Value Champion

Rationale for this Module

Among the Value Champions in our Fellowship, stakeholder assessment and engagement was just as important as leadership support to the success of their project. Understanding WHO stakeholders are (and there are always unexpected stakeholders), WHY they have an interest in your project, and HOW MUCH influence/power they have within a health care organization is critical to project success. It is important the learners finish this module with a new appreciation for this reality and have some ideas about how they will assess and engage with stakeholders during their overuse reduction project. Much of the work in the Project Workbook dedicated to “Understand Your Project Landscape” should be focused on this stakeholder assessment and engagement activity.

How to Preparation for this Module

This is a longer module and may take more than one-hour of class/group time because of the length of the small group exercise, so be sure and protect plenty of time for that exercise. The readings for this session are less academic, they provide pragmatic examples from the business world. There is also a recorded webinar about a stakeholder assessment done by one of our fellows that we recommend you watch before this session.

Suggested Agenda

• Welcome & Introductions (5 minutes)
• Large group: introduction to the module + discussion of readings (15 minutes)
• Small group: break out exercise (20 minutes): In groups of 3, have the clinical value champions complete the case study exercise below
• Large group: putting it all together (10 minutes)

Small Group Exercise/Case Study

The small group exercise below is based on the overuse reduction project discussed during the recorded webinar described above. Divide the class into groups of 3-4 individuals for the exercise below. Note that there are 3 parts to the small group activity so you should keep track of the time and make sure each small group does not spend too much time in one section so that they can complete the activity.

Background: Early identification of a stakeholder and ongoing management of the relationship with that stakeholder can significantly increase the likelihood of success for a project. Stakeholders are loosely defined as persons, positions, or organizations that have an interest in your overuse reduction project because of how it might impact them. This interest can be vested in multiple domains, and it isn’t uncommon for a given stakeholder to have multiple reasons to have an opinion about your project. It is also important to realize that a stakeholder’s perspective and opinion can, and does, change over time.

Case: Your project goal is to reduce the utilization of percutaneous intravascular central catheters (PICC) within your inpatient medical service. You have completed your data analysis, created your Project Charter, and have support from your direct supervisor. You are now ready to identify stakeholders.

Who are Potential Stakeholders? A systematic approach can help ensure that the identification process is thorough. Some of the domains that create stakeholders, such as patient safety or improving clinical outcomes, are straightforward. Others, such as revenue or workload, can be less obvious but not less critical. The last group, while still of great importance, can be very difficult to identify and categorize. This last group includes domains such as internal politics and career implications. Here are some examples of stakeholders from three different domains to consider as you identify stakeholders for the PICC line project described above.

• Clinical Stakeholder Domain: What persons/groups/organizations are impacted in a clinical fashion by a reduction in PICC lines?
  • Patients may have fewer complications from PICC lines, such as infections, but at the same time may experience more peripheral IV placements.
  • Nurses may prefer PICC lines for clinical convenience but are also likely to have a desire to reduce complications, such as infections.
• Revenue Stakeholder Domain: Revenue domain presents a unique scenario where revenue generation is almost always associated with a stakeholder that will support the project and revenue reduction will almost always be associated with a stakeholder that will oppose the project. Who are the people involved in PICC line insertion for whom there is a revenue implication?
  • Supply Chain: Did the supply chain director just sign a contract for a year’s supply of PICC lines that will now go unused and impact the bottom line of their department?
  • Radiology: some PICC lines are inserted using imaging, does this department receive additional revenue for providing this service?
• Workload Stakeholder Domain: For whom does this project create additional work and for whom does this project create less work?
  • The service that places the PICC will have less work. If they are overworked and experiencing high turnover rate among their staff, the PICC staff will likely be in support of the project. However, they might be concerned that a reduction in PICC line placements will result in layoffs of staff, thus they may view this project as a threat to their job security and oppose the project.

Case:

• You’ve identified the PICC line placement service, frontline nursing, and patients as having clinical reasons to be stakeholders. They likely have mixed views due to workload changes and patient safety improvement.
• You’ve identified the leadership of the PICC service as well as the front line PICC staff members to have workload examples.
• Nursing managers and medical directors have patient safety interests, with a reduction in PICC leading to a reduction in central line infections and catheter associated DVTs (this is also a workload reduction as they are required to analyze each of these events in writing for the Office of the Chief Quality Officer.)
• The PICC service bills for their services and the radiology service is financially responsible for their budget, so a reduction in PICC placements will reduce revenue for the radiology service, which makes the radiology service leadership a stakeholder as well and potentially an opponent of projects that would reduce PICC utilization.
• The PICC service is staffed by late career nurses and has been used by HR to navigate low performing nurses from other settings, such as operating rooms and intensive care units. This places HR at the stakeholder table as well, but largely for institutional political reasons that are separate from the patient and the clinical team at the bedside. They will likely be interested in the project and the outcome, but not necessarily in an activist role. In other words, they are interested in the outcome and would benefit from early notification so they can plan accordingly.
• Another political stakeholder is the Chief Nursing Officer. The CNO came here from another institution and has been open in remarking that the PICC service should really be within nursing and not within radiology, which is how it was set up at the CNO’s prior institution.
• Lastly, the Chief Quality Officer is likely to be highly interested and supportive. You know from our background research that PICC lines increase complications, so it is highly probable that the CQO will be in support of a project that will reduce PICC lines.

Small Group Exercise Part 1: Using the technique in the stakeholder video, place each of the stakeholders below on a stakeholder power mapping grid in relative position to each other.

• Chief Nursing Officer (CNO)
• Radiology Leadership
• Frontline Nursing
• Medical Director
• Nursing Unit Director
• Human Resources
• PICC Service line
• Chief Quality Officer (CQO)

After you have placed the stakeholders in the graph, identify 3-4 additional stakeholders using the guidance provided in the readings, and place these additional stakeholders on the graph as well, also in relative position to the other stakeholders.

 Small Group Exercise Part 2: You have identified stakeholders and mapped them on a structured grid. Now it’s time to develop a stakeholder management and engagement strategy. Using the grid as a guide, which 2 stakeholders are most likely to oppose the project? (Note that it is not only acceptable but necessary to consider a stakeholder’s power within the organization as well as their history – are they outspoken and willing to play an active role in opposition? A powerful opponent that is unlikely to expend time and energy to intervene is likely less of a threat to the project than a mid-level manager that is highly outspoken.) After identifying the greatest threats, identify the two greatest supporters.

Engagement is not a One-Time Event: The first pass of stakeholder identification should really focus on the natural state of the stakeholder. Who do you think is likely to support or oppose your project based entirely on hearing about your project through happenstance from a third party? There are also stakeholders that are less likely to be active at first but could become active when they learn more about the details of the project. For example, a nursing director may initially think that PICC reduction is a bad project and needs to be opposed because it will create intravenous access difficulty for their front-line nurses. Does the nurse manager know the risk between PICC utilization and complications? If not, a discussion around this data could move the nurse manager from opponent to supporter by changing her stakeholder domain from primarily considering the workload of their direct reports to a position based on patient safety and a reduction in workload (fewer complication reports to file).

Small Group Exercise Part 3:

1. Which identified stakeholders identified as major threats to the success of the project can potentially be mitigated by highlighting a different approach to the project?
2. Which stakeholders identified as a supporter are at risk for converting to opponent if they have even a minor misconception of the project?
3. In both cases, pick 1-2 stakeholders and describe how their position can be preserved as a supporter and how their position can be mitigated if they are an opponent. For example, the CQO is a senior executive with great respect in the organization. You need to ensure the CQO hears about this project as a PICC reduction project to reduce DVT and central catheter infection rates. This will solidify the CQO as a supporter.
4. Another example, the unit nurse manager. As discussed above, the unit nurse manager could be potentially a supporter or opponent, depending largely on the perspective from which the project is viewed. Turning an opponent into a supporter is always desirable, so a meeting with the nursing manager is set up to discuss the project.