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The five stages of acceptance of quality initiatives by the medical staff.

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Consider the various reactions that physicians and other health care workers experience when trying to implement new patient safety measures.

In 1969 Elizabeth Kubler-Ross described the five stages of dying, which helped us understand and better help those who were dealing with death and bereavement.

Similarly, though with no intention of mocking the seminal work of Ross, there arc very clear stages of evolution in a medical staff when they are asked to adapt national quality standards, and to respond to a call to action to eliminate entities that have been well-entrenched and accepted as a normal part of inpatient care such as ventilator-associated pneumonia, central line bloodstream infection, etc.

There seems to be common ground in accepting change in that if you examine the reaction of the medical staff to these issues, they mimic closely the stages as described by Ross:

1. Denial

2. Anger

3. Bargaining

4. Depression

5. Acceptance

If we better understand why there is resistance to implement change that clearly brings about improved outcomes, we will be in a better position to design initiatives that invoke change in clinical processes.


The first: reaction that physicians are likely to have to new quality initiatives is to deny that a problem exists in the first place. Normally, this reaction is borne of the fact that the clinical issue meant to be addressed by the initiative was never brought to anyone's attention in the past.

A good example would be the IGU initiative to eliminate ventilator-associated pneumonia. Until this came up as a national agenda item, VAP was accepted as an inevitable consequence of long-term intubation and ventilation.

Physicians working in an ICU already are convinced that they do everything possible to prevent the development of VAP before a possible alternative is brought to their attention. They, therefore, deny that the problem can be improved upon.

The indicators that have been shown to reduce the incidence of VAP are not complex. The easiest one to comply with is the elevation of the head of the bed to 30 degrees. Most physicians who practice in a modern ICU arc aware of the data on head of bed elevation. They believe that every patient who is intubated already has the head of the bed at the proper elevation.

There is universal surprise when data are presented that show a less than 50 percent compliance rate. Denial has to be anticipated and preempted with clear, concise data that shows irrefutable evidence that practice can be improved.


The second stage of acceptance is that of an angry response to the initiative and any change in the routine of practice is likely to evoke this. This is a particularly irksome issue because it alone can be the downfall of any quality initiative unless it is proactively addressed.

Under most circumstances, no quality urinative can be successfully implemented without some inconvenience to physicians, whether it be a new form to fill out, another thing to check on rounds, another signature with date and time, etc. The requirement to do any of these new processes should be a medical staff mandate, not an administrative one.

This is where a close working relationship with the medical executive committee is invaluable. It is the opportunity to work with department chairs on issues at a high enough level such that the indisputable fact of improving patient outcome can be seen as far and away more important than the inconvenience at the sharp end.


Nothing lowers the anger barrier faster than an endorsement by one's peers.


When the bargaining stage begins, the battle is over. The war continues and will only end victoriously if you recognize and deal with the last two stages. This is not the time to let the guard down.

Bargaining begins with trade-offs. You may hear such things as "Since we started the new insulin order sheet, my rounds take a lot longer. Can you give me another week to complete my delinquent charts?"

The answer here is yes, you will be happy to take the physician off the delinquent medical record list. This is an indirect conversation between you and the physician that acknowledges that what you asked to be done is not without a price and that you appreciate the effort.

You only reach this stage when, in this example, the physician realizes that although rounds take longer to order insulin according to the literature, outcomes are better, patients are happier and the physician is no longer a length-of-stay outlier.


The fourth stage, depression, is an interesting one. It is really more related to feelings of guilt than anything else. It is subtle in the sense that it is not frequently admitted to, rarely discussed and can be fleeting in duration.

The nature of guilt is the realization that, yes, it is possible to eradicate bloodstream infections related to central lines. Why didn't we, the physicians, drive this initiative? What do you think of when you remember the family of the patient last year who died of sepsis due to an infected central line?

Changes in medicine that bring about improvement in outcome used to happen over decades and centuries. Who among us wonder about the patient who died of pneumonia because there were no antibiotics or of smallpox because there were no vaccinations? These changes occurred very slowly and the improvements were more generational than they are now.

We are demonstrating to physicians changes in their practice almost on a week-to-week basis that dramatically improve outcomes and patient well-being. If this stage is unrecognized and not dealt with in an understanding manner, the war can be lost because this is the point where a physician will realize that although he practices well, there is actually room for improvement and the thoughtful physician will ask himself: "If I was able to eliminate the threat of bloodstream infection due to central lines, what else can I do to help my patient?"

This is a seminal moment in quality improvement and patient safety that begins the self-generation of ideas and a renaissance of cooperation.


There is a palpable transformation in a medical staff that has successfully changed an outcome. Whether it is high scores in publically reported core measures, a Leapfrog survey, successful implementation of an ICU collaborative, pressure ulcer collaborative, or, simply, the reduction of catheter-associated urinary infections.


The management of implementing quality initiatives needs to be done in a thoughtful manner, cognizant of the sometime complex but manageable reaction that physicians have to change.

Robert M. Pickoff


Chief medical officer of Hunterdon Healthcare System in Flemington, N.J.

By Robert M. Pickoff, MD, MMM
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Title Annotation:Quality
Author:Pickoff, Robert M.
Publication:Physician Executive
Geographic Code:1USA
Date:May 1, 2009
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