Should Orientation Be Mandatory?

You must decide if the new physician orientation will be mandatory. The penetration of your message in the physician staff will increase as orientation moves from “voluntary” to “an expectation of new physicians” to “mandatory”. The remainder of this chapter will provide an orientation which I used at St. Vincent Hospital using the Ascension Health Mission Statement. You will see easily how to adapt the story of your own hospital and incorporate your mission statement. This orientation method is designed for a small group of 6 – 15 physicians. Larger groups can be oriented with this method by creating several smaller groupings for the discussions and letting the small groups bring key points to the larger group. Smaller facilities may orient only one or two physicians each year. In that situation, the physician champion, a chaplain and a potential mentor could cover the same material during a shared breakfast. You might groom some of the physician staff to be mentors particularly for new physicians.

What to include

What should you include in the orientation? One philosophy is to provide a deluge of everything you need to know, introduce physicians to key administrators and provide access to computers and lockers. For the physician who is new to town, living out of a suitcase and confused about where to park, the deluge will only add to fear and uncertainty. Consider rather providing a few critical points of orientation: Peer contacts The story of the hospital Focusing the new physician’s personal purpose Patient’s need for purpose Resources for the new physician’s personal development and self care Resources for their medical practice

Orientation - Why Bother

You may not have an orientation program at all at your hospital; the Army has basic training. We imagine that physicians come to the medical staff completely trained because we diligently check their credentials before admitting them to the staff. Your new physicians may be completely competent in the practice of medicine, but they are rookies in your hospital, with all of the fear and uncertainty that being a rookie entails. Many follow role models from medical school and training programs. Some eagerly anticipate substantial changes in their lives as they enter practice. Other new staff physicians may have been in practice for long periods of time at other institutions. They may be joining the staff with little enthusiasm under pressure from partners. They may have served at for-profit hospitals. They may believe that expressions of faith are inappropriate in practice. Some have a strong personal faith and want to express their faith in their work. Orientation is the first and best opportunity to align their goals with the hospital mission, allay their uncertainties and find appropriate models for them.

Where to start

New physicians are the most malleable physicians on your medical staff. The work you do for them will be the most efficient work that you do as a physician champion. New physicians are an investment in the future culture of the hospital. In other words, the changes you make in your physician orientation program will bear most of its fruit in a few years.

New Place

The programs you create for spiritual formation rely partly on place. Elements of the Seton Cove Spirituality Center remind us of the magnificence of creation, the warmth of companionship, the availability of a safe haven, the presence of a greater power, and the value of our work. When you plan your programs keep the importance of place in mind. The physicians on your staff often come from the operating room, a patient’s bedside, the family consultation room crushed under a tower of problems and complaints. They have worked long hours. Sometimes their lives are severely out of balance, and they are simply ground into rubble. Sometimes you must help them find them a new place.

Filter the activities of a retreat center

Dear Readers, Please accept my apologies for a considerable gap in the posts on this blog. My wife, Suzy, and I decided that we needed to invest time in a Spanish Language immersion to facilitate our mission activites in Central America. The process was consuming and the blog postings lapsed. Continuing the thoughts from the last posting in September: Your retreat center will become popular. People will want to schedule receptions, bar mitzvahs, church retreats and weddings. Hospital managers will ask to hold planning sessions. You must hold the line. All of these activities will dilute the sacred quality of the place you build. The rule at Seton Cove is that at least 50% of the program must be of a spiritual nature. Our vice president of Mission Services, the Director of Seton Cove, the Site Manager and the Program Facilitator form the Seton Cove council and approve all programming. Build a filter like this into the charter of your retreat center.

The Kitchen

The kitchen is the center of gravity at Seton Cove. People automatically collect there. People feel most at home there and talk with greater ease. Story after story is shared around the kitchen table. People laugh and have a good time. The kitchen is appointed much like a home kitchen. Meals are often included in physician and staff programs but are not prepared in the kitchen. Catering services simplify program planning. Since the caterer’s timing is not usually precisely the program leader’s timing the oven proves valuable for keeping foods warm. In serving the needs of physicians, regard the time in the kitchen as time for them to process thoughts, teachings and discoveries from the formal program. Think of it also as a time for physicians to develop relationships with each other. In this time of increasing physician isolation, relationship building helps build healthy physicians. Therefore, the kitchen helps build healthy physicians.

Seton Cove Features

A chapel is used for worship services, mass, prayer, and meditation. A library and small, honor-system bookstore are devoted to spiritual literature. Overnight accommodations are available for up to twenty and are connected by a short hallway to the remainder of Seton Cove. The rooms are for single occupancy and include a private bath. They do not include a television or a telephone in hopes that people will not be distracted from their time of reflection. The overnight rooms are used by people who come long distances for Seton Cove programs. Small offices for most of the Seton Cove staff are tucked away on the second floor.

Seton Cove

A retreat center, especially a center directly on the hospital campus, sends a clear message to the physicians and employees that their spiritual health is important. The Seton Cove Spirituality Center at St. Vincent Hospital, Indianapolis is an excellent example and represents the vision of one of my mentors, Sr. Sharon Richardt, DOC. It was named after Sr. Elizabeth Ann Seton, the first of three canonized American saints and founder of the Daughters of Charity order in the United States. The Seton name points toward the rich tradition of the hospital and provides opportunities to tell some of the hospital story.

Seton Cove provides a sanctuary for harried health care workers, including physicians. It is set in a partly wooded area with a large pond inhabited by geese, ducks, heron, muskrat and fish. The rooms were set such that there is an excellent view through any window. The center accommodates several activities and programs. Meeting spaces are suitable for group sizes ranging from two to fifty people. The largest meeting room is equipped with a liquid crystal display (LCD) projector and a sound system. Square tables and movable chairs allow multiple seating configurations. The most common configuration is to pair the tables for six people. The room is equipped with a room divider, but it is not often used. Two smaller rooms provide meeting space for up to 30 people each. Both rooms have a television and digital video disc (DVD) player, but microphones and sound systems are not needed. Square table and moveable chairs work well in the smaller rooms also. One of the rooms was furnished with round tables and moveable chairs but is used rarely. Another meeting room is smaller yet and furnished like a comfortable living room, emphasizing two conversation circles. It accommodates twelve and works very well for small meetings and breakout groups. This and other rooms at Seton Cove have art and clearly displayed quotes that remind visitors of our faith heritage.

The Business Meeting Room

Will administrative meeting rooms become a sacred place for your physicians? Even if an important transformation occurs there, few will come to regard the room as a touchstone or a sacred space. In contrast a retreat center promotes reverence for place. You can probably rent a suitable center close to your hospital. You can acquire and convert an adjacent home into a retreat center. Finally, you can build a center. Acquisition and building are more easily justified if the retreat center is also available for the use of hospital employees. Few hospital budgets can fund the purchase of a retreat center, but other funding sources include a hospital foundation grant and interested benefactors.

Programs vs. Place

The place for educational programs is simply an auditorium or conference room with appropriate audiovisual equipment. The more spiritual the program, the more self-revealing physicians are asked to be, the more the chosen place needs to be insulated from clinical activities, including the electronic intrusions of portable communications gear. Program participants can be asked to silence their cell phones and pagers as they would in a concert or theater. A meeting room in a non-clinical area works well for spiritual, self-revealing programs. Often hospital administration offices include a suitable meeting room. It should have minimal hallway traffic, a table, chairs that can be moved, comfortable air handling, and good lighting, preferably with a dimmer switch. Projection equipment, a sound system and a window to the outside are optional but useful.

Looking for significance

Physicians have daily spiritual experiences at work but may not recognize their importance. You will have opportunities to be their rear-view mirror and help them find importance. People first experience events then put them into some context. Many times you will encourage colleagues to tell their stories and help them discover a greater context. The greater context is the one that helps the physician find meaning and purpose. When you work with a physician’s story there are two places to consider. The first place is where the event happened, because that place shapes the physician’s context. The second place is where you hear the story. You have little control over either venue but ask about the place. Questions like: “Why did that happen here?” Or: “What did it mean to you that it happened here?” For instance, an anesthesiologist who just had a dust-up with a surgeon may have a different context for the event if it occurred in the operating room, the recovery room, or the family consultation room. Ask: “Are you comfortable talking about that here in the nurse’s station? Would you prefer to grab a coffee or find an empty conference room?” The value of storytelling is far greater when the raconteur is comfortable with the surroundings.

Sacred places

We regard some places as sacred. Ground zero is one such place. An operating room, a patient’s bedside, the family consultation room can all be sacred. Our lives reside somehow in those places. They are places of significant personal transformation and commemoration. Events can make a place sacred to us, but there are places that invite an awareness of the sacred. As a physician champion begin to look for the places of invitation.

Crucial for a protege

If you have a formal spiritual formation process for your team, invite the protégé to participate as early as you can. The protégé may be eager to participate, but they may resist. Do not be discouraged. Resistance does not necessarily reflect a problem with the candidacy. Gentle inquiry into the points of resistance will help you deal with them. People nearly always will give a reason that they decline your invitation, but probe deeper. You might ask if other things about the spiritual formation process concern them. Even those with no particular points of resistance simply will require repeated, gentle invitations before they invest their time. Remember to pray for the protégés, especially at this crucial time.

Proteges Roles

Protégés can also help you recruit physicians to programs. Recruiting is a public statement that they value these programs. Such public affirmations reinforce their personal commitment to the mission. As their activity becomes public, they will be introduced to the spiritual side of many of their physician colleagues for the first time, and they will develop recognition as spiritual leaders in the medical staff. As the protégé begins to recruit, you will need to teach how to manage a database. Find one approach to database management in the chapter by that title. The database is an important tool for recruiting. It helps identify groups of physicians for targeted, personal invitations based on their expressed interest, referrals from other physicians, and other previous exposures to your programs.

The Move to Greater Involvement

The protégé will have participated in some of the programs and activities already, but now is the time to invite participation in all of the programs. Time constraints prevent physician protégés from participating in every iteration of the program, but at least one experience of each of the programs should be encouraged. After experiencing a program as a participant, the next step is to co-facilitate that program. Co-facilitating gives the protégé a chance to develop skills, learn specific programs, and build confidence as you supply modeling, encouragement, guidance and feedback.

Emerging Champion

To bring someone into this role is to mentor. Begin talking informally with possible successors. Build by inviting them to help with projects. Invite them to join a substantial dialogue with the mission team. This is a good time for team members to articulate their perception of each other’s skills and spiritual gifts. The mutual approbation of such a dialogue helps motivate candidates and increase the mission team’s cohesiveness. Conversations like this go a long way to define early team relationships which then evolve with a growing appreciative disposition. The candidate now becomes a protégé and will have many questions about what will seem uncharted territory for most physicians. The dialogue will allow other team members to answer questions and give perspective.

Methods

The budding physician champion will need methods to help physicians self-discover, renew motivation, and re-energize. He or she should be able to develop CME (continuing medical education) programs, practice meditation and prayer, become comfortable with public prayer, and learn methods of formative reading (in contrast to informative reading.) There will be calls to create presentations and speeches for larger groups. Some personal skills warrant development, too. Among them are journaling, fasting, and intercessory prayers. Skill acquisition takes time and confirms that identifying your successor is the first priority task for a new physician champion.

Listening

General medical training does not provide all of the skills that you need for this work. Listening to people is unquestionably the most important skill to develop. We might imagine that we physicians listen well and often. Instead, we use an “efficient listening style,” whereby we listen selectively to find a story that fits our diagnostic paradigm. Once we recognize an acceptable theory of disease we commonly cut short the conversation. Physicians interrupt their patients’ stories within an average of 30 seconds. To be effective in the physician champion role, listening will require a greater interest, a much greater investment of time and a realization that the dialogue itself can be therapeutic.

Key Positions

A spiritual map gives you an idea of physicians that are particularly important for you to develop. These are physician roles that require careful discernment at hiring. It is much easier to hire the right physician than to change the zebra’s stripes. As you create the map it clarifies the points of influence and where to install physicians who model the culture of compassion and mutual care.

Flow of spirituality

With baseline information from the inquiries of the last two posts you can begin to map the flow of spirituality within your medical staff. The exercise will inform your strategies for swinging the medical staff toward a new cultural goal. Some of the basics are these: The bedside care of the patient is the primary goal. Physicians who teach other physicians multiply their influence. Physicians who lead other physicians multiply their influence less strongly than the teachers. Physicians who befriend other physicians are strong influences. One might surmise that higher volume physicians will provide more spiritual care, and this is true unless they become so busy that they omit spiritual care.

New Publication

I'm happy to announce the publication of my new book, "The Physician Champion: Agent for a Compassionate Culture". It is currently available from Amazon. Go to Amazon.

I hope you enjoy it.

Spiritual Report Card

Your hospital probably already has a patient satisfaction survey that patients complete at or near the time of their discharge. Consider adding four questions:
1. While you were in the hospital, did anyone address your spiritual concerns?
2. During your hospitalization, did you feel that a greater power was at work in your healing?
3. Did you experience anything that was an affront to your faith tradition?
4. Would you be willing to speak in more detail about your experiences with a hospital representative?

Opening the Spiritual Dialogue

A few more questions may open the door to spiritual dialogue:

What role does faith play in your work?
How do you differentiate religion and spirituality?
How do you see spirituality in your work?
How do you see spirituality in the work of other physicians?
Are you spiritually nourished at work?
How does spirituality enter the hospital?
Would the hospital look different if its physicians were spiritually mature?
What would you like to see happen within the hospital to improve physician spirituality?
Given time and resources, how could you personally optimize spiritual maturity within the hospital?
What are you planning for the future?
What support would you hope for?
Can you recall stories of a patient’s or a colleague’s spiritual experiences?
What else would you like to talk about?

Some questions to ask

What is a typical day like in your practice?
As you do your work what energizes you?
What depletes you?
When you are depleted, who do you talk to?
What do you do to alleviate stress?
What inspired you to become a physician in the first place?
What parts of the hospital’s mission are most important to you?
What are the top two or three goals that you want to achieve in your practice?
How could the hospital better support you?
How could the hospital better support other physicians?
How could you better support other physicians?

Framing the Conversation

What should you talk about? You want to find out what people are thinking; avoid a monologue on yourself or what you what to accomplish. Ask questions. Ask if you may take notes or record the conversation. Questions sets will be different depending on the role of the person you interview. You might frame the conversation by saying "Our hospital is committed to the provision of holistic care, mind, body, and spirit. I am here today to acquire information that might improve our ability to meet the spiritual needs of physicians here. The purpose is to help me plan programs and opportunities for physicians. Your responses will be confidential, of course."

Conversations

If you work at a very large hospital,schedule interviews selectively. Generally, you want to hear from the administrative and medical staff leaders as well as physicians who are not in staff leadership roles. Sample from new physicians, mid-career and seasoned physicians. Sample from different specialties, and from high, medium, and low volume admitters. If you have a residency training program, be sure to talk to the program directors. You might interview selected nurses and other staff. After you have interviewed 8 – 10 people, you could plan your first programs, but continue taking vital signs until you have worked through your interview list. Non-physicians can help with this project if a large number of physicians will be interviewed.

Spirituality Map

Think about the idea of a spirituality map, try to determine what each of the interviewees represents. There are detectors, connectors, deflectors, inspectors and teachers. The inspectors are just sniffing around to see what is going on. They are not necessarily committed to cultural change. The detectors have detected or discovered life balance and practice as though they were in the culture of caring. The connectors have a wide network of social and professional contacts. They are the people who can influence many others on the staff. The teachers change the way others think. The deflectors are the resistant, slow adopters. With this in mind the spirituality map becomes a strategy map for cultural change.

Diagnostic Conversation

Plan to have many conversations. You might think that a series of one-on-one conversations is time consuming and that it diverts you from your primary goal of changing your medical staff to a culture of mutual care and mission alignment. On the contrary as you take the spiritual vital signs, the conversations will themselves express your care, model mutual care, and provide you with a map of spirituality in your hospital. I concede that this will be time consuming but assert that it will be enjoyable time, well spent. Interview the staff members in a relatively private place, like an office. People will be more comfortable and more easily available if you meet in their office.

Next Step

When The Eleven Questions screen shows a problem, you begin to ask questions. There are many questions to ask but the best place to start is with a simple question: "Where is the pain?"

What does the Assessment Tool tell us?

The Eleven Questions© are like a stool Hematest, though not so uncomfortable in the acquisition, nor so messy in the analysis. They don’t tell you what is wrong. They only tell you that something is wrong. If any question scores at 3 or less, it’s time to intervene. The kind of intervention will be determined by a deeper analysis. OK, so the analysis can be a little messy, and a consultant may help clarify the right steps to take.

Be a Follower

I promised to provide a guide to the results of the survey from my last post. Next time I will. Meanwhile, some of you readers might want to be a "Follower" of this blog. You can do that easily by clicking the link in the right sidebar, way down below the list of reading references. If you have a Google account (cost free), you can also opt to receive an e-mail whenever someone posts. You can always add your comments to any posting. I always appreciate feedback.

Thanks,
Malcolm

Medical Staff Culture Assessment Tool - The Eleven Questions©

Try this assessment. Ask simply whether the following behaviors in your medical staff are:

5 – Usually true 4- Often true 3-Sometimes true 2-Often false 1-Usually false

1.Physicians are deeply committed to the hospital mission.
2.Physicians do not experience malpractice suits here.
3.Patients receive high quality care.
4.Physicians cooperate with the hospital’s safety and quality initiatives.
5.Nurses and staff enjoy excellent relationships with the physicians.
6.Physicians honor and support their medical staff officers.
7.Hospital administrators enjoy good relationships with the physicians.
8.Physicians practice good ethics.
9.Patients are very satisfied with services they receive at the hospital.
10.Physicians enjoy good life balance with stable relationships at home.
11.Physicians support the hospital foundation financially.

Next time we will look at how to understand the results.

Medical Staff Culture Check

Each person within a culture has a unique perspective. Does your medical staff culture need some tuning? If one person thinks “yes” and another “no”, how can you decide? People make observations all of the time and ultimately develop a perception of the frequency of behaviors. Some will make accurate observations and others will have a “feel” for how often a behavior plays out. There will be pockets of subculture, too. In a large organization, culture may prove difficult to define. Next time I will give you eleven simple questions to ask members of your organization. The answers will pinpoint trouble spots in your medical staff.

Medical Staff Development - Alignment strategies

Directorship was not the answer because it focuses mission alignment too narrowly. Directorships can be effective if the directors understand how create alignment in their reports.

Joint venture was not the answer although it can be effective in creating alignment in a particular service area. However it is constructed, there will always be and “us and them” relationship. That “us and them” is a warning flag that alignment is superficial.

Exclusive contract was not the answer because those excluded from the contract are alienated to some extent by the mission.

So, the answer is “b”, physician employment. The employment approach allows alignment to occur on multiple levels in: recruiting, organization, tasking, goal setting, performance evaluation, compensation and professional development.

Was your answer different? Why?

Medical Staff Development - Alignment strategies

Quiz:
Which of these alignment strategies is most likely to align the medical staff on the hospital mission?
a. Joint venture
b. Physician employment
c. Directorship
d. Exclusive contract
Post your answer in the comments section, and I will post mine and why next time.

Medical Staff Development - Quality

Physicians take pride in quality. Once a medical staff shifts from thinking about quality as something each individual provides and begins to think about quality as a team effort, there is a subtle but important shift in pride. It becomes pride in the team. It becomes pride in the institution. In its ultimate form, the team and the institution become a community of mutual care. What about alignment strategies based on pay-for-performance? They point back to individual quality and individual performance. They point away from the team and the community. How do you move from a culture with an individual focus to a culture with a team focus? Blatantly self-serving though it is, I want to refer you to my new book, soon to be released, entitled The Physician Champion, An Agent for a Compassionate Culture.

Medical Staff Development Communications

There are so many things to communicate to the medical staff. Physicians consequently have a lot showing up on their radar screen. How do you communicate a mission message? Do you fax, tweet, blog, e-mail, snail mail or use the internet? Which of these you use depends mainly on the preferences of your medical staff. The more important issue is how you incorporate a mission message into each of these media. Keep in mind that the same banner message with each communication is the easiest approach, but it will be progressively ignored as physicians jump to the new material. Link the main idea of each message back to the mission. It will develop a mission-focused pattern of thinking for you and your physician readers.

Medical Staff Development - Social Events

Merry New Year! Now that you have survived the peak season for social events, I thought that we might look at social events as a part of medical staff development and physician formation.

Physicians assemble for social events during the year. These are opportunities to re-infuse mission goals. The hospital gala is the perfect venue to celebrate mission and relief work or charitable giving. The staff retreat is an excellent opportunity to link the hospital mission with operational initiatives. These are places where spiritual healing can occur if the programs are properly orchestrated. These are places where vision is cast. What is the vision that we are casting? What is the direction that we are going? Is it only consistent with the hospital mission or does it drive the mission?