Getting physician buy-in--even without direct authority.

If you're like many physician leaders, you are probably accountable for an ever-increasing portfolio of programs, most of which are critical to the success of your organization.

To achieve results, you need to engage A-team players--physician leaders and frontline clinicians. Your success ultimately depends on your ability to get others to be accountable and, in turn, for them to hold others accountable when you don't have direct authority.

We often hear physician leaders say, "I can't be effective unless I have the authority to manage the individuals and processes." This is sometimes referred to as the "reporting relationship excuse." Leaders, however, can get results by using influence without relying on organizational structures and reporting relationships.

Let's take a look at techniques for leading change initiatives in health care organizations where there is accountability without authority.

Sources of power

We define power as the ability to make requests that are fulfilled and offers that are accepted. Requests and offers begin a cycle of commitment to action that produces organizational results.

Leaders have many sources of power at their disposal, some based on direct authority and some based on influence. The structural power conferred by line reporting relationships is based on the ability of "the boss" to hire and fire. Typical models are found in the military command structure and the traditional corporate model.

However, physician leaders more often work in a complex matrix environment without this type of power. They must understand and master alternate sources of power.

Consider these five types of alternative power.

1. Connectional power refers to the implied ability of a leader to influence based on the leader's connection to more formal or respected sources of power. Your known relationship to the CEO, for instance, can represent connectional power.

2. Informational power refers to your access to knowledge that is useful to the individual you are trying to influence. Pleasing you may create access to that knowledge.

3. Coercive and reward power refers to your ability, in the absence of formal authority, to make things easier or harder for those whose cooperation you need. This can mean the ability to give or withhold rewards or to create or remove barriers.

4. Referent power is derived from the desire to emulate you. Individuals whom you seek to influence and who admire your skills, position, or stature may seek to please you in order to "be like you."

5. Expert power is your incremental knowledge and skills in areas respected by those you seek to influence. Respect for your keen understanding and insight may yield cooperation.

These alternate power sources are useful for both influencing activity and results as well as encouraging your emerging leaders and A-team players to step up to more accountability.

You probably already possess alternate power sources. Can you enhance your ability to use them effectively?

It's all about framing

Making a good case for a new initiative is an essential skill for leaders, particularly when trying to influence individuals over whom there is no direct authority.

Everyone wants to know how and why an initiative is important and how it will impact them personally, especially one that requires extra effort, behavior change, or explicit personal accountability.

We call this the WIIFM--"What's in it for me?"

Consequently, it is critical to frame the initiative or effort so that those affected are inside the frame. In our implementation and improvement work, we ask members of the organization: "What will it take for you to participate or commit?" This question respects their concerns and allows them to envision themselves inside the new frame and tell you what they will need to commit to your initiative.

You can't always promise everything, but "at least you cared enough to ask." The skill of framing is particularly important when seeking buy-in from the A-team, those opinion leaders whose commitment will be noticed by others, increasing the chance that your initiative will take hold, disseminate through the organization and be sustained.

Linking to organizational strategy

Making the case for internal change frequently falters because the request is not explicitly connected to the strategic goals of the organization. This is another part of the frame. Sustainable success can best be achieved if the appeal is firmly rooted in the organization's strategy and its goals clearly linked to the organization's goals.

The leader's task is to connect the dots for those you are seeking to influence. Making the case may reinforce alternate sources of power (i.e. referent, informational, connectional, reward power) as you create excitement and link yourself and your proposed solutions to achieving the envisioned future.

We often use the stonecutters' parable to illustrate the importance of connecting to the greater cause. The story tells of three stonecutters in the 14th century. Each was asked to describe his work.

The first stonecutter replied with bitterness that he was cutting stones into blocks.

The second stonecutter, performing the physically same task, described it as building an arch that was visibly taking shape.

The third stonecutter responded with great pride that he had the privilege of participating in the building of a great cathedral.

Similarly, health care leaders seeking to build teams or develop a deep leadership bench must provide an exciting context linked to achieving organizational vision and strategy, and enhancing personal rewards (WIIFM).

Telling the story

It is human nature to be engaged by stories. The ancient art of storytelling is a valuable leadership tool to build engagement.

Stories lend integrity to disparate observations or facts by weaving them into a coherent, integrated whole. They build understanding, which is the first step in building commitment and engagement. In the absence of a story, stakeholders may connect the dots in ways you do not intend.

An effective story enhances participation in key initiatives and attracts A-team players to take on new accountabilities.

Managing resistance

Humans respond in predictable ways to changes in their world. In the 1960s, Elisabeth Kubler-Ross described the five stages of grieving for patients and families facing bereavement: denial, anger, bargaining, depression and acceptance.

Similarly, people in organizations go through predictable stages when they are faced with a changing reality at work, especially one that requires significant behavior change or the loss of valued professional and personal relationships.

Organizational psychologists have recognized that people traverse several evolutionary stages before making actual behavior changes or participating even after hearing a case for change: denial, resistance, exploration, and commitment.

While people may initially respond to your request for participation, they will likely need to pass through the remaining steps before being fully on board. Interestingly, it is at the point of resistance when engagement first takes hold.

Many leaders, when faced with resistance, lose courage and back off, thereby effectively immunizing the organization against change. Instead, leaders should see signs of resistance as proof of engagement and accelerate their efforts with confidence.

In our 25 years of work with health care organizations, we have identified several effective techniques for managing resistance and moving stakeholders through the stages leading to commitment and loyalty.

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One of the most successful frameworks for bringing people on board in the face of inevitable active and passive resistance is harnessing the "energy of resistance" to create a win-win outcome.

Much like the martial art of aikido, the result is obtained not through direct combat and counter-resistance but by skillfully orchestrating the incoming and outgoing messages in a way that engages the resistant person(s) in an alliance that leads to an acceptable solution. The steps illustrated in figure 1 demonstrate the use of incoming (steps 1-4) and outgoing (steps 5-8) listening and messaging skills to achieve the desired result.

Even in the most complex health care organizations, it is possible to exert influence, get buy-in from A-team players and others without relying on the traditional sources of power. By assuming that a given stakeholder is a potential ally-in-waiting rather than an opponent, the effective leader can use the tools elaborated here to greater success.

Through identifying and using alternative forms of power, effectively making the case, and recognizing and managing resistance wisely, you can build strong teams and achieve the results you need in the absence of direct authority.

Resources

* Cohen, AR and Bradford, DL. Influence Without Authority. New York: John Wiley & Sons, Inc., 1991.

* Denning, S. "Telling Tales," Harvard Business Review, May 2004.

* French, JPR Jr., and Raven, B. "The bases of social power." In D. Cartwright and A. Zander (eds.), Group Dynamics, New York: Harper and Row, 1960.

* Kubler-Ross, E., On Death and Dying, New York: Simon & Schuster/Touchstone, 1969.

* Rogers, EM. Diffusion of Innovations, 5th edition, New York: Free Press, 2003.

Stephen Blattner, MD, MBA, is consulting manager for The Bard Group in Newton, Mass. He can be reached at 617-630-1731 or [e-mail].

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Mark Wenneker, MD, MPH, is consulting manager for The Bard Group in Newton, Mass. He can be reached at 617-630-1731 or [e-mail].

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By Stephen Blattner, MD, MBA and Mark Wenneker, MD, MPH

RELATED ARTICLE: 8 Key Principles of Physician Buy-in

Many health care executives find that getting buy-in from physicians is one of the hardest aspects of meeting strategic goals or improving performance. Through our experience, we have identified eight key principles that increase the likelihood of physician engagement in organizational change efforts. They are:

1. Treat a physician like they would treat a patient: listen and emphasize. Those are the best ways to build trust and respect.

2. Solicit physician input through interviews and focus groups. These forums give physicians a chance to voice their concerns and feel heard by the organization. Adopt a problem-solving mentality by asking them what it will take for them to commit.

3. Respect physicians' time. Schedule meetings at times when physicians are most available: early morning, lunchtime, or the end of the day.

4. Make it quantitative. Physicians respond well to data.

5. Link the work to performance and quality programs so there is no disconnect. It is not enough to have a program and expect physicians to care about it inherently.

6. Communicate frequently about a project's intent and progress so physicians understand what is happening and what is needed from them next.

7. Address skepticism head-on. Dealing with concerns directly and honestly is the best policy for building trust and gaining commitment.

8. Reward and recognize physicians' contributions.

--By Mark Wenneker, MD, MPH, and Stephen Blattner, MD, MBA

Story Element                        Goal or Purpose

What we are trying to achieve?       Be specific about the immediate
                                     work and purpose
Why we are trying to achieve it?     Explicitly connect this work to
                                     organizational strategy and goals
The consequences of maintaining the  What will happen if nothing changes
status quo
Why do I (the leader) personally     It's important to a real person who
care about this effort?              matters to the stakeholders
How will the changes look and feel?  Generate a realistic image of
                                     what's to come
What's in it for the listener?       Don't leave the WIFFM question to
                                     speculation
What is needed from the listener?    Make an explicit request of each
                                     stakeholder
What will the leader provide to      Put skin in the game--make it a
ensure success?                      collaboration
What's coming next?                  Don't leave listeners wondering
                                     about "the other shoe." Lay tracks
                                     for future initiatives or
                                     leadership challenges.
When will the listener hear more?    Commit to communicating