotile, 2002)
• Start Collegially
• Separate the Person from the Problem Behavior
– Clarify Underlying Issues
• Focus
 On the problem behavior
• Do not debate: Each topic deserves it’s
own conversation
• Convey hope beyond tension
Process
• Incident reported - any source
• Investigated – Informal first
• Reviewed by Chair/CMO
• Meeting called with Chair/CMO - “cup of coffee”
• Escalated to leadership if repeated behavior or clearly egregious.
• Moved to a corrective action plan.
Language Matters
• Some things you might say...
– “We are here to discuss your behavior, and your behavior is not
consistent with...”
– “Recall that we have a Professional Behavior policy, and behavior
was not...”
– “We expect that our team acts...”
– “We have __ episodes documented when you did [or failed to
do]__”
Discouraging Disruptive Behavior. Vanderbilt School of Medicine. Nov, 2008.
Confronting Disruptive Behavior
Anticipated Reactions
• Flight
• Subject-Changer
• Apologizer
• Denier
Virginia Beeson. The Advisory Board, 2009
Confronting Disruptive Behavior
Anticipated Reactions
• Fight
•
•
•
•
Rationalizer
Blame-Shifter
Score-Keeper
Negotiator
Virginia Beeson. The Advisory Board, 2009
Confronting Disruptive Behavior
Language Matters
• Use “Nevertheless, the fact remains....”
• Separate process issues from the point of this
intervention
“In the meantime...”
Intervention Guidelines
• Don’t Ignore the Obvious
–Anticipate responses ranging from
acceptance to denial to anger to hurt
–Remember: The higher the hierarchy, the
higher the shame and guilt
Language Matters
–Explain that You Will Follow-Up
• “If things don’t improve, or if you don’t comply with the plan, the
consequences will be...”
Document
Document
Document
Document!
Discouraging Disruptive Behavior. Vanderbilt School of Medicine. Nov, 2008.
How to Confront Inappropriate Behavior
The Resilient Physician (Sotile & Sotile, 2002)
• Follow-up
• Manage Post-Disruptions Turmoil
–Provide staff protection against retaliation
–Decreased productivity
–Workarounds
–Turnover
–“Lost” Administrative Time
In the Final Analysis:
a preemptive plan most effective
• Appointment of Excellent Physicians
• Orient heavily on Vision and Culture
• Build trust between Physicians & Leaders
• Set and communicate expectations
• Coach and train physician behaviors
• Measure performance vs. expectations
• Provide feedback on performance
• Coach to improve poor performance
Transformation Requires
An appeal to the “Heart”, not just the “Head”
~Comments from The Heart of Change by John Kotter
“Changing behavior is less a matter of giving people
analysis to influence their thoughts, than helping them to
see a truth to influence their feelings.
Both thinking and feeling are essential, and both are
found in successful organizations, but the heart of
change is in the emotions. The flow of see-feel-change
is more powerful than that of analysis-think-change.”
Promoting Resilience
1. Protect Happiness
2. Focus on Uplifts
3. Believe in Something Bigger
4. Accept the Call to Character
5. Manage Your Coping Style
6. Rethink “The Balanced Life”
7. Embrace Good Work
8. Lead with Passion!
9. Deepen Your Relationships
10. Be a Hero
Source: Sotile, WM & Sotile MO. Letting Go of What’s Holding You Back. 2007
Hero
A hero is someone
who creates safe spaces
for other people
—The Resilient Physician. Wayne & Mary Sotile (2002)
Striking a Balance in Physician Selection !
Primary Care
Referrals
Unique talent
New physicians
Specialty gap
Growth
Need
Word of mouth
Everyone else is
Interest
Leaders must own the process!
Effective Physician Selection
• Organizational Needs
• Organizational Values
• Process of recruitment – we or they formally or informally - Pre
application
• Meets criteria - send application
• Process of evaluation – gather information
• Process of selection – Peer interview – committee deliberation - is
there a fit?
Teamwork
is:
• The ability to work together toward a common vision.
• The ability to direct individual accomplishments toward organizational
objectives.
• It is the fuel that allows common people to attain uncommon results.
Andrew Carnegie
Evidenced-Based System
Behavior and
Performance
Management
Goals and
Skills
Slide 53
Process
and
Technology
COPYRIGHT © STUDER GROUP
Please do not quote or disseminate without Studer Group authorization
"Culture outperforms
strategy every time; and
culture with strategy is
unbeatable."
Quint Studer
Slide 54
COPYRIGHT © STUDER GROUP
Please do not quote or disseminate without Studer Group authorization
Questions?
Slide 55
COPYRIGHT © STUDER GROUP
Please do not quote or disseminate without Studer Group authorization
“Always bring it back
to values . . .”
Quint Studer
Slide 56
COPYRIGHT © STUDER GROUP
Please do not quote or disseminate without Studer Group authorization
2014 Studer Group Institutes
Slide 57
COPYRIGHT © STUDER GROUP
Please do not quote or disseminate without Studer Group authorization
The Physician Partnership
Institute: A Path To Alignment,
Engagement and Integration
September 3-4 Indianapolis, IN
Value of Learning for
both days rated
95%
Post-Conferences Available!
Visit our website to view topics and dates.
Attendees will learn how to:
 Improve patient loyalty and the patient experience
 Utilize best-in-class communication techniques to drive performance in
CAHPS, mitigate risk and promote patient adherence
 Engage and lead physician colleagues to integrate and execute system goals
 Create a physician measurement system to track performance & productivity
 Align physician behaviors with organizational objectives to create a shared
mission shared, purposeful mission built around the patient
www.studergroup.com/institutes
Slide 58
COPYRIGHT © STUDER GROUP
Please do not quote or disseminate without Studer Group authorization