Home The Quarterly 2012 Clinical engagement: Change the language, change the outcome


Clinician Engagement: Change the language, change the outcome Print E-mail
The Quarterly 2012

A number of recent experiences in a variety of health organisations have caused me to reflect on aspects of clinician engagement. The last decade has spawned considerable discussion and research on this topic. The use of “clinician” as a generic term encompasses all health professionals, but we know we are talking primarily about doctors as there is no point in engaging all of the other clinicians if doctors are not part of the equation. In health services, doctors determine most of the costs are able to effectively sabotage strategy and can make the most noise and media impact, so clinician engagement activities need to be focused here.

Surely this is a worthwhile strategy? Surely if we work assiduously at engagement it will deliver us the holy grail of the efficient, effective, high quality care, safe health service that we are seeking? Surely if we spread leadership education to all doctors, they will take up the baton with enthusiasm and become true organisational people? That’s how the theory goes, so why hasn’t it happened after a decade of talking and trying? Why is it so difficult?

From executive management’s point of view of course, it’s “them”. “They” are difficult. They won’t toe the line. They won’t attend the important meetings even though they are invited. They don’t manage their departments well. They don’t control costs. They don’t care about the health service as a whole. It’s a common litany of complaints about how difficult and unyielding doctors are.

From the doctors point of view it’s also “them”, but a different them. It’s executive management. “They” don’t understand how we manage patient care. They only care about the bottom line. They only invite us to meetings in a tokenistic way as the meetings are always at the time of clinic or operating theatre sessions. They don’t provide us with appropriate data so we can manage our costs. They don’t really care about our opinion.

So we have our parallel universes. And yet patients still receive quality care, often not as efficiently or effectively as possible but nevertheless, from a professional and clinical point of view, care on the whole is safe and appropriate. Executive management believes it is genuinely trying to engage with doctors and being knocked back. Whilst doctors continue to be unaware of, or unwilling to accede to, the overtures that management is trying to make.

Applying first principles

To try to make sense of this situation it is worthwhile going back to first principles. What is engagement? What drives engagement? Do we really understand what it is we are trying to do and what outcomes we want to achieve?

True engagement is emotional as well as intellectual. An engaged employee cares about the future of the organisation they work in and is prepared to invest discretionary effort into the organisation. They do not come just to do a task but to be part of the organisation and contribute to its success. They do this because they are emotionally invested in this success. They want to work in an organisation they are proud of.

Considerable research on drivers of engagement has identified a variety of factors, some of which are particularly pertinent to doctors in health services. These include:

  • Perceptions of the ethos and values of the organisation
  • Regular feedback and dialogue with superiors
  • Quality of working relationships with peers, superiors and subordinates
  • Effective internal communications

    These drivers provide the key to engagement or in reality provide the key to why using the term “engagement” can actually work against a health service trying to get doctors to invest emotionally and intellectually in its success. The drivers clearly identify that this investment is a two way process. This means a partnership where if the health service wants doctors to invest, then the health service must in turn demonstrate that it also invests both emotionally and intellectually in its medical staff. This is not a one-way street, where one engages doctors so that they will do whatever the health service wants. There are responsibilities and obligations on both sides and a partnership should develop based on trust. This latter is what is most often missing and this is what stymies the engagement process. In this way, the drivers are often negative and work against a true partnership.

  • Perceptions of the ethos and values of the organisation

    All health services have developed values. They sit in the annual report, or up on a wall. They may have been developed collaboratively with staff. However, very few health service organisations use these values consistently to underpin decision making and strategy. In some organisations decisions appear to be made in clear contradistinction to the values. As a result of this, medical staff have a perception that executive management is hypocritical. They often feel that the only thing important to executive management is the bottom line or maintaining good relationships with government. They see this as working against good patient care. This has an impact on trust between executive management and medical staff.

  • Regular feedback and dialogue with superiors

    Often the organisation does attempt to consult medical staff, but only does this when there are strategic decisions to be made. There is the lack of an ongoing open dialogue that builds the relationship and engenders mutual trust and respect. Building the relationship assists with understanding each other’s issues and problems and assists with more willingness to be flexible with, for example, meeting times on both sides when significant input is required from medical staff.

  • Quality of working relationships with peers, subordinates and superiors

    In health services, relationships with peers and subordinates are usually robust, although this is not always the case, when strong individuals come together in one unit. Nevertheless, these are usually the strongest relationships for medical staff. However, for the reasons given above, for senior medical staff in particular, relationships with superiors may be strained, particularly if superiors are not medical. Again lack of trust and mutual respect contribute to this.

  • Effective internal communications

    Emotional and intellectual investment depends on knowing what is happening in the health service organisation and understanding how it impacts on individual doctors and patients. Internal communication also helps medical staff to understand the constraints and pressures that affects the health service and executive management. Poor internal communication can be highly detrimental with mixed messages and misunderstandings that alienate doctors and confirm their views about perceived organisational values and executive management’s underlying agenda. Successful communication with doctors is a complex issue as it requires many different approaches to capture a critical mass of the workforce. This takes consistent and continuous time and energy that management is not always prepared to invest.

Changing the language
It is clear that the underlying barrier to building a partnership is a lack of mutual trust and respect. Using the term “engagement”, I believe strengthens this barrier by confirming with executive management that although getting the doctors engaged means some work on their part, this small amount of involvement should satisfy medical staff and bring them fully on board with organisational goals. Once this happens, health service management may believe that their work is done and that from now on the medical staff should continue to maintain their involvement.

However, if the language is changed to “building a partnership”, this completely transforms the way that we look at relationships within the health service. Partnership means that we work together for the greater good. There is no partnership without:

  • Mutual trust and respect
  • Clear common goals where both partners work together and support each other to achieve these
  • The culture of the organisation providing the context in which these mutual obligations and supports can flourish
  • Continuous nurturing from both partners to maintain mutual trust and respect

Medical staff perceptions are that they can perform the task they see themselves employed for i.e. the provision of good patient care, without any real involvement with the health service as a whole. As most senior medical staff in health organisations throughout Australia remain part time or visiting, it is usual for them to complete the task then move on to another work place. To some extent, medical staff are comfortable with this. It is less distracting to focus on what they enjoy and where their areas of competence lie. Most will not feel that they are an integral part of a partnership unless they are actively and continuously involved in health service matters by management, so that trusting relationships develop and continue. If we remember that as well as being professionals medical staff are also human beings who want to feel valued and respected, then partnerships can be fostered for the benefit of the health service, the medical staff and management. In those health services, where management continuously works on this, I have seen partnerships develop, but they remain fragile unless continuously nurtured.

Building partnerships

There are numerous barriers to building partnerships in health services and these have prevented the overall engagement strategy being successful. Barriers include:

  • The time and investment needed on both sides to strengthen relationships, particularly by executive management which has the most to lose if doctors are not on board. Meeting organisational goals is more difficult without doctor involvement.
  • The rapid turnover of executive management in many health service organisations, so that even if the relationship building process begins, it is interrupted by personnel changes and must start again.
  • A lack of understanding by management that to engage doctors, a clear value proposition of “what’s in it for me” needs to be developed. There is no overriding need for doctors to get engaged as they can still look after their patients competently without engagement. Indeed, getting involved means taking time that they could otherwise spend on direct patient care.
  • The laissez faire way that we orientate senior doctors to our health services, enforces the message that we just want them to do the task that they are employed for. Even then, we rarely define the task well and assume that they know what is needed. We take a lot of time ensuring that they are fit and proper professionals to work in our health service, but no time to really integrate them into the health service and make them feel valued participants in care and service delivery.

So to engage our medical staff, we first need to engage our executive managements. We need our non doctor management colleagues to admit that a good health organisation cannot become an outstanding health organisation unless doctors are fully involved. We need to include in this that getting doctors invested in the success of the health service will impact on the bottom line. There needs to be a genuine effort to get to know medical staff as people and to respect them not just for their professional expertise but for the other qualities and skills that they can bring to a health service. Individuals will all bring something different and management will not know what this is unless they build the relationship and find out. This needs to be a genuine effort and it needs to be ongoing, respectful and consistent. It needs to involve listening to medical staff members’ views and being prepared to be flexible. Over time, this will be repaid by the medical staff as partnerships are built and medical staff invest emotionally and intellectually in the organisation’s future.

In parallel with this, medical staff need to be treated like all other staff in relation to orientation to, and integration with, the health service at the time of initial employment and throughout their employment. This will require Medical Administration to work with department and divisional heads to develop systems that support senior doctors to feel part of the whole health service and to find discretionary time for contributing outside their hands on professional tasks. Developing these systems at grass roots level, will act as a protective mechanism where changes in executive management occur and the partnership at this level needs to be rebuilt.

Like any other investment in business, the strategy needs to clearly define outcomes, be carefully planned, comprehensively implemented and continuously evaluated. Like any other business strategy that is worthwhile, development and implementation will be challenging and time consuming with many hairpin bends along the road that will need to be carefully negotiated. However, without executive management taking the lead, partnerships will never be built. And, without the influence of RACMA Fellows in positions of authority in health services, there is less likelihood that executive management will understand why building partnerships with doctors is so important and the best ways and means to achieve success in this.

So if we really want to get the best out of medical staff in health services, we need to change the language that we use. We need to stop talking about engagement with its connotations of a one way process and work on developing, implementing and nurturing partnerships based on mutual respect and trust between those who lead health services and the doctors who deliver key services to patients.

Dr Lee Gruner
Chair Education and Training Committee