Physicians have typically been trained to be independent decision-makers focusing on individual patients and episodes of care. The future healthcare environment, however, will require multidisciplinary teams, population health management and care coordination with all members of the team working at the top of their training. To adapt to this new environment, physicians often need to span boundaries and move out of their comfort zone. Health system leaders can engage physicians in spanning boundaries by setting a direction, aligning goals and attaining commitment. Leaders also need to communicate with physicians with messages that are consistent with the stages of change.
Boundary spanning: Challenging learned behaviorsThe average age of physicians in this country is 55. In college and medical school, we weren't doing a lot of team problem-solving and teamwork. Today, medicine is very team-oriented. Medical schools are using team approaches and group problem solving in their curricula. However, many of our more experienced physicians find learning to work in multidisciplinary teams is a challenge. Managing patient populations, in addition to individual patients, will also prove challenging. Finally, there's a new expectation that care doesn't end at the doors of the physician's office, hospital room or surgical suite; care needs to be coordinated, and physicians are responsible for making sure care coordination occurs across the continuum of care.
These three challenges within healthcare transformation demonstrate the need for health system leaders to guide physicians in boundary spanning and engage them in new areas.
Establishing direction, alignment and commitment
To lead physicians in boundary spanning, Catholic Health Partners and Mercy work with the Center for Creative Leadership to train leaders, including physician leaders, in a three-step process. The first step is establishing a direction ? achieving a shared understanding of goals and strategy around a team approach, population health management and care coordination. It's critical that physician leaders are engaged in setting the direction and are able to clearly articulate the vision and shared goals.
The second step is aligning people: Individuals and teams need to be clear on their roles and the roles of others. It's important to "connect the dots" and move ahead in a coordinated, focused manner. However, removing traditional healthcare silos, sharing resources and establishing new teams that lead to changes in existing roles and processes can be perceived as threats to individual security. Leaders can gain alignment by starting with changes that address shared needs and feel safer for the physicians and others involved with the change. To be successful at improving healthcare value, we must take people out of their comfort zones but we do not want to throw them totally off balance. Sometimes a safer area is a recognized, unmet need. Addressing a shared, unmet need may be less threatening as an initial step.
Once direction is established and alignment is being promoted, the stage is set for building commitment with physicians by suggesting roles in the boundary spanning process. An environment of trust, transparency and mutual respect fans the sparks of passion into steps of commitment.
Warning signs: Evidence of imbalanceAll three elements ? direction, alignment and commitment ? need to be present for physicians' boundary spanning to be successful. Certain signs can alert leaders to an imbalance:
??? ?Overwhelmed. Physicians who feel they're being pulled in different directions or who take an attitude that "this too shall pass" signal a lack of direction.
??? ?"Us vs. them." Language of "us vs. them" and "me vs. he/she," including accusations of others not doing their part, are signs of a lack of alignment.
??? ?Just talking. If people don't "walk the talk" or they get only easy tasks accomplished, there is likely a lack of commitment.
To avoid an imbalance of direction, alignment and commitment, leaders need to communicate to physicians based on the stage of change they're in.
Communication and stages of change
The stages of change may seem similar to the stages of grief. When confronted with a boundary spanning change, people often react initially with denial and believe that the change will not occur or will fail. In this stage, communication should focus on awareness ? explaining in broad terms what the change is and its relevance to physicians. For example, if a hospital is introducing mandatory clinical documentation and order entry in an electronic health record to physicians, leaders should explain the concept of adopting EHRs and the high-level advantages.
The next stage is resistance, in which people are not completely against the change, but feel as if they have lost some sense of control, which may lead to negative engagement. Communication in this phase should include specific details about the change to help physicians better understand it. In the EHR example, leaders could describe the process and benefits of e-prescribing, rapid note completion, easier access to clinical information and other specific EHR components.
After resistance, physicians begin to explore the change. They may begin to recognize a benefit of one component of the change, such as e-prescribing freeing up time previously spent writing prescriptions. The transition between resistance and exploration is critical, and represents a transition from failure to success. Communication should encourage commitment from physicians to begin to engage them with specific tasks in the change. In the EHR example, physicians could be asked to participate in development of order sets and redesigning workflows. ?
The last stage, realization, occurs when physicians understand the benefits of the change as a whole and begin to articulate the benefits to peers. They truly engage in the change. In this stage, communication should include feedback to physicians, updates on progress and encouragement to keep physicians engaged.
Progressing through the stages of change
It is important to remember that like the stages of grief, physicians advance through the stages of change at different speeds. In addition, progression through the stages is commonly accompanied by some periods of regression. Physicians may begin to explore the change and then fall back into denial temporarily before progressing again. This internal questioning and challenging is necessary to ultimately reach a strong, enduring commitment.
Leading physician engagement means leading boundary spanning and learning to communicate through the stages of change. By moving physicians and other clinicians out of their comfort zone and helping them understand the change, health system leaders can engage physicians in healthcare transformation and position the organization for success.
Kenneth Bertka, MD, is a family physician and vice president of physician clinical integration at Toledo, Ohio-based Mercy, part of Catholic Health Partners.
Robert Heizelman, MD, is a family physician and health information technology medical director of Mercy Medical Partners at Mercy.
More Articles by Dr. Kenneth Bertka:
How Does the Rise of Computers in Exam Rooms Impact Patient Care?Mercy's Journey Toward Patient-Centered Medical Homes, Population Health
Don't Fear Clinical Integration: One Reason Community Hospitals May Have an Edge
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