Starting a new column in a monthly publication has been a strange experience. This second column, written without the benefit of any feedback from you, my physician colleagues, has been a far more difficult undertaking than last month’s maiden effort. I realized that espousing the importance of measurement is good, but how can that effort be undertaken that effort if you are not the boss or if measurement driven change would not be welcomed in the ED? Recent publications offer new insights into transcending both of these barriers to improvement.
Sometimes, we find ourselves charged with the responsibility for solving some problem but without the authority to proceed. Frustrating! Issuing direct orders won’t solve the problem; people will look at you as if you’ve just grown another head. Perhaps administration in preparation for an upcoming JCAHO survey — especially now that medical errors are in the news — has said all physicians’ must write their charts and prescriptions legibly. You know you would stand a better chance of having your neighbor’s cat roll over on command. In this situation, negotiation specialist Roger Fisher and his colleague Alan Sharp (Getting It Done: How to Lead When You’re Not in Charge, Harper Business, 1998) suggest a model of “lateral leadership.”
Messrs. Fisher and Sharp detail a five-step method that anyone can apply, thereby becoming a “lateral leader.” Establishing goals, thinking systematically, learning from experience (while it’s happening), engaging others, and providing feedback seem intuitive on first reading. In practice, rather than giving orders as if some distant leader from above, engage colleagues as partners right at the scene of the work. Applied consistently to meetings or projects, this will enhance the likelihood of successful accomplishment of the project.
As an example, if you’re not the boss, why would your feedback possibly matter to a colleague? We’ve all heard the expression, “You catch more flies with honey than with vinegar.” Appreciation, simply and genuinely expressed, is always valued. So, too, will helping a colleague get his point across by asking a feeling question: “How do you feel about doing it this way?” Genuine appreciation and support of a colleague will pay dividends later.
A new approach may be remarked upon or distrusted at first, but just as a new hair style is accepted in time, so too will a new way of working with colleagues — if you persist.
Yet, perhaps the ED isn’t ready for the changes precipitated by initiating measurement in support of evaluation and improvement. A recent commentary by Daniel DeBehnke, MD, (Acad Emerg Med 2000;7:282) offers a seven-step approach for organizational change. As Dr. DeBehnke observes, regardless of which model (QA, CQI, TQM, PI, etc.) the ED might adopt as a change process, the steps are basically the same and provide a worthy guide.
Begin by determining where you are, or as I wrote last month, “start measuring now.” Knowing where you stand when you start enables your later demonstration of the magnitude of your success. Deciding where you would like to be may be the mandate that’s been forced upon you — legible handwriting — or more optimistically, the consequence of your group’s effort at setting an ambitious but realistic goal.
You, whether the boss or lateral leader, will be the process champion and thus take charge of both measurement and the process change whose result you seek to measure.
Critically important, gaining buy-in to the process change is the next step. Engaging others and responding candidly to their questions and concerns will gain believers or at least quiet some dissidents. A few engaged, credible colleagues — especially those trusted by co-workers — are important to get started. Do not wait for 100 percent buy-in or group consensus; the process will never move forward. Early, credible supporters will bring others into the fold over time. Devote the time and personal attention one-on-one, early on to gain the support from opinion leaders.
Tools that support measurement and the change sought ease implementation. Examples of support tools include custom order sheets — such as a chest-pain order sheet — with boxes to check off that comply with practice guidelines. Optimizing physician charting is easier with a laminated pocket-size card with prompts for complete dictation or a paper chart with lightly printed prompts for all aspects of a standard history and physical examination. A charge-nurse end-of-shift report form can simplify measurement when solving problems of admitting patients to the hospital is the focus of the effort. Support tools make it easier for even a naysayer to participate while maximizing measurement and supporting change.
Giving feedback both to the group and to each individual is not sufficient. Specific advice on desired behavior change must be suggested. Most physicians believe they understand what is required, but results will improve if colleagues are engaged and everyone learns from experience by providing specific suggestions for an alternative action.
For example, I always go back to a referring physician after a patient complains that his physician told him, “The ED should have … [done something different].” I always listen to the physician, hear what he has to say, and encourage him to call me the next time, even page me if it’s an odd hour rather than complain to the patient about the ED. I tell them, “The patient can’t fix the problem in the ED, but I can if I know about it. Also, if you complain to me and I don’t fix it, you can complain about me to the hospital CEO.”
Make certain to re-evaluate the results. Measure more than once before deciding whether the goal has been accomplished or must still be tweaked. Accomplishing a goal of changing the organization or colleagues in a particular direction requires re-evaluation of progress and reinforcement of the desired behavior. Change in the emergency department and the physicians who work there is an ongoing constant, or should be. “Even if you’re on the right track, you’ll get run-over if you just sit there,” said Will Rogers.
Whether measuring and improving something about the emergency department or something about the practitioners who work there, effecting lasting change requires both constant effort and a multi-factorial approach. A systematic process for changing the ED and the application of lateral leadership can help achieve goals, without turning the leader into a two-headed monster in the eyes of colleagues.