Physician Engagement Who and How

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Physician Engagement!Who and How!

• Howard Beckman, MD, FACP, FAACH
• April 2, 2009

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Getting StartedKnow Your Destination

• Articulate or Review Goals of the Project
• Define desired outcomes from engaging physicians
• Clarify why practitioners should want to
  participate
• Run available data to determine the degree to
  which variation exists
• DO NOT Visit before the Data is Vetted
• Choose behaviors for which action ? Improvement

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Who to Visit Prioritizing

• Identify Practices with large patient populations
  and the greatest negative variation from the
  mean
• From those groups start with practices with whom
  there is a relationship already or Practices
  whose members contain community leaders/respected
  in specialty
• Seek Practices whose variation from others is in
  areas for which there is a clear actionable
  recommendation for change

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Reaching Out Initial Contact

• Publicize the project and its value through
  organizational outlets (avoid surprises and
  normalize the process)
• Board meetings
• Committee or Specialty meetings
• Newsletter
• Project champion

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Reaching Out Initial Contact

• Work through the practice manager using outreach
  staff if available
• Provide the reason for the visit as a usual part
  of organizational activity. RIPA is working hard
  to help our members deliver the best possible
  care. Currently, we are focusing on improving
  heart failure guideline adherence and would like
  to visit with Dr. Jones to discuss our
  initiative
• Conduct communications with respect,
  transparency, and a non-judgmental tone.
  (Anything I know about you, you can know)
• Suggest that the office manager and key staff are
  invited to attend if the physician(s) is desires
  (suggesting nothing terrible is coming).

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Reaching Out Initial Contact

• Suggest the meeting will last 45-60 minutes
• Schedule to take place at the physicians office
  (for their convenience).
• Offer for the meeting to be at breakfast or lunch
  time and that food will be provided for
  practitioner and staff (a peace offering).
• Inform the practice manager that a medical
  director and a provider outreach staff member
  will be attending.

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The Visit Team First Visit

• Medical Director
• Finds way to join with practitioner
• Explains visit
• Shares variation chart
• Listens for response
• Responds to emotion as well as concerns
• Identifies next steps
• Transfers follow up to team member

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The Visit Team First Visit

• Outreach staff/QI Nurse/Provider Relations
• Observes interaction for clues to stage of change
  and unaddressed issues
• Tracks involvement and emotions of office staff
• Records follow up tasks to ensure completion
• Demonstrates interest in assisting with
  improvement effort
• Offers feedback at debriefing about what worked
  and missed opportunities

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Respectful Collaboration with Practitioners The
Stages of Change

• Blind Fury Silent Rage
• Anger
• 
  Agitation
• 
  
• Bargaining
• Denial
  1-2 yrs
  Acceptance
• Time
• H Beckman, MD, AJMQ, 2006 Adapted
  from E. Kubler-Ross

Emotion
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What to Bring to the First Meeting

• Main Goal Your score appears to be different,
  lets explore the data.
• What type of data? The variation chart
• Objective 1 Show the variation chart and WAIT
  for a response
• Objective 2 Determine the stage of change
  Denial, Anger, Bargaining Based on the Response
• If denial Ask what additional information is
  needed
• If anger listen and work to understand the
  underpinnings of the anger continue to explain
  why change is needed. Do Not Respond Defensively
  or try to bargain !!!!!
• If bargaining Ask for his/her thoughts on why
  the variation and what additional data is needed
  (introduce the team member who will do the follow
  up)
• Objective 3 When asked, What can I do? Or What
  is it you want? Be prepared to offer suggestions
  and/or interventions.
• Frame answer in good medical care!

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How much data is enough?

• Show the variation chart only peer comparison
  is the most compelling
• Have evidence to support the recommended behavior
  available
• Dont bring drill down data wait for it to be
  requested
• The purpose of the visit is to initiate
  reflection

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Case Mix Adjusted Utilization Curve Fiberoptic
Laryngoscopy in ENT
Dr. You
Rate per 100 Episodes
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After the Visit

• Create a set of deliverables and share with the
  group contact/leader
• Arrange regular follow up to share data reports
  and encourage behavior change
• Offer meetings, materials, other support as
  needed to help him/her/them succeed in changing
  behavior
• Ask if you/we are adhering to the projects core
  values

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Following Up

• Post first meeting thank you email with review of
  follow-up items
• Deliver deliverables on time
• Solicit concerns, questions, suggestions
• Reiterate core values and goals of program
• Include practitioners on planning and action
  committees

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Approaching Physicians Todays work

• What have been your biggest challenges to date?
• From your point of view, what other aspects of
  visit dynamics HAVE to be covered today?
• Remember to look for CLUES, attend to the
  SEQUENCES that create outcomes and use the TABLE
  metaphor
• Lets go for it Have Fun!!!

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Role Plays

• Rules of Role Play
• Fishbowl Exercise
• Rapid Sequence Responses

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Questions/Concerns
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Bibliography

• Beckman H, Fisher T. Change Package. California
  Quality Collaborative. 2008
• McDonald R, Roland M. pay for Performance in
  Primary Care in England and California
  Comparison of unintended consequences. Ann Fam
  Med. 20097121-127.

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