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HiQuiPs: Preparation Part 2 – Stakeholder Engagement and Behavior Change

Updated: Feb 28, 2022

Authors: Ahmed Taher, Cori Atlin, Shawn Mondoux, Shawn Dowling

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)

Figure 1. Categorize stakeholders by interest, influence or power (source: Imperial College London,

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)

Figure 2. Cabana et al's frequently cited approach for clinical behaviour change (source: Cabana et al.,

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)

Different perspectives on provider behavioural change (source: Adapted from Gurses et al., 2010)

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

Interaction of different characteristics and provider behaviour change (source: Adapted from Gurses et al., 2010)

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.

Senior Editor: Ahmed Taher

Copyedited by: Paula Sneath, Yoyo Chen


  1. 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.

  2. Brugha R, Varvasovszky Z. Stakeholder analysis: a review. Health Policy Plan. 2000;15(3):239-246.

  3. Clarkson MBE. A stakeholder framework for analyzing and evaluating corporate social performance. Academy of Management Review. 1995;20(1):92-117.

  4. Kotter JP. Leading Change. Boston: Harvard Business School Press; 1996.

  5. Brugha R, Varvasovszky Z. Stakeholder Analysis: A Review. Health Policy and Planning. 2000;15(3):239-246.

  6. Imperial College London. Stakeholder Management [Powerpoint]. 2017 Jun [cited 2018 Aug 9]. Available from:

  7. 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.

  8. 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.

  9. 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.

  10. 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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