HiQuiPs: Preparation Part 2 – Stakeholder Engagement and Behavior Change

In Education & Quality Improvement, HiQuiPs by Ahmed TaherLeave a Comment

You have recently finished a review of incidents that have been flagged in your ED. You have chosen a pertinent issue to tackle, formed a core group to work on the project, and formulated a SMART aim statement after reading our last HiQuiPs post. The median time for obtaining 12-lead ECGs is 13 minutes, while guidelines recommend less than 10 minutes.1 Your aim is to decrease the initial 12-lead ECG acquisition time by 3 minutes over the next 2 months.  

As you start to discuss the project with your team, you decide to outline all the stakeholders involved in the process. Stakeholders are “individuals, groups, or organizations who have an interest (stake) and potential to influence the actions and aims of an organization, project, or policy direction”.2 Before starting the project, an important exercise is to perform a stakeholder analysis, which involves evaluating and understanding the perspectives of stakeholders and their relevance to the project or policy.3 This can increase project success by informing design, preparation, implementation, or evaluation. These steps are also in line with the time-tested change model introduced by Kotter.4 This model begins with creating a sense of urgency and building a guiding coalition. This can be achieved through the imperative created by a strong aim statement and effective stakeholder engagement.

Stakeholders in this quality issue may include physicians, triage nurses, other ED nurses, patients, ECG technicians (if available), porters, and administrators such as the nursing manager, department chief, etc. A useful approach is to categorize stakeholders across their interest in the issue and their influence or power. This analysis can be used to plan how much, and what kind of attention to pay to the stakeholders.5 This can range from keeping them well informed, to directly involving them as illustrated below.6 

QI stakeholders

The general approach is to recognize the variability in positions and to plan accordingly. For example, the nurse manager disagrees with the initiative and doesn’t think there is a quality issue present. Therefore, given their high influence and interest, you would need to manage them closely by informing, engaging and working closely with them. Having discussions early on about the different stakeholders, then involving them appropriately, may help prevent roadblocks once the interventions take place.  

Now that you have organized your stakeholder engagement approach, you reflect on the various levels of interest and support for your initiative. You have already created a project charter that addresses the different team members and stakeholder responsibilities. Project charters were covered in our previous post.

You also think about the different stakeholders involved and complex interactions that are required for the initial ED 12-lead ECG acquisition process. You worry about the difficulty in getting different stakeholders to change their behaviour that may be needed in your QI intervention. This concern is not unfounded. For example, clinician adoption of new evidence or guidelines can take an average of 17 years from dissemination.7 Clinician behaviour change is a complex phenomenon that is affected by a multitude of factors. There are a variety of conceptual models explaining this phenomenon. Cabana et al. is a frequently cited approach which names challenges across domains of knowledge, attitudes, and behaviour.8

Sequence of behaviour change

Adapted from Cabana et al.8

Another comprehensive approach that synthesizes different perspectives on provider behavioural change presents an interdisciplinary framework.  This approach includes characteristics that span the provider, the guidelines or intervention, the system, and the implementation plan. Examples of each are illustrated as follows:9

Characteristics Details
Provider Characteristics Personal traits of health care providers, such as their attitudes toward guidelines in general.  These include self-efficacy, outcome expectancy, motivation, and subjective norms.
Guideline, Intervention, & Innovation Characteristics Aspects of the guideline or innovation itself that affect uptake, for example how complex the guidelines are. These include relative advantages, compatibility with clinicians’ values, complexity, trialability.
System Characteristics Structural features of the healthcare organization, rules, culture, and peer pressure. These include task factors, present tools and technology, physical environment factors, and organizational factors such as leadership and culture.
Implementation Characteristics Aspects to when and how a guideline or innovation is implemented, including change processes and promotion strategies.  These include the tension for change, change agent characteristics, the presence of opinion leaders, and the presence of behavioural competition.

These different characteristics interact with one another in ways that may impede or facilitate provider behaviour change.

Behaviour change

Adapted from Marsteller et al.10

A thorough review of these potential barriers may reveal issues such as unfamiliarity of nurses or physicians with the guidelines, not enough ECG machines being available, or other local policies about initial patient interactions that conflict with obtaining early ECGs. It is important to consider these factors as you start to reflect on the different strategies that may be pursued as part of the QI project. As behaviour changes may be challenging, reflecting on these characteristics may enable targeted actions or the evolution of the QI interventions to assist with behavioural change.10

In summary, we have thought about the potential stakeholders for our project and elements of behavioural change that may affect our intervention. Now we are ready to focus on our final -and most exciting – part of preparation: Performing a Root Cause Analysis.  Stay tuned for next month’s post.

Finally, if you have enjoyed our posts, and if you are looking for more HiQuiPs related resources, the Canadian Association of Emergency Physicians (CAEP) has recently launched the Quality Improvement and Patient Safety Resource Centre.

This post was copyedited by Paula Sneath 

Click here for more articles in the HiQuiPs series!

**UPDATE (November 2020): The HiQuiPs Team is looking for your feedback! Please take 1 minute to answer these three questions – we appreciate the support!**


Antman E, Anbe D, Armstrong P, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction–executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation. 2004;110(5):588-636. [PubMed]
Brugha R, Varvasovszky Z. Stakeholder analysis: a review. Health Policy Plan. 2000;15(3):239-246. [PubMed]
Clarkson MBE. A stakeholder framework for analyzing and evaluating corporate social performance. Academy of Management Review. 1995;20(1):92-117.
Kotter JP. Leading Change. Boston: Harvard Business School Press; 1996.
Brugha R, Varvasovszky Z. Stakeholder Analysis: A Review. Health Policy and Planning. 2000;15(3):239-246.
Morris Z, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med. 2011;104(12):510-520. [PubMed]
Cabana M, Rand C, Powe N, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282(15):1458-1465. [PubMed]
Gurses A, Marsteller J, Ozok A, Xiao Y, Owens S, Pronovost P. Using an interdisciplinary approach to identify factors that affect clinicians’ compliance with evidence-based guidelines. Crit Care Med. 2010;38(8 Suppl):S282-91. [PubMed]
Kahan S, Gielen A, Fagan P, Green L. Clinicians and Behavior Change. In: Health Behavior Change in Populations. 1st ed. JHU Press; 2014:550.
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Ahmed Taher

Ahmed Taher

Ahmed is an Emergency Physician at University Health Network and Mackenzie Health in Toronto. He completed the Toronto FRCPC Emergency program, and a Masters of Public Health program at Johns Hopkins Bloomberg School of Public Health with certificates in Quality Improvement & Patient Safety, as well as Public Health Informatics.
Ahmed Taher
- 2 months ago
Cori Atlin

Cori Atlin

Dr. Cori Atlin is an Emergency Physician at North York General Hospital and Trauma Team Leader at Sunnybrook Health Sciences Centre. She obtained a MSc in System Leadership and Innovation at the University of Toronto. Her interests include trauma, global health, and utilizing health technology to optimize system flow.


Dr. Shawn Mondoux is an emergency physician at Hamilton Health Sciences (HHS) and faculty at McMaster University in Hamilton, Ontario. He obtained a masters of Quality Improvement and Patients Safety (QIPS) at the University of Toronto and serves as QI advisor to all projects within the ED. He has a strong interest in clinical QI work as well as the education of PGME learners in QI principles.
Shawn Dowling

Shawn Dowling

Shawn is an Emergency Physician, the Senior Medical Director of the Physician Learning Program and the Clinical Content Lead for the Calgary Zone Emergency Department. His areas of interest include improving knowledge translation using strategies such as audit and feedback, clinical decision support and computerized order entry to minimize gaps in care, and improve resource stewardship. He also has an amazing wife, three amazing daughters and loves to balance out his life with running and cycling as much as he can.
Shawn Dowling
- 1 day ago