Get off the “high horse” in healthcare

Shahrokh Shariat | © feelimage / F. Matern
Shahrokh Shariat | © feelimage / F. Matern

A four-dimensional framework plan could help to give the transformation process a new qualitative boost – for the benefit of patients and doctors

Medical and technological advances are astonishing – and yet the healthcare system cannot always deliver on its promises. Because the hard work and best intentions of individual physicians are simply no longer sufficient to provide efficient, high-quality treatment at all times, given today’s growing complexity. Instead, a fundamental transformation is needed to put healthcare back on track – away from a system built around individual physicians to one that focuses on the team and the value and benefits to patients. 

In fact, we doctors are told that we would easily accept new organisational structures, working methods and performance targets. At the same time, we struggle daily with a seemingly endless stream of patients, constantly hearing that our efforts – no matter how much we perform – are not enough. We go through different stages of frustration to varying degrees. Many have even reached anger.

Optimism and motivation

In view of these fears, how can we as doctors best contribute to the transformation of health care? I believe it is particularly important to draw on our reserves of optimism, courage and resilience. We also need to develop an understanding of behavioural economics and social capital in order to improve outcomes and efficiency. It might be useful to follow a framework plan based on the writings of the economist and sociologist Max Weber: common goals, self-interest, respect and tradition. Perhaps we can use these motivational levers to get the doctors on board.

Patient or doctor – wrong customer focus

What exactly do managers in hospitals want from their doctors? A look at private hospitals is instructive here, as their number is increasing in response to the changing healthcare system in our country. Private hospitals expect loyalty from their doctors – such as referring most or all of their patients to their respective private institution. This increases their turnover. The administration of a private hospital sees its true “customers” not in the patients, but rather in doctors who deliver patients. Working with doctors to reduce costs or improve quality is seen as important – but is clearly less important than revenue growth.

Hospitals and physicians can no longer maximize revenues in the short term only, but must focus on a long-term strategy to both improve revenues and reduce costs – while increasing value for patients. One approach here, for example, would be to focus on a common goal.

“Change vortex” – and reward

The above-mentioned adaptation of Max Weber’s “Typification of Social Action” describes four motivational tools that can help managers to involve doctors in the redesign of the health care system. These days, many discussions about the health care system mainly deal with the problems – skyrocketing costs and fluctuating quality. In order to take away doctors’ fears of what a reorganisation of the health care system might make worse for them, we need to make clear what the reward for the – inevitable but temporary – “whirlwind of change” is: an optimised health care system for patients.

Outstanding performance must also pay off

Like most employees, physicians can also be motivated by job security. This self-interest, which is quite understandable, can be channelled accordingly to encourage commitment in various ways. In a model in the United States, I have seen that up to 20 percent of a physician’s potential salary can depend on the performance of the physician – measured by specific goals or by how they perform in and as a team. For example, urological surgeons are compensated according to how reliable their key processes are – such as various screenings or the reduction of postoperative complications. Such performance incentives aim to reward leadership skills and cooperation and to motivate everyone to work towards optimizing patient care.

In our public health care system, however, physicians receive a fixed salary – in the belief that financial incentives could potentially have negative consequences. But this could also be addressed: Some US hospitals employ doctors on one-year contracts and subject them to annual performance reviews, for example at the Cleveland Clinic in Ohio. Doctors see this not only as an opportunity to receive feedback, but also as an opportunity to consult with hospital managers about possible improvements. I am convinced that such approaches can be effective in the long term – but only if they are used to advance goals that are consistent with the common goal.

Measuring results and making them transparent 

Other possible motivational impulses include the approach of measuring results. Doctors want positive feedback and are also anxious not to lose the respect of their colleagues. Some health organisations even publish data on the individual quality performance of doctors on their websites. For doctors, in any case, the knowledge of the public perception of their performance is a strong motivation.

The University of Utah Health Care in the USA used this kind of transparency to achieve better patient evaluations. Initially, managers communicated patient evaluation data from individual physicians personally and confidentially with them. Next, the data was shared internally so that doctors could see each other’s ratings and comments from their respective patients. Finally, this information – both positive and negative – was published on the website for all doctors to see. The greater the transparency, the better the overall performance. A key to Utah’s success with this program is that it was introduced in stages, allowing doctors to get used to each stage and improve.

Identity and tradition make us proud

When doctors value their affiliation with a health organization, they try to adhere to the standards and traditions of that organization. For example, since its foundation in the 19th century, doctors at the Mayo Clinic have naturally followed its dress code – ties for men and stockings for women. The Mayo Clinic also has its own standards for how its doctors communicate with each other and how they interact with patients. The symbolic statement is clear: “There is a ‘Mayo way’ of doing things. Don’t start with us unless you’re willing to accept that uncompromisingly.”

The standards and traditions are “translated” into coordinated treatment processes that are highly valued by patients and fill doctors with pride. This is also one of the main reasons why Mayo succeeds in engaging many of her students and assistants throughout their careers.

Off the high horse, into the common boat

A sustainable transformation or reorientation of the health care system requires the willingness to gear health care services to the needs of patients. Above all, it also means the end of the status quo and its obsolete “high horse”. Of course, it will be a challenge to convince doctors to “jump on” this strategic change, especially those who have practised the old system for many years. But we cannot wait for the retirement of entire generations of doctors.

Winning over doctors – even the old guard – to this cause is a management challenge that must be tackled. If successful, their enthusiasm will be extremely enriching for the new common vision. After all, it is a fundamental concern for doctors to meet the high expectations placed on them as healthcare providers by delivering the best possible results for all their patients. (Shahrokh F. Shariat, 21.10.2016)

PROF. SHARIAT

Christina Mayer – Assistant
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