convince a group of people to use a new antibiotic pre-operatively to decrease surgical wound infections.

Goal: To convince a group of people to use a specific, new type of antibiotic for patients pre-operatively in order to decrease surgical wound infections.

Scenario: You are a healthcare administrator that is trying to introduce a change in practice to a group of stakeholders. Your goal is to help them understand the rationale and need for the change, and to get a sense of the areas of resistance to the change. The change under discussion is to implement a new antibiotic to be given one hour before surgery starts as a way of reducing post-op wound infections. The Centers for Medicare and Medicaid Studies (CMS) have indicated that timely pre-op application of specific antibiotics is becoming a requirement and will be a publicly reported indicator on the CMS Web site for your hospital. Thus, institution of this new procedure is something you really need to pull off.

As the administrator in this scenario, you will hear the initial responses of each of the stakeholders. You will then be presented with several options for your response. Select the option you think is most effective.

Review the stakeholders’ responses to the option you selected. According to their own perspectives and prerogatives, the stakeholders will respond in different ways to each choice. Your goal is to achieve some level of buy-in to the change.

• The antibiotic is new and people aren’t familiar with it.
• Requires administration within one hour of the actual surgery start time.
• Requires administration by IV.
• Adds a step to the busy pre-op nurse’s work load.
• Saves the hospital $28,000 per year.
• Research shows wound infections down 47% with this new antibiotic if it is administered in a timely fashion.

• Pharmacist: He’s learned about the new antibiotic through his research studies, and is excited about using it.
• Pre-op Nurse: She is worried about having one more thing added to the pre-op activities list she must complete before the patient goes to surgery, but she’s very interested in doing the right thing for her patients.
• Surgeon: He hates government mandates, doesn’t like to be told what to do, generally has a pretty good track record for his patients’ outcomes after surgery, but has no idea what his actual rates of wound infection are.
• Finance Analyst: It’s all about the money. Don’t make it harder by concentrating on anything other than the dollars.

Stakeholders’ Background Thinking

Pharmacist: I really like this idea, because this antibiotic is better and cheaper too. If we can standardize to this antibiotic, I can save money by stocking only one antibiotic for surgery. It will save my staff time in preparation also. This is a great idea for me and my department.

Pre-op Nurse: I am just worn out trying to keep up with all the changes they keep hitting us with. It’s hard enough to do my job and remember to do things differently and use different items. Why can’t they give me a break? Now I’ll have to start an IV as well as give a drug, and they are already pressuring me to get the patient ready for the OR faster. Sometimes I just want to go home!! But I got into nursing to help people, and if this really makes a difference, I guess I can suck it up.

Physician: The government makes me crazy! Those bureaucrats think they know how to practice medicine better than I do. The last thing I need is some ivory tower academic telling me what antibiotics to give! I’ve been doing this for 30 years, and I know what works and what doesn’t. The stupid hospital better shut up and let me do what I know is right and stop telling me how to be a doctor. My patients like me and that is what counts. I’m sure voting Libertarian in the next election!

Financial Analyst: I have been tasked to save this hospital hundreds of thousands of dollars this year, and this one change will save us a bundle. Why are they all arguing? This change could save their jobs! Don’t they get that it’s all about the money? I wish they’d just shut up and approve the change so we could go get lunch.

First Responses of Stakeholders
• Pharmacist: “This is really important. All the research on this new antibiotic shows that it makes a big difference in reducing wound infections. We could get our rate from 13% presently down to 2%. We need to do this.”
• Pre-op Nurse: “This is going to take much more time. We’ve always been able to give our patients pill antibiotics, and now you want me to have to start an IV and administer the drug that way? What happens if I give it and the surgery is delayed? There is already so much I have to do to get the patient to the OR.”
• Surgeon: “What a bunch of horse hockey! I’ve been using the same antibiotic for 25 years and its fine. No need to make silly changes just to keep the government happy. What do they know about medicine anyway? All they want to do is make us follow some stupid ‘cookbook’ and it’s ridiculous. They should just leave all that up to the doctor.”
• Finance Analyst: “It saves money. Just do it.”

Administrator’s Response Options
Select one:
1) “Well, we have to do this because it’s a government requirement.”
2) “You all raise valid points of concern. The evidence shows a significant benefit to our patient care.”
3) “What could be done in the implementation that would relieve some of your worries?”

Responses to Option 1
Pharmacist: “We can make this switch as soon as you are ready.”
Pre-Op Nurse: “We’ll have to tell the patient to come in four hours before the surgery to do this. What a pain.”
Surgeon: “The heck with this. You can’t make me do it.”
Finance Analyst: “It saves money. Just do it.”

Responses to Option 2
Pharmacist: “There is a real benefit. Surgical site infections drop like crazy. It’s the right thing to do.”
Pre-op Nurse: “I want to do the right thing. If Pharmacy can get the drugs up to the unit in the morning, maybe I can start the IVs faster.”
Surgeon: “I’m all about patient care, but why can’t I use what I’ve always used?”
Financial Analyst: “It saves money. Just do it.”

Responses to Option 3
Pharmacist: “It would help me to know how many drug doses to stock in the OR each morning so I can make sure they have what they need on hand.”
Pre-op Nurse: “That would sure help me. We can begin by having the IVs pre-prepared so we just have to put the needle in the patient.”
Surgeon: “Can I see the data about wound infections? How do I stack up against other surgeons?”
Financial Analyst: “Great, you all see it. It saves money. Let’s do it.”

As is usually the case, it is possible to achieve some measures of acceptance of changes. The way you respond will affect your ability to do this. However, in real life, it rarely happens this quickly.

When involved in negotiations, key elements to remember include:
• Pay close attention to the reasons people give for their resistance. You will gain a better insight into their thought processes and can tailor your responses to their perspectives.
• You may have to ask questions several times to dig into the real reasons why people may oppose something. The opposition sometimes can be driven by fears and anxieties, but those are not usually expressed initially. However, if you keep asking questions and listening carefully, they will begin to emerge.
• Once you have a sense of the perspectives of the various stakeholders about the change, you can begin to address them and use them to overcome any objections to the change.
• Sometimes the best you can get in the initial conversations is a willingness to move away from “I’m not gonna.” to “Let me see the data.” That’s a big step toward willingness.

Based on this initial scenario, develop an implementation plan. It should include:
• The administrator’s initial statement of what is being implemented and why.
• (Review the stakeholder’s background thinking and first responses.) The administrator’s (your) response option choice.
• How to communicate with the stakeholders (especially if they need further convincing).
• What evaluation criteria are needed?
• Time frames.
• Other items you think would be valuable to include.

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