The problem in many places is that the expectations and demands made on doctors, increasing accountability and requirements to work in more organized and systematic ways has challenged the basis of their traditional relationships with the hospital. The privileges that doctors had enjoyed including a high level of freedom, protection from the rigors of the market and toleration of behaviours not permitted in other staff have been gradually under attack. The old deal has been replaced without any explicit conversation and across the world this has been manifesting itself in discontent amongst many doctors. The antidote is to openly discuss what’s changing and why with physicians, then creating a shared vision that truly has meaning and, also jointly, defining a new and explicit deal that supports both the organization’s success and physicians’ professional pride and satisfaction. This approach is based on research on the idea of the psychological contract adapted for healthcare by Amicus Inc.
Gary Kaplan MD the president and CEO of Virginia Mason Medical Center decided to address this head on and to develop a new ‘compact’ between Virginia Mason and the physicians who worked for it. The initial reason for this was a period of financial challenge leading to Gary’s appointment as CEO and the development of a new vision and strategy for the organization.
How it led to productivity improvement
The first phase consisted of interviews with physicians by Jack Silversin of Amicus. Dr. Kaplan says, Jack quickly uncovered that a big part of the frustration our doctors were feeling was their sense that Virginia Mason was not the same organization they had joined. The deal they had been promised – and that they had enjoyed – was, in their eyes, violated.
A retreat was organised for the physicians and managers. Gary identifies this as a key turning point. Helped by a long serving physician leader the staff took time out to think about the issues. Dr. Kaplan says ‘They candidly talked about the old deal which was characterized by autonomy, protection and entitlement. And, they shared their sense of loss and frustration. There was actual mourning for the aspects of the past that were not going to come back. I know that the emotional catharsis that some – not all – experienced during the retreat had a huge impact on readiness to move forward. The group that attended the retreat (most of the medical staff) brainstormed some elements of what a new compact should look like.’
The next phase of compact development took more than six months. First, a group was set up to take the idea forward. This was a broad group of enthusiasts and skeptics. The CEO joined the committee but was clear that he did not want his comments to influence others. His role was to help ensure that the “asks” of the organization were not going to be outside the scope of what the organization was prepared to give.
Department meetings were held in which the draft compact was vetted, discussed and improved. Feedback from many meetings was collected and a second draft went out for more discussion. This happened through the Spring of 2001. It was summer by the time the compact was finalized and shared with all physicians in departmental meetings.
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Dr. Kaplan says: ‘Was there resistance to this new set of reciprocal expectations? Less than one would anticipate. If we had come out of the retreat and circulated the draft that emerged as a done deal I guarantee there would have been pushback. In the end, a very small number of doctors did leave our organization because they didn’t agree with the idea of such clear cut expectations or didn’t like what it obligated them to. My entire career had been at Virginia Mason Medical Center so seeing physicians leave on my watch wasn’t easy. But if the match between our expectations and an individual physician’s isn’t a good one, everyone is better off when that physician chooses to practice elsewhere. The culture that has evolved out of our compact is helping all our improvement efforts to succeed.
Dr. Kaplan reflects that ‘looking back it is fortunate that we undertook the compact work when we did. It preceded our learning about Toyota Production and I believe is a significant contributor to the progress we’ve made in adopting our Virginia Mason Production System. One key lesson for me is how essential transparency is in all that we do. It’s critical to know your current state so you can improve any value stream or process. And being absolutely transparent regarding what physicians can expect of VMMC and what, in turn, is expected of them is the only way to succeed and have physicians who are professionally fulfilled and contributing 100% every day.
Last, the Japanese word, “nemawashi” captures why our compact work has been successful. It means “tilling the soil” which was taking the necessary time to have deep conversations. The reflection we did and the compact change that resulted has allowed us to move further and faster than we otherwise could have. The compact has proved to be an extremely useful way of aligning physician behavior with what the organization needs from them to achieve our shared vision – “to be the quality leader and transform health care.”
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Virginia-Mason Medical Center Physician Compact
- Recruit and retain superior physicians and staff
- Support career development and professional satisfaction
- Acknowledge contributions to patient care and the organization
- Create opportunities to participate in or support research
Focus on Patients
- Practice state of the art, quality medicine
- Encourage patient involvement in care and treatment decisions
- Achieve and maintain optimal patient access
- Insist on seamless service
Listen and Communicate
- Share information regarding strategic intent, organizational priorities and business decisions
- Offer opportunities for constructive dialogue
- Provide regular, written evaluation and feedback
Collaborate on Care Delivery
- Include staff, physicians, and management on team
- Treat all members with respect
- Demonstrate the highest levels of ethical and professional conduct
- Behave in a manner consistent with group goals
- Participate in or support teaching
- Support and facilitate teaching, GME and CME
- Provide information and tools necessary to improve practice
Listen and Communicate
- Communicate clinical information in clear, timely manner
- Request information, resources needed to provide care consistent with VM goals
- Provide and accept feedback
- Provide clear compensation with internal and market consistency, aligned with organizational goals
- Create an environment that supports teams and individuals
- Implement VM-accepted clinical standards of care
- Participate in and support group decisions
- Focus on the economic aspects of our practice
- Manage and lead organization with integrity and accountability
- Embrace innovation and continuous improvement
- Participate in necessary organizational change
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The process of developing an explicit compact is facilitated when the following conditions are in place:
- Sufficient trust between doctors and administrators to be able to have candid conversations
- Education for doctors about market and economic changes that are driving the need to change the way health care is delivered
- Development: wide and deep ownership of a shared vision – a picture of where the organisation is heading – that resonates with all
- A guiding coalition or committee that can champion a compact change process with the physician body
- Sufficient patience to allow a process that touches every doctor – NOT a “roll out” from senior leaders
- Ample time for doctors and administrators to engage in dialogue about what behaviors are needed
- Will from the top to hold both administrators and physicians accountable for living the compact commitments once a document is created that is broadly supported
- Top leaders demonstrate they are NOT exempt but are standard bearers for new behaviors and open themselves to feedback about how their behaviors are or are not consistent with the new compact
Source: Amicus Inc. with permission
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