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Engaging Doctors in the Health Care Revolution
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From the June 2014 Issue
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Executive Summary

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A health care revolution is under way, and doctors must be part of it. But many are deeply anxious and angry about the transformation, fearing loss of autonomy, respect, and income. Given their resistance, how can health system leaders engage them in redesigning care? In this article, Dr. Thomas H. Lee, Press Ganey’s chief medical officer, and Dr. Toby Cosgrove, the CEO of the Cleveland Clinic, describe a framework they’ve developed for encouraging buy-in.

Adapting Max Weber’s “typology of motives,” and applying behavioral economics and other motivational principles, they describe four tactics leadership must apply in concert: engaging doctors in a noble shared purpose; addressing their economic self-interest; leveraging their desire for respect; and appealing to their sense of tradition.

Drawing from experiences at the Mayo Clinic, Geisinger Health System, Partners HealthCare, the Cleveland Clinic, Ascension Health, and others, the authors show how the four motivational levers work together to bring this critical group of stakeholders on board.

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Despite wondrous advances in medicine and technology, health care regularly fails at the fundamental job of any business: to reliably deliver what its customers need. In the face of ever-increasing complexity, the hard work and best intentions of individual physicians can no longer guarantee efficient, high-quality care. Fixing health care will require a radical transformation, moving from a system organized around individual physicians to a team-based approach focused on patients. Doctors, of course, must be central players in the transformation: Any ambitious strategy that they do not embrace is doomed.

Three types of land tenure arrangements apply to allotments in London today. Statutory allotments, by far the most common, are situated on borough land that has been acquired or appropriated by a council for the specific intent of gardening (London Assembly Valentino amp; Garavani Mink Open Sneakers CKH0wXKVCw
). These sites are afforded significant protection—in theory at least—and several conditions must be satisfied before they can be sold or used for other purposes (London Assembly 2006 ). Temporary allotments, on the other hand, are hosted on council land that is allocated for other uses and receive little protection from disposal. The Small Holdings and Allotments Act 1908 (and subsequent related legislation) places a duty on boroughs in England and Wales to provide a sufficient number of plots for their constituents, but no such obligation applies to the boroughs of Inner London. There are also allotments on privately owned land, and these have equivalent legal standing to temporary allotments.

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Fig. 4

Number of allotment sites per borough in Greater London. Data from London Assembly ( 2006 )

Concomitant with the decline in plot provision has been an increase in demand, with waiting lists for plots growing from 1,330 people in 1997 to 4,300 in 2006. The length of waiting lists in Greater London has skyrocketed since 2006, with council surveys in 2010 and 2011 revealing that 16,517 and 16,655 people, respectively, were registered for plots and that 12 boroughs were not accepting new applicants in either year (determined from online databases cited in London Assembly 2006 ; no data were available for three and five of Greater London’s 33 boroughs in 2010 and 2011, respectively). The legislation associated with allotment provision is complex (London Assembly 2006 ), but the fact that demand for allotments is high (or, indeed, simply that it exists) must raise the question as to whether some boroughs are breaching their statutory duties (Campbell and Campbell 2011 ). Furthermore, a significant threat to allotments emerged in early 2011 when this 103-year-old obligation for councils to provide allotments to meet demand was targeted in a cull of “burdensome legislation” that local authorities had to contend with (Merrick and Jewsbury 2011 ). A campaign to protect the legislation was mounted, enlisting numerous food and gardening celebrities, and its success was confirmed when Prime Minister Cameron gave it his backing in the House of Commons (Merrick and Hickman 2011 ).

Government support for urban agriculture in London has been mixed. As Executive of the Greater London Authority, the policies of the Mayor of London are important in setting the prominence and direction of urban agriculture in development planning for Greater London. Mayor Ken Livingston released his Food Strategy for London in 2006 (Mayor of London 2006 ), but agriculture was notably absent: “While farming remains an important consideration for London, this strategy is explicitly and predominantly a food strategy.” In fairness, the Food Strategy noted that the London Plan (Mayor of London Salvatore Ferragamo Classic slip Abqh7zgu
), released in 2004, was the appropriate planning document, and urban agriculture did receive specific representation in this plan (Policy 3D.14 Agriculture in London). However, the London Plan underwent a full revision following the election of Mayor Boris Johnson to office in 2008 (Mayor of London 2011 ). The London Assembly scrutinized the Mayor’s draft Plan and provided a list of ten recommended amendments/additions relating to urban agriculture (London Assembly 2010 ). Some of these were taken on board, and the policy directly relating to urban agriculture in the revised London Plan is Policy 7.22 Land for Food , which states that (1) the Mayor will encourage “thriving farming and land-based sectors in London” and (2) “the use of land for growing food will be encouraged nearer to urban communities via such mechanisms as Capital Growth .”

Table 2. Key principles, participant dialogue, and research and policy implications when assessing scientists.

https://doi.org/10.1371/journal.pbio.2004089.t002

The first principle is that contributing to societal needs is an important goal of scholarship. Focusing on research that addresses the societal need and impact of research requires a broader, outward view of scientific investigation. The principle is based on academic institutions in society, how they view scholarship in the 21st century, the relevance of patients and the public, and social action [ 10 ]. If promotion and tenure committees do not reward these behaviours, or penalise practices that diminish the social benefit of research, maximal fulfillment of this goal is unlikely [ 25 ].

The second principle is that assessing scientists should be based on evidence and indicators that can incentivise best publication practices. Several new ‘responsible indicators for assessing scientists’ (RIAS’s) were proposed and discussed. These include assessing registration (including registered reports); sharing results of research; reproducible research reporting; contributions to peer review; alternative metrics (e.g., uptake of research by social media and print media) assessed by several providers, such as Altmetric.com ; and sharing of datasets and software assessed through Impact Story [ 54 ]). Such indicators should be measured objectively and accurately, as publication and citation tools do currently. Some assessment items, such as reference letters from colleagues and stakeholders affected by the research, cannot be converted into objective measurements, but one may still formally investigate their value [ RED Valentino Metallic Leather Ballerinas with Stud Embellishment Gr IT 41 e62L9vT2em
].

As with any new measures, RIAS characteristics need to be studied in terms of ease of collection, their frequencies and distributions in different fields and institutions, the kind of systems needed to implement them, and their usefulness in both evaluation and modifying researcher behaviours and the extent to which each may be gamed. Different institutions could and should experiment with different sets of RIAS’s to assess their feasibility and utility. Ultimately, if there were enough consensus around a core set, institutional research funding could be tied to their collection, such as underlies successful implementation of Athena Scientific Women's Academic Network (SWAN) for advancing gender equity, which has been highly successful in the UK [ 56 ].

One barrier to implementation of any RIAS scheme is whether it would affect current university rankings (e.g., Times Higher Education World University Rankings). Productivity, measured in terms of publication output, is an important input into such rankings. Participants felt that any RIAS dashboard could be included in or as an alternative to university ranking schemes. However, these ranking systems are themselves problematic; the Leiden CSTS has recently proposed 10 principles regarding the responsible use of such ranking systems [ 57 ].

Men may resist organizational changes favoring women because they view gender equality as zero sum—if women win, men lose. How then do you enlist men as agents of change? Few men oppose the idea of benefiting from the entire talent pool—at least in theory. But some are concerned about actually leveling the playing field. In practice, of course, the blind auditions in orchestras have increased competition for male musicians. And the inclusion of women affects competition for men in all jobs. I understand that increased competition can be painful, but I am too much of an economist to not believe in the value of competition. There is no evidence that protectionism has served the world well. Enlisting men is partly about helping them to see the benefits of equality. Fathers of daughters are some of the strongest proponents of gender equality, for obvious reasons, so they can be particularly powerful voices when it comes to bringing other men along. Research on male CEOs, politicians, and judges shows that fathers of daughters care more about gender equality than men without children or with only sons. I would urge fathers of daughters to be outspoken in their own organizations and to advocate for equality not just as a broad goal, but to actively help drive the changes I describe here—collecting baseline organizational data, promoting experiments, measuring what works, changing processes to limit the impact of our biased minds and level the playing field, and so on. A big part is, simply, continued awareness building—not just of the problem but also of the solutions available to organizations. I recently gave a talk on Wall Street to an audience that was male. I started by inviting people with children to raise their hands. Then I asked those with daughters to raise their hands. Many hands were up. I told them that this made my job easy as some of my biggest allies were in the room. It broke the ice, especially when I told the audience that my husband and I only have sons—who are great feminists, I might add, and in small ways have already brought behavioral insights to their school by reminding the principal to refer to teachers in general as both “he” and “she.”

A version of this article appeared in the July–August 2016 issue (pp.62–67) of .

Gardiner Morse is a senior editor at

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4 COMMENTS

With the concept coming into the organization cultures, many policies are being re-defined. We do have introduced new policies, trying to address day-to-day issues of women colleagues and ultimately trying to have a better diverse workplace. But personally, i would like to understand few more things over here; for the sake of having a diverse workforce, are we suppose to divert the policies and are we suppose to have policies which are subject to change in terms of bringing a diverse culture. We should have equality but how much equity can be compromised, is not defined anywhere. If one organization has provided equal opportunity for it's people, created a harassment free work atmosphere and does fair performance assessments then is the requirement of deviating the policies for the sake of Diversity exist? The question is to all.....Regards,

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