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Implementing change: How adjustments in communication approach helped BEST-CLI trial register on radar
BY KRISTINA GILES, MD
I had the privilege of interviewing Alik Farber, MD, the division chief of vascular and endovascular surgery at Boston Medical Center in Boston, where he also is associate chair for clinical operations in the department of surgery. Of course, we all know him as one of the national co-chairs for the BEST-CLI (Best endovascular vs. best surgical therapy in patients with critical limb ischemia) clinical trial.
COMMUNICATING FOR BUY-IN:
Q. How did you communicate your vision for the BEST-CLI trial and how did your strategies for communication change over the course of the trial?
A. Communicating the vision is very important as that is how it gets translated into something that can be operationalized. Matthew Menard, MD, and I had the idea for BEST-CLI over a beer but had no idea what this endeavor would entail. We sought advice from Bob Zwolak, MD, then-SVS president, and Ronald L. Dalman, MD, then chair of the Research Council, and, on their advice, contacted the National Institutes of Health (NIH). We brought together an experienced group of experts for next conversations. We partnered with New England Research Institute, a data coordinating center, and reached out to our community of surgeons to garner further support. These communications were difficult because, at the end of the day, I don’t think people believed the trial would get off the ground. So how do you strategize in that situation? The answer to that is complicated. We knew we needed to show others that we did not waiver in our own beliefs; we had to press forward. Once we were funded, things changed. The people surrounding us now actually believed that we could pull it off. As such, the dynamic and subsequent communication changed. We adjusted to communicating a vision that was now about trial execution.
Q. How was it different when you were talking to key opinion leaders versus someone in the NIH or a different stakeholder?
A. We had to work hard to get key opinion leaders to believe in our vision and in our ability to carry it out. Talking to the NIH was different. When I “cold-called” the acting head of the cardiovascular branch I was shocked she actually took me seriously. The reality is that the NIH has a process in place for evaluating “pitches” from investigators, be it a Nobel Laureate or a first- timer. When communicating with stakeholders, you have to have a sense for their interests and adjust your communication accordingly. When talking to BESTCLI site investigators, we had to figure out what the issues were at their site and come up with ways to help them surmount any barriers to enrollment.
Q. Tell me about a situation in your role as chief of clinical operations in which you had to communicate a changing vision. How did you approach this and how was it received?
A. While a member of our hospital’s Value Analysis Committee I asked our chief medical officer if I could try to standardize vendors for our endovascular platforms (including interventional radiology, interventional cardiology and vascular surgery) to decrease costs. Physicians have their own opinions about devices and had no financial incentive to make changes, making starting the conversation difficult. I called a meeting with all physician stakeholders and asked them to consider having a conversation about how standardization might help our medical center. I emphasized the importance of having physicians lead this process, given that physicians often are excluded from such conversations. I emphasized their voices would be heard. We went over bucket lists of all devices and identified as a group what were “must haves”; it turned out that there were very few such items. The rest we agreed to treat as “commodities.” Then, we sent out requests for proposals to the vendors. When those came back, we as a group discussed them and the changes that would need to occur if we were to go with any given company as primary vendor. During this process one of the physicians asked, “What do I get out of this?” I replied, “Satisfaction of doing what is best for the medical center.” In the end we all came to an agreement and found a cost savings of $1.2 million for the institution.
Q. “The Heart of Change” authors John Kotter and Dan Cohen use the term “empowerment” to describe removing management, system, mind and/or information barriers. Do you have an example of how you attracted interest from a group?
A. After the above scenario, our CMO asked me to chair the Value Analysis Committee. Getting new products and devices into our hospital has been broken for a decade. My administrative partner and I designed a pathway to bring new devices into the facility and continued to look at other opportunities in the operating room to help standardize and decrease costs. I invited many physicians to directly participate in these teams and working groups, thereby helping empower our physicians to make important administrative decisions. This led to significant buy-in for these processes from the physician community.
Q. How have you used feedback to help empower others for change?
A. Feedback is very important and brings up the importance of leadership style. There are multiple leadership styles, each with its own advantages and disadvantages. I learned in business school that to be a successful leader one has to understand what leadership style(s) you feel most comfortable operating in and what leadership style best fits the individual to whom you are giving feedback, not to mention the associated situation. As such, the leader has to be flexible and comfortable navigating through the various leadership styles based on the issue at hand. In giving feedback, you have to understand what style is needed. For example, I generally use a democratic style in divisional discussions. Recently I used a more autocratic style in developing our division’s strategy surrounding the COVID-19 pandemic.
CREATING SHORT-TERM WINS
Q. The leadership book includes this chapter: In successful change efforts, empowered people create short-term wins—victories that nourish faith in the change effort, emotionally reward the hard workers, keep the critics at bay and build momentum. How did you go about using short-term wins to help drive the BEST-CLI trial efforts?
A. In its execution phase the trial is like a protracted battle to get it successfully completed. I recently read about a special forces operative who talked about the five-minute rule used in battle: soldiers are taught to think only in five-minute increments. Looking at BEST-CLI and what was needed to get it accomplished has always been overwhelming. All along, we have been breaking it down into manageable components. For example, every site visit was a new challenge and we found new ways to make wins at various sites. At one struggling site I encountered a physician, reported to be the site’s busiest, who told me he believed in bypass and therefore did not see a need for BEST-CLI. I told him that the trial presented an opportunity to show the potential supremacy of bypass and therefore was the very reason why we needed him to enroll his patients. This clicked for him and the site then increased its enrollment. This was one five-minute period in the BEST-CLI battle at that site. Short-term wins—in aggregate—led to bigger gains. As the trial draws to a close, I appreciate the many five-minute intervals that have led to our current position of starting to see some light at the end of the tunnel.
Q. How do you overcome setbacks that threaten to block progress?
A. With setbacks, you have to take a look at the grand vision. In this vein, you have to take a step back, look at the big picture and then reorganize in order to try to get a win. Specific to BEST-CLI, there were some sites that we could not get to enroll no matter how hard we tried to help them. However, we helped turn the tide in many other sites.
Q. Any final anecdotes that you feel relates to this process overall?
A. At our hospital, we had a problem with only 40% of our first cases starting on time. I was volunteered to try to fix this problem. The chair of anesthesia showed me a two-page list of surgeons who were late and causing the issue. I told him this was learned behavior, that the surgeons stopped coming on time because cases were seldom ready to go when they were supposed to. We created a working group, crafted staggered starts, identified stakeholders in this process, assigned responsibilities to every group and got buy-in. Ultimately, we improved our first-case starts to 85%. This was a valuable primer for operationalizing an important process for our operating room.
Kristina Giles is assistant professor of surgery in the division of vascular surgery and endovascular therapy in the University of Florida College of Medicine in Gainesville.