The levers of influence. (Positively Influencing Physicians).

PHYSICIAN EXECUTIVES ARE struggling to discover and implement strategies to provide high quality health care in an efficient and effective fashion. Some initiatives attempt to restructure the financing and organization of health care services. Other efforts have been developed to decrease demand and, in some cases, actual need. An emerging strategy is to modify physician behavior.

Physicians often determine the demand for health care services, as well as control the clinical processes aimed at improving health outcomes at the individual and population level. Given their Important role in enhancing health status and improving the health care delivery system, It is critical that physician executives master the tools necessary to positively influence physician behavior.

Physician executives are challenged to develop ways to leverage health care organizations' most valuable resource- human resources. Influencing physician behavior is one of the most useful management techniques to improve and sustain high performance. There is no substitute for good management.

The psychological contract

There are a few basic notions that shape the psychological contract between the physician executive and physicians.

1. The goal is to influence, not control, physician behavior. The major difference is that influence creates a climate of commitment, whereas control breeds compliance and resistance.

2. The focus is to influence behavior that is relevant to the design and delivery of health care. Do not to try to alter physicians' attitudes. In some circles, this might be termed "brainwashing"--a common response to this approach is anger. Psychologists have found in both laboratory and applied settings that there is a weak association between attitudes and behavior. (1) For example, a physician might not philosophically agree with clinical resource utilization methods, yet will behaviorally employ them.

3. No individual can be forced to do whatever he or she does not want to do, even under the cruelest of circumstances. A physician's behavior is more likely to be influenced to the degree that an interdependent relationship exists with the physician executive. For instance, employed physicians are more likely to be influenced by the physician executive's requests, directives, and policies than solo practitioners with a largely fee-for-service patient base.

Respect for the individual is paramount. As the physician workforce becomes increasingly diverse, physician executives need to understand what respect looks like, sounds like, and feels like among their heterogeneous colleagues.

Assumptions about physicians

There are a number of assumptions that must be tested on each physician to prevent stereotyping. Also, physician executives need to assess themselves with respect to their value system as a professional and individual. In general, physicians:

* value autonomy, especially clinical autonomy

* prefer data-based arguments and learning

* make quick, fact-based decisions

* demonstrate little tolerance for "organizational politics"

* focus on the best interests of the patient and his or her family

* seek both intrinsic rewards, like providing high quality care, and extrinsic rewards, like earning more money

* struggle with the optimal way to provide resource efficient and effective, high quality health care

A model for influencing physician behavior

A model to effectively influence behavior includes setting clear expectations, measuring and monitoring performance, providing feedback, and rewarding and recognizing improvement. If all else fails, then try discipline. This five-step approach is based on the science of human behavior and working with physicians in diverse settings, ranging from academic medical centers to small practices, and reflects the work of Howard Kirz, MD, and the other faculty members of the American College of Physician Executive's Managing Physician Performance Course. While the model is described sequentially, in reality it is an iterative process. The steps need to be followed to achieve the desired result--to influence physician behavior, not to change attitudes.

1. Set clear performance expectations

The first step is often forgotten or simply ignored. The desired behavior must be described in a way that the physician can understand and then act upon. An example would be for a physician executive to say: 'Dr. X...our mission directs each of us to value patient satisfaction. I expect all doctors, including yourself, to achieve a patient satisfaction rating of no less than 95 percent, as measured by our patient satisfaction survey."

In short, spell out the desired behavior and, if possible, the frequency, intensity, and appropriateness. A useful analogy is laser surgery--its clinical effectiveness is dependent on multiple factors, like appropriateness, intensity, and focus. The same holds true for influencing physicians. The desired behaviors must be described in a way that focuses the expertise, energy, talent, and discretionary effort on a set of concentrated performance behaviors.

Key physician executive behavior

The ability and willingness to translate organizational vision, mission, goals, and strategies to individual physician performance behaviors.

2. Measure performance expectations

The second step, measuring the desired behaviors, is based on observations or quantifiable, systematic data. In the example of Dr. X, the physician executive informed him that the behavior would be measured with patient satisfaction data. The data and even the observations need to meet the criteria of reliability, the consistency of the measurement, and validity, the accuracy of the data.

Key physician executive behavior

The ability to move beyond intuition and speculation when describing desired behavior and use more reliable and valid measures, such as observation and quantifiable, systematic data.

3. Monitor performance and provide feedback

Monitoring changes in behavior should not be confused with controlling and manipulating--it simply means following up with the physician in a supportive and constructive manner. For example, the physician executive would sit down with Dr. X and explain that he would be monitored from the perspective of improving performance and contributing to the goals of the organization and the patients.

Physician executives cannot monitor others cloistered in their offices. The real power of monitoring is realized when it is connected with feedback. Emerging clinical information systems will provide data to review performance in a more timely and accurate fashion. Physician executives, armed with this data, will be able to coach physicians in how to self-monitor their behavior. This approach allows them to grow, develop, and perform while maintaining control, respect, dignity, and accountability.

Key physician executive behavior

The physician executive's repertoire needs to include the ability to monitor, coach, and provide feedback. As Vincent Lombardi said, "Paralyze resistance with persistence."

4. Reward the expected behavior

While physicians are motivated by the Inherent nature of clinical work, they also need to be acknowledged and rewarded when goals are met. Recognition is even more salient given the challenges of practicing medicine in today's fast-paced environment. In some cases, physician executives are the only supportive characters in the physicians' work lives. Patients are armed with Internet data and demands, while managed care companies are squeezing every ounce of clinical effectiveness and efficiency out of physicians' offices.

While recognition is simply acknowledging the work and contribution of a given physician, rewards are more tightly associated with behavior. Specifically, tangible (compensation) or intangible (praise) rewards are typically reserved for accomplishing goals.

It is worth considering offering a reward before the goal-directed behavior is even attempted. This is the "carrot approach to motivation." For example, a vice president of medical affairs needs the medical directors and clinical team leaders to spend countless hours and energy preparing for NCQA over the next three months. The VPMA might give the physicians a reward prior to the NCQA site visit to influence their behavior. The obvious risk is that some physicians might run with the money and not produce, but this will be the exception. If this happens, don't use the carrot approach with that physician again--implement other types of managerial influence, including discipline.

Key physician executive behavior

The capacity and willingness to deliver timely and appropriate rewards, while recognizing the work of all physicians.

5. If all else fails, try discipline

There will be cases in which steps one through four will not yield the intended results, leading to frustration and perhaps even anger. As a physician executive, you need to stay in control of your emotions and the situation at hand. Be careful not to become "emotionally hijacked" and allow your feelings to cloud your judgement.

If all else fails, one easy option is to admit that all physicians, as individual human beings, have an inalienable right to choose their destiny. The flip side is that, as the physician manager. you have the responsibility to act in a way that preserves the organization's best interests. As such, you have the right to use discipline--not to be confused with punishment or threats.

Discipline is the last ditch attempt to influence a physician. The ante is raised and physician executives need to clearly communicate that a negative consequence, like termination or supervised practice, will be imposed dependent upon the individual's behavior. You will need to determine the type of negative consequences that are possible given your role in the organization.

Many physician managers interpret discipline to mean threats, which are no more than declarative statements about what will or will not happen. Discipline consists of a process to monitor behavior and ultimately follow-through on the negative consequences in a timely fashion. There are two principles to keep in mind during the discipline process: (1) respect must be continually preserved; and (2) documentation is essential to minimize exposure to legal risks.

Key physician executive behavior

Demonstrating courage in the face of adversity, in the spirit of preserving the organization's integrity and all that it represents.

Understanding physician values

The emphasis of this article is on leadership and managerial influence. The other side of the coin is the nature of followership and behavior change. Physicians are not "natural" followers. However, they hold very tightly to those beliefs and behaviors that they value. This can work in physician executives favor if they understand them. There are two basic reasons that physicians hold onto certain beliefs and practices with an "iron-clad" fist:

1. Professional socialization. The rigors of medical school, internship, and residency foster a climate in which knowledge is transmitted from one generation to the next. Additionally, case conferences and Grand Rounds provide a forum to discuss and share what works and what doesn't, as well as a visible way to encourage physicians to view the world from a different perspective and experiment with new behaviors. The lesson is to "recreate" some of these learning and sharing opportunities. Also, consider the power of mentors as role models--they can discuss desired behaviors without risking assaults on the physicians' competence, compensation, and character. Accordingly, the physician executive should serve not only as a leader and manager, but also as a mentor and coach.

2. Common roots of human change. Behavior change is far more complex than "doing it or not doing it." The Nike slogan "Just Do It" is motivating, but over-simplified. James Prochaska, MD, author of Systems of Psychotherapy, discovered the common roots of human change. (2) He reviewed psychotherapy technologies and found that the core processes of change include:

* consciousness-raising--the surfacing knowledge and experiences that were previously unknown. An example is defining performance behaviors.

* emotional arousal--while similar to consciousness-raising in that knowledge is enhanced, it is accompanied by a set of feelings that intensifies the process. For example, defining performance behaviors that make a difference in the lives of patients and physicians ignites the emotional sensitivity of physicians.

* commitment-the dedication to achieving an external and/or internal goal and "walking the talk." For instance, commitment is one of the outcomes of reward and discipline due to the high stakes involved.

* helping relationships-they are based on the psychological contract between physician executives and physicians. Coaching and mentoring are two examples of helping relationships.

* self-reevaluation-the internal process of analyzing information in an attempt to reinterpret and/or reshape reality. An example is measuring performance expectations, which results in a shift from personal to objective knowledge.

* rewards-they represent those things that individuals value in a way that desirable behaviors increase. For instance, performance-based incentive plans direct behavior in desired directions.

* environment control-the degree of legitimate authority that the physician executive has to reward and discipline. In other words, environmental control is the "bite to the bark."

By understanding the critical elements of these change processes and the dynamics of influencing physician behavior, physician executives can become masters of influence rather than mere technicians.

Conclusion

Physician executives face the daunting challenge of influencing behavior, while knowing deep in their souls that each physician has an inherent personal, professional, and civic right to choose his or her path and way of being in the world. yet, each physician also has to deal with the consequences of expressing this free will.

References

(1.) Fisher, C.D. On the Dubious Wisdom of Expecting Job Satisfaction to Correlate with Performance, Academy of Management Review, vol. 5, 1980, pp.607-612.

(2.) Prochaska, J.O. and Norcross, J.C. Systems of Psychotherapy: A Transtheoretical Analysis. 3ed. Pacific Grove, California: Brooks/Cole, 1994.

RELATED ARTICLE: INFLUENCING PHYSICIAN BEHAVIOR IN A UNION ENVIRONMENT

The American Medical Association's recent decision to support collective bargaining is likely to have a profound impact on how physicians are managed. A union environment requires a different approach--the management rights clause of the contract spells out the managerial actions that can be taken. Another distinction is that a "union steward" might be present at some of the discussions with the physician under consideration. But the physicians are not the employees of the bargaining unit--they are only being represented.

Differences in managing union physicians are the focus on organizational justice and the emphasis on the rigorous application of policy and procedures. There are two types of organizational justice: procedural and distributive. Procedural justice addresses the inherent and perceived "fairness" of the process under discussion. For instance, procedural justice is served when physicians are treated in accordance with the contract policies and procedures. Distributive justice deals with results, for example, an arbitrator's ruling. Physician executives need to abide by policies and procedures to promote an atmosphere of trust, fairness, and good faith. Failing to manage organizational justice and comply with policies and procedures increases exposure to grievances, legal disputes, plummeting morale, and poor public relations.

ASSUMPTIONS ABOUT PHYSICIANS

There are a number of assumptions that must be tested on each physician to prevent stereotyping. Also, physician executives need to assess themselves with respect to their value system as professionals and individuals.

In general, physicians:

* value autonomy, especially clinical autonomy

* prefer data-based arguments and learning

* make quick, fact-based decisions

* demonstrate little tolerance for "organizational politics"

* focus on the best interests of the patient and his or her family

* seek both intrinsic rewards, like providing high quality care, and extrinsic rewards, like earning more money

* struggle with the optimal way to provide resource efficient and effective, high quality health care

THE ROOTS OF CHANCE

Behavior change is far more complex than "doing it or not doing it." James Prochaska, MD, author of Systems of Psychotherapy, discovered the common roots of human change. (2) He reviewed psychotherapy technologies and found that the core processes of change include:

* consciousness-raising

* emotional arousal 

* commitment

* helping relationships

* self-reevaluation

* reward

* environmental control

A Model for Influencing Physician Behavior

This five-step approach is based on the science of human behavior and working with physicians in diverse settings, ranging from academic medical centers to small practices.

1. Set clear performance expectations

Spell out the desired behavior and, if possible, the frequency. intensity, and appropriateness.

Key physician executive behavior

The ability and willingness to translate organizational vision, mission, goals, and strategies to individual physician performance behaviors.

2. Measure performance expectations

Measure the desired behaviors with observations or quantifiable, systematic data. The data needs to be reliable and valid.

Key physician executive behavior

The ability to move beyond intuition and speculation when describing desired behavior and use more reliable and valid measures, such as observation and quantifiable, systematic data.

3. Monitor performance and provide feedback

Monitoring changes in behavior means following up with the physician in a supportive and constructive manner. The real power of monitoring is realized when it is connected with feedback.

Key physician executive behavior

The physician executive's repertoire needs to include the ability to monitor, coach, and provide feedback.

4. Reward the expected behavior

While physicians are motivated by the inherent nature of clinical work, they also need to be acknowledged and rewarded when goals are met.

Key physician executive behavior

The capacity and willingness to deliver timely and appropriate rewards, while recognizing the work of all physicians.

5. If all else falls, try discipline

Discipline is the last ditch attempt to influence a physician. The ante is raised and physician executives need to clearly communicate that a negative consequence, like termination or supervised practice, will be imposed dependent upon the individual's behavior.

Key physician executive behavior

Demonstrating courage in the face of adversity, in the spirit of preserving the organization's integrity and all that it represents.

RECOMMENDED RESOURCES

ARTICLES

Bloor, K., Freemantle, N. Lessons from international experience in controlling pharmaceutical expenditure: Influencing doctors, BMJ 1996 Sep 28;313 (7060) :818.

This article reviews policies influencing doctors' prescribing of drugs--particularly the use of budgetary restrictions, information and feedback, and guidelines--and evaluates the impact of these policies.

Goodpastor, W.A., Montoya, I.D. Motivating physician behavior change: social influence versus financial contingencies. International Journal of Health Care Quality Assurance. 9(6):4-9, 1996.

This article explores strategies for implementing clinical practice guidelines based on the various factors that influence physician behavior and recommends a direct behavior management strategy based on financial contingencies.

Jogerst, G.J., Kligman, E.W. Editorial: what influences physician practice behavior? Archives of Family Medicine. 5(9):455-6, 1996 Sep.

An editorial on what influences physician practice behavior.

Lassa, J. Comparing physician outcomes and influencing change. Healthcare Information Management. 10(l):17.22, 1996 Spring.

An urban medical center uses outcomes data so that physicians can compare their performance with that of their peers. There is a physician demand for this data, and the benefits of constructive use justify the effort.

Leider, H.L. Influencing physicians: the three critical elements of a successful strategy. American Journal of Managed Care. 4(4):583-8; quiz 591-2, 1998 Apr.

This article describes the challenges inherent in influencing physicians and reviews the essential elements of any successful strategy for achieving physician support and participation.

Reece, R.L. Changing perception: an interview with Charles E. Dwyer, PhD. The Physician Executive. 25 (2):51-5, 1999 Mar/Apr.

This interview with Dr. Dwyer explores solutions for changing the perceptions of today's beleaguered physicians and how to influence them.

BOOKS

Gallup E. Slayton C. How Physicians Can Avoid Surrender and Lead Change: Gaining Real Influence in your own Health Care Organization Before it's Too Late. Tampa, Florida: ACPE, 1997.

This extensive guide to the formation of physician organizations is at once a call to arms and the arms themselves. The authors' thesis is that physicians can seize a leadership role in the changing health care delivery system and gain an advantage for themselves and their patients, based on their experience in setting up a physician organization in Kansas City Missouri. Member price: $30.

Dwyer, C.E. Shifting Sources of Power and Influence. Tampa, Florida: ACPE, 1992.

A "how-to" book on gaining and using influence in the struggle for power in organizations. The book builds on the principle that organizations are no more than collections of individuals, and it is the behaviors of those individuals that drive organizations. Dr. Dwyer shows how this organizational theory pursued intelligently can lead to influence. Member price: $20.95.

Thompson, D. Keys to Winning Physician Support, 2nd Edition. Tampa, Florida: ACPE, 1999.

Dr. Thompson has extensively updated his highly successful book to provide useful guidelines to foster the cooperation he believes is imperative for continued excellence in the delivery of health care services to the American public. Member price: $25.

CONFERENCES

Managing Physician Performance in Organizations

Faculty: Howard Kirz, MD, MBA, FACPE 

William Martin, PsyD

Sue Cejka

Timothy Keogh, PhD

This course gets down to the nitty-gritty details of recruiting and managing medical professionals, including evaluating physicians' performance and motivating them to do their best. Highlights include: why it's important to define your expectations from the beginning; feedback--it's better to give and receive; how being a "coach" can help motivate staff; and how to handle marginal performers.

4 days, 24 CME Credits.

Influence Through Effective Communication

Faculty: Timothy Keogh, PhD

Through this course, physician executives learn to use communication to boost confidence in their leadership, inspire creativity among their colleagues, and spur people to action.

2 days, 12 CME Credits.

Managing Change and Innovation in Medical Organizations

Faculty: Andre Delbecq, DBA Robert B. Klint, MD, MHA 

This course shows you how to push your organization ahead of the pack by fostering a spirit of innovation and a readiness to try new ways of doing things. Highlights include: Assessing your organization's readiness for change and innovation; contemporary and creative approaches to managing innovation; and leadership requirements and personal career impacts of rapid change in organizational settings.

4 days, 24 CME Credits.

Physician in Management II

Faculty: Charles Dwyer, PhD

Rick Brinkman, MD

Roger Dawson

Paul Tiffany, PhD

Leland Kaiser, PhD

The course is designed to equip physician executives with the skills to lead today's health care organizations. (PIM I is a prerequisite for this seminar). Highlights include: the shifting sources of power and influence among you, your colleagues, and your organization and how to influence people to do what you want them to do.

4.5 days, 31 CME Credits.

Bruce Campbell 

William "Marty" Martin, PsyD, MPH, MA, is a Clinical Assistant Professor in the Department of Health Systems Management at Tulane School of Public Health & Tropical Medicine and Managing Director of Martin Pair Consulting & Training. He has consulted with organizations like The Johns Hopkins Hospital, Kaiser Permanente, and The National Institutes for Occupational Safety & Health. He can be reached by callingat 504/988-6758 or via email at [e-mail].

1. Prochaska, J.O., Norcross, J.C., and DiClemente, C.C. Changing for Good. New York, New York: William Morrow Publishers, 1994.

2. Sperry, L. Corporate Therapy and Consulting. New York, New York: Brunner/Mazel Publishers, 1996.

3. Guillory, B. and Galindo, L. Empowerment for High Performing Organizations. Salt Lake City, Utah: Innovations International, Inc., 1994.