Breaking Barriers: Communication with a Resistant Audience
Christin Pritchard, RN, BSN and current UIC health informatics graduate student speaks on how effective communication can help implement health systems when dealing with a resistant audience.
Introduction
CP: So basically, I just want to start out with a little story. Everyone has heard the saying “you can’t teach an old dog new tricks.” I believe that this often relates to older people, and they refer to that often when talking about new technology. One of the challenges that we face as health care or IT professionals is how to effectively communicate the benefits of technology to a resistant audience.
I wanted to share a success story with you that we recently experienced. Dr. James ? is a 76-year-old provider at the Heatlh system that I work at. One day he walked up to me and said “Christin, how can I do electronic documentation? I want to learn how. You know, if only all people felt this way. Communication with a wiling audience is much easier to do, no matter what the topic, communicating with a resistant audience can be extremely difficult.
Slide 1
So today, I’m going to talk about how to break barriers with a resistant audience. A little about me. I’m in the Master’s of Science in Health Informatics program at University of Illinois Chicago. My anticipated graduation date is in the Spring of 2013, and as I mentioned before, this presentation was put together for Communication Skills in Health Informatics. I graduated from Illinois Wesleyan University in 2006 with a Bachelor’s Degree in Nursing. After graduation, I took a job at Proctor Hospital in Peoria, Illinois and I worked on the floor there for about eight months. After that eight-month period, I took a charge nurse role on the Orthopedic/Neurology Unit, and I took that role and I was in that role for about two years.
Being the charge nurse really helped me to enhance my communication skills because I was facilitating discharges, transfers, admissions with the floor staff, administration, case management and then with the providers. So I really got a chance to work on enhancing my communications skills.
I currently work as a clinical analyst at Great River Health System in West Burlington, Iowa and I’ve been in this position for about a year and a half. My primary roles here are project management and to implement electronic processes and systems.
Slide 2
So here I’m just going to … here is a list of the topics I’m going to cover, and the first thing I’m going to talk about is the purpose of today’s presentation.
Slide 3
And the purpose of the presentation is just to discuss how effective communication can implement projects with a resistant audience. As I mentioned earlier, communication with a willing audience is much easier than with a resistant audience, but there are still challenges.
Slide 4
I’m going to base this off of experience, so…
Slide 5
…one thing I have been implementing is computerized physician order entry. So what exactly is computerized physician order entry? It is usually referred to as CPOE for short. CPOE is the process of entering orders electronically through an electronic health record. It has many different benefits to the patients and providers. As the providers are entering the orders, there’s drug-to-drug interaction checking; there’s drug-to-allergy interaction checking. The system can queue for duplicate orders and let them know that “It’s already been ordered. Are you sure you want to order this also?” This is an incredibly hot topic right now, as it is a requirement for meaningful use in both provider offices and eligible hospitals.
A little bit about health system statistics for us. Great River Health System has 96 active providers, so currently 32 of those providers are utilizing CPOE. We recently went live in our Emergency Department with ordering medication by the providers. With that huge task that we have accomplished, we have met the CPOE requirement for Stage 1 of meaningful use. We are currently at 50% of all unique patients have one medication order entered. That’s a huge goal for us that we’ve reached and we’re pretty proud of our providers here for complying with that.
A little bit more about the project. CPOE implementation started prior to my employment at the Health System with a pilot position in April 2009. Shortly after the pilot was… started, I was hired and part of my job description was to provide education on the electronic health records to providers and other staff. I became the lead of the CPOE project shortly after I started. To further along the project we asked for volunteers to participate with CPOE. At that point in time, meaningful use requirement wasn’t even a blip on our radar. We weren’t looking for that. We knew it was coming but it wasn’t something we were focused on.
One of the reasons that the project was different at that time is that we were working with a team of volunteers. These were people who wanted to participate. If you called them, they called you back. If you emailed them, they emailed you back. They wanted our help. It made communicating with this group of providers much easier.
Recently, we have run out of volunteers. They… It’s not something that everyone wants to jump up and do. CPOE has become a requirement for our hospital, and they’re wanting to apply for the financial incentives and reimbursement from the government through meeting the meaningful use requirements. So according to our administration, CPOE is no longer an option, but something that has to be done. They’ve seen the millions of dollars it can mean for our health care system, and attached to projects like CPOE, it’s become a huge priority.
Well, it has become a priority for administration. That does not mean that it has become a priority for the providers who will be participating with the project. And as you can tell, I’m not here to bad-talk providers. It’s just something that’s different to their workflow.
Slide 6
So, we’re going to identify who is a resistant audience.
Slide 7
According to Dictionary.com, to resist is “to make a stand or make efforts in opposition, or to act in opposition.” And so what makes a person resistant?
In my experience, a resistant audience is one that has unanswered questions, so they’re not quite sure of what’s going on. They don’t understand the process. They’re unwilling to change their current processes and they might also be fearful of process changes. As evidenced by my story at the beginning of the presentation, a resistant audience is not always an old audience. They’re not always the older people that you’re dealing with, and they’re not always people in positions of authority. A resistant audience can be a collective group of people.
So what are identifying qualities for a resistant audience? Body language is a huge one for me. If while you’re talking to them their arms are crossed, or they’re not paying attention. Are they on their BlackBerry checking their email or texting someone? What about the tone of their voice? Do they have an accusatory tone when they’re asking questions, or is the volume of their voice elevating as the conversation progresses?
And finally, negative language. Is the audience speaking poorly about the proposed changes? They’re listening to what it is that you’re asking them to do, and they’re adamant about the fact that they’re not going to do this and no one can make them. We… I encountered a few of those people in this organization, as I’m sure other people have also in other places.
Slide 8
Ok. So the next topic we’re going to are perceived barriers, and there’s two things about perceived barriers I wanted to bring up. The resistant audience may have perceived barriers, but not all of the barriers to communication are just on one side. Communication is a two-way street…
Slide 9
…so I’ve definitely identified barriers for myself in implementing this project. One of those is speaking to authority figures. Communicating to someone who is in a position of authority can be very intimidating, and until you have a culture in your organization or in your office that promotes open communication between people of all authority figures, then it’s going to be difficult. There’s always going to be a hierarchy.
Another perceived barrier for me is speaking to an unknown audience. So being new to the organization when I started the project… I’m still fairly new… I’ve only been here for about two years. I don’t know a lot of the people in the … at Great River. We have about 1,900 employees here so it’s a rather large organization. And especially not knowing all of the providers is a challenge for me. So out of the 32 providers that are currently live with electronic order entry, I have oriented 27 of them. So out of those 27 providers, I met twenty of those providers for the very first day… the very first time, the day I was orienting them. I was going to tell them how to do something and that can be very intimidating for me. And not a common occurrence for physicians… a nurse telling them what to do. This is a very big concern for me. If they didn’t know me and I didn’t know them, how effective can communication be?
And then the last perceived barrier that I’ve identified is the validity of their concerns. So implementing a process that they have very real concerns about. I’ve lived and breathed this project for the past year, and then the concerns that the providers have presented to me, they’re all true. I wish I could be able to say that this is not going to be a timely process. That there’s definitely a learning curve to implementing something electronically. I wish I could say… I wish I didn’t have to say those things to them, but it’s true and in this case when an audience has concerns that are real, it makes it much more difficult to try to overcome those barriers.
Slide 10
So next I wanted to address the perceived barriers of the audience. So “someone else is telling me what to do.” Let’s be honest. No one really enjoys being told to do something they don’t want to. I don’t like it. Probably most people don’t. It’s something that we have to do but for providers it’s a little bit different. People aren’t always telling them what they have to do. One of the things we’ve come across is multiple times is that “My colleague already told me that I won’t like this.” We’ve had multiple providers come into their first training session and say something similar to this. It’s hard to communicate with an audience that has preconceived notions of a process.
Timely. Time is a huge barrier when you’re asking people to implement a new process. And time is very valuable, not just for health care providers but for anyone. Any process that requires a big time commitment from an individual for training or for follow-up can cause an individual to be resistant to participate.
And the last barrier that I identified for the audience is change. My manager has told me many times that being a change agent isn’t for sissies. And that’s kind of our motto in here. We’re seen as agents for change in our organization and it’s very hard and it’s challenging, but we can do it. So for an audience that doesn’t like change, it’s not easy and it’s one of the biggest reasons that an audience will resist a new process.
They’re comfortable with their current routine. They know what they have to do when they wake up in the morning. They know what they have to do in their current process and they feel that they don’t need to change anything.
Slide 11
Ok. So how do we break those barriers that have been identified by myself and for the audience?
Slide 12
The number one thing I can advise people is to be prepared. Knowing the material is one of the most integral pieces to overcoming barriers in communication with a resistant audience. Looking unprepared to a group of people is something that a resistant audience will pounce on. They’ll look at that moment of weakness and they’ll say “They don’t know what they’re talking about.” You really need to understand what it is and know what it is you’re talking about for them to understand and get your point across.
The second thing that I think we can do to break barriers in communication is to be up front about project downfalls. This has been a really big success for me, especially with the CPOE project. When I have met with providers, I’ve said “These are the things that I’ve heard from your colleagues.” “This is where you might have a difficult time adjusting,” and “We realize that this is a big time commitment to you.”
Asking the audience what they’re concerned with and identifying their barriers up front is something that can really help also, and when you ask them this, … their concerns…, it gives you an opportunity to be an active listener. So listening to what they have to say is a big help to them.
And then also, clearly defining the benefits of the project. If you can do this as soon as possible, be up front about what it is that… what’s in it for them, you can have a list you can present to them and then you can talk about those things. And having open communication about those benefits.
Another thing that I’ve identified as helpful to breaking communication barriers is to use multiple types of media. For example, with this project, we have communicated at meeting with short presentations. We have sent out updates in staff development newsletters. To educate providers, we use PowerPoint as a training manual. We print off the PowerPoint for them to take home with them, and we also provide access to the PowerPoint electronically on our intranet here at the hospital.
With any changes for CPOE, we email providers routinely, and then we also send out mass communications about this project via fax. So don’t limit the media that is used. Not everyone learns the same way and you can reach a broader audience by supplying information in as many.
Slide 13
Frequently asking for questions is a huge way to overcome barriers. When you’re communicating with a resistant audience, ask questions often. What is it that they are concerned about? If you don’t have the answer, tell them that you will get back to them. If you follow up with a provider, or with a resistant audience period and say you’re going to follow up with them, you can create a huge level of… a huge trust with them. And just by following up with the things you don’t know the answers to, you’re already breaking down those barriers because you’re getting back to the. You’re addressing the concerns that they had.
If possible, involve the audience with any development. Making a resistant audience feel like they are part of the process can change your opinion of what you’re asking them to do by allowing them to provide input into the …and letting them be involved in the decision-making, they feel that they’re in more control of the process, they’re more in control of things that they might not necessarily want to do. If you can give them choices, they’ll be able to help you.
Then also, as far as communication style, being calm and collected can only help your cause. Be very understanding when audience members are expressing their concerns. Again, active listening. Use statements similar to “I hear what you are saying and your concern is very valid.” Making sure to always be positive is important when communicating with a resistant audience. And then don’t ever speak poorly about an individual. Using negative language around others is not something that makes you look positive. And you don’t want to look negative to a resistant audience.
And then timely follow-up, as I mentioned earlier. This can be an essential way to not only to be professional but to improve your relationships. If you said you would check on an answer, be sure the provider gets an answer and be reliable. It can only establish a good working relationship.
Slide 14
OK, so wrapping it up, I just want to review what we talked about for steps to effectively communicating with a resistant audience. Make sure that you identify the resistant audience and more importantly, identify barriers that you might put up as well as barriers that the audience may has presented and then use good communication to overcome those barriers.
And that’s all I have for today, so if anyone has any questions, I’d be more than willing to answer them.
Host: Thank, you so much Chris and I appreciate it. So at this time, I would like everyone to send in their questions via the chat that is available on your screen, and I’ll hold on for them for a little while. I’m not seeing any at this time.
Here we go. Here we go. Are there any printouts available for the presentation? I will be posting this on the UIC Web site, so you will be able to print out them from there.
Were you working full-time… are you working full-time during your coursework? So I guess, are you working full-time while you’re taking CP: Yes, I am. I think that this is definitely…time management is really important when you’re doing… having a full-time job and working on graduate school. I think that a lot of the professors in the program do realize that and it is something that is often addressed in your discussion boards for the classes. And it isn’t just figuring out what it is that you have to do every day. Some classes are easier than others and time management is definitely important.
Host: Ok great. How are you evaluating the effectiveness of your instruction to your groups?
CP: That’s a good question. One of the things that we do do is follow up with the providers after two to six… we do a follow-up at two weeks after they go live with this process, and we follow up with them again at six weeks and we ask for any of their feedback. And most of the providers we see I round up on the floor and when you’re training with them in a one on one environment, because that’s what we do right now, we don’t do classroom settings, we just do one-on-one trainings, you’re almost forced to develop a working relationship. And a lot of them, they feel really comfortable coming to us and talking to us if they have questions or issues. But as far as giving them an evaluation tool, we don’t do that. We do follow up meetings with them.
Host: OK. Can you give us a specific example of dealing with a passive aggressive customer that interfaces well with you but undermines your progress behind the scenes? Have you had to deal with anything like that?
CP: Uh. I’m trying to see how I can put this nicely. I think there’s one particular provider in our organization who is a big proponent for using technology in health care, and you always need one of those. We do not have a physician champion in our organization unfortunately, which is you know, too bad for us, but he’s kind of been the go-to person for that. And as far as being passive-aggressive, when he’s out, you know, when he’s talking to us one on one, he’s very positive. You know, he’s saying “Oh, I think that this is great. I wish we could do a little bit more with the functionality,” but then when he’s speaking to his colleagues, he says things like “Oh, you’re not going to like it at all.” Or “This really is a huge time commitment.” So what he says to us is one thing, and what he says to others is another.
And the ways we’ve handled that is, I’ve addressed him head-to-head. I’ve asked him “When we talked you said this to me, but I’ve heard from others that you’ve said such-and-such.” And I think that the really important thing is that you’re always honest in communication, and if you ever have someone that is like that, I’ve always felt that the best thing is to approach them directly instead of going over their head, so… that’s how we’ve handled that person.
Host: That’ makes great sense. Did you have a physician champion supporting you while you implemented CPOE?
CP: No, not at this time. It’s really kind of been …our hospital… we’ve struggled with implementing CPOE as far as organization-wide. I think we finally…. The best thing that could have happened to me in terms of this project is that meaningful use made it a requirement, that you had to have a certain percentage of meds ordered on each individual patient and now that we have the administration’s support, because they see the dollar signs, like I mentioned, and the presentation attached to achieving Stage 1 Meaningful Use, they’ve really pushed it forward. We do have an EHR committee here, an Electronic Health Records committee, and that’s comprised of IT Management staff or IT Director, some vice presidents and then we’ve got physicians on that committee and they’re the ones that are really driving this now. We’ve presented them with the plan, and they’re the ones that are pushing it out to the other providers in the organization, and that has made a huge difference. We don’t have to push anymore. It’s not coming from the IS Nurse. It’s coming from a committee of their colleagues, and that’s something that you can’t really put a value on it. It’s invaluable when you’re trying to implement something that people don’t want to do.
Host. OK. The questions are rolling in now. What are some of the common questions/concerns from the resistant audience in using technology in health care and how did you go about answering them?
CP: Sure. One of the biggest things I hear every day is that “I do not have time to do this.” You know, everyone’s busy. We realize this, especially providers. When you look at their standard workflow, they get up in the morning, they all have families that they have to take care of. They come in, they have to round on their patients and then they have to go their offices and see, you know, those patients. And then they get calls from the hospital, so how can you make this timely for them? And that’s what we really focus on in our department, is to make it as efficient as possible. So specifically with this project, what are things that we can do to make up time for the provider?
Well, one of the things is that if they get a message from a nurse at their office, they can go in electronically and put those orders in themselves. They do not have to call back to the floors, they don’t have to wait for a nurse to get on the phone to give an order. They can put an order in from their office. They don’t have to call. So that’s one thing that we’ve given them time back on. The other thing that we’ve done for this specifically is create customized order set for them, so if they know that every time a patient is admitted with chest pains, this is what they want to order, we’ve put that in an order set specifically addressing their needs and what they want to order and that’s made up a time difference, a huge time difference for them also.
But time is a real big thing that we hear with technology. And then we also have, you know, the things like “I’m not a techy person, how can I do this? ” And we actually spend a little but more time with those people who are concerned with you know, their underutilization of technology. We do rounds with them more frequently. We make ourselves more available. You really… it’s different for each person.
Host: That kind of segues very nicely into this next question, and that’s …your technology experience and how much computer IT background did you have when moving into this position?
CP: That’s a good question. I had zero. I had absolutely none. I’ve learned a lot of things since starting in this department. I’ve mentioned some of my roles as being project manager and then implementing electronic processes. One of the other things that we also do. I am on-call for our IT Department about three times a year, so there are things that I have learned to do, like changing tapes for our backup process, and I know what questions now to ask if we’re going to install a new printer. You know, someone wants a desktop PC, I know exactly what it is that we need to do, but primarily we’re associated with… my job as a clinical analyst, we’re associated with our clinical software. Not so much the hardware piece, but I learn stuff every day so that’s always a good thing.
Host: So then what are some of the things that you’ve learned during your other experiences and what part of your background has made you successful in this new position you’ve started?
CP: Sure. I think one of the most important things for me is that I’ve worked and had clinicals at other hospitals. I’ve worked in different environments. I’ve worked in a doctor’s office. I’ve worked in a hospital as a floor nurse. I’ve worked as a charge nurse. When I was in undergrad, I’ve had clinicals at probably thirteen different facilities, so I was able to see different kinds of workloads. And the big thing about being an analyst in an IT position and having a clinical background is being able to assess the workflow of the group that you’re working with and figure out how you can make technology a part of the process, not an addition to their workflow. So how can you integrate technology into their day-to-day jobs, and if you’ve done that job, it makes it that much easier to understand, as opposed to doing your job and then doing your technology piece. How can you incorporate it, and really having that background helps, and you approach projects from a different perspective.
Host: This is more of a specific question. “I have experience in a primary care setting, and was wondering if resources are limited, no funding for adoption, updates of EMR, how does one keep providers engaged in adapting as the EMR changes or is enhanced. Can you say what you put into newsletters, etc, things like that? Oh, I’m sorry, no funding for a person focused on EMR adoption and updates, so there’s really no… I guess… people assigned to be the champion within this organization, and how does one keep providers engaged in adapting as the EMR changes or is enhanced? Does that make sense?
CP: I think so. I think with… I’m assuming you’re working … talking about working in a provider office?
CP: That needs to be really driven by those providers, or the people who own the office. For people who do not have electronic health records now, and they’re going to start facing less reimbursement when we reach the year 2013, getting them the education piece up front now, while you still have time, or staying on top of what the meaningful use guidelines are. If you have one person in your office who might not be designated as that now, you might want to figure out what it is that …if there’s a knowledge deficit on what education or what technology is needed, and how you can get the reimbursement money, because really, it all comes down to making money for these doctors in private practices and especially if they’re not associated with a health care, with a health system. It’s going to cost a lot of money to implement the technology but at the same time, if you don’t implement it, then you’re going to start losing reimbursement from CMS. So, it’s really important to stay on top of it, and I guess the biggest piece is getting this information to whoever’s in charge like a director or an office manager. Or even the providers. And I think it’s really hard to keep providers engaged. The big thing specifically with CPOE is patient safety, but when we talk about implementing technology, it all comes down to dollars right now, and I think that’s really important. That might get their attention quicker.
Host: It always does, right? Christin, what role do you hope to move into after you complete your degree?
CP Right now, I am in an office. Our IT Department is about 20 people. We have a director, three managers and our clinical staff is myself, two other people and my manager. And I hope to move into a management position after this. I will share though, that one of my co-workers this week was offered a consulting position at DelPro, and honestly, this field right now is so prevalent, so hot that you can pretty much write your check. I mean, knowing what she’s being offered, it makes it very appealing to basically do whatever it is that you want, and if you really love it and you get it, and this is something that you want to do, I would recommend doing it because it’s not just going to go away in 10 years when these EHRs are implemented.
I mean, we’ve got the local level to focus on, and then we’ve got regionally, you know that connectivity between hospitals in a region, and then you’ve got national connectivity. I mean this is going to take a long time for this to be implemented. I know the government has said it needs to be done by a certain point, but you know this is going to be going on for a long time, so there’s a lot of opportunities out there. So, if I don’t go into management, I can always do something else.
Host: Ok, we’re going to take two more questions. This one is another specific question. It says “Christin, I am currently working as a staff RN, so I would like to use this degree to advance my career. Do you have any recommendations of areas that I could become involved in at a unit level?
CP: Sure. One of the things that I was… I think that helped me in getting this position is that I was a super-user when my last hospital implemented BMV, so like the bar-code medication verification, and just having that experience of being a super-user with a specific technology makes them think that… er, not makes them think but lets them know that you’re interested in being innovative and interested in being a leader. And that’s something you have to do in this type of position. You have to be able to manage projects. You have to implement things and, having that experience as being a super-user or even just going to your IT Department, or asking your manager what projects are coming up. “Is there something that I could be involved in?” would really help.
Host: That’s great. Thank you. So another specific question, and this is “I’m in a position where my role is to present new ways of documenting medical office visits to providers, and they are not happy about the changes. Any helpful hints to changing the negativity? We do not have a physician champion either.
CP I guess, to me, the biggest thing I would do is sit down with each provider individually, one-on-one. I would never, I mean, to me, this is something I would never do is stand in front of a room and ask them to tell me what’s wrong, because you’re going to get feedback from everybody, and honestly, negativity feeds other negativity. So if you can get them in an isolated situation and you know, say, “What is it exactly that you know, you see as a problem? And so you ask them questions and they give you your feedback and say “Well, what is it that you want the system to do?” And I think that one of the parts of this job is to listen to your audience and see what it is that they’re asking for and then find a way that you can do it.
I mean there are certain things, there are limitations to software. You know, we all realize that. I’m not a coder, er not a coder. I’m not a software writer, I can’t even come up with the right term right now, but finding a way to utilize the software and what it can do to your benefit and getting their input is the biggest thing. You know, they might say “I don’t like it” but why don’t they like it and what do they want it to do? I think that’s a really big thing.
Host: OK. And I know I said that we were going to stop after that one but there’s another good question that I think that I think might be… might need an answer. That would be “What recommendation do you have for someone with just IT experience and no clinical background? Do you work with a lot… any people that have come in with a strictly IT background and have tried to move into the health care field?
CP: Yeah. I guess, like I said, we have our clinical department and out of the 22 or so people that are clinical, er 22 people in our IT Department, only 4 of them are clinical, so the rest of the people in our IT Department at the health system do not have a clinical background. So, I guess if you could volun… I mean, if you’re not currently working in a health care environment, look for those types of jobs. On a job search Web site and see. A lot of people I’ve worked with recently who were just hired and don’t have any health care experiences, we’ve actually had side meetings and I’ve asked them “do you understand the clinical flow and why this needs to work this way?” And having relationships with clinical analysts really helps. I don’t know. I’m trying to figure out if they work in health care already. If not, uh… I don’t know. That’s a good question.
Host: Well, I think that you did give a promising answer that you know, you do work with, you know a majority of IT people that don’t have a clinical background .
CP: Yeah, one of the analysts that I work with, she worked at [unintelligible] for 18 years and then she came here. I mean, she had no health care background whatsoever but a lot of the analyst positions right now in IT Departments are big on project management, so if you have project management skills and you have an affinity to learn, you know, the workflows of places, and figuring things out then you’ll be successful.
Host: And then we’re going to end it with one last question about the program in general, and that is “What is the most challenging and rewarding subject in your coursework so far?
CP I have to say my current class that I’m taking right now is BHIS 510 and that is Healthcare Information Systems. And it’s very ironic, because it’s what I do every day. I work with HDIS with MetaTech, you know I work with one software system and that’s what I do. But it’s very challenging because it’s asking us to analyze it from a different perspective. So, you know what is it about integrating ancillary systems with, you know, your EMR that is important, and trying to view it from the different sides of things, but it’s challenging because I don’t do that work all the time. But the most rewarding thing about it is that everything, and I can say this about the program in general, everything I have learned from this program I can use directly in my job every single day. I can’t say it enough. This program you know the graduate program in general is going to make me a better employee.
Host: Wonderful. Well thank you so much Christin for your time. I truly appreciate it. To the audience, this presentation will be posted on the University of Illinois at Chicago Web site, and that’s www.healthinformatics.uic.edu. If there are any further questions, feel free to email them through the GoToWebinar or at admissions@healthinformatics.uic.edu. Alright everyone, have a great afternoon. Christin, thank you again, and enjoy your afternoon.
