Health Human Resources Developing a Physician Engagement Agreement at The Ottawa Hospital: A Collaborative Approach Chris G. Scott, Anne Thériault, Shaun McGuire, André Samson, Christine Clement and Jim R. Worthington Abstract The Ottawa Hospital (TOH) is focused on providing safe, high-quality care to its patients. TOH has identified physician engagement as a critical factor for improving the quality of care they provide. The physician engagement strategy developed at TOH involved a qualitative inquiry into the impediments and facilitators of engagement. Using concurrent focus groups, researchers collected and analyzed the physicians perspective regarding engagement. A systematic analysis of the verbal data was used to construct a statement of mutual understanding between the physicians and the hospital (physician engagement agreement). The process of developing this agreement is the focus of this article. Engaging physicians and clinical leadership on the organizational strategies to improve quality performance is an essential pre-condition to providing safe, high-quality care (Gosfield and Reinertsen 2008). Many hospitals have consequently adopted physician engagement as a top strategic priority. In order to gain a better understanding of the key drivers of physician engagement, Taitz et al. (2011) performed a qualitative study of 10 high-performing US hospitals. One of the six key drivers that were identified was the use of a physician compact, which has been described as a social agreement that lays out, in behavioural terms, what physicians expect to give to the hospital and what physicians expect to get from the hospital in return (Shukla et al. 2009; Silversin and Kornacki 2000). One example of success in developing and using a physician compact as a vehicle for enhancing physician engagement is the Virginia Mason Medical Center (VMMC) (Bohmer and Ferlins 2005). In September 2000, the chief executive officer of VMMC, Dr. Gary Kaplan, recruited Jack Silversin, a leading healthcare consultant, and through a collaborative and iterative process involving frontline physicians, developed a physician compact (Bohmer and Ferlins 2005). Given the differences between the Canadian and American healthcare systems, The Ottawa Hospital (TOH) explored whether such a social agreement could be developed in a Canadian context using a rigorous, replicable methodology. Research Context and Objectives In 2008, TOH set a goal of attaining top 10% performance in quality and patient safety in North America. Enhancing physician engagement was one of three fundamental strategies to achieve that goal. TOH worked in collaboration with Hewitt Associates to develop a physician-specific engagement survey. This survey was conducted and analysed by Hewitt Associates in order to provide a baseline measure and identify the drivers of physician engagement at TOH. The findings of this survey were used to inform the dialogue between the hospital and the medical staff, with a goal of a hospital-physician engagement 50 Healthcare Quarterly Vol.15 No.3 2012
Chris G. Scott et al. Developing a Physician Engagement Agreement at The Ottawa Hospital agreement. The development of the engagement agreement involved using a qualitative research methodology to gain a deeper understanding of the impediments and facilitators of engagement. The process and unfolding of this qualitative research study are the focus of this article. Methodology The research study was conducted using an approach inspired by grounded theory methodology (Corbin and Strauss 2008). The findings are based on a structured and systematic analysis of verbal data generated and collected during a full day of thematically anchored, concurrent focus groups. Participants The research participants were 44 physicians from TOH who volunteered to participate in this endeavour. The sampling procedure was akin to what is designated within qualitative methodology literature as purposive sampling (Patton 2002). People were selected because they were able and willing to contribute meaningfully to the research endeavour. In addition, the following criteria were stipulated for participants: Each must be an active physician at TOH. Each must be in a non-administrative position. Efforts were made to include physicians who would represent the diversity of the population of physicians (i.e., sex, campus, specialty etc.). The sample included physicians from the following departments: anaesthesia, critical care, emergency, family practice, laboratory medicine, medicine, obstetrics/ gynecology/newborn care, ophthalmology, psychiatry, radiology services and surgery. Twenty-seven physicians were male, and 17 were female. The physicians cumulated an average of 12 years of experience at TOH with a range of between zero and 29 years. Data-Collection Procedures Data collection proceeded through a parallel set of four concurrent focus groups (total of eight). Focus groups are ideal when addressing questions of how and what, as was the case with our study. The eight focus groups were hosted by trained facilitators to explore the issue of physician engagement. The facilitators guided each group exploration along four separate but related themes using semi-structured interview protocols (see Appendix A at http://www.longwoods.com/content/23020). The themes reflected the four core values of TOH: commitment to quality, working together, respect for the individual and compassion. Embedded within each theme were the associated drivers of engagement as identified by the Hewitt survey. The four thematic protocols were presented separately during four consecutive one-hour blocks of group discussion. Each group was exposed to the four topics on a rotational basis within the two sets of four. A scribe was assigned within each group to keep a written record of the exchanges and disclosures that occurred. The scribe also interpreted in vivo and extracted the essential elements and meanings presented by the participants. This methodology was chosen because physician engagement strategies are known to be most effective when they arise from within the group that will subsequently use them (Heenan and Higgins 2009; Silversin and Kornacki 2000). Giving the physicians a voice in this process provides context-bound information and also encourages ownership by asking the physicians to be expert informants in their own engagement processes (Heenan and Higgins 2009). Data-Analysis Procedures Subsequent to the focus group event, researchers amalgamated responses and compiled a thorough list of all themes, examples and definitions that the scribes had noted during the focus groups. These field notes and discussion summaries (including paraphrases) constituted the research results and were treated as verbal data. The researchers performed a systematic and structured thematic analysis according to the procedures described by Braun and Clarke (2006) (see Appendix B at http://www. longwoods.com/content/23020). This data-driven analysis (as opposed to theory-driven analysis) method identifies patterns and themes across the data set. The results depict a conceptual scheme that represents the physicians perception of their engagement at TOH. The creation of the physician engagement agreement was an exercise that involved many actors and processes (described below), and the results of the qualitative analysis of the focus group data were instrumental in defining the terms of the agreement from the physicians perspective. The Report The analysis of the verbal data yielded nine major themes and 20 subthemes that were grounded in the participant responses. They were divided logically under the headings physicians perception of physicians responsibilities and physicians perception of organizational responsibilities. Examples of major themes that represented physicians perception of physician responsibilities were accountability, manifesting commitment to organization and client-centred work. Examples of themes that represented physicians perception of organizational responsibilities were fair allocation of resources, and enhanced performance evaluation and quality measures. Each of the major themes had a number of related subthemes. We conducted a validation check to ensure that our interpretation of the physicians input was accurate and that the thematic structure accurately reflected the thoughts, feelings, opinions and intentions disclosed by the focus group members. While a majority of respondents endorsed the findings of the report, several participants had modifications and specifica- Healthcare Quarterly Vol.15 No.3 2012 51
Developing a Physician Engagement Agreement at The Ottawa Hospital Chris G. Scott et al. tions to propose. In order to avoid modifying aspects of the report that reflected the common voice, paraphrases of these comments were added in italics under the relevant section. Development of the Physician Engagement Agreement The themes and subthemes that emerged from the systematic and structured thematic analysis were reviewed by two researchers. Each theme was described by a series of corresponding statements. The corollary to each statement was framed as the corresponding statement of commitment. The aggregate set of commitment statements was compiled to form the hospital s commitment to physicians. The physicians commitments to the hospital side of the agreement was developed by the CEO and Senior Management Team using the approved TOH Standards of Behaviour document and cross-referencing it with the statements of commitment derived from the physician engagement focus groups. The two sides of the physician engagement agreement were then given to a group of professional writers to ensure that the document met plain language requirements and was written in a way to be inclusive of the general principles identified as important by both the hospital administration and TOH physicians. Gaining Approval In early September 2010, a draft of the Physician Engagement Agreement was circulated to the 44 physicians who participated in the focus group sessions. Their feedback was incorporated into the draft document, and it was sent for review by the Medical Advisory Committee and Senior Management Team. Subsequently, the draft agreement was sent to all 1,183 TOH physicians for review (see Appendix C at http://www.longwoods. com/content/23020). Physicians were asked to forward any feedback on this document to their department or division head, the chief of staff or the president of medical staff or directly to medical affairs. All feedback was reviewed and minor modifications were made; once complete, the agreement was sent to the Medical Advisory Committee and Senior Management Team for Figure 1. The Ottawa Hospital Physician Engagement Agreement 52 Healthcare Quarterly Vol.15 No.3 2012
Chris G. Scott et al. Developing a Physician Engagement Agreement at The Ottawa Hospital final approval. The approved Physician Engagement Agreement (Figure 1), signed by TOH president and chief executive officer, was mailed to all physicians for signature. Discussion TOH s physician engagement strategy consists of several separate but related components, including accountability, physician performance measurement, physician leadership development, enhanced communication and values alignment. The accountability and performance measurement strategies were developed alongside the engagement agreement. For additional information regarding physician accountability and performance measurement, refer to the article by Forster et al. (2011) titled Improving Patient Safety and Physician Accountability Using the Hospital Credentialing Process. Identifying, understanding and agreeing on the roles of the hospital and its medical staff are essential steps in improving quality of care (Gosfield and Reinertsen 2008). The aim of developing the engagement agreement was to align the values of the physicians and hospital administration. It is used as a framework around which ongoing dialogue on quality improvement between the hospital and physicians is based. By using a rigorous approach to collect and summarize physician input, TOH ensured a fair and accurate representation of the physicians and administrative expectation sets. In addition, the very process of engaging physicians in the development of the agreement fostered collaboration, transparency and respect. Physicians at TOH repeatedly expressed their gratitude for the opportunity to participate and disclosed a renewed sense of ownership for the quality agenda. This approach has its limitations. The proposed construct solely addresses the relationship between physicians and hospitals as organizations. It does not address the relationship between physicians and other stakeholders within the care environment. Finally, the agreement, a hospital-wide statement, must be broad enough to be inclusive of all specialties. This general document does not replace the need for more specific policies and procedures that are founded on aligned values between physicians and hospital organizations. At TOH, physician engagement is a key element of a multifaceted strategy geared toward improving quality of care within our institution. This research process was conducted within the context of that broader strategic initiative in order to assess a baseline value and gain a deeper understanding of the impediments and facilitators of physician engagement. This statement of aligned values forms the underpinning of other strategic interventions designed to address the themes identified during this process. Both the process and the end product represent a concerted effort to include the physician voice in the development of a strategy that joins ongoing efforts to enhance physician engagement at TOH. References Bohmer, R.M.J. and E.M. Ferlins. 2005. Virginia Mason Medical Centre. Harvard Business School Case Study. Boston, MA: Harvard Business School Publishing. Braun, V. and V. Clarke. 2006. Using Thematic Analysis in Psychology. Qualitative Research in Psychology 3: 77 101. Corbin, J. and A. Strauss. 2008. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory (3rd ed.). Thousand Oaks, CA: Sage. Forster, A.J., J. Turnbull, S. McGuire, M.L. Ho and J.R. Worthington. 2011. Improving Patient Safety and Physician Accountability Using the Hospital Credentialing Process. Open Medicine 5(2): E79 86. Gosfield, A. and J. Reinertsen. 2008. Finding Common Cause in Quality. Physician Executive 34(2): 26 31. Heenan, M. and D. Higgins. 2009. Engaging Physician Leaders in Performance Measurement and Quality. Healthcare Quarterly 12(2): 66 69. Patton, M.Q. 2002. Research and Evaluation Methods (3rd ed.). Thousand Oaks, CA: Sage. Shukla, S., L. Meyer and D. Stingl. 2009. Physician Compact: A Tool for Enhancing Physician Satisfaction and Improving Communication. Physician Executive 35(1): 46 49. Silversin, J. and M.J. Kornacki. 2000. Creating a Physician Compact That Drives Group Success. Medical Group Management Journal 47(3): 54 62. Taitz, J.M., T.H. Lee and T.D. Sequist. 2011. A Framework for Engaging Physicians in Quality and Safety. BMJ Quality and Safety. DOI: 10.1136/bmjqs-2011-000167. About the Authors Chris G. Scott, BSc, MA, MHA, is a senior business analyst in the performance measurement department at The Ottawa Hospital, in Ottawa, Ontario. Mr. Scott s focus is on organizational performance, specializing in stakeholder engagement. Anne Thériault, MEd, PhD, is an associate professor in the Faculty of Education, Department of Psychology, at the University of Ottawa, in Ottawa, Ontario. Dr. Thériault is a practising psychologist. She also teaches and conducts research in the domain of counselling psychology. Shaun McGuire, BSc, MD, MBA, CCFP, FCFP, is medical director of medical affairs at The Ottawa Hospital, and an assistant professor in the Department of Family Medicine, University of Ottawa. André Samson, PhD, is a professor in the Faculty of Education, Department of Psychology, at the University of Ottawa. Dr. Samson teaches in the field of career counselling. Christine Clement, BScN, MA, is the director of medical affairs and patient advocacy at The Ottawa Hospital. Jim R. Worthington, MB, ChB, is the senior vice-president of medical affairs, quality and patient safety at The Ottawa Hospital. He was an emergency physician, who moved into formal management position, now focused on improving quality and patient safety through physician engagement and many other strategies. Dr. Worthington can be reached at 613-761-4203 or by e-mail at jrworthington@ottawahospital.on.ca. Healthcare Quarterly Vol.15 No.3 2012 53
Health Human Resources Developing a Physician Engagement Agreement at The Ottawa Hospital: A Collaborative Approach Chris G. Scott, Anne Thériault, Shaun McGuire, André Samson, Christine Clement and Jim R. Worthington Appendix A. Concurrent Focus Groups Provisional Interview Guide Objectives: Capture reciprocal nature of engagement Encourage ownership of quality agenda Translate expectations and intentions into observables/ behaviour set Operationalize four principal values of The Ottawa Hospital s vision The four focus groups will have same progression of questions that are articulated around each of the four pillar values that support a quality and safety agenda: commitment to quality, working together, respect for the individual and compassion. Nature of the questions: 1. Phenomenological a general and phenomenological overview of physicians experiences of the value. What does it mean to them? How do they define it? Do they buy into it? Does it fit with who they are professionally? How are they living out the value? 2. Physician responsibilities engagement agreement; getting physicians perspectives on what would constitute indices of individual commitment to the stated value 3. Administrative responsibilities engagement agreement; getting physicians perspectives on what would constitute indices of corporate commitment to the stated value 4. Follow up on Hewitt survey tie value into the indicators of commitment identified as obtaining a modest level of endorsement by Hewitt, and get detailed and rich descriptions of their responses; expansion on the survey results to include examples and elaborations of responses and trends A Focus Group 1: Commitment to Quality 1. What does commitment to quality mean to you? How do you define this? Do you feel connected to this value? Why? Why not? represent physicians commitment to the value in their perspective? How could physicians reasonably be expected to demonstrate their commitment to this value? to the value of commitment to care? What do you expect to see? 4. The results of the survey (themes work processes, resources) show that some of the indicators that pertain to this value were not strongly endorsed by all. For example, one of the statement items was, We have effective processes to set priorities for using scarce resources. This item was not as strongly endorsed as others. Can you comment on resources and the process of resources allocation? How does management of resources impact commitment to quality? B Focus Group Two: Working Together 1. What do working together and teamwork mean to you? How do you define these? Do you feel connected to this value? Why? Why not? represent physicians commitment to the value of working together? How could physicians reasonably be expected to demonstrate their commitment to this value? to the value of working together? What is already in place Healthcare Quarterly Vol.15 No.3 2012
Developing a Physician Engagement Agreement at The Ottawa Hospital Chris G. Scott et al. that exemplifies this value? What do you expect to see? 4. The results of the survey (theme managing performance) show that some of the indicators that pertain to this value were not strongly endorsed by all. For example, one of the statement items was, The way my administrative performance is measured here makes sense to me. This item was not as strongly endorsed as others. Can you comment on performance evaluation? How does performance evaluation impact on your capacity or motivation to be a team player? C Focus Group Three: Respect for the Individual 1. What does respect for the individual mean to you? How do you define this? Do you feel connected to this value? Why? Why not? represent physicians commitment to the value of respect for the individual? How could physicians reasonably be expected to demonstrate their commitment to this value? How can you walk the talk? to the value of respect for the individual? What do you expect to see? 4. The results of the survey (theme resources) show that some of the indicators that pertain to this value were not strongly endorsed by all. For example, one of the statement items was, When we adjust our resourcing priorities, we make sure we communicate the changes effectively. This item was not as strongly endorsed as others. Can you comment on how communication is perceived? Does communication affect levels of respect? If so, how? Or The results of the survey (theme administrative management) show that some of the indicators that pertain to this value were not strongly endorsed by all. For example, one of the statement items was, Administrative management consults appropriately with physicians when making decisions. This item was not as strongly endorsed as others. Can you comment on this? How is consultation with physicians related to respect for the individual? D Focus Group Four: Compassion 1. What does the value compassion mean to you? How do you define it? Do you feel connected to this value? Why? Why not? represent physicians commitment to the value of compassion? How could physicians reasonably be expected to demonstrate their commitment to this value? What are observable signs that this value is being lived out loud? to the value of compassion? What do you expect to see? 4. The results of the survey (theme health and well-being) show that some of the indicators that pertain to this value were not strongly endorsed by all. For example, one of the statement items was, Physician health and well-being are strongly supported by this organization. This item was not as strongly endorsed as others. Can you comment on physician well-being at The Ottawa Hospital? Appendix B. Thematic Analysis Methodology Thematic analysis methodology is a step-by-step inductive approach. In the first step, the researcher becomes familiar with the data by transcribing and compiling verbal data. In the second step, the researcher identifies the most basic elemental codes that are at a higher level of abstraction than the raw data and involve some interpretative and inductive work. The codes organize the data into meaningful groups. In the third step, the researcher groups the codes together under overarching themes. These themes are then reviewed (step four) and defined (step five). In the final stages of the analysis, the thematic structure is refined and a report is written outlining the conceptual ordering (major themes, subthemes etc.) along with examples. Healthcare Quarterly Vol.15 No.3 2012
Chris G. Scott et al. Developing a Physician Engagement Agreement at The Ottawa Hospital Appendix C. Physician Engagement Agreement Development Timeline MAC = Medical Advisory Committee; SMT = Senior Management Team; TOH = The Ottawa Hospital Healthcare Quarterly Vol.15 No.3 2012