Physicians Leading | Leading Physicians

Is Improvement a Matter of Urgency?

Article · December 13, 2017

Consider this brief exchange, and how a physician leader ought to respond:

Chief of surgery at department meeting: “Our metrics around rehospitalization for the past half year haven’t gotten any better. The board quality committee asked some hard questions about medical staff plans to move the numbers, so that’s why I put it on today’s agenda.”

Surgeon: “Move it to another time. Our biggest issue has to do with the reduction in support for CME. First, it’s pressure to maintain certification, then they take away CME money. This is crazy and total nonsense. You’re going to need to do something about this.”

An experienced and wise chief won’t let her meeting be hijacked, but will steer the conversation back to the surgeons’ role in reducing rehospitalizations. Her challenge is to convey a sense of urgency for improvement that gets everyone’s attention.

Urgency isn’t the same as frenetic, uncoordinated activity — too much of which goes on already. When every test is ordered “stat,” the term loses relevance; when everything’s important, no clear priority heads the list. Urgency is a deeply felt belief that for an important priority, business as usual is indefensible; improvement is imperative. Change thought leader and author John Kotter says that if a matter is urgent, the leader doesn’t just believe that it’s important to have a key meeting on it today, but that the meeting must result in some action that moves the change effort forward in a meaningful way. Urgency means results are needed, not just activity. “When people have a true sense of urgency, they think that action on critical issues is needed now, not eventually, not when it fits easily into a schedule.”

Effective leaders don’t leave it up to individuals to draw their own conclusions about where best to focus effort — they make it clear which issues are urgent. When others are complacent, it’s the leader’s responsibility to galvanize action. A significant breakthrough for many physician leaders is the recognition that they have the ability and responsibility to raise the heat, or discomfort level, on colleagues to get their attention to move beyond the status quo. But, intentionally dialing up the heat to contribute to psychological distress isn’t a favorite activity of most leaders I know. The notion that they should be creating tension or bringing discomfort to colleagues is inconsistent with how many leaders see their role.

Too often, leaders don’t want to risk their reputation or how colleagues view them by openly discussing a scandal unfolding on their watch. In their own minds, and in the minds of many clinicians, leaders are there to protect, to inspire confidence by keeping a firm hand on the tiller. Because of that expectation, many tend to downplay errors, mishaps, reports of poor performance. When a medical group’s poor quality metrics were shown in one meeting I attended, the leader’s response was, “But in reality, we’re no worse than anyone else.” Rather than using data to risk discontent, the leader’s natural reaction was to normalize underperformance so that colleagues wouldn’t feel bad about their organization. That desire to minimize bad news is why so many change efforts lurch from start, to pause, to fade-out. If a leader can’t bring his or herself to make colleagues uncomfortable with the current level of performance, then the change effort won’t ever develop the traction it requires.

How should a leader create enough distress or pain to jump-start a change process without devastating morale or, at a personal level, jeopardizing his or her own credibility or position? How should a leader bring heat to an issue when so many already feel overwhelmed by unrelenting change and underappreciated for what they do . . . when colleagues are so close to extremis that they have neither time for nor interest in another the-sky-is-about-to-fall presentation?

While tricky, this isn’t impossible territory to negotiate; it is an essential capability that successful leaders can and must cultivate.

To start, let’s go back to the metaphorical dial; it can be moved in either direction to titrate the level of heat called for. A leader must know whether anxiety about a clinical issue is already too high and what’s needed is to dial down the stress, or whether the situation is plagued by a lack of awareness of the true urgency, in which case, bringing on more heat is the right move. Too much anxiety can cause people to block out important messages, skip meetings, become disengaged. Clinician disengagement is typically a sign that there isn’t enough meaningful light shed on an issue — but not always. One needs to understand context (is everyone distracted by an EMR implementation?) and have a feel for the level of anxiety or complacency clinicians are experiencing relative to the performance metrics that must improve.

Here are some tips on how and when to dial up or dial down the heat to bring about the desired outcome:

Dial down the heat when anxiety is too high to productively motivate change:

  • Separate distracting noise from the relevant and critical signal. Clinicians may be bombarded with disconnected messages about the need for improvement — either in overall performance or regarding a particular metric. Pulling back and disengaging is a common coping mechanism when all one hears is “this is bad; that has to improve; the hospital across town is eating our lunch.” The leader’s role is to sort out the key messages and bring forward an agenda that is doable and critically important.
  • Create headspace by taking back nonessential work. If clinicians can’t focus their attention on truly urgent priorities because they are overwhelmed, then leaders should relieve the burden of activities that aren’t essential — extend deadlines, put extra resources to those tasks, or take some items off the agenda. Some departments are overwhelmed with expectations for change because the leader can’t or doesn’t want to say “no” and manage upward to his or her superiors. Demonstrate that an initiative is urgent by resourcing it appropriately and minimizing distractions that keep others from putting effort to it.
  • Recognize the stress that everyone’s feeling. Be sincere and generous with positive acknowledgement. Too often, the empathetic arrow in a leader’s quill goes unused. Especially if demands for change from outside the department or institution are running high, and stress levels reflect this, a leader’s acknowledgement of conditions and everyone’s effort has real significance.
  • Align local and institutional priorities. Do all in your power (and manage upward to the extent possible) so that priorities are aligned up and down the organization. The lack of clear alignment and focus is often the root of stress-creating demands that are at cross purposes, that sap time and energy, and that fail to resolve truly urgent issues.

Dial up the heat to demonstrate a need to act when complacency is high:

  • Don’t rely on logic or rational arguments to generate urgency. John Kotter calls the typical approach to create urgency — explain clearly, appeal to logic, show a PowerPoint deck — “analysis-think-change.” Most leaders will try to grab others’ attention through a rational appeal. This has limited effectiveness when complacency is high. In contrast, “see-feel-change” approaches appeal to emotions and have greater appeal. Patient stories, told in person, are one example that has resonance with clinicians. Any experience or activity that allows clinicians to feel in their gut that the status quo isn’t working has a better chance of grabbing attention than solely fact-based appeals.
  • Give data emotional heft. There is a role for unvarnished data and facts. But these, too, tend to be more powerful motivators if they pack some emotional punch. The power of un-blinded performance or patient experience data lies in providing an emotional, not just intellectual, experience to the doctor looking at how he or she stacks up to colleagues.
  • Check the tendency to soften the blow when you need others to feel discontent. Catch yourself trying to soothe away urgency with statements about current performance that feel natural but where the subtext is, “I know I handed you a bitter pill so here’s something sweet to balance it out.”
  • Convey your personal belief that better performance is achievable. Creating discomfort to sharpen the need to act on an urgent need is no easy task for most leaders. Communicating your personal conviction that better performance is doable — if all work together — helps others understand your commitment.

Leaders have a critical role to play in dialing up or down the heat needed to spur specific changes to address urgent matters. Without a shared belief that action is needed and needed now, good intentions, careful plans, and arguments for change won’t get results. Focus your efforts early in the process on ensuring that others feel the sense of urgency for improvement that you do.

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